Turning the table on hip replacement

Behind the double doors of Oak Hill Hospital’s operating room No. 4 a surgical team led by Dr. Fady Zeidan is replacing someone’s hip – a common procedure done over 190,000 times a year in the United States. But this surgery is different and in this area, Oak Hill is the only place it’s being done.
The procedure is called the anterior approach to hip replacement. It’s less invasive than the traditional and widely used posterior approach and different in that the patient is lying on his/her back on a specially designed table. The surgeon accesses the hip joint though an incision in the front as opposed to the side or the back. The damaged joint is removed and replaced without cutting through any muscles.
“The table is a positioning device which is going to be able to place the leg in a way to expose the femur independent of the patient’s size, height and weight,” explains Zeidan. “The advantage to the patient is because you are not cutting any muscle, they recover much faster, they can be back on their feet much faster and they can go back to their normal routine faster.”

Traditional hip replacement

Hip replacement, also called arthroplasty, is an operation in which the diseased/damaged parts of the hip joint are removed and replaced with new, artificial parts which can be plastic, metal or ceramic.
Osteoarthritis is the most common reason for hip replacement and as the population ages, the need for it is expected to rise.
The replacement of a hip requires a surgeon to remove the ball at the top of the femur (femur head). Cartilage and surrounding bone are cleaned out of the socket where the femur head was. A cup shaped implant is put into that space. A stem is placed in the femur. It is either held in place with bone cement or “press fit” which means it’s pressed firmly into the femur and bone grows around it. A ball is attached to the top of the stem. The ball fits into the cup (socket) and the patient has a new hip. Depending on the type of prostheses, a spacer may also be used.
The procedure is complicated. It involves a fair amount of manipulating of the femur and pelvis. In the traditional posterior approach the hip is accessed from the side or back with an 8 to 10 inch incision. The muscles and tendons are detached while the surgeon maneuvers the damaged hip out and puts the artificial hip in. At the end, the muscles are sewn back into place.
Because the muscles have to heal before the patient can fully enjoy the relief their new hip provides, the recovery period is about 6 months, During that time a patient’s mobility is restricted to avoid the most common complication – dislocation of the new ball from the socket.
Because of the stress put on the femur and the pelvis during the procedure some people whose bones are severely weakened by osteoarthritis may not be good candidates for hip replacement. Overweight and obese people are also at high risk for complications and they, too, are often turned away.
Over the years, doctors and researchers have been working to improve the prosthesis and the procedure to shorten recovery time, reduce the risk of dislocation and make hip replacement available to more people.
The special surgical table recently purchased by Oak Hill achieves at least one of those goals.

Technique is tied to the table

The $100,000 table is called the hana or PROfx table and has been called a “breakthrough” in the field of hip replacement. It has carbon fiber spars that support and manipulate the leg during surgery. It has a sterile robotic attachment that can reach inside the incision and lift the femur so that it is more easily accessible to the surgeon. Throughout the procedure the patient’s feet are in the table’s compression boots, which prevent clotting.
Because it can create traction, torque and mobility, the table itself is a surgical instrument. And because it allows the patient to be positioned on their back the surgeon can get to the hip more directly through a 4 to 6 inches incision in front of the hip. Going in that way allows the surgeon to take advantage of a natural pathway between the muscles and tendons so instead of detaching them to access the hip, they are simply moved out of the way.
“You don’t cut anything so you’re not sewing anything back in place as far as muscle,” says Zeidan. “That’s why people can go back to their routine because they have good control of their legs. They feel confident because the muscles have been left in tact.”

Not a new technique

The technique for this procedure has been around in France since 1947. In the late 1990’s Dr. Joel Matta who trained in France, brought it to the United States and started teaching it. Matta is also credited with co-designing the table, which makes the less invasive anterior approach possible.
Although its use is growing, the procedure is not being done everywhere. Zeidan tells Hernando Today that to his knowledge, he is the only one in the area using it and Oak Hill is the one of the few hospitals in the state with the table. “There are very few in the Florida area – maybe 4 or 5. There’s another one in Ocala and I think there’s one in Naples and Jacksonville.
The technique has obvious advantages for the patient and Zeidan believes there are two main reasons its not being done more widely. “Number one, it’s technically hard to do. The learning curve is slow so it takes somebody who’s really committed to learning it. Number two, only a few hospitals are willing to spend the money on the table.”
Another advantage of the patient being on their back is that the surgeon sees real-time X-rays during the procedure.
“When you do a routine hip replacement, the patient is on their side and it’s very hard to do the X-ray,” Zeidan explains. “Sometimes you get a patient who has longer legs. You can really recreate the anatomy which you cannot do all the time with patient on his/her side.” The surgeon can also check placement of the parts during the surgery to insure absolute accuracy.
The table and the technique also make it possible for overweight and obese people to have the surgery. Since the muscles are not cut there’s less risk of the new hip popping out of place. Also the position makes it easier for the surgeon to cut through the additional adipose (fat) tissue between the skin and the muscles. The ability to use the X-ray in the case of obese people is very helpful in placing the parts of the replacement hip.

Seeing is believing

As opposed to the three to six month recovery period for traditional hip replacement, most people who have the anterior approach are out and about in six weeks or less. It’s an outcome most patients find hard to believe, even after they’ve been through it.
“It went better than I thought,” says Dona Treager of Hernando Oaks. Treager had her left hip replaced on Jan. 5 of this year. After three weeks she went to have Zeidan check her incision. She was using a walker, “He said what are you doing with the walker?” Treager recalls, “He said get rid of it, you don’t need it.”
Treager said she’d been using the walker because no one told her not to and she wanted to be cautious. She had been concerned about dislocating her new hip. When she went back to Zeidan for her 6-week (and final) follow up, she was surprised again.
“I had this whole list of questions and I started to get through the first and he says no restrictions,” says Treager. “I wasn’t really expecting that and my husband wasn’t expecting it.”
Three days after seeing Zeidan, Treager, an avid golfer, played nine holes. A week after her visit she played 18 holes in a ladies tour.
“The quality of life is wonderful. It’s nice to be pain free. You forget how miserable that is over the long haul because you’re dealing with it on a daily basis.”
Treager is also an educated medical consumer. She knew she was going to need hip replacement and before she saw Zeidan she had begun researching techniques. “I looked up hip replacement surgery on the internet. I got into all kinds of Web sites and I found out the different types of surgery and anterior, from what I read, cut no muscles,” she said. Treager was ready for Zeidan. “I asked what approach are you using, anterior of posterior? He said how’d you find out about that. I said I looked it up. I wanted to know what was going to happen.”
“It’s driven by patients,” says Zeidan. “I saw a guy who told me everybody’s asking him who was his surgeon. Patients, sooner or later, will say I want to do it that way. I’ve had quire a few patients come in from Tampa and St. Pete and Clearwater.”
Treager is certainly a fan. “Had I known that I could have gotten as much relief as I did I probably would have done it sooner, ” she says. “I would say that if anyone is really incapacitated for something like this, the procedures they’re doing these days – it’s a miracle what they can do now. My grandmother had arthritis so badly she was confined to a wheelchair. It’s a different world today.”

For More Information
If you’d like some more information about this technique or have any questions about hip replacement surgery in general, here are a few of many Web sites that may help. If you’re interested, there are also live videos of the procedure available on the Internet.
Medline Plus – www.nlm.nih.gov/medlineplus/hipreplacement.html
Mayo Clinic – www.mayoclinic.org/hip-replacement
Total Hip Replacement by Dr. Joel M. Matta, M.D. – www.hipandpelvis.com
DupuyOrthopaedics – www.or-live.com/depuy/2051

Virginia Diaz writes regularly for the Hernando Today Health Today section. She lives in Brooksville and can be contacted at [email protected].

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