MU surgeon brings new approach to hip resurfacing

Friday, October 5, 2007 | 2:00 p.m. CDT; updated 4:57 p.m. CDT, Tuesday, July 22, 2008

COLUMBIA — Hip resurfacing changed Dan Cosby’s life twice in the same year.

Cosby, a recreational soccer coach, was diagnosed with osteoarthritis in both of his hips in 2003. After living with pain for four years, Cosby underwent hip resurfacing in January at the age of 54.

“I was to the point where I was hardly walking,” Cosby said. “I was just shuffling along.”

Sonny Bal, an associate professor of orthopedic surgery at MU, performed a traditional hip resurfacing on one of Cosby’s hips in January.

Hip resurfacing is a surgical procedure performed to address a worn-out hip joint. It involves reshaping the ball of the femur, or thigh bone, and capping it with a metal cup. The concave socket of the pelvic bone is similarly lined with metal.

“Smooth metal surfaces have less friction than worn-out bone, resulting in easier mobility and pain relief,” Bal said.

After the first resurfacing, Cosby spent two weeks using a walker around the house.

In May, Bal operated on Cosby’s other hip using a new approach to hip resurfacing he developed with Joel Matta, an orthopedic surgeon at St. John’s Health Center in California.

Although resurfacing has been around for 30 years, Bal’s approach avoids cutting through muscle and tendon by entering the front of the thigh and spreading the muscles apart. To ensure accurate component placement, Bal places a small pin in the hip and verifies its placement with X-rays. This technique avoids tissue damage and creates a smaller scar in the thigh.

Cosby was the second person in the country to undergo this procedure, Bal said. Bal was also able to enter the thigh through a smaller-than-standard, 6-inch incision.

After this second procedure, Cosby said he saw a major difference in his activity level when compared to his first hip resurfacing operation.

“Within two days, I noticed that I was carrying the walker around the house,” Cosby said.

With both of his hips in great shape, Cosby can demonstrate moves to his soccer team without wincing in pain.

“I was having problems reaching over and picking a ball off the ground. Now I’m back out there on the field,” Cosby said.

Bal has since perfected the minimally invasive approach by using a 4- to 5-inch incision instead of the 10 to 12 inches required in traditional hip resurfacing.

Bleeding and pain are reduced for the patient because there is less muscle and tissue trauma. Recovery time, hospital stay and total cost are also reduced. Bal has performed this procedure on five patients with good results, and his rationale for developing the minimally invasive technique is simple:

“The less I do, the better the patient’s recovery,” Bal said.

A practical advantage of hip resurfacing is that if future surgery is needed, the preserved bone is useful, Bal said. Young and active patients can wear out a prosthetic hip joint and require a revision surgery at least once in their life.

“Hip resurfacing is advantageous because the surgeon will still have bone to work with for future reconstruction,” Bal said. “Some surgeons believe that bone preservation allows hip-resurfacing patients to enjoy a higher activity level, although this may reflect the younger age and better health of patients selected for this procedure.”

Total hip replacements are usually recommended for patients older than 50 whose bones are not as strong.

Some surgeons, however, remain skeptical of hip resurfacing. Michael Berend, an orthopedic surgeon at the Center for Hip and Knee Surgery in Mooresville, Ind., said that hip resurfacing addresses a nonexistent problem, saying that there is no evidence to suggest that resurfacing is better than replacement.

Bal agrees that information on the future impact of resurfacing is scarce and suggests that hip replacements aren’t for everyone.

“Dr. Berend is correct in that a concern with hip resurfacing is that we do not have reliable long-term data with this procedure. However, if hip replacements were equally successful in all age groups, there would be no hip resurfacing,” Bal said.

Berend said he’s not convinced that hip resurfacing patients have a faster recovery time. “The recovery time is similar after hip replacement and hip resurfacing,” he said.

Berend has also seen some negative outcomes with resurfacing: improper positioning of the components or decay of the preserved bone on the femoral head.

Bal, however, emphasizes the importance of the preserved bone.

“Conserving bone in the femur is a key advantage of hip resurfacing; the operation is essentially a pre-hip replacement that preserves the option of subsequent hip replacement,” Bal said.

“The fact is that young and active patients tend to wear out the artificial bearings of total hip replacements. ... Living bone is bio-mechanically superior to metal and plastic; it transmits pain, position, vibration and related feedback to the brain,” Bal said. “These complex functions cannot be replicated by prosthetic devices.”

Berend also said that those undergoing hip resurfacing often need a second operation sooner.

“Early re-operation for patients undergoing hip resurfacing is within 90 days for one out of 50 patients due to fracture and need for new implants,” Berend said.

Bal hopes that his new minimally invasive technique will assuage some common fears about hip resurfacing that Berend and others might have.

“Dr. Berend’s concerns about the trauma and morbidity of repeat surgery are valid. It made no sense to sacrifice muscle and tendons to save bone,” Bal said. “This new technique addresses many of the concerns that Dr. Berend expresses. Hip resurfacing can now be done in our practice without cutting through muscles and tendons.”

To Bal, a restorer of antique automobiles, a diseased hip is similar to an old car: with some devoted remodeling and a few additional metal parts, both can be running in top form in no time.

His present project is the development of selective resurfacing of the arthritic knee joint. Bal hopes the procedure will reduce the number of total knee replacements.

“Ligament preservation in knee resurfacing should allow patients to recover quicker, and their knee should feel more natural than those who undergo total knee replacement,” Bal said.

Bal is already looking for ways to improve the medical procedures he practices.

“What we do today, we should not be doing in five years,” he said. “For those of us who are driven, we have to keep inventing.”

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