- The Washington Times - Monday, February 28, 2005

As recently as three months ago, Paul Maas wouldn’t step off a curb with his right leg for fear his damaged right hip might give way.

Today, the 68-year-old Bel Air, Md., man walks as much as possible without giving a second thought to which foot lands first.

Mr. Maas underwent a new brand of hip-joint replacement surgery in December that requires far less tissue trauma than conventional hip procedures. Doctors make two small incisions — each 1 to 2 inches long — to insert the metal ball and hip joint that will replace the damaged bone and cartilage.

A standard hip replacement may involve making incisions from 6 to 10 inches long and slicing muscles to help doctors visualize the surgery.

Less invasive methods mean less time in the hospital and a speedier return to active living. A patient undergoing standard hip-replacement surgery might stay in the hospital up to 15 days. Now, a hospital stay of just a day or two is often the case. The newer surgery also results in less pain and more freedom for the patient, leaves smaller scars and causes less blood loss than previous methods.

The new operating method, which was first used in 2001 and is spreading across the country in several variations, still represents the minority of hip-replacement procedures. Doctors caution that the technique requires specific, intensive training for surgeons who likely have plenty on their plate as it is, and not every patient is a good fit for the surgery.

Mr. Maas reports that he could barely walk in the months leading up to his December surgery. He had suffered with a debilitating hip condition for more than two years but says it took just two hours to set the joint right.

He needed 10 days of physical therapy, but after eight weeks, he declares himself “more normal” than he has been in some time.

“I’m ecstatic about it,” he says. “The only inconvenience is that you can’t drive a car for two or three weeks [after the surgery].”

The surgical process might sound like a brand of arthroscopy at first, with its modest incisions and lack of major tissue trauma, but arthroscopic surgery is performed with the aid of a tiny camera. The hip-replacement technique requires a fluoroscope, which uses X-ray beams to help illuminate the surgical site for the doctor. This visual aid also helps with vascular surgeries.

Dr. Albert J. Folgueras, an orthopedic surgeon at Mercy Hospital in Baltimore who uses the Zimmer MIS two-incision hip-replacement surgery, one of several new methods to replace hips with minimal tissue trauma, says miniature cameras won’t work for the surgery because doctors need “a slightly bigger panoramic view” of the surrounding tissue.

Hip-replacement surgery has involved four key concerns for the past 30 or so years, Dr. Folgueras says. Researchers worried about infection, the rate of dislocation for the new hip, the artificial hip’s durability and implant failures. Now, as doctors are growing comfortable coping with each of these issues, they’re able to consider an improvement to the overall process as is done with the minimally invasive approach, he says.

The procedure isn’t for everyone suffering from a degenerative hip condition. Patients who are obese or have abnormally sized bones may not be eligible. The operation also isn’t suited for patients who have had prior hip surgery.

“I still do a lot of open hip surgeries,” Dr. Folgueras says.

The minimally invasive movement proved a hot topic for physicians gathered for the 72nd annual meeting of the nonprofit American Academy of Orthopaedic Surgeons in the District last week. The doctors generally reported that processes like the minimally invasive hip surgery technique are routinely requested by orthopedic surgery patients.

Dr. Thomas S. Thornhill, professor of orthopedics at Harvard Medical School, says there’s no doubt more and more surgeries will be performed using less invasive methods.

The difficulties lie in both in how the technique is taught and how the results are measured, Dr. Thornhill says. Medical cynics also must be appeased.

Whatever skepticism doctors may have about the process will be blunted as soon as more scientific evidence dents the industry’s peer-review publications, he says. Once that information rolls in, he says, doctors will embrace the technique in greater numbers, confident the transition isn’t chiefly concerned with reducing hospital stays.

The learning curve for the uninitiated surgeon also could be considerable. One pertinent question is what constitutes sufficient training in the technique.

“Is it a two- or three-day course? Is it [working in a] cadaver lab? Is it going to observe, then assisting in surgery?” Dr. Thornhill asks.

“Our residents train in a supervised fashion for five years. They learn a lot of techniques, then they specialize for a full year in an area of interest. It begs the question: What is sufficient training and recertification to assure competence?

“We don’t really have the non-biased peer-review studies that we will have to [have to] really know the position,” he says.

For Mr. Maas, the results so far speak for themselves.

Today’s hip replacements — made of either cobalt chromium or titanium alloys — can last up to 20 years without breaking down.

“That’ll be enough for me,” Mr. Maas says.

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