Interviewed by Vicky Marlow October 1, 2008

1.) Hi Dr. Ball, can you please first start out by telling us how you got started with Hip Resurfacing and give us a little background on your experience as a surgeon. Where did you train for hip resurfacing? Who trained you? Did you continue your training after starting resurfacing?
I trained with Dr. Amstutz and Dr. Schmalzried in Los Angeles for one year with a specific focus on hip resurfacing. During that time, I scrubbed on about 250+ resurfacing cases. Since returning to San Diego where I practice now, I have done about 100 resurfacing cases.

Photo: Dr. Ball

2.) Do you do the neck capsule preservation technique in your surgeries?
The majority of the hip capsule is preserved during the surgery. Additionally, the synovial lining on the femoral neck is preserved.

3.) Which approach do you prefer to use anteriolateral or posterior?
I prefer the posterior approach.

4.) What is your opinion on the Direct Anterior approach for hip resurfacing, not the antero-lateral approach where the incision is on the side but the Direct Anterior approach?
This may prove to be a viable approach for those surgeons who have mastered it for total hips (like Dr. Joel Matta). However, it is still somewhat investigational for resurfacing, and I don’t think that it will ever be shown to be superior to the posterior approach. Furthermore, there are some technical considerations with this approach, particularly for the bigger, stiffer patients (who happen to be the most common resurfacing candidates). Resurfacing itself has enough specific technical considerations (implant positioning, cement technique, etc.) so why add yet another set of technical issues?

5.) How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
It is a gradual process, starting within about a month and maturing for the ensuing 6 months.

6.) Barring any complications, how many days in the hospital will a patient normally stay?
Usually 2 to 3 days.

7.) What is your typical recovery time after resurfacing, what is your typical rehab protocol? 90 degree restriction? Walker” Crutches Cane? amount of time? Blood thinners? TED stockings? Ice? PT
Recovery is gradual and somewhat variable from patient to patient. Most patients are pretty comfortable getting around without assistive devices (crutches or cane) within 2 to 3 weeks. I encourage patients to use an exercise bike right away as a ‘motion machine’ pedaling with the non-operative leg and letting the operative leg go along for the ride. My patients typically get home physical therapy (where the therapist comes to the house) for a few weeks. However, frequently patients progress faster than the home based therapist can push them. About half of my patients will continue with outpatient therapy for longer than a month. I use blood thinners; typically injectable (Lovenox), and TED stockings for 2 weeks after discharge from the hospital.

8.) How long before a typical patient is allowed to drive a car, return to work?
Return to driving depends on the hip; right leg operates the pedals so return to driving is usually around 4 to 5 weeks for the right. For the left hip, I advise patients not to drive until they are off the pain meds (otherwise they may end up like Brittany Spears or Heather Locklear). Usually patients can drive within a couple weeks after left hip surgery.

Return to work depends on the job. I let patients tell me when they want to go back. I have had patients go back within one week (desk job with lots of independence to make their schedule) and have had patients out for 2 months for construction type work.

9.) What is the recommended time you tell your patients before they can start to run again/do impact sports? Are there any sports you don’t want your patients to participate in after surgery? Out of the patients you have resurfaced what are some of the sports they have returned to?
Patients can resume low impact sports (biking, swimming, walking, golf, etc.) as soon as they are comfortable. For high impact sports (jogging, tennis, basketball, etc.), I recommend waiting 6 months since this is the window when femoral neck fractures most commonly occur. This is an evolving area in resurfacing and I suspect this time frame may shorten in the future. However, I would rather not have my patients be the people experimenting with post-op activity limits. There are enough patients out there that want to push it and will define the safety limits for all of us.

10.) What is your take on cementless (femoral) devices for resurfacing?
This may be a viable option but will probably never be shown to be superior. The cemented devices are doing so well, it will be hard to ever statistically prove this as an improvement.

11.) Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
Case by case basis but clearly the younger patients have the most to gain and the older patients (particularly with osteoporosis) have the least to gain and the most to lose (increased risk of femoral neck fracture). Total hips have already been proven very durable and effective in older patients.

12.) What type of anesthesia do you use general or epidural or ?
Usually a combination of general plus regional anesthetic nerve block or epidural plus multi-modal pain management post-operatively.

13.) Are there any cases that you will not take in particular, AVN, dysplasia, small cysts. Maybe touch on some of the very difficult cases you have been able to resurface.
Severe, sub-total head involvement AVN and significant dysplasia are not good indications for resurfacing. I have done resurfacing with fairly large femoral head cysts. The key is to have enough strong, healthy bone to support the reconstruction.

14.) Do you do bilateral surgeries same day, if not how far apart do you recommend?
I do about 8 to 10 bilateral hip resurfacing surgeries per year. I typically recommend doing it staged (at least one month apart), but in young, healthy patients, the risk of simultaneous bilateral surgery is sufficiently low.
 
15.) What device do you prefer to use for hip resurfacing?
I am currently using 2 different devices; the Wright Medical Conserve Plus, and the Birmingham (BHR) by Smith and Nephew. Clinical results with each have been equally successful in my hands.

16.) If you can’t perform a hip resurfacing – what THR device do you prefer and why?
I use the DePuy total hip – Pinnacle Acetabular cup and Corail Femoral Stem.

17.) What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?
Varies by the surgeon. If the surgeon is a high volume hip surgeon doing 200+ total hips per year, that surgeon’s learning curve will probably be short – maybe 20 or so cases. For other surgeons that don’t do much hip surgery to begin with, the learning curve could be in excess of 100 procedures.