Dr. Marwin Interview, NY
Interviewed by Vicky Marlow November 3, 2008
1.) Hi Dr. Marwin, 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 got interested in HR several years back during a time period when both minimally invasive surgery and hip resurfacing came into the orthopaedic consciousness. Bone preservation seemed very intriguing to me because in reality it meant preservation of normal anatomic and kinamatic relationships. Small incision surgery was just that – surgery through a smaller hole. Did this mean preservation of the soft tissue envelope or as the pundits say, “preservation of ligaments, tendons, and muscle”. With the stretch on the soft tissues, I didn’t really believe it.
- I trained in Birmingham with Mr. McMinn.
- After I was trained, I did some cadaveric work before I operated on a human.
2.) Which approach do you prefer to use anterolateral or posterior?
I do a direct lateral approach to the hip. I do very little capsular release. The capsule is opened in the front for dislocation. The posterior capsule is left intact. And the capsule is closed anatomically at the completion of the case.
Direct lateral approach (anterolateral approach) which includes an anterior dislocation.
3.) 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?
Direct anterior approach seems intriguing. It requires some expensive equipment like a special table. It seems better suit for THR than HR. Plus, there is a steep learning curve. Theoretically, it seems advantageous, but I can accomplish everything I need to including an excellent exposure without disrupting the posterior capsule through a direct lateral approach.
4.) How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
I do a BHR, so the socket is noncemented. It takes four to six weeks for ingrowth.
5.) Barring any complications, how many days in the hospital will a patient normally stay?
3 and at the longest 4 days. My hip resurfacing patients tend to be very motivated. They want to be out of the hospital fast. Plus, almost all patients will go home rather than to inpatient rehabilitation….even the bilateral cases.
6.) What is your typical recovery time after resurfacing, what is your typical rehab protocol? 90 degree restriction? Walker” Crutches Cane? Amount of time? Blood thinners? TED stockings? Ice? PT?
Because I use a direct lateral approach with an anterior dislocation AND the HR has a large diameter head, I stop “hip precautions” at 2 weeks. I put my patients typically on 2 Lostrand crutches first. I try to avoid walkers. I wean them to a single crutch or cane as soon as possible. I want the HR patient to drive the car within 3 – 4 weeks. I use an extended DVT prophylaxis protocol. While in the hospital, I use Arixtra. At home, my patients take aspirin. I use a 4 week protocol. Outpatient PT is started immediately. My typical HR patient does not get much help from post in-home PT. I’ll prescibe TEDS stockings for those limbs that are very swollen. I don’t use them in all patients.
7.) How long before a typical patient is allowed to drive a car, return to work?
As stated above, I want a patient driving a car within 3 to 4 weeks of surgery. A patient with a sedentary job can return to work within a month of surgery. I don’t allow running and jumping for 6 months to protect the femoral neck. A patient with a physically demanding job (construction worker) has to modify the activities. If a laborer can avoid running, jumping, heavy lifting and pushing, he or she can return to work within 6 weeks.
8.) 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?
As stated above, 6 months. After six months, patients are allowed to return to all sports. Patients have returned to running, skiing, tennis, basketball, softball, bowling, handball, soccer.
9.) What is your take on cementless (femoral) devices for resurfacing?
I consider myself a BHR “purist”. The BHR technique has the best clinical results worldwide. Therefore, I’m not considering noncemented femoral components at all. I cement all femoral components and will continue to do so until I see some data on noncemented techniques that is convincing.
10.) Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
65 for males. 55 for females. Plus, I will not resurface a female who is child bearing age. Therefore, the window for females is very small in my practice. Also, any female I operate on must have bone densitometry. The study must be normal.
11.) What type of anesthesia do you use general or epidural or ?
Patients will have general or combination general/epidural.
12.) 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?
The great majority of my cases are primary osteoarthritis. I will do mild dysplasia cases (Crowe 1 or 2). I avoid AVN. Small cysts in the femoral head have not been a problem for me as long as they are not at the head/neck junction. I’ll expand my indications for unusual cases. For example, I resurfaced a hip in a young man with AVN who also had femoral stenosis distally from previous femoral shaft fracture and retained screws for broken hardware. There was no canal for a femoral component. The hip resurfacing was a unique solution for a patient who needed a hip arthroplasty.
13.) Do you do bilateral surgeries same day, if not how far apart do you recommend?
I will do bilateral cases in the same day. My patients actually do very well with bilateral cases. The patients must by healthy. Most of my resurfacing cases are young and healthy anyway.
14.) What device do you prefer to use for hip resurfacing?
15.) If you can’t perform a hip resurfacing – what THR device do you prefer and why?
The total hip replacement of choice is a noncemented arthroplasty. I like to use the BHR socket. I’ll use a noncemented, tapered stem (S and N Anthology) with a large metal head.
16.) What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?