Nov. 13, 2003 -- Hip replacement surgery has allowed millions of Americans crippled with arthritis to once again walk pain-free -- but traditionally, only after weeks or months of recovery. But a new technique is helping to transform this popular surgery into an outpatient procedure -- and allowing most patients to recover fully much sooner.
With this technique, first performed in February 2001, nearly 90% of patients leave the hospital the day of or day after their hip replacement surgery, instead of the traditional weeklong stay. The technique is also proving to be virtually pain-free in many patients and results in less surgery blood loss and less chance of post-operation blood clots. It also reduces or eliminates months of grueling rehabilitation therapy and is proving to drastically cut the risk of later chance of limping.
Go Home the Same Day
"Virtually all of my patients now go home the same day of their surgery," says Chicago orthopedic surgeon Richard A. Berger, MD, who pioneered the procedure and has since performed it on more than 200 patients. "Most are walking with no support at all within a week of surgery, rather than the several months it takes with traditional surgery. For them, it's proven to be better and safer than the traditional method."
The reason: The Zimmer Minimally Invasive Solutions 2-Incision technique allows surgeons to install the same artificial hip joint through two small incisions -- each no more than 2 inches long -- rather than the traditional single incision between 4 and 12 inches long.
By doing this with new smaller surgical instruments designed by Berger, an MIT-trained mechanical engineer-turned-surgeon, those who perform hip replacement surgery can now operate between muscles, tendons, and ligaments rather than cutting through these soft tissues.
About 90% of pain resulting from hip replacement surgery -- done on some 250,000 Americans a year -- results from cutting through this tissue, Berger tells WebMD.
He and three other pioneers of the procedure -- named after Zimmer Inc., the company that manufactures the smaller surgical instruments -- document outcomes in 375 patients who have had this new procedure since Berger first performed it nearly three years ago at Rush Presbyterian-St. Luke's Medical Center in Chicago. Their findings appear in the November issue of the Journal of Bone and Joint Surgery.
At least 80% of those patients getting the Zimmer procedure left the hospital within 24 hours of their hip replacement surgery. In order to be discharged, patients must demonstrate an ability to walk and climb stairs by themselves or with crutches or a cane, and require less potent oral pain medication.
A second study, not yet published, on other patients studied since that first group indicates the outpatient rate is now approaching 90% or better, says Berger.
None of the patients studied in the published research had any complications or needed to be readmitted for additional surgery, meaning their artificial joint remained fully attached. With the traditional surgery, a small number of patients have these postoperative problems.
Berger says many of his patients require no medication for postoperative pain. And since their scars are smaller, they heal faster and lose less blood in surgery. -->
Two Incisions, Smaller Instruments
With traditional hip replacement surgery, a large incision cutting into tissue is needed for surgeons to see and maneuver the artificial hip joint into place. But with the new technique, the two small incisions allow the surgeon to view the bone area from two different angles, and the smaller instruments allow for maneuverability in the smaller space.
The new procedure also doesn't require surgeons to twist the leg as was traditionally done, so veins aren't "kinked" -- raising risk of a post-op blood clot, says Berger. "So far, not a single patient I operated on has developed a blood clot," he tells WebMD. "By comparison, 3 to 5 percent of those getting traditional hip replacement do."
Others are equally impressed with the Zimmer procedure, which is also being developed for knee replacement surgery.
"With the smaller instruments in the hands of specially trained surgeons, this offers numerous benefits to everyone," says Dana C. Mears, MD, PhD, of the University of Pittsburgh Medical Center. He also contributed to the newly published report and first conceived the concept of a two-incision surgical technique for hip replacement procedures about 10 years ago.
"The patient has a faster recovery and less pain, if any," Mears tells WebMD. "The hospital can release patients sooner. And since months of the rehabilitation process can cost $20,000 or more per patient, and many getting hip replacement surgery are on Medicare, by reducing that rehabilitation to days or eliminating it altogether, the health-care system can save billions of dollars a year."
Another first with the Zimmer procedure: X-rays are used during, rather than following, hip replacement surgery to ensure the artificial joint is properly aligned and installed.
While Berger and Mears are among the first surgeons to do the Zimmer procedure, it's now performed by some 300 orthopaedic surgeons in the U.S., who receive special training by Zimmer Inc. and must be specially licensed to use the smaller instruments.
Not for Everyone
"This procedure is technically more demanding for the surgeon, but patients have less pain and can get back to their normal functions and everyday activities much sooner," says surgeon Donald M. Kastenbaum, MD, assistant chairman of orthopaedic surgery at Beth Israel Medical Center in New York City. "I don't want to call it better than traditional hip replacement surgery, but it's certainly a better procedure for certain patients. Anytime a patient can return to work or their regular activities sooner, it's a good thing."
Generally, the procedure is not recommended for severely overweight or overly muscular patients, says Kastenbaum, who has performed the Zimmer hip replacement surgery technique since August but was not involved in the published study.
"I did my first Zimmer procedure two weeks ago and I'm thrilled with it," says Michael C. Racklewicz, MD, an orthopaedic surgeon in Wilkes-Barre, Pa. "For me, the biggest advantage is not only that there's less pain involved for the patient, but there is less tissue trauma. My patient was able to walk with a cane immediately following the surgery, and with no limp at all.
"It will be years before we really know the long-term outcomes," Racklewicz tells WebMD. "But from what I know and have personally seen so far, this new method is really something."