October, 2007

Hi Vicky,
It was great to finally meet you also. I was impressed with your knowledge base and interest level. Good to hear from you and it was a lot of fun getting to know you at the Miami conference. Your synopsis was right on and the pictures were great. As far as the questions go:

1.) Why do you choose to use the posterior approach over other approaches?
The most important reason I use the posterior approach is to spare the gluteus medius and avoid an abductor lurch after surgery which is fairly common with a lateral, antero-lateral and to a lesser extent anterior approach. Patients who desire to get active again are very dissatisfied if they have abductor weakness; if you detach a portion of the gluteus medius then you really have to protect its repair for 6 or so weeks after the surgery as Paul Beaule does. Another reason I like the posterior approach is the exposure one can attain for the femoral head and the ability to effectively use the stylus to get the guidewire in exactly the right position.

Photo: Dr. Rogerson

2.) How long do you feel it takes for the bone to be fully healed, grow into the prosthesis? What is the recommended time you tell your patients before they can start to run again/do impact sports?
I think it takes 6-8 weeks for the bone to effectively grow into the acetabular component but I restrict high impact activities longer than that to avoid stress fracture in the femoral neck in patients that have not been able to be active for some time. if the patient has forced themselves to be impacting right up to the time of surgery like Gary then I would let them get back sooner. In general, I hold off the patient from high impact heel strike for 4-6 months post-op. They can run in a pool and jump rope sooner. Each case is individualised based on the patient's bone quality at the time of surgery.

3.) What is your take on cementless devices.
I think the presentation and the xrays shown by Dr. Papavasileou were very telling. Many of the xrays showed significant neck narrowing not seen on the cemented BHR xrays. I think this is because the ingrowth on the cementless heads is "spotty" and leads to variable stress shielding of the distal inferior neck and calcar bone. Some of the xrays were very ominous appearing and will likely result in delayed neck fracture. Therefore, I will stay with the thin cement mantle produced by the BHR technique to spread out the forces coming down the femoral neck and avoid the stress shielding.

4.) Which resurfacing device do you prefer to use?
I definitely prefer the Birmingham prosthesis compared to the others on the market. This relates to the metallurgy with the as cast large block carbides and better wear than the heat treated metals, the precise instrurnentation and the line to line fit of the femoral component, and the truly impressive results at 10 year follow-up.

Hope this covers the issues. Again, great to see you finally at the meeting.

Your friend, John Rogerson

Updated additonal questions July 6, 2009

1.)  When and where did you train? 
I trained with Dr. McMinn and Dr. Treacy in England, and also visited and scrubbed in with Dr. DeSmet in Beligum in 2005.  Prior to going to Europe for my training, I visited Dr. Schmalzried, Dr. Mont, and Dr. Stachnew, and scrubbed in for surgery with those physicians in 2003 and 2004  I also performed metal-on-metal big femoral head arthroplasty for approximately four years prior to starting to pursue metal-on-metal resurfacing arthroplasty.  I have continued to attend multiple meetings and recently traveled to Belgium to attend Dr. DeSmet’s 2009 hip resurfacing meeting.

2.)  How many times during surgery have you had to change to a THR instead of a resurfacing and why was the change made?  Zero. 
I do get preoperative CT scans if I have a question as to whether resurfacing will be possible, and to date we have not had to change the proposed operation during the case.

3.)  For what reasons would you switch from resurfacing to a THR after starting the surgery?  If you switch, what device would you be using for a THR? 
I would switch to a metal on metal big femoral head total hip replacement during surgery if the bone quality was inadequate to support the femoral component or if a significant notching of the femoral neck had occurred during the reaming process.  To date we have not had to do this.

4.)  What hip resurfacing device (prosthesis) do you use, how long have you been using it and why do you prefer it?  Do you have any financial stake in that device company? 
The Smith & Nephew Birmingham resurfacing component.  I prefer it for the fact that the metal has been in use in Europe for an extensive period of time, and there is 11 plus years of good data by Dr. McMinn indicating a very high success rate with the Birmingham prosthesis. 

I also feel it has the most precise guide system in terms of its implantation, and I like the line-to-line fit of the femoral component with the femoral head, which I feel gives more stability to the femoral fixation.  I also like the metallurgy of the “as-cast” porous coating of the acetabular component which allows the cobalt-chrome-molybdenum alloy to maintain very large block carbides which are more resistant to wear.

  I do not have any financial stake in the device company.

5.)  Do you use cemented or uncemented? Why? 
I use an uncemented acetabular component and a cemented femoral component, as per Dr. McMinn.  When performing resurfacing, many of the heads are deformed and sclerotic and do not have good cancellous bone on the superior flattened portion that would do well with a non-cemented component. 

6.)  Do you cement the stem? 
I do not cement the stem.

7.)  Will you be preserving the neck capsule? 
I do preserve the neck capsule and I do a modified posterior capsulotomy much like Dr. DeSmet.

8.)  Do you re-attach the gluteus maximus tendon? 
I do re-attach the gluteus maximus tendon very conscientiously with an arthroscopic anchor and two non-absorbable sutures, as well as two absorbable sutures.

9.)  What type of anesthesia do you use? 
I use a general anesthesia with complete muscle relaxation.

10.)  How long does the surgery normally take? 
The surgery usually takes an hour and 45 minutes.  I do not try to break speed records, and I am very meticulous in the instrumentation so as not to notch the femoral neck.  This may be one reason we have had no femoral neck fractures.

11.)  What surgical approach do you use?  Anterolateral, Direct Anterior or Posterior? 
I use a posterior approach as per Dr. McMinn and use a modified posterior capsulotomy as per Dr. DeSmet.

12.)  What is the incision length? 
Incision length is usually about 8 inches, but I make the incision long enough so that the acetabular component orientation is correct, with the use of a straight impactor.

13.)  What is your post-op pain control plan? 
Postoperative pain control plan is PCA the night after surgery, then oral analgesics starting the next morning.  People are usually starting to get off narcotic oral meds at day three or four and switching to extra-strength Tylenol.

14.)  What hospital do you use? 
I use Meriter Hospital in Madison, Wisconsin.

15.)  What is their infection rate? 
We use laminar airflow rooms and hood system, and the infection rate is extremely low.

16.)  What drugs/methods do you use for anti-coagulation after surgery?
  I use enoxaparin postoperatively for 14 days, followed by aspirin for 6 weeks.  We also use sterile sequential stockings during the surgical procedure and postoperatively for day one and two.

17.)  How long will I be in hospital? 
patients will be in the hospital for two days postoperatively and then transfer to a rehab facility for twice a day physical therapy, one on land and one in the water, with Dermabond on the incision and an occlusive dressing.  The total stay in Madison will be for one week, at which point patients will be on one or two forearm crutches and usually starting to bear weight fully after one week.  By two to three weeks most patients are off crutches, bicycling, and using an elliptical trainer.

18.)  How successful have you been obtaining insurance approvals for resurfacing? 
Generally, very successful in obtaining approvals for resurfacing.

19.)  What is the rehab protocol? 
We utilize the HipHab rehab protocol as described on my website at www.orthorogerson.com.

20.)  When will I be 100% weight bearing? 
Many patients are full weight bearing within the first week, but on average it takes patients two to three weeks to fully get off the assistive forearm crutches and walk without a limp.

21.)  What assistive devices will I use for walking after surgery? 
Will you provide them or do I need to purchase my own?  Forearm crutches, which we will provide and are paid for through your insurance company.

22.)  How long on 2 crutches, 1 crutch, cane? 
Two crutches usually a week, one crutch for one to two weeks, generally no cane.

23.)  What if any restrictions do you place on your patients after surgery and how long do they last? 
We don’t let patients flex the hip up past 90 degrees for the first 3-4 weeks.  They may then flex past 90 degrees as long as their knee is rolled out for another 7-8 weeks.  By three months there are no significant restrictions on range of motion, except in females who are hyperlax.  In these individuals we do not have them bring their knee up to their chest and internally rotate for six months, and even at that point don’t encourage that particular maneuver.  We do avoid high-impact activities such as running and jogging until five to six months post-op.

24.)  Will I be given any at home nurse or PT care? 
Decisions as to whether or not home physical therapy will be needed after the HipHab program are individualized and based on how each patient is doing.  In general, most patients don’t need continued home physical therapy.

25.)  If both hips are bad, how do you handle bilateral resurfacing? 
I do not tend to do bilateral resurfacing in one setting.  There has been a reported femoral neck fracture that occurred when a patient was rolled over for the second resurfacing, while the acetabular component was being impacted.  In general, I tend to do one hip, and when the patient has recovered after 8-12 weeks, we would then pursue the second hip.

26.)  Do you have other hip resurfacing patients that I could talk to about their experience? 
We have multiple hip resurfacing patients that are enthused to discuss their resurfacing experience with prospective patients.  Contact Cathy in my office at 608 231 3410

27.)  What is your opinion of my returning to whatever work or activities I have done in the past? 
Most patients return to all activities without restrictions by six months.

28.)  Have you done resurfacing for anyone who has returned to these activities? 
We have had patients return to Ironman and marathon running, biking across South America from 0-16,000  feet elevation, barefoot skiing, tennis, racquetball, handball, and essentially every other sport.