COLUMBIA — On Monday, disputed 2006 Tour de France champion Floyd Landis set out to the start/finish line on Market and 7th Streets in downtown St. Louis, facing the Arch along with 118 other professional cyclists to kick off the long-anticipated Tour of Missouri.
The countdown from the crowd around the riders echoed past the massive buildings and into an overcast but brightening sky: "Five ... four ... three ... two ... one." And with that the metal herd was off: hundreds of feet shoving pedals to the earth, twisting gears, spinning wheels and stirring the air before casting it against the howling spectators in a cool breeze.
As Landis eased around the bend of the turn ahead and melded into a mass of riders, it was not at all apparent that he was competing in the seven-day, 612-mile race on an artificial hip to correct a condition that, until about 1997, would have ended the career of any professional athlete.
Just before stage one in the circuit race in St. Louis, Landis, 33, took a few minutes outside of his tour bus — roped off from the dozen or so fans waiting to meet him — to talk about the surgery three years ago that helped him return to competitive cycling. "Apart from people wondering how (the hip is) doing, I pretty much forget that it's there," he said.
He would not answer questions about the doping allegations that cost him the Tour de France trophy. "Pretty much everything's been said about that," he said. In 2007, Landis wrote a 306-page book seeking to clear his name from such charges: "Positively False: The Real Story of How I Won the Tour de France."
But Landis did say he would like to compete again in the Tour de France if given the opportunity, and that he wrote the book because he felt it was important to tell the story from his point of view.
Birmingham Hip Resurfacing, the procedure that restored Landis' hip, is available for younger patients who suffer with an early onset of arthritis in the hip, typically from diseases like osteoarthritis, hip dysplasia and avascular necrosis. Unlike a total hip replacement that replaces the hip joint with a metal joint and plastic socket cup, BHR, as it is known, shaves the arthritis off the head of the hip bone, which is then covered with a metal cap and inserted into a metal socket cup.
It is the metal-to-metal feature of the BHR operation, coupled with minimal bone loss, that appeals to arthritic patients who want to remain physically active.
"The biggest advantage of the Birmingham hip is that you just don't put restrictions on people," said Dr. Ben Holt of the Columbia Orthopedic Group and a BHR practitioner in Columbia. "With the total hip (replacement) we're usually asking people not to run, not to jump, not to lift heavy weight.
"So the attractiveness of (BHR) is that it allows people to get back to whatever activity level that they want."
Holt said BHR patients are almost always arthritic and that many have suffered an injury that led to early arthritis.
"Generally, a 45-year-old shouldn't have developed arthritis by that time, but they did because they had an injury to their hip some years before," Holt said.
That's exactly what happened to Landis.
"I just made a mistake on a turn," he said, recalling the spill in 2003 that fractured the head of his femur while he trained near his home in California. "I was training by myself and fell and somehow landed just the wrong way on it. When you fall on your bike, you land on your hips, generally.
"I've fallen hundreds of times but that time it just happened to be the wrong angle and fractured it."
After the accident, Landis' hip was never the same, he said. He began to develop a condition called avascular necrosis, a disease marked by a lack of blood flow to an area of bone, resulting in arthritis. In Landis' case, that area was the femoral head, which collapsed as a result.
Landis described the arthritis in his hip as a dull ache that set in after bike training and kept him up at night, affecting his mood. But after the surgery, he said "it's completely gone now."
"My hip is 100 percent," he said.
Holt said that while the BHR procedure has been around for years, it has been slow to enter into American medical practice because initially BHR practitioners had to train for it in England, where the procedure was established.
"They only have a certain number of visitors available each month, so they have a long waiting list of surgeons waiting to train," Holt said.
Now, there are enough trained BHR practitioners in the U.S. that it's no longer necessary to go abroad to learn the procedure.
Holt, who received his training in October 2006, said the majority of BHR patients are young people like Landis. Because the BHR procedure minimizes bone loss, much of the success of the operation relies upon strong and healthy bone to support the Birmingham hip, particularly the neck of the femur. Holt said that's a reason BHR is an option for younger people.
The failure rate was higher among older patients in England, he said.
"Part of the Birmingham hip is a cap that you put on the upper end of the femur, so you need that bone to be structurally supportive of this device," Holt said. "And those patients that were older ... had a much higher fracture rate."
"By the time it came to the United States there was some guidelines that, in general, it wasn't recommended for anyone over 60," he said. Holt added that he would not do the procedure for women over 50 because they are more susceptible to osteoporosis.
Holt said that because the BHR procedure is more conserving of the bone, patients recover quicker despite the fact that the procedure is more invasive to soft tissue.
"We have frequently had people that go back to work in two weeks," he said
Landis was on crutches for about six weeks, and it took several months to regain his strength and flexibility.
"Aw, crutches are never fun," he said with a smile. "I think everybody takes for granted their ability to do things for themselves until they're put on crutches for awhile; it's not pleasant."
Landis finished 62nd during Monday's race in St. Louis, biking the 75 miles in 2:43:56. Mark Cavendish of team Columbia-HTC won first place in the men's competition, and Brooke Miller of team TIBCO won first place in the women's competition.
Cavendish also won stage two Tuesday in 4:16:53, racing from Ste. Genevieve to Cape Girardeau; Thor Hushovd won stage three Wednesday in 4:26:50.4, racing 114.3 miles from Farmington to Rolla.
Stage four begins today in St. James at 2 p.m. and is projected to end in Jefferson City 5:45-7 p.m.