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 Dynamic Chiropractic
– March 12, 2009, Vol. 27, Issue 06
Hip Resurfacing: Not So Good for Women
By Deborah Pate, DC, DACBRWe’re chiropractors, not surgeons, so why do we need to know about hip replacement procedures? Becausewe have patients who have hip replacements and we are treating them for symptoms that may be associatedwith the hip replacement. I’m not going to review how to perform an orthopedic exam, nor am I going toreview how to take films of total hip replacements. This is a brief “heads up” on the problems with a fairlynew surgical treatment for arthritic hips called
hip resurfacing
.In a traditional hip replacement, the head and neck of the femur are removed and replaced with a prosthesis.In a hip resurfacing, most of the head and neck are preserved and an artificial cap is placed over the head of the femur. The idea is to preserve as much of the femur as possible and postpone the need for a total hipreplacement a decade later. The procedure is aimed at middle-age patients who are physically active and areexpected to outlive the normal 15-to-20-year lifespan of a full hip replacement. Sounds very logical, andmany people have benefited from the procedure.However, studies from some countries where resurfacing has been used longer than in the United States,including England, Sweden and Australia, have repeatedly shown a higher failure rate for women whoundergo the procedure than for men. A recent British study released in September 2008 by the RoyalCollege of Surgeons of England found that 3.7 percent of the 2,360 women who underwent resurfacing inEngland had tohave a second operationto repair the same hip within three years.
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That compared with arate of follow-up surgeries of 1.6 percent or less for women who received traditional hip replacements. Themost frequent cause of failure is fracture.The problems with hip resurfacing in some women first emerged in places like Australia, Sweden andEngland that operate databases, known as registries, which regularly track the outcomes of orthopedicprocedures and are publicly available. The United States does not have such a national tracking system. Iknow I am diverging just a little, but it is amazing that the U.S. does not have a joint replacement registry.Registries in other countries benefit everyone involved. The surgeons benefit from receiving more timely
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data that could improve patient outcomes, and the manufacturers benefit by knowing how their implants areperforming. It helps determine which products are poor performers and should be removed from the market.It can also act as a benchmark for determining truth in advertising, as the manufactures who inflate theirresults will become readily apparent.But back to the issue of hip resurfacing – I believe it is very important that we chiropractors know what typeof hip surgery a patient has undergone, particularly if manual manipulation is being considered. A femalepatient with hip joint resurfacing shouldraise a red flag.
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The most common reason for failure of hipresurfacing is fracture. It does not take much force to fracture these resurfaced hips if they are about to fail. Iknow of one patient who simply crossed one leg over the other and the prosthesis failed. Of course, this is just one case and most likely a very rare occurrence, but it got my attention.Because of this experience, I suggest we be very careful with manual manipulation that might affect a hipthat has been resurfaced. My reasoning is that these patients may already be experiencing failure of theprosthesis and it is only a matter of timing as to when the fracture may occur. Special care should be takingto rule out the possibility of fracture. Recent films should be compared to postop films. A bone scan or MRIof the hip should be performed to rule out a stress or occult fracture. Even after ruling out any possibleproblems with the prosthesis, I would recommend avoiding using the hip as a fulcrum.If any of your patients are considering hip resurfacing (particularly female patients), I would make themaware of the potential problems. The head researcher of the English study, Dr. Jan H. van der Meulen, hasgone so far as to suggest, in an article in
TheNew York Times
, that theprocedure should be limited to menunless other factors come into play.
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In the U.S. last year, resurfacing representedonly a small fractionof the 430,000 hip replacements thatoccurred; about 10,000 to 15,000 cases.
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But that number is expected to increase by 40 percent to 50percent. Patients see advertisements or hear from others about advantages of hip resurfacing in youngeradults – all without scientific evidence – and want the procedure. If your patients are in need of a total hip replacement, I suggest you inform them of the potential problemsand encourage them to have a frank discussion with their surgeon about the alternatives available. Also tellpatients to ask about possible conflicts or ties to the manufacturer involving the implants the doctor isrecommending. And as always, tell them that when considering surgery, seek a second opinion.
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