Innovative Approach To Hip Replacement Surgery Gets Patient Back On The Hiking Trail Fast

There are five words that a healthy, active 52-year-old woman doesn't expect to hear: "You need bilateral hip replacements."

But that's what an orthopedic surgeon at Cedars-Sinai Medical Center emergency room told me in April 2004 when I came in for X-rays and answers about my constantly aching legs.

"Shouldn't I just stretch more or take Motrin," I asked. "Besides, I'm way too young! Aren't hip replacements Granny Land?"

Not anymore. I found out I'm riding a predicted wave of active baby boomers who will need hip replacements much younger than Grandma and Grandpa did. According to the National Center for Health Statistics, about 220,000 Americans received hip replacements in 2003, the latest year for which data was available.

And as boomers age, such procedures are expected to increase by 60 percent, according to the American Academy of Physical Medicine & Rehabilitation. And be warned, couch potatoes: Another cause of hip failure is obesity.

Like me and aerobics queen Jane Fonda, who just had one bum hip replaced, many boomers will develop osteoarthritis, a wearing-down of cartilage and synovial fluid in the hip joint causing pain that increases until walking is impossible. Hips are designed to last a lifetime. But thanks to my years of 10-mile runs, hard-court tennis and marathons, mine wore out early.

After finding out both my hips were shot, I also found out that hip replacement surgery, first performed in the U.S. in 1971, is one of the most successful surgeries in medical history. But the details are disturbing: 8- to 12-inch lateral or posterior incisions on legs and buttocks, muscles removed from bones, lots of morphine, long hospital stays and three to six months recovery.

Post-op precautions to prevent dislocations are also daunting. Never sit below a 90-degree angle for the four to six months following the procedure; don't cross your legs or stand pigeon-toed; and sleep with a pillow between your legs for months.

"Malcolm in the Middle" star Jane Kaczmarek had a traditional hip replacement surgery last year. "I always knew I would need this done because shallow hips run in the family. It was painful and took months to get back on my feet. I dread doing the other hip."

I considered a new, minimally invasive surgery. Reports at the 2005 meeting of the American Academy of Orthopedic Surgeons found little difference in outcome or recovery time between traditional hip replacement surgery and minimally invasive surgery.

But there was a catch. "Some surgeons are trying to outdo each other with smaller 2-inch incisions," explained Charles Moon, assistant director of orthopedic trauma at Cedars-Sinai. "It may lead to implant positioning problems."

Then I read about the anterior approach, in which an incision is made through the front of the hip without cutting through major muscles. The technique has been performed in Europe for more than 30 years and was pioneered in the U.S. by Joel Matta, head of orthopedic surgery at Good Samaritan Hospital near downtown Los Angeles. Because the incisions are smaller (3 to 4 inches), the anterior approach is sometimes confused with minimally invasive surgery. But there's a difference: Unlike most minimally invasive surgeries, the anterior approach cuts no major muscles; it goes between them.

Matta first saw an anterior hip replacement surgery performed in Paris in 1981 by French orthopedic surgeon Emile Letournel. With the help of a special table, Letournel accessed the hip through a frontal incision without cutting through large muscles.

Matta was intrigued but didn't perform an anterior hip replacement procedure until 1996, when a patient who'd had one hip replaced in France asked him to do the other one. Matta was so pleased that he began doing 20 to 30 anteriors a year. Now he uses the approach exclusively and travels the U.S. and Europe teaching the anterior technique to other doctors.

Matta also helped to modify the special table used in the procedure and has a financial interest in the new ProFX table sold by OSI, a Northern California surgical table manufacturer. According to OSI representative Mark Lane, there are currently more than 100 tables in U.S. hospitals and medical facilities. Each table costs $150,000.

"The table is really the key to doing an anterior approach," says Matta, who has performed more than 750 anterior surgeries. "A total hip replacement is an invasive procedure, but the anterior preserves musculature and causes less tissue trauma so the recovery is faster and less painful."

Admittedly, the table is scary-looking. Before surgery, the patient's feet are fitted into what look like ski boots. During surgery, the table rotates the patient's leg, lowering the foot to the floor and extending the hip. After the initial incision, a hook dips in and slides through a natural space between the muscles, lifting the femur up for preparation and implant insertion. Leg lengths, cup placement and femur implant positioning is checked by a fluoroscopic unit before incisions are closed.

As creepy as the table looked, I was thrilled to be dubbed an "ideal candidate" by Matta.

"The anterior approach is particularly good for active patients," explained the soft-spoken Matta, 58. "Your hospital stay will be shorter. The risk of dislocation will be significantly reduced. Leg lengths are more accurately controlled and your scars will be significantly smaller. And I can replace both your hips in one surgery."

And there are no post-op precautions. After surgery I could cross my legs, sit as low as I want and forget that darn leg pillow. Matta's only edict: Walk as much as possible. Sign me up!

Not everyone thinks the anterior approach is the future of hip replacement surgery. I spoke with several surgeons who prefer the traditional approach. One top L.A. orthopedic surgeon, often called "Dr. Hip," would only replace mine one at a time via a 9- to 10-inch lateral thigh incision. He'd replace the second hip three to four months after the first. Spend a year of my life recuperating from surgery? Uh, no thanks.

"The main resistance from established orthopedic surgeons is the learning curve for the anterior approach," explains Stanford University orthopedic surgeon Michael Bellino, who has performed 50 anterior cases since getting the ProFX table in 2003. "It takes time to learn. Why do two cases a day when you can do six?"

But this attitude is changing, largely due to patient demand. "Most of my patients come to me asking for the anterior," says Bellino. "They've heard about it from friends, read about it online and are very medically savvy. I've never seen a more powerful patient response to a new surgical approach."

Houston orthopedic surgeon Stefan Kreuzer made the switch from posterior to anterior and says the majority of his practice is due to referrals from enthusiastic former patients such as Frederico Pena, former Secretary of Energy for President Clinton.

An increasing number of orthopedic surgeons are embracing the anterior approach. More than 20 California surgeons - including Moon at Cedars-Sinai and Larry Mendez at the University of Southern California University Hospital - now perform anterior hip replacement surgery on the ProFX table. A consortium of a dozen surgeons - including Kreuzer, Bellino, Andrew Yun of Los Angeles, James Grimes of Bakersfield, Gary Bradley of Santa Barbara and David Dodgin of Walnut Creek - are tabulating data from a combined 1,700 cases for a study. Orthopedic surgeons in the U.S. who are equipped with the ProFX table are on a physician referral list on the OSI Web site (http://www.scoi.com/).

"As more reputable surgeons and medical centers compile objective scientific data on the anterior technique, I believe the credibility will increase," Matta predicts.

This new technique may not be for everyone. But I'm glad I found Matta and his funky table. One month after my initial diagnosis, I was wheeled into the Good Samaritan operating room and prepped for anterior bilateral hip replacement with uncemented titanium implants.

After an epidural anesthetic (for less nausea and blood loss) a nurse stuck my feet into those wacky ski boots. Fasten your seat belt, I thought, this could be a bumpy ride. But the Friday morning surgery went smoothly. I took my first steps that night and went home on crutches Monday afternoon. And no morphine. Just Tylenol.

Even with an attentive husband/nurse, the first week home was challenging. But I did twice-daily neighborhood walks, tossed one crutch at day five and the other at day nine. At week three, I was swimming with a kickboard in the West Hollywood pool and seeing personal trainer/therapist Paul Drew. He'd long treated traditional hip replacement surgery patients and observed traditional HRS but devised a new drill for me, his first anterior client.

"The anterior surgery lets you rotate your hips at all angles with no fear of dislocation," Drew told me. "Using fitness balls and bands, you'll be able to restore your balance, strength and flexibility much faster."

I got back on track - weights, yoga and spin classes - fast. And at six weeks, I hiked the French Riviera, climbed the Maui volcano and snorkeled the Molokini Crater.

My metal hips are much stronger than my old painful crumbling joints. But I only think about them when I set off airport metal detectors. I know it's silly, but it's fun to shock stern-faced security guards with proof that I'm bionic: the laminated ID-size X-ray of my new hips that Matta's nurses gave me.

Also see; hip replacement glossary.

About The Author:

Elizabeth Snead is a successful author and regular contributor to http://www.hip-replacement-care.com. Information on hip replacement; the cause, diagnosis, symptoms, surgery and treatment for recovery and rebuilding your body.