PPH offers new form of total hip replacement

By: BRADLEY J. FIKES - Staff Writer | Sunday, September 10, 2006 8:36 AM PDT ∞

On the morning of Monday, Aug. 28, Jeff Rogers was taken to the operating room of Palomar Medical Center. For the next few hours, a surgical team led by Dr. Thomas Knutson removed Rogers' right hip joint and implanted a prosthetic replacement.
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By Tuesday morning, Rogers was able to walk with crutches. On Wednesday, he was released from the hospital, subject to checkups from a physical therapist.

By Friday Rogers said he was recovering nicely, with postoperative pain under control and diminishing, able to handle his own needs in his East Escondido condominium.

"I was pleasantly surprised after the surgery," Rogers said that Friday, his voice sounding strong and cheerful.

Rogers had reason for cheer. A few weeks of relative inactivity struck him as a good bargain to be free of pain. After his recuperation, Rogers can resume a near-normal life, including driving and his maintenance job at the Redwood Terraces senior housing community in Escondido.

"It's shocking how much weight I can put on it already," Rogers said.

Feeling the pain


Rogers is typical of many patients seeking hip surgery. He has osteoarthritis, a degenerative form of arthritis. The disease wears down the protective cartilage that allows smooth movement of the hip joint. That joint consists of the ball-shaped upper end of the femur, the thigh bone, which rotates in a socket formed by the pelvis.

The hip joint bears a lot of weight, and its cartilage wears away with increasing age. Weight is also a factor; obese people put more of a strain on the joint.

Rogers, who turns 52 on Sept. 20, had been active as a construction worker, a job which requires a lot of walking. As the years advanced, he started feeling pain that kept on getting worse.

"There was no cushion left in the joint. It was bone on bone contact," Rogers said. "I was taking four Vicodins a day to control the pain so I could work."

Rogers heard of Knutson and the minimally invasive hip replacement through a referral from health care professionals at Redwood Terraces.

Busy doctor


Hip joint replacements used to be much more difficult and extensive, requiring months of rehabilitation. But Rogers was lucky: He found in Knutson a physician skilled in a less invasive hip joint replacement that allows patients to begin moving on their own almost immediately.

Although the procedure was first done decades ago, it has continually improved. Few surgeons are trained to perform this minimally invasive procedure. Dr. Knutson is training more doctors throughout Southern California.

When he's not training doctors, Knutson is busy with his own patients. That leaves him with litlle time for anything else: A scheduled interview for this article had to be cancelled when Knutson was unexpectedly called in.

Advanced technology


Hip joint replacement has traditionally been carried out through incisions made into the side or back of the hip. That approach required cutting of several important muscles; the gluteus minimus and medius, along with the more familiar gluteus maximus (the major muscle in the buttocks) and the tensor fascia lata muscles. The latter two connect through an attachment called the fascia lata/iliotibial band, forming what's called the "deltoid of the hip."

By keeping these muscles and attachments intact, recovery is speeded, wrote Dr. Joel M. Matta, chair of orthopedic surgery at Good Samaritan Hospital in Los Angeles.

"My own concept of minimally invasive is that it is more important what we do under the skin than the specific length of the incision. Stretching, contusing and abrading tissue is not what I call minimally invasive," Matta wrote in the article, online at (www.newhipnews.com/physician/surgical.html). "The main advantage of this approach is that it is not necessary to detach or split any muscle from the pelvis or the femur and the "hip deltoid" is not disturbed. The result is that there is an immediate stability of the hip that obviates the need for dislocation precautions. Also, there is a rapid recovery of function."

Whatever the approach taken, total hip joint replacements create an entirely new area of contact between the ball of the femur and the pelvis. A metal cup with a liner of plastic, metal or ceramic is fitted into the pelvis. The femur's upper end is sawed off and the prosthetic ball joint is hammered into place.

The operation


It took about an hour from the start of the operation to the actual implantation. When a North County Times reporter and photographer entered (in medical gown, cap and foot coverings), Rogers was already anesthetized unconscious on the table. Rows of medical devices, instruments and computers filled much of the room.

In the back, a stand held a large metal plate reaching more than six feet off the ground. That was for use during a mid-operation X-ray. People who didn't choose to wear protective aprons could retreat behind the plate until the X-ray was done.

Trays, gowns and tables were color-coded: Blue and green signified sterile surfaces. A high-pitched beep signaled Rogers' heart rate, which varied slightly during the operation.

Knutson opened an incision in front of the right hip, which he gradually widened. An assistant suctioned away the blood that occasionally flowed. He cleared space for the implant with instruments such as a whirring cylindrical tool that resembles an elongated cheese grater. The operation made a fair amount of noise at times, sounding more like a carpentry project than the delicate surgery it actually is.

Road to recovery


Reached Tuesday to check up on his progress, Rogers sounded even more cheerful than Friday.

"There's very little pain left, hardly any," Rogers said. "The only time I take it is at night before I go to sleep."

And Rogers passed a minor milestone of sorts Tuesday: He left his condo to take out the trash.

"I'm feeling better and better about the whole thing," he said. "I was sort of panicking right before surgery, having second thoughts about the whole thing. But I'm really glad I went ahead with it."

Contact staff writer Bradley J. Fikes at bfikes@nctimes.com or (760) 739-6641.

Minimally invasive total hip joint replacement


Performed at: Palomar Medical Center

Performed by: Thomas Knutson, M.D.

Total hip joint replacement is recommended for patients who have major pain from a damaged hip joint who can't get relief in other ways. The new joint is less sturdy than the natural healthy joint, therefore patients will be advised against strenuous activities that put stress on the joint. For this reason, this surgery is more often performed in older patients, who are not likely to be as active as younger people. The new joint eventually needs additional surgery, but that can take as long as 20 years.

Within these limits, hip joint replacement surgery usually delivers "excellent" results, according to an article by Medline Plus, a project of the U.S. National Library of Medicine and the National Institutes of Health. More than 80 percent of patients can walk unaided after the operation, according to the article.

"Be careful after surgery that you don't dislocate the prosthesis," states the article. "The new hip will not have the same range of movement of the original joint, although you should eventually be able to return to your previous level of activity. While you should avoid vigorous sports such skiing, or contact sports, many people go on to play tennis and golf quite successfully. The article is available at: (http://www.nlm.nih.gov/medlineplus/ency/article/002975.htm).