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Monday, December 05, 2005

Byline: Donna Halvorsen; Staff Writer

Marjorie Therres got a new left hip on a Wednesday, and she was walking with a walker outside her hospital room the next day.

"You surprised everyone," said Dr. Mark Heller, the orthopedic surgeon who implanted the hip in the 77-year-old Minneapolis woman.

Everyone, that is, except Heller, a champion of minimally invasive hip surgery. Therres was one of the first Minnesotans to have the new type of surgery, which is done to get people back on their feet faster, with shorter hospital stays, less pain and fewer narcotic pain relievers.

Therres was able to travel to her lake home three days after surgery, and the next week when she saw Heller, she was taking only Tylenol for pain. She was still using a walker, but Heller said she was doing well.

"I think the only reason you're using the walker now is that that knee is so bad," he told her, adding that he'll replace the severely arthritic knee whenever she's ready.

But the new hip was fine. Therres said she had some stiffness but couldn't really feel that it was there.

Minimally invasive hip replacement surgery requires two small incisions instead of one large one and folds muscles and tendons back rather than cutting through them.

Experts say it's the cutting that creates pain and requires a longer hospital stay, perhaps some time in a nursing home and then weeks of recovery at home before the patient can do any serious walking.

In Chicago, many patients of Dr. Richard Berger, a pioneer of the minimally invasive approach, go home the same day.

A new standard

Heller, who is affiliated with the Minnesota Orthopaedic Specialists in Edina, performs 150 hip surgeries a year. He said that same-day standards will probably be the norm here, too, once physicians have had more experience with the procedure. He was trained in it earlier this year and has been using it about four months. The new procedure makes up only 10 percent of his practice so far, but he expects it to grow to 90 percent.

The new procedure is controversial in medical circles. In the June issue of the Journal of Arthroplasty, Dr. David Hungerford of Johns Hopkins University in Baltimore said that while conventional hip surgery has been studied extensively, the minimally invasive technique has not. "For this to be widespread, you have to convince skeptics like me," Hungerford said at the March meeting of the American Academy of Orthopaedic Surgeons in San Francisco.

Berger, of Chicago, told the gathering that his early patients stayed in the hospital three or four days but recuperated faster, using crutches for an average of five days or a cane for eight days. He then decided to shorten the hospital stay and discharged 92 of 100 patients the same day. Before being discharged, they had to receive physical therapy and show they could get out of bed by themselves, stand up from a chair, walk 100 feet and go up and down stairs. None of the patients had complications, Berger said.

While surgeons haven't flocked to the procedure, arthroscopic knee surgery wasn't popular when it began 25 years ago, either.

"People didn't want to have it done; surgeons didn't want to perform it," Heller said. But after five years, "everything was arthroscopic, and that's what's going to happen here." In 10 years, he predicted, nearly all hip replacement surgery will be minimally invasive.

"It's more difficult now, just like arthroscopy was 25 years ago," he said. But as time goes by, the procedure, like arthroscopy, will be adapted and adopted, he said. "It's the direction we need to go."

About 168,000 people nationwide will have hip surgery this year; it's unknown how many of the procedures will be minimally invasive. Patients typically are 60 to 75 years old, according to the American Academy of Orthopaedic Surgeons, but baby boomers, unwilling to give up their mobility as their bones deteriorate, are bringing the age down.

Heller said that in the first five years of his nine-year surgical practice, most people having hips replaced were older than 65. Since then most have been younger than that. That coincides with a trend toward greater durability of implanted hips. With improved materials, Heller said, hips that once lasted 10 or 12 years could last 20 years or more.

Damage from arthritis, both osteoarthritis and rheumatoid arthritis, develops over time. It is the most common reason for hips to deteriorate. The diseases either wear away or damage the cartilage that cushions the hip bones. The result is that hips become stiff and painful. Walking and everyday activities can be difficult.

Heller is convinced that not only is the minimally invasive procedure better for patients, but also has benefits for surgeons. "When I walk out of a room having done a minimally invasive hip, I'm actually more confident than I am when I have the hip opened up," he said. "The reason is that I have my X-ray machine there."

The X-ray machine looms above the surgical site, and a screen in front of Heller showed his every move as he operated on Therres at Fairview-University Medical Center's Riverside campus.

Therres was a good candidate for surgery, he says, because she has good bone structure and had gone through conventional hip surgery - twice - on the other hip. In June Heller redid a replacement in her right hip because it was crumbling even though it was only six years old. It was a hip system that was popular in the 1990s but had a high failure rate, he said.

A not-so-minimal process

With Therres, Heller used the same parts used in conventional surgery - stem, ball, socket and a cartilage replacement. The main difference was that he put them in through two small incisions.

He began by making a 2 1/2-inch cut in the groin area through which he did most of his work. In conventional hip surgery, the incision is 10 to 12 inches long. The smaller incision helps avoid cutting muscle and reduces damage to tissue.

The hip bones are too big to come out of the small incision in one piece, so Heller uses a tiny power saw to remove the bones in pieces. There's no room for error. If he makes the first cut too high, one leg will be shorter than the other. If he makes it too low, he won't be able to get the new hip into place.

"If there's any part of this where you have to take your time and work it out, this is it right here," Heller said.

Therres' bones came out with relative ease - "You could spend two hours getting that out" - and he attributed the effort as much to her anatomy as to his skill as a surgeon.

Next he pushed a chromium cobalt shell, the "socket," tailored for the smaller incision, through the incision and pounded it into place. He took time to make sure that he removed all of the arthritis, that there was no space between the socket and the bone, that the socket was locked into place, that the alignment of Therres' legs was right. The socket's surface is rough to allow bone to grow into it.

Heller then placed two screws in the socket - that step, he said, helps surgeons sleep at night, confident that the replacement is solidly in place. Next, Heller snapped the new "cartilage" - a polyethylene cup-like device - into the socket.

For the final stage of the surgery, Heller made a 1 1/2-inch cut in the buttock to place the replacement stem into the femur, or thigh bone. Like the socket, the stem is designed to allow bone to grow into and around it. Last, the chromium ball is pushed through the small incision, positioned to length and inserted into the socket.

The leg was tested over and over to make sure the socket worked right, and then the surgery is finished. It took one hour and 25 minutes, a time he said would be reduced with experience.

A week later Therres, mother of eight, grandmother of 27 and great-grandmother of 10, and her husband, Jim, were relieved that they would be able to go to Florida for the winter as planned, returning to the mobile home that was spared by Hurricane Charley.

Therres said she has had enough surgery for a while, but would have the minimally invasive surgery again if the time comes.

That surgery isn't for every patient or doctor, Heller said, and it may take time for it to become the gold standard for hip surgery. For now, he said, "I know this is new because nobody has said they've seen it on the Learning Channel."

Donna Halvorsen is at dhalvorsen@startribune.com.

A new way to replace hips

A new minimally invasive hip surgery technique is likely to speed a patient's recovery time by reducing blood loss and tissue damage. Here's a look at the new procedure.

1. For the minimally invasive procedure, a 2.5-inch incision is first made in the groin area. Tendon and muscle tissue are spread apart. The thigh bone (femur) is pulled away from the hip socket.

2. A tiny power saw cuts the head of the femur into small pieces that are removed one by one. Some soft, interior bone tissue may also be removed.

3. The hip socket is scraped to remove damaged material. A bowl-shaped metal implant is placed in the socket and held there by friction or screws. To smooth joint movement, a plastic liner is snapped into the socket implant.

4. A 1.5-inch incision is made in the buttocks (see diagram above). A metal stem is inserted through this incision into the femur's marrow cavity and is held in place by friction. If the ball portion of the implant is separate, it is attached to the stem at this point. 5. The attached ball is positioned into the socket, soft tissue is readjusted and the incisions are sewn up.

Sources: Zimmer Inc.; Minnesota Orthopaedic Specialists P.A.

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