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Revolutionary hip operation that's left patients crippled for life

By ANGELA BROOKS
Last updated at 12:24 AM on 10th March 2010

It's supposed to be the cutting edge answer to arthritis. But as this shocking report reveals, hip resurfacing can wreak havoc with your body.

John Hallam was right when he thought that hip resurfacing would change his life.

Only it didn't change it in the way he was expecting. Four years ago he consulted an orthopaedic surgeon about his painful arthritic hip.

The retired solicitor believed hip resurfacing would be a less drastic alternative to total joint replacement and allow him to enjoy the sailing for which he'd moved to Cornwall.

But today, John needs a stick to walk because metal particles from his resurfaced hip triggered aseptic lymphocytic vasculitisassociated lesions (ALVAL), which destroyed the blood vessels and muscles in his hip.

Shockingly, John is far from unique. The serious problems caused by hip resurfacing and metal hip replacement joints are just starting to emerge.

Hip resurfacing is designed to tackle arthritis - where joint cartilage is worn away leaving bone rubbing on bone, which causes severe pain.

With conventional hip replacement, the hip socket is relined and the worn-out top of the thigh bone is replaced with a prosthetic ball. In resurfacing, the socket is relined, but the ball is covered with a smooth cap.

The first resurfacing was performed in the 1950s, and was a catastrophe. As the ball moved, tiny particles of teflon were shaved off, triggering an immune response which destroyed bone and soft tissue.

So British doctors were sceptical when, in the 1990s, surgeons in Birmingham developed cobalt chrome resurfaced hips.

'From the word go, there were reservations,' says John Skinner, an orthopaedic surgeon at the Royal National Hospital in Stanmore. 'There were fears that some patients could develop a hypersensitivity to the metal.'

Yet these fears abated as promising early results started trickling through. The new approach was held to be less likely to dislocate or to cause fractures.

When orthopaedic units reported good results, the excitement became hard to contain. Worldwide, tens of thousands of people bought into the dream that hip resurfacing seemed to offer - a pain-free hip that could last ten to 15 years with no - limitations on an active lifestyle.

In the early Noughties, sales of resurfacing implants soared to approximately ten per cent of the 70,000 hip replacements carried out in Britain each year - 40,000 people now have resurfaced hips.

But about five years ago, surgeons noticed problems - patients starting complaining of pain around their resurfaced hip.

Their X-rays appeared fine, but, says Dr Skinner, investigations showed patients with pain were more likely to have high concentrations of cobalt and chromium in the natural lubricating fluid which would collect around the groin and the joint.

'On the mild end of the spectrum, patients were reporting pain and tenderness and would have inflamed thickening of the soft tissues around the hip,' says Dr Skinner. 'With the most severely affected patients, you'd see loss of muscle and bone caused by cell death in and around the joint.'

This is what happened to Hamish Muirhead. The retired businessman, 72, was referred to Dr Skinner after years of agony following hip resurfacing in 2001. He'd been booked for an outpatient appointment, but was admitted immediately. 'He was extremely ill.' says Mr Skinner. 'I've seen an awful lot of these ALVAL patients, and he was the worst I'd ever seen.

Risks: Hip resurfacing is designed to help arthritis sufferers. The first operation in the 1950s was a catastrophe

'His hip socket was totally destroyed and what was left of the ball was loose and resting against part of the remaining pelvic bone. He had a wound in the side of his hip you could put a fist through that would not heal. He had lost most of the gluteal muscles (buttock muscles), some of the top of the hamstring muscles and he also had secondary infections.'

Hamish spent the next six months in hospital, needing three operations to cut out the dead tissue and bone.

Last year, he had a replacement hip fitted - necessary because he had so little pelvic bone remaining.

Because of the lost bone in his hip and leg, his left leg is now 3.5cm shorter than the other one. He hobbles and needs a stick.

'Before all this I'd play golf three times a week. My golf club have told me to just come down and play at a time if I want - and I fully intend to - in a buggy.'

Last year, consultants at the Nuffield Orthopaedic Centre, Oxford, termed the swellings that ALVAL can cause inflammatory pseudotumours - benign tumours which caused cell death. In a paper published last year, the Nuffield group noted that women were more likely to be affected, and that women under 40 were at the highest risk.

In a group of 1,224 patients who had hip resurfacing over the past ten years, four per cent needed a new hip because of pseudotumours, while the figure rose to six per cent for women over 40, climbing to 13.1 per cent in women under 40. The average rate of repeat surgery following conventional hip replacement is between one and three per cent.

So why do younger women appear to be at greatest risk? One theory is that some patients develop a hypersensitive reaction, and this is more likely to occur in younger women because the implants are harder to fit accurately in smaller-boned women.

This is technically unforgiving surgery, where perfect alignment is absolutely paramount as the slightest error could mean the ball isn't cradled perfectly in the socket, leading to friction which releases metal particles.

Investigators also know that implants with a smaller surface areas aren't as well lubricated and could be prone to more wear.

'What we are striving for is a perfect fluid film between the ball and the socket,' says Mr Skinner. 'This means that the surfaces aren't touching each other, so won't cause friction. The bigger the radius of the ball, the more likely we are to achieve that.'

As fears over these issues grow, sales of resurfacing implants in Britain have fallen. Surgeons say patients with pain-free resurfaced hips should have no cause for concern, but younger women are being counselled against it because surgeons have no way of predicting those who will be affected.

However, the surgery remains an option for younger, robust men who appear to fare best with it. Kevin Jervis, 49, a police sergeant from Norwich, was a perfect candidate. He lived in continual pain so intense he couldn't put on his own shoes, so had both hips resurfaced in 2003.

He has since gone on to achieve the highest Tae Kwon Do ranking, and says hip resurfacing has given him back his life.

Jeremy Latham, consultant orthopaedic surgeon at Southampton General Hospital, says: 'Some orthopaedic surgeons who do a lot of hip surgery have some concerns about resurfacing. But this needs to be kept in perspective.

'Hip resurfacing remains a good option for the right patient. I think we need to carefully to screen and select patients so we can tailor the best procedure for every patient.'

However, the Medicines and Healthcare Products Regulatory Agency is concerned enough to have set up an advisory group. It is preparing a briefing which is expected to form the basis of advice to be issued to patients next month.

Read more: http://www.dailymail.co.uk/health/article-1256521/Revolutionary-hip-operation-thats-left-patients-crippled-life.html#ixzz0hxpAu1zX

From Times Online

November 23, 2009

Is hip resurfacing the best solution for arthritis?

Hip resurfacing has been marketed as a superior alternative to full replacement for younger people. But think carefully

Dr Mark Porter

RECOMMEND? (1)

At least a quarter of a million people in the UK are troubled by arthritic hips — a problem that often comes to light in early middle age when pain and stiffness start to limit activities such as tennis, golf and weekend walks. Surgery is the definitive treatment and works very well for most people, but in the past decade there has been a shift away from conventional hip replacement towards the newer hip resurfacing techniques that are supposed to be better suited to active lifestyles. But is resurfacing all it’s cracked up to be?

I have two friends, one aunt and a handful of patients who have had their hips resurfaced over the past few years and all are doing well, but experiences elsewhere suggest others may not be so lucky, and I am now much more cautious about recommending it than I used to be.

The concept of hip resurfacing has been around for decades but only started to make a significant impact in the UK in the late Nineties. It now accounts for 8 per cent of the 65,000 hip replacements performed every year, and around half of all procedures in patients under the age of 50. But the latest figures suggest that this upward trend is reversing amid concerns that resurfacing has not lived up to the initial hype.

Arthritic joints in younger patients have always presented a challenge to surgeons because artificial hips of all types wear more quickly in active recipients. A typical elderly patient undergoing hip surgery for arthritis can expect their new hip to be trouble free for at least ten years. But for someone aged between 55 and 75 there is a 1 in 14 chance that they will need to have their hip operated upon again (revised) within a decade, and in the under 55s this doubles to around 1 in 7. It was hoped that resurfacing would be the solution to this premature failure.

Conventional hip replacement involves cutting out the arthritic joint and replacing it with an artificial one made up of a metal ball on a stem wedged or cemented into the upper part of the thigh bone, and a smooth cup (typically plastic) inserted on the socket (pelvic) side. In terms of patient satisfaction, it is one of the best operations modern surgery has to offer, but plastic sockets are prone to wear, and both stem and socket can work loose if subjected to too much stress and strain.

Resurfacing involves shaving the arthritic ball side of the joint and covering it with a metal cap, which then fits into a metal socket on the pelvic side. The theory being that this “metal-on-metal” hip will be more durable, and even if it does fail prematurely, it is easier to revise because you can cut off the resurfaced ball and put in a conventional prosthesis.

And so hip resurfacing was marketed as the 21st-century approach to arthritic hips amid claims that it was a stronger, more stable alternative to conventional hip replacement and ideal for active people — a campaign backed by endorsement from numerous sportsmen and celebrities. But more than ten years down the line the picture isn’t looking so rosy.

The latest figures available from the UK National Joint Registry (NJR) show that the three-year revision rate — a measure of the number of artificial hips that fail and require replacement — is nearly four times higher for hip resurfacing than for conventional hip replacement (4.5 per cent versus 1.3 per cent).

Perhaps most worrying of all is that resurfacing appears to be second best even in the group to which it is most actively promoted — men under the age of 55. Data from the NJR suggests that they are at least one and a half times more likely to need a repeat operation within three years if they opt for resurfacing rather than the best of the conventional procedures. And older patients and women fare much worse. A woman aged 65 who opts for resurfacing could be up to ten times more likely to require revision within three years compared with one who had a total hip replacement.

But high failure rates are not the only worry. There is also concern about the side-effects of chromium and cobalt ions released when the resurfaced ball joint rubs against the metal socket in the pelvis. The leaching of these metals into the rest of the body may prove harmless, but there are suspicions that, as well as causing localised tissue and bone damage, it could have a detrimental effect on other organs in the body. Only time will tell.

John Timperley, honorary secretary of the British Hip Society and a consultant orthopaedic surgeon in Exeter, believes that it is time that marketing campaigns were countered by hard fact: “The belief held by many patients that the newer resurfacing technology must be better, simply doesn’t stack up when you examine the evidence — indeed the opposite is true. New in this context means experimental, whereas the prostheses used in the more established hip replacement have been tried, tested and refined over decades. I know which I would choose.”

But as a consultant working at the hospital that developed the leading conventional prosthesis, you might expect him to say that.

Martyn Porter, who chairs the editorial board at the NJR and operates at the Centre for Hip Surgery at Wrightington Hospital in Lancashire, also has reservations about resurfacing but feels that patient selection and the experience of the surgeon are key factors. “Some surgeons have published very low revision rates for resurfacing suggesting that experience and high volumes lead to better results. Even so, it is now probably best reserved for younger men.”

Bottom line? As with all surgery, choosing a good surgeon, experienced in whatever approach they advise, remains the best option. A new hip has to be tailored to the individual — there is no one ideal fix for everyone — so if your surgeon suggests a conventional replacement, don’t push for resurfacing just because you have heard it is better. It is unlikely to be.

For more information visit the National Joint Registry at njrcentre.org.uk.

E-mail questions to drmark@ thetimes.co.uk or write to times2, 1 Pennington Street, London E98 1TT