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Getting a new hip may go easier when surgeon cuts less

February 6, 2002 Barbi Martin got a new hip Tuesday while her doctor worked through an incision less than half the usual size - a 3 ½ -inch cut that could make her recovery faster and less painful.

In every other way, the operation was just like the estimated 300,000 hip surgeries done in this country annually.

Although the shorter incision does not eliminate discomfort, patients say it reduces the pain caused by the usual footlong cut through muscle to reach the hipbones. Only one surgeon is doing this procedure in Central Florida, but Dr. David Dore thinks other physicians could turn to the kinder cut in the future.

"It's a more difficult operation for the surgeon, so I don't think everyone will go to it. But once you see it's much better for the patient - less pain, less bleeding - it's hard to go back," said Dore, medical director of the Joint Replacement Center at Florida Hospital Celebration Health. "There's just a lot less dissection, a lot less cutting of muscle, a lot less tissue damage."

Finding a less destructive way to do hip surgeries is important because the number of such procedures is expected to increase with the aging population, reaching up to 600,000 a year in the United States by
2015.

But surgeons also caution there is no proof yet that the smaller incision is better for the patient. The procedure is being done by a small number of doctors nationwide, and more study is needed to document a true advantage, said Dr. John Callaghan, an orthopedic surgeon and president of the American Association of Hip and Knee Surgeons.

Too early to be sure

"We think it's a good idea that people are working on a lot of innovative approaches, but it's too early to report any large benefits from this," said Callaghan, who is a professor of orthopedic surgery at the University of Iowa in Iowa City. "Eventually, this [small-incision surgery] may become the standard, but we're not there yet."

Dore had additional training in Chicago and New Jersey to learn how to carry out the work through a smaller opening. He has done about a dozen of the surgeries so far.

Martin, 57 of Vero Beach, will need to use crutches for weeks, then a cane before she can walk without any assistance. Her new artificial hip still must grow into her bone - a process that is not reduced by the shorter incision. But she is hoping for less pain and tenderness from a traditional surgery.

Back to the dance floor

Her ultimate goal is to hit the dance floor, work in the yard and return to the active life she had before her degraded hip made it too painful to be on her feet for long.

"I've had to give up a lot of things. I can't even clean the house the way I used to," said Martin, who works for the Press Journal newspaper in Vero Beach. "Dr. Dore said I may not be swing dancing, but I'll definitely get back on the dance floor."

In hip surgery, the doctor removes diseased portions of the hip and replaces them with artificial components. People typically need the operation because of injuries, arthritis, bone tumors and loss of blood flow that causes the bone to wither away.

Although the surgical procedure itself is not changed by the small incision, the doctor has to alter his technique to get the work done, Dore said.

"There are little tricks that you learn, moving the leg as you're doing it," he said.

The surgery also requires modified retractors - surgical tools used to push muscles out of the way to reach the hip. Dore said he starts with the smaller cut but stands ready to widen it if necessary. A patient's anatomy may make it too difficult to work through a 3-½ -inch incision. Even so, Dore said, he expects to reduce the incision every time by at least 50 percent of the traditional surgery.

She's a believer

Aline Pierce, 69 of Kissimmee, had both of her hips replaced in surgeries four years apart. The first was done the traditional way in 1997, but Dore took out her second hip in January using the new approach.
For Pierce, there is no question that the smaller cut gave her a better recovery.

She had put up with the pain, which was keeping her awake at night, because she dreaded the idea of going through another hip-replacement procedure.

"I knew what I went through the first time, and I didn't much care to go through it again," Pierce said.
"But things were altogether different with this surgery. When I went to see [Dore] for my checkup, I wanted to kiss him."

Before the technique gets full support of orthopedic surgeons, however, Callaghan said, research is needed to make sure the smaller incision doesn't lead to new problems, such as a greater chance of infection or dislocation. He said it could be another five to 10 years before doctors reach a consensus on it.

But Dore has found an unquestionable advantage for his patients. He sees the advance as a natural outcome of the push throughout medicine to reduce incisions and improve a patient's recovery.

"I was somewhat skeptical at first, and I thought I'd wait to see how it goes," Dore said. "But the reality is, this is eminently doable."

Robyn Suriano can be reached at rsuriano@orlandosentinel.com or 407-420-5487.