Hip resurfacing:

By Felice J. Freyer
Journal Medical Writer

SOUTH KINGSTOWN

The guys wanted it. Guys in their 40s and 50s, who once spent hours playing tennis or doing karate, and who, now hobbled by arthritis, poured their energy into finding a solution to the pain in their hips.

They came to Dr. Robert C. Marchand, printouts in hand, minds made up, and said, I want this. What they wanted was hip resurfacing — a new alternative to total hip replacement that preserves more bone, and is reputed to last longer, withstand impact and allow a greater range of motion. Perhaps allowing for more years of karate kicks.

Marchand, who is with South County Orthopedics, had observed a hip resurfacing procedure in his wife’s native Germany. In Europe, he says, people are running marathons with hip-resurfacing implants. He thought his patients were on to something, and resolved to give them what they wanted.

He took a course last year in hip resurfacing in Boston and went to New York to train with a surgeon there. After persuading South County Hospital to buy the necessary equipment, he began doing the procedure last fall. So far, he has completed about 45 resurfacing procedures in people age 20 to 71.

And he remains the only doctor in Rhode Island who will do it.

Others are wary. Those interviewed said that hip resurfacing, available in the United States only since last year, has yet to prove its value and may have more risks than patients realize.

“For patients, there’s always a tendency to think something new offers an advantage,” says Dr. Roy K. Aaron, professor of orthopedics at Brown University’s medical school and medical director of rehabilitation at Miriam Hospital. “As surgeons, we know that’s not always the case. … I’ve been around long enough to see things come and go, and come and go.”

In the traditional treatment for arthritic hips, called total hip replacement, the surgeon saws off the top of the thigh bone, hollows it out and inserts a metal implant topped by a metal or ceramic ball, which rests inside a plastic cup implanted in the hip socket.

In hip resurfacing, instead of sawing off the top of the thigh bone, surgeons reshape it, preserving most of the natural ball. Then they cement a metal cap over the ball, which slides inside a metal cup pressed into the hip socket. Both are made of cobalt chrome.

Some think this metal-on-metal construction will last longer and withstand high-impact activities such as running. More bone is preserved, so that even if the implant does break down, the patient can then get a total hip replacement. Also, the ball is bigger, thought to be less likely to dislocate from the hip socket, and affording a greater range of motion.

All this makes the procedures especially popular with active baby-boomers. “They come in at six weeks [after surgery], cross their legs and put on their shoes,” Marchand says. “They say, ‘I haven’t done this in a year.’ ”

Journal photos / Bob Breidenbach

Dr. Robert Marchand performed hip resurfacing surgery on Janice Blais in February. Blais, 52, says "I am fabulous! I am back to me, the me I was. I have no pain. I wear high heels. I now spring out of my chair in the office."

But hip surfacing will only work in people who have strong, dense bones with no signs of osteoporosis. And the metal ball and cup rubbing together produce ions that float in the blood, the urine and even exhaled breath. It is unknown whether the metal ions have long-term effects, but they’re the reason why hip surfacing is not offered to any woman of child-bearing age or anyone with kidney disease.

THE PROCEDURE has been popular in Europe for more than a decade, but it has been slow to catch on in the United States. A handful of doctors were performing hip resurfacing as part of clinical trials, but not until May 2006 did the FDA approve a hip-resurfacing device, the Birmingham Hip Resurfacing System.

Even so, some U.S. doctors remain distrustful of European data and want more long-term results.

Marchand, firmly in the let’s-do-it camp, thinks doctors may be biased against the procedure because earlier, plastic versions of hip resurfacing in the 1980s failed disastrously, with implants quickly coming loose. Using tougher materials, today’s versions have eliminated the fatal flaws of the ’80s, Marchand asserts.

“They all love it,” Marchand says of his patients. “Most are on one crutch in a week. It’s hard holding them back.”

Marchand offered these comments in the lounge outside the South County Hospital operating room in late February, where he had just completed another hip resurfacing procedure. This time the patient wasn’t one of the guys, but a 51-year-old woman from Pawtucket, Janice Blais.

Blais, now 52, said in an interview two weeks later that she had always enjoyed walking for exercise and dancing for fun, but by late last year found she couldn’t move without limping. “I read an article in People magazine about how they do this in India,” she said. Not eager to go to India, Blais researched the procedure and found out that it was being done at South County Hospital.

Blais is the secretary to the chief of pediatrics at Hasbro Children’s Hospital, which is part of Rhode Island Hospital. She was surprised, but undeterred, by the fact that her own employer, the state’s major academic medical center, wasn’t offering the procedure.

She met with Marchand at South County. He told her all about the operation, and suggested she go home and think about it. Instead, she insisted on booking surgery right then.

Two weeks after the surgery, in mid-March, Blais reported for her first follow-up visit with Marchand. He put her x-rays up on the light box, and said, “You’re good.”

“I feel great,” Blais said. “I can’t believe it. I have no pain.” Blais was still using a walker but expected to dispense with it soon. Marchand said she could practice driving on quiet roads, once in a while.

“I’m going to have my life back,” Blais said. “I’m going to be up to speed by summer.”

“Just go slow!” Marchand urged.

Interviewed just over a week ago, three and a half months after surgery, Blais was even more delighted. “I am fabulous!” she said. “I am back to me — the me I was. I have no pain. I wear high heels. … I now spring out of my chair in the office.”

Blais said that when she went for her one-month follow-up appointment with Marchand, she left her cane at home. She promised to go right home afterward to get it, but instead she went shopping. She went dancing on May 1. In mid-May she went for her first long walk — and covered two miles. Now, she walks two or three miles a day.

“It’s amazing,” Blais said. “The surgery’s amazing.”

EVEN AS patients exult, the debate continues among doctors. Dr. Scott Rubinstein, a Chicago orthopedist who favors hip resurfacing for appropriate patients, says many are discouraged from it by surgeons who don’t do the procedure.

“If someone’s interested in getting this done, they need to be evaluated by someone who does them,” Rubinstein said. “It’s certainly not appropriate for everyone. You need to look at this as one way to have your hip done. Like any surgery, there’s no right answer for everyone.”

In looking at the evidence, it may come down to a question of whether one sees the glass as half-empty or half-full. Rubinstein, like Marchand, finds the 10 years of data from Europe convincing. “I don’t think it’s going to be any worse than the other stuff. I personally think it’s going to be better,” he says. “It’s one of these time-will-tell kind of things.”

But another orthopedist who does not do hip resurfacing, Dr. Kimberly Templeton, of the University of Kansas Medical Center, makes a very similar comment: “It’s one of those procedures where the jury is still out.”

Templeton says that working in the tight ball-and-socket joint of the hip can be hazardous, with a risk of damaging a blood vessel supplying the femoral head. In total hip replacement, that doesn’t matter because the femoral head is cut off. But it’s preserved in hip surfacing. “If the vessels are damaged, then some of the bone would die off, and the implant would come loose,” she says. “If you’re going to have it done, have it done by someone who has done a lot of these. Understand the risks and complications.”

Aaron, the Brown professor, is especially concerned about the metal ions that the cobalt chrome implant is known to release into the body. “That’s very worrisome. In animals these have been carcinogenic,” he says. “We’ve not seen cancers in humans.”

Aaron said he really hopes that the hip-surfacing procedure proves to be successful, but he wants more long-term evidence. “You have to decide when you want to jump on the band wagon,” he says.

Dr. John A. Froehlich, of University Orthopedics, who specializes in sports medicine and reconstructive surgery and practices at Rhode Island Hospital, also says he’s not ready for that bandwagon.

But he points out that patients are not facing a simple choice between old-fashioned total hip replacement and brand-new hip resurfacing. The traditional hip replacement technology has also been advancing, with procedures that preserve more bone, more durable materials, and smaller incisions.

He’s pleased with the results he’s getting with the latest versions of hip replacement. “I think I can give people a more predictable result the way I’m doing it,” Froehlich said.

With people now living into their 80s, and getting sore hips in their 50s, anyone who gets hip surgery is going to have to have it redone, perhaps multiple times, Froehlich adds. “No matter what they’re made of, they will loosen and wear. That is something that is not recognized by the public,” he says.

“There is no panacea.”

ffreyer@projo.com