Tim Taylor, former professional hockey player, post BHR surgery

What does your hip patient want to get back to?

Hip pain limited Tim Taylors performance. After choosing the BHR system, he is back to enjoying activities pain free.

Why BHR?
What does your hip patient want to get back to?
The BIRMINGHAM HIP Resurfacing (BHR) System was designed to provide younger or more active patients with a bone-preserving, anatomically correct alternative to total hip arthroplasty that may support an active lifestyle.

After his BHR procedure, former pro quarterback Steve Beuerlein returned to coaching his sons football team. A study shows improved function and faster recovery in BHR system patients compared to patients with THA.1

Where do you want your hip patient to be in 15 years?

A wear resistant metal-on-metal articulation, large diameter bearing and bone preserving procedure provides durability, stability and preservation of normal anatomy that may improve the patients long-term results.

With a total hip replacement, a large amount of bone is removed

With the BHR system, the outer layer of the femoral head is removed

The BHR system keeps more of the original bone allowing patients to regain their active lifestyle

The Australian National Joint Registry2 shows a higher recorded survivorship rate in both the male <55 years of age and male 55-64 years of age groups for primary hip resurfacing procedures compared to primary conventional hip procedures (primary diagnosis OA excluding infection). The BHR system was designed as an alternative for these younger or more active patients where, historically, total hip replacements have not performed as well.
Resurfacing vs THA male 55-64
4.5 4 3.5 3 2.5 Revision rate % 2 1.5 1 0.5 0 1 2 3 4 Years 5 6 7
SRA THA

THA has great results For younger or active patients, BHR results are even better

Resurfacing vs THA male <55

4.5 4 3.5 3 2.5 Revision rate % 2 1.5 1 0.5 0 1 2 3 4 Years 5 6 7
SRA THA

Bone preservation

Bone preservation is a central concern for younger patients who want to return to an active lifestyle. By preserving the function of existing bone rather than removing and replacing a large section of the femur, natural anatomical biomechanics can be maintained. Improved bone strength
The BHR system preserves a large portion of the natural femoral neck and head. Studies show a significant increase in proximal femoral bone mineral density (BMD) in BHR patients compared to THA patients at two years. These studies conclude that the BHR device better transfers physiological load for preserving bone stock than a long-stemmed device.3,4

Post-operative stability
The larger diameter bearing and bone preserving procedure of the BHR system may restore patients normal anatomy. This, in turn, can reduce the risk of dislocation.
Figure 1: BHR at 10 years

Revision Surgery
Which would you rather revise after 10 years, BHR (Figure 1) or THA (Figure 2)? Total hip replacement patients can experience proximal femoral bone resorption and distal remodeling, as shown here. The BHR system preserves this bone, which therefore may be in condition to receive a primary stem at the time a total hip could require a complex revision.

Figure 2: Tapered proximal loading THA at 10+ years

Globally proven clinical results

The BIRMINGHAM HIP Resurfacing (BHR) System has demonstrated exceptional clinical results worldwide.
Published articles from around the world demonstrate unrivaled performance of the BHR device in many surgical centers.
Author McMinn et al3 Shimmin et al4 Treacy et al Nishii et al
6 5

Site Birmingham Melbourne Birmingham Osaka Oxford

8

N 1,626 230 144 50 79 1,354

% survival 98.4 99.1 98.0 96.0 95.1 97.2

Follow-up 5 years 5 years 5 years 5 years 7 years 7 years

Steffen et al7 Oswestry Registry

8 countries 45 surgeons

The BHR system is the world leader of hip resurfacing

The 2008 Australian Joint Replacement Registry Annual Report2 contains data from September 1999 to December 2007 and is among the most compliant registries globally.
With 7,682 implantations, the BHR device accounts for 72% of all resurfacing devices implanted

to date in the registry.

The BHR device has follow up from the inception of the registry in 1999 and consistently shows

the lowest recorded revision rate of any resurfacing device for seven years. Australian National Joint Registry Annual Report 2008 Yearly cumulative percentage revision of resurfacing hip systems
Cumulative percent revised Resurfacing product ASRTM AdeptTM BHR ConserveTM Plus Cormet Cormet 2000 (HAP) Durom

1 year 3.8 0.5 1.5 3.2 2.1 6.3 3.5 1.7 5.7

2 years 5.3 4.8 2.1 3.2 3.3 7.4 4.7 5.7

3 years 6.0 2.5 6.0 4.5 8.4 5.8 5.7

5 years

7 years

3.6 10.1 6.5 10.3

4.6

MitchTM TRH Recap

Metallurgy matters at startup

The BHR implant is produced using high carbon cobalt chrome left in the As Cast (never heat treated) micro-structural condition. As Cast components show substantially less wear than heat-treated components.11

As Cast CoCr BHR implants

Magnified cross sections show block carbides* integrated throughout the metal structure.These carbides are harder than the metal substrate and reduce wear, especially at startup.

A magnified cross section retrieved after 26 years in-vivo shows block carbides integrated throughout the metal structure. BHR metallurgy is based on this successful clinical heritage.

As Cast CoCr Ring implant

Double heat-treated CoCr implant

A magnified cross section of a double heat-treated CoCr implant shows block carbides depleted in both quality and quantity. Thermal processes including hot isostatic pressing, solution heat treatment and sintering alter the microstructure directly affecting the wear resistance of the material.12, 13, 14

10 year Kaplan-Meier Survival Analysis of CORIN Hip Resurfacings (Revision for any reason as the end-point) 100 Survival probability (%)

Wear studies have shown that cobalt chrome in the As Cast form has superior wear resistance compared to other forms of the alloy.15 ,16, 17 Clinical data examining a single surgeon series of resurfacing cases has shown a decrease in long-term survivorship with a double heat-treated implant versus a single heat-treated implant with identical implant geometry.18,

96% 90 86% 80 Single heat treated (n=107) 70 60 50 0 2 4 6 Follow-up in Years 8 10 Double heat treated (n=184)

Clearance matters in motion

The BHR system is designed to a precise geometry based on clinically successful first generation metal-on-metal total hips, which provides fluid lubrication in the bearing reducing long-term wear.19 Providing fluid lubrication

The longevity of a metal-on-metal bearing is linked to its ability to generate and sustain a fluid film. At rest, static pressure can force fluid out of the bearing. In motion, hydrodynamic forces create a fluid film that lubricates the joint. There is an optimal radial clearance* associated with each bearing diameter. When this clearance is produced, the converging wedge between the head and cup draws in and transports lubricating fluids between the components extremely well.

fluid film

In comparison, studies show that smaller clearances result in increased friction.20, 21 Increased friction can lead to frictional torque force between the head and cup that can cause cup micromotion which may hamper bone ingrowth.22 Smaller clearances may not allow sufficient lubrication which may increase long-term wear.23 In hip arthroplasty, impaction of the cup can result in cup deflection. Ultra-low clearance bearings can suffer from a clamping effect if the combination of deflection and low clearance does not allow for actual net clearance.

Friction vs clearance in pre- and post- distorted cups for metal-on-metal bearings

Superior fixation

The BHR implant has a hemispherical cup design with the cast-in POROCAST ingrowth surface. This HA coated ingrowth surface does not require any heat treatment to attach beads and therefore preserves the carbide structure. This surface is integral to the cup and not a spray on coating.

POROCAST ingrowth surface

* block carbides: microscopic, ceramic-like particles that form during the casting of high carbon cobalt chrome. They become an integral part of the cast metal microstructure and are harder (more wear resistant) than the metal substrate. * radial clearance: the space defined by the difference between the radius of the femoral head and the radius of the cup. This clearance provides a space in the bearing in which viscous fluids can lubricate the movement of the head within the cup.

References
1.

Haddad FS, Bull J, Soler JA. Hip resurfacing has superior sustained functional outcomes when compared to Total Hip Arthroplasty. Presented at: AAOS. March 6-8, 2008; San Francisco, CA. Australian Orthopaedic Association National Joint Replacement Registry Annual Report 2008. Kishida Y, Sugano N, Nishii T, Miki H, Yamaguchi K, Yoshikawa H. Preservation of bone mineral density of the femur after surface replacement of the hip. The Journal of Bone and Joint Surgery (Br) (March 2004), 86-B 185-89. Hayaishi Y, Miki H, Nishii T, Hananouchi T, Yoshikawa H, Sugano N. Proximal femoral bone mineral density after resurfacing total hip arthroplasty and after standard stem-type cementless total hip arthroplasty, both having similar neck preservation and the same articulation type. J Arthroplasty. 2007 Dec; 22(8):12081213. FDA Review Memo, BHR Important Medical Information, Page 59. Back DL, Dalziel R, Young D, Shimmin A. Early results of primary BIRMINGHAM HIP resurfacings - An independent prospective study of the first 230 hips. J Bone Joint Surg Br, 2005, 87(3):324-9. Treacy RB, McBryde CW, Pynsent PB. BIRMINGHAM HIP resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br (2005 Feb) 87(2):167-70. Nishii T, Sugano N, et al. Five-year results of metal-on-metal resurfacing arthroplasty in Asian patients. JOA (2007) Vol. 22 No. 2. Steffen RT, Pandit HP, Palan J, Beard DJ, Gundle R, McLardy-Smith P, Murray DW, Gill HS. The five-year results of the BIRMINGHAM HIP arthroplasty An independent series. J Bone Joint Surg Br (2008 Apr); 90-B:436-41. Richardson JB, et al. Minimum 7-year outcome of the BIRMINGHAM HIP Resurfacing. A review of 1,345 cases from the 2007 international register. Presented at the 2007 British Orthopaedic Association. Nelson K, Dyson J. Wear simulation of a metal-on-metal resurfacing prosthesis. AEA Technology Group, Harwell, UK. 1997. Que L. Effect of heat treatment on the microstructure, hardness and wear resistance of the as-cast and forged cobalt-chromium implant alloys. Presented at the Symposium on cobalt-based alloys for biomedical application. Nov 3-4, 1998, Norfolk, Virginia, USA. Varano R, Bobyn JD, Medley JB, Yue S. Does alloy heat treatment influence metal-on-metal wear? Poster #1399 presented at the 49th Annual meeting of the Orthopaedic Research Society. New Orleans, LA, USA. 2003. Cawley J, Metcalf JEP, Jones AH, Band TJ, Skupien A. A tribological study of cobalt chromium molybdenum alloys used in metal-on-metal resurfacing hip arthroplasty. Wear, 255 (2003) pp. 999-1006. Ahier S, Ginsburg K. Influence of carbide distribution on the wear and friction of Vitallium. Poc Inst Mech Eng, 1966; 181:127-9. Clemow AJT, Daniell BL. The influence of microstructure on the adhesive wear resistance of a Co-Cr-Mo alloy. Wear, 1980; 61:219-31. Wang KK, Wang A, Gustavson LJ. Metal-on-metal wear testing of chrome cobalt alloys. In: Digesi JA, Kennedy RL, Pillar, eds. Cobaltbased alloys for bio-medical applications, ASTM STP 1365: Wear Characterization. West Conshohocken, PA 1999; 135-44. McMinn DJW. Ten year Kaplan-Meier survival analysis of McMinn Corin hip resurfacings. Journal Of Engineering In Medicine, 2005, Proceedings Institute of Mech Engineers, Part H. McMinn D. Development of metal/metal hip resurfacing. Hip International. 2003; 13(1) suppl 2. DJW, et al. Friction testing in metal-on-metal bearings with different clearances using blood as lubricant. 52nd Annual Meeting of the Orthopaedic Research Society, 2006. Paper No. 0500. Kamali A, Daniel JT, Javid SF, Youseffi M, Band T, Ashton R, Hussain A, Li CX, Daniel J, McMinn DJW. The effect of cup deflection on friction in metal-on-metal bearings, AAOS, 5-8 March 2008, Poster Exhibit. DJW. BHR lecture, BOA Manchester 2004. A, Vassiliou K, Elfick APD, Scholes SC. The effect of running-in on the tribology and surface morphology of metal-on-metal hip resurfacing devices in simulator studies. JEIM Part H 2.

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20. McMinn 21.

22. McMinn

23. Unsworth

Orthopaedic Reconstruction & Trauma Smith & Nephew, Inc. 1450 Brooks Road Memphis, TN 38116 USA

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