1.) Hi Dr. Stuart Gordon, 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?

After graduating from Jefferson Medical College (1981), I accepted an orthopaedic surgical residency at Columbia-Presbyterian New York Hospital. At Columbia, I had the good fortune to have two mentors who are legendary teachers in the field of joint replacement surgery, Frank Stintchfield and Nas Eftekhar. In 1987, I was awarded a fellowship in Adult Reconstructive Surgery of the Hip and Knee with Drs. Robert Booth and Richard Rothman at the Rothman Institute at Pennsylvania Hospital and Thomas Jefferson University Hospital in Philadelphia. Pennsylvania Hospital is the oldest hospital in the USA, founded by Benjamin Franklin before the Revolutionary War. I have performed over 3500 hip replacements in my private practice located just 15 minutes from center city Philadelphia. In 2006, I started my involvement with hip resurfacing and attended several national and international meetings on this innovative technology. After workshops with Dr. Bob Bourne in London, Ontario and Dr. Ronan Treacy (from Birmingham, England),I started performing Birmingham hip resurfacings. Last year I attended the Advanced Topics course in Hip Resurfacing with Dr. Edwin Su at The Hospital for Special Surgery. At this meeting, I had an opportunity to meet the inventor of the BHR prosthesis, Dr. Derek McMinn, and learned much from our discussion. This year I will be having a BHR procedure for my arthritic hip! After rehab, I fully intend to continue participating in ice hockey, rowing, and alpine skiing.


2.)   Do you do the neck capsule preservation technique in your surgeries?

Absolutely. In order to preserve vascular ingrowth to the femoral head, I take special precautions to preserve the posterior capsular tissue. I invented a tissue and bone retractor (Innomed Company) that specifically assists the surgeon to retract and lift the femoral neck without harming the posterior /superior neck region.
 

3.)  Do you re-attach the gluteus tendon?

For those patients with supple muscle/capsular tissues, the gluteus max tendon insertion may not need cutting. If I incise the tendon, I repair the attachment with heavy suture.


4.)  Which approach do you prefer to use anterolateral or posterior?

I prefer the posterior approach as taught by Dr. McMinn. I have experience with both surgical approaches.


5.)  What size do your incisions normally range in inches?

4-7 inches dependent on body habitus and muscle bulk. I do not compromise the implant positioning because of concern over the length of the incision.The posterior incision is cosmetically pleasing and several of my BHR women have told me that they have no trepidation over wearing a bikini.

6.)  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?

I have no experience in the direct anterior approach for joint replacement. I have performed this approach for pediatric cases.

 
7.)   How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?

6-8 weeks. The Smith and Nephew BHR acetabulum (cup) is coated with a hydroxyapatite layer which enhances bony ingrowth (bone welds) into the implant.


8.)   Barring any complications, how many days in the hospital will a patient normally stay?

Most patients can be safely discharged in two or three days to a home care program. Out of towners will go to the Philadelphia Airport Marriott after discharge. This hotel is 7 minutes from my office.
 

9.)   What is your typical rehab protocol?  90 degree restriction? Walker” Crutches Cane? amount of time?  Blood thinners?  TED stockings?  Ice?  PT

Most patients leave the hospital on two crutches weight bearing as tolerated. I ask patients to avoid adduction (crossing their legs) for 6 weeks. I do want my patients to be active in working on range of motion early on, but do ask them to avoid more than 120 degrees of flexion the first 6 weeks. Driving at 3-4 weeks is reasonable as long as they have good balance and motor strength. Using a cane at 4 weeks is fine and if they have excellent balance, no cane is needed. I use a blood thinner for 6 weeks, usually Lovenox (ten days) followed by Aspirin (325mg twice daily). I will use TED stockings for those patients with leg swelling or venous insufficiency. I strongly encourage my patients to use good common sense: elevate their legs if they have any swelling. Do not sit watching TV for hours…….sit, stand, walk, stretch, and elevate several times a day. I work closely with a committed Home Care team of therapists and nurses to whom I am always accessible. 
 

10.)   How long before a typical patient is allowed to drive a car, return to work?

Most patients can drive at 3-4 weeks depending on their balance and muscle control. If they are still taking narcotics, their ability to drive may also be questioned. For an office position, 3-4 weeks is a reasonable time period for convalescence. For physical work, 2-3 month is more reasonable.

 
11.)   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?

Each patient must be individually evaluated for return back to sports. Jogging /running is appropriate at 3- 4 months. Contact sports may be allowed at 6 months. Each patient should have an evaluation with a physical therapist to determine strength, balance, propioception, endurance, and motor skill tests, in order to make a reasoned decision. I have sprinters, ice hockey players, soccer athletes, martial arts athletes, plumbers, carpenters, construction workers, fitness enthusiasts in my resurfacing practice. After all, these are the type of patients who want a high –demand joint replacement.


12.)  What is your take on cementless (femoral) devices for resurfacing?

My opinion is that presently we do not have sufficient data to use a cementless technique for the femoral implant. Based on the McMinn/Treacy experience and Australian Registry series, except for investigational purposes, we should employ well-tested and proven cemented femoral implants.
 

13.)  Do you have a cut off age for resurfacing patients or do you go on a case by case basis?

Physiological age and bone density/geometric parameters are of great importance in selecting appropriate candidates for hip resurfacing. The most difficult cases are for women who have smaller femoral heads.


14.)  What type of anesthesia do you use general or epidural or spinal?

All patients undergo a regional block, spinal anesthesia with IV sedation. This makes for a safe and quite comfortable surgical experience. I use a portable cell saver blood retrieval system which minimizes the need for using Red Cross blood post operatively. Haemonetics  makes the blood management device called  the “OrthoPat” system.


15.)     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.

Patients with secondary arthritis (from childhood hip disease) are the most challenging. Mild hip dysplasia (often found in women with early arthritis) is usually straightforward. AVN cases are particularly challenging and for this reason, I inform my AVN patients that hip resurfacing may not always be appropriate or technically feasible if large cysts are discovered at time of surgery.

16.)  Do you do bilateral surgeries same day, if not how far apart do you recommend?

I will do bilateral replacement at one sitting; however these patients must have a cardiology work up prior to surgery.
 

17.)  What device do you prefer to use for hip resurfacing and why?

After a careful analysis of the available hip resurfacing systems, I strongly support the Smith and Nephew Birmingham Hip Resurfacing inplant devised by Derek McMinn. The Conserve Plus hip is also a good alternative. These two systems are the “best in class” for design and metallurgy. Once in the surgeon’s hands, the short and long term success of the operation largely depends on the consistent ability of the surgeon to place the components in the correct position.


18.)  If you can’t perform a hip resurfacing – what THR device do you prefer and why?

BHR cup with Smith and Nephew non-cemented Synergy stem and large metal head.  If any metal allergy is present, I would use a Smith and Nephew R3 cup and large oxinium head with Synergy non-cemented stem. Oxinium is an oxidized zirconium head and has excellent wear and fatigue mechanical properties.

19.)What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?

If a surgeon has had an extensive traditional hip replacement experience and is fellowship trained in hip surgery, then the learning curve is accelerated. I felt comfortable at 20 surgeries. However, the hip surgeon must never be cavalier in approaching this procedure even he has performed 100 resurfacings. 100% commitment and preparation are the key elements to helping each patient achieve an excellent result. We always learn from experience: it is the wisest teacher. Excellent results are a product of the  consistent execution of the technique.