Hip replacement

Hip replacement, an operation that about 300,000 Americans undergo each year, is one of the great success stories of modern medicine.

This is the first in a series of articles that will address pocketbook and other consumer considerations involved in choosing and using health care.

But woe to those who outlive their artificial hips, which typically cannot be counted on to last more than 20 years or so.

Because it is difficult to extract and replace a worn-out or defective artificial hip, doctors routinely advise patients to put off hip replacement as long as possible. For middle-aged or younger people whose hips have been damaged by disease or injury, that typically means a punishing waiting game.

Now, though, an alternative to total hip replacement can offer an interim solution to many younger patients.

The alternative, called hip resurfacing, usually yields at least as many short-term benefits as a total replacement. It costs about the same and is typically covered by insurance.

And though many patients can expect to outlive the treatment’s effectiveness, hip resurfacing has the advantage of preserving enough healthy bone to allow for a future total hip implant.

“It’s nice to know that down the road, if necessary, it will be an original total hip — not a revision,” said Keith McDonald, a 54-year-old air traffic controller from Melville, N.Y., whose right hip was resurfaced late last month. This past Tuesday, just 15 days after the operation — and at least a week earlier than doctors would recommend — Mr. McDonald drove his car. “Every day I do more,” he said.

Tens of thousands of patients around the world have had hips resurfaced in the past decade. That includes some Americans who went overseas before the Food and Drug Administration started allowing it to be done in this country last May.

“The demand from patients and surgeons is tremendous,” said Brian Austin, of Smith & Nephew, the British maker of the F.D.A.-approved resurfacing system.

More than 400 surgeons in the United States have now been trained to use Smith & Nephew’s product, which is known as the Birmingham Hip System. Competing devices already sold overseas are expected to begin arriving in this country later this year.

For all its potential advantages, hip resurfacing surgery is actually no easier for the patient or doctor than hip replacement. And the recuperation may not be any quicker. While many activities can be resumed within weeks, complete healing can take six months or longer.

And a number of medical and health conditions, like kidney disease and obesity, may make even young patients poor candidates for resurfacing.

There are enough potential drawbacks, in fact, that doctors offering hip resurfacing say — as they do with standard hip replacements — that the procedure should be deferred as long as possible. That typically means waiting as long as the patient can tolerate the pain from the arthritis, bone damage or other conditions afflicting the hip.


“You should have pain every day before you even think about it,” said Dr. William B. Macaulay Jr., a Manhattan surgeon who is one of this country’s leading practitioners of hip resurfacing. “If you are doing it in people with moderate pain who just want to improve their tennis game, that’s crazy.”

Experts say that 10 percent to 15 percent of hip-replacement candidates may find hip resurfacing a viable alternative. But unless they are Web-savvy like Mr. McDonald, who learned about it only through his own Internet research, they may not have heard about the procedure.

Patient-support Web sites like Surfacehippy often post complaints from patients saying that surgeons not trained in resurfacing tend not to tell their patients about it.

“I’ve been a volunteer paramedic with the Melville Fire Department since 1971, so I’m interested in medicine and not reluctant to do research on the Web,” said Mr. McDonald, recalling how he had discovered resurfacing and found Dr. Macaulay, the surgeon who operated on him.

Vincent Torretta, a second patient who underwent hip resurfacing with Dr. Macaulay the same day as Mr. McDonald, also discovered the procedure through his own Web research. Mr. Torretta, 60, a loan data analyst with Bank of New York, lives halfway up a mountainside near the Pennsylvania border in Glen Spey, N.Y. He sought relief when chronic pain in his left hip and knee left him unable to pursue outdoor activities.

He found that Dr. Macaulay, the director of the Center for Hip and Knee Replacement at NewYork-Presbyterian/Columbia hospital, was the nearest expert in resurfacing.

“It sounded like it would allow me to lead a more active life,” Mr. Torretta said.

He said his insurer, United Healthcare, initially denied coverage because he wanted to go out of the approved doctors’ network and that several of the United representatives whom he spoke with on the phone were confused because they had never heard of the procedure. United eventually provided oral approval. Mr. Torretta still did not have that in writing by the time he underwent the operation.

Publicity about the procedure may soon pick up. Stryker, a big American maker of artificial joints, is expected to begin marketing a similar British-designed device by early fall. Another device maker, Wright Medical, is close on its heels.

Other big orthopedics companies like Zimmer Holdings, Biomet and the DePuy Orthopaedics division of Johnson & Johnson that are selling resurfacing systems overseas are further from getting approval in this country.