The following opinions are those of Dr. Robert Klapper who has been an orthopedic surgeon for over thirteen years. They reflect his experience after doing thousands of hip and thousands of knee surgeries. In 2001, he performed 170 joint replacements. Over 100 of those were hip implant surgeries. Dr. Robert Klapper is Co-Director of The Joint Replacement Institute at Cedars-Sinai Medical Center in Los Angeles and is the Clinical Chief of Orthopedics also at Cedars.
Doctors are starting to do hip implant surgery through smaller and smaller incisions. Some are using a 4" incision. Others are using two 1" incisions. Smaller incisions are very attractive to patients, because they're less mutilating to the surrounding tissues. I think all surgeons should be trying to do hip surgery through as small an incision as possible, but there are some things to keep in mind. You do not want to compromise the sciatic nerve, which isn't as easily seen through a smaller incision. You do not want to compromise the surgeon's ability to measure leg length carefully, which isn't as easily done through a smaller incision. And through a small incision, surgeons can't do as good a job with respect to the three dimensions at work in the hip, and therefore the risk of dislocation increases. It's still very early in these attempts to perform hip implant surgery through small incisions, and I always tell my patients, "Be skeptical!" Let anything new be used for long enough that you aren't one of the guinea pigs. A lot of new surgical techniques come out and are considered "the new answer," but then after problems arise, those same techniques fade away and aren't used anymore. Don't have surgery with something new that could prove problematic a few years from now. Further, don't confuse mini incisions with minimally-invasive surgery. 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 decade 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. 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. 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. Resurfacing of the Femoral Head You will hear about a procedure that resurfaces only the femoral head, the ball side of the ball and socket joint of hip. It doesn't require the removal of the head of the femur, nor does it need an implant placed inside the femur (thigh bone). If this technique were as good as it first sounds, every orthopedic surgeon would be adopting it. Here's the reason we haven't: while resurfacing the femoral head may require less cutting and removal of bone on the ball side of the joint, the larger head that's created requires that you remove more bone on the socket side to accommodate it. That means that there's less bone, less room for revisions, redoing the surgery, which is inevitable in all of these cases. We have to keep in mind that no implant lasts forever, that we always have to plan for the revision later in that patient's life. And by removing so much bone from the socket side of the joint, from the pelvis, the surgeon is causing himself problems for the next surgery fifteen or twenty years from now. You want to remove as little bone as possible from the socket side of the joint, even if that means having to remove the femoral head and having to place an anchor down the femur, which is exactly what the implant is. Then people ask: what if we just took a little more bone off from the femoral head? We have to look at the laws of physics and biomechanics. We're dealing not only with downward compressive load forces onto the hip joint but also rotational shear forces. Because of the rotatory torsion placed on the hip joint, a resurfaced head of the femur on the end of the femur bone could spin right off the top, even if it's cemented. A deeper anchor is needed to contain all the types of weightbearing forces we place on our hips. Further, as these forces are constantly evaluated by our bodies, we can start to see bone underneath a resurfaced femur being resorbed, making it loose, making it weak, making it fail. Ceramic Implants and Metal-Against-Metal Implants. Ceramic implants are not new. They've been used in Europe for the past twenty years, and, in fact, they're being recalled in Europe right now. 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. When you work with it to shape it into the different sizes that we need in orthopedics, you learn that one of the problems with it is that it can crack. I don't mean to panic anybody. So far in America there has been no recall on ceramic surfaces, but cracking is the downside to using ceramics. I have so many young patients, people in their forties, thirties, and even twenties who have hip implant surgeries, that I'm always tempted to say, "Let's put something into your hip that's going to last longer," but I refuse to make my patients guinea pigs. I refuse to put something in that doesn't really have a track record here in America. What looks good at one year, what looks good at three years, and what looks good at five years isn't enough for me. I need to know what it's going to be like twenty years later, and we just don't know that yet. Very few implants have been around that long. The metal against plastic ones that I use show that 90% of them are still functioning twenty years later. When surgeons tried metal against metal, they have recently found that toxic levels of metal-breakdown products show up in the joint and in the patients' urine. These toxic levels may be high enough to be cancer causing. How long does the toxicity stay? Does it get diluted with time and go away? These are questions we don't have the answer to yet. 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. Computer-guided surgery, robotics, will be especially helpful to us in reproducing a patient's leg lengths. My dad was a carpenter who taught me to measure twice and cut once. I take a lot of pride in the fact that in the operating room I take measurements of the femur prior to cutting any bone so that I know what the numbers really are in surgery, not just from Xrays. Then as I finish the surgery, I can measure from landmarks that I made on the bone so that I'm sure I've exactly reproduced the leg lengths. To have a computer assist me in doing that would be very helpful. 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. |
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