From The Desk Of Clarence Bass
— Reprinted with permission from Clarence Bass – August 30, 2006
“With the new approach [to hip replacement], you’ll have so little pain you’ll forget to complain.” Judge Dan Sawyer, Shreveport, LA
“By hindsight, the traditional approach is almost barbaric.” Dina Roane, RN, Research Coordinator, Memorial Bone & Joint
Miracle in Houston
Walking on New Hip Day of Surgery
As I begin writing, my new hip has been in place for only 10 days. But what an amazing 10 days it has been. As the Blond Bomber, Dave Draper (27 & 60, Personalities) might say, I’m soaring high above the clouds in bright sunlight. Thanks to the marvelous new approach pioneered and perfected in this country by Los Angeles-based Joel Matta, MD, the mentor of my surgeon Swiss-born Stefan Kreuzer, MD, I’m more optimistic about the future than ever. I can’t wait any longer to begin telling you about it.
Carol and I flew into Houston Sunday afternoon, and I checked into Memorial Hermann Memorial City Hospital the next morning. I was taken into the operating room about 12:30, and my surgery was completed about 3:20 (longer than usual because of my musculature). I was out of recovery and in my room at approximately 6. By 9 that evening, the nurse had me out of bed and on my feet. I was able to put full weight on my new hip, with no pain. I then made a full lap around the orthopedic wing with the aid of a walker. I was a little uncomfortable and shaky, but nothing that could be called pain.
The next morning I was walking with a cane, again with some discomfort but no pain. A physical therapist had me do some exercises and showed me how to navigate stairs with a cane. He also gave me "A Patient's Guide to Rehab After Anterior Total Hip replacement." Later that morning, Dr. Kreuzer came by to see me. After we talked, at my request, he jotted a progressive week-by-week rehab plan on a paper towel. Knowing that I'm more eager than most patients, he added, "I won't be disappointed if you do less."
After lunch, Dr. Zoran Cupic, Kreuzer’s partner, who assisted in the surgery, came into the room, checked my incision, and asked if I wanted to go home. I did, of course. The nurse gave us some instructions on changing the dressing and a few other things.
I was released from the hospital at mid-afternoon, almost exactly 24 hours after completion of the surgery.
This was a little faster than usual, probably due to my physical condition (more on that below), but not much. The typical hospital stay after the new procedure is two to three days, according to Dr. Kreuzer's office.
Carol and I were back in our hotel room by dinner time.
On Wednesday, I practiced walking in the hallway with a cane. The next morning, Carol and I took a walk outside, with me still using the cane. That afternoon I went up and down the stairs in the hotel, again with aid of the cane.
On Friday morning, before my first post-op appointment, I walked without the cane for the first time. At the doctor’s office, I absent-mindedly left the cane in the X-ray room! The technician walked down the hall and returned it to me in the examining room, where Carol and I were waiting to see Dr. Cupic. Forgetting the cane was a good sign, they said. We thought so too. (According to Dr. Matta, the median time of first walking without an assistive device is eight days.)
I used a cane to walk through the airports, but needed no other assistance. Carol and I were home in Albuquerque on Friday evening. Our trip to have my hip replaced, round trip, took a few hours over five days.
New Replacement Procedure
I used a cane to walk in the street in front of our house on Saturday—but never used the cane again. (The median time when patients stop using an assistive devise, according to Matta, is 15 days.) On Sunday, six days after the surgery, I walked down and up the two flights of stairs in our house, without favoring my new hip or using the handrail. I did the stairs five times on Monday and 10 the following day. On Tuesday, I walked down and up the hill below our house.
I’m stiff, of course, and sore. It would be next to impossible to extract my old hip and put in a new one without inflicting some trauma. I am working with bruised and stretched muscles (not cut, as I will explain momentarily), and complete recovery will take time. In addition, the bones in my thigh and hip were cut and reamed, respectively, to accommodate my new hip. Dr. Kreuzer says “no lower-body weight training for six weeks,” to give the bone time to grow solidly around the new joint in the thigh (femur) and the hip socket (acetabulum). After that, I should be able to gradually resume my training virtually unimpaired. (See 6-week and 6-month follow-up reports below.)
The only word for the whole scenario is amazing.
Judge Dan Sawyer,* who told me about the new procedure, has had both hips replaced, first the old way and last year using the new approach. After his first hip, about two years ago using the traditional approach, Dan says he felt like a mummy and couldn’t turn over in bed without help for about eight days. With the new method, he went into the hospital on Thursday morning and was released about noon on Saturday—and he’s 78. (He’s a lifetime weight trainer and looks much younger.)
A newspaper article on Dr. Kreuzer’s website says after traditional surgery, where an 8- to 12-inch incision is made on the side or rear of the hip, some patients are barely able to walk using a walker two or three weeks later. Another article I read online says full recovery may take three to six months.
I’m not a doctor and don’t know all the technical details, but the basic difference is that the new approach goes in from the front and cuts no major muscles; it goes between them. The quads and glutes remain intact. Dr. Kreuzer gave me a brochure prepared by his office which says, “The hip is exposed by following a natural plane between muscles and without detachment of muscles or tendons from the bone.” There is almost no chance of dislocation, because the muscles are still working to stabilize the hip joint, just like before the operation. The technical name for the new procedure is “minimally invasive anterior approach.” According to Matta, a special table is the key to doing an anterior approach. The table and X-ray fluoroscope are used to position the leg to expose the hip joint, and then line up the new joint with the other hip and leg. (More about the new approach below.)
My Hip Problem and Rehab (New Input from Dr. Matta)
Frankly, I don’t know why my hip went bad. No one can say with certainty. Many factors were probably involved. Fifty-five years of steady training may have simply taken a toll on my hip. An unusual curvature of the spine inherited from my mother may have helped the process along. Doing the split snatch, with my right leg extended far to the rear, in my early years of Olympic lifting and later when a shoulder problem prevented me from using the squat style, probably contributed as well. On the other hand, many athletes have their hip or knee replaced decades earlier. For example, a front-page story in The Wall Street Journal, from the Winter Olympics in Turin, Italy, reported that 1996 U.S. figure skating champion Rudy Galindo had both hips replaced at age 33. It may be that my hip would've worn out earlier without training. Who knows?
My training was clearly a benefit when I needed a hip replacement. Lean, active people are the best candidates for the anterior approach (all approaches actually). Overweight people and those with brittle bones are more problematic. The procedure is not appropriate for deformed hips or when repairing an existing replacement, according to Dr. Kreuzer.
Excess fat makes it more difficult for the surgeon to see the operative field. Some or most of the procedure is done with specially designed, small surgical instruments under indirect vision on a TV monitor. “Active X-ray control is used to ensure correct position, sizing and fit of the artificial hip components,” explains the brochure given me by Dr. Kreuzer. “Side by side television monitors compare the X-ray image of the patient’s opposite hip to the operated hip.” A tiny camera and light source are typically inserted into the incision site. Visibility is one of the reasons why many surgeons steer clear of the procedure. Other reasons are the $150,000 cost of the special table, and the steep learning curve. To the best of my knowledge, no one in New Mexico, where we live, does the anterior approach taught by Dr. Matta. That’s likely to change--in New Mexico and elsewhere--as more patients become aware of the minimally invasive approach.
"It is true that patients who are obese or have fragile bone have at least slightly higher risk with anterior hip replacement," Dr. Matta told me in a personal communication, "but they are still candidates and I think anterior hip replacement is still their best choice." What's more, he suggests quite logically that "the obese unfit person" may actually be the most in need of the "rapid rehabilitation" afforded by the anterior approach.
Sounds like something to be decided by doctor and patient on a case-by-case basis.
In addition, Dr. Matta offers the slide presentation on his website (see below) as evidence that "visualization of the bone is actually very good" in small incision surgery using the anterior approach. (The incision averages four inches; mine is three inches.)
Another reason why the anterior approach is best suited for healthy people is the length of time under anesthesia. The fact that the surgery is not done under direct vision makes it take longer (1.2 hours average, according to Matta's website), which increases the risk, especially for people with health problems. It may be an exaggeration, but another article suggested that some doctors prefer the old way because they can do two or three replacements in the time it takes to do one the new way. “Why do two cases a day when you can do six?” said a Stanford University orthopedic surgeon, who has done 50 hips using the special table.
The time difference may not be as great as suggested. It probably varies from doctor to doctor and case to case. Dr. Matta wrote in an email: "Every Wednesday I usually do 6 hip replacements in 2 operating rooms--I perform the surgery in one room while the patient is anesthetized, positioned, and prepped in the other--and I am typically done with the 6 surgeries by one-thirty or two in the afternoon. Fast is good as long as it is precise and high quality."
I don’t know exactly how long my surgery took, but Dr.Kreuzer told Carol in the waiting room afterward that it was longer than usual. Remember that my muscle mass prolonged the procedure. Special care was required to avoid cutting my muscles. (Dr.Kreuzer told Carol I had the biggest tensor muscle in my thigh, near the point of incision, he’d ever encountered; in fact, I seemed to have two tensors.) It was more than five hours between the time I was wheeled into the operating room and when I was moved from recovery to the orthopedic ward. General anesthesia makes some people sick, but I felt okay when I got to my room. No pain and no nausea. (I was relieved that the surgery was over. I told Carol I loved her, our son—and Dr. Kreuzer.)
Another problem is that many patients, perhaps most, come to hip replacement surgery in a debilitated condition. Their muscles are weakened from pain and disuse. Understandably, they avoid movements that hurt. “This leads to an imbalance where the stronger muscles become shorter, thereby stretching and lengthening the weaker muscles,” says a handout I received from the rehab people at the hospital. “These imbalances change the way the hip joint usually works. An imbalance of the hip muscles can significantly affect the way you walk or perform other physical activities.” This makes rehabilitation take longer. In addition to recovering from the surgery, they have to spend time regaining strength and correcting the imbalances; they basically have to learn to walk and move again. I managed to avoid that problem almost entirely.
I avoided movements that hurt, but still managed to preserved most of my muscle mass. It hurt to walk more than a short distance, climb stairs or lift my leg to get in a car--but not to squat. I worked my lower back, glutes and hamstrings using a terrific hyper-extension bench made by Bigger Faster Stronger in Salt Lake City, Utah (see photos), and my quads by squatting and doing leg extensions. I also used The Frank Zane Leg Blaster to good effect. The only muscles that suffered are those that pull my right leg and knee forward and up, the hip flexors. The movement that hurt most was lifting my leg to get in the car, especially the high seat in our Jeep. Those muscles are sore and weak, and I am now working to rehab them. Fortunately, prior to the surgery, I lost little, if any, muscle or strength in my lower back, glutes or quads, where many hip-replacement patients have imbalance problems.
Dr. Kreuzer says I will lose some muscle mass during the quiet period required after the surgery. At four weeks, I can see a slight deficit in my right thigh, but everything else looks and feels pretty good. I’m working to keep the loss to a minimum. My pre-op training gives me a substantial advantage in the rehabilitation process. When my hip flexors heal and regain strength, my thigh and everything else should come back rapidly. (See Updates below.)
My dad was a wonderful doctor and I know a wonderful doctor when I see one. In this case, I had at least three that fall into that category.
Matthew Rounseville, DO, is my primary care provider. Having cared for and been a friend to our family through good times and bad, life and death, he knows more about me than any other doctor (with the possible exception of Arnie Jensen and Lynn McFarlin, my former and present doctors, respectively, at the Cooper Clinic). Talk about bedside manner, Matt’s got it in spades. When I went to see him about the pain in my hip, he didn’t refer me to a general orthopedist, he sent me to a sports medicine specialist.
That’s how I had the good fortune to see Robert Wilson, MD. It took Dr. Wilson only a few minutes to realize that I’m not the run-of-the-mill fitness minded 67-year-old. After five weeks of Hyalgan injections failed to restore the function of my hip, he encouraged me to explore the new procedure popularized by Dr. Matta. With the help of a list of doctors in adjoining states provided by Dan Sawyer’s surgeon (Cambize Shahrdar, MD), I did some research on the Internet and zeroed in on Dr. Kreuzer. Wilson urged me to go see him and wrote an insightful and extremely helpful letter of introduction. Describing me as “an unusually fit body builder and fitness writer who finds it extremely important to be able to maintain his exercise program, maintaining muscle mass and range of motion,” he asked Dr. Kreuzer to consider me for “the minimally invasive surgical option.” Needless to say, that letter gave me a huge head start in explaining myself to Dr. Kreuzer.
Kreuzer is an extremely busy man. Each room in the orthopedic ward where I walked after the surgery had the patient’s name and that of the doctor. It seemed to me that his name was on every other door; Carol made the same observation. Nevertheless, on our first visit, he walked into the examining room where Carol and I were waiting, calmly sat down on a step used to help patients up on the examining table, and listened to us like we were his one and only concern. “If you took the time to come here to see me, I’ve got as much time as necessary to discuss your problem,” he told us. I decided in a matter of minutes that he was the guy to do my hip. Carol, an astute judge of character, usually takes longer to decide, but she readily agreed.
During that first appointment with Dr. Kreuzer, I emphasized that I expect to continue hard training, weights and aerobics, after having my hip replaced, recognizing, of course, that some adjustments may be necessary. He asked if it was important to me to be able to squat. I said, “Yes, absolutely.” He promised to “make some calls” to determine the best femoral head and socket cup to meet my requirements.
Several weeks later, I received a call from Dr. Kreuzer. He explained the basic choices (metal on metal, ceramic on ceramic, and Oxinium on polyethylene), and outlined the pros and cons of each option. His favorite, he said, was the Oxinium femoral head. He said it was probably the best option “in view of my exercise habits.” He gave me the name of the company that developed Oxinium and the new head, UK-based Smith & Nephew, and suggested that I check it out and let him know. I was impressed. That told me that he was making a special effort to meet my needs.
I was even more impressed when I learned about the properties of Oxinium. Smith & Nephew, which holds the trademark on the name, says Oxinium is the result of a process that allows oxygen to absorb into zirconium changing its surface from a metal to ceramic. The ceramic surface reduces friction, while the metal remains super strong.
A News Release from Smith & Nephew says that people under sixty have often been denied a hip replacement because “implants currently used are not expected to withstand the wear and tear placed on them for longer than 10 to 15 years.” I assume that means normal wear and tear. Yikes! I’d probably be in trouble.
“The ultimate quest is to find a hip replacement that lasts a lifetime in order to prevent the need for further surgery,” UK orthopedic surgeon Fares Haddad is quoted as saying.
Hip replacements with the Oxinium head “could last twice as long as standard devices,” says the News Release
“Compared to the traditional cobalt chrome implant, Oxinium is 4,900 times more resistant to abrasion, 160 times smoother and twice as hard.” There’s more to an implant than the head, of course. Hip implants have three components: A socket cup, a femoral head, and a stem that fits into the femur. The socket cup wears faster if the surface of the head is scratched or roughened.
The cup recommended by Kreuzer is made of polyethylene, a form of plastic. The News Release says, “Even a single scratch on the [traditional] cobalt chrome surface can increase the rate of plastic wear by 10 times, and substantially reduce the life span of an implant.” That, of course, makes the wear-resistant properties of the Oxinium head extremely important
An Oxinium head in a polyethylene cup, both made by Smith and Nephew, sounded good to me.
But Dr.Kreuzer wasn’t done looking for the best combination. He called me in the holding area at the hospital on the morning of the surgery to say he’d found a better socket cup made by Stryker Orthopaedics, a U.S. company, and that it was on the way. I’d be well rewarded for waiting a few extra hours for it to arrive, he said. So Carol and I waited.
The surgery, originally scheduled for 8:30, didn’t get under way until about 12:30. Seeing patients (and their loved ones) come into the holding area, and then, be wheeled off to the operating room all morning was like being on the set of General Hospital. Kreuzer drew a picture of the new cup (thinner, but stronger, with substantially more surface) on a paper towel for Carol and me shortly before I was wheeled off into the operating room. The last thing I remember is getting a glimpse of the special table.
A miracle in Houston? I think so. A sturdy new hip, a new life!
* This article is dedicated to Judge Dan Sawyer, whose counsel and encouragement were tremendously helpful before and after my replacement surgery. Thanks Dan! You’re one of the best friends a guy ever had.
[Editor: Medical information on the surgical procedure for doctors can be found on Dr. Joel Matta’s website (www.hipandpelvis.com); includes a 60-frame slide presentation on the procedure showing multiple views through the small incision (not for the squeamish). Both Matta’s website and the website of Drs. Kreuzer, Cupic and Dutta (www.memorialboneandjoint.com) contain additional information for patients. Dr. Kreuzer also has a new website devoted entirely to anterior hip replacement (www.anteriorhip.net); includes patient testimonials and much more.]
I saw Dr. Wilson for my 6-week follow-up exam. "Clarence is doing quite well at this time, progressing through his physical therapy as prescribed and now gradually getting back to training," he wrote in a file note provided to Dr. Kreuzer and Dr. Rounseville. "He demonstrates a very easy range of motion [in his hip] .... He has good muscle development in right quad and hamstring compared to the left. He apparently is biking now with no pain. I repeated x-ray ... and there appears to be no loosening of the joint components."
In short, I'm doing well. The only problem is that my hip flexors are not coming back as fast as I expected. Both Kreuzer and Wilson urge me to me "take it easy" and give my body time to rebuild the strength and range of motion in this area. As explained above, my right hip flexors were sore and weak, the only muscles debilitated prior to the surgery.
Dr.Wilson's report after 6-month follow-up exam: "Clarence, now 68 years of age, is feeling and appearing quite fit having recovered very well from his right total hip replacement. His surgical scar at this point is normal, about three inches long and well-healed. He has developed good strength in the gluteus and hamstrings, the quadriceps, the abductors and adductors of right hip. He walks without a limp and he has a range of motion which is nearly equal that of his normal left hip. He has the ability to internally and externally rotate about 45 degrees in a 90/90 seated position. He has flexion at the hip to 135 degrees, he has extension to10 degrees from the neutral and all of this is very tolerable. X-ray shows excellent fit and adherence to bone in both the acetabular and femoral components.
ASSESSMENT: Excellent result, right total hip replacement for osteoarthritis."
My report: I've made good progress since 6-week exam. My hip flexor strength and range of motion are almost back to normal. I can lift my right leg to get in our Jeep with no discomfort; you'll remember that this was a painful maneuver before my surgery. I can pull my knees up and do a hanging hip curl for my lower abs with only a little lag in my right leg. I can do a full squat comfortably, as shown below.
I'm doing the Lifecycle and Airdyne at close to intensity levels achieved before the surgery. I started out slowly, of course, and my hip has responded very well as I increased the load from week to week. As you might expect, I got too enthusiastic at times and had to back off a bit. But I'm now doing intervals at very respectable levels with minimal complaints; I have a little stiffness in the hip, but it warms up well and doesn't hurt. (My experience may offer encouragement to Floyd Landis. I realize, of course, that stationary cycling hard for about 30 minutes twice a week is hardly the same as cycling up and down mountains every day for three weeks in the Tour De France. Nevertheless, it's a step in the right direction. Go Floyd!)
I have resumed doing the Back Raise and Glute-Ham Raise on the Glute-Ham Developer, as planned. (See text and photos above.) It feels good and my lower back, glutes and hamstrings are quite strong. I'm also doing Nautilus leg extensions and leg curls; again, it feels good. I haven't started doing barbell squats yet, but for reasons other than my hip. As mentioned, free squats feel good; I do them almost every day. The problem is that compression of my lumbar spine causes tingling and numbness in my left foot (new hip is on right); that's why I've decided to forego weighed squats for the time being. It's not a problem because I'm working low back, hips and legs quite effectively with the other exercises mentioned. (I may add the Zane Leg Blaster next; it's designed to minimize pressure on the lower back. I haven't decided.)
My only complaint is that I still have some numbness in the area of my new hip and my upper thigh. The numbness comes and goes, but is present to some degree all the time; it's worse after sitting for long periods and better with exercise. My hip works fine; the numbness has no effect on function. I wish it would go away, of course. Dr. Kreuzer is optimistic that most of the numbness will eventually disappear. Dr. Matta says some permanent numbness in the area of the incision is not unusual, but the rest usually goes away with time.
All in all, I'm very happy with my new hip. As Dr. Wilson says, I've had an excellent result. Dr. Kreuzer did a superb job. My scar is beautiful.
Check-out my range of motion in the photos below.
Selected Reader Feedback
Dr. Matta Comments
I am delighted to hear of your great result. Thank you for making it known with your "Miracle in Houston" story. The great part is that your recovery is not unique to you or only one surgeon using the technique. Those of us using and advocating the technique have encountered resistance and much skepticism from our orthopedic colleagues, but happily patients like you are driving this forward. It's always hard to be completely objective regarding your own "baby" but I think that this is the real thing and my hope is that this technique will change how hip replacement is done around the world in a positive way. How many medical treatments create such enthusiasm on the part of the patient that they want to "tell the world" as you are doing? (See above for comments by Dr. Matta on suitable candidates for new procedure and other matters.)
Joel Matta, MD
Stuart McRobert's Mother
The hip replacement you had is amazing. The speed of recovery is staggering. My mother had both her hips replaced about 20-23 years ago. She had them done separately, about three years apart. Her recovery was very slow. She was largely bedridden for a couple of weeks or so after each. It was perhaps four months or so after each operation before she was back to full mobility. And she was in good condition for her age, always active and lean. Although at the time there were claims that the life expectancy of a false hip was only 10 or 15 years, my mother's hips are (touch wood) fine today, and she has averaged several miles [of walking] a day, every day, for over 20 years.
Stuart McRobert, Cyprus
A relatively new procedure was used [when I had my hip replaced at age 39]. The cup had holes in it which allowed the bone to grow in and around it, eventually adhering it permanently. One had to treat the replacement as if it were a fracture. I had to be on crutches and initially could only put 10% of my bodyweight on that leg, gradually increasing the amount of weight over a period of a few months. I was weight training consistently and running a great deal since I was young, and had the motivation to do my own therapy at home. It still took a long time to recoup. Eleven years later, at the age of 50, the prosthesis broke and penetrated my pelvis. I had to have an emergency revision. The first hip lasted me just shy of eleven years. This second one has just gone beyond that point. You are so lucky to live at a time when this new and wonderful procedure was available. Your article, regarding your experience, will be of benefit to anyone who may have to endure a replacement in the future. Since my first hip only lasted 11 years, I am prepared for the possibility of having to have it done again. If so, I would definitely seek a doctor to perform the anterior method. John S.
With many more people exercising today than years ago, I think in the future we will see hip and joint problems being very common to the point of epidemic levels.
Hip Resurfacing Alternative
I had my hip "resurfaced" by Doctor Thomas Gross in Columbia, South Carolina (www.grossortho.com). Gross also practices minimal invasive surgery, although he still goes into the hip from the side. The resulting scar on my hip is approximately 4.5 inches long. I too had a very fast recovery. I returned to work in 18 days and was walking over a mile within the first week. My procedure doesn't appear to have been as pain free as what Doctor Kreuzer is doing though. I chose the [metal-on-metal hip surface replacement] that Gross uses due to the possibility of continuing [my very active lifestyle]. I was stationary biking and working the StairMaster within 4 weeks. I was also able to return to the gym the week I returned to work--amazing considering that my hip had been killing me for around 5 years. Hip resurfacing has allowed me to do pretty much what I want. I'll never dead-lift or do regular squats again, but that's my choice to be on the cautious side. I'm currently [doing] either hack squats or hip belt squats with a dumbbell between my legs. I can go as heavy as I want. Sunday is my Concept2 rowing day, I resumed doing that on Thanksgiving last year, and that's been great. I've also started swimming, [which] I couldn't do prior to the surgery due to the pain when kicking. Mountain biking and hiking is something my wife and I also have resumed. It appears to me that if Doctor Gross could combine his resurfacing with the front entry method of Doctor Kreuzer it would be fantastic. I'm not convinced that the [implant] will hold up in the femur due to the torque that would be coming from lifting weights. My understanding is that that type of implant cuts the top of the femur off. There's torque situations where you would twist the implant right out of the femur and that's not likely with resurfacing [where the femoral head is preserved]. My implant is rock steady. It's been incredible.
An obvious conclusion is that elderly folk will almost, without exception, be recipients of health dramas in their latter years, and being in good physical condition is a terrific plus to recovery. Time itself, in conjunction with genetic disposition, will not preclude any of us from the likelihood of surgery situations--stuff wears out!--and for most old folk, they are at the worst stage of their lives, physically, to handle such situations. Your bladder and hip surgeries send a glaring message that physical assaults on your person will have less impact if you're in shape to handle them. Rather than wiping you out, they are just minor bumps that put you off balance for an instant, and from which you re-stabilize your run to the touchdown line.
Roy Rose (See Success Stories 3, "Lifetime of Lifting Produces Archery Gold")
You've always looked bionic and now you are!
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