Hot Topics in Hip Surgery

The following opinions are those of Dr. Robert Klapper who has been an orthopedic surgeon for over twenty years. They reflect his experience after doing thousands of hip and thousands of knee surgeries. Over the past year, he has performed over 400 joint replacements equally divided between hip and knee implant surgery. Dr. Klapper is Co-Director of The Joint Replacement Institute at Cedars-Sinai Medical Center in Los Angeles.

Mini Incisions

Surgeons are doing hip implant surgery through smaller and smaller incisions than in the past and this has been a great advance. The fact that we no longer cut through muscles has caused a vast improvement in patients' recovery times. They are leaving the hospital earlier, recovering more quickly.

My incisions have changed tremendously over the past ten years. I emphasize not violating the muscles and tendons - muscles are pushed out of the way rather than cut. I enter the hip joint at an angle that allows for more preservation of these vital structures. The implants used are smaller and less bulky. They are more customized to match the actual size of the patient's anatomy. And the bearing surfaces we use - metal, plastic, and ceramic - are all more durable than they were before.

The smaller size of the incision, the reduction of trauma on the muscles and tendons to do the surgery, the customized implant components, and the more durable bearing surfaces have all added up to great advances in the quality of today's hip implant surgeries.

When you immerse yourself in water, pain is reduced because the coolness of the water distracts you from your pain, and because the hydrostatic pressure of the water helps reduce swelling and inflammation. All of this adds up to comfort and relaxation in the water.

Doctors are still doing major surgery through these small incisions, surgery that replaces your own natural cartilage with artificial implants. No matter how long the incision, implant materials can wear out, loosen, or even dislocate. Recognize that the truly minimally-invasive surgery is when no implant is used, when your own hip joint is left intact, and that is hip arthroscopy. Everyone is familiar with arthroscopy of the knee and shoulder, and over the past two decades we've revolutionized its use for osteoarthritis of the hip. I've created and patented special tools that allow me to reach further into the hip for treatment. See hip arthroscopy for more.

Glucosamine

Everybody talks about glucosamine and hundreds of my patients use it, primarily because tremendous amounts of money have been poured into this "cure" for arthritis. The people who have found glucosamine are searching for a way to remain holistic, to find an answer other than surgery, and I applaud them. I truly wish there were a pill you could take to grow cartilage or even to maintain cartilage. Speaking from my own experience, I have yet to see any of my patients avoid surgery because of taking glucosamine. Yet many of them say they feel better. It's my understanding, after talking with the rheumatologists at Cedars, that a study was finally done looking at why these reasonable people say they feel better when glucosamine isn't really doing anything to the cartilage. The answer: there are elements in the glucosamine that are Tylenol-like, so you feel better because there's a painkiller and less pain, not because there's been a structural improvement in your cartilage.

I do believe that the future will be stem cells, but I don't believe the treatment will be in my lifetime. Meanwhile, please be skeptical of "cures for arthritis."

Synvisk Injections

Synvisk and other lubricating agents were originally designed in Canada as an outgrowth of that country's socialized medicine. Long lines of people have been waiting to have implant surgery that can't be handled by socialized medicine, and so Synvisk has been a means for them of postponing surgeries and buying these patients time before they can schedule hip implant surgery. Since I don't normally do these injections, I get to see the people who come to me for a second opinion, those who are having problems with their injections. Some of my own patients have pleaded with me for Synvisk injections, and I have done a few. Ultimately, not one of them has avoided surgery.

Ceramic Implants and Metal-Against-Metal Implants

Ceramic implants are not new. They've been used in Europe for the past thirty years, and, in fact, they have been recalled in Europe recently. They aren't being recalled in the United States.

The ceramic heads are beautiful and they have great wear characteristics, much better than metal against metal or metal against plastic. However, the ability of ceramics not to wear out and the toughness and the stiffness of ceramics -- those very positive characteristics become a negative when you learn that ceramics is also more brittle. *Many surgeons use ceramic implants. I have not used them because in the rare case that the ceramic might crack, it has shattered like glass breaking into many little pieces, so revising a cracked ceramic implant is quite tedious and you have to hope you get all the pieces out. In my view, the risk-benefit ratio for the patient is not warranted. Plus there are also occasional problems with squeaking in which you can hear a high-pitched squeak with every step.

**Metal against metal implants are still being used and are still controversial. There's more data showing they don't cause cancer, but they have had problems with squeaking. Metal ions from the metal-on-metal friction are released and can compromise the immune system. It's not yet known what effect filtering the ions from the body will do to the kidneys.

The metal against plastic ones that I use show that 90% of them are still functioning twenty years later. When we use metal against plastic, there's no metal breakdown or toxicity, because the plastic wears out first. At least we know what's going to happen. There's no cracking or toxic unknown. We know that when the plastic wears out, say in twenty years, we don't need to take the whole femoral component out of your thigh bone, because it's not loose. There's no need to take the titanium acetabular socket out of your pelvis, because it's not loose. All we do is snap the plastic out and snap a new piece of plastic in. During the revision, you're not cutting bone, just replacing the plastic. In my estimation, the revision surgery is only about 10% of the trauma, healing, and pain as the initial surgery.

Robotics / Computer Navigation

Robotics sounded very helpful to me ten years ago. But I have not been impressed yet. To me it seems like using your GPS to go to your local supermarket down the street. You already know how to get there. Perhaps it will be useful to a new surgeon, but for an experienced surgeon, the cost and the time don't make sense to me.

Here's a summary of my advice:

Ask your doctor lots of questions. Be skeptical. Take advantage of the internet to learn as much as you can about your hip condition. Read our book Heal Your Hips. Ask your surgeon to go over your Xrays with you. Don't let him just read you the report. You need to learn to read them and watch the progression of your hip condition yourself. Keep your own Xrays so if you change doctors you'll have all your Xrays together in one place showing the progression over time.