A less-debilitating alternative to hip-replacement surgery

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When his right hip finally failed in 2006, when the grinding pain became so unbearable that he could no longer run or play golf, when he had to hoist his leg into the car using his arms, when the uber-active life he had known had ceased, Keith Gault resigned himself to the inevitable.
Hip-replacement surgery loomed.
At the ripe young age of 49.
So the Cool, Calif., resident, who works as a firefighter for the city of Sacramento, logged on to the Internet and started doing research. And he recoiled at what he found.
"With a total hip (replacement), they tell you, 'Don't turn your foot inward or raise your knee above 90 degrees,' " Gault says. "I'm thinking, 'Man, I'm going to be dislocating this thing every week with my lifestyle. I mean, if you're in your 60s or 70s and do knitting and nothing more, then a total hip is fine."
Knit one, purl two?
Not this dude.
Gault ran marathons and triathlons, even completed several ultramarathons, was an avid hiker and mountain climber, and harbored a deep and abiding passion for golf. Plus, he was a firefighter -- not exactly a cushy desk job.
"I'm thinking, 'There's got be something better,' " Gault recalls.
He eventually learned of a less-debilitating procedure, hip resurfacing, that preserves more of the femur (thighbone) and involves capping the tip and lining the socket with metal. That, proponents claimed, gave people more mobility so they could maintain their game on the tennis or golf course and hit the roads for cycling.
Problem was, hip resurfacing had yet to gain FDA approval in the United States when Gault first learned of it. He said he was just about to purchase a plane ticket to India to have the procedure done out of pocket when, in May 2006, FDA approval came.
So in January 2007, Dr. Raphael Klug of Kaiser Permanente Medical Center, in Roseville, Calif., performed the surgery. Three months later, Gault was again hiking, golfing and, of course, working.
"I feel good enough to go out and run a marathon," he says, "but it's not worth it. Not after what I've gone through. I believe that's how I got the hip there in the first place. Maybe I just wore the thing out."
Gault, now 52, was the perfect candidate for the less-severe hip operation, Klug says. In a way, he typifies the aging baby-boomer population, which plays hard and isn't willing to give in to degenerative injuries.
The thought of a "full hip" -- removing the top of the thighbone and replacing it with a prosthesis -- is anathema to many boomers, Klug says.
"I see a lot of guys in their 40s who were either athletes or who've done construction work, and they've got worn-out joints and still have to work and function," Klug says. "I didn't feel really good cutting off their femoral neck in a total hip (surgery). But that was the only option they had for a long time."
No longer. According to the American Academy of Orthopedic Surgeons, 39 percent of hip-replacement surgeries in 2006 were performed on patients ages 45 to 64. It's too soon to compile statistics on hip resurfacing, but, anecdotally, many of those younger patients are choosing reshaping over replacement.
"There's a little self-selection going on there for the active person," says Dr. Ron James, orthopedic surgeon for Mercy Medical Group in Sacramento. "With resurfacing, people are seeing it as liberation rather than limitation."
Make no mistake, James adds: Hip replacement remains the "gold standard" of care.
"The most reliable result is a total hip; it's a known quantity, especially in your 60s and 70s," he says.
Long-term studies on hip resurfacing have yet to be done. The procedure, after all, has only been done for 13 years, starting in Europe.
But, preliminarily, hip resurfacing has some distinct advantages and disadvantages.
Advantages: Because more of a patient's femur is preserved, a second surgery years later for a total replacement is made easier. Also, there's the greater stability in the joint, coupled with the possibility of greater range of motion.
Disadvantages: In resurfacing, there's a greater risk for fracturing the femur when the stem of the cap is implanted in the bone. Preliminary studies in Sweden and Australia have shown that there's a higher failure rate for resurfacing for women than men, most likely because of bone weakening from early onset of osteoporosis.
"If there's any weakness, you can be at increased risk of fracture," James says. "We're concerned about women, because they need smaller-size replacements. And it's that smaller size that is turning up to have slightly more problems than larger sizes (caps)."
Also, because resurfacing involves metal-on-metal artificial joints, Klug says "metal ions are shed in greater concentrations in blood and urine, so people with kidney disease or women of child-bearing age are not candidates."
Research has shown that standard hip-replacement parts (made of metal and plastic) last up to 20 years -- longer in a laboratory setting. As for resurfacing parts, Klug says, "The 13-year survivorship has been as good or better than a total hip. We can extrapolate that it should do at least as well as a total hip. But we don't know for sure."
Follow-up surgeries, the so-called "revisions," are common for both types of hip patients. The American Academy of Orthopedic Surgeons reports that 46,000 hip "revisions" were performed in 2004, the most recent data, and the number is expected to double by 2030.
With a second surgery looming a decade or two down the road, James says, the resurfacing patients perhaps will be more apt to have a better outcome.
For total-hip-replacement patients, "that second surgery is more difficult, and patient satisfaction, outcomes and functionality are far less than from the first surgery," he says. "Their range of motion deteriorates. They have more dislocations and infections, more bone loss, pain and blood loss.
"With resurfacing, when you do that revision, it turns out you're getting a result very similar to first (total) hip (replacement). That alone is wonderful."
But even hip resurfacing is not the same as having a healthy, organic hip. At February's annual meeting of the American Academy of Orthopedic Surgeons, a study was presented showing that resurfacing patients' high expectations for return to activities are often not met.
Sixty-two patients, whose mean age was 54, were interviewed up to 36 months after surgery. More than half had some pain that interfered with their sporting activities.
Gault, however, points to well-known endurance athletes including cyclist Floyd Landis and triathlete Scott Tinley, who have had hip resurfacing and returned to form.
So he's back climbing mountains, hiking and storming the golf course.
"This has given me my life back," he says.

(Sam McManis can be reached at smcmanis(at)sacbee.com)

(Distributed by Scripps Howard News Service, www.scrippsnews.com.)
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