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Hip surgery moves to outpatient arena
Shorter recovery with minimally invasive approach
Those actual cases from Rush University Medical Center in Chicago compare with a four- to five-day hospital stay for traditional hip replacement surgery.
"We’re measuring recovery in terms of days, rather than weeks or months," says Richard A. Berger, MD, orthopedic surgeon and assistant professor of orthopedics at Rush.
Approximately 300,000 hip surgeries are performed annually, and it is projected that as many of 600,000 hip replacement will be performed every year by 2015.1
Berger says that 80% of hip replacement patients are eligible for this procedure, which involves two small incisions. The procedure has not been attempted on the morbidly obese.
The minimally invasive two-incision total hip arthroplasty technique uses one incision for preparation and insertion of the acetabular component and the other for preparation and insertion of the femoral component.
"Unique instruments have been developed to aid in this technique," Berger adds. "Fluoroscopy aids in many steps in this procedure to ensure the proper placement for the incisions and accurate component positioning and alignment."
He performed minimally invasive hip surgery on 85 patients in 2003, and he says that 100% of the patients left the facility the same day. In an initial study of 120 patients, 93% left the same day, and the other 7% left the following day.2 The same-day discharges included a 76-year-old patient.
Data from the initial group show a low complication rate and no readmission from the group. Patients ranged in age from 29 to 76. The average age of the last 100 consecutive patients undergoing this procedure at Rush is virtually identical to that of patients at Rush undergoing traditional total hip replacement, 55 years old vs. 56 years old, Berger explains.
"We have done older patients up to 80 years old and patients with major medical problems," he points out. "They have also gone home the same day."
Berger says there are multiple benefits to the minimally invasive procedure. For example, no muscles or tendons are cut as part of the exposure, he says. "This allows the surgery to be performed without tissue trauma," he adds. "Therefore, it results in less pain and a much quicker recovery."
He acknowledges that the procedure takes about 20-30 minutes longer than the traditional procedure and is technically difficult, "but with proper training, it can be performed well with a low complication rate, lower than traditional surgery, and patients truly recover remarkably quicker."
The procedure requires specialized training that is offered at only a few places around the country, Berger says. In addition, specialized instruments are required.
Because the procedure has not been performed on morbidly obese patients, proponents of the minimally invasive approach recommend patients have a body mass index (BMI) of less than 30 for the procedure.3
Although proponents are enthusiastic about the procedure and its potential, some surgeons are taking a more skeptical approach.
"All of us hope that people can get back to normal as soon as possible after a joint replacement," says John J. Callaghan, MD, Lawrence and Marilyn Dorr chair and professor in the Depart-ment of Orthopedic Surgery at The University of Iowa Hospitals and Clinics in Iowa City. "How-ever, if this has any effect on the long-term outcome of this procedure, it wouldn’t be worth it."
Potential issues include infection, death from pulmonary embolism, higher rates of early revision, and dislocation, Callaghan says. He also raises concerns about the patients’ ages. "The problem is that two-thirds of patients who need hip replacement are elderly patients who have other medical problems and other social issues, including some who may live alone or only having other elders who can help take care of them," he says.
Callaghan is more pessimistic about the growth potential for this procedure than others such as Berger. "Five to 10 years from now, I can envision 10% to 15% of people having some sort of so-called minimally invasive [hip] surgery," he says.
Callaghan compares the push for minimally invasive hip surgery to the movement to perform carpal tunnel surgery endoscopically. Currently, only 5% to 10% of surgeons perform the procedure with the endoscopic approach, he says. With minimally invasive hip surgery, "I feel the data are not there yet for large numbers of patients and with large numbers of surgeons doing it," he says.
In a published article, Callaghan pointed out major complications following total hip replacement that require revision, including failure of fixation, instability, and infection.3 To minimize failure of fixation, implant bone interfaces must be optimally prepared, he wrote. To minimize dislocation, components need to be positioned optimally, bony impingement, including osteophytes removed, needs to be eliminated, and stability needs to be assessed, he pointed out. To minimize infection, tissue trauma and time of the operation need to be minimized, as does the time of operation, Callaghan wrote. "Small incisions do not address these problems, and they could potentially increase each of these problems, especially in the hands of the less skilled surgeon or the surgeon who is doing fewer procedures."
Berger contends the complication rate is lower than traditional total hip replacement. "I’ve had one small intraoperative fracture in the first 150 cases," he says. "There have been no readmissions, no dislocations, and no reoperations in this group."
To avoid medical liability issues, patients must understand there is a learning curve including potential for increased nerve palsy and component malposition, Callaghan wrote. "Legally, the surgeon should recognize he or she will be judged by the same standards as the surgeon using conventional incisions. It will be hard to defend a new norm, which allows for a higher complication rate." Patients may have extremely high expectations of the surgery and may not understand the complications well, he warned.
Still, many surgeons are attracted to the new procedure. About 100 surgeons have been trained, and about 20 to 25 are performing this surgery on a regular basis, according to Rush University Medical Center.
As more surgeons are trained, Berger predicts, "minimally invasive surgery is able to move from the academic setting into the community, so those who need the surgery have access to it across the country, not just at an academic medical center like Rush."4
1. Rush University Medical Center. Pioneering Hip Replace-ment Surgery Sends Patients Home the Day after the Operation — First Minimally Invasive Hip Replacement Surgery in the World Performed at Rush as Part of Research Study. Chicago; 2001.
2. Duwelius PJ, Berger RA, Hartzband MA, et al. Two-incision minimally invasive total hip arthroplasty: Operative technique and early results from four centers. J Bone Joint Surg 2003; 85:2,240-2,242.
3. Callaghan JJ. Skeptical perspectives on minimally invasive total hip arthroplasty. J Bone Joint Surg 2003; 85:2,242-2,243.
4. Rush University Medical Center. Study of Hip Replacement Patients Finds 80% Eligible for Minimally Invasive Surgery — 93% Leave Hospital Same Day; Even Seniors Can Have Outpatient Surgery. 2003; Chicago.
Source and Resource
For more information, contact:
• Richard A. Berger, MD, 1725 W. Harrison St., Suite 1063, Chicago, IL 60612. Phone: (312) 243-4244.
For information on the surgical procedure, go to www.zimmer.com. Click on "Medical Professional," "What’s New at Zimmer," and "MIS 2-Incision Hip Replacement Procedure.