Floyd Landis’ hip replacement

We all know by now that Floyd Landis’ surgery was reported as successful. I did notice that he chose to undergo a different procedure, femoral head resurfacing. I thought that was an interesting choice as this is not the traditional total hip replacement. This procedure has the advantage of being minimally invasive (smaller incision). The downside is that long term outcomes of this type of procedure are not as well known.

MAJOR DISCLAIMER: I am not a doctor much less an orthopaedic surgeon. I did not even stay at a Holiday Inn Express last night. Therefore I should not be thought of as an expert on anything (except beer).

Looking through the literature on published studies that may give insight into what Floyd can expect, there is one study from the Journal of Clinical Orthopaedics and Related Research that looks at this. The abstract can be viewed on the National Institutes of Health website.

One reason, I suspect, that data is not as available is that payers may not be inclined to pay for this surgery over total hip replacement because they do not want to pay for the same surgery twice. Once for the resurfacing and then again when/if the femoral neck breaks. Bone breaks. titanium does not.

Another thought when reading this. First, an athlete in supreme physicial condition should have better outcomes. Second, current outcomes measurements do not apply to Floyd. For example, does returning to normal life mean racing at a high level?

Editors Note: My apologies. I accidentally deleted the original post when I came back to edit it to add some interesting postulations on outcomes and the world class athlete. It is being dubbed “The Lance Armstrong effect.” I’ll get to that at a later time since I used my time this morning recreating the post. Unfortunately, the comments are gone. Again, I’m sorry. Off to soccer and lacrosse!

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30 Responses to Floyd Landis’ hip replacement

  1. Michael (MD) in NC says:

    For detailed and unbiased information about modern Metal-on-metal hip resurfacing, check out http://www.activejoints com . For a pro resurfacing disscussion group with 5000 members most of whom have had the procedure, try yahoo groups “surfacehippy”.
    The prothesis is cobalt-chrome-molybdenum. It has been placed in bikers, iron-man contestants, mountain climbers, kickboxers, tennis players, dancers and many others. It has been around since 1990. Floyd was actually operated upon by Ronan Treacy, a pioneer orthopedic surgeon in this procedure. He flew into San Diego from the UK to “assist” the official orthopedist. This is the best prosthesis for an athelete. The one Floyd received is the BHR (Birmingham Hip Replacement) which is now FDA approved in the united states.

  2. pelotonjim says:

    Thanks doctor! One thing I was sure of was that with three years of knowing, Floyd was going to get the best procedure from the best people. When reports note the “change” in procedure, I started look. One thing noted is Bo Jackson is on his third hip replacement. That got me curious about outcomes.

  3. Joe Foster says:

    Mr. Landis
    I will be having the BHR surgery the 5 of June I have researched all the options and have choose resurfacing so that I could have an active life stile after surgery. I have not seen much information on post operation and how fast the rehab takes to be active again. I am a Dive Master and scuba dive often and would like to know how soon I could be back to my life style again.
    Thanks and good luck.
    Joe

  4. pelotonjim says:

    Mr. Foster,

    Thanks for dropping by the blog. This is not a site by Floyd Landis. I would be honored to have had him stop in for a read. I also am not a physician so I can’t provide you with any advice. That is probably for your personal physician who is familiar with you and your case. All I can say is good luck.

    Jim

  5. Dr. William Cory Foulk says:

    Having received BHR reline in December of 2005, I have completed three Ironman triathlons, two ultra-marathons a marathon and the Ultraman World Championships in which i placed 11th overall in 2006 at 11 months post-op. I have two Ironman events, and Ultraman Canada and Ultraman World’s scheduled later this year.

    For me, there was no doubt that a reline was the right option, not a total hip replacement. The best surgeons around felt a total hip would last approximately three years with my lifestyle; the BHR is likely to last ten to fifteen, maybe more (I am currently in a study to help find out).

    I was lucky enough to ride with Floyd several month’s post-op, and his recovery was near total. I ran the first marathon at three months post-op. The athlete effect is import – but it must be recognized that this procedure is for athletes! That was the driving force behind it’s development – to get active people back in action.

    I will say however that there is one mis-statement of note. This is not minimally invasive due to incision length. My incision, which is typical, is around ten inches. It is minimally invasive because it preserves bone, as well as muscle and tendon connections. Th esurgery is much more complex than a total hip replacement, but is worth it if you are active and a candidate.

    Aloha kakou,

    Cory Foulk

  6. kathy Taylor says:

    can any one please help me my husband had a BH replacement 8 weeks ago this has given him his life back, He is 50 on boxing day and I wiould love to purchase some BH replacement cycling shorts and top for him, Floyd has been an inspiration to my husband who is in the RAF and now after 10 years of pain from a car accident he is now pain free. If any one can point me in the right direction I would be grateful.
    Kathy Taylor

  7. dr. william cory foulk says:

    kathy –

    http://www.bikeparts.com/

    is the link to the clothing. go to apparel and then tight jerseys and then smith and nephew and there are the jerseys and shorts. cool.

    cory foulk

  8. Willie says:

    Question for Dr. William Corey: I’ve been riding for over 13yrs both Road and Mountain biking. Last year I fractured my hip twice from a downhill fall on the Mountain bike, resulting in arthritis. I’ve since been riding my bike with this pain and would like to know if this hip resurfacing would be a good option for me. I’m 42 and still very active. I have the desire to compete and ride for worthy causes. My current doctor advises me that a hip replacement will only mask the pain and that I would eventually be back for a full hip replacement. Bottom line is “He doesn’t believe in hip resurfacing”. Any advice you can give me would be greatly appreciated.
    Sincerely
    Willie

  9. Tess Lerback(Odekirk) says:

    Aloha Corey,

    I am writing to you for help. My brother, if you remember was a professional moto-cross racer. About two years ago he had his hip replaced. Now we learn that the Zimmer Duram is recalled, He can’t not get anyone to help him, Doctors do not return his calls, he went to UC Davis, they do not return with results…he is now on crutches and close to suicidal. My dad died of Melanoma in July, prior to his death,my brother lifted by father from bed to chair, although he was told not to lift more then 25lbs, he had to take care of dad. With this and the recall, we are desperate, he can not work and is tempted to go to India. Can you recommend someone who sould be willing to help? Thank you so much, I am glad to see you are doing well.

    Tess

  10. dr william cory foulk says:

    willie –

    there are 18,000 orthopedic surgeons in the u.s. today; fewer than 1,000 have received formal training in the BHR procedure. the balance are likely to think of a resurfacing as somethig that was tried in the 1980’s – a hemi-spherical resurfic, where only one side fo the joint was treated, not both. this procedure was a miserable failure.

    the new resurfacing sufers by assoication the reputation of this much older and significantly different procedure.

    i would say yes, 100%, go find a good trained surgeon that does both, and get a second opinion. i just finished my 5th ultraman in november on this reline, and i have 8 ironman finishes. i run 50-80 miles week in training, and have no pain related to the reline – i have the same old aches and pains we all have! no way around that.

    go to surface hippies and read some stories, or smith and nephews website and get more info. you can always email me direct at drfoulk@gmail.com.

    thanks,

    cory foulk

  11. dr william cory foulk says:

    tess! email me direct at drfoulk@gmail.com! i will see who i can get to help him in the bay area!

    cory foulk

  12. Ken Snowden says:

    Hi Cory,

    I am writing you as a fellow hip resurface patient of Dr. Bose. I had a BHR on 10/11/08 and shortly after returning home from surgery I had an incident where I stumbled and caught myself on the surgical leg and felt a snap and movement in my hip joint. My gate cycle and standing on the hip imidiately changed and has never been the same since. At seven months now, I cycle 200 miles per week which has been my MO for years but I can’t get the position or strength back in my hip. It actually is worse. Follow up X-rays are satisfactory to Dr Bose that there has not been any slipage but I am not convinced. There is no way this movement is normal or like my other hip. In your personal experience and others you have known, have you come accross this? Are there multidirectional images that can be taken to prove this? I would appreciate your comments……Thanks

    Ken Snowden

  13. cory foulk says:

    hey ken –
    i can’t imagine it came loose like that, not after the crashes i have had, though i suppose anything is possible. i know one triathlete who did knock the acetabular cup loose, but i think his surgeon likely used too large a ream and the cup never was installed correctly. watching them put the cup in on video or in a cadaver lab, you would not believe the force involved.

    you may have torn the hip capsule open or something, that sounds more likely. a manual manipulation of the leg would give more info than a radiograph. perhaps you could see a local BHR doc or your local GP under vijay’s guidance and have them test it that way.

    let me know if i can help,

    cory

    drfoulk@gmail.com

  14. John Angell says:

    Dear Dr Foulk,

    I am 62 years of age, facing the prospect of a hip-resurfacing op in the future, and thought I would do a little research as to how Floyd Landis got on with his, as I recall he “won” the Tour with an arthritic hip, and at the time, I recall, was anticipating having a replacement done.

    I cycle regularly, and believe me, I would like to continue after the op. I ‘googled’ Floyd, and found this website which I have not visited before. I am most impressed at some of your postings, and the apparent effectiveness of the ‘BHR’ procedure referred to.

    The following is a description of the procedure that my consultant is proposing:

    “I would do what I call a modified hip resurfacing. A hip resurfacing is done in a relatively young patient with good bone stock on either side of the hip joint. The acetabulum (cup in the pelvis) has got good bone but your femoral head is full of cysts (holes) and I wouldn’t be able to do a pure resurfacing. I would therefore use a resurfacing cup with a large metal head of the resurfacing procedure but put that on a femoral stem to minimise the chance of a femoral neck fracture which is not uncommon if the bone of the actual femoral head is poor. After this operation you should be able to cycle and walk and undertake most of the exercises that you wish to do in the future.

    I see no reason why you shouldn’t continue cycling at the present time but if you feel that your symptoms have deteriorated I would be happy to put you on the waiting list”.

    Do you have any comment on this? And does this gel with you as being a ‘BHR’-procedure?

    Clearly, I would like the most effective joint that will give robust performance & resist the affects of the wear & tear associated with cycling/walking etc..(don’t we all)…, but I guess its the ‘cysts’ thing which could be a complication(?)

    Basically, do you recognise the proposed treatment as being the most effective? Being English, I am limited by what our National Health Service can provide, but would certainly consider going private & paying for the op myself, if a better form of replacement is otherwise available.

    I look forward to any comment with interest.

    Regards,

    John

  15. pete says:

    hi, i am 52 and should have had a resurfacement but to cut a long story short ended up with a metal on metal thr , the metal on metal thr shares the same size bearings with the resurfacement sizes so the risk of dislocation are the same ie minimal ,i had thr first hip done about 18 months ago and the second hip done 3 months ago , i have been out cycling today for 22 miles with no problems whatso ever , if your femeral head has cysts it may not take a resurfacement but the lage bearing thr is just as good , i had both mine done here in the uk under the national health, the thr stems are a long term relaiable fixing with a good track record ,if you have to go down this route because of the cysts you should be fine, pete

    • John Angell says:

      Hi Pete; Thanks for the comment, received with interest.

      Glad that both THRs seem to be holding up OK. All the best for many years good biking to come. I hope that any future spare parts required, will only be for the bike…!

      One of these days I’m going to do the Ventoux…..maybe see you up there!

      John

  16. dr. william cory foulk says:

    hi guys –

    A large diameter metal on metal total hip is what is being suggested here. because the joint capsule is removed, the risk of dislocation is higher than with a resurfacing, and you will be limited somewhat in your running because of “stress shielding”. i believe your ortho may not have made the cut in the resurfacing training, and therein is not offering it as an option. there is no such thing as a partial resurfacing as he is suggesting, that is just marketing.

    total hip replacements are well proven and effective. the drawbacks are very well cataloged. you will be limited in what you can do, but you will be far better that you are today.

    for me, i was not interested in being limited in what i could do. simple as that. so i chose the real deal. i would suggest that at the very least you find a qualified ortho who is allowed to perform both procedures, and have them give you a blow by blow comparison in your exact case. that is the only real way to choose.

    good luck, and let m eknow how it turns out. i am off to ultraman canadian championships next weekend. the bike component is 270 miles. excellent!

    cory foulk

  17. addavis637 says:

    I’m currently scheduled for BHR surgery on 9 Sep09. I was a dedicated triathlete before the hip arthritis sidelined me. I can do limited cycling, but the bad hip is so displaced, the knee “splays” 20 degrees from the top tube. How soon was Floyd competing after his BHR and what is the usual recovery protocol for someone following this surgery? Thank you

  18. dr william cory foulk says:

    i don’t know what the usual protocol is. i know what i did. that included a 5k run on day six post-op, a road marathon at day 89 post-op, and back to back ironman events at month 7 and 7 1/2.

    i also know i trained specifically for the surgery before i went in. i was also one of the top ultra-distance triathletes on earth when i went in.

    so to develop a rehab protocol, you have to give a lot more info besides a turn-out of 20 degrees. how much specific pre-op training are you doing? what is your absolute state of fitness now? your body fat percentage? weekly mileage?

    what is the real state of the joint? floyd was on crutches for months, zero weight bearing, because cyclists have such crummy bone density to start with. incredible fitness, bad bones.

    so addavis, give me a little more info, maybe i can give you some ideas,

    thanks,

    cory

  19. addavis637 says:

    Cory,
    Thank you for your response. I have to give you BIG kudos for your quick recovery. I understand you are definitely an exception.

    To answer your questions, prior to the surgery,the joint was bone-on-bone, but good density. I am still on crutches and my doc has emphasized NO more than 75% weight bearing until 6 weeks is over (Oct 20). In the meantime, I really want to jump back on the bike and ride to within at least 75% MHR just to stay in shape, but the post-op recovery is very slow-going.

    I was 10% BF just prior to the surgery, and since I could not run, cycled at least an hour a day either on the computrainer or fluid trainer.My weekly milage rarely exceeded 200miles, but I incorporated weights and cardio. My resting hr is 45bpm, and while in recovery following surgery, it dropped to 38.

    I hope that gives you a little info. The doc has me walking on eggshells with his emphasis on the fragility of the femoral neck, which amazes me how you were able to run 5k so soon. He has told me to stay away from running for a year. Tough, but if I can cycle/swim in the meantime, I’m good.

    Looking forward to your ideas.
    Addavis

  20. dr. william cory foulk says:

    Only your doctor knows what it is like in there, and only he knows what he DID in there. This is a complicated surgery, and has many opportunities to nick the femoral neck. Failures in the femoral neck are almost always due to placement problems or the surgeon dinging the neck and then the patient loading it before the dings heal. 6 weeks to 3 months or longer.

    The one year restriction is from the very first era of this device, and has since been revised significantly. But again, only he knows what he did, so there you are. When Rick Rubio had his done, Hayato Mori (the surgeon)said his bones were so dense the tools smoked. Rick ran a marathon at four months post-op, and Mori revised his feelings about running sooner – for some. No doctor will agree to a marathon in four months, or like me three months, but my doctor just said to follow my comfort level. I do not do pain meds and didn’t after day one, so I could monitor how things felt.

    I had trouble stationary biking, it pushed my hip outwards and was uncomfortable for me, so i stayed away from it and stuck to the treadmill, learning to get rid of the ;limp, the pelvic swing – which appeared walking and disappeared while running because both feet leave the ground running.

    Floyd couldn’t weight bear either for six weeks, i think the surgeon had to build up the head of his femur with bone paste to get it back to size, this could have been your case. it turned out okay for him. Cyclists have poor bone density, too, that could be a factor.

    What sort of event are you training for or would you like to train for?

    Cory Foulk

  21. addavis637 says:

    Your explanation makes much more sense now, so thank you. All I know about the surgery is that “it went very well.”(doc’s words). No explanation about density or using bone cement was ever given.

    I guess my bone density was like that of Floyd’s. Not much impact for the past three years obviously made a difference, and hence the six-weeks 75% weight bearing is a cautionary measure.

    My Pain is still a big factor. I’m experiencing max pain in the back of the thigh/knee at night, and what I’m told is that this is common and a result of the girations that the doc’s put the leg through during the surgery. The strength in the operative leg is coming back very slowly.

    My ultimate goals: I’d like to run a 5K next fall and ultimately train for an Olympic distance triathlon for 2011.

    Since the surgery, I’ve increased my calcium and vitamin D intake, hoping that these will help the formation of new bone. How do you feel about glucosamine/chondroitan/hyaluronic acid?Do any athletes use HgH to increase their recovery time?

    Thanks again for the feedback.

  22. cory foulk says:

    i don’t do glucosamine, my joint is metal now. newer data is showing less and less effect for glucosamine. it may be like all supplements, if you are deficient, you will notice huge gains, if you are not, you won’t.

    i think that aqua running will be a big tool in your recovery, as mine. since you can control the amount of weight on the joint by how deep you are in the water, you can do 50% or 75% weight bearing and still get full range and range of motion muscle mapping while you are under restriction. not aqua jogging. shallow water running, in 4 or five feet of water.

    start weight lifting as soon as able, too. not sitting on a bench. what i did was assisted squats, under a smith bar. i would grab the bar, and use it to support a lot of my weight, while i went down into a full squat, and back up. repeat, etc. big difference in how much of my glute was recruited on the operative side, along with my adductors. same thing with lunges. i used the bar to hang from, controlling most of the move through each rep. from water running the progression is running on grass, then a treadmill, then dirt trails, then pavement. pay attention to form. yhou can never have good enough form.

    do not do seated leg extensions. they will cripple you for days. when cleared, do squats, leg presses, and torsional moves. nothing ballistic, ever. when i started swimming i did mostly fly, so i could splint my leg with the good one. i then worked in a few laps of breaststroke, then crawl, then backstroke.

    running off the bike is hard, the hip is not warmed up even though you would think it should be. rick rubio does a lot of oly distance tris, send me an email and i will give you his email.

    cory

  23. Ben says:

    Cory,

    Just to clarify a couple of things – large head metal on metal hip replacement is more stable than a BHR due to the increased head neck ratio but similar jump distance. You can also repair the hip capsule. It is not bone sparing on the femoral side but there is accumulating evidence that resurfacing (where you have to match the acetabular size to the head) actually resects more bone than a traditional THR.

    Patients with painful metal-on-metal articulations should seek orthopaedic advice from a surgeon who has experience in dealing with ALVAL and pseudotumours both associated with metal-on-metal resurfacing with an incidence of approximately 5% at 5 years.

    A huge amount of information can be found on the topic at either http://www.jbjs.org.uk or http://www.jbjs.org both reputable orthopaedic journals.

    I perform both resurfacing and all types of traditional THR (hybrid, uncemented, cemented, alternate bearings etc).

    Athletes in particular should choose their surgeon not their replacement and be mindful that the failure rate of resurfacings is approximately 8 times that of traditional joints in the first five years (see the Australian or British joint registry).

    Each orthopaedic surgeon will give a different opinion, but the accumulating data is that resurfacing offers little over hybrids, and introduces significant risks.

    Ben

  24. geraldatwork says:

    I had total hip replacement on my left hip 8 weeks ago. I am 61 and a recreational cyclist doing 50-60 mile rides on the weekends on Long Island, NY. I had the more traditional metal on metal device made by DuPuy(s) with an antro-lateral 7″ incision.The results so far have been great bike riding wise. I did my first ride at 19 days post surgery a very flat, slow 10 miles. I have increased the speed and mileage each week to where last weekend at just under 8 weeks did 46 miles with 2100 feet of climbing. If I had to run I don’t think I could at this point. However I don’t think it is recommended with this type of hip device.

  25. cory foulk says:

    total hip replacements were never designed for running, and it is not about the bearing surfaces being high wear metal (MoM). it is about the nature of how the THR loads the remains of the femur. it is a tapered shaft entering straight down the bone, like a wedge. high impact can cause it to split the femur like a bamboo stalk. so no, a THR is not for running. depuy does make a hip resurfacing similar to the BHR, and a friend of mine – a national level cyclist – also runs on it. but again, it is a resurface, which preserves the bone and stress loading design of the original hip.

    i have another friend who attempted an ironman on a total hip, and ended up dropping while in great pain on the run.

    cool you are riding though!

    cory

  26. geraldatwork says:

    Question about the resurfacing. My understanding is the new ball (re-)surface and pin is cemented on/in the top of the femur. I thought cementless devices last longer. So wouldn’t the resurfacing require a revision of some sort say after 12-15 years? BTW I finally got over 50 miles on my road bike, 8 months and 5 days post replacement.

  27. cory foulk says:

    why? that is the question i asked the doctors. has the cement ever failed? no. so why would cementless last longer? if the failures are in other areas, that is the control.

    this is not a total hip, where the cement fails because the wedge shape of the device is loading the bone through the cement. this device bears on the bone directly. the cement stops it from rotating and that under a very light load. you can easily download the actual lab reports for failures. i have done [still do] leg presses with 805 pounds for reps with this device, using the independent leg press machine so there is no cheating.

    the cementless device that was developed in the u.s. has a very short history, with only a few patients. it may or may not last longer, it has barely been around to tell. my hip has been used for fifteen years in it’s current config, in over 100,000 active patients. i have 9 ironman finishes and 5 ultraman finishes on it, far more miles in racing and training than anyone ever put on any type of hip arthroplasty. it has not failed, or loosened.

    i could have had cementless, i did not like that they were solving a non-problem by thinking about it like it was a fifty year old technology (total hip), and maybe using the idea of no cement to get around a patent to make money, instead of using it to improve MY life. i asked if the cement failures were a problem! no one could show me data on cement failure in resurfacing devices.

    your body. do the research. do not believe one source, not me, not one doctor. not the internet. it is too late in your case anyway, but if your other hip goes out, you deserve the best.

    thanks,

    cory

  28. geraldatwork says:

    Thanks cory. I am 61 and my other hip will probably be ok for the next 4 or 5 years. By then I’ll be too old for a resurfacing. I looked into it for my recently replaced hip and most of the doctors suggested I go with the trad. replacement.

  29. alan says:

    To Ben, there are lies, damn lies and statistics. I eagerly plied the Australian registeries when researching these proceedures. NOWHERE did I see that resurfacing had a failure rate of eight times the THR failure rate at five years. Double was the most for certain groups AND that represents a patient selection issue. I fail to see why you consider a metal on metal THR “more stable” because of increased head neck ratio. This means that impingement of the neck is more likely in a poorly positioned resurfacing device. Not a desired outcome, but a surgical error or patient selection issue, not a device problem. The issue with acetabular bone removal is known and has been largely (succesfully) delt with by surgeon education and smaller incremental sizing of the devices. Newer studies bear this out. You mention ALVAL and psuedotumors. It is more complicated than that and they can occcur with metal on metal THR and other articulations. The 5% number at five years you give seems to be based on extrapolation by ONE British study. It is not an actual number that I have seen. Essentially you are combining metal sensitivity (allergy) and metalosis (direct toxicity due to abnormal wear resulting in high local metal concentratons) into one entity. True it is possible that they are on a continuum, but I don’t think that this is been proven or accepted. You are absolutely correct that someone with a painful metal on metal articulation should be seen by an “expert” in that area. Revision needs to be done rapidly to avoid extensive tissue damage if one of the forementioned is the cause.

    For us “high impact folks”, one of the main reasons for getting resurfacing are to avoid a thr periprosthetic fracture which would result in a very nasty femoral revision with poorer outcomes. Bo knows, Arnold knows, just ask them. “Athletes in particular should choose their surgeon, not their replacement…” I agree, choose someone who really does both. The first guy I went to was going to give me a ceramic on ceramic THR. A great choice for longevity, but not for someone who is running two to four miles four times a week, mountain biking, and returning to snowboarding and touch football later this year. If I trash this thing, then almost for sure I can get what will amounts to a primary THR. I would then be forced to settle for a “low impact life”. I urge all to do their homework, understand their unique relative risk to benifit of any proceedure and then decide. For me the choice is clear, anyone with good bone stock who wants high impact sports in their future, well really has no choice. alan

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