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BIRMINGHAM HIP Resurfacing System surgery has helped more hip pain patients around the world than any other hip resurfacing surgery available. Their experience – and yours – can be broken down into four basic parts. Resurfacing spares bone instead of replacing it Unlike a total hip replacement (THR), the BIRMINGHAM HIP resurfaces the joint. The worn cartilage and damaged first layer of bone are removed and a fresh, low-wearing metal surface is installed. Total hip replacements require the removal of the upper segment of bone, the hollowing out of the upper half of the leg bone, and a large spike fixed to this upper bone, replacing the top part of the femur. For either procedure, the socket is prepared by shaving off the damaged cartilage and the first layer of bone. An appropriately sized replacement socket is pressed into the bone. For the BIRMINGHAM HIP, this socket has a new low-wear metal surface on the inside. For a THR, the socket often will instead accept a liner made of plastic, ceramic or metal. To prepare the head, or ball, of the hip for a BIRMINGHAM HIP head, the cartilage and first layer of bone are shaved off as well. The appropriately sized head is pressed onto the prepared bone, with bone cement used to fill any gaps and holes in the bone. For a THR, the head and neck of the leg bone are removed. A cavity is opened up in the upper portion of the leg bone to fit the stem of the THR. The stem is pressed into place and a ball is placed onto the stem. This new head is often much smaller than the patient's original head.  Your Bone, Your Anatomy The shape of your hip determines how it moves and feels. In total hip procedures, surgeons spend a lot of time assessing device position to try to restore your anatomy. Because the BIRMINGHAM HIP head fits over the neck of your leg bone in the right position for your hip ball, your anatomy is correct for you. Even if your leg is now short due to arthritis, the BIRMINGHAM HIP head fits where your head is supposed to be, often restoring leg length lost due to the degeneration of cartilage and bone. For those patients with more severe anatomic changes, skilled, BIRMINGHAM HIP trained surgeons can sometimes correct for anatomic issues. Only a trained surgeon can assess whether you are a candidate for this procedure. The BIRMINGHAM HIP Preserves Bone Density Bone gets denser when regularly loaded. If left unloaded, the bone atrophies, becoming less dense. Because a total hip is fixed about a third of the way down from the top of the remaining leg bone, the upper part of the leg bone loses density over time. A BIRMINGHAM HIP loads the upper leg bone more like the way that it is loaded normally. This is demonstrated in studies showing bone density improving from the pre-operated state(1). These studies show a decrease in the bone density of THRs, which has been demonstrated in many other studies. The BIRMINGHAM HIP leaves the option of a total hip for later Although failure of a BIRMINGHAM HIP is rare (less than 1.5% at 5 years in some studies), any joint procedure includes some risks. Total hips also have similar rates of complications requiring revision. Should a revision be required for a THR, removal is a complicated and time consuming procedure that then requires implantation of a larger, often stiffer THR. Each operation reduces the options left to the patient as time goes on. Because the BIRMINGHAM HIP procedure spares bone, a standard total hip stem could be used in a revision of a BIRMINGHAM HIP. For younger or more active patients who are more likely to cause an implant to come loose, this can be a great advantage. The developers of the BIRMINGHAM HIP paid attention to details. They looked at what had been successful in the past. They looked deep into the design and structure of those devices. They kept what they felt were critical features and performed studies to analyze those features that were in question. Two basic areas were found to be critical to the functioning and long-term performance of a metal-on-metal hip resurfacing. The first area was the design and metal phase of the bearing itself. For this, the surgeons had the advantage of being able to replicate the design and metal phase of metal-on-metal total hips that were used in the 60s and 70s. Those with low wear that were revised for other reasons were compared to those with unacceptable wear rates. Certain features were identified and form the basis of the BIRMINGHAM HIP design. Regarding fixation, none of the previous resurfacing devices clearly identified what would work best. The difficulty is that there was failure because of bearing problems, surgical problems and patient selection problems. A pilot study was done to determine the best method of fixation. Further development based in discoveries in other areas of total joint replacement helped refine the design. Now, after a decade of use, the fixation and design of the BIRMINGHAM HIP is the gold standard of resurfacing design. The Effect of Metal Phase on Wear The metal phase is also very critical. Unlike a mechanical device, the hip cannot have lubrication forced into it, nor can it run constantly. It, by its nature, starts and stops regularly. Each time this occurs, lubrication diminishes and the metal surfaces rub against each other. The study of early metal on metal total hips showed better performance from the parts that were cast from high carbon metal without further heating. The BIRMINGHAM HIP is intentionally left in the metal phase created from the casting process. This process leaves large blocks of hard material, called carbides, made from a mix of carbon and the metal. These blocks are significantly harder than the metal surrounding them, and they provide a significant amount of wear resistance. Heat treating the material causes the carbon to dissolve back into the metal, losing the wear resistance benefits. Many competitive resurfacings have been heat treated to make it easier to polish the bearing or to attach porous material for bone ingrowth. These products do not maintain the metal phase that has been proven in both the long track record of the early metal-on-metal total hip implants and the decade long track record of the BIRMINGHAM HIP. Press fit socket enhanced with bony ingrowth It is common today to have a socket that is firmly attached to the pelvis through the use of bone ingrowth. The most common way to achieve this is to attach a porous material to the back of the shell using a heating process that basically welds the materials together. To maintain wear properties, the BIRMINGHAM HIP must avoid heat treatment. Therefore, developing a porous surface on the back of the socket was a challenge. It was achieved by casting the porous surface and the shell at the same time. This eliminates the need to heat treat the structure maintaining the wear benefits. Additionally, the porous structure of the back of the socket is coated with hydroxyapatite (HA). HA is a material that is made from calcium phosphate and is similar in structure to bone. The design and coating of the BIRMINGHAM HIP have remained the same over the last decade, leading to consistent outstanding clinical results. Areas of potential developments The BIRMINGHAM HIP has demonstrated outstanding clinical performance. The key concerns clinically are with femoral neck fractures, which happen more in older, less active patients, and metal ion production, which is a problem for any metal on metal, or for that matter, any metal orthopaedic implant. Reducing metal wear is important and has been part of further R&D supporting the BIRMINGHAM HIP for the entire decade that it has been used. Clinically, metal wear in the BIRMINGHAM HIP has been of limited problem, restricted mostly to implants that haven't been positioned correctly. Any development in an improved bearing surface needs to be clinically evaluated and compared to the outstanding results shown with the BIRMINGHAM HIP. Femoral neck fractures have been shown to be related to patient selection, surgical technique and bone quality. Improving the implant design to work better with patients with poor bone quality is being undertaken now, but no obvious answers have been found. Therefore, potential improvements need to be studied clinically to see where they have benefits and risks. Surgeons who have been trained to use the BIRMINGHAM HIP System understand patient selection and the surgical technique issues. Other resurfacing components have been introduced with changes to the basic BIRMINGHAM HIP design. None of these have yet demonstrated any clinical improvement. Because of its outstanding clinical results, the BIRMINGHAM HIP design has remained constant over the last decade and will remain constant for some time to come. What is the hip joint and what does it do? Your hip is a ball-and-socket joint that allows you to move and balance. It’s made of bones, cartilage, ligaments and muscles. The two bones that are a part of the hip joint are the femur (thighbone) and the pelvis. The femur ends in a round ball, which fits snugly into the pelvic socket (called the acetabulum). This snug fit is cushioned by a smooth cartilage lining. A tough matrix of ligaments connects the femur and pelvis keeping the hip joint in place and functional. Muscles attach to the hip joint, providing the ability to move the legs. Common causes of hip pain and hip replacement Arthritis is the leading cause of hip pain. It is a progressive disease that wears away the smooth cartilage lining of the hip’s ball-and-socket joint. As the cartilage gets damaged and wears, the pain from the rubbing of the two sides of the hip joint increases. This pain eventually increases until surgical intervention is necessary. Total hip replacement and hip resurfacing are potential treatments for hip pain from arthritis. Before Surgery Your BIRMINGHAM HIP* Resurfacing System procedure starts with an appointment with your orthopaedic surgeon. This initial surgical consultation may include X-rays, a medical history and physical, and a list of your medications and allergies. Your surgeon may review the BIRMINGHAM HIP Resurfacing System procedure and answer any questions you have about hip pain, hip resurfacing or any other pre-surgical issues. Day of Surgery After being admitted you will be taken to the appropriate pre-surgical area where the nursing staff will take your vital signs, start intravenous (IV) fluids, and administer medications as needed. You will be asked to empty your bladder just prior to surgery, and to remove all jewelry, contacts, etc. (Rings not removed will be taped). Once you change into a surgical gown, you will be taken to the operating room. The anesthesiologist will meet you and review the medications and procedures to be used during surgery. Your surgeon will, of course, see the day differently. Your surgeon will start the operation with a technique to approach the hip joint. The surgeon then prepares the bone for resurfacing, using specialized instruments supplied by Smith & Nephew, the manufacturer of BIRMINGHAM HIP* Resurfacing System implants. The head of the femur is prepared to receive the resurfacing component, and the socket is shaped to accept the new resurfacing cup. Once this is accomplished the socket is inserted in a position to give stability to the hip, and allow the bone to grow around it. This encourages long-term security in the newly refinished hip joint. Finally, the resurfacing head component is fixed into position using bone cement. Following a careful inspection of all components your surgeon will then close the surgical approach path with sutures. It is common for the surgeon to leave a drainage tube exiting from just below the incision for a couple of days after BIRMINGHAM HIP Resurfacing System surgery, but in some cases it is not necessary. After Surgery Recovery from hip resurfacing usually begins the day after surgery. Many patients try a few steps with crutches. Most BIRMINGHAM HIP* Resurfacing System patients return home in two to four days. Many patients can get back to walking and low-stress activities quickly, but some may need to limit activities depending upon special conditions. Follow your doctors advice to do what is best for your particular situation. The weeks after hip surgery Walking is the key to a speedy return to your active lifestyle. But don’t overdo it. Swimming is good, but you shouldn’t attempt other sporting activities, including golf, until getting cleared by your surgeon. Talk to your doctor about planning a regular exercise and stretching program. Precautions after BIRMINGHAM HIP Resurfacing System surgery Although it happens very infrequently, the most common cause of revision for a BHR is femoral neck fracture. When this occurs, it is usually in the first 6 to 12 months before the bone in the upper femur adjusts to the resurfacing cap. During the first 6 to 12 months, the bone in this area gets denser and stronger, allowing greater use of your hip. Follow your surgeon’s advice regarding return to activity so that your have the best chance for success. The first 6 to 12 months after a BIRMINGHAM HIP Resurfacing System operation are the most vulnerable for the new hip joint. You’ll want to try out your new resurfaced hip. But you’ll also want to be smart, and take it slowly. Avoid heavy lifting and high-impact activities like jogging or jumping during this period. Don’t twist or squat. Driving can resume around four to five weeks after hip resurfacing surgery, pending physician approval, as can sexual relations - but try to avoid extreme movements of the hip for around three months. Your surgeon will provide more information specific to your surgery and condition. Click here (PDF, 70 KB) to review the patient information guide to hip resurfacing. Life after Surgery In many cases, patients having hip resurfacing surgery have been able to return to activities they enjoyed before hip pain. Remember to listen to what your body tells you, and what your doctor recommends. If you begin to have pain or swelling, contact your physician for advice. FAQS about BIRMINGHAM HIP RESURFACING SYSTEM How do I know if I’m a candidate for hip resurfacing? The BIRMINGHAM HIP Resurfacing is ideal for younger or active patients considering hip replacement surgery as a treatment for hip pain or hip arthritis. Hip resurfacing is especially relevant to patients concerned about bone conservation. Many hip pain sufferers under the age of 60 will outlive a traditional hip replacement and require a second, more difficult hip replacement surgery. For such patients, hip resurfacing might be the best route. Many active patients over 60 years old are also good BIRMINGHAM HIP candidates, following review by a physician. Inactive or elderly men and women are not ideal candidates for hip resurfacing surgery. Also, some chronic forms of arthritis severely deform the hip bones. Hip resurfacing may not be the best option for such patients. As always talk to your doctor about what choices are right for you. Surgeons trained on the BIRMINGHAM HIP will be able to evaluate you to see if you are a candidate. How long will my BIRMINGHAM HIP Resurfacing System implant last? It is impossible to say how long your implant will last because so many factors play into the lifespan of an implant. A clinical study showed the BIRMINGHAM HIP had a survivorship of 98.4% at the five year mark (3), which is comparable with the survivorship of a traditional total hip replacement in the under-60 age group. What are the disadvantages of hip resurfacing? The primary disadvantage is that hip resurfacing is a relatively new technology compared to hip replacement, and therefore has not generated clinical data beyond ten years. Still, many changes to traditional hip replacement devices have been introduced recently in order to address certain shortcomings. These also have a limited amount of clinical follow-up. The mid-term success has been extremely encouraging. The BIRMINGHAM HIP has been more closely studied and more widely implanted over more years than any other resurfacing implant system. The operation for hip resurfacing is similar to a traditional hip replacement, but not identical. Because hip resurfacing surgery conserves, rather than removes, the femoral head (thighbone), it may be considered a bone conserving procedure compared to traditional hip replacement surgery. At the same time, hip resurfacing surgery is, in some ways, a more demanding surgical technique for the surgeon. While the metal on metal implant used in the BIRMINGHAM HIP is more durable than the metal-on-plastic joints used for traditional hip replacement surgery, the resurfaced joint does still wear, resulting in an increase in metal ions in the patient’s blood and urine. It is also worth noting that in studies of patients with historical metal on metal devices, including those implanted for long periods, no adverse reactions have been documented. Because the BIRMINGHAM HIP relies on the femoral neck of the patient, femoral neck fracture can still occur. Femoral neck fracture is an unfortunately common problem in the elderly. A total hip eliminates this risk by removing the neck of the femur. |
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