Minimally Invasive Surgery for Complete Hip Arthroplasty Using the Anterior Approach

Gates Chili High School

February 23, 2009

The ilium, ischium, and pubis make up the hip bone. The acetabulum is the socket in the hip bone where the head of the femur, also known as the femoral head, fits and makes a ball-andsocket joint. This ball-and-socket joint creates a large range of motion and a great deal of strength, when the joint functions correctly. Rheumatoid arthritis, injury, bone tumors, and vascular necrosis of the femoral head are many of the causes for the need of a hip replacement, also known as complete hip arthroplasty, but the most common cause is degenerative arthritis. Degenerative arthritis, also known as osteoarthritis, is the slow breakdown of cartilage in one or more joints which is usually caused by age. Cartilage is a dense, rubbery material that is located in the joints to ease friction and absorb any type of shock to the joint. Osteoarthritis can occur in almost any joint, but it typically occurs in the weight bearing joints like the spine, knees, and of course, the hip. The traditional method for hip surgery requires a 10 14 inch incision and necessitates that the surgeon either cut or detach important muscles supporting the hip to expose the joint. After exposing the joint, a saw is used to cut off the femoral head and a drill is used to create a cavity in the femur where a prosthetic stem attached to a ball is inserted. This prosthesis is usually made from a type of metal and is used to replace the femoral head. The stem is typically held in place by plastic bone cement. Some of the metals that are used to make the prosthetic stem and ball are stainless steel, alloys of cobalt and chrome, and titanium. Then a reamer is used to cut out a space in the pelvis for the prosthetic socket, which is typically made of polyethylene. The prosthetic ball fits into the new socket and recreates a ball-and-socket joint. Hospital stay after surgery is a week or less and complete recovery takes three to six months. As a result of damaging many muscles, there is short term surgical pain. Minimally Invasive Surgery or MIS is a term used to describe any type of surgery that uses fewer or smaller incisions to do the operation. These changes make the surgery less painful

with less recovery time and less overall cost. When using MIS for hip arthroplasty either one or two 2 4 inch incisions are used resulting in only two to three days in the hospital, less pain medication, a likely chance of less blood loss and fewer blood transfusions, and a shorter recovery time and rehabilitation period. There are a couple different types of MIS procedures being used quite frequently in place of traditional hip replacement methods, but even newer and more advanced methods are being perfected. One new MIS technique known as the anterior approach has been developed recently. The anterior approach uses a natural interval between muscles located in the inner thigh as opposed to the back or outer thigh to replace the damaged joint. This gap in the muscle groups supporting the hip allows the procedure to commence without detaching or damaging any muscles or tendons. With this new method, patients can expect to walk after only two days and be back to work in ten. The Anterior Approach for Total Hip Arthroplasty is a very complicated surgery and is very difficult to perform. It takes a very talented and experienced surgeon to perform an operation like this, and Dr. Michael Klotz is one such doctor. He is the only surgeon in the Rochester area that performs the anterior approach for complete hip arthroplasty. Dr. Klotz has only just begun performing this method of hip replacement in December of 2008. Previously, he worked at Highland Hospital, but recently he left Highland to become the director of the joint replacement group at Unity Hospital. The reason the anterior approach is not practiced by many surgeons is that it is a very difficult method to teach. The main challenge is that there is only one angle from which the surgeon is able to see the joint. Also, since it is such a demanding procedure, the surgeons being educated on the technique usually are performing fifty or more hip replacements annually.

Unity Hospital had to purchase a new type of operating table called a Hana Hip and Knee Arthroplasty Table to enable Dr. Klotz to perform this surgery properly. In contrast with other operating tables, the Hana table has two separate supports for each leg and has the patient positioned on his or her back, instead of one large platform where the patient lays on his or her side. These supports are able to lower the leg which helps push the hip up and out making it easier for the surgeon to reach the joint without damaging muscles. It also facilitates the possibility of replacing both the right and left hip in one surgery, because the patient is not lying on his or her side, blocking the other hip. After surgery the patient has to rest for a day, and soon begin therapy to help the joint heal correctly. Physical rehabilitation at Unity Hospital's Joint Replacement Unit is performed in a group format, instead of being coached individually. Patients in the group are at different stages of rehabilitation and they are able to see how other patients, who are further along in the recovery process, are healing. By seeing other patients improve, it can relieve some of their own fears. They can be encouraged by others who are going through a similar experience. Disorders in the hip, such as osteoarthritis, can cause discomfort and pain and may even require hip replacement that hinders your ability to work while in recovery. Minimally Invasive Surgery for complete hip arthroplasty is able to drastically reduce the time in the hospital after surgery and the time away from work and daily activities. MIS is a less expensive option for hip replacement and with the addition of new technologies, like the Hana table, and new techniques, like the Anterior Approach, a serious surgery can be turned into a much more comfortable experience.

Work cited: "Joint replacement, hip." American Medical Association complete medical encyclopedia, 2003 ed. Hill, James A. "Hip." World Book Encyclopedia, 2008 ed. 2005, Global Consumer Awareness of Joint Replacement Options, Minimally Invasive Hip Replacement, http://www.bonesmart.org/pdf/MIS_Hip.pdf (February 11, 2009)

DePuy Orthopedics, Inc., 2009, Anterior Approach Surgery, http://www.hipreplacement.com/DePuy/about/about_surgery/anterior_surgery/index.html (February 11, 2009) NYU Langone Medical Center, 2008, Surgical Table Facilitates Minimally Invasive Hip Replacement Surgery, http://communications.med.nyu.edu/news/2008/surgical-table-facilitates-minimally-invasivehip-replacement-surgery (February 11, 2009)