Dr. Rogerson Interview, Madison, WI
1. Will you perform my hip resurfacing personally or have an assistant do the surgery?
I perform all of the hip resurfacings personally, with one of my two PAs as the first assistant. We have a well-trained team at Stoughton Hospital involved with every case.
2. How many resurfacings have you done (not observed or assisted with, or including hemi-resurfacings)?
As of October 7th 2014, I have now performed 770 hip resurfacings since 2006.
3. Where did you train?
I trained with Dr. McMinn and Dr. Treacy in England in 2005, and also visited and scrubbed in with Dr. DeSmet in Belgium in 2005. Prior to going to Europe for my training, I visited Dr. Schmalzried, Dr. Mont, and Dr. Stachniw 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 hip resurfacing.
4. How many complications have you had?
In my series I have seen one superficial and two deep infections. One deep infection started from a drain site, and we no longer use percutaneous drains postoperatively. The second deep infection occurred a year and a half after the hip resurfacing procedure from an infected hernia repair.
5. How many resurfacing failures with revision to Total Hip Replacement (THR) have you had?
I have experienced three femoral neck fractures that went on to revision: two from excess early high-impact activities against medical advice and one later stress fracture well below the prosthesis. I have had one revision secondary to recurrent dislocation after falling off a bleacher at six weeks post-op. I have had two deep infections, as noted above, that required revision surgery. I have had one metal allergy reaction with pseudotumor that required revision. In my series since 2006 I have a 98.3% survivorship of the prosthesis still functioning well.
6. How many loose acetabular cups have you had?
In my series I have had no acetabular cup loosenings or loosening of femoral components. I have done one revision of a resurfacing done in Belgium by Dr. DeSmet for a loose acetabular component.
7. How many times during surgery have you had to change to a THR instead of resurfacing and why was the change made?
I have had one case where the patient had significant cystic changes in the femoral head, where preoperatively I told him he had a 20% chance of getting a resurfacing, and he wanted me to start out as if I was doing the resurfacing to see if it was possible. It was not possible, and I performed a metal-on-metal big femoral head arthroplasty for him, and he has done well.
8. For what reasons would you switch from resurfacing to a total hip replacement after starting the surgery? If you switch, what device would you be using for a total hip replacement?
The reasons to switch would be inadequate bone quality under the femoral head or inadequate fixation at the time of surgery of the acetabular component, or a technical error with notching of the femoral neck, which would make the patient more susceptible for ultimate femoral neck fracture. At the present time, I would use the Smith & Nephew titanium Polar stem with an Oxinium head and a metal-on-polyethylene socket.
9. What hip resurfacing device/prosthesis, do you use? How long have you been using it, and why do you prefer it?
I have only used the Smith & Nephew Birmingham hip resurfacing prosthesis since its FDA approval in 2006. Prior to it receiving FDA approval, I performed one Wright Medical hip resurfacing using a compassionate use permit from the FDA. I definitely prefer the Birmingham hip prosthesis compared to others that are presently on the market. This relates to the metallurgy of the prosthesis, particularly the acetabular component, which is an “as cast” metal with large block carbides and better wear characteristics than heat treated metals. The precise instrumentation and the line-to-line fit for the femoral component of the Birmingham is the best on the market, and Drs. McMinn and Treacy’s 16-year results with the BHR are very impressive when compared to total hip arthroplasty results in young, active individuals.
10. Do you use cemented or uncemented and why?
I use an uncemented acetabular component and a cemented femoral head component, which is the standard with the Birmingham hip resurfacing. At the time of surgery, one sees frequently many femoral heads that are deformed and very sclerotic, and do not have good cancellous bone on the superior flattened portion of the femoral head. I believe that these types of arthritic heads do better with a very thin cement mantle within the femoral head component that evens out the forces on the femoral neck and assures good fixation in bone that would otherwise be compromised because of its sclerotic nature.
11. If both hips are bad, how do you handle bilateral resurfacing?
I have not done a bilateral hip resurfacing during the same setting. There has been one reported case of a patient rolling over for the second side, and with impaction of the acetabular component on the second side a fracture of the femoral neck component occurred on the first side. I generally wait at least eight weeks between procedures.
12. Do you have other hip resurfacing patients that I could talk to about their experience?
I have multiple patients that are enthusiastic to talk to prospective hip resurfacing candidates. They are both male and female, and come from all walks of life and have every conceivable activity demands. Prospective BHR patients may call the office at (608) 231-3410 to receive this information.
13. What is your opinion of when I can return to work and other activities, including sports?
Patients generally can return to a sedentary job in two to three weeks from the time of surgery. For more vigorous work, realistically it would be four to six weeks, and for any high-impact activities I restrain patients for six months postoperatively.
14. Have you done resurfacing for anyone who has returned to high-impact activities?
I have had patients return to just about every conceivable sporting activity, including power weightlifting, Ironman and endurance contests, mountain ice climbing, martial arts, barefoot, slalom, and snow skiing, swimming, biking, basketball, tennis, handball/racquetball, wrestling, etc.
15. Will you be preserving my hip capsule?
I do use a hip capsular preservation technique which preserves the circulation along the posterior femoral neck as much as possible, and is meticulously repaired at the closure of the case.
16. What anesthetic do you use?
General anesthetic with complete muscle relaxation, with the patient in a lateral decubitus position on the operative table.
17. How long does the surgery take?
2 to 2½ hours. I use an extensive skin closure technique utilizing Stratafix (a barbed sub-cuticular stitch), reinforced with Prineo mesh and Dermabond glue. This takes a little longer, but it avoids skin staples and is more resistant to infection.
18. What surgical approach do you use? Anterior or posterior?
I use a posterior approach, which I feel has less risk for injury to the gluteus medius tendon and avoids a postoperative abductor lurch gait pattern. Trochanteric osteotomy and an anterolateral approach that releases the gluteus medius is at much higher risk for developing postoperative limp, in my experience. Another reason I like the posterior approach is the exposure that one can attain for the femoral head and the ability to effectively use the stylus to get the femoral head guide wire in exactly the right position.
19. What is the incision length?
Usually, about 6-8 inches in length, and is shorter in thinner patients.
20. Do you use staples, self-absorbing stitches, drains, etc.?
I use absorbable sutures as well as an arthroscopic anchor with two non-absorbable sutures in the upper tendinous portion of the gluteus maximus repair. I use an absorbable suture in the fascia lata and subcutaneously; and a barbed sub-cuticular stitch for the skin, reinforced with Prineo mesh and Dermabond glue. I have not used drains since having one infection from a drain site early in our series. Usual blood loss is 250-300 cc, and the postoperative hematoma (black and blue) generally is minimal.
21. What is your post-op pain control plan?
I use long-acting Marcaine instilled around the deep tissues and the incision. Post-operatively the day of surgery I typically use the acute pain dosing regimen for Celebrex, along with IV Ofirmev (acetaminophen). Oral oxycodone and IV dilaudid are utilized for breakthrough pain as well. Post-op day one and beyond I typically switch to oral hydrocodone as needed and Celebrex daily. Patients may switch from hydrocodone to oral acetaminophen when pain is under good control typically after 3-5 days. I also use large gel ice packs around the incision and anterior thigh post-operatively for swelling and pain control.
22. What hospital do you use?
Stoughton Hospital in Stoughton, Wisconsin, with the post-operative HipHab rehab program in downtown Madison at Capitol Lakes rehabilitation facility. See my website at www.orthoteam.com for more information about my HipHab rehab program.
23. What is your infection rate?
I have had no infections while practicing at Stoughton Hospital, and their infection rate is extremely low. The two previous immediate post-operative infections occurred when I was practicing at another hospital. This makes my overall post-operative infection rate 0.2%.
24. Have any of your patients had infections or required IV antibiotics following resurfacing?
I use peri-operative IV antibiotics at the time of surgery and for the first 24 hours thereafter. I had one immediate post-operative superficial infection that required an incision and drainage and IV antibiotics for six weeks, with resolution of the infection and maintenance of the prosthesis. I have had to perform one revision arthroplasty from a deep resurfacing infection that was seated from the drain site immediately post-op. I no longer use percutaneous drains post-operatively. I have had one late infection that seated a hip resurfacing from an infected hernia repair a year and a half post-op that required revision in another state.
25. What drugs, methods do you use for anticoagulation after surgery?
During the operative procedure, when blood clots usually form, I use sterile Kendall thigh-high pump stockings on both legs. Post-operatively, I use an oral anticoagulant (Xarelto) for three weeks, followed by one month of aspirin 81 mg per day. With this regimen, I have not had a recognized DVT or pulmonary embolus.
26. How long will I be in the hospital?
The patient is in the hospital for 2.5 days including the surgery day before transferring to the HipHab rehab facility.
27. How successful have you been at obtaining insurance approvals for resurfacing?
At present, insurance coverage for hip resurfacing is similar to total hip replacement, but may vary depending on the patient’s policy. Please call my office at (608) 231-3410 to inquire about potential cost for the BHR procedure.
28. What is the rehab protocol?
See my website at www.orthoteam.com for my unique and innovative HipHab rehabilitation program that combines both land and warm water pool PT.
29. What assistive devices will I use for walking after surgery?
The first day or two you will be using two lightweight forearm crutches, and usually after several days you go to one forearm crutch on the non-operative side, and are generally off crutches somewhere between 1½ to 3 weeks post-op. Some patients require the use of a walker immediately post-op until good balance is attained.
30. When will I be 100% weight bearing?
Usually between 1½ and 3 weeks post-op. The patient may be weight bearing as tolerated immediately following the procedure, unless otherwise specified. Patients should continue using forearm crutches until there is no pain or limp.
31. What assistive devices will I use for walking after surgery?
Forearm crutches, as noted above.
32. How long on two crutches, one crutch, cane?
33. What, if any, restrictions do you place on your patients after surgery, and how long do they last?
I allow patients to get back to walking immediately as noted above; elliptical training at one to two weeks post-op; stationary bicycling starting at three weeks post-op; driving once the patient is off narcotic pain medication during the day and can walk without pain; golf at three months; and resumption of activities without restriction at six months.
34. Will I be given any at-home nurse or PT care?
Because of our successful HipHab rehab program you will not need any in-home nursing/ PT care. When patients leave HipHab they are confident in returning home, they are able to navigate stairs, as well as all activities of daily living. Patients may continue with outpatient physical therapy for gait training and strengthening when they return home, and a prescription for this outpatient PT is given to the patient at their pre-operative discussion.
35. How long do you feel it takes for the bone to be fully healed, grow into the prosthesis, and what is the recommended time you tell your patients before they can start to run again/do impact sports?
The bone starts to grow into the acetabular component by six to eight weeks and continues to remodel the proximal bone of the femur and the femoral neck up to a year postoperatively. I allow patients to get back to non-impact activities very quickly, as noted above, but I have patients avoid high-impact, and heavy lifting while torquing activities for six months post-operatively. Each case is individualized based on the patient’s bone quality and pre-operative activity status.
36. Do you presently use metal-on-metal big femoral head arthroplasty?
If I am not doing the Birmingham hip resurfacing, which retains the patient’s femoral neck and shaft in its original state, I utilize the Smith & Nephew Polar stem with an Oxinium femoral head mated to a highly cross-linked polyethylene liner in a metal shell for the acetabular component. There is increasing concern in the orthopaedic community about the metal corrosion that can be produced with cobalt-chrome-molybdenum heads on the modular neck of either a titanium or cobalt-chrome stem. Because of this, I am now using the Oxinium femoral head, which oxidizes on the surface to ceramic. This produces much less wear on the polyethylene liner compared to a cobalt-chrome-molybdenum femoral head, and is not as brittle as a complete ceramic femoral head.
37. What causes heterotopic bone growth?
Heterotopic bone growth can be caused by injury to the muscle fibers during the operative procedure and bone debris from the acetabulum and femoral head shaving. I have not had any clinically significant heterotopic bone formation to date. I utilize a specialized drape around the femoral neck that captures all of the bone debris so that it does not infiltrate the soft tissues around the hip.
38. Can you tell me if I’m a good candidate for hip resurfacing?
To find out if you are a good candidate for hip resurfacing, proceed to my website at www.orthoteam.com and fill out the 3 required forms: HIPPA, Medical History Questionnaire, Hip Questionnaire. Send these forms via e-mail or mail along with a disc of your digital hip x-rays (information about specific views required can be found on my website).
Mail: John S. Rogerson, M.D., S.C.
Attn: BHR Analysis
2 Science Ct.
Madison, WI. 53711
I can determine 90% of the patients who are good candidates with the above measures. Occasionally, a patient may have some cystic changes in the acetabulum or femoral head that would require that they obtain a CT of the hip to determine the advisability of resurfacing. Patients who are more local are usually seen in my office for physical evaluation, x-ray analysis, and discussion. Out-of-town patients that come from long distance engage in telephone conversation before arriving in Madison the day before surgery, and they see myself and one of my PA’s the afternoon before surgery for exam and discussion prior to surgery.