This is a transcript of a Live Chat in the Surface Hippy Chat Room with Dr. Raterman on August 7, 2012
[Pat Walter] 7:59 pm: I would like to introduce Dr. Raterman of FL. Thank You for taking time to do the doctor chat and answer questions for us.
[dr raterman] 7:59 pm: Thanks for having me.
[Pat Walter] 8:00 pm: Dr. Raterman – Could you tell us when you trained to do hip resurfacing and about how many you have done to date?
[dr raterman] 8:01 pm: I trained with Dr. McMinn in Birmingham, England in December 2005. Did the first procedure in May 2006 and currently have done approximately 1500.
[jim] 8:02 pm: how are the resurfacings holding up in athletes in your experience
[dr raterman] 8:03 pm: They are doing extremely well in high demand athletes. Prefer this procedure to anterior approach total hip replacements in athletes, particularly impact athletes.
[Firemanrick] 8:03 pm: A panel of U.S. government experts said Thursday, June 28, 2012, that metal-on-metal hip implants have little use in most patients, with evidence mounting that the devices deteriorate sooner than other implants, shedding particles of metal into the surrounding joint and bloodstream.
…The panel, convened by the U.S. Food and Drug Administration, stopped short of advocating a ban on the devices, as some experts have done in Britain, the Associated Press reported. Your thoughts?
[dr raterman] 8:05 pm: The panel was commenting on total hip arthroplasty with hip resuracing mixed in. I believe that they have different outcomes and are two different procedures and should not be lumped together. In my experience, to date, most ion issues are implant position related.
[Pat Walter] 8:06 pm: What device do you use for hip resurfacing
[dr raterman] 8:07 pm: I use Corin predominantly with some Smith and Nephew thrown in.
[arff2004] 8:08 pm: Hello Dr Raterman , I’m 6 months post op from having my right hip resurfaced by you and have been felling great. Im playing hockey at least once a week and back working at fire department. My question is how many total hip replacements have u had to do of the 1500 resurfaced hips you have done?
[dr raterman] 8:09 pm: Thanks for the support. I do approximately 425 hips a year, and very rarely convert a hip resurfacing to a total hip replacement. Only exception is in the case of AVN.
[jbolling] 8:10 pm: Recent literature indicates that women are not as successful as men with resurfacing. What are your thoughts on this (reasons for the lower success rate)?
[dr raterman] 8:12 pm: You need large, strong hip bones to adequately support a hip resurfacing. Men have more bone mass and generally larger sizes of hip resurfacings are placed. McMinn’s data has shown that men with small sizes have similar fracture rates to women.
[Firemanrick] 8:12 pm: Clarification. Birmingham Resurfacing is the procedure, not the brand of components?
[dr raterman] 8:13 pm: No, Birmingham Hip Resurfacing is Smith and Nephew’s version of hip resurfacing, while Corin Cormet is Corin’s version of a hip resurfacing.
[stever] 8:12 pm: I have heard from other docs say ‘why get a resurfacing and have to get a total later’ I guess they think it will not last, any thoughts?,
[dr raterman] 8:14 pm: Data from Europe reflects high 15 year survival rate. It is a bone sparing procedure and very easily converted to a total hip replacement. Total hip arthroplasty has a very high failure rate in male patients under the age of 55 who are incidentally the best patients for hip resurfacing.
[jbolling] 8:15 pm: Regarding women and resurfacing, if you have osteopenia should you consider taking bisphosphonates or other bone-building medications before the procedure?
[dr raterman] 8:17 pm: I have treated a small number of patients this way with good success. However, many insurance plans will not cover the medicine for this purpose and out-of-pocket expenses are high in Florida. If you can afford the medicine it is worth considering, but be aware of side effects and don’t be surprised if it is denied by your insurance.
[Firemanrick] 8:16 pm: Anterior or posterior incision? Why do you prefer the one you use?
[dr raterman] 8:18 pm: Hip replacements I prefer anteriorly while resurfacing I still do posterior because there are no instruments or guides for anterior hip resurfacings other than a free-hand technique.
[mssams] 8:16 pm: Concerning candidate selection for resurfacing, what info does an x-ray present to you?
[dr raterman] 8:19 pm: X ray templating is key to a successful hip resurfacing. It provides me with data about size and/or technical pitfalls that I may encounter during the procedures.
[dr raterman] 8:22 pm: I am also working with computer navigation to optimize component position and reduce the outlier phenomenon with standard guides.
[jim] 8:19 pm: do you ever use the cementless implants or have you considered it?
[dr raterman] 8:20 pm: Would love to try cementless hip resurfacing, as intuitively it makes excellent sense, but it is not FDA approved.
[Firemanrick] 8:22 pm: I assume you bring in THR components contingent upon what you find inside?
[dr raterman] 8:23 pm: I do enough hip work that we always have a back-up plan available should any unforeseen problems be encountered.
[kc_nole] 8:22 pm: Dr Raterman, at what threshold are you choosing a total hip over a resurfacing?
[dr raterman] 8:25 pm: Women between the ages of 58 and 65 with osteopenia have the highest fracture rate in my series. I recommend either biphosphonates or total hip replacement. Patients with AVN that have whole head involvement or at high risk for ongoing problems secondary to asthma or alcohol I have a low threshold to convert.
[abc123] 8:23 pm: Dr. Raterman, Do you believe that running after hip resurfacing decreases the lifespan of the device? What is your estimate of the lifespan of a BHR
[dr raterman] 8:27 pm: I am cautious about running in that in my series I have had several BHR cups fail to ingrow which necessitated an early revision. I have not seen higher rates of fracture or metalosis in runners. But I am cautious about early return to running and most of them tend to cheat on me.
[Firemanrick] 8:25 pm: When speaking of cemented v. uncemented, are we talking about the "socket" component?
[dr raterman] 8:28 pm: All acetabular components are press-fit and all FDA approved femoral components are cemented. So cementless in this regard is in reference to the femoral component.
[jbolling] 8:27 pm: What is the T score threshold for you to consider biphosphonates?
[dr raterman] 8:29 pm: There is no data to support biphosphonates for this use so I generally speak to the patient about the risks and benefits and examine the X ray and don’t realy utilize any particular T score.
[Firemanrick] 8:30 pm: Preserving the hip capsule, can you elaborate please?
[dr raterman] 8:30 pm: I always repair the posterior capsule as well as the external rotators as part of my surgical technique.
[abc123] 8:31 pm: So, in terms of running after a BHR. Provided that the patient waited for 1 year post op (Upper end range of general surgeon recommendation), then you feel that running is OK? Or do you advise your patients against running at all after a BHR
[dr raterman] 8:33 pm: I talk with the patients about the level of running they wish to return to; I have patients who have actively competed in marathon distance events and try to win their age group. However I recommend against full return to running for 6 months to give the acetabular component plenty of time to ingrow.
[dr raterman] 8:33 pm: More casual runners, tennis players and ice skaters, I’ve had no problems with.
[stever] 8:34 pm: how bout surfers
[dr raterman] 8:34 pm: Surfers are easy.
[Pat Walter] 8:34 pm: I had some asking about sky diving – what do you think?
[dr raterman] 8:35 pm: Never jump out of a perfectly good airplane is my motto. However the Tampa area is home to a very active sky diving community, several of which are dong it on hip resurfacings, compliments of me.
[Firemanrick] 8:35 pm: I live alone, 6′ 1", have an Infiniti 2-door A/T. How soon can I drive post-op?
[dr raterman] 8:36 pm: My rehab protocol is very aggressive and I allow driving at three weeks or when you’re off narcotic medications.
[jim] 8:36 pm: have you seen any ‘yoga’ people or such dislocate the device? i’ve seen tae kwon do guys do 180degree splits after the procedure..
[dr raterman] 8:37 pm: No, the yoga people do extremely well and I encourage all my patients to begin yoga at 6 weeks post-op.
[mssams] 8:36 pm: What criterion do you utilize to determine if someone over 60 years old could be a candidate for BHR?
[dr raterman] 8:39 pm: I have a series of over 100 patients over the age of 65 who have had no revisions secondary to fracture or metallosis. I do not believe chronological age is the limiting factor, but physiologic age is the determinate in my practice. My oldest hip resurfacing is a 75 yea old male scuba diver.
[fmmike] 8:37 pm: Dr. Raterman, I am 8 days post operation from a left hip resurfacing by you and your team at Florida Hospital in Tampa. I can’t speak highly enough of your expertise and professionalism. Anyone considering this precedure in Florida (or anywhere else for that matter) would be wise to seek your council. Thank you!
[dr raterman] 8:39 pm: Thanks for the plug! Try to do the best I can for everyone.
[Pat Walter] 8:40 pm: Do you do bilaterals at the same time or prefer to do them one at a time with some time inbetween?
[dr raterman] 8:41 pm: I do bilaterals in selected patients and have had no significant problems. However they are in excellent condition with no cardiovascular history and a reasonable BMI. Most patiens prefer to space the procedures approximately 2-3 months apart.
[abc123] 8:41 pm: Dr. Raterman: What are your thoughts on where hip replacement or hip resurfacing is going? What are patients 10 years from now going to be looking at in terms of options? Same things as we see today in the MoM(metal on metal) resurfacing devices, more CoC(ceramic on ceramic)?
[dr raterman] 8:44 pm: While I’m not on the manufacturing side, it is very expensive to develop a new bearing surface and the market will be a niche market more than likely, which in the future is going to be very regulated, I am afraid. I have seen prototypes of ceramic and even carbon fiber; however, the manufacturer did not feel certain that the market would warrant the research and development costs. In the short term, I see metal on metal hip resurfacing as weathering the metal on metal hip replacement storm…with only a few surgeons doing a large volume.
[Pat Walter] 8:45 pm: What is the importance of choosing a surgeon with a lot of experience to one who does a few resurfacings now and then? Is there a learning curve to hip resurfacing?
[dr raterman] 8:48 pm: In my opinion, the main problem with metal on metal bearings has to do with technical issues of implant position which are totally in the control of the surgeon. A more experienced surgeon is helpful in this regard to lower the number of outlying positions which can occur. Data has supported a steep learning curve for resurfacing of approximately 100 procedures. And few surgeons seem comfortable with the larger exposure and instrumentation that hip resurfacing requires.
[Firemanrick] 8:46 pm: I saw you 13 months ago, apprehensive about giving up the bone I was born with, but now my hip is keeping me from doing things that involve a lot of walking. I believe its time for another appt. I’ve talked to several of your pts. in the Lakeland area & they speak highly of you.
[dr raterman] 8:49 pm: Thank you, will be happy to re-evauluate you at your discretion.
[GARYCAG] 8:48 pm: From your experience, can the hip resurfacing be saved if a pseudotumor develops?
[dr raterman] 8:50 pm: Pseudotumors represent a soft tissue reaction to a metal bearing and whether it is due to a patient sensitivity or a poorly positioned implant I would recommend changing the bearing surface at the time of excision of the tumor.
[jim] 8:50 pm: have any procedures been developed yet to ascertain the health of the femoral head and implant connection under the cap after resurfacing?
[dr raterman] 8:52 pm: Several isotope studies have been developed but errors in interpretation are common and they are not widely available. So they do not seem to be able to predict fracture and are used on a limited basis for research purposes.
[Pat Walter] 8:51 pm: Do you feel there are very many people with real allergic reactions to MOM or that many of the problems are from poor placement of components?
[dr raterman] 8:53 pm: Statistically, implant malposition is a much more common cause of soft tissue reactions than true allergy. Allergic reactions are approximately 1 per thousand.
[abc123] 8:51 pm: Do you have a standard protocal in your practice for blood work to test for Co/Cr levels at regular intervals? Should I ask my surgeon or GP to have these taken?
[Pat Walter] 8:51 pm: Should MOM hip resurfacing patients have blood test to check metal ion levels on a regular basis or only if there are problems?
[dr raterman] 8:55 pm: Fortunately I have never implanted a recalled hip. I would only recommend routine ion levels in that instance, as the ion levels that are considered acceptable have proven to be a moving target. With no one really having enough confidence to remove an asymptomatic hip in a patient with slightly elevated ion levels.
[GARYCAG] 8:54 pm: When you state changing the bearing surface in regards to the pseudotumor – does that mean a total hip replacement?
[dr raterman] 8:56 pm: Yes, I would convert to a total hip replacement.
[Pat Walter] 8:55 pm: Have you done any acetabular cup revisions for another surgeon’s poorly place component to save a hip resurfacing?
[dr raterman] 8:57 pm: Yes, I have revised acetabular components and preserved the femoral head to maintain a hip resurfacing. I have not had good success repairing fractured femoral necks or other post-traumatic injuries.
[rob] 8:58 pm: I am a 37 year old BHR recipient. Dysplasia and FAI were causal factors in my arthritis. I fear my son may have the same issues. Is there any early intervention for people like this… saving them a BHR or THR in the future?
[dr raterman] 9:00 pm: Yes, there is a strong familial component to hip dysplasia and a pelvic osteotomy can be performed at an early age which in European data has been successful in preserving or prolonging the need for hip resurfacing or replacement. It is not very popular in the US because of the size and magnitude of the surgery and is best done prior to the onset of significant symptoms or any arthritic change.
[Pat Walter] 9:00 pm: Dr. Raterman, Thank You for taking time to answer all our questions. It really helps to hear positive information about hip resurfacing and the future of hip resurfacing.
[dr raterman] 9:01 pm: My pleasure. Thank you all for your time.