Re: German data on metal ions?

[Guest guest]

Good questions. I don't have the answers - I suppose the thing is to

ask your surgeon if he knows what he's talking about.

There's a lot of smoke and mirrors around. Aah, the German data...

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever

since I

> started researching treatment options for the OA in my right hip.

Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic

surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

surgeons.

> He didn't seem to have terribly good reasons for this --

resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

which have

> resulted in the Germans not using MoM bearings any more. I'm

concerned

> about this one and have looked into it a bit -- found some stuff

from the

> American Academy of Orthopaedic Surgeons Convention, and some

papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I

was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@m...

[Guest guest]

JD,

Could you supply the references that you have found? Thanks.

Don W

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever

since I

> started researching treatment options for the OA in my right hip.

Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic

surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

surgeons.

> He didn't seem to have terribly good reasons for this --

resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

which have

> resulted in the Germans not using MoM bearings any more. I'm

concerned

> about this one and have looked into it a bit -- found some stuff

from the

> American Academy of Orthopaedic Surgeons Convention, and some

papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I

was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@m...

[Guest guest]

Hi

A general interest in what you said. - Did a " google " search on Kathy Merritt

- nothing. Have you more detail please.

Rog

German data on metal ions?

Hi folks!

I've been lurking on the list for a couple of months now, ever since I

started researching treatment options for the OA in my right hip. Very

helpful, hopeful, and inspiring group, I must say!

Anyway, I just had a rather depressing meeting with my orthopedic surgeon

and was hoping some of you could give me some advice.

My ortho is very down on hip resurfacing, as I gather are many US surgeons.

He didn't seem to have terribly good reasons for this -- resurfacing is

unproven in the long term, resurfacing surgeons keep changing their

materials, that sort of thing.

But on the metal ions/cancer issue, he referred to " German data " which have

resulted in the Germans not using MoM bearings any more. I'm concerned

about this one and have looked into it a bit -- found some stuff from the

American Academy of Orthopaedic Surgeons Convention, and some papers by

Kathy Merritt.

I haven't run across any studies etc from Germany, though, and so I was

wondering if any of you might know what he's talking about!

Thanks for any help,

J.D.

walker@...

[Guest guest]

Hi Don and Rog --

Hope I didn't give you the wrong impression; I don't have the mysterious

" German data " that my ortho surgeon referred to! I just have other,

non-German stuff that I've gotten from this group and from casual searches

on the internet.

Anyway, the Kathy Merritt pieces are these (let me know if you want

summaries):

* Merritt K, Rodrigo JJ,1996: Immune response to synthetic materials.

Sensitization of patients receiving orthopaedic implants. Clin Orthop 71-79

* Merritt K, Brown SA, 1996: Distribution of cobalt chromium wear and

corrosion products and biologic reactions. Clin Orthop S233-243

And the core of the AAOS thing was this:

" In all patients the serum levels of cobalt and chromium increased

following resurfacing although the extent of the increase varied greatly

between patients. The data shows a definite trend of decreasing ion levels

after 4 years. This may be consistent with running-in wear and healing of

the peri-prosthetic tissues providing a smooth, stable joint. "

Best,

J.D.

=========

From: donw_donw <dwilgus@p...>

Date: Wed Jun 4, 2003 7:16pm

Subject: Re: German data on metal ions?

JD,

Could you supply the references that you have found? Thanks.

Don W

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever

since I

> started researching treatment options for the OA in my right hip.

Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic

surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

surgeons.

> He didn't seem to have terribly good reasons for this --

resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

which have

> resulted in the Germans not using MoM bearings any more. I'm

concerned

> about this one and have looked into it a bit -- found some stuff

from the

> American Academy of Orthopaedic Surgeons Convention, and some

papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I

was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@m...

walker@...

===================

" The people can always be brought to the bidding of the leaders. That is

easy. All you have to do is tell them they are being attacked, and denounce

the peacemakers for lack of patriotism and exposing the country to danger.

It works the same in any country. "

-- Hermann Goering, Nazi

[Guest guest]

Are you referring the following abstract from AAOS? I've been meaning to

comment on this, but have been swamped with work and other things of late.

One detail I want to point out is that the study finds problems with very

specific valence for ms of Chromium and Cobalt. Specifically Cr[VI] which

has been known all along to be a potential troublemaker, but there is no

reason to believe that a significant fraction (or possibly any fraction) of

the Cr in the joint space from metal wear is Cr[VI]. The metallic Cr would

have to go through some chemical reactions and a noted scientist in the

field of the effects of metals on industrial workers has told me that the pH

of the body is such that these reactions are unlikely and are really only an

issue with inhaled or swallowed Cr. Cr[iII] would be a more likely valence

form (found here and elsewhere to be safe). I am not as familiar with the

Co valance form implicated here. I think it might be misleading for them to

state that the concentrations are similar to those " detectable in

peri-prosthetic tissue " because I am not aware that the testing and

measuring being done is identifying or even capable of identifying the

individual valence forms.

I am not aware of any dire German data, and the Germans are, in fact, using

MoM resurfacing. Their neighbors, the Swiss, have the company Sulzer (now

Centerpulse, soon to be either Zimmer or +Nephew) who were the leaders

in the MoM THR business (at least until the started having unrelated

problems with their acetabular shell backings).

-

Induction of apoptosis in the T lymphocyte Jurkat cell line by prosthetic

metal ions

Poster Board Number: P001

Location: Morial Convention Center

Hall D

Adult Recon/Hip

Harpal S Khanuja, MD Cockeysville MD

V. Polosky, MD Baltimore MD (a - Good Samaritan Hospital, Orthopaedic

Rheumatology Fund)

S Hungerford, MD Baltimore MD

Katsuro Tomita, MD Kanazawa Japan

Carmelita Frondoza, PhD Baltimore MD (a - Good Samaritan Hospital,

Orthopaedic Rheumatology Fund)

Tamon Kabata, MD,PhD Kanazawa Japan

Background: Exposure to prosthetic metal ions has been implicated in

osteolysis, local immune dysfunction, and carcinogenesis or mutagenesis that

may involve apoptotic T cell death. The present study investigated the

ability of metal ions to induce T cell apoptosis. Methods: The prototype

Jurkat T lymphocyte cells were cultured with: titanium (Ti [iII]), cobalt

(Co [iI]), chromium (Cr [iII], Cr [VI]) ions at different cencentrations for

up to 72 hours. Cell viability, proliferative capacity and apoptotic indices

were evaluated. Results: Co [iI] and Cr [VI] induced cell death in a dose

and time-dependent manner. Incubation with a concentration greater than

10?g/ml of Co [iI] or greater than 1?g/ml of Cr [VI] induced caspase-3

expression, nuclear condensation and fragmentation of chromatin by 48 hours.

Apoptosis was confirmed by DNA ladder fragmentation analysis and

transmission electron microscopy. The concentrations of metal ion that

induced apoptosis were relatively close to that detectable in

peri-prosthetic tissue. Ti [iII] and Cr [iII] did not induce apoptosis at

the concentrations tested. Conclusion: We discovered that Co [iI] and Cr

[VI] induce T cell death via apoptosis. Chronic exposure to critical

concentrations of metal ions could result in apoptosis of T cells around and

distant to the prosthesis. This could lead to potential pathological

reactions. Our study prompts increased awareness of the potential

deleterious effect of metal ions released from prosthesis.

> German data on metal ions?

>

>

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever since I

> started researching treatment options for the OA in my right hip. Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

> surgeons.

> He didn't seem to have terribly good reasons for this -- resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

> which have

> resulted in the Germans not using MoM bearings any more. I'm concerned

> about this one and have looked into it a bit -- found some stuff from the

> American Academy of Orthopaedic Surgeons Convention, and some papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@...

>

>

>

[Guest guest]

Hi ! Actually the bit from AAOS (see below) I have is different, and

has only to do with measuring serum levels of cobalt and chromium, not with

testing their effects on cells.

So, best as I can translate the science-speak, what these folks are saying

is that they put a bunch of human cells in a test tube with titanium,

cobalt, and chromium. And they found that the more Co[iI] and Cr[VI] the

cells are exposed to, and the longer they're exposed, the more the cells die.

(Apoptosis -- had to look that one up! " a genetically determined

destruction of cells from within due to activation of a stimulus or removal

of a suppressing agent or stimulus that is postulated to exist to explain

the orderly elimination of superfluous cells -- called also programmed cell

death " )

I must admit that's a little scary, to me anyway. Still, you're right that

Cr[iII] comes out OK, and we don't have reason to believe that the metal

ions resulting from MoM prostheses will turn out to be, or into, Cr[VI].

And Cr[VI] has indeed been known for a while to be carcinogenic, so maybe

in the end this little study tells us nothing we didn't know before!

Thanks for the input!

Best,

J.D.

============

At American Academy of Orthopaedic Surgeons New Orleans Convention this

February (2003) they were told the following by British OS's:

The bone preserving aspect of hip resurfacing combined with minimal wear

metal-metal technology provides a very attractive solution for the younger

arthritic hip. The long term effects of the inevitable metal ion release

however, remain a concern. Serum ion levels from metal-metal resurfacing

hip patients were measured pre-operatively and then every year for up to

five years. Blood was collected using a standardised technique to ensure no

metallic contamination. Chromium analysis was by graphite furnace atomic

absorption (ETA-AAS) using a 4100ZL or A800 perkineimer instrument. Cobalt

was analysed by inductively coupled plasma mass spectrometry (ICP-MS).

Measurements were taken from 39 patients with 7 bilateral cases.

Pre-operative levels were only taken from 15 patients, and these were

universally low (below 20nmol/l). In all patients the serum levels of

cobalt and chromium increased following resurfacing although the extent of

the increase varied greatly between patients. The data shows a definite

trend of decreasing ion levels after 4 years. This may be consistent with

running-in wear and healing of the peri-prosthetic tissues providing a

smooth, stable joint. Younger patients (<40) had significantly higher ion

levels than older patients (>60). Anecdotally, there was some evidence of

increased ion levels associated with steep cup angles.

===============

============

Message: 18

Date: Wed, 4 Jun 2003 22:05:18 -0500

Subject: RE: German data on metal ions?

Are you referring the following abstract from AAOS? I've been meaning to

comment on this, but have been swamped with work and other things of late.

One detail I want to point out is that the study finds problems with very

specific valence for ms of Chromium and Cobalt. Specifically Cr[VI] which

has been known all along to be a potential troublemaker, but there is no

reason to believe that a significant fraction (or possibly any fraction) of

the Cr in the joint space from metal wear is Cr[VI]. The metallic Cr would

have to go through some chemical reactions and a noted scientist in the

field of the effects of metals on industrial workers has told me that the pH

of the body is such that these reactions are unlikely and are really only an

issue with inhaled or swallowed Cr. Cr[iII] would be a more likely valence

form (found here and elsewhere to be safe). I am not as familiar with the

Co valance form implicated here. I think it might be misleading for them to

state that the concentrations are similar to those " detectable in

peri-prosthetic tissue " because I am not aware that the testing and

measuring being done is identifying or even capable of identifying the

individual valence forms.

I am not aware of any dire German data, and the Germans are, in fact, using

MoM resurfacing. Their neighbors, the Swiss, have the company Sulzer (now

Centerpulse, soon to be either Zimmer or +Nephew) who were the leaders

in the MoM THR business (at least until the started having unrelated

problems with their acetabular shell backings).

-

Induction of apoptosis in the T lymphocyte Jurkat cell line by prosthetic

metal ions

Poster Board Number: P001

Location: Morial Convention Center

Hall D

Adult Recon/Hip

Harpal S Khanuja, MD Cockeysville MD

V. Polosky, MD Baltimore MD (a - Good Samaritan Hospital, Orthopaedic

Rheumatology Fund)

S Hungerford, MD Baltimore MD

Katsuro Tomita, MD Kanazawa Japan

Carmelita Frondoza, PhD Baltimore MD (a - Good Samaritan Hospital,

Orthopaedic Rheumatology Fund)

Tamon Kabata, MD,PhD Kanazawa Japan

Background: Exposure to prosthetic metal ions has been implicated in

osteolysis, local immune dysfunction, and carcinogenesis or mutagenesis that

may involve apoptotic T cell death. The present study investigated the

ability of metal ions to induce T cell apoptosis. Methods: The prototype

Jurkat T lymphocyte cells were cultured with: titanium (Ti [iII]), cobalt

(Co [iI]), chromium (Cr [iII], Cr [VI]) ions at different cencentrations for

up to 72 hours. Cell viability, proliferative capacity and apoptotic indices

were evaluated. Results: Co [iI] and Cr [VI] induced cell death in a dose

and time-dependent manner. Incubation with a concentration greater than

10?g/ml of Co [iI] or greater than 1?g/ml of Cr [VI] induced caspase-3

expression, nuclear condensation and fragmentation of chromatin by 48 hours.

Apoptosis was confirmed by DNA ladder fragmentation analysis and

transmission electron microscopy. The concentrations of metal ion that

induced apoptosis were relatively close to that detectable in

peri-prosthetic tissue. Ti [iII] and Cr [iII] did not induce apoptosis at

the concentrations tested. Conclusion: We discovered that Co [iI] and Cr

[VI] induce T cell death via apoptosis. Chronic exposure to critical

concentrations of metal ions could result in apoptosis of T cells around and

distant to the prosthesis. This could lead to potential pathological

reactions. Our study prompts increased awareness of the potential

deleterious effect of metal ions released from prosthesis.

walker@...

===================

" The people can always be brought to the bidding of the leaders. That is

easy. All you have to do is tell them they are being attacked, and denounce

the peacemakers for lack of patriotism and exposing the country to danger.

It works the same in any country. "

-- Hermann Goering, Nazi

[Guest guest]

Thanks, and J.D.! This was enlightening, and may explain

where the concept of " ion toxicity " came from??

This underscores that one can not assume that just because one form

of an element is toxic, that all forms must be? I'm thinking of

good ol' oxygen...take away a molecule (carbon dioxide) or add one

(ozone) and it will kill you

Deb

> Hi ! Actually the bit from AAOS (see below) I have is

different, and

> has only to do with measuring serum levels of cobalt and chromium,

not with

> testing their effects on cells.

>

> So, best as I can translate the science-speak, what these folks

are saying

> is that they put a bunch of human cells in a test tube with

titanium,

> cobalt, and chromium. And they found that the more Co[iI] and Cr

[VI] the

> cells are exposed to, and the longer they're exposed, the more the

cells die.

>

> (Apoptosis -- had to look that one up! " a genetically determined

> destruction of cells from within due to activation of a stimulus

or removal

> of a suppressing agent or stimulus that is postulated to exist to

explain

> the orderly elimination of superfluous cells -- called also

programmed cell

> death " )

>

> I must admit that's a little scary, to me anyway. Still, you're

right that

> Cr[iII] comes out OK, and we don't have reason to believe that the

metal

> ions resulting from MoM prostheses will turn out to be, or into, Cr

[VI].

> And Cr[VI] has indeed been known for a while to be carcinogenic,

so maybe

> in the end this little study tells us nothing we didn't know

before!

>

> Thanks for the input!

>

> Best,

>

> J.D.

>

> ============

> At American Academy of Orthopaedic Surgeons New Orleans Convention

this

> February (2003) they were told the following by British OS's:

>

> The bone preserving aspect of hip resurfacing combined with

minimal wear

> metal-metal technology provides a very attractive solution for the

younger

> arthritic hip. The long term effects of the inevitable metal ion

release

> however, remain a concern. Serum ion levels from metal-metal

resurfacing

> hip patients were measured pre-operatively and then every year for

up to

> five years. Blood was collected using a standardised technique to

ensure no

> metallic contamination. Chromium analysis was by graphite furnace

atomic

> absorption (ETA-AAS) using a 4100ZL or A800 perkineimer

instrument. Cobalt

> was analysed by inductively coupled plasma mass spectrometry (ICP-

MS).

>

> Measurements were taken from 39 patients with 7 bilateral cases.

> Pre-operative levels were only taken from 15 patients, and these

were

> universally low (below 20nmol/l). In all patients the serum levels

of

> cobalt and chromium increased following resurfacing although the

extent of

> the increase varied greatly between patients. The data shows a

definite

> trend of decreasing ion levels after 4 years. This may be

consistent with

> running-in wear and healing of the peri-prosthetic tissues

providing a

> smooth, stable joint. Younger patients (<40) had significantly

higher ion

> levels than older patients (>60). Anecdotally, there was some

evidence of

> increased ion levels associated with steep cup angles.

> ===============

>

>

> ============

> Message: 18

> Date: Wed, 4 Jun 2003 22:05:18 -0500

> From: " Brewster " <kbrews@c...>

> Subject: RE: German data on metal ions?

>

>

> Are you referring the following abstract from AAOS? I've been

meaning to

> comment on this, but have been swamped with work and other things

of late.

> One detail I want to point out is that the study finds problems

with very

> specific valence for ms of Chromium and Cobalt. Specifically Cr

[VI] which

> has been known all along to be a potential troublemaker, but there

is no

> reason to believe that a significant fraction (or possibly any

fraction) of

> the Cr in the joint space from metal wear is Cr[VI]. The metallic

Cr would

> have to go through some chemical reactions and a noted scientist

in the

> field of the effects of metals on industrial workers has told me

that the pH

> of the body is such that these reactions are unlikely and are

really only an

> issue with inhaled or swallowed Cr. Cr[iII] would be a more

likely valence

> form (found here and elsewhere to be safe). I am not as familiar

with the

> Co valance form implicated here. I think it might be misleading

for them to

> state that the concentrations are similar to those " detectable in

> peri-prosthetic tissue " because I am not aware that the testing and

> measuring being done is identifying or even capable of identifying

the

> individual valence forms.

>

> I am not aware of any dire German data, and the Germans are, in

fact, using

> MoM resurfacing. Their neighbors, the Swiss, have the company

Sulzer (now

> Centerpulse, soon to be either Zimmer or +Nephew) who were

the leaders

> in the MoM THR business (at least until the started having

unrelated

> problems with their acetabular shell backings).

>

> -

>

>

>

> Induction of apoptosis in the T lymphocyte Jurkat cell line by

prosthetic

> metal ions

> Poster Board Number: P001

> Location: Morial Convention Center

> Hall D

>

> Adult Recon/Hip

> Harpal S Khanuja, MD Cockeysville MD

> V. Polosky, MD Baltimore MD (a - Good Samaritan Hospital,

Orthopaedic

> Rheumatology Fund)

> S Hungerford, MD Baltimore MD

> Katsuro Tomita, MD Kanazawa Japan

> Carmelita Frondoza, PhD Baltimore MD (a - Good Samaritan Hospital,

> Orthopaedic Rheumatology Fund)

>

> Tamon Kabata, MD,PhD Kanazawa Japan

>

> Background: Exposure to prosthetic metal ions has been implicated

in

> osteolysis, local immune dysfunction, and carcinogenesis or

mutagenesis that

> may involve apoptotic T cell death. The present study investigated

the

> ability of metal ions to induce T cell apoptosis. Methods: The

prototype

> Jurkat T lymphocyte cells were cultured with: titanium (Ti [iII]),

cobalt

> (Co [iI]), chromium (Cr [iII], Cr [VI]) ions at different

cencentrations for

> up to 72 hours. Cell viability, proliferative capacity and

apoptotic indices

> were evaluated. Results: Co [iI] and Cr [VI] induced cell death in

a dose

> and time-dependent manner. Incubation with a concentration greater

than

> 10?g/ml of Co [iI] or greater than 1?g/ml of Cr [VI] induced

caspase-3

> expression, nuclear condensation and fragmentation of chromatin by

48 hours.

> Apoptosis was confirmed by DNA ladder fragmentation analysis and

> transmission electron microscopy. The concentrations of metal ion

that

> induced apoptosis were relatively close to that detectable in

> peri-prosthetic tissue. Ti [iII] and Cr [iII] did not induce

apoptosis at

> the concentrations tested. Conclusion: We discovered that Co [iI]

and Cr

> [VI] induce T cell death via apoptosis. Chronic exposure to

critical

> concentrations of metal ions could result in apoptosis of T cells

around and

> distant to the prosthesis. This could lead to potential

pathological

> reactions. Our study prompts increased awareness of the potential

> deleterious effect of metal ions released from prosthesis.

>

>

> walker@m...

>

> ===================

> " The people can always be brought to the bidding of the leaders.

That is

> easy. All you have to do is tell them they are being attacked, and

denounce

> the peacemakers for lack of patriotism and exposing the country to

danger.

> It works the same in any country. "

>

> -- Hermann Goering, Nazi

[Guest guest]

J.D. -

My HMO Orthopedic Surgeon warned me off metal-to-metal saying " you

know the Brockovich story? " I really can't make the connection.

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever since I

> started researching treatment options for the OA in my right hip. Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic

surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

surgeons.

> He didn't seem to have terribly good reasons for this -- resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

which have

> resulted in the Germans not using MoM bearings any more. I'm concerned

> about this one and have looked into it a bit -- found some stuff

from the

> American Academy of Orthopaedic Surgeons Convention, and some papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@m...

[Guest guest]

One of the three OS I spoke to in the US told me that metal on metal

causes cancer (the other 2 use MOM and made no such statement). When

I told Dr. DeSmet about it, he said the only study he had ever seen

relating MOM to cancer was one that for some reason showed that there

was LESS lung cancer!

My guess is that plastic particles are of greater concern - and that

was the model THR that the three US surgeons were trying to sell me -

the gold standard, they said.

> > Hi folks!

> >

> > I've been lurking on the list for a couple of months now, ever

since I

> > started researching treatment options for the OA in my right hip.

Very

> > helpful, hopeful, and inspiring group, I must say!

> >

> > Anyway, I just had a rather depressing meeting with my orthopedic

> surgeon

> > and was hoping some of you could give me some advice.

> >

> > My ortho is very down on hip resurfacing, as I gather are many US

> surgeons.

> > He didn't seem to have terribly good reasons for this --

resurfacing is

> > unproven in the long term, resurfacing surgeons keep changing

their

> > materials, that sort of thing.

> >

> > But on the metal ions/cancer issue, he referred to " German data "

> which have

> > resulted in the Germans not using MoM bearings any more. I'm

concerned

> > about this one and have looked into it a bit -- found some stuff

> from the

> > American Academy of Orthopaedic Surgeons Convention, and some

papers by

> > Kathy Merritt.

> >

> > I haven't run across any studies etc from Germany, though, and so

I was

> > wondering if any of you might know what he's talking about!

> >

> > Thanks for any help,

> >

> > J.D.

> > walker@m...

[Guest guest]

Hmmmmm, as I recall vaguely from seeing that movie, chromium

[VI] ( " hexavalent chromium " ) was what was poisoning the water supply of

Hinkley, CA.

So , did you get resurfaced anyway??

Best,

J.D.

============

J.D. -

My HMO Orthopedic Surgeon warned me off metal-to-metal saying " you

know the Brockovich story? " I really can't make the connection.

[Guest guest]

J.D.,

I've heard your story so many times now. And if you'll read back

through the messages, you'll run into many others whose first visit

to the Ortho garnered them the same results.

There are four major factors in play that could cause an orthopedic

surgeon to be negative on resurfacing: prior resurfacing failures;

distrust of the European medical communities' statistics on

resurfacing; our litigious society; and, unwillingness to loose

business to resurfacing. Resurfacing got a bad rep years ago when

there were failures due, I believe, to faulty device design. But that

was some 25-30 years ago and the device design and materials have

changed for the better. This surgery has been successfully performed

in Europe for the past 11-12 years. Resurfacing is currently in

trials in the U.S. and it is sounding as though the stats here are

good also.

has provided us with an easy way to research the subject. Just

go to the left margin and check out " Files " and " Links " . There you

will find medical reports on resurfacing, helpful links and other

information to help you make your decision.

Then, if you are still interested in resurfacing, I would suggest

that you consult with one of the doctors here or overseas who are

doing resurfacing. They are much better qualified to address the

subject than is a doctor who doesn't do resurfacing and probably

wants to give you a THR.

As for the doctor's caution regarding MOM and ions. Chances are if

he gave you a THR, he'd be using MOM. What's the difference whether

it's MOM THR or MOM resurfacing? I've not read a German report on

the subject. But the question was asked to Dr. DeSmet, when a group

of us met with him in Belgium in February, and he said it wasn't a

problem. Good luck. 2/19/03 BHR DeSmet

> Hi folks!

>

> I've been lurking on the list for a couple of months now, ever

since I

> started researching treatment options for the OA in my right hip.

Very

> helpful, hopeful, and inspiring group, I must say!

>

> Anyway, I just had a rather depressing meeting with my orthopedic

surgeon

> and was hoping some of you could give me some advice.

>

> My ortho is very down on hip resurfacing, as I gather are many US

surgeons.

> He didn't seem to have terribly good reasons for this --

resurfacing is

> unproven in the long term, resurfacing surgeons keep changing their

> materials, that sort of thing.

>

> But on the metal ions/cancer issue, he referred to " German data "

which have

> resulted in the Germans not using MoM bearings any more. I'm

concerned

> about this one and have looked into it a bit -- found some stuff

from the

> American Academy of Orthopaedic Surgeons Convention, and some

papers by

> Kathy Merritt.

>

> I haven't run across any studies etc from Germany, though, and so I

was

> wondering if any of you might know what he's talking about!

>

> Thanks for any help,

>

> J.D.

> walker@m...

[Guest guest]

Thanks, ! This is very helpful.

I suspect that with my OS at least the last three of the reasons you

mentioned for being suspicious about resurfacing are in play. He is, or at

least thinks of himself as, an expert in the field, and I suspect that in

part what's going on is that THR is what he's always done and is very good

at. So naturally alternatives are under a cloud, for him.

As to the MoM, he's proposing a ceramic- or metal-on-polyethylene THR for

me, not MoM. But the polyethylene is exactly what I'm worried about, at my

age. Many of the materials so helpfully made accessible through the

site indicate that that's a fine prosthesis if you're older and/or more

sedentary, but that the wear (and hence revision) rate for younger/active

folks is pretty bad.

So it seems as if the choice is between the known path -- not being very

active and hoping to eke 15 years out of a polyethylene THR -- or the

lesser known path -- doing the resurfacing, being more active, and seeing

what happens down the road.

Anyway, I'm going to try to get a second opinion -- and thanks to everyone

in this group for the encouragement and helpful contributions!!

Best,

J.D.

At 08:20 PM 06-05-03 -0000, cosmicmama wrote:

>J.D.,

>

>I've heard your story so many times now. And if you'll read back

>through the messages, you'll run into many others whose first visit

>to the Ortho garnered them the same results.

>

>There are four major factors in play that could cause an orthopedic

>surgeon to be negative on resurfacing: prior resurfacing failures;

>distrust of the European medical communities' statistics on

>resurfacing; our litigious society; and, unwillingness to loose

>business to resurfacing. Resurfacing got a bad rep years ago when

>there were failures due, I believe, to faulty device design. But that

>was some 25-30 years ago and the device design and materials have

>changed for the better. This surgery has been successfully performed

>in Europe for the past 11-12 years. Resurfacing is currently in

>trials in the U.S. and it is sounding as though the stats here are

>good also.

>

> has provided us with an easy way to research the subject. Just

>go to the left margin and check out " Files " and " Links " . There you

>will find medical reports on resurfacing, helpful links and other

>information to help you make your decision.

>

>Then, if you are still interested in resurfacing, I would suggest

>that you consult with one of the doctors here or overseas who are

>doing resurfacing. They are much better qualified to address the

>subject than is a doctor who doesn't do resurfacing and probably

>wants to give you a THR.

>

>As for the doctor's caution regarding MOM and ions. Chances are if

>he gave you a THR, he'd be using MOM. What's the difference whether

>it's MOM THR or MOM resurfacing? I've not read a German report on

>the subject. But the question was asked to Dr. DeSmet, when a group

>of us met with him in Belgium in February, and he said it wasn't a

>problem. Good luck. 2/19/03 BHR DeSmet

>

>

>

>> Hi folks!

>>

>> I've been lurking on the list for a couple of months now, ever

>since I

>> started researching treatment options for the OA in my right hip.

>Very

>> helpful, hopeful, and inspiring group, I must say!

>>

>> Anyway, I just had a rather depressing meeting with my orthopedic

>surgeon

>> and was hoping some of you could give me some advice.

>>

>> My ortho is very down on hip resurfacing, as I gather are many US

>surgeons.

>> He didn't seem to have terribly good reasons for this --

>resurfacing is

>> unproven in the long term, resurfacing surgeons keep changing their

>> materials, that sort of thing.

>>

>> But on the metal ions/cancer issue, he referred to " German data "

>which have

>> resulted in the Germans not using MoM bearings any more. I'm

>concerned

>> about this one and have looked into it a bit -- found some stuff

>from the

>> American Academy of Orthopaedic Surgeons Convention, and some

>papers by

>> Kathy Merritt.

>>

>> I haven't run across any studies etc from Germany, though, and so I

>was

>> wondering if any of you might know what he's talking about!

>>

>> Thanks for any help,

>>

>> J.D.

>> walker@m...

>

>

>

>

[Guest guest]

J.D.

Check my posting today about my husband's cousin. His patient was, I

believe, in her mid thirties and sky diving can, from time to time,

be a high impact sport. She was at 11 years and going strong the last

time he saw her.

The group of us, who were in Belgium for surgery together in Feb,

asked Dr. DeSmet about the resurfacing life expectancy issue. In a

nut shell, based on existing follow-up studies and stats out of

Europe, he thinks a good resurfacing should last indefinately

provided the bones stay strong. 2/19/03 BHR DeSmet

> >> Hi folks!

> >>

> >> I've been lurking on the list for a couple of months now, ever

> >since I

> >> started researching treatment options for the OA in my right

hip.

> >Very

> >> helpful, hopeful, and inspiring group, I must say!

> >>

> >> Anyway, I just had a rather depressing meeting with my

orthopedic

> >surgeon

> >> and was hoping some of you could give me some advice.

> >>

> >> My ortho is very down on hip resurfacing, as I gather are many

US

> >surgeons.

> >> He didn't seem to have terribly good reasons for this --

> >resurfacing is

> >> unproven in the long term, resurfacing surgeons keep changing

their

> >> materials, that sort of thing.

> >>

> >> But on the metal ions/cancer issue, he referred to " German data "

> >which have

> >> resulted in the Germans not using MoM bearings any more. I'm

> >concerned

> >> about this one and have looked into it a bit -- found some stuff

> >from the

> >> American Academy of Orthopaedic Surgeons Convention, and some

> >papers by

> >> Kathy Merritt.

> >>

> >> I haven't run across any studies etc from Germany, though, and

so I

> >was

> >> wondering if any of you might know what he's talking about!

> >>

> >> Thanks for any help,

> >>

> >> J.D.

> >> walker@m...

> >

> >

> >

> >

[Guest guest]

Yes, I did see that one! An inspiring story indeed, and I could really use

some inspiration right about now... :-|

I checked out Dr. DeSmet's website and noted that he's officially

noncomittal about life expectancy there:

" 9. What is the expected life for the BHR hip as compared to THR?

I DON’T KNOW! It is only one of the possibilities to do longer than 10

years in young and active people! If you don’t get osteolysis (bone that is

going away) or no measurable wear of the friction couple BHR can last very

long. Just give me a crystal bal. There are large metal-on-metal

articulations that stayed for more then 30 years. "

( http://www.hip-clinic.com/en/html/answers.shtml#a9 )

Now, as I understand it (and I'm a real amateur here!), the most common

reason for revising a THR is osteolysis and loosening of the prosthesis,

caused by small particles being worn off of the acetabular cup.

Might this not be a problem with MoM designs, including resurfacing? Maybe

the metal particles are too small or of the wrong composition to cause

osteolysis? I'm thinking this might be a reason to hope for greater

longevity... :-)

Best,

At 09:31 PM 06-05-03 -0000, you wrote:

>J.D.

>

>Check my posting today about my husband's cousin. His patient was, I

>believe, in her mid thirties and sky diving can, from time to time,

>be a high impact sport. She was at 11 years and going strong the last

>time he saw her.

>

>The group of us, who were in Belgium for surgery together in Feb,

>asked Dr. DeSmet about the resurfacing life expectancy issue. In a

>nut shell, based on existing follow-up studies and stats out of

>Europe, he thinks a good resurfacing should last indefinately

>provided the bones stay strong. 2/19/03 BHR DeSmet

>

>

>> >> Hi folks!

>> >>

>> >> I've been lurking on the list for a couple of months now, ever

>> >since I

>> >> started researching treatment options for the OA in my right

>hip.

>> >Very

>> >> helpful, hopeful, and inspiring group, I must say!

>> >>

>> >> Anyway, I just had a rather depressing meeting with my

>orthopedic

>> >surgeon

>> >> and was hoping some of you could give me some advice.

>> >>

>> >> My ortho is very down on hip resurfacing, as I gather are many

>US

>> >surgeons.

>> >> He didn't seem to have terribly good reasons for this --

>> >resurfacing is

>> >> unproven in the long term, resurfacing surgeons keep changing

>their

>> >> materials, that sort of thing.

>> >>

>> >> But on the metal ions/cancer issue, he referred to " German data "

>> >which have

>> >> resulted in the Germans not using MoM bearings any more. I'm

>> >concerned

>> >> about this one and have looked into it a bit -- found some stuff

>> >from the

>> >> American Academy of Orthopaedic Surgeons Convention, and some

>> >papers by

>> >> Kathy Merritt.

>> >>

>> >> I haven't run across any studies etc from Germany, though, and

>so I

>> >was

>> >> wondering if any of you might know what he's talking about!

>> >>

>> >> Thanks for any help,

>> >>

>> >> J.D.

>> >> walker@m...

>> >

>> >

>> >

>> >

[Guest guest]

J.D.

I reported the essence of the comments DeSmet made in Feb, re life

expectancy for the BHR, correctly and he allowed one of the

participants to video the entire session. I have no explanation for

his website statement on the subject. It doesn't conflict with what

he said to us, it just isn't definitive and I understand your need to

know. That's what prompted us to ask the question. If you would like

clarification, I would recommend that you get it from the horse's

mouth. His email address is Koen.Desmet@.... If that address

doesn't show up in this posting go back to his website, his email

address is there. He's very good at responding quickly. You might

want to ask him what he thinks about the ion question while you're at

it. 2/19/03 BHR DeSmet

> >> >> Hi folks!

> >> >>

> >> >> I've been lurking on the list for a couple of months now,

ever

> >> >since I

> >> >> started researching treatment options for the OA in my right

> >hip.

> >> >Very

> >> >> helpful, hopeful, and inspiring group, I must say!

> >> >>

> >> >> Anyway, I just had a rather depressing meeting with my

> >orthopedic

> >> >surgeon

> >> >> and was hoping some of you could give me some advice.

> >> >>

> >> >> My ortho is very down on hip resurfacing, as I gather are

many

> >US

> >> >surgeons.

> >> >> He didn't seem to have terribly good reasons for this --

> >> >resurfacing is

> >> >> unproven in the long term, resurfacing surgeons keep changing

> >their

> >> >> materials, that sort of thing.

> >> >>

> >> >> But on the metal ions/cancer issue, he referred to " German

data "

> >> >which have

> >> >> resulted in the Germans not using MoM bearings any more. I'm

> >> >concerned

> >> >> about this one and have looked into it a bit -- found some

stuff

> >> >from the

> >> >> American Academy of Orthopaedic Surgeons Convention, and some

> >> >papers by

> >> >> Kathy Merritt.

> >> >>

> >> >> I haven't run across any studies etc from Germany, though,

and

> >so I

> >> >was

> >> >> wondering if any of you might know what he's talking about!

> >> >>

> >> >> Thanks for any help,

> >> >>

> >> >> J.D.

> >> >> walker@m...

> >> >

> >> >

> >> >

> >> >

[Guest guest]

Hi Jude,

Thanks for the PS. I have been too busy with work and getting back into

tennis, but I check the surfacehippy board and try to read a few topics.

I'm glad to hear that you are doing well with your climbing. I also agree

with your response to the metal ion stuff. As I recall, DeSmet told me that the

double heat treated BHR device greatly reduced the metal ions in the system.

My tennis is going well but I wish I could devote more time to training

regularly which is essential for a rigorous sport like tennis. I was cramping

and

pulling calf and hamstring muscles because I was out of shape but my strength

and stamina is coming along just fine and my movement is very good again!

I hope people who want to ask me questions on bilateral will use my name in

the subject area so I won't miss the question.

Take care my Belgian DeSmet hippie sister,

Saeed

[Guest guest]

J.D.

Hope to. Still working on the appeal.

> Hmmmmm, as I recall vaguely from seeing that movie,

chromium

> [VI] ( " hexavalent chromium " ) was what was poisoning the water supply

of

> Hinkley, CA.

>

> So , did you get resurfaced anyway??

>

> Best,

>

> J.D.

>

> ============

> J.D. -

>

> My HMO Orthopedic Surgeon warned me off metal-to-metal saying " you

> know the Brockovich story? " I really can't make the connection.

>

>

[Guest guest]

J.D.

The other thing to consider is the size of the femoral ball of the

prosthesis. It appears that this is a major factor in dislocations.

The larger the ball - the closer it is to the natural hip and the less

the chance of dislocation. I don't believe any prostheses are made

with a large ball and polyethylene acetabular liner because the

polyethylene wear is proportional to the surface area of the bearing.

So, even if you can't get a resurfacing, you would probably be better

off with a M-o-M THR.

This is exactly what Dr. Mont has proposed to me if I ever get through

all the insurance hurdles. He's not sure, from my X-rays, if he will

be able to do a resurf -- if he can't, he proposes to put a M-o-M THR

system in.

> >> Hi folks!

> >>

> >> I've been lurking on the list for a couple of months now, ever

> >since I

> >> started researching treatment options for the OA in my right hip.

> >Very

> >> helpful, hopeful, and inspiring group, I must say!

> >>

> >> Anyway, I just had a rather depressing meeting with my orthopedic

> >surgeon

> >> and was hoping some of you could give me some advice.

> >>

> >> My ortho is very down on hip resurfacing, as I gather are many US

> >surgeons.

> >> He didn't seem to have terribly good reasons for this --

> >resurfacing is

> >> unproven in the long term, resurfacing surgeons keep changing

their

> >> materials, that sort of thing.

> >>

> >> But on the metal ions/cancer issue, he referred to " German data "

> >which have

> >> resulted in the Germans not using MoM bearings any more. I'm

> >concerned

> >> about this one and have looked into it a bit -- found some stuff

> >from the

> >> American Academy of Orthopaedic Surgeons Convention, and some

> >papers by

> >> Kathy Merritt.

> >>

> >> I haven't run across any studies etc from Germany, though, and so

I

> >was

> >> wondering if any of you might know what he's talking about!

> >>

> >> Thanks for any help,

> >>

> >> J.D.

> >> walker@m...

> >

> >

> >

> >

[Guest guest]

J.D.

I was scheduled to have THR on NHS (National Health Service which is

free) 3 times in the last 6 months. Each time I turned down the place

in hospital, I was told that I'd be put at the back of the queue again.

Meanwhile, having stumbled across this site, I have researched BHR

within my layman's limits. I concluded that BHR on the upside:

* Was a less invasive procedure

* Had a faster recovery time than THR

* Had less restrictions on movements and activities after the

procedure has been completed and rehab concluded

* Can cost less than THR (if you want to / have to go private)

* Has a projected life span way in excess of THR, in theory it

could last your life-time (the latest THR stats I came across suggest

that time between revisions has shortened to 8-10 years despite

improvements in technology, materials, and procedures; this is

speculatively being explained by a combination of contrasting factors -

a significant increase in obese and overweight patients who put

additional stresses on the prosthesis and on the remainder of the femur,

and/or a significant increase in overactive fit persons who pursue

sports much more intensely and much longer in their lives than the

general population did some 40 years ago when the average time between

remissions was in excess of 15 years)

* Was more suitable for active and relatively younger patients

(I was certainly more active than the average 52-year old male)

and on the downside:

* Was less proven (approx 10 years and 10,000 interventions

largely in the Saxon world only, and here I included Belgium's centre of

excellence run by Dr. DeSmet)

* Had fewer practitioners performing it

* Had less centres specialising in it

* Had less well defined post operative physiotherapy and

recovery procedures (including pain management)

* Had a strong body of physicians who were openly sceptical

about this procedure (however, I can't forget the fact that profit and

economics do probably play a part here, as, I guess, the cost of

BHR-type prosthesis is less than those used in THR procedures, and that

may mean less incentives for physicians as they spend less money with

suppliers; additionally, a 50-year old is likely to be a THR patient 3

times for each hip if s/he were to live to the average age of 80; by the

way, it also seems that your femur can take no more than 3 revisions - a

decidedly awkward fact for very young OA patients as they have to wait

in pain until they reach this age when 3 revisions will see them through

to the end of their life)

* There are at least 2-3 competing technologies in resurfacing,

a fact that makes choices and stats more difficult

and could find no relevant difference in the following arguments:

* MOM / plastic / ceramic etc. - same (non)issues apply

* Type of anaesthetic used/applied

When I discussed my preference for BHR over THR with my OS (a Professor

of OS who taught most of the British OSs that currently perform BHR), my

winning argument, that led to him writing to a former student of his who

is a well known BHR practitioner, was that IF BHR WERE TO BE LESS THAN A

SUCCESS I HOPE IT WILL BE, I CAN THEN FALL BACK ON THR.

Please, bear in mind that these are my conclusions from analysing the

available data. This does not mean that another individual analysing

the same data may not come to the opposite conclusion, that THR is a

better option than BHR.

Regards

Dan

* (07974) 981-407

* (020) 8501-2573

@ dan.milosevic@...

Re: Re: German data on metal ions?

Thanks, ! This is very helpful.

I suspect that with my OS at least the last three of the reasons you

mentioned for being suspicious about resurfacing are in play. He is, or

at least thinks of himself as, an expert in the field, and I suspect

that in part what's going on is that THR is what he's always done and is

very good at. So naturally alternatives are under a cloud, for him.

As to the MoM, he's proposing a ceramic- or metal-on-polyethylene THR

for me, not MoM. But the polyethylene is exactly what I'm worried about,

at my age. Many of the materials so helpfully made accessible

through the site indicate that that's a fine prosthesis if you're older

and/or more sedentary, but that the wear (and hence revision) rate for

younger/active folks is pretty bad.

So it seems as if the choice is between the known path -- not being very

active and hoping to eke 15 years out of a polyethylene THR -- or the

lesser known path -- doing the resurfacing, being more active, and

seeing what happens down the road.

Anyway, I'm going to try to get a second opinion -- and thanks to

everyone in this group for the encouragement and helpful contributions!!

Best,

J.D.

At 08:20 PM 06-05-03 -0000, cosmicmama wrote:

>J.D.,

>

>I've heard your story so many times now. And if you'll read back

>through the messages, you'll run into many others whose first visit

>to the Ortho garnered them the same results.

>

>There are four major factors in play that could cause an orthopedic

>surgeon to be negative on resurfacing: prior resurfacing failures;

>distrust of the European medical communities' statistics on

>resurfacing; our litigious society; and, unwillingness to loose

>business to resurfacing. Resurfacing got a bad rep years ago when

>there were failures due, I believe, to faulty device design. But that

>was some 25-30 years ago and the device design and materials have

>changed for the better. This surgery has been successfully performed

>in Europe for the past 11-12 years. Resurfacing is currently in

>trials in the U.S. and it is sounding as though the stats here are

>good also.

>

> has provided us with an easy way to research the subject. Just

>go to the left margin and check out " Files " and " Links " . There you

>will find medical reports on resurfacing, helpful links and other

>information to help you make your decision.

>

>Then, if you are still interested in resurfacing, I would suggest

>that you consult with one of the doctors here or overseas who are

>doing resurfacing. They are much better qualified to address the

>subject than is a doctor who doesn't do resurfacing and probably

>wants to give you a THR.

>

>As for the doctor's caution regarding MOM and ions. Chances are if

>he gave you a THR, he'd be using MOM. What's the difference whether

>it's MOM THR or MOM resurfacing? I've not read a German report on

>the subject. But the question was asked to Dr. DeSmet, when a group

>of us met with him in Belgium in February, and he said it wasn't a

>problem. Good luck. 2/19/03 BHR DeSmet

>

>

>

>> Hi folks!

>>

>> I've been lurking on the list for a couple of months now, ever

>since I

>> started researching treatment options for the OA in my right hip.

>Very

>> helpful, hopeful, and inspiring group, I must say!

>>

>> Anyway, I just had a rather depressing meeting with my orthopedic

>surgeon

>> and was hoping some of you could give me some advice.

>>

>> My ortho is very down on hip resurfacing, as I gather are many US

>surgeons.

>> He didn't seem to have terribly good reasons for this --

>resurfacing is

>> unproven in the long term, resurfacing surgeons keep changing their

>> materials, that sort of thing.

>>

>> But on the metal ions/cancer issue, he referred to " German data "

>which have

>> resulted in the Germans not using MoM bearings any more. I'm

>concerned

>> about this one and have looked into it a bit -- found some stuff

>from the

>> American Academy of Orthopaedic Surgeons Convention, and some

>papers by

>> Kathy Merritt.

>>

>> I haven't run across any studies etc from Germany, though, and so I

>was

>> wondering if any of you might know what he's talking about!

>>

>> Thanks for any help,

>>

>> J.D.

>> walker@m...

>

>

>

>

[Guest guest]

Check your daily vitamin bottle and you will see chromium listed as an essential

mineral. I sincerely wonder about some doctors that are practicing. GEEZ! The

hexavalent chromium is a configuration that does not occur in a MOM hip

prosthesis!!!! It is all a measurement of volume really. Too much Vitamin A is

harmful. Too many Mcs hamburgers are harmful. That chromium/cobalt ions

cause cancer is pure SPECULATION. There is NOT ONE DOCUMENTED CASE. It is good

to do your research, however. You have to be comfortable with your choice. I

know I am and I'm climbin' 5.11 again!!

Rock climbin' Jude

LBHR De Smet 09/11/02

PS- To Saeed!

How are you doing? You must be busy and playing great tennis. We don't hear

from you as much as we used to... actually a good sign, isn't it!

Re: German data on metal ions?

Hmmmmm, as I recall vaguely from seeing that movie, chromium

[VI] ( " hexavalent chromium " ) was what was poisoning the water supply of

Hinkley, CA.

So , did you get resurfaced anyway??

Best,

J.D.

============

J.D. -

My HMO Orthopedic Surgeon warned me off metal-to-metal saying " you

know the Brockovich story? " I really can't make the connection.

[Guest guest]

Thanks for this great comprehensive list, Dan! It's interesting how all the

downsides of BHR have to do with its novelty, and I guess that's true of

the fear of metal ions too...

Best,

At 01:23 AM 06-06-03 +0100, Dan Milosevic wrote:

>J.D.

>

>I was scheduled to have THR on NHS (National Health Service which is

>free) 3 times in the last 6 months. Each time I turned down the place

>in hospital, I was told that I'd be put at the back of the queue again.

>Meanwhile, having stumbled across this site, I have researched BHR

>within my layman's limits. I concluded that BHR on the upside:

>

>* Was a less invasive procedure

>* Had a faster recovery time than THR

>* Had less restrictions on movements and activities after the

>procedure has been completed and rehab concluded

>* Can cost less than THR (if you want to / have to go private)

>* Has a projected life span way in excess of THR, in theory it

>could last your life-time (the latest THR stats I came across suggest

>that time between revisions has shortened to 8-10 years despite

>improvements in technology, materials, and procedures; this is

>speculatively being explained by a combination of contrasting factors -

>a significant increase in obese and overweight patients who put

>additional stresses on the prosthesis and on the remainder of the femur,

>and/or a significant increase in overactive fit persons who pursue

>sports much more intensely and much longer in their lives than the

>general population did some 40 years ago when the average time between

>remissions was in excess of 15 years)

>* Was more suitable for active and relatively younger patients

>(I was certainly more active than the average 52-year old male)

>

>and on the downside:

>

>* Was less proven (approx 10 years and 10,000 interventions

>largely in the Saxon world only, and here I included Belgium's centre of

>excellence run by Dr. DeSmet)

>* Had fewer practitioners performing it

>* Had less centres specialising in it

>* Had less well defined post operative physiotherapy and

>recovery procedures (including pain management)

>* Had a strong body of physicians who were openly sceptical

>about this procedure (however, I can't forget the fact that profit and

>economics do probably play a part here, as, I guess, the cost of

>BHR-type prosthesis is less than those used in THR procedures, and that

>may mean less incentives for physicians as they spend less money with

>suppliers; additionally, a 50-year old is likely to be a THR patient 3

>times for each hip if s/he were to live to the average age of 80; by the

>way, it also seems that your femur can take no more than 3 revisions - a

>decidedly awkward fact for very young OA patients as they have to wait

>in pain until they reach this age when 3 revisions will see them through

>to the end of their life)

>* There are at least 2-3 competing technologies in resurfacing,

>a fact that makes choices and stats more difficult

>

>and could find no relevant difference in the following arguments:

>

>* MOM / plastic / ceramic etc. - same (non)issues apply

>* Type of anaesthetic used/applied

>

>When I discussed my preference for BHR over THR with my OS (a Professor

>of OS who taught most of the British OSs that currently perform BHR), my

>winning argument, that led to him writing to a former student of his who

>is a well known BHR practitioner, was that IF BHR WERE TO BE LESS THAN A

>SUCCESS I HOPE IT WILL BE, I CAN THEN FALL BACK ON THR.

>

>Please, bear in mind that these are my conclusions from analysing the

>available data. This does not mean that another individual analysing

>the same data may not come to the opposite conclusion, that THR is a

>better option than BHR.

>

>Regards

>

>Dan

>

>* (07974) 981-407

>* (020) 8501-2573

>@ dan.milosevic@...

>

> Re: Re: German data on metal ions?

>

>Thanks, ! This is very helpful.

>

>I suspect that with my OS at least the last three of the reasons you

>mentioned for being suspicious about resurfacing are in play. He is, or

>at least thinks of himself as, an expert in the field, and I suspect

>that in part what's going on is that THR is what he's always done and is

>very good at. So naturally alternatives are under a cloud, for him.

>

>As to the MoM, he's proposing a ceramic- or metal-on-polyethylene THR

>for me, not MoM. But the polyethylene is exactly what I'm worried about,

>at my age. Many of the materials so helpfully made accessible

>through the site indicate that that's a fine prosthesis if you're older

>and/or more sedentary, but that the wear (and hence revision) rate for

>younger/active folks is pretty bad.

>

>So it seems as if the choice is between the known path -- not being very

>active and hoping to eke 15 years out of a polyethylene THR -- or the

>lesser known path -- doing the resurfacing, being more active, and

>seeing what happens down the road.

>

>Anyway, I'm going to try to get a second opinion -- and thanks to

>everyone in this group for the encouragement and helpful contributions!!

>

>Best,

>

>J.D.

>

[snip]

[Guest guest]

Yes, I don't think there's a conflict either! I wouldn't be surprised if a

doctor wants to err on the side of the more conservative in his official,

public, on-the-record statements (like the one on the website), but is

willing to tell you his more honest opinion face to face.

I might try getting in touch with him directly -- was also thinking of

sending him my x-rays to see if I'm even a candidate for resurfacing, which

I don't officially know yet!

Best,

At 10:55 PM 06-05-03 -0000, cosmicmama wrote:

>J.D.

>

>I reported the essence of the comments DeSmet made in Feb, re life

>expectancy for the BHR, correctly and he allowed one of the

>participants to video the entire session. I have no explanation for

>his website statement on the subject. It doesn't conflict with what

>he said to us, it just isn't definitive and I understand your need to

>know. That's what prompted us to ask the question. If you would like

>clarification, I would recommend that you get it from the horse's

>mouth. His email address is Koen.Desmet@.... If that address

>doesn't show up in this posting go back to his website, his email

>address is there. He's very good at responding quickly. You might

>want to ask him what he thinks about the ion question while you're at

>it. 2/19/03 BHR DeSmet

>

>

>

>> >J.D.

>> >

>> >Check my posting today about my husband's cousin. His patient

>was, I

>> >believe, in her mid thirties and sky diving can, from time to

>time,

>> >be a high impact sport. She was at 11 years and going strong the

>last

>> >time he saw her.

>> >

>> >The group of us, who were in Belgium for surgery together in Feb,

>> >asked Dr. DeSmet about the resurfacing life expectancy issue. In a

>> >nut shell, based on existing follow-up studies and stats out of

>> >Europe, he thinks a good resurfacing should last indefinately

>> >provided the bones stay strong. 2/19/03 BHR DeSmet

>> >

[snip]

[Guest guest]

J.D.,

Good. Sending your e-rays is an excellent idea. I think you'll find

Dr. DeSmet wonderful and if you decide to have him perform your

surgery, you won't be disappointed.

You can FedEx (or other form of delivery service) your x-rays or you

can email them digitally. The longest it's taken him to respond to

an email from me has been about 5 hours. I know how important it was

for me to have his answer and I'd imagine it's a big question for you

too. Whether you have them delivered or send them digitally, he'll

email you a response as soon as he's looked at them.

Keep us posted. 2/19/03 BHR DeSmet

> >> >J.D.

> >> >

> >> >Check my posting today about my husband's cousin. His patient

> >was, I

> >> >believe, in her mid thirties and sky diving can, from time to

> >time,

> >> >be a high impact sport. She was at 11 years and going strong

the

> >last

> >> >time he saw her.

> >> >

> >> >The group of us, who were in Belgium for surgery together in

Feb,

> >> >asked Dr. DeSmet about the resurfacing life expectancy issue.

In a

> >> >nut shell, based on existing follow-up studies and stats out of

> >> >Europe, he thinks a good resurfacing should last indefinately

> >> >provided the bones stay strong. 2/19/03 BHR DeSmet

> >> >

>

> [snip]

[Guest guest]

Putting foreign materials into the body is always tricky. Even well " proven "

materials can cause a reaction when the patient happens to be sensitive to a

substance. I'm at a loss when an OS says he's content to place a cemented

stem and a poly cup but a resurfacing device is bad because of the unknown

potential of metal wear.

At least some more enlightened THR surgeons are placing press fit,

non-cemented stems eliminating the " bone cement " aspect of the foreign

material exposure, but the wear particles from the polyethylene cups is a

known cause of synovitis and loosening of fixtures. The surgeon's assertion

that replacing a worn cup is " no problem " shows an unfortunate preference

for what's convenient for the surgeon over concern for the patient's health.

The next " step up " if you will is MOM, non-cemented devices. The concerns of

polyethylene debris is eliminated but there has been demonstrated wear on

the relatively small bearing surface and dislocations is still a problem.

Ceramic devices are an attempt to minimize concerns about contamination and

a non-cemented, ceramic/ceramic hip is the first choice of many surgeons and

orthopeadic professionals who are concerned about this issue.

Younger, active patients tend to choose large diameter devices. Increasing

the diameter of the bearing surface has two big advantages. The larger

surface area creates a lubricating film of synovial fluid that combines with

modern precision machined components to reduce friction and wear. The larger

diameter also reduces the dislocation concern and increases allowable

activity levels for younger and more active patients.

My information is that a cementless, MOM, large diameter total hip would be

a very good option for the younger, active patient. There is optimism that

cementless, non-poly devices, either MOM or COC, could very well be a

lifetime solution... but... The official stance of the profession remains

that hips last a limited time and a fifty something patient should plan for

revision. All three surgeons I talked to said you WILL need a revision,

it's only a question of when. All three surgeons I talked to recommended the

resurfacing procedure instead.

The rationale was that resurfacing leaves open the possibility of a total

hip later. I follow the same rationale for my dental patients. To replace a

missing tooth, first, have an implant supported individual crown. It's

conservative, doesn't touch the surrounding teeth and if it fails, the

patient can always have a bridge placed. Being conservative of structure and

leaving other options open makes sense and is the reason that I have chosen

resurfacing for myself. But there ARE tradeoffs!

I am not happy that resurfacing devices require going back to the " bone

cement " to attach the device to the head of the femur. " Bone cement " is

methylmethacrylate resin similar to what we dentists use to make dentures.

Methylmethacrylate resin is not particularly biocompatible, it is not a

strong durable material, it is porous and absorbs odors and fluids*. I would

be much more comfortable if I had direct boney ingrowth to attach the ball

as I will for the cup. Maybe if enough of us can keep some pressure on the

manufacturers a non-cemented femoral component will become available in the

future!

*NO, I don't have citations for these opinions, just 24 years of " clinical

impressions " from working with the material.

I'm assured by manufacturer's reps that methylmethacrylate is not being

used structurally,

just to fill the gaps between the head of the femur and the device and that

the same technique has proven extremely reliable in knee replacements. I

also have to go back to the idea that if a revision is needed, a total hip

can still be done.

Or can it? OK, you can still remove the head of the femur and place a stem,

but what about the acetabular cup? Success in replacing this part will

depend on the difficulty of removal and the amount and quality of bone

remaining. Insufficient bone might require complicated bone grafting and a

prolonged recovery period. Positioning of the acetabular cup is the most

critical part of hip surgery for future function and comfort. Will the

future revision be done without compromising these outcomes?

I've emphasized in the past and repeat myself here. Every patient is an

individual with their own strengths and weaknesses. Each patient needs to

have a thoughtful evaluation by one or more surgeons with careful regard to

the factors that would make one option stand out above the rest.

Is the patient young or old, active or sedentary, generally healthy or beset

by chronic conditions of some sort. Is there plenty of bone in the hip

girdle for a future revision? Young active patients may chose the rugged

durability of a resurfacing device.

Do they have allergies or any tendency or family history of autoimmune

disease? These patients may be better off with a ceramic/ceramic

non-cemented hip.

Do they have compromised circulation, diabetes or other conditions that

reduce their ability to heal and resist infection? These patients must be

very careful in their choice of procedure and their post operative recovery

efforts.

Most everyone here is very pleased with the results of their resurfacing

procedures and I myself am confident that it is the right path for me to

follow. But I also think that other options can be very good and should not

be dismissed without careful consideration.

This is a wonderful discussion group but I repeat, talk to the surgeon. If

he makes a recommendation you don't understand, ask " why? " . If he hasn't

thought his answer out enough to give you sound reasoning and good research

to back it up, how come you're paying him the big bucks? The patient must

keep asking questions until the answers make sense and the choice is clear.

Well, guys and gals, sorry about the long winded rambling message. I wish

you all every success with your treatment and recovery!

Mike

[Guest guest]

<snip/>

>

>I am not happy that resurfacing devices require going back to the " bone

>cement " to attach the device to the head of the femur. " Bone cement " is

>methylmethacrylate resin similar to what we dentists use to make dentures.

>Methylmethacrylate resin is not particularly biocompatible, it is not a

>strong durable material, it is porous and absorbs odors and fluids*. I

would

>be much more comfortable if I had direct boney ingrowth to attach the ball

>as I will for the cup. Maybe if enough of us can keep some pressure on the

>manufacturers a non-cemented femoral component will become available in

the

>future!

I was under the impressionthat for BHRs they used a calcium-based adhesive

that was absorbed (eventually) into the body. The cup is supposed to allow

f bone ingrowth too. The Midland site mentions the adhesive you do, but

(near as I can tell) only in it's section on historical resurfacings. Mind

you, they don't seem to say what they are using now.

Also, how long do crowns last? I remember one dentist saying that gold

crowns can last up to 50 or 60 years if properly installed. Is this really

true? My crowns are rated for 20 or so years, I think.

I'm not trying to be grumpy, just get my facts straight.

Thanks for the long post. I found it well-written and interesting.

Cheers,

-- Jeff

rBHR Aug. 1, 2001

Mr McMinn