SMALL INCISION TOTAL HIP REPLACEMENT ARTHROPLASTY MERCY HOSPITAL MIAMI, FLORIDA May 3, 2007

Transcription

1 SMALL INCISION TOTAL HIP REPLACEMENT ARTHROPLASTY MERCY HOSPITAL MIAMI, FLORIDA May 3, :00:08 ANNOUNCER: Welcome to Mercy Hospital in Miami, Florida. Over the next hour, you will see two important orthopedic procedures used to help thousands of people suffering from hip pain. A small-incision total hip arthroplasty and arthroscopic hip femoroacetabular impingement resection. Hip pain is not limited to senior citizens. It can begin to affect people in their 40s. The labrum and cartilage may become destroyed as the femur and pelvis bones pinch together. Otherwise known as hip impingement, this form of hip pain is increasingly being recognized as a cause of hip osteoarthritis. Arthroscopy of the hip is a mainstream surgical procedure with welldefined indications and expected outcomes, primarily because of recent advances in surgical instrumentation and techniques. In addition to the live hip replacement, you will see footage of an arthroscopic hip femoroacetabular impingement resection. Remember, OR-Live makes it easy for you to learn more. Just click on the "request information" button on your webcast screen and open the door to informed medical care. Now let's go live to the operating room. 00:01:15 PIETER J. HOMMEN, MD: Hello, everybody. I'd like to welcome you all to Mercy Hospital here in sunny Miami, Florida. I'd like to thank you all for joining us on OR- Live.com for a live webcast of a total hip arthroplasty surgery. This is a very special program. Not only are we broadcasting this in English tonight, but also in Spanish, the first of its kind. My name is Dr. Pieter Hommen. I'm an orthopedic surgeon here in Miami, and my colleague, Dr. Carlos Lavernia is here behind me doing a -- about to start a total hip arthroplasty live. So that's a total hip replacement surgery. Actually, I think right here we can pan in, this is the view of Dr. Lavernia's hip before we start this procedure here. I'd like to turn it over to Dr. Lavernia real quick and have him start here. 00:02:07 CARLOS J. LAVERNIA, MD, FAAOS: Good afternoon. I'd like to welcome everybody to Miami. I'd like to introduce my team. We have today quite an international representation here. We have Enrique Roy, from the Republic of Hialeah here in Miami. We have Diego Cardona from Cali, Columbia. Camilo and Carlos; Camilo's from Cuba and Carlos from Nicaragua. They're -- as you know, Miami's very close to the United States, so we speak many languages down here. As you can see in the field right now, I have drawn out -- if we can have the field, please -- the old way of doing a hip replacement, which is a very, very long incision between approximately 12 to 14 inches, right between my fingers. As you can appreciate, the new, or the modern way to do a hip is a much smaller incision that, depending on the size of the patient, can vary from anywhere from as little as centimeters all the way out to another 10 inches, depending on the size of the patient. And you can appreciate it here, the new way and the old way. The patient has what's called a regional anesthetic. In this case, it's an epidural. And I forgot to introduce Dr. Suarez back

2 there, who's the magician with a needle. This patient, we avoid general anesthetic in these procedures, and what you see me holding in my hand is a local anesthetic that we are now injecting right where we're going to do the incision. And as you can imagine, the patient's not feeling anything because he is already under a regional block. Everything from the waist down is pretty much completely numbed. The reason I'm putting this local anesthetic in the area of where I'm going to cut is to block even more receptors right before I get started. This patient needs a hip replacement because he has a disease called osteoarthritis, which is essentially a destruction of the hip joint. Because the patient cannot tolerate the non-operative route, which means the pills and the shots and the therapy that was tried, he is unable to function. He has severe pain at rest and at night and is unable to do most of the activities of daily living without pain. The hip joint is a ball-and-socket joint that on occasion will carry pretty close to six times body weight, and in a regular person, during walking, the patient will actually have anywhere between two to four times body weight on the hip. The hip can get quite sick from a number of diseases, including sports injuries. And I'm going to now have Dr. Hommen tell us a little bit about some of the most common injuries that we see in the athlete that may lead in a later stage in life to having a destroyed hip and needing a hip replacement. Suture. 00:05:28 PIETER J. HOMMEN, MD: There's a -- the sports injuries, hip injuries, are fairly common depending on the type of sports that patients are involved in, anywhere from golf to contact sports like football and hockey. There is an incidence of tears of the labrum. The labrum is a lip that goes around the cup side of the hip joint. There's the ball side and the cup side, and the cup side is surrounded by a flimsy labrum tissue that can get torn. Reasons for that labrum to get torn can be from something called hip impingement. If there's a bump or a bony prominence on the hip neck, that can -- every time the patient brings that hip into flexion can cause that labrum to start to tear. That labrum, when it tears, can actually cause to -- cause later arthritis and cartilage delamination, and basically end up leading to an arthritic joint. Why don't we pan in to some of that arthroscopic video footage real quick, maybe show you the incisions an arthroscopic surgery would require. I'll show you that in one second. Actually, here we showed some footage of a little difference between the incisions that we saw just a minute ago and arthroscopic. These are two portals being placed into the hip. There's a camera and a shaver. And you can see, that's pretty much hip arthroscopy incisions right there, and you can put a few of these portals around the hip joint and, you know, perform a resection of the labrum, repair the labrum if you needed to, or take some of that bony bump off of the hip. So those are some of the sports injuries that we do see. There are other injuries, but we can talk about that in a second. Why don't we talk to -- 00:07:08 CARLOS J. LAVERNIA, MD, FAAOS: We can come back now to the -- let's start with the x-ray. If we can show the x-rays of this patient? As you can appreciate on that picture, that's a ball-and-socket. The big long bone is called the femur bone, or thigh bone. It's the largest bone in the body, and right at the top, that ball and socket is what we call the hip joint. And the hip joint in this particular patient is pretty destroyed. There's no space between the ball and the socket, and as you can see, that will actually cause, every time the patient moves, pretty severe pain. And it can -- it can be as mild as just an occasional groin feeling that something's not quite right all the way up to as severe as having the patient not be able to walk and have to be in a wheelchair. So the spectrum of the hip disease varies quite a bit from very mild to extremely severe and very, very limiting to -- to anybody, young or old. What I'm doing right now that you can see here is I'm entering into the hip joint through a very small cut in the muscle. In the past, we used to take about double

3 the amount of muscle that I'm taking right now, and because we have better instruments and we have much more experience doing these smaller incision operations, we have to damage a lot less bone. And right now I'm almost about to enter into the actual hip joint. The hip joint has a liquid inside called synovial fluid that -- once, a little smaller -- that lubricates the hip. And you'll see some of that liquid coming into the field right now. 00:09:02 PIETER J. HOMMEN, MD: I'd like to remind anybody, if anybody has any questions or comments or would like to ask Dr. Lavernia or myself anything during this webcast, please click on the MDirectAccess on the bottom of your screen and we will take those questions and try to answer as many as we can. 00:09:23 CARLOS J. LAVERNIA, MD, FAAOS: And I'm about to enter the actual hip joint, so if we can have the camera right here, we'll be able to show -- let me have a pituitary - - be able to see how much damage there is on this femoral head or ball. And normally, it has a very nice, smooth surface on top that's called cartilage, and this cartilage has extremely unique mechanical behavior. The coefficient of friction on a healthy joint between the parts is lower than that of ice on ice. Through either an injury mechanism, an infection, or disease process, the lubrication characteristics are lost, the surfaces become incongruent, and all of a sudden you start to have a piece of raw bone rubbing on another piece of raw bone. Now, the arthroscopy of the hip, which is a procedure that Dr. Hommen was showing you a little earlier, what it does is it -- through a certain type of procedure, it's able to prevent the progression of the arthritis. This is something relatively new. When I was doing my training in orthopedics, that procedure did not exist in the United States. There were a few European centers doing it, but they were doing the procedure open like I'm doing this hip replacement, and they were not being imitated by any other centers throughout the world. In the recent past, the femoroacetabular procedure, which you will see pieces of, has become a relatively common procedure that's done now in a lot of major cities in the United States and in Europe. 00:11:26 PIETER J. HOMMEN, MD: Yeah, if we could pan in a little bit on that view, we could maybe see the approach to that hip a little bit. What Dr. Lavernia's doing there is he's actually taking that little yellow wand in his hand, that's a Bovie device, and he can actually very atraumatically go through -- go through muscle and tendon and get that approach to that hip in a more minimally invasive technique with this procedure he's using here today. The femoroacetabular impingement, what we -- what we did with that was -- the standard way of going into that hip was to dislocate the hip much like Dr. Lavernia's going to do today and remove that bump on the bone. With an arthroscopic technique, the advantage of that is not to dislocate the hip, do it through smaller incisions like the ones you just saw earlier with the camera, and resect that bump. And the patients actually go home that same day, so -- but we'll talk about that, we'll show a little bit more video clip of that in a second. 00:12:23 CARLOS J. LAVERNIA, MD, FAAOS: Yeah, this procedure, as opposed to an arthroscopy, requires an in-patient stay anywhere from two to five days, depending on the patient's age, the other medical conditions, or comorbid factors that are associated with the case. For example, if the patient is a diabetic and is very, very overweight, patient has a heart condition, patient has problems with the lungs. It's a little different than a healthy 60-year-old that has just a hip damaged and that needs just a replacement. That kind of patient, with the newer techniques that we have today, can actually go home in essentially a matter of two days. 00:13:10

4 PIETER J. HOMMEN, MD: Dr. Lavernia, some of the patients -- or some of the people are wondering how long after your replacement are you letting the patients walk? 00:13:17 CARLOS J. LAVERNIA, MD, FAAOS: What I've just done now is dislocate the hip, and I've taken the socket and the ball apart, and you can see the ball just came up. To do that, I use this bone hook right here that's kind of a brutal instrument. And to answer the question of our viewer, the patients put weight on the hip the next day. And in some cases, the same day. They can put full weight, which in a lot of cases they don't do because they're a little sore, but in some cases they do. So it's quite variable from patient to patient. Now you can see the femoral head -- pickups -- or ball side of the socket. You can see how deformed it is. On a normal patient that doesn't have hip arthritis, the femoral head has a very nice shine to it. It's very nice and round, it doesn't have all these bumps that we can see right here, okay? 00:14:18 PIETER J. HOMMEN, MD: Yeah, those would be the bumps that we would see in an early case of femoroacetabular impingement, some of those bumps on the neck there. but show us that cartilage a little bit, the white, glistening area on that femoral head. Show us that a little bit. 00:14:30 CARLOS J. LAVERNIA, MD, FAAOS: It doesn't have that much. It's pretty much -- 00:14:33 PIETER J. HOMMEN, MD: Yeah, looks pretty eroded. 00:14:34 CARLOS J. LAVERNIA, MD, FAAOS: It looks like a billiard ball. It's extremely damaged from the process of arthritis, and what -- what it causes is just severe pain when it rubs against the ball side. And right now what I'm doing is doing my first cut because I have to cut the femur bone in order to fit it with the new hip. And I'm using a regular old saw to make that initial cut. And now I'm able to show you a little better how bad this really is when you look at it. And you can see how this femoral head has no cartilage on it. This is like a billiard ball. Normally, it has -- in this side of the femoral head, there's a little cartilage left, and I'll show you a little bit of it. You can see it coming off right there, but it's extremely, extremely raw. And this patient was having a really hard time existing with that raw piece of bone rubbing against a raw piece of bone in the groin or the acetabular side. 00:15:50 PIETER J. HOMMEN, MD: In the early stages of that, there are arthroscopic techniques to perhaps microfracture or to stimulate that cartilage to regrow. That would be done at an earlier stage of -- of cartilage change or cartilage degeneration. So once it gets to this stage, there's really no regrowing of that cartilage. This is a hip that is not going to benefit from any kind of an arthroscopic technique or any kind of cartilage-regrowing type techniques. 00:16:18 CARLOS J. LAVERNIA, MD, FAAOS: Now I'm getting ready to find the medullary canal of this femur. I'm drilling a hole right at the top portion of the bone, and Dr. Hommen has a sample of the hip device that I utilize, and I'm putting a rod inside the femur to find that canal, which is where that femoral stem is going to be placed. This instrument right here is called a rasp, and what it does is it prepares that bone to receive the actual replacement hip, the femoral component of that hip. And what I'm doing with the rasp and this mallet is I'm preparing the bone and sizing to see what type of device and what size of device I'm going to use. And now we already planned the surgery utilizing computers. We'll show you that in a second. And we think we're going to end up using a size 10 implant. The real size is determined here

5 in the operating room based on what I feel, and I think we're going to stop at the next size. 00:17:36 PIETER J. HOMMEN, MD: I'll show you that in a second. I have an actual size 10 component here, so we can show you exactly what that looks like. There we go. This is -- this is a femoral stem here. This is what Dr. Lavernia's going to eventually be placing into the -- into the hip here. This is a titanium aluminum alloy type stem that is going to go down into the femur, into the canal of the femur, okay? 00:18:04 CARLOS J. LAVERNIA, MD, FAAOS: Now -- PIETER J. HOMMEN, MD: Go ahead. 00:8:05 CARLOS J. LAVERNIA, MD, FAAOS: Okay, I'm sorry, Pieter. Now I'm getting ready to work on the socket side. I'm already finished preparing. And as you can see, my hands are deep in the wound. And now I'm putting retractors in here to pretty much allow myself and the assistants to see and so that we can position properly where we're going to put the socket side of things, which is what Dr. Hommen will show you in a second. 00:18:38 PIETER J. HOMMEN, MD: The socket is actually this component right here. I have a sample in my hands. This is a -- the acetabular component we call this, this is a fiber-metal titanium shell. If you would show that -- here, this is the titanium shell here, okay, and that head and the stem here go inside this plastic dish. This plastic dish here is a -- a cross-linked plastic or polyethylene. This would go inside here; this is how the hip would move, okay? It's a very low coefficient of friction and this fits inside the cup or the acetabular part of the hip. This is inside the femoral canal. 00:19:24 CARLOS J. LAVERNIA, MD, FAAOS: Now I'm getting ready to prepare the socket side or acetabulum to receive the actual implant, and I'm going to be sizing it much the same way with a similar type instrument called a grader to receive that metal part that Dr. Hommen was showing you. 00:19:46 PIETER J. HOMMEN, MD: Maybe if they could show that a little bit better with that acetabulum exposure. 00:19:50 CARLOS J. LAVERNIA, MD, FAAOS: And what I'm doing right now is I'm preparing, removing all the soft portions of the hip, or labrum, which as you'll see later on, is one of the things that you try to preserve and protect with an earlier surgery like the arthroscopy. 00:20:09 PIETER J. HOMMEN, MD: What I can show you, actually, is the inside of that joint looking through an arthroscope. If we'll pan to the in-the-joint video of the arthroscopy, I can actually show you what that looks like when you're looking at it in a camera perspective. This -- on the right side is the femoral head. That white cartilage, that's normal cartilage. That is a non-arthritic hip of the femoral head. On the left side, when you're looking straight on, is the acetabulum or the cup side. There's a little shaver going in there, and that's a labrum, that little piece of flimsy tissue that my shaver, the metal shaver is on, that is the lip I was talking to you about before, and that is a source of pain in this patient. There's a labral tear, kind of a degenerative type tear that we shaved out. He was a 40-year-old police officer, a very active guy, and came in with mechanical clicking and symptoms in the hip, not an arthritic type patient. This is not the -- this is not a patient that has a full-blown

6 arthritis that -- you know, those are not the patients that we do hip arthroscopy on. You can see here, I'm just removing some of this labrum here from the hip joint. 00:21:16 CARLOS J. LAVERNIA, MD, FAAOS: Okay, we're -- we're getting ready to prepare the socket now. I have already exposed, if we could have a camera -- 00:21:23 PIETER J. HOMMEN, MD: That's a great view right there. That's a really nice view. 00:21:25 CARLOS J. LAVERNIA, MD, FAAOS: If we could have the camera in -- point inside. Is there any way we can get that camera a little better to show the inside of that hip? This is the grader device that we use. As you can see, it's got a rough surface here to prepare the bone so that the bone will be in what we call a bleeding-bed fashion to allow that metal that I'm going to put in here to get ingrown. 00:21:50 PIETER J. HOMMEN, MD: And this is what that metal looks like. If you show this, I'll show you the metal cup again. He's actually preparing the surface where this shell would eventually sit in it. This shell right here. Okay, this would go inside. These have little screw holes where we can fix this shell into the bone with -- with screws if needed. And again, this is the plastic liner inside. This is the canal that he's -- this is exactly what he's preparing right now in that acetabulum or the socket. So that's labrum you took out there, right? 00:22:27 CARLOS J. LAVERNIA, MD, FAAOS: Yep. 00:22:28 PIETER J. HOMMEN, MD: And that's the labrum we as arthroscopists would do anything to try to preserve, but in an arthritic hip when you're replacing, that's something that we would remove so as to not cause further pain. It's really not needed. 00:22:41 CARLOS J. LAVERNIA, MD, FAAOS: Now I take a sequence of these graders starting with the size that I want to begin with, which is a 46, and we're going in twomillimeter increments in order to prepare that socket to receive that metal part and grow into the metal shell. This kind of technology has been around for a little bit. 00:23:14 PIETER J. HOMMEN, MD: Somebody wanted to know if this is going to be a cemented cup. 00:23:18 CARLOS J. LAVERNIA, MD, FAAOS: It's cementless. Everything that I do around the hip uses no bone cement. In the hip side, in my opinion -- and there are surgeons that disagree -- the better way to do a hip is with no bone cement. So I use universal biological fixation on these cases, and what I do is I let the bone heal into the metal. 00:23:46 PIETER J. HOMMEN, MD: When was the first hip replacement performed? 00:23:49 CARLOS J. LAVERNIA, MD, FAAOS: Very good question. Probably in the 1940s, 1950s. And the first center for hip surgery was in England, in Wrightington, England, by a gentleman who got knighted based on his contribution to orthopedics, Sir John Charnley. And when this thing started, he was using pretty much all cement, only cement on both sides of the hip, on the socket side and on the femur side. Okay. 00:24:35 PIETER J. HOMMEN, MD: You can see here, this is a nice tight fit for that component when it's -- it is actually impacted into the bone.

7 00:24:41 CARLOS J. LAVERNIA, MD, FAAOS: I'm ready. Now I am happy with what I got and I'm going to have them give me a 58mm shell to put in here. 00:24:52 PIETER J. HOMMEN, MD: Again, that's this component that I showed you earlier. That's what we would be putting into the joint. 00:24:57 CARLOS J. LAVERNIA, MD, FAAOS: Pituitary. 00:25:06 PIETER J. HOMMEN, MD: Another question. How long is the rehabilitation after a hip replacement surgery? 00:25:10 CARLOS J. LAVERNIA, MD, FAAOS: It's a lot less than a knee replacement procedure, but overall, I tell the patients they can count on being in some pain for probably two to three weeks after the surgery. Although I have a patient in the hospital right now that was in really bad shape that waited quite a bit of time to get his hip done, and he had no pain, even after a procedure as labor-intensive as this. He was sitting in his bed the day of surgery already feeling the benefit, so in a nutshell, it's variable, but I tell the patients to count with around four weeks of time before they can go back to a sedentary type work. I have had doctor patients that have gone back delivering babies two weeks after two of these, but that would be the exception. There are other patients that have taken six months to get back. So there's quite a bit of the spectrum. With the newer pain-management modalities, the rehabilitation is much faster. This is a real implant that I'm putting in the patient. It's called a Trilogy socket, and it's got fiber-metal around it made out of titanium, and the inside shell and a round portion of the shell is made out of an alloy, titanium aluminum vanadium. It's one of the super-alloys, and the biocompatibility of these implants is spectacular. They do not get rejected. We have over 40 years of experience with this material in the hip and the knee joints. Now I'm going to impact it in place. 00:27:01 PIETER J. HOMMEN, MD: You can see, orthopedics is a little bit of a manual type procedure. The recovery after a hip arthroscopy is a little bit different also. If you fix a labrum, you know, in general, I have patients weight-bear-- partial weight-bearing and, you know, recovery really depends on letting that labrum heal. If it's -- if I remove a little piece of that bone, the resection of the bone, I have patients partially weight-bear, not letting them put full weight down for a couple weeks just to protect that hip and prevent any kind of break in the bone. It is a little bit weaker after we've removed some of that bone, but you can see here he's putting in a screw into the cup, and that's going to secure that cup. 00:27:47 CARLOS J. LAVERNIA, MD, FAAOS: Like Dr. Hommen said earlier, some surgeons don't use these screws. I tend to sleep better if I put them in, so I put them in on all my cases. 00:28:11 PIETER J. HOMMEN, MD: So what type of pain medications are you prescribing or giving after this type of a surgical procedure? 00:28:16 CARLOS J. LAVERNIA, MD, FAAOS: Great question. In the past, we used to treat the pain after surgery whenever it got bad, so the patients would sit in their beds and they would call that nurse when the pain got really bad. One of the most important advances in hip surgery, which I think -- another one? Already did it -- is what we call preemptive pain management. The patients get pain medication around the clock. They pretty much get a pill every six hours whether they have pain or not.

8 And what that does is it allows that pain to never get really bad, and it makes a patient not have these huge highs and lows, and therefore they rehab a lot better. Let's have the plastic, please. 00:29:09 PIETER J. HOMMEN, MD: So you think that with the minimally or smaller incision surgeries that we're doing and the better expertise with postoperative pain management, you think this has all contributed to longer or -- shorter stays, I mean -- shorter stays in the hospital and -- and faster road to recovery, right? 00:29:28 CARLOS J. LAVERNIA, MD, FAAOS: Absolutely. I think that pain management is more important than the incision. I think if you look at the combination of both, having a smaller incision with less damage, it gives you the faster rehabilitation and getting back to life a lot sooner. This is the plastic that Dr. Hommen showed you earlier. One of the things that he mentioned is that it's highly cross-linked. This plastic has been used in the United States for about five years, and it's one of the most important advances in terms of materials in the last 25 years. The plastic that we used to use was not cross-linked, and the cross-linking is a chemical process through which these parts become much more capable of resisting wear. Let me do it again. So now we're -- we've completed half of the surgery. The socket side, when I put that piece of plastic in, is now done. 00:30:37 PIETER J. HOMMEN, MD: While we have a minute here before he goes to the femoral side -- 00:30:40 CARLOS J. LAVERNIA, MD, FAAOS: And what I'm going to do right now is try the mechanics of the hip, okay? So we're going to -- I checked. We're going to check the length of the leg, we're going to check the stability of the leg because these hips, they can pop out. For the first six weeks, the patient has to be very, very careful in terms of what movements they do and what things they try to do. If they try to be a little too aggressive with some of the motions, that hip will pop out of socket, and it's one of the most horrible experiences that the patient and the surgeon can have. 00:31:18 PIETER J. HOMMEN, MD: Now, is that a common experience, someone wanted to know. 00:31:21 CARLOS J. LAVERNIA, MD, FAAOS: That is not a very common experience. It depends on the surgeon, it depends on the type of technique that they use to put the hip in. At Mercy Hospital, our dislocation rate is less than 1 in 50,000. In some centers, it can be as high as 1 in 100. Go ahead. 00:31:39 PIETER J. HOMMEN, MD: Is there a difference in technique that you would attribute to that? 00:31:41 CARLOS J. LAVERNIA, MD, FAAOS: Yes. Yes. Yes. The technique that I use definitely has less problems than other techniques and it does have its drawbacks. For example, I have to go in the front of the hip to achieve that type of stability. Some surgeons go in the back of the hip. And going in the front causes a little bit more work for the patient. 00:32:05 PIETER J. HOMMEN, MD: What are you showing right there? 00:32:07 CARLOS J. LAVERNIA, MD, FAAOS: I'm measuring using a very primitive little string how this hip is now compared to what it was before in terms of the length of the hip.

9 So what I'm showing in here is that I've made the hip a little bit longer than what it was. And so I'm going to try to shorten it a little bit. 00:32:27 PIETER J. HOMMEN, MD: Now, is that a problem, to lengthen a leg a little bit? 00:32:29 CARLOS J. LAVERNIA, MD, FAAOS: It's not that big of a problem. Most patients that never have had hip surgery, that never had hip pain, that are walking around and they get measured, have one leg longer than the other, and they never notice a difference. 00:32:43 PIETER J. HOMMEN, MD: And is it common to have a leg slightly shorter before surgery? 00:32:46 CARLOS J. LAVERNIA, MD, FAAOS: It is very common to have a leg slightly shorter. Very, very common. So what I'm doing right now is cleaning out some of the damaged tissue that the patient out and I'm going to now dislocate the hip in order to be able to finish the preparation of that thigh bone. 00:33:14 PIETER J. HOMMEN, MD: So again, the thigh bone, we're going to be placing this stem component in here. 00:33:18 CARLOS J. LAVERNIA, MD, FAAOS: Correct. 00:33:19 PIETER J. HOMMEN, MD: I'll show you that again right here. This is the stem that we're going to be placing in the bone. Okay, it is a -- a metallic stem, okay, a titanium aluminum alloy type stem as well. All right, and it's got this -- this sort of a -- a pattern on here which is a -- allows for a scratch fit type hold onto the bone, okay? 00:33:51 CARLOS J. LAVERNIA, MD, FAAOS: I'll take a little bit more neck, guys, okay? 00:33:55 PIETER J. HOMMEN, MD: And that's a rasp right there. That's actually a trial -- that's one of the compon-- that's not the real component going in, that's just to prepare the bone itself for this type of an implant. 00:34:04 CARLOS J. LAVERNIA, MD, FAAOS: I was just -- lateral. I'm letting it go down. Okay. I don't know. Come up. I need that saw for a second. I'm going to take now a little bit more neck to make my reconstruction match a little bit better what the patient had before. 00:34:32 PIETER J. HOMMEN, MD: I have a very good question here. If a patient had arthritis or hip pain in both hips, are they a candidate for having both done? 00:34:42 CARLOS J. LAVERNIA, MD, FAAOS: Yep. 00:34:43 PIETER J. HOMMEN, MD: Or both at the same time or -- 00:34:45 CARLOS J. LAVERNIA, MD, FAAOS: Yes, yes. I do about -- other way, other way, other way. Okay. I will do in a year...about probably 2% bilateral hips in a whole year, so very infrequent. But it does happen, and when it's a young patient they can be done both at the same time. On an older, sicker patient, I will actually avoid doing them at the same time, and on occasion what we do is we do them a week apart. We stage them pretty close together so that when the patient leaves the

10 hospital, his problems are resolved. Okay, now we've decided on the right size stem and I'm going to need a By sizing this trial rasp in the patient's bone, I can better decide what the proper hip stem that I'm going to use is. So now I'm -- I'm done preparing the femur side and I'm going to get the real hip. I'm going to change gloves in order to handle the implant. Yep, do it, :36:14 PIETER J. HOMMEN, MD: How long would you say that implant takes to kind of grow into that hip? 00:36:17 CARLOS J. LAVERNIA, MD, FAAOS: Six weeks. They've done studies in animals and in some humans in which they've implanted these porous, coated pieces in the patient's bone and they allow them to be in place for two weeks, three weeks, four weeks, five weeks, and then they check the amount of bone that has grown into that particular implant, and they've quantitated the optimal time for bone to grow into these implants is around six weeks. 00:36:49 PIETER J. HOMMEN, MD: And when you say these implants are biocompatible, when you said that they're very friendly to the bone and everything around it, what does that exactly mean? 00:36:56 CARLOS J. LAVERNIA, MD, FAAOS: Biocompatibility is the ability of an artificial material to live inside the body without being rejected. What I'm showing you right here is the actual hip -- it's called the ML taper hip. I designed this hip with a group of surgeons and engineers, and it's made out of, like Dr. Hommen said, aluminum, vanadium, with titanium. It's an alloy. And it's got a plasma-spray surface right here that bone grows onto, and it allows that hip to become part of the patient. And now I'm getting ready to put the final implant in place and -- and almost the second half of the surgery is completed. Now, once again, I have a fake ball that I'm going to try in here to see how this feels in terms of length and in terms of stability. Because the one thing you want to make sure is that the hip is stable. So now I ask my assistant to pull, and I put this back in the socket. I like that. I'm very, very happy with what I've got in here, so let me get a pickup. There we go. 00:38:29 PIETER J. HOMMEN, MD: So the patient right now is -- is asleep or is awake? 00:38:32 CARLOS J. LAVERNIA, MD, FAAOS: No, the patient's -- the patient's sedated. 00:38:35 PIETER J. HOMMEN, MD: Okay. 00:38:36 CARLOS J. LAVERNIA, MD, FAAOS: The patient is relaxed and having a good time, and he's going to wake up with a brand-new hip. Go up. 00:38:44 PIETER J. HOMMEN, MD: I thought I heard our anesthesiologist talking to our patient earlier, so... 00:38:47 CARLOS J. LAVERNIA, MD, FAAOS: Yeah, no, the patient's awake. And now you watch me move that hip in space, okay? I'm moving the leg around with my finger inside the patient's hip to make sure that I have a stable construct, that this hip is not going to dislocate. Okay, now I'm happy with that and I need a minus-3. Bone hook? 00:39:08 PIETER J. HOMMEN, MD: So what he's doing now is the minus-3, that means the size of the neck of the implant, so in addition to the stem that he's already placed inside

11 the bone, he's going to make up for any length that he needs by -- by putting either a long neck or a short neck onto the -- onto the stem itself. 00:39:26 CARLOS J. LAVERNIA, MD, FAAOS: I can change, like Dr. Hommen is saying, the size of this neck, okay? And I can also change the size of the ball. So this is called modularity. It's one of the big advances that we've done in the last 25 years in terms of allowing me to now change my mind in terms of the patient's length and the patient's biomechanic characteristics. And what I have here is a real deal. This is a real ball that I'm putting right on the stem, okay? And now I'm fixing it. I need a little bone, please. I'm fixing that to the patient's priorly implanted stem, and it's actually a soldering type effect in which, through friction, okay, that part gets welded onto the other part and the force necessary to take these apart can -- can be more than 2,000 pounds. 00:40:29 PIETER J. HOMMEN, MD: Now, I actually have a patient from -- from Venezuela looks like who wrote me a question: if I was going to seek a total hip replacement or have my hip replaced, who do I see? What kind of a specialist do I see? And what questions do I ask my doctor? 00:40:48 CARLOS J. LAVERNIA, MD, FAAOS: That's a very good question. I think the most important thing is that you seek an orthopedic surgeon that has special expertise in implant surgery. Most orthopedic surgeons are well-trained in doing total hip replacement, and -- but if I were having one done, I would seek one that does a lot of this surgery. You want somebody that does 50 or more a year. That gives you a relatively good chance of getting a good result. We have done some studies here at the Orthopedic Institute in Miami to look at surgeon volume and outcome, and there's no question about it that the more you do, the better you get at it. Now I'm putting a drain in here. This drain will keep this hip from developing what's called a hematoma because there will be some bleeding inside after I close the wound. So this plastic tube that I'm putting in here will take the blood out, and through a system, okay, that we have -- let me have the drain. 00:41:55 PIETER J. HOMMEN, MD: How long does that drain stay in usually? 00:41:58 CARLOS J. LAVERNIA, MD, FAAOS: It stays in 24 hours. 00:41:59 PIETER J. HOMMEN, MD: And that -- and does it hurt to take that out? 00:42:02 CARLOS J. LAVERNIA, MD, FAAOS: It hurts a little bit. It's not fun, but this system right here allows me to give the patient the cells back, okay? 00:42:10 PIETER J. HOMMEN, MD: So it may reduce the risk of transfusion. 00:42:12 CARLOS J. LAVERNIA, MD, FAAOS: Exactly right. I give the patient some of the cells back. 00:42:16 PIETER J. HOMMEN, MD: What's the -- what is the risk or the rate of transfusions needed after surgery of a hip replacement? How many of those patients out of 100 would you say may require a transfusion? 00:42:27 CARLOS J. LAVERNIA, MD, FAAOS: Around 10% when they start with a hemoglobin greater than That's a caveat. So when you're starting right before surgery and you check, okay, the hemoglobin has to be greater than a certain value. Then your

12 odds of needing a transfusion are pretty low. So now I'm ready to close the wound. So we're all done, the hip is in place. 00:42:55 PIETER J. HOMMEN, MD: So how long was that, about 40 minutes, and we're already closing. Not even. So is that about standard, would you say, for a hip replacement surgery? For a first-time hip replacement? 00:43:07 CARLOS J. LAVERNIA, MD, FAAOS: I think for a first-time hip replacement in an experienced center, that's about standard. 00:43:13 PIETER J. HOMMEN, MD: And how long would -- if you had done a revision instead, you know, where you -- the patient -- 00:43:17 CARLOS J. LAVERNIA, MD, FAAOS: Yeah, when you have to redo these things, which on occasion you have to redo them because they get loose or something doesn't work properly and the patient's having pain because the hip is too big or the socket is too big or we have mechanical malfunctions, those operations are quite complex and they can last -- or they can be up to three hours in length. So they can be quite, quite long. 00:43:46 PIETER J. HOMMEN, MD: Somebody just asked a question about arthroscopy after hip replacement surgery. Yes, it has been done. There's very limited indications, but for some patients who have -- maybe the cup was put in a little bit in a position where a tendon snaps over it as you move your hip, those patients can actually undergo an arthroscopic release of that tendon. So that's a couple small portals on the side of the hip to -- to -- you know, rather than going back in through an incision, a larger incision. So those are -- but the indications for arthroscopy after hip replacement, they're pretty small. 00:44:24 CARLOS J. LAVERNIA, MD, FAAOS: They do help when they're needed because they avoid having to go back into this big, big hole and having to redo everything again. Because when you come back for the second time, the incision has to be at least four times what I've done in here. So there's no doubt about it that arthroscopy will be helpful on rare occasions in total hip replacement. 00:44:46 PIETER J. HOMMEN, MD: Somebody asked me if I can do a hip ar-- hip arthroscopy to replace the hip. At this point, no, we're not there yet. This is a -- you know, hip arthroscopy, even though it's been around since the early 1900s, it's actually -- actually no joint at this time can be replaced using an arthroscopic technique. That includes the knee or the shoulder. But we're getting there. I think smaller incisions are -- are leading the way, and I think that in the next 10 years, who knows, we may be putting in shoulder, hip, and knee replacements through a tiny poke-hole incisions and using a robotic-type surgeries also will help. And if -- Dr. Lavernia, maybe you could tell us a little bit about your experience with hip replacement surgery using a computer or a robot or something of that sort. 00:45:30 CARLOS J. LAVERNIA, MD, FAAOS: That's a great question. We here at Mercy are doing research on computer-assisted orthopedic surgery in general, not just in hips and knees but we're going to start pretty soon doing some ligament reconstruction with these computers. And the computers are not meant to replace a doctor, but they actually help the physician find anatomic landmarks on relatively difficult-to-find situations. For example, you saw how primitive the measurement that I did was with those strings. Well, with the computer-assisted technology, I am able to get a

13 computerized reading of what the length of the patient is. Now, the current status of computer-assisted technology is such that when I use it, it doesn't help me and it makes me slower. But it will get to the point where it's going to help me quite a bit and it's going to make me faster. 00:46:28 PIETER J. HOMMEN, MD: So you think maybe for the inexperienced or -- or newer surgeons on the field, that might be a better technique than somebody who's more experienced, has done a lot more cases. 00:46:39 CARLOS J. LAVERNIA, MD, FAAOS: I couldn't agree with that statement more. I think that right now, the way the technology is, computer-assisted surgery is actually not quite there yet in terms of helping the surgeon do a better operation in less time. 00:46:53 PIETER J. HOMMEN, MD: Show us a little bit about how that technique would be done. What's the difference between what you just did and maybe how that computer reads where everything is in space? 00:47:03 CARLOS J. LAVERNIA, MD, FAAOS: Well, right now I think my implant is in 45 degrees of lateral opening and 10 degrees of anteversion. If I had the computer, the computer would tell me that it's really in 23 degrees of lateral opening and 10 degrees of abduction, so -- anteversion. So the computer-assisted technology will give you much more accurate readings and will allow the surgeon to know where things are in space before they close. 00:47:35 PIETER J. HOMMEN, MD: And using that technique, have you ever had to change what you thought would look good to something that the computer's telling you to use? 00:47:43 CARLOS J. LAVERNIA, MD, FAAOS: Great question. Not really. It's just the opposite. The computer has told me to go one way and I've ended up going another way. 00:47:51 PIETER J. HOMMEN, MD: And on an x-ray afterwards, you saw that you were right. 00:47:53 CARLOS J. LAVERNIA, MD, FAAOS: Yes. I think it's going to get there where that computer's going to be better than I am, there's no doubt about it, but I think that right now the different systems out there, they take a little long to prepare and they actually don't -- don't really make me a better or a faster surgeon. We have mechanical things that we use to try to improve the position of these components, and they work quite well. 00:48:22 PIETER J. HOMMEN, MD: So if I were to see an orthopedic surgeon, what would -- should I come in with an MRI, a bone scan? What should I come to the office with? 00:48:33 CARLOS J. LAVERNIA, MD, FAAOS: Let me get the shot. One thing that I want to show the audience right now is, again, I'm injecting the tissue with a syringe with local as well as systemic -- I need another needle, please. 00:48:51 PIETER J. HOMMEN, MD: And that really helps with the postoperative pain. 00:48:54 CARLOS J. LAVERNIA, MD, FAAOS: It does. Postoperatively, for the first 24 hours, there'll be pretty high concentration of pain medication in the tissue, as you saw me injecting. And right now, I'm on the next-to-last layer. I'm closing the fascia, it's called, right before I go to the skin.

14 00:49:14 PIETER J. HOMMEN, MD: And that's an absorbable suture, meaning that suture will -- 00:49:17 CARLOS J. LAVERNIA, MD, FAAOS: This suture will go away. The suture will disappear in a matter of two months, it won't be there anymore. But by then, the body will have already healed the tissues and it won't be needed there. 00:49:29 PIETER J. HOMMEN, MD: Yeah. 00:49:30 CARLOS J. LAVERNIA, MD, FAAOS: Do we have that? Ready? So it's a combination of, you know, the spinal that the patient has and this local stuff, and then the preemptive pain management that makes this truly small incision faster type of recuperation for the patient. And it used to be where these patients would go to rehabilitation and they would have to be out of life, if you would, for a period of a couple of months before they got back. And you know, these days, I've had some of my very highly in-shape patients go back to work in, you know, a matter of days. The other question that patients may have is what about ceramic hips? Because most likely you have seen on the internet or heard advertised ceramic hips. Well, in my opinion, ceramic hips are -- are nice, and I'm sure that the surgeons that use them fully believe that it's a much better reconstruction than the one that I just put in this patient, but in my opinion, the advantages that ceramic has over this plastic/metal combination that I used in this patient is definitely not worth it. Ceramic break, number one. The other big advantage that the metal and plastic has is that I had approximately eight options in terms of lengthening or shortening the leg as compared to only two or three options with a ceramic. So those are in a nutshell some of the advantages of the metal and plastic over the ceramic. 00:51:30 PIETER J. HOMMEN, MD: Again, I'd like to remind you, if you have any questions or any comments, please click on the MDirect button on the bottom of your screen. We're getting a lot of good questions. A lot of interest in this type of procedure. How many hip replacements do you think are getting done in the United States every year. 00:51:47 CARLOS J. LAVERNIA, MD, FAAOS: We -- we are probably going to hit 400,000 in Worldwide, over a million. Knee replacements, we're doing more. We're doing close to 600,000 knee replacements in the United States, and probably close to 2 million worldwide. It's very accessible, the surgery these days. It used to be where only a few surgeons knew how to do this type of surgery or dared do the surgery, but with this newer, you know, instrumentation, the availability of centers and surgeons has really made it something that's accessible and available to most people throughout the world. In some of the developing countries, the cost of the implant is what makes it prohibitive. For example, the implants utilized in certain areas of South America are locally made because the American implants are too expensive. And they use locally manufactured implants. 00:52:53 PIETER J. HOMMEN, MD: Another good question: how do you anticoagulate and what does that mean? 00:52:57 CARLOS J. LAVERNIA, MD, FAAOS: Very, very good question. After surgery, there's a risk of a blood clot, and one of the ways to avoid or minimize the risk is to thin the blood of the patient. And what we do is we give the patients coumadin, which is a blood thinner, and we thin them out so that it minimizes the chances of a blood clot. They stay on that coumadin for one month after surgery, and they are encouraged to

15 move because inactivity is not good after these surgeries. So we encourage these patients to walk and to be as active as possible after these procedures. The more they do, the better. Now, obviously, for the first few days, as you can imagine, the patients are a little sore. But tomorrow, this patient will be walking around our floor and probably will be going home either Sunday or Monday. 00:54:02 PIETER J. HOMMEN, MD: There's a real good question here. This patient that we're currently operating on, Dr. Lavernia, is a -- has osteoarthritis, right? But there's a rheumatoid component to this, I think. The patient had a -- an inflammatory arthritis as well. The patient -- somebody asked: if I have avascular necrosis, what does that mean and what are the treatments for that? 00:54:27 CARLOS J. LAVERNIA, MD, FAAOS: Okay. Avascular necrosis is actually one of my research interests, and it's a disease in which the blood supply to the femoral head dies. I'm sorry, the blood supply stops to the femoral head, and that femoral head dies. And when you have that femoral head die, you end up having that cartilage collapse and you have no -- no way to walk without pain because it becomes more and more and more painful, and it gets to the point where the femoral head becomes flat and the patients develop secondary osteoarthritis, which is a process by which both sides of the joint get destroyed, so the socket and the femur get completely destroyed. 00:55:22 PIETER J. HOMMEN, MD: And one more question we have is -- before we show a little bit of the hip arthroscopy in the last couple minutes here -- for patients who have osteoporosis, are they candidates for hip replacement surgery? 00:55:37 CARLOS J. LAVERNIA, MD, FAAOS: Great question. Absolutely. Osteoporosis is not a contraindication to getting your hip fixed. In some cases, it can be severe enough that you may need to put bone cement instead of using this cementless technique or biological fixation that I used, but that's very rare. For the most part, most osteoporotic patients do well with a press-fit device. There are studies that show that these patients do almost as well as non-osteoporotic patients. Now, the surgeon has to have expertise and they've got to handle the tissue and the patient very carefully because on an osteoporotic patient, if you're a little rough on the dislocation of the hip, you can actually cause a fracture. And that's a disaster when you break the bone during an operation. 00:56:27 PIETER J. HOMMEN, MD: Yeah, in the last couple minutes here, why don't we show a little bit of the peripheral compartment of the hip on the arthroscopy segment, and we'll come right back and we'll show the finished incision here on Dr. Lavernia's case. This here -- what we're showing here is the camera is inside the hip joint, and it's -- if you look here outside, I can show you what a camera looks like. The camera goes inside the hip and -- this is the one right here, okay? It's a small camera that we use. And it has a lens on the end, and that lens is hooked up to a video monitor through this cord, okay? And that allows us to basically play video games and look inside the hip joint. So you can see here, that's the labrum of the hip, okay? That's that little capsule of hip that we talked about. And there's a bump on top of the neck here, and that bump, as that hip -- as you bring your hip into a flexion -- can literally cause that labrum to become torn and is pretty painful. So what we do in this -- in this procedure is we literally take this little shaver here, this little burr, metallic burr, very small, and you place that into the hip and you literally can resect that bump away. And you can see here how that kind of works. It basically sucks up the -- whatever you're debriding into the -- inside of the cannula as you use it. So I'll show

16 you a little segment here of what that looks like. And again, this is what the camera looks like, and here's some of the instruments. We'll pan out to what the final product looks like here, and in the meantime, I'll show you what some of these instruments look like inside the hip joint. These are some of the graspers we would use. We can grab things with this. I'm not sure if you can see that, but it's -- okay. These are some of the graspers. Okay, very small little instruments. You can use also -- there's a variety of instruments to repair labrum anchors, anchors that are plugged into the bone that have little sutures on them. Why don't we show that final product of what that hip resection looks like here? Show a little video snippet of that and then we'll pan out to Dr. Lavernia's case and -- actually this is Dr. Lavernia's almost finished product. You can see here he's putting a last couple sutures in. It's a race. You can see, he's doing a great job, almost a completely cosmetic type procedure, and do patients tend to have incision pain after this type of surgery? 00:58:57 CARLOS J. LAVERNIA, MD, FAAOS: No, not really. I think that for the most part, they get incision pain for a few days after, but it goes away within probably a week. 00:59:07 PIETER J. HOMMEN, MD: Okay. Here you can see again -- here's that resection of that bone that we're taking off with that burr. And basically you're removing a prominence that you can see here, quite a large prominence, and as you resect this down, as that patient brings that hip into flexion and all sorts of motions, it's not causing that hip labrum to become torn off. Okay, and here's kind of a finished product of what it looks like at the very end. You can see here that neck, the bone -- the red stuff is the bone exposed. All that white thickened stuff that was on top of the neck, that synovial tissue, has been resected. So that's kind of what it looks like and this patient is doing real well and hopefully getting back to work in the next couple of days. He's only about a week and a half out and doing real well. So why don't we pan in one more time to see Dr. Lavernia's finished work here. Any other questions that anybody has? 01:00:05 CARLOS J. LAVERNIA, MD, FAAOS: I'd actually like to address two points that you probably, those that are watching have seen in the internet. It's a whole issue of surface replacement and the metal-on-metal hip replacements. And let's take the surface replacement first. Some centers are touting the surface replacement as the ultimate and the newest panacea to resolve the problem of hip arthritis, and if you really look at the literature, we have been doing surface replacement for at least 30 years. And I think at some point in time, it may be the best surgical intervention in osteoarthritis, but right now, if you look at the results of the hip that I just did -- the type of hip, the type of material that I utilized -- the predictability, the chances of getting a good result -- meaning 20 years from now, the chances of this patient having this hip in his hip and being happy with it -- exceed 90%. And with a surface replacement, we don't know. The chances of a fracture, okay, with surface replacement are around 5-6%. The chances of a fracture of the hip that's left with this operation is nil because you essentially remove the hip and all you have in here is a hip replacement. So in a nutshell, I think that surface replacement maybe someday be a great thing for patients, but right now, if I needed one of these procedures, this is exactly what I would get, a total hip replacement with the exact same implants I utilized right here. The metal-on-metal, finally, is a newer technology in terms of the types of metals that we have available now, in 2007, compared to when metal-on-metal came out, which was in the 1960s, is a much, much more complicated question. And the metal allergy issue has not been answered. There's a certain percent of patients that have metal-on-metal that have unexplained pain. And the upside, or the advantages, of metal-on-metal, in my

17 opinion, are not worth the trouble. So that's kind of in a nutshell the two questions that I wanted to address that somebody may have because they've been visiting different websites about hip surgery. And now we're putting the last staple, and we are done. 01:02:51 PIETER J. HOMMEN, MD: That was perfect time. I'd like to thank everybody for joining us here at Mercy Hospital for the first ever surgical broadcast done simultaneously in English as well as in Spanish. Thank you, everyone. Live from Miami, bye-bye. 01:03:08 ANNOUNCER: This has been a small incision total hip arthroplasty and an arthroscopic hip femoroacetabular impingement resection performed from Mercy Hospital in Miami, Florida. OR-Live makes it easy for you to learn more. Just click on the "request information" button on your webcast screen and open the door to informed medical care. 01:03:35 [ end of webcast ]