By: 24 September 2011

Modern Hip Resurfacing from Derek McMinn attempts to explain the complex world of Hip Resurfacing Arthroplasty from the history of the procedure to the development of the prosthesis, progressing through biomechanics and surgical technique, indications and complications with discussions on outcomes with personal recommendations.

In his preface Ronan Treacy gives us a fascinating insight on the process that led to renewed interest in the metal-on-metal arthroplasty, an insight into how “faint amusement” and “occasionally horror” at these procedures performed by “maverick and irresponsible” surgeons was gradually transformed into positive opinions, approvals and grudging respect and finally acceptance for the procedure. Derek McMinn has given an account of a young surgeons endeavour to attempt to manufacture his brand of hip, the one he believed in and one which he felt was discarded far too quickly when the concept had first emerged and the fascinating history behind Midland Medical Technologies (MMT).

The initial section deals with development perspectives and is a story of persistence of the small group of surgeons who believed in their invention to the amazing journey from rejection to worldwide acceptance. I have a nagging suspicion that caricatures included in this chapter may be images of early antagonists to this procedure. Nonetheless, the event leading up to the FDA approval for the prosthesis in 2006 is well charted and makes for fascinating reading. Materials and metallurgy, including machining processes, make for dry interludes yet are a background to the evolution of the prosthesis. Retrieval analysis gives us a case-by-case account of the various setbacks encountered along the journey and the scientific methodologies employed to study wear. The chapter on cementing technique for the BHR clearly spells out the recommended method. The modified cementing technique currently used to prevent a posterior mantle deficit has been mentioned.

One of the most important chapters for anyone embarking on this procedure is the vascularity of the femoral head in resurfacing leading to AVN, osteolyis, loosening, fracture or failure. Interesting yet unproved theories are advanced to the vascularity or lack thereof of the arthritic hip and consequently how the timing of the procedure may affect results. More technical information about techniques of estimating blood supply is provided by outlined blood supply studies. This chapter conclusively states that “intraosseous blood supply to the femoral head is maintained after resurfacing even if the division of the medial femoral circumflex artery occurs during a posterior approach”. Finally the section on metal ions is comprehensive in its treatment of metal particles and ions including their transport, clearance, measurement of the systemic metal exposure, DNA and chromosomal damage, metal hypersensitivity and specimen collection for analytical study.

The clinical sections dive to the depths of the most obvious like indications and contraindications to selection of the ideal candidate for the procedure and the timing of the surgery. Thromboprophylaxis and limitation of blood loss has been accorded its rightful importance. The outcomes do suggest that only 1.4 % of the unilateral BHR patients needed a blood transfusion for symptomatic anaemia and only 8.3% for those undergoing THR. The authors are convinced that “the combination of hypotension and non-usage of conventional anticoagulation reduces peri-operative and post-operative bleeding significantly”. This is indeed worthy of widespread consideration. Templating from conventional radiographs and computer templating is lucidly outlined.

A multitude of important pointers are provided for patient positioning and exposure. Particularly noteworthy were exposure of the sciatic nerve in patient with DDH and the Ranawat recommendation of division of the tendon of the gluteus maximus to avoid pinching of the sciatic nerve during leg rotation. Common pitfalls in acetabular preparation and insertion of a standard BHR cup are discussed and tips to avoid these outlined. Some photographs in this section could have done with a little more clarity and close-up. The section detailing insertion of the Dysplasia Birmingham HIP Resurfacing Cup (DBHRC) is comprehensive but is also a tad longer than may be necessary for most surgeons. Implantation of the femoral component of the BHR is described in superb detail and gives the most noteworthy account of the technique and likely complications to arise, discussed. The evidence for the recovery room x-ray though, is not convincing enough. Birmingham Mid-Head Resection (BMHR) prosthesis is described in lurid detail and is particularly helpful if purely for information for the trainee or the new consultant alike. With the detailed technique needed to execute a BHR in general and a MBHR in particular it is wisely recommended to leave the MBHR to the very expert.

Outcomes and Standards for hip resurfacing authored by none other than Paul Pynsent, the golden boy for statistical research and analysis at the Royal Orthopaedic Hospital is short, succinct and delivers the driest of information in a presentable and easy-to-digest format. In conclusion, “the BHR survival is above 95 % at 10 years for this young and active group in which traditional hip replacement has not demonstrated such success”. Perhaps one of the most important chapters is the results of BHR in different diagnoses like the young arthritic, AVN, inflammatory arthritis, post-septic arthritis and childhood disorders. This makes absolutely fascinating reading and gives the reader of the likely success rates and may help in pre-operative counselling. As regarding complications and revisions the author makes a point about the majority of failures needing revision to a total hip replacement which would have been a treatment option for the original disease anyway in absence of hip resurfacing.

In concluding paragraphs Derek McMinn alludes to and pays homage to Charley Townley who was his inspiration and whose surgical outcomes were a forerunner for the current state of resurfacing hip arthroplasty. This book comes with its own DVD for those who like to read or store this powerhouse of a book electronically.

In summary, this is a must-have for consultant orthopaedic surgeons who do or intend to dabble in resurfacing, to the trainee wanting to explore this area further and stack up on knowledge prior to their boards or exit examinations and a respectable reference manual for any medical library of repute.