How often do I have to attend for follow up?
Professor McMinn will outline follow-up protocols for patients based on their procedure. Normally, patients are followed up by X-rays and questionnaires and in certain circumstances with Metal-Ion testing if required.
When can I get back to hobbies and sporting activities following my Birmingham Hip Resurfacing (BHR)?
Watching our patient video testimonials will give you an insight of what activities our patients can do following their recovery after surgery. Joined @ the Hip is our patient focussed blog featuring the thoughts, stories and experiences of Mr McMinn's patients over the years. If you would like to know when you can start activities again after another one of Mr McMinn's implants please get intouch with us on firstname.lastname@example.org.
- Gardening - At about 2 months following post-op review
- Golf - Start gently at 4-6 months after operation and gradually increase
- Tennis - Start gentle doubles tennis at around 6 months after operation and gradually increase
- Skiing - 1 year post-op
- Running and jogging - 1 year after operation. At around 11 months, you may start jogging on a treadmill with good quality running shoes or trainers. Do this for a couple of months before you start running or jogging outdoors or participating in high-impact sporting activities like squash, cricket, football etc.
Do hip implants set off metal detectors at airports and do I need a letter to confirm implant in situ?
Patients do find that their hip implants set-off metal detectors at airports. A letter from a doctor is no longer given any credence by security officials because of the ease with which they can be 'created'. They may want to make further physical checks to be sure for themselves. We can however provide you with a letter if you wish.
Is there anything I should do prior to surgery to get into good shape i.e diet, vitamins, exercise etc?
It is important for you to have good quality bone in order for a Birmingham Hip Resurfacing to be successful. Anti-inflammatory medications and Aspirin tend to damage the bone in the femoral head of an arthritic hip.
You will find it beneficial to maintain good muscle strength prior to surgery as this helps with your post-operative recovery. This can be achieved by continuing to exercise within the limits of your own comfort, in particular, cycling and swimming.
Do I need to take antibiotics for dental treatment following hip surgery?
Antibiotic cover is advisable before any dental treatment for the first three months following hip/knee arthroplasty. Thereafter, there is no need for antibiotic cover unless you are being treated for an infection/sepsis (your Dentist will advise you if this is the case). In the presence of infection/sepsis, however, it is important for you to have dental antibiotic cover for dental treatment at all times.
What is the difference between a Birmingham Hip Resurfacing (BHR) and a total hip replacement (THR)?
The fundamental difference between a Birmingham Hip Resurfacing (BHR) and a conventional total hip replacement (THR) is in the femoral (thigh) side. A THR has a long stem inserted into the canal in the thigh bone. Hence the natural femoral head and part of the neck are removed and weight is transmitted through the stem directly into the upper third of the thigh bone. In a resurfacing, the aim is to preserve most of the femoral head and neck. The resurfacing femoral component therefore has a thin (3 to 4 mm) hollow ball surface that directly transmits weight to the femoral head bone underneath it and a very small stem that is not designed to transmit weight. The socket component can be similar in both the THR and a BHR.
There are other differences between a Conventional THR and a BHR. Conventional THR sockets are made of polyethylene (PE). Wear-debris generated from PE wear leads to loosening of the components. This is the primary cause of long-term failure of conventional THRs. PE wear and loosening are directly related to activity. Hence these THRs do not last well in younger and more active patients. In addition, the minimum thickness needed for a PE socket required that the femoral head had to be smaller in diameter than what a metal-metal joint would permit. A small diameter head has the potential to dislocate more readily than a normal hip and therefore the dislocation rates with conventional THRs are greater than those with BHRs.
However, the beneficial effects of a metal-metal joint have now been transferred from the resurfacing technology to replacements as well. These large diameter metal-metal THRs are showing great promise in reducing wear and dislocation rates. The only difference between a BHR and such large diameter metal-metal joints is the long stem. In a BHR, the absence of a long stem makes a revision, should this ever become necessary in the future, easier.
What is a Birmingham Hip Resurfacing (BHR) made of?
The ball (femoral) and socket (acetabular) components of a BHR are made of a tried and tested alloy of cobalt and chromium. This has been in use in orthopaedic surgery for over 70 years. The original alloy is an as-cast highcarbon alloy. The higher carbon content precipitates in the alloy as carbides which have the hardness of ceramics. They give the metal the needed resistance to wear. These carbides can be depleted by heat treatments in the later stages of manufacture - a process that is used in some other brands of resurfacings. They no longer enjoy the same wear resistance as an as-cast device such as the BHR. More information on the Birmingham Hip Resurfacing (BHR).
Who is a Birmingham Hip Resurfacing (BHR) suitable for?
A resurfacing is suitable for the treatment of a hip with severe arthritis when the femoral head bone quality is good. It is used more often in young and active patients than older and less active patients because conventional replacements do not last long in young and active patients. Further, a younger patient is more likely to need a revision of an artificial hip at some stage later in life, and it is easier to successfully revise a BHR than a THR.
BHR is likely to fail in patients with poor femoral head bone quality. Therefore, patients with poor femoral head bone quality are not suitable for a resurfacing.
More information on the Birmingham Hip Resurfacing (BHR).
When is the right time to stop waiting and have surgery?
Hip Resurfacing is an operation for pain, discomfort, soreness or stiffness arising from advanced arthritis of the hip, especially if the symptoms are seriously affecting your quality of life. In the absence of severe changes in your hip, other measures should be tried. However, once advanced changes develop, there is no merit in continuing to put up with it, especially if you are being forced to take anti-inflammatory medication regularly to keep the symptoms at bay.
It should also be noted that the typical patient is not in continuous pain or ache from the hip day in and day out. Most patients complain that their discomfort is related to activity. As long as they refrain themselves from
being active, they are comfortable. Participating in simple activities, which they had enjoyed all their lives, now seem to flare up their symptoms and make them suffer later that day or the following day.
Taking long-term anti inflammatory medication or aspirin tends to damage bone quality of the femoral head (ball part of the ball and socket hip joint) making it impossible to perform a successful hip resurfacing. In addition, these medications tend to make you bleed more at operation and cause more bruising and internal bleeding after the operation, thereby hampering your recovery and rehabilitation greatly.
What physical restrictions do you have after a BHR?
The day after your hip resurfacing operation you will be encouraged to stand and start walking. This early resumption of activities is one method of avoiding pooling of blood and unwanted clotting in your leg veins.
The first six weeks after the operation you are in the phase of soft tissue healing. Therefore you will be advised not to put your hip through extreme ranges of movement in order to avoid a dislocation.
After this period, the degree of soft tissue healing is adequate to protect your hip during any voluntary movement. As a matter of fact, the tendency of the healing scar is now to contract in order to gain strength. Contracting scar has the potential to create a stiff and sore hip unless the hip is subjected to regular exercise during this period. Hence you will be encouraged to progressively increase your range of hip movements and increase the strength in the muscles around the hip by resorting to activities like swimming and non-impact exercises in the gym (such as using the bicycle, rowing machine, cross-trainers etc). Any exercise that does not result in excessive loading of the hip is good at this stage. You should try and avoid high impact-loading exercises like running, jogging, football, squash etc for at least a year after the operation.
As your hip improves in flexibility and stability, you may gradually resume your hobbies over the next few months. You may start playing a gentle game of golf after around 4 months and doubles tennis around 6 months. During the next few months, as you find improvement in the strength of your hip, you will be able to play more rigorously. If you are very keen on resuming impact loading sports then please start jogging on the treadmill with good footwear for a few months starting around the eleventh month before moving on to outdoor jogging or high-impact sports.
The McMinn Centre produced a four-part documentary series about the first 12 months after BHR surgery. Click to watch Jim Jenkinson's Recovery.
How long will the implant last?
The development of modern hip resurfacings was based on the secrets of success gleaned from successful historic metal-metal hip replacements which proved their wear resistance, durability and biocompatibility over several decades. The era of modern metal-metal hip resurfacings started in 1991 when Mr McMinn pioneered them. The early models were prototypes that gave precious further information on the best design and material combinations that would make resurfacing successful. Review of the surviving hips amongst these early prototype models show that some of them are still functioning well, in spite of heavy usage over the past 20 years. The hybrid fixed model turned out to be better than the others. Hybrid fixation was therefore adopted in all later models. In 1997, the fixation was made even more reliable using an advanced porous fixation surface and the Birmingham Hip Resurfacing (BHR) was introduced. Mr McMinn has performed over 3400 BHRs since 1997 and over 150,000 BHRs have been performed worldwide.
Orthopaedic surgeons consider that an implant has failed if following the original surgery, the patient goes on to have another operation for revision of one or more of the components of the implant. Failure of the component could be either due to a fracture, loosening or any other cause leading to pain and loss of hip function. Nearly 12 years on following the introduction of the BHR, the failure rate in our group of over 3000 patients is 1.6%. Fracture of the femoral neck or a collapse of the femoral head due to pre-existing inherent weakness in the bone or due to premature excess activity early after the operation led to failure in 1.1%. Infection and some other very rare causes such as dislocation or metal allergy led to failure in 0.5%. All of these have then been converted to a total hip replacement and the patients are back to a normal lifestyle following their revision surgery.
Based on the trend of time to failure of an implant, statisticians calculate implant survival to denote what percentage in a given group of patients are likely to reach a certain time point, such as 10, 15 or 20 years after an operation, without the need for a revision. In the younger age group (under 55 years) with osteoarthritis, the implant survival in Mr McMinn's series of BHRs is 99.5% at 11 to 12-years follow-up. The comparative figures for implant survival with the conventional cemented Total Hip Replacement in this age group and diagnosis are 81% at 10 years and 33% at 16 years, according to the Swedish Hip Arthroplasty Register.
What is the difference between a Birmingham Hip Resurfacing (BHR), Birmingham Mid Head Resection (BMHR) and Total Hip Replacement (THR)?
Click Here for a printable information sheet which will give an overview of the variations between the different component options (requires Adobe Acrobat Reader)
Does Mr McMinn have any information for patients concerned about metal ions?
Yes. We have a list of questions (posted by hip resurfacing users) which have been answered by the McMinn Research team. Please click here to see the full list of questions and answers.
What are pseudotumors and what causes them?
A few centres have reported a phenomenon, which has been named pseudotumors by a renowned orthopaedic hospital in Oxford. The term pseudotumor refers to a problem, whereby a hip resurfacing or a metal-on-metal (MoM) hip replacement fails with a painful swelling or with collection of fluid around the hip joint. The word pseudotumor has caused consternation among patients who were worried if this is some kind of a hidden cancer or a pre-cancerous condition. These need to be put into perspective. First, let us be clear that these reactions have nothing to do with cancer.
Second, there isn't a single artificial hip system metal, ceramic or plastic, that does not generate wear debris and all types of wear debris have been associated with these pseudotumor-type adverse reactions.
Third, it is now becoming apparent that in a majority of cases of pseudotumors, the primary reason for the development of these reactions is excessive material being worn out from the device because they had been fixed in a skewed fashion in the first place. No artificial hip device lasts long unless it is placed in an optimal position. The components that had been removed in Oxford were tested in a highly sophisticated laboratory. It was found that in every case with a pseudotumor, the wear pattern in the components suggested edge-loading i.e. the components had worn excessively in an unnatural manner because of their placement in an unfavourable position. In components which did not show edge-loading i.e. those components which had been placed in the correct position to start with, no one had developed a pseudotumor.
Most modern artificial devices whether metal, plastic or ceramic, do not tolerate surgical error in component positioning. They wear excessively if they are fixed incorrectly and in the case of ceramics or modern plastics they can also break. Excess wear leads to pain and failure. Hip resurfacing is a technically challenging operation and minor surgical error may occur, especially when performed by surgeons who are not highly experienced. The degree of difficulty is further increased if the patient is a woman because hips in some women may be shallow or the upper end of the thigh bone directed differently. Their bones are petite, leaving no margin for error. The design of some types of resurfacings has been shown to be even less tolerant to minor malpositioning. One Centre reported pseudotumors only with ASR resurfacings, while they did not see any with Birmingham Hip Resurfacings. Therefore an experienced surgeon and a well-proven device are the key to success with a resurfacing.
Furthermore some women are constantly exposed to metals like nickel in costume jewellery which may pre-sensitize them to the tiny amounts of nickel found in the resurfacing or replacement components. It is not yet clear if there is a very tiny group of patients who would react badly in the face of expected and regular amounts of wear. The percentage of patients who may react like that is believed to be very rare, of the order of 1 in a 1000 or less.
The McMinn Centre's response to the MHRA Alert has more information.
What symptoms do these patients develop?
Out of over 3000 resurfacings over the past 12 years, we had 11 patients who were treated for a local adverse reaction like this. In a majority of these there was only a collection of fluid around the hip joint nearly 10 years or more after their original operation. They complained of groin pain or discomfort. A few developed swelling of the foot or ankle because of the collection of fluid above. In many cases there were subtle X-ray changes, although not in all.
What is the solution if a person develops a pseudotumor several years after a hip resurfacing?
If a person presents with a history suggestive of a pseudotumor, he/she needs to be examined by an orthopaedic surgeon and undergo X-rays, a special multi-slice CT scan and some blood tests in order to establish the diagnosis. The CT scan must be able to reduce artefact from the metal in order to provide any useful information. In some cases it may be necessary to exclude infection by aspiration of the hip joint. If it is indeed a pseudotumor then a revision operation to convert the resurfacing into a total hip replacement with a non-metal-metal bearing will have to be performed.
How do patients recover after revision of a resurfacing to a hip replacement for a pseudotumor?
The 11 patients described above have recovered as if they were recovering from any first hip replacement. Their hips are functioning well. The worst affected of these patients underwent the revision operation in January 2010 and needed bone grafting of the acetabular socket. She has seen the sensational reports in the newspaper and questions, "What is all the fuss about? I have had 10 good years of my life restored to me. I had then been in my early 50s and now I am in my 60s. I noticed hip discomfort a few months before the 10th anniversary of my operation and I had to undergo a revision operation to convert my hip resurfacing into a hip replacement and I am now getting back to normal again." She adds, "Ten years ago, had I known that I would need a revision at this stage I would not have changed one thing. I would have gone ahead with the resurfacing operation." Two months after her revision operation, she kindly agreed to be filmed and you can follow watch her interview here.
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