Dr. Macaulay Interview, NY

Interviewed by Vicky Marlow on May 8, 2008

1.) Hi Dr. Macaulay, Welcome to the interview. Can you please first start out by telling us how you got started with Hip Resurfacing and give us a little background on your experience as a surgeon? Where did you train for hip resurfacing? Who trained you? Did you observe after the initial training and/or do cadaver labs prior to your first patient?

I have been performing versions of hip resurfacing for more than 5 years now. I fell in love with the concept of total hip resurfacing while on the British Traveling Fellowship (BTF, sponsored by the US Hip Society which every two years sends two of the most promising young hip surgeons in the US to the UK), a four week tour of 9 or 10 UK sites with a reputation for superior hip surgery. I was quite surprised to see hip resurfacing being performed at 5 of those sites. These patients were amongst the most enthusiastic about their surgery and theirs surgeons) that I had ever come across. I came back to the US and started paying more attention to presentations at national meetings reading more about.

Back to training….During the BTF, I visited Derek McMinn in Birmingham and observed three cases (I observed approximately 10 other MOMHR’s at the 4 other sites visited that performed them)….it seemed rather straight forward to me since I had been resurfacing femoral heads for 4 years at that time; but, as I observed seeing patients back in clinic, placing the socket (as part of a metal-on-metal articulation, something I was taught previously did not work) seemed to make the relief of pain more complete and long lasting. This visitation to McMinn in 2004, however, did not “count” as official training; therefore I returned to Birmingham for official training in March of 2006 to observe cases by Ronan Treacey, the other BHR innovator. At this visitation I saw techniques which would help me expose the hip better and complete the case faster…by this time, I had been performing other MOMHR’s since March of 2005 on a compassionate use basis. Shortly after the BHR was approved, I attended a course at in Memphis in late May or early June of 2006 which involved cadaveric BHR’s which made me even more familiar with the instruments, implants and procedure.

Dr. William Macaulay

2.) What surgical approach do you use the anterior or posterior and why?

Partly because Mrs. McMinn and Treacey did it that way, but also because I had been performing all my total hip and early resurfacing through a posterior approach…it is still my contention that patients limp for less time following a posterior approach as opposed to any other way. Very often my MOMHR patients put aside their cane within 2 to 4 weeks.

3.) How long does a typical resurfacing surgery take?

The mean operative time (typical hip resurfacing) takes 1 hour and 14 minutes (74 minutes “skin to skin”). Last week I did a flawless MOMHR on a thin person in 54 minutes skin to skin (including a cosmetic subcutical closure on the skin).

4.) Barring any complications, how many days in the hospital will a patient normally stay?

My average length of stay of MOMHR patients is exactly 2.23 days (I know because we keep the data and will eventually publish it)

5.) What is your typical recovery time after resurfacing, what is your typical rehab protocol?

Typical patients are 90 % improved in 4 to 6 weeks. Last week I saw a gent back who got bilateral MOMHR’s (5 and a half weeks post surgery) who has squatting over 700 pounds (against medical advice).

90 degree restriction?
I use 120 degree flexion restriction for MOMHR’s after the spinal wears off (2 hours post surgery)…never seen a dislocation.

Walker?
Usually one day.

Crutches Cane? Amount of time?
Usually off cane in 2 to 4 weeks.

Blood thinners?
Multimodal approach use aspirin for low risk patients.

TED stockings?
None.

Ice?
As desired.

PT?
Typically 6 weeks.

6.) How long before a typical patient is allowed to drive a car?

1-2 weeks left hip, 3-4 weeks right. Return to work…self employed: fulltime at 3 weeks; hates/tolerates their job: 6 weeks.

7.) How long do you feel it takes for the bone to be fully healed? Grow into the prosthesis?

3 months

What is the recommended time you tell your patients before they can start to run again/do impact sports?

4 months

Are there any sports you don’t want your patients to participate in after surgery?

Sky diving is discouraged…other than that…no.

Out of the patients you have resurfaced what are some of the sports they have returned to?

Downhill skiing, windsurfing, cycling, professional dancing, paddle tennis, tennis, squash, martial arts, weight lifting

8.) What is your take on cementless (femoral) devices for resurfacing?

Will NEVER use one…cannot work as well

9.) Which resurfacing device do you prefer to use and why?

Currently BHR: most experience with it most medium term survivorship data

10.) Do you have a cut off age for resurfacing patients or do you go on a case by case basis?

Average age is 49.1 yrs (95% between 40 and 60); youngest is 17 (didn’t want total hip), oldest was 76 (good bone)

11.) Do you preserve the neck capsule?

Yes, completely.

12.) What type of anesthesia do you use general or epidural or ?

Spinal or epidural (more than 95%)

13.) Are there any cases that you will not take in particular, AVN, dysplasia, small cysts?

I have done patients with each of these, but approach them VERY carefully.

14.) Do you do bilateral surgeries same day, if not how far apart do you recommend?

I do.

15.) If you can’t perform a hip resurfacing – what THR device do you prefer and why?

I occasionally will “bail-out” to a metal-on-metal (or ceramic on highly crosslinked poly) THR, if the longterm survivorship of the MOMHR does not look promising (based on bone quality to the touch and to the eye).

16.) What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?

50 maybe (for some surgeons, they will never get to proficiency)

17.) How many hip resurfacings have you done to date and how many do you do on a weekly basis?

87 BHR’s
8 Conserve Plus
32 other
Total: 127 (as of April 18th), roughly 1 to 2 per wk on average, but at busier times 3 or 4)

18.) How successful have you been obtaining insurance approvals for resurfacing?

Spotty early (prior to May 2006); no problem now.

19.) Do you test for metal allergies or bone cement allergies?

Only patients who complain of skin irritation from costume jewelry