Hip Arthroscopy

Innovative procedure may help postpone - or eliminate - the need for hip replacement surgery.

Hip arthroscopy may help postpone the need for hip replacement surgery - or eliminate it altogether. At the very least, says Dr. Klapper, "it buys patients time, maybe five or ten years. And I predict that during the next decade, hip implants will dramatically improve."

Causes of Hip Pain

Dr. Klapper links hip pain to the destruction of cartilage. The cartilage between bones provides the perfect lubrication necessary to move joints. If this cartilage is destroyed - through a genetic defect, trauma, infection or tumor - pain, joint stiffness and decreased range of motion may result.

Hip Patient

Arthritis of the hip causes a gradual loss of this cartilage; in its early phases, it triggers a vicious cycle. The arthritis changes the chemical make-up in the joint fluid, which leads to irritation of the lining and fraying of the joint. This reaction, in turn, causes more inflammation and more fraying. The hip pain associated with this condition is unique among joint pain problems in that it can keep one from sleeping through the night: hip pain from rolling over can jolt a person from a deep sleep.

Previously, there were few treatment options for hip pain, and a hip replacement was virtually inevitable. While this technique has improved countless lives, there exists a built-in obsolescence with every implant. "There's a fundamental flaw in the concept of taking out someone's bone and cartilage and putting in metal and plastic," Dr. Klapper notes. "Even under the best possible circumstances, the implant wears out and will need to be replaced. I predict hip implants will eventually be made of more natural material that won't undergo the same stresses and wear-out, but this may be several years down the road."

In the interim, hip arthroscopy, which actually helps break the vicious cycle caused by the arthritis, may postpone some of the damage. "For this reason, I believe hip arthroscopy offers patients with hip pain a viable alternative," Dr Klapper adds

Hip Arthroscopy Candidates

Rene Ruegg

Candidates for hip arthroscopy include active individuals who have painful hips, where there exists an opportunity to preserve the amount of cartilage they still have. A physical exam and X-ray can help determine if someone is a candidate.

An Outpatient Procedure

Hip arthroscopy is done on an outpatient basis and performed under a regional or general anesthesia. Dr. Klapper, working in collaboration with aerospace engineers, has created a set of tools specifically designed for hip arthroscopy. He explains, "Jet engines have limited entry sites, making them difficult to repair. The same holds true for arthroscopic surgery - we must insert some sophisticated tools into small spaces. The unique instruments we have developed allow us to do this.

"In hip arthroscopy," says Dr. Klapper, "we make small holes in the patient's hip area. Through these openings, we insert a camera lens (the image is displayed on a video screen) and the specialized instruments. We then clean out the frayed lining and inflammation, which may prevent further deterioration of the joint." The procedure takes about one-half hour to perform.


Providing Real Relief

Dr. Klapper says the advantages of hip arthroscopy can best be illustrated through two of his recent cases:

The first case involves a 38-year-old private investigator whose past had come back to haunt him. In his 20s, the man had fractured his pelvis in a car accident which, in turn, led to the beginnings of osteoarthritis. "The patient had tried everything to alleviate the pain," says Dr. Klapper, "including weight reduction and medication, but the groin and hip pain continued to increase. His X-rays showed preservation of most of his cartilage but the early changes of osteoarthritis." The patient underwent hip arthroscopy and experienced significant relief from the pain. He subsequently returned to his work.

The second case involves a 43-year-old nurse who was experiencing painful clicking and popping in her hip, and progressive difficulty walking. There was no history of trauma, and an X-ray and MRI scan did not reveal arthritis. "Her only significant past history was multiple breast implant surgeries, to which she had a rejection response," Dr. Klapper says. "Her personal physician felt she was developing a connective tissue disorder from her breast implants, which may have been causing the hip pain."

When a needle was inserted into the woman's hip joint for a culture, ten times the normal amount of fluid was pulled out of the joint, indicating a non-infectious form of inflammation. She was referred to Dr. Klapper, who performed hip arthroscopy and was able to make a diagnosis and treat the patient at the same time, cleaning out her joint to prevent further damage. "The woman returned home the same day, and has since done very well," says Dr. Klapper. The procedure substantially reduced her pain, and she is enjoying life again.

Visionary Innovator

Although Dr. Klapper has focused much of his current interests on hip arthroscopy, he is perhaps best known for the development of an ultrasonic tool that has greatly improved hip revision surgery (performed to replace worn out hip implants).

"Performing a second hip replacement procedure is challenging because we have less bone and muscle to work with," he says. "While in my residency, I was distressed to discover that during revision surgery, surgeons used a big hammer and chisel to remove the cement surrounding the first implant. The already weakened bone had to be chopped up to remove the cement, and then wired back together before implanting the second replacement. The procedure took eight to ten hours with monumental blood loss. I figured there had to be a better way."

Borrowing ultrasound techniques that allow construction workers to drill through bedrock, Dr. Klapper designed an ultrasound instrument to remove the implant and cement without injuring the bone. The unit generates waves that convert cement from a very rigid material to a softer substance the consistency of chewing gum. This substance is then scraped out, eliminating the need for a long operation with a hammer and chisel.

Dr. Klapper patented this device, and it is in use today. He believes that inventions in the near future may offer new options for relief of hip pain. "I foresee a day when the treatment for hip pain may be entirely non-invasive," he says. "Until that day, we can offer patients hip arthroscopy, which is certainly a significant step in the right direction."

I'm involved in some new projects that will allow us to do this complex hip arthroscopy without traction and without X ray guidance. These are the two aspects of the surgery that are hard for surgeons to learn to do. I've never liked the idea of putting the leg on traction since it can create complications of damage to the nerves and blood vessels that supply circulation to the ball and socket joint. For that reason I am pursuing new tools and patents using balloon technology for this aspect of the surgery. I've been working closely with invasive cardiologists who pioneered this balloon technology for placement of stents to avoid heart bypass surgery. This gave me the idea of putting a catheter into the hip joint and blowing up a balloon to separate the ball from the socket, thus creating space in which to do the surgery.

Latest Innovations

Today we use better positioners on the operating room table. These positioners keep the hip exactly where we want it and allow us to enter the joint more elegantly and safely.

The flexibility of tools has improved tremendously so that it's easier to work on areas of the joint that were previously hard to reach with our instruments.

The treatment with the arthroscope for labral tears and early arthritis has been truly a revolution. It has been great to be a pioneer and to participate in the innovation.

-Dr. Robert Klapper, M.D.

I'm very choosey about who can have this surgery. Although I've done hundreds of these surgeries, I could have performed a thousand by now on patients who wanted them. I only offer it to people whol legitimately are candidates. I won't scope a hip just to buy a year or two. I'll do it to buy a patient five to ten years. So far, less than 5% of my hip arthroscopy patients have ended up having implant surgery.

-Dr. Robert Klapper, M.D.

My goal is to make this surgery easy enough that more and more surgeons can do it.

-Dr. Robert Klapper, M.D.

I'm also working on technology to see inside the joint without X ray so that there will be less radiation for both the patient and surgeon. The hip is a difficult joint to enter arthroscopically, so we currently use X ray to be certain the scope is actually inside the hip joint. I believe we'll be able to use ultrasound for this same purpose and no longer have to radiate the patient and the surgeon to do the surgery.

-Dr. Robert Klapper, M.D.