Less invasive hip replacement operations on the horizon

From The New York Times:

Hip replacement is one of the most successful operations in all of medicine, which prompts many orthopedic surgeons to think, as one leader in the field put it, “Why change something that doesn’t need fixing?”

But that leader, Dr. Robert Berghoff; his colleagues at Arizona Orthopedic Associates in Phoenix; and other orthopedic surgeons around the country believed that improvements were possible, especially with regard to reducing complications and speeding recovery.

The technique these surgeons use is called anterior hip replacement, one of several minimally invasive operations that are associated with a shorter hospital stay, smaller incision, less trauma to muscles, less pain and blood loss, reduced risk of dislocation after surgery, faster healing and a quicker return to normal activities.

“The morning after surgery I was able to walk without a walker or even a cane and could put my full weight on the operated side,” Jack White, a 71-year-old personal trainer from Paradise Valley, Ariz., said in an interview. “The next day I walked 50 yards without a limp and was able to go home, where I did physical therapy five days a week for two weeks. On Day 5, I walked a mile and a half, and in Week 4, I taught my aerobics class and played 18 holes of golf with no pain and no problem.”

The operation was introduced in the United States more than two decades ago by Dr. Joel M. Matta of the St. John’s Health Center in Santa Monica, Calif., who also helped design a special operating table to simplify the procedure.

Another minimally invasive form of hip replacement, the PATH technique, was developed by a Los Angeles orthopedist, Dr. Brad L. Penenberg.

Dr. Patrick Meere of New York University Langone Medical Center and the Hospital for Joint Diseases in New York tells me this method has the same advantages as the anterior approach, results in no activity limitations and also offers a safety net: If anything goes wrong during the procedure, the problem can be repaired without having to do a more extensive operation.

Nearly 200,000 hip replacements are performed each year in the United States, and the number continues to grow as the population ages. There is no age limit for this elective operation unless an underlying health problem makes any operation too risky.

The usual reasons for hip replacement are osteoarthritis, rheumatoid arthritis and traumatic arthritis, all of which can cause pain and stiffness that limit mobility and the ability to perform activities of daily living. Most patients try less drastic measures — physical therapy, medications (pain relievers, anti-inflammatory drugs and glucosamine supplements), injections of hyaluronic acid and walking aids — before deciding that surgery is their best hope for escaping chronic pain and disability.

To appreciate the potential benefits of minimally invasive methods, it helps to know how hip replacements are usually done.

General or spinal anesthesia is used for the operation, which typically takes one to two hours. An incision 10 to 12 inches long is made through the muscles on the side of the hip to expose the hip joint, and the diseased bone tissue and cartilage are removed. An artificial socket is then implanted into the pelvic bone and a metal stem is inserted into the thigh bone, the top of which is replaced by a metallic ball to create a ball-and-socket joint that mimics the function of a natural hip joint.

The average hospital stay is four or five days, followed in most cases by extensive rehabilitation. Patients are told not to cross their legs or bend at the hip more than 90 degrees after surgery — in some cases indefinitely, because these motions can cause dislocation of the replaced joint that requires a repeat operation.

Possible complications of the surgery include blood clots, infection, fracture and a change in leg length. Possible delayed complications include dislocation of the new joint, breaking or loosening of the prosthesis and stiffening of the tissues around the joint. Although modern materials have extended the life of implants to 20 years or so, they can eventually wear out and require replacement.

Patients should prepare ahead for limitations associated with postoperative recovery. The American Academy of Orthopedic Surgeons suggests these home modifications: safety bars or handrails for the shower or bath; a raised toilet seat and shower bench; a long-handled sponge and shower hose; handrails on all stairways; removal of all loose carpets and electrical cords in walking areas; a dressing stick, sock aid and long-handled shoe horn; a reacher to help you grab objects without bending or climbing; a stable chair with firm cushion, back and arms; and firm pillows for chairs, sofas and cars so you can sit with knees lower than your hips.

You might also rent a commode if there is no bathroom on the first floor; arrange for help with cooking, shopping, bathing and laundry for several weeks; prepare and freeze individual meals in advance of surgery; and place frequently used kitchen, bathroom and clothing items within easy reach.

Studies comparing long-term results of minimally invasive hip replacement with more traditional surgery have had mixed results, and all forms of hip replacement have benefited from improved anesthetic and pain management techniques. Surgeons who routinely use less invasive methods maintain that there are decided advantages for most patients, even though the operation itself can take somewhat longer.

Perhaps most important is that major muscles in the buttocks and thigh that help to stabilize the hip joint are not cut, reducing the risk of dislocation and speeding recovery. Patients spend less time in the hospital and, like Mr. White, return to normal life more quickly.

Still, Dr. Berghoff emphasized, it takes time to become adept at the procedure, as with any complex surgery. In choosing a surgeon, ask how many of the operations the surgeon has done using the proposed technique and with what results.

Regardless of the type of operation, as Mr. White found, it helps to have supporting muscles as strong as possible before surgery, perhaps through several sessions with a physical therapist if the patient’s condition allows it.