The Latest Procedure multi-media project builds on Eight’s 30-Year anniversary of making television history with the first live broadcast of open heart surgery in 1983. Watch video of the pilot program, Anterior Total Hip Replacement Surgery, below.
JIM CISSELL: 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.
ANNOUNCER: 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.
JIM CISSEL: 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.
DR. TED FIRESTONE: Thanks, Jim.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
JIM CISSELL: And who needs this surgery: at what age, what severity?
DR. TED FIRESTONE: 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 mal-alignment 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.
JIM CISSELL: Now, traditionally this surgery has been done posteriorly. Can we talk a little bit about what's the advantage to the anterior approach?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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. Dr. Firestone.
DR. TED FIRESTONE: Hey, Jim, good to see you.
JIM CISSELL: You as well.
DR. TED FIRESTONE: Great timing, I was just looking at the x-ray of our next case.
JIM CISSELL: Okay.
DR. TED FIRESTONE: If you look at the x-ray, you can really tell the difference between the two, can't you?
JIM CISSELL: Yes, sir.
TF Here's the right hip. Pretty much normal. Ball and socket with cartilage in between.
JIM CISSELL: That left one, totally out of the socket.
DR. TED FIRESTONE: It really is.
JIM CISSELL: Look at the gap difference.
DR. TED FIRESTONE: 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.
JIM CISSELL: Yep.
DR. TED FIRESTONE: 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.
JIM CISSELL: Let's go.
DR. TED FIRESTONE: I want to show you some things about this specialized operating room that we use for a joint replacement procedure.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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?
JIM CISSELL: That's a pretty fancy table there.
DR. TED FIRESTONE: 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.
SEAN BRIMACOMBE: You have to unlock it here. This will drop the leg down.
JIM CISSELL: Mm-hmm.
DR. TED FIRESTONE: 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?
JIM CISSELL: Yes, sir.
DR. TED FIRESTONE: 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... with this saw.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: Okay? So after we have the cup in, then we have to do the femoral side.
JIM CISSELL: All right.
DR. TED FIRESTONE: 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.
JIM CISSELL: Wow.
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
DR. JOEL MATTA: 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.
JIM CISSELL: So the precision, consistency, and less tissue damage.
DR. TED FIRESTONE: 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.
JIM CISSELL: 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.
DR. TED FIRESTONE: Catherine, hi.
PATIENT: Good morning.
DR. TED FIRESTONE: Nice to see you.
PATIENT: Good to see you, too.
DR. TED FIRESTONE: Are you ready?
PATIENT: I'm ready.
DR. TED FIRESTONE: Okay, I want you to meet Jim.
PATIENT: Hi, Jim.
DR. TED FIRESTONE: She has a really bad hip.
JIM CISSELL: What happened? Injury, or just...?
DR. TED FIRESTONE: 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.
PATIENT: 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.
DR. TED FIRESTONE: 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.
PATIENT: I'm ready to change my life. I can't wait to get back to my life, let's put it that way.
DR. TED FIRESTONE: So let me mark the leg. I want to make sure we do the correct one. Which one are we doing?
PATIENT: Left side.
DR. TED FIRESTONE: Correct. You said you were walking with a walker right now?
PATIENT: Within the last... how many days, four days, five days? I was using a crutch for a couple days and limping pretty bad.
DR. TED FIRESTONE: All right, so I'll see you inside.
PATEINT: I'll see you inside.
DR. TED FIRESTONE: Great.
PATIENT: Thank you, nice to meet you.
JIM CISSELL: Good luck. You, too.
DR. TED FIRESTONE: 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.
JIM CISSELL: Yep.
DR. TED FIRESTONE: 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.
JIM CISSELL: Wow.
DR. TED FIRESTONE: 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.
JIM CISSELL: And the femoral -- the head is where you're replacing the ball, the lining?
DR. TED FIRESTONE: 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?
JIM CISSELL: Wow, yeah.
DR. TED FIRESTONE: It's a sign of inflammation. Well, you saw how badly she was hurting, right?
JIM CISSELL: Yeah. Using a walker at her age, that's amazing.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: Okay, saw? Okay, so here's an oscillating saw, battery powered.
DR. TED FIRESTONE: Bones bleed a lot more than people think.
JIM CISSELL: Yeah.
DR. TED FIRESTONE: 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.
JIM CISSELL: Oh, God. Oh, the head's loose.
DR. TED FIRESTONE: Okay, so I've taken this ring of bone out, femoral neck.
JIM CISSELL: Wow.
DR. TED FIRESTONE: 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.
JIM CISSELL: Yeah, there's a lot of movement there, yeah.
DR. TED FIRESTONE: 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 --
JIM CISSELL: And how's the surface of that one compared to an average one or a typical one? Is that all scarred up?
DR. TED FIRESTONE: Well, we never remove normal ones, but it would be like a cue ball, and that looked like...
JIM CISSELL: Lumpy.
DR. TED FIRESTONE: 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. 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. Pretty decent bone quality.
JIM CISSELL: That's a good thing, no?
DR. TED FIRESTONE: Yeah, very good.
JIM CISSELL: So what happens if you find the femur has got osteoporosis? Can you just not do it, or...?
DR. TED FIRESTONE: 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.
JIM CISSELL: That's a great view of the acetabulum.
DR. TED FIRESTONE: 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. 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.
JIM CISSELL: Last ream, right?
DR. TED FIRESTONE: 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.
JIM CISSELL: So that is just a press-fit?
DR. TED FIRESTONE: The ream's a 53, and this is a 54.
JIM CISSELL: Doesn't require screws or adhesive or anything, huh?
DR. TED FIRESTONE: 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?
JIM CISSELL: Yes, yes, sir.
DR. TED FIRESTONE: He's moving the whole pelvis.
JIM CISSELL: Yeah, I see, the whole body.
DR. TED FIRESTONE: 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.
JIM CISSELL: Yep.
DR. TED FIRESTONE: 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.
JIM CISSELL: There it comes.
DR. TED FIRESTONE: 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.
JIM CISSELL: This is the messy part.
DR. TED FIRESTONE: Keeps the bone with it. See that?
JIM CISSELL: Yeah.
DR. TED FIRESTONE: Now I'm going to identify the canal, canal finder. Okay. So that's going to be my angle of broaching. Okay.
JIM CISSELL: So it looks like you're almost at the outer perimeter of the head of the femur.
DR. TED FIRESTONE: 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.
JIM CISSELL: Oh, really?
DR. TED FIRESTONE: 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.
JIM CISSELL: Yeah? Good.
DR. TED FIRESTONE: Retract. Good. You have your shield on, right?
JIM CISSELL: Yeah, I do.
DR. TED FIRESTONE: Next size up is what?
DR. TED FIRESTONE: 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.
JIM CISSELL: Still allowing for a compression fitting on the final insert.
DR. TED FIRESTONE: Correct. You want a little advancement with every blow.
JIM CISSELL: Yep.
DR. TED FIRESTONE: 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.
JIM CISSELL: Plastic instead of ceramic.
DR. TED FIRESTONE: 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.
DR. TED FIRESTONE: How many millimeters less offset?
VOICE: Three millimeters.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: So those locking pegs are what holds it in the socket?
DR. TED FIRESTONE: Yeah, I don't know if you can see this on the monitor, how I'm trying to lever the liner out?
JIM CISSELL: Right.
DR. TED FIRESTONE: That's a very solid fit.
JIM CISSELL: Yeah.
DR. TED FIRESTONE: 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.
JIM CISSELL: Mainly because patients do better when you're done.
DR. TED FIRESTONE: Well, that was the number one.
JIM CISSELL: Yep. So this is the final one before the last insert?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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.
JIM CISSELL: Tested it and confirmed it with x-rays, Jim.
DR. TED FIRESTONE: Yep. To what precision are you placing it? I mean, half a millimeter?
DR. TED FIRESTONE: 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.
JIM CISSELL: Wow. And she had a leg that was shorter than the other, and you were going to try to adjust some for that?
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: Oh, really?
DR. TED FIRESTONE: Yeah.
JIM CISSELL: So that doesn't get pounded down flesh?
DR. TED FIRESTONE: Well, watch.
JIM CISSELL: Aha.
DR. TED FIRESTONE: 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.
JIM CISSELL: Okay.
DR. TED FIRESTONE: 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.
JIM CISSELL: A lot higher.
DR. TED FIRESTONE: 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.
JIM CISSELL: Sure.
DR. TED FIRESTONE: Okay, come on out with that.
JIM CISSELL: Oh, that's pretty.
DR. TED FIRESTONE: 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?
JIM CISSELL: Oh, yeah, yeah.
DR. TED FIRESTONE: Not coming out fully rotated.
JIM CISSELL: Right.
DR. TED FIRESTONE: 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.
JIM CISSELL: So, insert's in place. Liner's in place. Now he's got to sew her back together again.
DR. TED FIRESTONE: 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?
JIM CISSELL: Amazing.
DR. TED FIRESTONE: There's a lot of work involved.
JIM CISSELL: Yeah.
DR. TED FIRESTONE: Most of our patients have really woken up very comfortable and been able to start walking in just a couple hours.
JIM CISSELL: Jeez, that doesn't seem possible. It doesn't.
FEMALE STAFF PERSON: 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.
MALE STAFF PERSON: Unbelievable.
FEMALE STAFF PERSON: Keep breathing, okay? Want to get up a notch?
JIM CISSELL: Wow.
FEMALE STAFF PERSON: Okay, I'm going to follow your lead.
JIM CISSELL: Does it feel any different since he adjusted the length a little bit? Can you tell?
PATIENT: I feel like a new person. Let's just put it that way.
JIM CISSELL: Perfect. I still can't believe, after seeing how intensive a surgery that is, that these patients seem to experience very little pain.
DR. TED FIRESTONE: 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.
JIM CISSELL: Amazing. So it's been three weeks since Katie's surgery now. How is she doing?
DR. TED FIRESTONE: 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.
PATIENT: Good to see you, too.
DR. TED FIRESTONE: So two weeks tomorrow.
PATIENT: Yes, sir.
DR. TED FIRESTONE: I want to bring it up here and put it like that.
PATIENT: I haven't done that forever.
DR. TED FIRESTONE: What's that?
PATIENT: I can't remember the last time I did that.
DR. TED FIRESTONE: 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.
PATIENT: It just kind of adds a little bit more security.
DR. TED FIRESTONE: 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.
PATIENT: It's at the right height?
DR. TED FIRESTONE: Yeah, so take a couple more steps without the cane. Great. All right.
DR. TED FIRESTONE: You happy?
PATIENT: I'm happy.
JIM CISSELL: Wow. So how long typically for total recovery?
DR. TED FIRESTONE: 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.
JIM CISSELL: And hopefully they won't have to do it again. You were saying these can last 30, 40 years?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
JIM CISSELL: I understand that some people use the anterior approach, but they don't use the orthopedic table. Why is that?
DR. TED FIRESTONE: 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.
JIM CISSELL: What about a surgeon who might say the table's too expensive?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
JIM CISSELL: 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?
DR. TED FIRESTONE: 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.
DR. TED FIRESTONE: 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?
JIM CISSELL: 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.
JIM CISSELL: One last question, Dr. Firestone. What makes a hip replacement surgery a good hip replacement surgery?
DR. TED FIRESTONE: 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.
JIM CISSELL: Dr. Ted Firestone, thank you very much for your time, your expertise, your invitation, and your great surgery in the O.R.
DR. TED FIRESTONE: Thank you, Jim.
JIN CISSELL: 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.
VOICE: 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.
Dr. Edward Diethrich visited Eight and The Latest Procedure set during a break in filming. He shared thoughts about his experience and offered encouragement to the production team involved in the pilot.
Dr. Ted Firestone had the opportunity to talk with Dr. Joel Matta about the past, present and future of anterior hip replacement as a part of The Latest Procedure project. Dr. Matta is the physician credited with bringing the anterior hip replacement approach to the United States from France. He developed and has extensively taught his own way of performing the surgery, which is known as the Matta Technique.
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