Dr. Della Valle Interview, Chicago, IL
Interviewed by Vicky Marlow May 2, 2011
1.) Hi Dr. Della Valle, 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 was intrigued by the idea of hip resurfacing as an alternative to conventional total hip arthroplasty. Specifically, the data showing that hip resurfacing performs best, in the patients in whom a conventional total hip performs worst (young, active male patients) was particularly appealing.
I am always a bit “suspicious” of new technology but decided to get training, try ten cases and see how the patients did prior to making a judgement; it is easy to say that something doesn’t work when you haven’t tried it!
I was fortunate enough to spend time in Birmingham with Mr. McMinn and was impressed with what I saw including how carefully they followed their patients to learn as much as possible about their own outcomes. His care in patients selection as well as the surgical technique also impressed me. I left for Birmingham on a Thursday, returned on Sunday and did my first case on Monday. After my ten cases were done, it was pretty clear that the surgical technique was comfortable for me and the patient outcomes were great.
At first, the surgical exposure made me somewhat uncomfortable (I was used to much smaller incisions) but we quickly realized that the resurfacing patients recovered just as fast, if not faster than a conventional total hip. This experience really challenged many of my own ideas about the relationship between incision size and early patient recovery. At this point, many of our patients are “fast tracked” as they are young and healthy and are able to get up with physical therapy on the day of surgery and go home the day after (just one night in the hospital).
As I became more interested in hip resurfacing, I was curious about the early outcomes in the hands of surgeons like myself who had just learned the procedure which lead to our publication on the “Early outcomes of BHR in the United States”. Research is a big part of my practice and life and this project really helped me to learn a lot more about hip resurfacing. We have done a few other projects since then on the topic.
I also went back and did a cadaver after my first ten which I found very helpful at improving my surgical technique.
2.) Do you do the neck capsule preservation technique in your surgeries?
One of the things that Mr. McMinn stressed when I visited with him was great care with the soft tissues around the femoral neck. I try to perform the procedure exactly the way that he taught me! Although orthopaedic surgeons tend to like to “modify” the procedure and “make it their own” I personally recognize the experience gained in Birmingham and have tried to reproduce their technique as exactly as I can. I have also been to a few resurfacing courses and continue to learn from live surgeries and videos on ways to improve my technique. I think we all continually learn from one another and with our own experience.
3.) Do you re-attach the gluteus tendon?
4.) Which approach do you prefer to use anterolateral or posterior?
5.) What size do your incisions normally range in inches?
Hard to say…bigger than my total hips? Based on our experience that the patients seem to get better quickly with little pain and the knowledge that accurate component placement is critical, I make the incision as big as it needs to be to get the job done right. A guess about two hand breadths?
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 think it is intriguing but at the same time, we recently published our prospective randomized study comparing the two-incision technique (similar to the direct anterior) and a mini posterior technique for conventional total hip replacement and we saw no difference in length of stay in the hospital (measured down to the hour), requirement for pain medications or functional recovery. While in expert hands this procedure works, I honestly don’t think it will make a difference in terms of patient based outcomes. Further, early on the learning curve for this procedure means that complications may be more frequent, a certain percent of patients will have some numbness in their thigh and in our experience, some patients didn’t really like the anterior based incision (they preferred one on the lateral side of the hips). So I guess in summary, I think in expert hands it works but I am not sure it will make a difference to the patient which at the end of the day is what is most important.
7.) How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
Good question! Not sure…probably takes somewhere between 6 weeks and 6 months but I don’t think we really know the answer to that question.
8.) Barring any complications, how many days in the hospital will a patient normally stay?
Often times overnight but that is patient dependent. Maximum is three days.
9.) What is your typical rehab protocol? 90 degree restriction? Walker” Crutches Cane? amount of time? Blood thinners? TED stockings? Ice? PT
Patients are allowed to weight bear as tolerated right away but we do ask them to use at least a cane for the first 6 weeks. We also ask patients to follow hip precautions for six weeks and then start stretching with their physical therapist. We use Coumadin for most patients x 3 weeks. No TED stockings. Ice if it makes the patient feel better.
10.) How long before a typical patient is allowed to drive a car, return to work?
Patients can drive at 3 weeks so long as they are off of pain medications. Return to work is very variable. For desk jobs, some folks go back at 3-4 weeks while patients who do heavy labor may require up to 3 months off from work.
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?
We ask patients to “take the season off” as Mr. McMinn taught me as far as running sports or things like skiing. The data suggests it is ok to run at 6 months to one year and I tell patients that if they can wait for a year, I would do so to ensure full healing. They can do other things (that do not include running) starting at six weeks.
We perform resurfacing in part so folks can get back to doing whatever they please. We have had patients who have run marathons and even done triatholons so for me there are no restrictions after things have “healed”.
12.) What is your take on cementless (femoral) devices for resurfacing?
Interesting but unproven. The cemented femoral components seem to work pretty well but I will admit that the “midhead” BHR is intriguing and would help me to extend the procedure to patients with AVN and the like.
13.) Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
All such decisions are complex and must be made in conjunction with the patient on an individual basis. Each patient is a bit different and may have a different tolerance for complications.
14.) What type of anesthesia do you use general or epidural or ?
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.
As above, all cases must be individualized. We have done some young folks with rheumatoid arthritis, chondrolysis and pigmented villonodular synovitis who have done great. Controversial indications but just shows you how individualized the process is.
16.) Do you do bilateral surgeries same day, if not how far apart do you recommend?
Occasionally but I prefer to do them one at a time.
17.) What device do you prefer to use for hip resurfacing and why?
BHR. It is the only device I have used and it has the longest track record.
18.) If you can’t perform a hip resurfacing – what THR device do you prefer and why?
Smith & Nephew is used most commonly. It really depends on why the patient is not a candidate for hip resurfacing and what they “want” from their hip. Again, these are very individual decisions but many wind up with a metal on metal total hip with a BHR cup.
19.) What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?
Again, I think that is hard to answer. If a surgeon is an experienced hip surgeon, particularly one who has done many complex primaries or revisions, they can probably become proficient more quickly than someone who has not done many total hips prior to learning BHR.