Dr. Huddleston Interview, L.A., CA

1.) Hi Dr. Huddleston, 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 did my first hip resurfacings in the mid eighties. There was great enthusiasm all over America for the Indiana Conservative Hip as it was called. It was doomed to failure because it was a metal on plastic design. The plastic was the weak link. I did 56 of them and they all failed within four years.

There was little interest in surface replacement in America until the good results with the Birmingham hip became apparent.  It was a metal on metal design and McMinn had a track record extending more than eight years with good results by the time the Food and Drug Administration would allow it to be used in America.

The FDA would not allow anyone to install this new system until they had had training in the technique in Birmingham. I was one of the first surgeons from Los Angeles to take the training in Birmingham June 2006, which was one month before the implant was released in the U.S. I was trained by Dr. Ronan Treacy who was one of the co-developers of the procedure.

Since then I have attended two major Surface Replacement Conventions in the U.S.: one in Annapolis and one in Los Angeles. Experts from around the world presented results, refinements and closed circuit, live training from the operating room.

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

3.) Do you re-attach the gluteus tendon?
I do not detach this tendon unless I have to (very rarely). If I do take it down I re-attach it with #2 Tycron which is an unabsorbable stich.

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

5.)  What size do your incisions normally range in inches?
Four to six 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 experience with it and have never seen it done.

7.)   How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
Probably well-ingrown by six months and fully in-grown by a year.

8.)   Barring any complications, how many days in the hospital will a patient normally stay?
Two nights to three nights total.

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

Local “pain cocktail” injections at surgery almost eliminate post op pain. Local ice packs are helpful in controlling swelling. Full weight bearing starting the day after surgery. A walker or crutches at first. Off all walking aids as soon as the patient can do so safely (usually within a week). Coumadin for two weeks and then one Aspirin a day for two weeks more. No flexion over 90 degrees for six weeks. No TED hose because it is VERY difficult to get on and almost impossible to get on and not bend the hip over 90 degrees. Very little physical therapy is needed unless there is muscle weakness to begin with. Patients are encouraged to walk as much as possible from day one (a mile or more a day as soon as possible) and that is the BEST physical therapy they can get.

10.)   How long before a typical patient is allowed to drive a car, return to work?
Driving as soon as they get home and are off narcotics with left hips, and one month with right hips. Return to work depends on the type of work. Sedentary jobs within one to two weeks if they can get to 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?
Six weeks to chipping and putting, three months to unrestricted golf.  Skiing on intermediate slopes and doubles tennis after six months. No jogging for a year and no basketball ever. Several have retuned to tennis and skiing.

12.)   What is your take on cementless (femoral) devices for resurfacing?
I have no experience of them. They are experimental. They seem to be a good idea but I will not use them until there has been a good track record.

13.)   Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
I go on a case by case basis, but generally for males 60 is my cut off and for females 50.

14.)   What type of anesthesia do you use general or epidural or ?
We use epidural anesthesia coupled with a light general. The recovery is quick, there is no pain at all for several hours after the operation, and there is evidence that the incidence of deep vein thrombosis is lower

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.

If more than one third of the femoral head is lost to AVN or bone cysts it is unwise to resurface. Congenital dysplasia has to be dealt with individually since there is so much variability in the anatomy. Thee has to be enough bone to work with.

16.)   Do you do bilateral surgeries same day, if not how far apart do you recommend?
I recommend at least a month apart.
17.)   What device do you prefer to use for hip resurfacing and why?
I prefer the Birmingham Hip because I was trained on it, and because it showed the best outcome of all the available systems from the Australian Registry of 2008.

18.)   If you can’t perform a hip resurfacing – what THR device do you prefer and why?
My number one choice is the metal-on-metal Prodigy Stem/ASR Cup combination from Johnson and Johnson.
I like metal-on-metal because it will not wear out.
I have had only two loose Prodigy stems and two fractured stems out of over three thousand, and I have not seen a failed ASR cup. The results worldwide of the Prodigy/AML  stem has been outstanding.

19.)   What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?
Twenty five to thirty at a minimum. Totally proficient by a hundred.