Wednesday, October 17, 2007

Hip to be spared...

This post is a bit nontech, but perhaps many people will be interested in what I am experiencing. I left Tokyo on 14 October for NYC, and will remain in NYC a few weeks. I'm getting my hip joint fixed.

I've always been physically active in my adult life, but had to stop nearly everything 2 years ago because my right hip was giving me problems. This meant the end of biking, running, hiking, basketball, raquetball, and my passion - ultimate frisbee. It was a hard pill to swallow, but the pain and the diagnosis by a Japanese doctor indicated the hip joint was failing. I was told to lose weight and bike or swim to keep in shape, and hope to delay joint replacement until my 50s (I was 41 at the time).

Well, in the two years that followed I couldn't do much exercise because of the excruciating pain. Biking was impossible. Swimming was OK, but the distance I had to walk to do it was often difficult. And with my job standing and lecturing, as well as use of trains for my commute - things deteriorated. Adding a few pounds didn't help either.

In May of this year, the pain was so bad I went to a nearby clinic to see an orthopedist, and he told me the joint was in its 'terminal' phase, and that my left one was not in good shape either. You can see the Xray at right, bad hip is on the left side of the photo.

I started looking for local solutions to my problem - in Japan. I went to a reputable orthopedic hospital in Shinjuku and was told they could do total hip replacement (THR), and use a ceramic joint fitting. Unfortunately, THR is very destructive, basically cutting off the entire top quarter of the femur. And THR's may only last 10-15 years, with revisions requiring more bone destruction. Usual candidates for THR are in their late 50s or 60s, but for someone my age I just couldn't see whacking off so much bone. Unfortunately, this is the only technique readily available and in common practice in Japan.

You can see a THR example below left. This image is from Dr. Edward Prince, M.D.

Fortunately, there are other alternatives to THR, namely a relatively new technique called 'joint resurfacing' that was tried (and failed) in the 1970's, then completely revamped
about 10 years ago. The original successful version of joint resurfacing is the Birmingham Hip Resurfacing System (or BHR) developed by Derek McMinn in Birmingham, England. BHR was in use in England from 1997, and was FDA approved for use in the US in May, 2006. There have been other similar systems developed (Cormet, e.g.), but BHR seems to be the most commonly used. The advantage of BHR is very clear for younger patients: less bone loss, more future options, higher potential levels of activity. You can see from the below right BHR photo (from Orthoworks, UK), that the implant size is considerably less - a femoral cap over or replacing the ball and a matching cup inserted into the pelvis. There are reports of many athletes having this surgery, including Floyd Landis, and they are able to continue their activities at similar or higher levels.

Of course, there are potential problems with BHR, and with only 10 years of supporting data - there are a lot of questions that remain unanswered. The first of these is longevity. We just don't know the lower or upper limits of lifespan of BHR implants. The other issue is the potential problems from metal on metal joints releasing ions into the bloodstream. BHR uses Chromium Cobalt, and there isn't enough long term info to determine its effect. Another risk involves stress on the femur neck. Therefore, the placement of the implant is critical. The angles must be carefully worked out so that stress doesn't exceed the bone's capacity. This also means that the patient needs to have good bone mass to support this implant, compared to THR.

Fortunately, I meet all the criteria for BHR and am at the young end of the spectrum (average age is 48 years). Unfortunately, I had to look outside of Japan. Yes, there were a few places offering BHR in Japan, but the replicates of BHR performed were very small by those surgeons. Given the importance of positioning the implant correctly, a surgeon's number of BHR surgeries (as well as successes) is critical. BHR is relatively common in Europe, with Dr. Smet in Belgium having the most experience. There are actually two or three UK trained surgeons in India performing BHR (Dr. Bose in Chennai the most senior of these), and the cost of doing that surgery is very low compared to the US. Medical tourism to India is very popular, as a result of such low costs.

Given that US surgeons have only had limited time for BHR, only a few have had much experience, including the trials leading to FDA acceptance. Since my insurance was willing to pay for nearly all expenses, I decided to look for surgeon in the US with experience. When I combined this with a comparison of the best hospitals for orthopedic surgery, I came up with one particular choice: Hospital for Special Surgery (HSS) in New York City, and Dr. Edwin Su. HSS has the lowest infection rate in the country, as well as the highest ranking by US News and World Report. Dr. Su has nearly 400 BHR cases to his credit, and I liked the fact that he is publishing research papers on his surgical work. Plus, I was able to find and email him directly - and he answered me in short order. So, about 2 months ago I began making arrangements to come to NYC for my surgery. There have been many hurdles, but Dr. Su's office staff made many efforts to help me out. The hardest part for me has been separating from my 11 month old daughter and wife for a few weeks. But after meeting Dr. Su and the hospital staff, I know that I made the right choice. I'm in very good hands. These are quality people.

So, I go under the knife on Oct 19th, and will probably stay in NYC for at least 2 weeks after for rehab. I'll probably post more of my experience in the future. In the mean time, I will try to see some of NYC.


Anonymous said...

Hip Resurfacing Surgery is indeed a miracle of modern medical science. Its a pity that this procedure till recently was not available in the United States. While surgeons at hospitals in India like the Wockhardt Hospitals Group which is a part of Harvard Medical International have been performed it on hundreds of patients with excellent outcomes.

The sensational thing about the high is indeed the cost, which is one sixth or eighth of that in the US, UK or Canda.Defenders of organized medicine are fond of saying that the United States has the best healthcare in the world, but I challenge that. I don't think we have the best healthcare in the world, I think we have the most expensive healthcare in the world. In fact, in terms of results for dollars spent, I think the United States ranks very near the bottom of quality medical care at the state of the art, internationally accredited hospitals the list of all industrialized nations. We get less actual health than anyone else for each dollar that we spend.

Last year one of my uninsured friends who was otherwise faced with the prospect of mortgaging her property to pay for hip surgery here chose to go to India for hip resurfacing surgery at Wockhardt Hospitals in Bangalore . I could not believe when i saw her walking flawlessly and her life has changed completely. She says she can't honestly say that we can't remember ever been taking care of us by so many nice, kind, and caring people as at Wockhardt Hospital in India. Just check out some amazing videos about real people talking about their experiences on the following weblink

umijin said...

I agree about the overpriced status of US health care, and if I didn't have adequate insurance coverage - I probably would go to India or Belgium.

I'm a supporter of socialized medicine, but after seeing Japan's health care system I do question it's efficacy in all cases. For small things - socialized medicine is great. But for life threatening matters - I'm not very impressed with what I see in Japan. (And I've yet to hear of a Japanese pediatrician that will not prescribe an antibiotic to an infant/toddler at the drop of a hat. It's ridiculous.)

I'd say that the US does have great state of the art care, maybe better than most countries. But it costs you an arm and a leg to get that level of care - your point, perhaps.

I don't doubt that I would have gotten great care in India, but I wouldn't have the mental comfort level I have here in NYC. Plus, I don't have to deal with general anaesthesia here, which I would have to elsewhere.

Anonymous said...

Hello Mac,

Like the previous writer I'm kind of surprised that you chose the "new kid on the block" in the US for your procedure instead of India who I think has done more of these than any other country in the world. Of course, I live in India and that gives me a different perspective. But I had the chance to meet a patient that Wockhardt worked on because we're members of the same church, and I also got to meet a couple of other patients that were getting their hips resurfaced. One of them got both hips resurfaced and I was just amazed to see him get up out of his chair, pivot a bit, and then walk across the room withoug cane or walker or anything, and grab something he wanted me to see, pivot clear around, come back and hand it to me. My eyes must have been as big as saucers as I looked at him and said, "THAT's TWO HIPS!"

It's cause for awe and he was certainly singing the praises of Dr. Malhan, I believe is his name.

In addition to all that, there are three Americans living in Bombay who have formed a medical tourism company some time ago which they haven't even advertised yet, and just for whoever else is going to read this blog, they should have the opportunity to know about these guys who charge absolutely nothing for their services. I've used them and can vouch for them. They are America's Medical Solutions at

Anyway, Mac, you've got my vote and I hope we'll get a positive report from you. Dan

Anonymous said...

One more thing, Mac, my church friend did NOT use a general anaesthesia in India either. You should see these hospitals. They put to shame anything I'd seen elsewhere in the world.

umijin said...

Anonymous 2 & 3, regarding India, I think people have their own comfort levels, hence a large part of the bias. I admit my own bias - and part of that is being a biologist with some knowledge of epidemiology.

I ultimately made my choice based on the best hospital and doctor per particular region.

I didn't look into Wockhardt or Dr. Malhan, because they have less experience than Dr. Bose and the Apollo hospital in India (AFAIK) with resurfacing. They weren't on my radar at all for India. Unfortunately, the Apollo hospital (with the real BHR king, Dr. Bose) wouldn't work with my insurer.

I ruled out Thailand and Bumrumgrad very quickly, because the surgeon didn't respond directly to my questions, and often didn't answer them at all.

I ruled out Europe (Smet, Belgium) because of the distance from Japan, and lack of any family support there.

There were several good candidates in the US (that met US standards and mine), and I ultimately based my choice on a balance between location, hospital ranking, and surgeon's experience. My MD is not the 'new kid on the block', at least in the US. He has an excellent track record and nearly 400 BHR cases. And frankly, I'm a bit relieved he doesn't do so many BHR per week, compared with others overseas. His staff also worked closely with my insurer, not only getting a letter of payment guarantee, but making it possible for me to afford outpatient care in NYC.


Hi Mac,
Hope your hip is doing well and that you are back to work in Japan.
Hip resurfacing is probably not very popular in Japan due to the lack of demand. Asian patients hardly suffer from primary osteoarthritis of the hips. The commonest diseases in Asia requiring a hip replacement alternative are Avascular necrosis, ankylosing spondylitis. The inflammatory arthritis are not very suited due to soft bone and high risk of fracture.
Hip resurfacing has been practiced at Chennai Knee surgery centre by Dr.A.K.Venkatchalam for many years now. His website offers videos of patient testimonials, live resurfacing operation and tips on surgery.
The cost of hip resurfacing surgery is unbleivable at only 7500 US dollars for a seven day stay. This is one of the cheapest packages for hip resurfacing in India

umijin said...

Funny how you refer to yourself and clinic in the third person...

Anyway, thanks for the clarification on why Japan might not have much demand for BHR procedures. What you say makes some sense.

My guess is that this will change as people with active lifestyles opt not to just tolerate giving up their activities and putting up with the pain/discomfort. This will involve going against cultural tendency to accept inconvenient things - so it might not happen quickly.

Anonymous said...

Very helpful article and discussion that validates much of what we've learned with a day or two of surfing the Web. Judging from my wife's case, it seems to be true that little is known about resurfacing in Japan, even by doctors. We're insured but leaning toward India on the basis of surgeon experience levels.