Answers: 1. What type of resurfacing device are you using?
BHR (Birmingham Hip Resurfacing), which has a metal-on-metal bearing, manufactured by Smith & Nephew Company (MMT Company has been sold in March 2004 to the Smith & Nephew Company www.smith-nephew.com) and CONSERVE PLUS (C+), manufactured by Wright Medical Company ( www.wmt.com ).
 2. In what sense does these devices differ from the Wagner Resurfacing procedure?
The poor results of Wagner resurfacing are mainly caused by poor performing bearing couples (metal-on-poly, or ceramic-on-poly). Not by the resurfacing procedure itself. The main problem with young and/or active patients was the wear of polyethylene. Especially in the case of the Wagner prosthesis with a big metal head on a thin polyethylene socket, the wear is increased by a factor 4 to 10.
3. How many resurfacing surgeries have you performed?
See frontpage.
4. Do you also do hemi-resurfacing?
I am doing only total resurfacings. Hemi’s (hemiarthroplasty) are not performed in Europe. They are not done because they are not performing as well as full resurfacings. In the USA they are done because the total resurfacing is not yet FDA approved! In young people cartilage will wear out and osteoarthritis symptons will occur.
5. How long have you been performing resurfacings?
We started in September 1998 with the BHR procedure. In May 2004 the new Conserve Plus design (Thin Shell) was introduced in my practice.
6. How long have you performed THR’s also?
I have performed a few thousands of THA (see frontpage). I am still doing everything in THR, you have to choose the best prosthesis for every patient. For a patient older than 75 this will be a cemented stem with a
metal-on-poly cup! Economically and scientifically the best. For other patients it can be uncemented ceramic-on-ceramic, or metal-on-metal. Until the age of 75 I use ceramic-on-ceramic with the largest possible head diameter (28-32-36 mm) (www.stryker.com).
7. How old is the BHR / Conserve Plus (C+) procedure?
BHR procedure is developed in 1996/97. The first metal-on-metal resurfacing is from Feb. 1991. The resurfacing is already 40 years old, metal-on-metal is 40 years old (the oldest dates from 1938!). Both ideas were put together by Mr. McMinn in 1989.
The Conserve Plus design was introduced by Dr. Amstutz in 1995.
8. How old is the oldest BHR / C+ hip?
Oldest BHR is from 1997. My oldest patient is around 75 (Male patients with a young wife – very active older male patients still can be suitable for BHR).
Oldest C+ hip dates from the year 1996. As long the bonequality is good, resurfacing can be performed.
9. What is the expected life for the resurfacing hip as compared to THR?
I DON’T KNOW! It is only one of the possibilities to do longer than 10 years in young and active people! If you
don’t get osteolysis (bone that is going away) or no measurable wear of the friction couple, metal-on-metal resurfacing can last very long. Just give me a crystal bal. There are large metal-on-metal articulations that stayed for more then 30 years. If activity will play a big part in the wear of the prosthesis, is today also questionable.
10. What is the worst complication that you are aware of with resurfacing?
Fracture of the neck of femur. When it occurs, you get a stem with a big modular head. I have only one patient with this, but afterwards he is now, one of my happiest patients. See also COMPLICATIONS. In most of the
series, all over the world, fractured neck of femur has an incidence of 1%.
11. What other complications might I be at risk for?
None more then with any other procedure: infection, nerve lesion, thrombosis, …, death?
The chance of unequal leg length or dislocation is much lower then in THA. See also COMPLICATIONS.
12. What is your greatest success story with BHR?
Marathon runner, national champion tennis player, heavy sea wind surfer, Mont Blanc and Kilimanjaro climber, Triathlon runner, competition Paraglider. Every day people are amazing me. But the greatest success stories are just the happiest people, whatever they do!
13. What will be done when a resurfacing fails?
A normal primary THR can be done. In rare cases a revision to another resurfacing is still possible. The
procedure needed depends on the reason for revision. If the femural head requires a revision, due to wear, a large diameter modulair head on stem could be placed, with a perfect fitting into the existing cup. Even the cup can be revised with a new resurfacing cup with a one size larger diameter. We have done extensive research on this topic together with the manufacturers of the device. See table Posterior Revisions.
14. What might I expect as far as surgery and complications in case of revision surgery?
Every next operation of course can lead to a lesser activity or function level. The most severe problem is
infection, but even then there still can be found solutions for this. Revision always has to be seen as a major and difficult procedure.
15. What is the cost of the surgery?
Cost of surgery depends on the individual social security system, country of the patient and type of surgery (cost of implant, length of stay). One can always send a personal request by email to receive a personal cost analysis. Please forward your request to helpdesk@hip-clinic.com.
16. What kind of follow up will be required?
Practically none, 1 x-ray after 1 year, and an x-ray every 2 years for abroad patients.
17. Should I have a local surgeon here to follow up my recovery?
This is not necessary but always can be beneficial.
18. If I decided to have the surgery, when might I be able to schedule it?
We have a waiting list of about 10 to 16 weeks.
19. What is the normal recovery time? Time on crutches? Time with a cane? Time before I can begin most normal exercise?
1 to 2 weeks 2 crutches, 1 to 2 weeks 1 crutch. No cane. What is normal exercise? Actual daily living means 4 to 5 weeks. More strenuous activities can begin from then one, like patient feels for himself. Patient has to be his own barometer.
20. I can try to obtain digital copies of my X-rays, but if they are not available, where can I FEDEX, or mail my originals?
You can email or sent them to the office of the clinic, see Contacts for address information. (FEDEX works well).
21. How long after the procedure crutches have to be used?
The common rule is:
Two crutches have to be used as long as it is needed and felt by the patient himself. The physiotherapist also can decide to discontinue the need of two crutches. In normal circumstances this means:
- 4 to 6 weeks for a classical total hip prosthesis or revision.
- 1 to 3 weeks for a resurfacing procedure.
Everything depends on the patient himself, is different from surgery to surgery. In a young patient with a resurfacing, two crutches can be left at 1 or 2 weeks. In an older patient (>75) with classic THA this becomes 4 to 6 weeks.
The use of one crutch starts as indicated above. The change from 2 crutches to 1 crutch depends normally on the possibility of weight bearing on the operated limb, the confidence of putting weight on the limb, and the
disappearance of pain with weight bearing.
Walking without crutches starts when the disturbed gait disappears, and full weight bearing on the operated limb is no problem anymore.
22. What is the weight-bearing program after a total hip prosthesis?
Almost full weight bearing is allowed after every total hip prosthesis. (1 or 2 days postoperative)
Normally this makes no difference if a primary “cemented”, “uncemented” prosthesis, or a revision procedure has been done.
MY RULE IS:
- Or a prosthesis is immediately stable and full weight bearing is allowed
- Or the prosthesis is NOT initially stable and full weight bearing will NEVER be allowed.
This means that it is rare (some revision cases) that only partially or non-weight bearing will be prescribed (to protect bonegrafts).
23. When can I get out of bed after surgery?
One day after a resurfacing you can get out of bed and start walking.
In a classical total hip prosthesis this is also 1 day.
In a severe revision case this can mean 2-5 days.
24. When can full weight bearing start?
The day after surgery walking is encouraged in a resurfacing.
With a classical THA this is also 1 day, starting to walk with two crutches or a frame.
Even with a normal revision case FWB is allowed when people start walking.
25. Should I bring my own crutches to the hospital?
It is advisable to bring your own crutches to the hospital. For overseas patients it is better to buy the elbow crutches at the hospital (app. 25 EUR).
26. Are physiotherapeutic exercises necessary before the operation?
It is not necessary, but when available they exist of muscle strengthening exercises, gaining mobility of the hip joint (can be painful!) and learning to walk with crutches. This can fasten up the postoperative revalidation.
27. How big is the incision of the operation?
In a classic total hip replacement the length of incision is between 8 – 15 cm (3-6 inch), depending on the difficulty of the operation (e.g. revision surgery and obesity of the patient). In the resurfacing procedure the incision is longer (15 – 30 cm/6-12 inch) because of technical-anatomical reasons (saving the femoral head).
The length of incision has no influence in the postoperative rehabilitation.
Minimal invasive surgery is not applicable to resurfacing today. Minimal invasive surgery in total hip corresponds with a lot of early complications (17%). The prosthesis placement is often “blind”. A reduction of the incision to “minimal incision” is done by everybody. The 2-incision minimal invasive technique is disregarded by most of the surgeons.
28. Does the length of incision influence the rehabilitation?
No! A bigger incision does not mean that there will be more damage to the muscular structures. On the contrary, if you need a bigger incision to get better exposure, the placement of the implant can be done more precisely.
Even with an incision of 30 cm you are able to walk well after 24 hours.
29. Which approach do you use?
For the resurfacing procedure I always use the posterolateral approach for technical reasons. For a classic total
hip replacement I changed after having performed 1800 procedures from lateral to posterolateral approach as well. The posterolateral approach does have many advantages: the abductors (gluteus medius muscle) responsible for normal gait remains intact, so less patients suffer from permanent abnormal gait after hip prosthesis. There is a much better view to place the components in a more correctly way (very important for
revision surgery). There will be less repetitive muscle damage in revision surgery; there are fewer patients with complaints of trochanteritis (irritation of the bursa) compared to the lateral approach. The only disadvantage of the posterolateral approach is the larger incidence of dislocations in inexperienced hands / learning curve.
30. Where do I have to pay attention after a total hip replacement?
The most important is that you give opportunity to the soft tissues to heal, so to avoid dislocations. The most critical period is during the first 6 weeks.
31. How long do I have to stay in the hospital?
Everything depends on type of surgery, age and condition of patient.
Young patients, resurfacing procedure: 2 – 5 days
Classic total hip prosthesis, active patient: about 5-7 days
Classic total hip prosthesis, older patient: 7 – 14 days
Revision surgery: 7 – 21 days depending on:
- Type of surgery: replacement of 1 or all components
- Age of patient
Situation at home is also very important! Think about daily meals, dressing assistance …
32. How is the wound getting closed?
Normally staples are closing the wound. In young patients (ladies!) and on request the wound is getting closed intracutaneously.
33. When do the stitches or staples have to be removed?
Half of the stitches or staples are normally removed after 14 days. The remaining half is removed after 16 days. Depending on the individual patient, one can decide to remove the staples later on. Staples are removed with a special device.
In case of an intracutaneous suture, one only has to cut off one end of the suture. It is not the purpose to remove the complete suture because it is resorbable.
34. When do I need a total hip replacement?
Pain is the most important indicator! The surgeon should not operate based on an x-ray only. The clinical consequences of the osteoarthritis of the hip are decisive for operation.
35. When do you use a prosthesis with ceramic-on-ceramic or metal-on-metal?
See also total hip replacement in the young patient.
Below the age of 75, one can decide to use either ceramic-on-ceramic or metal-on metal to reduce wear and
lengthen the survival ship of the prosthesis. It also depends on the degree of physical activity of the patient.
36. What is the importance of injections with Hyaluronic acid in the treatment of osteoarthritis of the hip?
In consequence of the favourable results concerning the injection of hyaloronic acid into the knee, this type of treatment is also applied when a premature cartilidge degeneration of the hip is diagnosed. As apposed to the administering of such an injection into the knee, which can safely been done during a consultation at the practice, that of the hip has to be done in the operating room at the hospital under sterile conditions with the
guidance of X-Ray technology. The use of a local anaesthetic is preferred. A stay of one day in hospital is required. The treatment of consists of three infiltrations/injections with an interval of one week. At present the primary indications are favourable.
37. Where is the pain localised when I suffer form hip osteoarthritis?
Pain is mostly localised in the groin, buttock region, but can also refer to the whole thigh, lumbar spine and even the knee (sometimes even below the knee).
38. What treatment is possible before a total hip replacement?
Symptomatic treatment exists of classic painkillers (e.g. paracetamol), NSAID (Non Steroidal Anti-Inflammatory Drugs), or even Glucosamine and Chondroitenesulfates and diminishing physical activities (be aware of diminishing bone quality when used for a long time). Treatment with hyaluronic acid is rarely used at our department.
39. What means the sign of Trendelenburg ?
The sign of Trendelenburg becomes positive when one is suffering from a hip problem. It is characterised by a typical abnormal gait pattern. People are walking like a duck.
40. Can both hips be operated at the same time?
In severe osteoarthritis of both (bilateral) hips a bilateral procedure can be done. Both hips are operated on the
same day. Our experience today has not given more problems when this is performed in healthy people. A continuous epidural catheter and more blood transfusion are needed. Cell saver is used in these conditions. Patient has to be healthy, not obese, and the hip condition itself does not have to be severe.
41. Should I use a heating pad or ice packs?
We prefer ice packs, although both are effective to relieve pain. Both can be harmful in direct contact with the skin. It can damage the skin and even cause a severe burn. Never sleep with a heating pad on your hip. Ice can be used several times a day. Twenty minutes on, 20 minutes off, is the usual regime. In the first postoperative weeks heat is not recommended.
42. Do I have to take medications after the operation?
Painkillers as long as needed. Injections to prevent thrombosis are given for about 3 to 6 weeks.
If possible (no gastro-intestinal problems) Indomethacine or another anti-inflammatory is given to prevent heterotopic ossification (see also complicaties).
43. How long will my leg continue to swell and hurt?
The pain usually decreases rapidly during the first days, but discomfort can continue for a couple of months. The swelling is due to alterations in fluid return up the limb, and will gradually diminish, but may take a couple of months or longer. Mobilisation, exercise, stockings and elevation helps.
44. What kind of shoes should I wear?
Avoid high heels for a couple of months. There are no other restrictions.
45. When can I go up and down stairs?
You should learn to walk stairs with the physiotherapist at the hospital a few days after the operation on individual basis.
46. When can I drive a car?
This is not advisable during the first 6 weeks in a classical THA. It depends on ability to regain full pain-free control of the leg. With resurfacing driving is sometimes possible after a couple of weeks.
47. How much exercise can I do and when have I done too much?
Avoid over-exercise. Mild and moderate exercises are beneficial. The more active you are, the better, but within limits. Too much exercise will result in swelling and pain of the leg.
48. How long can I wait before surgery?
Time of surgery depends on clinical situation of patient. Patient has to decide whether pain becomes unbearable, or when disability comes too far. Postponement of surgery does not compromise clinical results of total hip replacement afterwards!
In case of resurfacing arthroplasty, we would like to mention that long-term use of anti-inflammatory drugs can compromise bone quality and make resurfacing impossible.
49. How many times can one perform revision surgery?
Number of revisions is unlimited as long as there is enough bone! It is absolutely not true that one can perform only two operations on each side.
50. What do I have to take with me to the hospital?
Elbow crutches (when possible), home medication, comfortable flat shoes, pyjamas, toilet requisites, and towels. Blankets and sheets are provided by the hospital.
51. What are NOT indications for resurfacing?
-OSTEOPOROSIS
-To much head deformity, where the leg length and offset (biomechanics) cannot be restored (see resurfacing CONTRA-INDICATIONS).
52. Is autologous blood transfusion done?
In Belgium blood donation is quite safe because of voluntary, not granted blood donation. In primary surgery normally no blood transfusion is needed. Cell-saver is used whenever necessary (e.g. bilateral procedure).
53. What are squeaking noises?
ALL ABOUT SQUEAKING NOISES. (seeing and hearing...? Click here)
Also called peeping, called by Dr.De Smet the “peepcreep”. The squeaking noises are produced due to a temporary lack of lubrication, a dry running of the metal-on-metal prosthesis. . It sounds as a non-lubricated creaking hinge of a door. The duration of the noise is normally less then 24 hours, and a one-time incidence.
It starts when the patient has an increase or change in activities. Stair climbing always generates or increases
the noise. (Possible provoking activities: mountain climbing, mountain walking, chopping wood,…)
It does not occur any more 2 years after surgery. Two year is the time interval that equals the running in period of a metal-on-metal friction couple. Running in means that the prosthesis is polishing itself. Immediately after surgery, the lubricant (lubrication film) between the 2 components of the prosthesis is blood. This will change
to serum with our own proteins after a while. The percentage of patients where squeaking noises appear is about 1.5%.
It is a benign incident that goes away spontaneously and do not need any panic. (let it know to your surgeon for statistical reasons!).
54. What is clicking, clocking or clunking?
The clunking noises and clicking feeling in the first 6 months after surgery is a temporary decoaptation of both components. This means that the two big metal parts of the prosthesis come apart and come together again. Having a large diameter this gives no wear of the prosthesis and will not destroy anything. Because of
the release of the capsule around the hip to be able to do a resurfacing procedure without sawing the head of, the hip joint is looser at the beginning. This is even more because of the badly trained muscles of the preoperative condition and all the fluid around the newly placed joint.
The clunking is painless and subsides once the capsule and muscles around the hip are fully healed. It occurs in the first 6 months after surgery and disappears progressively.
The incidence can be around 20% of all patients!
This finding should not be confused with local conflict problems with prosthesis or bone because of less ideal inserted implants. These will stay even after 6 months, will not become better, is painful and should be diagnosed by your physician.
55. Do you provide any agreement and insurance for surgery between your clinic and me ?
Every surgeon in Belgium always has an insurance if faults occur. For complications there is nothing that exist in terms of agreements, insurance or guarantee !
56. What is the warranty after the operation ? For example if I have a complication after a month or an infection during the operation or I’ll have continuous pain. What will you do in such cases, what is your responsibility and liability ?
In complications, problems known to happen in hip surgery there is nothing to be called liability. For a patient
the surgeon has always the responsibility to help him as much as he can, this with answering questions, giving advice and if you are at the hospital, or you come back to the hospital give you a treatment. For all complications needing more treatment and including a higher cost, patient has to pay for this.
57. Now, before surgery, I am using a crutch to walk, my leg bends badly. Can it influence the operation somehow ?
Not really. It is just the bonequality that is important, the longer time to surgery, the softer the bone, the higher the risk for fracture and risk that resurfacing is not possible anymore.
58. Will you make anaesthesia analysis before operation ?
Yes, full exams are done : blood results, electro cardiogram and an internal specialist is visiting you.
59. Do you have access to the Internet in the hospital for patients ?
Yes.
60. If the operation is possible, I would like to stay at the hospital as long as it takes for all the
post-operation processes to be completed, and leave the hospital on my crutch and not in a wheel-chair.
You normally leave the hospital with crutches, being able to help yourself as much as possible. Staying long in hospital makes the cost going up a lot !!
61. What happens when the installed hip wears ? What will I have to do ?
You will need another one. To be sure you got a prosthesis that wears the least as possible you need a ceramic on ceramic. But this means NO resurfacing, less possibilities to do everything !! After a resurfacing you still can get a total ceramic on ceramic and with a metal-on-metal (also in resurfacing) the wear is already very low.
62. How many revisions from resurfacing to THR have you performed ? What are the potential complications of such a revision ?
I have done now 21 revisions (only 5 of my patients!!). The complications are not really much bigger then in a
primary. Just dislocationrisk will be possibly as high as in normal revision cases (5 – 10 %)? (link -> revisions)
63. Do people who are excellent skiers return to the level of excellence that they were used to,
and in what time length (from your knowledge and experience with such people) ?
Normally they do. I had one going back after 3 weeks, but I would take 3 months. Skiing with resurfacing, even with a total hip should give no problems.
64. What kind of physical therapy do you recommend for your resurfacing patients and for how
long ?
Everything like they feel. For general rehab you could take 6 weeks, 3 months. If patients want to progress harder they can have longer or more frequent physiotherapy, but this would then be more like fitness training ! Physiotherapy in resurfacing is more guiding the patients then making them to work out exercises too fast and too hard. Passive forced flexion of the hip should not be done. It will often lead to groin pain.
66. Are there any known risk factors for fracture ?
Only severe osteopenic bone is a potential risk for fracture. Other reasons for fractures are technical or avascular necrosis of the femoral head.
67. Are there any known risk factors for avascular necrosis (AVN) after hip resurfacing ?
The approach is still questioned to be a risk factor for AVN. To lower the risk of AVN after hip resurfacing an approach different to the posterior or posterolateral approach is needed. The circumflex vessels should not be
destroyed. Even with the today’s low incidence of AVN after hip resurfacing 3 other approaches can be used. (see approaches LINK)
68. What other approaches (≠ posterolateral) can be used in resurfacing ?
1) Anterior approach (Watson-Jones) (Smith-Peterson)
2) Anterolateral approach
3) Ganz-approach (anterior dislocation, after anterior capsulotomy and greater trochanter osteotomy)
All 3 approaches keep the vascularisation of the femoral head intact (circumflex vessels). The anterolateral approach has the disadvantage of abductor muscle destruction with possible persistent gaitproblems.
The Watson-Jones and Ganzapproach do not have this problem where the big disadvantage in the Ganzapproach is the greater trochanter osteotomy.
1) Possible risk on not healing of the osteotomy (pseudarthrosis)
2) 6 weeks partial weight bearing with 2 crutches are necessary (only 10 kg!)
3) A second procedure for removal of the screws is necessary
69. What insurances have ever paid surgery ?
<not yet published, please contact the helpdesk>
70. Which nationalities had their surgery done at your clinic ? How many patients and from what country ?
See the page on patient demographics.
71. Which X-rays are needed for evaluation ? And how can the X-rays be sent ?
1) plain pelvis standing
2) anteroposterior view of the hip
3) oblique view or lateral view or “false profile” of the hip
X-rays can be send by email to helpdesk@hip-clinic.com (jpeg, jpg-files) not more then 1 MB,
NO DICOM – files (full CD rom is needed).
Full x-rays or copies can be send by normal mail or delivery service e.g. FEDEX
72. Are there any special precautions to be made with respect to dental care for patients with hip implants ?
Please read the information of the AAOS on this subject: click here.
Last updated: 06.05.2006
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