Dr. Brooks, Cleveland, OH
Interviewed by Vicky Marlow January 28, 2010
1.) Hi Dr. Brooks, 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 received training from Mr. Derek McMinn in Birmingham UK shortly after the BHR received FDA approval in 2006. I began doing hip resurfacing in September 2006. In 2008 I returned to Birmingham to spend time with Mr. Ronan Treacy, his co-developer. Both experiences were very valuable in learning the procedure, and both of these surgeons are very skilled and thoughtful teachers. It is a pity that overseas training is now rare, since that is where most of the experienced doctors work. I now attend most of the major hip resurfacing courses, and am a teacher now myself. I host visiting surgeons who want to learn the procedure at the Cleveland Clinic, and have established the Cleveland Clinic Center for Hip Resurfacing at Euclid Hospital. Several of us at Cleveland Clinic now perform hip resurfacing.
2.) Do you do the neck capsule preservation technique in your surgeries?
This does not apply, since I use the anterolateral approach.
3.) Do you re-attach the gluteus tendon?
This does not apply, since I use the anterolateral approach.
4.) Which approach do you prefer to use anterolateral or posterior? (This answer updated on 4/9/11)
Updated answer: I trained exclusively in the posterior approach for THR as a resident, and switched to the anterolateral approach in practice. I have used it exclusively in THR for 25 years, and in resurfacing since 2006. I have seen the direct anterior approach but have no experience with it myself.
My preference for the anterolateral approach is due to several issues.
1. The exposure is easy in either the posterior or anterolateral approach, but both the acetabulum and the femoral head are anterior-facing structures, so it is more logical to use some type of anterior approach. If you want to look someone in the eye, face them. In addition, the most common resurfacing situation I see is in a male with femeroacetabular impingement, who usually has a large femoral neck osteophyte anteriorly. Anterior exposure makes it very easy to reshape the anterior neck. I'm looking right at it. Almost every patient has a contracture of the anterior capsule, (flexion contracture) which is automatically and safely dealt with through an anterior approach.
2. The way I (and others) do an anterolateral approach, no muscle is cut transversely, across its fibers. The important abductors of the hip are split in line with their fibers, and those fibers blend over the trochanter eventually becoming continuous with the fibers of the vastus lateralis (quadriceps), an inch or so of which is split as well. Thus, an entire continuous sleeve of muscle and tendon is elevated as one sheet from the anterior hip capsule. Suturing afterwards then involves only side-to-side closure, and nothing needs to be repaired end-to-end. Side-to-side means that subsequent muscle contraction has the effect of closing the repair, not tugging on it. Contraction of the abductors and the quadriceps balance each other so neither muscle group has any tendency to pull away. This is in contrast to other versions of the anterolateral approach that I have seen where substantial portions of the abductors are indeed cut transversely. This needs to be carefully repaired, because any contraction with weight-bearing pulls on the suture line, and it may or may not heal properly. If it pulls apart you can get limping.
3. In a posterior approach, several relatively unimportant muscles are cut transversely, and repaired end-to-end. These include the piriformis, obturator internus, gemelli (two), quadratus femoris, and obturator externus. Many surgeons also cut the Gluteus maximus tendon to a greater or lesser extent. This is done more in resurfacing than in THR due to the greater exposure needed, and the fear of compression of the sciatic nerve by this tendon during rotation of the hip. G Max is not an unimportant tendon. It has to be repaired end-to-end, and as with anything else, subsequent muscle contraction tugs on this repair, which may therefore fail. So when all is said and done you may have 7 muscles cut transversely and repaired end-to-end. Is that OK? Yes, of course it is, as long as it is done right. Like everything else.
4. The posterior approach also cuts the posterior capsule. This should be repaired, in order to minimize the already low risk of dislocation with resurfacing. The anterloateral approach does not cut the posterior capsule. Dislocation is not an issue at all. We use no "hip precautions" such as avoiding certain positions, crossing of legs, twisting, or raised toilet seats.
5. The blood supply of the femoral head is largely posterior, with or without osteoarthritis. (Freeman's teaching not universally accepted). Multiple studies show that the blood supply is routinely disturbed using a posterior approach and not using an anterolateral approach. Certainly that cannot matter for THR, where the head is gone anyway. Oddly, good long-term studies from the UK show that it does not seem to matter in resurfacing, where it should matter. One might have thought that late femoral component loosening could occur with avascular necrosis of the reamed head. One could also think that femoral neck fracture, a result of accumulated non-healing microstresses (fatigue failure), would occur more in avascular bone than in living bone. The bottom line is that it doesn't seem to make a difference, but it should.
6. I don't like trochanteric osteotomies. Another entire set of complications comes up, especially trochanteric non-union, lateral hip pain, and hardware issues.
7. I haven't had a lot of limping. My guess is that it could be related to the details of the technique and newer instruments such as retractors that do not require much force with less muscle or nerve damage.
8. I haven't had a lot of clinically significant heterotopic bone, 0.2%.
In summary, I have looked at all the approaches and choose to do the anterolateral approach. My advice to patients is definitely do NOT shop around for a particular approach, as any approach will do beautifully as long as it is done right, and the converse is sadly true as well. Find a surgeon with experience in whom you have confidence, and he will do what works best in his hands. It's like getting on an airplane. At some point you just have to trust the pilot.
5.) What size do your incisions normally range in inches?
For normal size patients the incision is about 6-7 inches.
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 personal experience with it. My opinion is that any approach can give perfectly good results, so surgeons should do what they are most comfortable and experienced with. It is more important to do it right.
7.) How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
6 to 12 months
8.) Barring any complications, how many days in the hospital will a patient normally stay?.
9.) What is your typical rehab protocol? 90 degree restriction? Walker” Crutches Cane? amount of time? Blood thinners? TED stockings? Ice? PT
We have no “hip precautions” against dislocation because it is not necessary with a hip resurfacing done through an anterolateral approach. So there is no 90 degree rule, no issues with crossing your legs, turning over, lying on your side etc. You don’t need a raised toilet seat. Our restrictions are 75% weight bearing for 6 weeks (2 crutches), followed by the rest of the first year doing easier exercises like walking, swimming, cycling, golfing, and elliptical. I do not recommend running, jumping, or repetitive strains (like leg presses) for I year. An athlete would be “out for a season”. We either use Lovenox (enoxaparin) for 2 weeks followed by ASA for a month, or just ASA for 6 weeks. I get an ultrasound at 2 days and 10 days, since most DVT is silent and one wouldn’t know if you had it or not. We do not use TED stockings, but we use pneumatic compression stockings. Ice is routine. All patients receive detailed home instructions for exercises and most do not go to formal PT visits. Often, the patients know more about this surgery than the therapist anyway.
It may seem that we are overly cautious in our recommendations, but we have had only 1 femoral neck fracture in nearly 600 so far, and that patient was doing leg presses on a machine at only 8 weeks post-op. I believe bone needs time to recover from the surgery, and fractures are often the result of accumulated microstresses.
10.) How long before a typical patient is allowed to drive a car, return to work?
You can drive at 6 weeks. Probably most patients drive sooner than I tell them, especially with their left side done. You can return to office work (with someone driving you) at 2-3 weeks, although only very motivated people do that. We have wireless internet at the hospital and some patients work right away! A construction worker might be out for 3 months.
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?
They wait a year for impact sports. Following that, there are no restrictions at all. I have resurfaced many athletic people, with favorite sports such as tennis, racquetball, ice hockey, soccer, competitive cycling, horseback riding or running.
12.) What is your take on cementless (femoral) devices for resurfacing?
At this time, the reported failure rates for cemented BHR heads is so low (zero in Mr. McMinn’s thousands of OA patients) that I do not see a driving force to switch. We know that cementless heads can work in good bone, but not so well in weaker bone. There is no FDA approved cementless resurfacing in the USA. Dr Gross reports good results with the Biomet Recap, but the historical failure rate with the ReCap in other surgeons’ hands in the Australian National Joint Registry is high. The BHR does not offer a cementless head. Cormet provided one, but it is no longer used as far as I know.
13.) Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
We have learned that younger patients are the best candidates for resurfacing. Having said that, I have resurfaced several people over the age of 65 in individual circumstances such as excellent bone quality, a desire to be more active than most, or a femoral deformity that would make it difficult to implant a total hip stem.
14.) What type of anesthesia do you use general or epidural or ?
Spinal anesthesia is preferred to help avoid DVT, and we supplement that with an infiltration of long-active local anesthetic. Patients are sedated and snoozing, and are unaware of the surgery.
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.
Results with AVN are not as good as for OA, especially when there is more than 30-50% head involvement. I have done a number of AVN cases, but data shows that about 10% will fail in 10 years. Still, that’s not terrible when you consider the results with THR in this difficult group, and the ease of revision if a resurfacing is done first.
Similarly, the results in dysplasia may be worse, especially if the head size is small. Women tend to be the ones with dysplasia, and also tend to be smaller than men. This makes the surgery more difficult and accuracy more important. Doctors see a lot of dysplasia patients for resurfacing because it causes arthritis at a young age. I have a lot of dysplastic patients who are very happy to have been resurfaced. None have failed at this time. Small cysts are not a problem. Larger cysts may preclude resurfacing, especially if they are near the superior femoral neck, where they may cause fracture.
16.) Do you do bilateral surgeries same day, if not how far apart do you recommend?
The only same-day bilateral resurfacing I do is when there is so much deformity that rehabilitation of the new hip would not be possible. Otherwise I have the patient wait 3-5 months.
17.) What device do you prefer to use for hip resurfacing and why?
I use the Birmingham (BHR). I know there are a lot of different brands out there, some of them very good, but only three are FDA approved at this time: BHR, Cormet, and Conserve+. Of those three, the results with the BHR are considerably better in the Australian registry, and there is much more data available and reported, since it has been around the longest. There are some significant differences in metallurgy, clearance, instrumentation, cement mantle thickness, but most importantly in outcome. A recent development in the industry was J&J (DePuy)’s decision to drop the ASR, which was quite popular around the world. It had higher than expected failure rates. They picked up the Finsbury Adept, which has similar design philosophy and metallurgy to the BHR. It should do well, but for the time being does not have FDA approval.
18.) If you can’t perform a hip resurfacing – what THR device do you prefer and why?
I use the cementless Synergy stem, with a Reflection or R3 socket. Younger patients get ceramic-on-ceramic, and older patient get Oxinium or cobalt chrome on cross-linked poly. This is a taper stem design (as opposed to anatomic and cylindrical designs) and so has a lower risk of thigh pain and severe stress shielding. It also provides offset options to help avoid leg length discrepancy.
19.) What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?
50 – 100.