Cutting into recovery time
December 13, 2009

By Margot Sanger-Katz
Concord Monitor staff
Concord, New Hampshire
November 20, 2009  
"I couldn't really feel a thing," said Elaine Kelley, after her hip replacement surgery in October. Kelley received an unusual type of hip replacement in which the doctors cut through the front of the leg rather than the back or the side, reducing recovery time and muscle damage. Kelley elected to have a spinal epidural instead of anesthesia, and throughout the surgery, she chatted with the anesthesiologist.
It was only four hours after her surgeon had cut open her leg, sawed off the end of her femur, scraped out her hip socket and fitted it for an artificial replacement. But Elaine Kelley was walking.
Two nurses hovered at her sides as she navigated the hallways in Concord Hospital's orthopedic wing. They told her to walk more slowly and to lean on a walker. She complied, but only because they told her to.
"She's walking better than she did this morning," joked her husband, Barry Kelley.
Kelley, who suffers from severe arthritis due to an infection, has had more than her share of joint replacements in recent years. Her recent hip replacement was her second. She's also had knee and shoulder replacements.
This, she said, was the easiest surgery.

Her surgeon, Dr. Gary Jones, is one of three at Concord Orthopaedics who have begun using an unusual technique for replacing hips that they say is better for doctors and easier for patients. Instead of cutting through the back or the side of patients' legs, they
come in from the front - an approach that allows them to avoid cutting muscles and other tissues that help patients move and stabilize their hip joint.
"The fact is, they feel good, and they feel good faster," Jones said.
The anterior approach
Nationally, surgeons perform more than 120,000 hip replacements a year. The surgery is popular among patients, who generally rate it higher on measures of satisfaction and improved quality of life than any other surgery. For patients with severe arthritis, a creaky hip can make it difficult to get around. By replacing the worn parts of the joint with smooth artificial parts, surgeons are able to help people move more easily and with a lot less pain.
But though long-term satisfaction is high, recovery from a hip replacement can be rough. The two most common ways that doctors perform the surgery are by cutting open the back of the patient's leg - and slicing through muscles and ligaments - or entering the hip from the side - and severing different muscles.
That soft tissue can take months to heal, and patients often limp their way through a long recovery. Hip dislocations, especially during the first months, are also a concern with those procedures because connections that help stabilize the joint are severed.
The anterior approach Jones used in Kelley's surgery was designed to avoid many of those complications. Instead of cutting through soft tissue in the back or side of the hip, Jones made an incision on the front of Kelley's leg and stretched two muscles out of the way so he could access the hip joint itself without cutting any major supporting structures.
That approach means there's less tissue to heal after the surgery and all the muscles that hold the hip in place stay intact.
Anterior hip replacements have been around for a long time, but they've only recently caught on in the U.S. Jones and his colleagues Dr. Jeff Wiley and Dr. Stephen Fox learned the procedure from a California surgeon who trained in France, where the technique is common.
When Jones and Wiley started doing the surgery about 18 months ago, they were the only surgeons in New England who were doing it, they said. Now the procedure has started to catch on in the region. Surgeons in Manchester and at Dartmouth have ordered the special - and expensive - operating room table that makes the anterior approach possible by allowing surgeons to move patients' legs into a particular position. Jones and Wiley have expanded their practice from Concord Hospital and are now offering the technique to their patients at New London Hospital as well.
Jones said he thinks the procedure will continue to grow in popularity. "I think it's spreading," he said. "And I think it will become the most popular approach in the future."
Internal studies have shown that Concord Orthopaedics patients who have the new surgery tend to leave the hospital a day sooner than their patients did when they had the replacement done with older techniques. And Wiley said he sees a dramatic improvement in the speed of patients' recovery after surgery.
With the old surgery, only a handful of his patients would come in for four-week checkups without canes or walkers. Now, he said, it's the rare patient who comes to the office with a cane.
"It's just been a complete reversal," Wiley said.
Stephen Higgins, a New London painting contractor, has experienced the difference firsthand. When he had his first hip replaced in 2001, he hobbled around for nearly three months. He had his second hip done with the anterior surgery last year, and he said he was climbing stairs and doing laundry the day after he came home from the hospital.
"I was really so impressed," Higgins said. "I just took that walker and tossed it to the side. I said, 'This is in my way.' "
But though surgeons who prefer the technique love to sing its praises, many surgeons experienced in the older methods are skeptical about the new approach, especially since the old techniques work so well.
Dr. Stephen Kantor, the director of the division of joint replacement surgery at Dartmouth-Hithcock Medical Center, said he remembers a similar buzz about a new procedure eight years ago. A surgeon developed a "minimally invasive" hip replacement technique that was done through two small incisions. According to early studies, patients recovered much faster - and many surgeons switched over.
"Surgeons all over - well-intentioned surgeons wanting to perform the best possible treatment for their patients - pursued that surgery," Kantor said. "Then five years later, we started hearing about the complications."
Kantor said that from his review of current research, he's not yet convinced that the anterior approach is better than the tried-and-true surgical approaches.
"Are we going to mess with something that's already spectacular?" he asked. "We run the risk of actually hurting patients."
But Jones said he's not worried about long-term complications with the anterior approach. He was never persuaded that he could do high-quality replacements using the "minimally invasive" procedure, and he never tried it. But anterior hip replacement is different, he said.
"This is not a compromise," he said.
Both Jones and Wiley said since learning the new technique, they can think of just a handful of cases where they've chosen to replace a hip the old way.
Keep on moving

During her surgery, Kelley stayed awake and chatted with a nurse while Jones sawed, drilled and hammered at her hip from behind a surgical drape. Her feet were secured in ski boot-like braces that allowed the surgical team to manipulate her leg. The entire operation took just over an hour.
That night, as she was roaming the halls and cracking jokes with her husband and two of her adult children, she looked pale and she admitted she was sore. But within two days, she was ready for the long drive home to Berlin.
Kelley, who likes to keep moving, has been chastised for "overdoing it" after each of her previous surgeries. She came home after her operation and was instantly cooking, cleaning and climbing into a bathtub - though some too-busy days meant nights lying on the couch under an ice pack.
Kelley said she remembers countless restrictions when she had her first hip replaced. When she left the hospital, she took home a lift for her toilet seat and a special tool to help her put on socks without bending over. For several months, she avoided bending her hip by more than 90 degrees to reduce the risk of it popping out of place.
When she went home after her recent surgery, she had virtually no restrictions.
"It makes it so much more pleasant," she said, about a week after her surgery. "It's less worrisome because I don't have to worry about doing something wrong that's going to hurt me, or that I'm going to move the wrong way and put the joint in jeopardy."
Last week, about a month out, Kelley said it's her knee that gets sore when she gets too ambitious.
"I always do it," she said. "That's just my style."


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