The Latest Procedure - Anterior Hip Replacement Surgery

Uploaded by AZPBS on 15.11.2012

Transcript:

>> And now, an Eight original
production.
>> This time on The Latest
 Procedure...
The hip is one of the largest
and most important joints in the
human body.
It allows us to walk, run, hike,
and move about freely.
However, when this joint wears
out and patients suffer the ill
effects of arthritis, this
freedom of motion is met with
pain, eventual immobility, and
even difficulty sleeping.
In 2012, approximately 300,000
patients in the U.S. will
undergo a total hip replacement.
And of those, thanks to modern
advancements in both techniques
and technology, a growing number
of patients will choose a
procedure that will allow them
to regain a healthy level of
activity and resume a normal
lifestyle more rapidly than ever
before.
 The Latest Procedure: Anterior
 Total Hip Replacement Surgery.
[ ♪♪ ]
>> Major funding for The Latest
 Procedure: Anterior Total Hip
 Replacement Surgery was
provided by...
The Parsons Foundation: proud to
support PBS and health education
programming.
The Parsons Foundation inspires
hope by providing critical
funding at critical times to
communities striving to make a
difference.
And by these generous
contributors.
And by the friends of Eight.
[ ♪♪ ]
>> Hi, I'm your host, Jim
Cissell.
Welcome to The Latest Procedure.
Today we're going to be talking
about total hip replacement
surgery, and we'll actually take
you inside the O.R. to see one
of these amazing surgeries
firsthand.
While total hip replacement
surgery has been around since
the early 1960s, new techniques
and technologies are evolving
every day.
While there are numerous ways to
perform a hip replacement, today
we'll be focusing on just one of
these.
It's an approach called anterior
total hip replacement.
I'm joined now by Dr. Theodore
Firestone, who is the medical
director of the total joint
replacement program at
Scottsdale Healthcare Shea,
located in Scottsdale, Arizona.
Welcome, Dr. Firestone.
>> Thanks, Jim.
>> So, before we get into the
anterior approach, let's talk
about the basics of hip surgery.
What is it?
Why do people need it?
What are the causes?
>> Well, simply stated,
arthritis of the hip is where
the ball and the socket wear
out: the cartilage, the smooth
covering wears out, and that's
what causes all the problems.
So if you look at this
illustration, you can see that
there's some spurs that have
formed at the hip joint.
With a hip replacement, we
remove that arthritic femoral
head.
We then prepare the pelvis for
the acetabular component.
Then we go back to the femur
side.
We place a stem into the canal.
Then we place a femoral head
ball onto the stem, put it all
back together, and then that's
the new replacement, that's
what's making up for the
arthritic joint.
>> And who needs this surgery:
at what age, what severity?
>> Any patient that has pain,
suffering, disability, stiffness
from a worn-out hip joint is a
candidate for a replacement.
Why do they need it?
Many reasons.
Typically, the hip wears out
with time if there's a slight
malalignment from childhood.
Often there's trauma.
But basically, we're doing a lot
of patients who are in their 40s
and 50s that probably had some
type of mild abnormality in
their joint early on that over
time wore out and caused all the
problem.
>> Now, traditionally this
surgery has been done
posteriorly.
Can we talk a little bit about
what's the advantage to the
anterior approach?
>> Well, you're talking about
just different ways to get into
the hip joint.
And there are basically three
different ways.
So a posterior incision, or a
posterior approach, would be
based on an incision,
illustrated here, more toward
the back of the hip, closer to
the buttock region.
Then there's a lateral incision
which is based right over the
side.
And then there's an anterior
incision which is based where
your front pocket would be.
But more important than where
you place the incision is what
we do underneath the skin
incision.
So if we look at the next
illustration, so this is what we
would access with a posterior
incision.
That's the gluteus maximus, big
muscle.
So we would -- in a posterior
approach, you make an incision
into the muscle, spreading it in
line with the fibers, and then
you get down to the tendons in
the back of the joint and you
take them down off the femur to
get into the hip joint.
Now when we do the anterior
approach, you can see the
muscles in the front of the
thigh there, and we go in
between the tensor and the
rectus.
That's called an internervous
interval, because those muscles
are enervated by two different
nerves.
So we identify those muscles and
then we spread them apart, and
now we're looking at the hip
capsule, as you can see in the
diagram, and underneath that
capsule is the hip joint.
>> A few weeks ago,
Dr. Firestone was kind enough to
invite me down to show me
firsthand this anterior approach
to performing a total hip
replacement.
In this first segment, he showed
me many of the technologies and
instruments used to make this
procedure possible.
I think you'll find it a unique
mix.
Some things you'd swear came
straight from a carpenter's
workbench.
Others, they're as high-tech as
they get.
[ knocks on door ]
Dr. Firestone.
>> Hey, Jim, good to see you.
>> You as well.
>> Great timing, I was just
looking at the x-ray of our
next case.
>> Okay.
>> If you look at the x-ray, you
can really tell the difference
between the two, can't you?
>> Yes, sir.
>> Here's the right hip.
Pretty much normal.
Ball and socket with cartilage
in between.
>> That left one, totally out of
the socket.
>> It really is.
>> Look at the gap difference.
>> The ball's not even sitting
in the socket, the hip ball.
This is a classic case of
dysplasia to the 10th degree,
really advanced.
So she's ground down all the
cartilage.
Forget about that, that's long
gone.
Now she's ground down the bone.
You can see actually the hip is
actually flattened out.
>> Yep.
>> So we obviously need to
correct that situation with the
ball and socket, and we're going
to correct the leg length at the
same time.
So I had these plastic templates
that are going to help me
determine which size implant
that I'm going to use in the
next surgery, but I'll show you
that when we're in the O.R.
But, you know, next door I have
that table I was telling you
about.
I'd love to show you what it
looks like.
>> Let's go.
>> I want to show you some
things about this specialized
operating room that we use for a
joint replacement procedure.
>> Okay.
>> The first thing you're going
to notice is this wall.
It's called laminar flow.
And the air is going to blow at
a high flow -- purified air --
across the patient, keep the
dust to a minimum, decrease
particle count, one of the steps
we're going to take to decrease
our risk of infection.
What do you think of this?
>> That's a pretty fancy table
there.
>> It's a high-tech fracture
table.
It's called the Hanna table.
Dr. Matta designed this about
seven or eight years ago, and
what it is, is a fracture table
that has a couple of
adaptations.
Patient's going to be on the
back, secured with this post so
we don't get a lot of slide.
The feet are going to be
strapped into these ski boots.
Now when I get ready to do
certain parts of the procedure,
the leg is going to be put into
different positions.
The thing that helps most with
the anterior hip surgery using
this table is the femoral side,
where I put the stem in, because
we're going to drop the leg
down.
And that way the femur, the
thigh bone, is going to come up
into the wound.
So show him how that leg drops
down, Sean.
>> You have to unlock it here.
This will drop the leg down.
>> Mm-hmm.
>> So imagine the thigh
connected, coming up into the
incision that's going to be
here, and then we're going to
rotate.
So that really helps with the
exposure.
One of the things about anterior
hip replacement was the
acetabulum, the cup part, is
pretty easy to put in, but the
femur preparation was really
difficult.
This really helps.
The other thing that helps with
this is the use of this bracket
right here.
Because what I do during the
surgery is I put this hook
inside the patient, and what's
going to happen is this is going
to help elevate the thigh bone
up so the femur's in the opening
of the wound, and I'll be able
to prepare the femur for the
femoral component during the
broaching technique.
Sean, why don't you show him how
this elevates?
So the femur will be elevated
into the wound.
That way I can have great
access.
Because that was really the hard
part of the surgery with the
anterior approach in the past,
putting the femoral component
in.
And then the last thing about
the table: the base is
radiolucent.
So we're going to be able to
take this x-ray machine, wheel
it in right on top of the
patient, take a shot of the
pelvis.
I'll be able to check the
component positioning and the
size and the leg length.
So you want to see the tools?
>> Yes, sir.
>> Well, we call them
instruments, but here they are.
So after I get exposure, I'm
going to cut the head of the
femur off...
[ saw buzzes ]
with this saw.
>> (chuckles) Okay.
>> All right?
We're going to remove the ball,
and then I'm going to have
access to the pelvis, the
acetabulum.
So I'm going to put the cup in
at that point.
So after we cut the head off,
we're going to prepare the
acetabulum with this reamer.
>> Okay.
>> We're going to go up a
millimeter or two at a time
until I get the right fit and
feel in the acetabulum, and then
we're going to put in the cup.
Now I don't have the actual
component, but I have a trial.
This is what it looks like.
Just a hemisphere shell.
And when we put it in, we're
going to have a liner that's
going to lock into it.
>> Okay.
>> But this is the trial.
Sometimes I use it, sometimes I
don't.
So this is going to go into the
pelvis.
This is the cup, also called the
acetabular component.
>> Okay.
>> Okay? So after we have the
cup in, then we have to do the
femoral side.
>> All right.
>> We've got to put a stem into
the canal of the femur.
And how we're going to do that
is with a series of broaches.
We're going to start off with a
small broach, and this is going
to be introduced into the
femoral canal, into the thigh
bone.
>> Wow.
>> We're going to go up in size
one at a time until I get the
right fit, and then we're going
to put a trial in and put the
whole thing together with these
trial heads into the cup, and
that's going to be our trial
component.
And if everything looks good,
we're going to open up these
implants and put the real thing
in.
And I'm going to show you that
in the operating room.
>> Sounds good.
So a lot of the tools we saw
are used in all three
approaches: the posterior, the
lateral, and the anterior.
And yet in my research, the
anterior approach has been
around for about 35 years now,
at least in its primitive form.
Why is it now suddenly the
latest procedure?
>> What's new about the
procedure, Jim, is combining the
anterior approach with a special
operating table.
Dr. Joel Matta in Santa Monica,
director of the Hip and Pelvis
Institute there, world-renowned
pelvic fracture surgeon,
pioneered the anterior approach
using the table.
And I had the opportunity to sit
down with him the other day, and
we talked about things, and I
think you might find it
interesting.
>> What it comes down to, the
reason of using the orthopedic
table, is that the anterior
incision is a more difficult way
to access the femur than is, for
instance, a traditional
posterior approach.
That's the problem that's
presented is accessing the
femur.
So you don't want to have to
struggle, injure the soft
tissues, possibly create a
fracture, but the orthopedic
table is the tool that gives
consistent access to the femur.
So what the orthopedic table can
do, the way it positions the
lower extremity, the hook that
holds the femur up and
stabilizes it while you're
working on it, minimizes the
soft tissue trauma.
>> So the precision,
consistency, and less tissue
damage.
>> Pretty much.
I mean, that's why I switched
from the posterior approach that
I was using to the anterior.
I was always comfortable with
the anatomy, but having the
x-ray there to confirm the
perfect positioning, or as close
as you can get to perfect
positioning of the implant, is
really helpful.
>> We actually filmed several
surgeries during my visit with
Dr. Firestone, and while they
all turned out great, we've
picked just one to show you
today.
I must warn you, however, that
some of the images you're about
to see are somewhat graphic, so
be prepared.
In order to capture this
procedure effectively, we
mounted a special camera on Dr.
Firestone's head that you'll see
from time to time.
The surgical incision for this
kind of case is relatively
small.
Many times the only view into
that surgical window is Dr.
Firestone's point of view.
So enjoy the best seats in the
house as we take you inside the
O.R. to witness firsthand
anterior total hip replacement
surgery.
>> Catherine, hi.
>> Good morning.
>> Nice to see you.
>> Good to see you, too.
>> Are you ready?
>> I'm ready.
>> Okay, I want you to meet Jim.
>> Hi, Jim.
>> She has a really bad hip.
>> What happened?
Injury, or just...?
>> Well, she has a condition
where the ball never really
lined up with the socket, and it
wore off -- wore out over time.
But it's a really severe case of
arthritis.
I'm surprised she's actually
been able to go with it as long
as she has.
Because you have been limited
for quite a while.
>> Yeah, I've been probably
limping for a good eight years,
thinking that it was back
problems and pretty much being
in denial that it was anything
major.
So literally I found out that I
needed this a week before I met
with you.
>> Well, I'll tell you, when I
saw your x-ray, I was really
surprised you were able to go as
long as you did.
But you're pretty tough.
>> I'm ready to change my life.
I can't wait to get back to my
life, let's put it that way.
>> So let me mark the leg.
I want to make sure we do the
correct one.
Which one are we doing?
>> Left side.
>> Correct.
You said you were walking with a
walker right now?
>> Within the last... how many
days, four days, five days?
I was using a crutch for a
couple days and limping pretty
bad.
>> All right, so I'll see you
inside.
>> I'll see you inside.
>> Great.
>> Thank you, nice to meet you.
>> Good luck. You, too.
[ ♪♪ ]
>> Okay, Jim, so we're all
sterile now.
I've put some drapes, some
preliminary drapes around the
hip.
The patient's head is up there.
The foot is this way, you can
see.
You can still see the ski boots
that she's locked into.
And so I'm going to palpate some
anatomic landmarks.
The first one is the anterior
superior iliac spine.
We call that the ASIS.
Here's the crest of the pelvis.
The trochanter is down here.
The trochanter is the part of
the upper femur where all these
big muscles attach.
We're going to stay away from
them by coming anterior to them,
hence, anterior total hip
replacement.
Typically, a four- or five-inch
incision is necessary, but
really the length of the skin
incision, that's the least
important thing.
It's going to be what we do
underneath that really matters
most.
So you can actually see the
bulge of the tensor.
>> Yep.
>> So I'm going to angle the
incision.
Okay, so that's about four
inches there.
We'll put the self-retainer in.
So here's the fascial layer just
over the tensor: very thin,
sinewy type tissue.
This fascia separates the
muscles from each other.
Okay, so I'm going to try to
elevate this muscle off this
fascia.
You can see how nice and smooth
that relationship is.
So I'm feeling for actually the
top part of the femoral head and
the femoral neck.
And I'm just dissecting it away
from my fingers, so we're not
really using any sharp
instruments, just using the tip
of my finger.
And I'm going to try to just get
this blunt Colver retractor into
that interval right there above
the femoral neck.
Here we have the next muscle
we're going to identify, which
is going to be the rectus.
And you're just starting to see
a hint of it here.
And we're going to put another
retractor in.
All of a sudden you see the very
common leash of vessels, the
circumflex vessels, and we're
going to tie those off.
So we're going to...
tie this vessel off.
So we're just going to tie off
this leash right here.
That separates our rectus from
our tensor, and I'm actually
starting to feel the front
capsule of the hip joint.
>> Wow.
>> So believe it or not, we're
getting really close to the
joint, and all we've done is
spread two muscles.
And I'm going to take the Cobb
elevator, and I'm going to try
to find the inferior border of
the femoral neck now.
So Tristan's going to give me a
little rotation so I can sort of
feel the normal contour of the
femoral neck.
>> And the femoral -- the head
is where you're replacing the
ball, the lining?
>> Correct, the head and the
neck -- here's the neck, and the
femoral head is right in the
acetabulum right underneath this
capsule.
And we're going to get to it
now.
You're probably going to see
some synovial fluid when I get
into this capsule, because
that's what houses all the joint
fluid.
Look at that, you see the fluid
coming out?
>> Wow, yeah.
>> It's a sign of inflammation.
Well, you saw how badly she was
hurting, right?
>> Yeah.
Using a walker at her age,
that's amazing.
>> Yeah, using a walker, that
was -- I was surprised to hear
that when I saw her in my
office.
So we're going to just
preliminary get a capsule or
stay suture in, because this is
going to be our sort of trap
door to let the hip in and out
into the joint, the ball reduced
into the joint, when we do our
trials and our real thing.
Okay, can I have a clamp?
But I'm going to release down to
the inferior attachment of the
capsule so we can get some good
exposure and I'll be able to cut
the neck.
I'm going to do a two-staged
cut.
I'm going to take a little
napkin ring resection out of the
femoral neck, and it'll let me
take the femoral head out a
little easier.
>> Okay.
>> Okay, saw?
Okay, so here's an oscillating
saw, battery powered.
[ buzzing ]
>> Bones bleed a lot more than
people think.
>> Yeah.
>> Okay, a little traction.
That's a good thing.
That's why they heal when they
break or when they get an
implant in them.
>> Oh, God.
Oh, the head's loose.
>> Okay, so I've taken this ring
of bone out, femoral neck.
>> Wow.
>> Okay, so the head sits on
that; here's the neck.
So now we have the head, and
basically the head is pretty
much already out.
>> Yeah, there's a lot of
movement there, yeah.
>> It subluxed out of the joint,
very consistent with what we saw
in the x-ray.
It's flattened.
You can just see the big slope.
That's what she was -- that's
why she was on the walker.
I mean, that's --
>> And how's the surface of that
one compared to an average one
or a typical one?
Is that all scarred up?
>> Well, we never remove normal
ones, but it would be like a
cue ball, and that looked
like...
>> Lumpy.
>> Yeah, somebody got at it.
So what we can do at this point
is to get a quick x-ray just to
look at our femoral neck
resection, because I want to try
to make my opening for my
acetabular exposure as large as
possible so I can put the
reamers in and out.
But let's take a look.
This is the beauty of, I think,
the Matta approach for anterior
hip replacement, this table and
the fluoro.
Okay, take a shot.
[ beeps ]
Good.
So that's a pretty conservative
neck cut.
We can take a little bit more.
So let's get our double prong
retractor back in.
Okay, so there you can see our
neck resection that I did with
the first pass.
And now I'm going to take off
another -- let's see, it looks
like we've got about three or
four millimeters I can take off.
[ saw buzzing ]
Pretty decent bone quality.
>> That's a good thing, no?
>> Yeah, very good.
>> So what happens if you find
the femur has got osteoporosis?
Can you just not do it, or...?
>> Well, we encounter that quite
a bit.
The bone's a little bit softer,
so you have to be a little bit
more careful with it.
It cuts a lot easier.
But these implants that we use
are great.
They're great for hard bone,
they're great for soft bone.
I'll show you the implant we're
going to use on the femoral
side.
It actually is the best force
for osteoporotic-type bone.
Okay, so I've taken a little bit
more bone.
I see a little bit more capsule
I can release.
Okay, we'll switch positions.
Okay, you can raise the table a
little bit.
Watch my camera, because I'm
going to be looking right inside
her hip joint.
Can you guys see that pretty
well from my view?
I'm seeing the acetabulum really
well.
>> That's a great view of the
acetabulum.
>> Okay, now we're going to trim
the edge of the labrum around
the socket.
And I can see some definite
areas of bony wear on the
acetabulum.
She's had some bone loss here,
so we're going to have to be
careful to ream this
concentrically.
We're trying to create a
hemisphere so we can get a
press-fit with our implant.
Okay, so I have a pretty good
view right there.
Now, I templated a 52 acetabular
component.
That means I would ream to 51.
And I need a 1-millimeter
press-fit.
I'm going to make sure that I
don't let this reamer ride up.
I'm just going to start with a
preliminary ream.
The key to reaming the
acetabulum, Jim, is you want to
just, you want to make straight
passes in and out.
You don't want a lot of
eccentric, wobbly reaming.
You want to try to create a
perfect hemisphere.
Let's take a peek now.
Tom, come on in.
Now, in the past, when I was
doing the posterior approach, I
would have a good idea where I'm
reaming just by the anatomical
landmarks.
And that's what I'm looking at
now, but now I'm going to
confirm with an x-ray.
Okay, good.
So I'm basically heading
straight to where I want to
head.
And I'm looking at the
acetabulum and I'm starting to
see some decent bleeding bone,
less of that inflammatory tissue
in the lower portion of the
socket.
We're going to go up to a 50
now, Jim.
So I'm careful to maintain my
position.
Take a quick peek of that.
Step.
Beautiful, Tom.
So you can see that I've
maintained the desirable
position for the socket.
And I think now we're down to
the bone.
We're at 51.
We templated a 52.
[ grinding ]
I'm seeing a little bit of play
there.
And I did template between 52
and 54, so I'm happy.
Let's go, 53.
I'm going to use a 54 implant.
So this one I want to get just a
perfect, straight-on ream.
>> Last ream, right?
>> Perfect.
Okay, one last check.
Okay, Tom.
Great with that.
Okay, now here's our implant.
It offers porous coating.
It has a rough surface.
I'm not going to touch it,
because I want to keep it nice
and clean there.
And we have three holes in case
I wanted to use a screw.
So we're going to put that in
carefully.
Got to sometimes manipulate it
around the rim of the
acetabulum.
That feels pretty good there.
Make sure there's no soft tissue
catching it.
I definitely have a good
press-fit.
I can feel the rim really well.
Okay, x-ray.
>> So that is just a press-fit?
>> The ream's a 53, and this is
a 54.
>> Doesn't require screws or
adhesive or anything, huh?
>> The coating actually is an
adhesive.
Step.
Great.
Step.
Getting there.
All right, I like that position.
About 35, 40 degrees of lateral
opening.
A little bit of anteversion now.
I'm going to feel the anterior
rim.
And I have a couple millimeters
of bone just anterior to the
acetabular component.
Great, now I'm going to move
that around, absolutely no play.
That's not going anywhere.
Can you see that on the camera,
Jim?
>> Yes, yes, sir.
>> He's moving the whole pelvis.
>> Yeah, I see, the whole body.
>> So we definitely don't need
any screws.
I'm down all the way to the
reamed area.
I'm going to check that as well.
Give me a freer.
Looks good.
Pretty much 360-degree coverage.
Great.
Irrigation?
This is a trial, just a plastic
temporary implant that we're
going to put in to see which one
we want to use at the final
insertion.
Okay, great.
All right, now let's go do the
femur.
Neutral rotation.
Okay, now this hook is going to
elevate the femur into our field
of vision here and hook it onto
here.
Now I'm feeling underneath the
femur.
There is a natural recess in
between these two muscles that
allows me to just place that
hook without damaging anything,
having to cut through anything.
Okay, so now we're going to
lower the table a little bit
more.
Good.
And drop the leg out of the bag,
so step back, Sean.
So you can see how the leg's
going to drop down, and this hip
femur is going to come up into
our field of vision.
>> Yep.
>> Now I'm going to put the hook
into this outrigger.
And we'll place some deep
retractors around the femoral
neck.
This is really the trickiest
part of the operation in terms
of getting the femoral exposure.
And I'm just going to release
enough to start seeing the femur
mobilize up into the wound.
Now you can see the femur.
Now watch how when I use this
hook to raise, how the femur
will mobilize up.
>> There it comes.
>> There you go, perfect.
So I have great visualization of
the femur.
I've released the whole capsule
and the back edge.
All the other rotator tendons,
the piriformis, everything else
is intact.
Now we'll prepare the femur.
You want to use a little chisel
to create a slot in the femur.
Rongeur.
I'm going to start in the middle
and then take it backwards
laterally.
The key is to get out a little
bit lateral.
And I'm angling straight down
the femoral shaft.
>> This is the messy part.
>> Keeps the bone with it.
See that?
>> Yeah.
>> Now I'm going to identify the
canal, canal finder.
Okay.
So that's going to be my angle
of broaching.
Okay.
>> So it looks like you're
almost at the outer perimeter of
the head of the femur.
>> You have to start a little
laterally.
The tendency is to almost, in
the beginning, when you're not
really comfortable getting out
this far, the tendency is to get
a little bit too on the inside
medial.
Now here's our broach.
It's the smallest one, we start
with that.
I'm going to just go in line
with the femoral shaft.
This compresses the bone; it
doesn't really cut out the bone.
>> Oh, really?
>> It sort of impacts it.
I want to see my angle of
descent of the stem.
Okay, good.
Come on back.
She has pretty good bone
quality.
>> Yeah? Good.
>> Retract.
Good.
You have your shield on, right?
>> Yeah, I do.
>> Next size up is what?
>> Nine.
>> Nine, okay.
So I'm going to try to create
just a larger ML dimension in
the same slot as we go up in
size.
>> Still allowing for a
compression fitting on the final
insert.
>> Correct.
You want a little advancement
with every blow.
>> Yep.
>> See that I've buried the
broach a little bit below the
level of the neck cut that I
made.
So I'm going to use this --
another cheese grater.
A mill, mill this down to the...
neck level, because we are going
to have a collar on our implant.
I'll explain to you what that's
going to look like.
Give me a standard neck and a
minus head.
We're going to do a trial
reduction now.
Mallet.
Thank you.
Again, these are trials,
mimicking the real thing.
>> Plastic instead of ceramic.
>> Correct.
Okay, up and in.
So he's keeping the anterior
capsule out of the way.
That's why I like this little
flap here.
Neutral rotation there.
That looks good.
Let's take a peek, Tom.
We're going to be able to get
not only -- step, thank you.
Pull back.
Not only a great assessment of
leg length, but also offset,
which I think is sort of
undervalued.
You basically, it's how far the
femur is off the pelvis, and
that's just as important as how
long the leg is.
So we're going to print that up.
Okay, let's take this broach out
and put the liner in.
Up with the leg, please.
So now we're going to put the
real liner in.
I would like to see what that
lateralized liner looks like in
relationship to the one I'm
using here.
Needle holder.
>> How many millimeters less
offset?
>> Three millimeters.
>> I guess let's do a trial with
the lateralized liner.
What we're going to do here,
Jim, is because the offset, how
far my femur is away from the
pelvis, is reduced.
>> Okay.
>> So I'm going to try to get it
a little bit further out to
mimic the normal side on the
right.
So I have two ways of doing
that.
I can either change the femur
angle or I can lateralize the
liner.
And that's what I'm going to do.
I'm actually going to use a
liner that's going to bring the
center out a little bit more,
and it has the benefit of more
polyethylene.
And at the rate that this poly
wears, it should be good for 40
years.
So here's our thickness, here's
our poly liner.
Nice and thick, lateralized.
Going to fit into the shell
here.
It has these locking pegs.
Line the pegs up.
Wall impactor.
Cover it.
Great.
Check that.
>> So those locking pegs are
what holds it in the socket?
>> Yeah, I don't know if you can
see this on the monitor, how I'm
trying to lever the liner out?
>> Right.
>> That's a very solid fit.
>> Yeah.
>> And there's no movement at
all.
Okay, so now we're going to go
back and put our final femoral
component in.
I'm going to try that trial
again just so I can see how that
looks.
Can I have the hook?
Externally rotate 90.
You'll notice that I'm doing a
lot of talking.
I have to tell my assistant down
at the foot of the table where I
need the leg.
Back when I was doing the old
approach, I would have to hold
the leg and move it around.
So I didn't have to talk as
much, but I had to work hard.
Let's drop the leg.
I prefer this for so many
reasons.
>> Mainly because patients do
better when you're done.
>> Well, that was the number
one.
>> Yep.
So this is the final one before
the last insert?
>> Yeah.
Give me the mill.
Neck.
Minus head.
Mallet.
Okay, so step.
Come on in.
X-ray.
Okay, let me have a pelvis, Tom.
Step.
Okay, come on back, pull back.
>> So it looks like we're going
to do the final fitting with the
final insert into the femur
after he's tested it many times.
>> Tested it and confirmed it
with x-rays, Jim.
>> Yep.
To what precision are you
placing it?
I mean, half a millimeter?
>> You know, we're actually
trying to shoot for perfection.
Obviously, if we're a millimeter
or two off, that's still really
good.
Back in the day, you know, if
you were within a, oh, I don't
know, a half-inch or so, that
was about what you would expect.
>> Wow.
And she had a leg that was
shorter than the other, and you
were going to try to adjust some
for that?
>> Yeah, she has a lot of pelvic
tilt, but she does have some
bone loss that's created a leg
limp discrepancy, and we've
completely compensated for that.
Leg will be hopefully perfectly
equal.
So I will take the 10 stem.
>> Okay.
>> Mallet.
So here's our implant.
It has a HA coating, which the
bone loves, has an affinity to
the bone, and a titanium core.
And it matches up with the
broach we just put in.
So we're going to carefully
insert that.
And I'd like it to sit just
about there, right above, right
about, I don't know, a
half-inch, three-quarters of an
inch above the neck cut.
>> Oh, really?
>> Yeah.
>> So that doesn't get pounded
down flesh?
>> Well, watch.
[ chuckles ]
>> Aha.
>> So we have a good fit down
into the canal of the bone.
We also have the stabilizing
effect of the collar.
Okay.
Looks good, Jim.
I think we've restored a lot of
her leg length, and the distance
between the femur and the pelvis
looks good, the offset.
So give me the minus head.
>> Okay.
>> We're going to use a minus
head, a cobalt chrome head.
I pretty much knew I was going
to use the minus.
So that's the one I'm going to
use.
But we could also use one that
sits up a little higher.
>> A lot higher.
>> If we're a little short.
So depending on the patient's
own anatomy, we can modify it
with these heads, as well as
where we sit the stem.
>> Sure.
>> Okay, come on out with that.
>> Oh, that's pretty.
>> Isn't that nice and shiny?
It's a lot better looking than
what she had in there, right?
Okay, up and in.
Okay, great.
So let's look at this final
pairing.
I look at the relationship of
the ball and the socket.
Externally rotate 90 degrees.
So now we're going to rotate the
leg 90 degrees.
And you see how stable that is?
>> Oh, yeah, yeah.
>> Not coming out fully rotated.
>> Right.
>> Definitely not going to come
out the back, because I haven't
cut any tissues at the back.
And our leg lengths are just
about perfect, restoring all the
bone loss that she had and the
four or five millimeters of
shortening that she had.
So there you have it.
>> So, insert's in place.
Liner's in place.
Now he's got to sew her back
together again.
>> Okay, let's get a final
x-ray.
Step.
Looks good.
Okay, so here's our layers.
Our implant's in.
I just approximated the capsule.
I put the tranexamic acid in,
which is going to help us with
blood loss post-op.
Here's our tensor muscle.
Here's our rectus inside here,
and that's how we got into the
joint.
You can see past the capsule our
hip joint, ball and socket.
You know, the beauty of this
anterior hip, one of the real
benefits, the muscles that help
us abduct the leg, flex and
rotator completely intact.
So what'd you think?
>> Amazing.
>> There's a lot of work
involved.
>> Yeah.
>> Most of our patients have
really woken up very comfortable
and been able to start walking
in just a couple hours.
>> Jeez, that doesn't seem
possible.
It doesn't.
>> Take one of your hands,
Katie, and push off from the
bed.
Okay, and come on up.
Okay, you want to be looking up
and out.
But this is very typical of what
we see after an anterior
approach.
>> Unbelievable.
>> Keep breathing, okay?
Want to get up a notch?
>> Wow.
>> Okay, I'm going to follow
your lead.
>> Okay.
>> Does it feel any different
since he adjusted the length a
little bit?
Can you tell?
>> I feel like a new person.
Let's just put it that way.
>> Perfect.
I still can't believe, after
seeing how intensive a surgery
that is, that these patients
seem to experience very little
pain.
>> You know, it surprises me
too, Jim.
I think a lot of it has to do
with the approach, spreading the
muscles, the way we get into the
joint.
But, you know, she isn't really
requiring a lot of narcotic
medication, and that's pretty
much typical for the anterior
hip replacement patients that I
have.
I would say almost half go home
just relying on Tylenol.
And that's usually the first or
second day after surgery.
About 50 percent of patients, of
my patients, leave the day after
surgery, and the remainder
usually leave the second day.
>> Amazing.
So it's been three weeks since
Katie's surgery now.
How is she doing?
>> Well, I actually saw her at
13 days.
And like most patients, she's
doing very well.
She actually came in using just
a cane.
Katherine, nice to see you.
>> Good to see you, too.
>> So two weeks tomorrow.
>> Yes, sir.
>> I want to bring it up here
and put it like that.
>> I haven't done that
forever.
>> What's that?
>> I can't remember the last
time I did that.
>> Pretty good, isn't it?
So take some steps with the
cane.
It's just a little bit of an
added kind of support for you.
>> It just kind of adds a little
bit more security.
>> Yeah, but when it starts
getting in your way, that's when
I think it's time to get rid of
it.
Let me see.
>> It's at the right height?
>> Yeah, so take a couple more
steps without the cane.
Great. All right.
>> Okay?
>> You happy?
>> I'm happy.
>> Wow.
So how long typically for total
recovery?
>> Well, that depends on the
patient, but typically patients
do pretty well by two weeks,
walking with a cane.
The implant isn't going to
completely lock into the bone
for probably about six weeks.
After that, patients can advance
as tolerated.
Patients are usually hitting
golf balls by six weeks,
starting to hike six, eight
weeks, maybe three months.
My goal and my hope is that by
six months patients come back
and say, you know, I really
don't even know I have a hip
replacement.
And that's been happening, and
it's a really good feeling for
the patient and also for the
surgeon.
>> And hopefully they won't have
to do it again.
You were saying these can last
30, 40 years?
>> Well, that's the bearing
surface.
And that all depends on how long
our bearing surfaces are going
to last.
We were excited about metal on
metal, but there are some things
that are -- that have come to
light that are concerning.
So I think most surgeons are
going back to metal or ceramic
on polyethylene.
And the polyethylene has been
greatly improved over the last
10 years in terms of the
manufacturing and the
sterilization.
And so if you have the
appropriate thickness of
polyethylene and the patient
doesn't overdo it to the point
of maybe marathons, we should be
getting 30 to 40 years of solid
use out of our current implants.
>> Okay, we talked about some of
the variables of the equipment.
What about of the patients
themselves?
Is the surgery more -- is it
easier for people that are light
or heavy, tall or short, young
or old?
>> If a patient's mental
attitude is good, that's the
best.
Now, are there certain physical
challenges that a surgeon has to
deal with?
Of course.
Because we're not cutting any
muscle and we're spreading two
muscles, big, muscular guys are
a little bit more difficult.
But I've done patients up to
6'7", 6'8", 300 pounds.
But probably a patient like
Katie, a petite female, those
are the easier ones.
>> We talked about some of the
upsides, being able to do
physical activity that you
haven't been able to do for
years.
What are some of the risks
involved?
>> Well, it's surgery.
So anytime you're undergoing an
operation, there are risks.
And I just think that there's
nothing minimal about a total
hip replacement when it's yours.
I mean, putting something like
this in the body, it's not a
minimal thing.
I have my mentor in total hip
replacement, Dr. David
Hungerford from Johns Hopkins,
was asked about minimally
invasive surgery, and he
referenced Webster's dictionary
under the term of "minimal," the
definition of minimal.
There are two definitions: one,
"barely adequate," and "least
necessary."
So we don't want to do barely
adequate, we want to do the
least necessary.
And again, minimally invasive
sort of applied to the length of
the skin incision, and that
really is not the important
feature in all surgery, it's
what's done underneath the skin.
>> You know, I've heard some
surgeons talk about the anterior
approach and reticent to try it,
because apparently if things go
wrong, it's harder to bail out
of?
>> That's true.
I think that's why you really
need the experience going into
the anterior approach before you
try it.
I think the concern is that,
what we talk about is being able
to extend the exposure.
Any time you have a problem in
particularly hip replacement
surgery, it's usually a fracture
or -- well, typically a
fracture.
You want to be able to expose
the femur to fix the fracture.
Well, it definitely is more
difficult to get that kind of
extensile exposure when you're
doing anterior, because
remember, we're spreading
muscle.
We're not cutting anything off
the back of the femur.
So that's the difference.
Because we're spreading, we're
limited by how far we can
spread, as opposed to let's say
a posterior approach, where if
you got into trouble down lower
in the shaft, you could extend
the incision down by taking down
more of the muscle.
>> I understand that some people
use the anterior approach, but
they don't use the orthopedic
table.
Why is that?
>> That's true.
It can be done without the
table.
I prefer using the table because
when you don't use the table,
you have to do a lot of leg
rotation to put the femoral
component in.
When you use the table, as you
saw, the leg goes straight up
and down.
But certainly -- it's certainly
an excellent way to do a hip
replacement.
Certainly allows for the same
type of non-muscle cutting.
You're still spreading the two
muscles to get in from the
front, you're just not using the
table.
But I prefer the use of the
table and the use of
intraoperative x-ray to confirm
the component positioning.
>> What about a surgeon who
might say the table's too
expensive?
>> Well, the table I think is
about $80,000.
And you have to use some type of
table.
So the added expense, I think
it's justified with the results
we're getting.
In fact, my hospital just told
me they're buying a second one.
So obviously cost containment is
very important.
My length of stay has been cut
in half.
Half the people are leaving the
first -- half the patients are
leaving the first day, and then
everybody's leaving the second
day.
Avoiding dislocation, avoiding
problems with leg lengths,
faster return to work.
When you look at the big
picture, I think if you can have
an approach that cuts back on
that aspect of expenditures and
then has some inherent
expenditures in it, I think it's
probably worthwhile.
I think in the end you'd see
that it's probably cheaper.
>> One of the advantages of the
anterior over the posterior is
less chance of dislocation, but
some surgeons who defend the
posterior approach say that that
improvement or reduction of
dislocations is primarily due to
the larger head, as you had
talked about a little earlier.
Is that the case?
>> I wouldn't disagree with
that.
I have had dislocations with the
anterior approach.
Not many: less than 1%.
And I do try to use as large a
femoral head ball as possible,
but of course I want to keep the
polyethylene as thick as I can
as well.
I would say, though -- I would
say, however, that the
precautions are less with the
anterior.
So patients undergoing posterior
approach still have to be
careful with the flexion
position and any kind of
rotation.
As you can see, at two weeks
after our anterior hip, I was
able to have Kathy cross her
legs.
And she never really had a
pillow between her legs.
She didn't use a special toilet
seat.
So there's just an inherent
stability to the anterior
approach that the posterior
approach doesn't have.
You can do a great posterior
approach, have everything in the
right position, and you'll still
have -- you can still have a
dislocation.
I don't think that's the case
for the anterior.
>> So still about 70 percent of
these total hip replacement
surgeries are done from the
posterior approach.
You kind of wonder why isn't the
anterior catching on a little
faster?
Is it mostly because of the
difficulty of training the
surgeons?
>> Well, you know, I --
Dr. Robert Gorab, who was
instrumental in my getting
exposed to the anterior
approach -- he's a great surgeon
in Orange County -- told me that
about 25% of the hip
replacements -- this is pretty
recent, the other day -- about
25% of the hip replacements
in the United States
are being done with an
anterior approach, but it's
being done by about, well, less
than 20% of the surgeons.
So there's no question that the
anterior approach is gaining in
popularity.
And it's patient-driven.
I think that there will always
be a role for all different
kinds of ways of getting into
the hip joint.
I think the posterior approach
is going to be here for a long
time and the anterior approach
is going to be here for a long
time.
The lateral approach, where the
muscle gets taken down, I think
that's less and less -- in less
and less popularity all the
time.
But between a posterior approach
and anterior approach, I think
those are two great ways to do
hip replacements.
And if a surgeon's motivated and
has an interest in looking at
that as an option, it takes an
effort, making the effort to go
to a course or making the effort
to visit a surgery center that's
designated as a teaching center
for the anterior approach.
>> What about surgeons who cling
to the posterior approach and
say that there's no randomized
studies to prove that the
anterior is either better or
quicker or a more complete
recovery?
>> Well, I think that the
anterior approach has been
gaining popularity, and probably
in the next few years or 10
years there will probably be
some good literature comparing
both approaches.
But I would say that I think the
most important thing is for the
surgeon to feel comfortable with
taking care of the patient.
You know, things always change.
We're hopefully constantly
getting better at surgery and
taking care of patients.
Twenty-five years ago or so, Dr.
Anthony Headley did the total
hip replacement video, and he
used a cementless implant,
cementless stem and a cementless
cup.
Now, that was not the gold
standard back then.
Today it is.
So I'm hoping we're not going to
do hip replacements the same way
in 25 years.
I hope we're going to be doing
something different.
But for now this is a really
good way of doing a hip
replacement, as you can see in
this recovery.
And this recovery of Katie, that
wasn't a staged kind of thing.
That's a typical recovery.
I mean, out of the five we did
while you guys were in my
operating room, three of them
left the next day, two of them
left on day two.
I'm not recommending the
anterior approach as the end-all
way for all surgeons to do hip
replacements.
I did thousands of hip
replacements in a posterior
approach, and patients are doing
fantastic.
And I think that you can't
criticize surgeons who want to
continue to do a posterior
approach because it is
time-tested and it is -- in some
hospitals where you don't have
the table, you don't have the
choice.
Patients come to me and they
say, "Well, should I have the
anterior approach, should I have
the posterior approach?"
You know, this is what I find is
the best way for me to do a hip
replacement.
Personally, it's the way I would
have my hip replacement done.
But my advice to them is find a
surgeon that you trust that has
done maybe surgery on your
friends or a relative, and do
what they think is best for you.
Because that in the end is the
most important, surgeon comfort
level and the patient comfort
level.
>> One last question, Dr.
Firestone.
What makes a hip replacement
surgery a good hip replacement
surgery?
>> I think the end-all result
when the patient comes back at,
let's say, an arbitrary number
of six months and says, "Doctor,
I don't even know I have a hip
replacement in," I think that's
probably when you know that's a
really good hip replacement.
How you get there, there's a lot
of different ways to do it, as
we talked about.
But I would say, if you ask me
what a good hip replacement is,
it would be that.
>> Dr. Ted Firestone, thank you
very much for your time, your
expertise, your invitation, and
your great surgery in the O.R.
>> Thank you, Jim.
>> Thank you, sir.
We hope you enjoyed the program.
If you'd like to learn more
about anterior total hip
replacement, see bonus material,
or obtain additional educational
information, please visit us
online.
For The Latest Procedure, I'm
Jim Cissell.
We'll see you next time.
>> Major funding for The Latest
 Procedure: Anterior Total Hip
 Replacement Surgery, was
provided by...
The Parsons Foundation: proud to
support PBS and health education
programming.
The Parsons Foundation inspires
hope by providing critical
funding at critical times to
communities striving to make a
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And by these generous
contributors...
And by the friends of Eight.
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