Richard J Friedman, MD, FRCSC
Clinical Professor of Orthopaedic Surgery
Medical University of South Carolina
Chairman, Department of Orthopaedic Surgery
Roper Hospital, Charleston, SC.
Significant advances in orthopaedic surgery may allow squash players with previously disabling arthritis to continue playing at a highly competitive level. One of the most exciting procedures is hip resurfacing, a type of hip replacement that replaces the two surfaces of the hip joint, the ball and socket. The procedure is very bone conserving as the ball, or head of the femur, is retained. Instead of removing the head completely, as in a conventional hip replacement, it is shaped to accept an anatomically sized metal sphere. There is no large stem to go down the central part of the femur and the surface of the socket (the acetabulum) is also replaced with a metal implant, which is press fit directly into the bone.
The hip joint is designed for both mobility and stability, allowing the leg to move in three planes of motion. The hip provides an important shock absorption function to the torso and upper body as well as stability during standing and other weight-bearing activities. Arthritis of the hip is a disease that wears away the cartilage between the femoral head and the acetabulum, causing the two bones to scrape against each other, resulting in raw bone against raw bone. Osteoarthritis, or “wear and tear” arthritis, is the most common form of hip arthritis in North America. It is degenerative, and although it most often occurs in patients over the age of 50, it can occur at any age, especially if the joint is damaged or deformed in some way. When this happens, the joint becomes pitted, eroded, and uneven, with large bone spurs, or osteophytes, developing around the joint.
The most common symptom of hip osteoarthritis is pain, usually occurring towards the groin area and radiating down the front of the thigh during weight-bearing activities such as sports and walking. To decrease hip arthritis pain people usually compensate by limping, which reduces the force across the arthritic hip. Hip osteoarthritis will also result in a loss of motion of the hip joint, forcing patients to give up playing sports, being active and causing difficulty in doing simple daily living activities such as putting on socks and shoes. As a result of the cartilage degeneration, the hip loses its flexibility and strength. As the arthritis worsens, the pain may increase and become constant, even during non weight-bearing activities. All this leads to the clinical symptoms of pain, stiffness, and loss of mobility, with patients forced to give up their recreational activities.
Hip resurfacing procedure is primarily intended for use in younger patients who are in need of a hip replacement and wish to return to a high level of activity that may not be possible with a conventional total hip replacement. Such activities may include competitive sports such as running, cycling, tennis, racquetball and squash. In addition, patients who need a hip replacement and are under the age of 55, assuming they have a normal life span, have a very high chance that a conventional hip replacement will wear out and need to be replaced, or revised, during their lifetime, and therefore a resurfacing procedure offers potentially significant advantages in this age group.
Hip resurfacing may make future revision surgery easier because hip-resurfacing surgery leaves your femoral head in place and there is no large metal stem placed in the thighbone. A second replacement, or revision surgery of a conventional total hip replacement where your femoral head has already been removed and a large stem is already in place can be a more difficult operation, and consequently may last a shorter time than the original replacement.
For people needing a hip replacement under the age of 55, regular consideration is given for this procedure. People aged between 55 and 65 who are very active and otherwise fit may also be suitable for a hip resurfacing procedure, based on their bone quality and activity level. The procedure is rarely indicated for people over the age of 65, however, because a conventional type of hip replacement has an extremely good chance of lasting for the rest of their lives and allowing them to be as active as they wish.
The long-term results of this procedure are not yet known, as it has only been in clinical usage in its current form for 12 years; however, the results over this period have been excellent and are at least as good, if not better, than a conventional hip replacement. The long-term reliability of the implant will not be known until it has been in widespread usage for 15 to 20 years. Therefore, the main disadvantage at this time with this procedure lies in not knowing the long-term results. However, even if this procedure allows young patients to remain active in competitive sports for only 10-15 years, that is 10-15 years more than they otherwise would have with a conventional hip replacement, and the hip resurfacing has provided them with a marked improvement in their quality of life.
Although the operation for hip resurfacing is similar to a conventional total hip replacement, in some ways it is a more demanding surgical technique. Instead of cutting off the arthritic femoral head, the head is reshaped and resurfaced with a metal mushroom-like cap. This is secured in place with a type of cement. The hip socket is prepared in a similar fashion to a total hip replacement. Once the diseased cartilage is removed, a cup is press-fitted into place. Hip resurfacing leaves more of your natural bone in place and does not remove the femoral head or neck. The procedure may be performed under epidural, spinal or general anesthesia. Patients are usually discharged home after two to three days.
Recovery from any operation varies from patient to patient and post-operative rehabilitation programs vary from surgeon to surgeon. However, in most cases you will progress with your weight bearing status, going from a walker or crutches to a cane and then walking independently as quickly as possible. Other exercises will focus initially on regaining your range of motion, then muscle strengthening, and eventually stretching exercises. It is important to follow your surgeon’s instructions regarding progression to normal weight bearing and resumption of normal physical activity. The rate and effectiveness of your rehabilitation is critically dependent on your commitment to the physical therapy program as well as other clinical factors.
Hip resurfacing remains a relatively new procedure compared to a conventional total hip replacement, but it offers young active high demand patients the opportunity to return to normal activities.
RJ Friedman
Note from Richard Millman:
Richard Friedman is an active player and enthusiastic supporter of squash. He recently won his division at the Charleston Open in South Carolina. Richard is always available to talk about Hip Resurfacing and indeed other orthopaedic conditions. He is one of the most experienced Hip Resurfacing surgeons in the US today. You can reach Richard by emailing him at rjfriedman@mybones.com.
Hip Resurfacing—Richard Millman’s perspective 2 years out.
As many readers will know from my highly dubious Squash Magazine photo a couple of months ago, I am the lucky recipient of a Birmingham Hip Resurfacing, the procedure described in the article above by Richard Friedman. I wrote a comprehensive journal of my experience when I went to Chennai in India to have my procedure performed by the extraordinary Dr Vijay Bose.
At that time Birmingham Hip Resurfacing (BHR) was not FDA approved here in the USA. The very few clinical trials were beyond my financial means, even if the surgeons had had enough experience to elicit enough confidence to undergo uncharted territory. I was fortunate indeed, Dr Bose had trained with Ronan Treacy and Derek McMinn (the British inventors of the procedure) and had at that time done more than 700 BHR procedures. My BHR experience was wonderful and my time in India was the holiday of a lifetime—even if it was for surgery, I would recommend the trip with all my heart.
Now, I am delighted to say that Hip Resurfacing is available in the US and the insurance companies are covering it, sometimes even overseas. I have given my personal story and recommendation to an ever increasing number of squash players and I am happy to report that everyone who has decided to have the BHR is now fit and well and playing squash.
My list of suggestions if you are suffering hip pain and finding squash difficult:
Get an MRI and X-ray in consultation with a surgeon who has performed many Hip Resurfacing surgeries (there are now experienced surgeons to my knowledge in New York, Chicago—my friend Richard Friedman here in Charleston, SC).
Make sure they use either the BHR or Stryker procedures. Don’t be a guinea pig—make sure the surgeon has done several hundred surgeries. I strongly recommend checking out several websites: www.hipresurfacingindia.com is the site of my surgeon Dr. Bose and is full of great information. www.surfacehippyinfo.com is a group help site that is very useful. Richard Friedman’s site: www.mybones.com/procedures.php (click on Hip Resurfacing).
After surgery don’t make the same mistake I made and pay lip service to your rehab. I found out a lot about the mechanics of my body that I wish I’d known before I hurt myself. Unfortunately I found out after I neglected my rehab. I recommend that you approach your rehab as though you were an Olympic athlete preparing for the most important event of your life. And don’t try and do it on your own. Find the best sports physical therapist and the best personal trainer you possibly can and turn this surgery into an opportunity to not only recover, but to achieve the best conditioning ever.
With regard to my own recovery, I am now in the best shape I have been in for 15 years. I am training like fury and I am doing everything I can to prepare to compete in National and Worlds Championships. I don’t know what I am capable of, but I do know that there is no physical reason that I can’t succeed—thanks to Dr Bose and my Birmingham Hip Resurfacing. If you are having any hip pain—don’t hesitate! Act now and feel young again!
