New Tools, New Anesthesia, New Therapy Means Big Changes in Hip Replacement
David Heuck is a lot like most people when something hurts and doesn't get better. "I just didn't want to go in to see my doctor," he said. "I didn't want someone to tell me I'd have to have something done."
At 51, Heuck is the father of two young children, a busy executive and a guy who likes to be active. Golf is part of his daily environment and he enjoys the game. He'd been active in sports in his youth, but around the time he turned 14, that stopped being so easy when his lower back began to hurt. A doctor told him it was because his legs were different lengths. "Go to a shoe repair person and have an insert made," the doctor said. The back pain stopped.
As far as Heuck was concerned, that fixed the problem and life went on as usual. Two years ago, however, he played golf two days in a row. The next day, "all of a sudden, I had some pretty intense pain in my hip. I didn’t think much of it. I figured I'd tweaked something the wrong way," he said.
But it didn't go away, and it didn't go away, and Heuck turned to some online medical information which made him think he had bursitis, an inflammation in a joint that can resolve itself. "I was pretty good at compartmentalizing things," he said. "I just gimped along."
It gets depressing when you can't do things you normally would do. I just got to the point of thinking, 'This is how it's going to be.'
When he played catch with his son, he could only go for balls on one side of his body. When he bent down, it was an awkward, stork-like movement. He couldn't walk uphill or stand for any length of time. The pain was constant, even waking him at night. "It gets depressing when you can't do things you normally would do," Heuck said. "I just got to the point of thinking, 'This is how it's going to be.'"
Trying something different
This April, he walked up in front of an audience to give a presentation and his doctor happened to be there. Afterwards, he came over to Heuck and said, "What is up with you? Go get an MRI."
Within minutes of the MRI test's end, "the guy who's reading the results tells me he's surprised I'm even walking," Heuck said. His doctor began a search for someone to help. "He asked around and talked to people and gave me Dr. Miller's name. He said Miller was doing some new procedures that maybe were a little bit less invasive," said Heuck.
Miller is Matt Miller, MD, an orthopaedic surgeon at Stanford Hospital & Clinics, with a Stanford University undergraduate degree in human biology and a cum laude graduate of Boston University School of Medicine. His special interest and training is in minimally invasive techniques for hip and knee replacements and design of hip and knee implants and instrumentation.
He has also done more than 750 hip and knee replacements.
Miller represents a generation of surgeons "who grew up playing video games, so surgical techniques like arthroscopy, working from a monitor and using instruments to do something on a different plane make sense to us," he said. "It's about relearning what you're supposed to look for, where vital structures are and how to use the newer instruments to protect those structures."
The goal is to get people healed quicker so they can get back to work and get back to life.
Miller is also part of the broadening trend throughout surgical specialties to use smaller incisions, an approach that reduces tissue damage, which can reduce surgical pain and recovery time.
With hip replacements, the introduction of minimally invasive techniques, in combination with changes in anesthesia and rehabilitation has transformed a once-lengthy and very painful operation. "It is still a serious procedure, however," Miller said, "and patients should exhaust non-operative measures first.
All went well with Heuck's surgery, and when he was back at work only six days after Miller replaced his hip, walking unassisted, some of Heuck's colleagues thought he'd decided not to have the surgery after all.
- Replacing the ball and socket hip joint is a relatively new surgery the first routinely successful modern procedures were performed in the 1950's and 1960's. Now, more than 300,000 hip replacements are conducted each year in the US.
- Most hip replacement candidates are between 60 and 80 years old, but barring other health conditions, there is no weight or age limit.
- All our joints are cushioned by cartilage; when it becomes damaged or wears away, the absence of a cushion means pain from bone on bone contact. The hip is the largest joint in the body, the primary support of our body weight.
- The hip joint can deteriorate for many reasons; the most common is the effect of osteoarthritis, where the cartilage that cushions the movement of our bones wears away.
- Without that cushion, every movement of a joint becomes painful, even while resting, day or night. Being overweight also puts stress on the hip joints.
- Some sports activities may mean harder wear and tear on hip joints, and hip replacement at an earlier age.
- The pain may be dull and aching, or sharp. A worn-out hip joint may cause lower back or knee pain, too.
- Replacing the hip joint means putting a new covering on the socket, located in the pelvis and creating a whole new version of the ball-shaped top of the femur that fits into the socket. A metal stem is inserted about six inches deep into the femur, with a ball, usually metal, anchored to its tip to complete the mechanism.
- Hip replacement surgery may still mean restrictions on certain kinds of movement, like jogging or high-impact sports.
- When properly cared for, a well-positioned hip replacement can last for 20 years or more.
Smaller can mean faster
In Heuck's first meeting with Miller, the physician was very direct. "You've exhausted your non-operative options," Miller said, "and your best option is to have the hip replaced." Heuck's left hip had never formed properly—that had caused the difference in his leg lengths—and it failed quickly, relative to his age, Miller said. "That's often the case."
Miller explained what he wanted to do: Instead of a 10- to 12-inch incision, a three-to four-inch incision; instead of a general anesthesia, which often causes postoperative nausea and mental confusion, a spinal anesthesia, which would avoid that side effect and dampen nerve fibers that respond to surgical pain. He would also use a long-acting local infusion of a numbing, Novocain-like medication, in combination with a drug that causes blood vessels to constrict and keep the numbing medication from dispersing.
After the surgery, Heuck would be given pain medications, but fewer narcotics, which can interfere with a patient's ability to participate in therapy. Within hours of the surgery, Miller would be asking Heuck to get up right away, and expecting physical therapists to help Heuck walk and get himself in and out of bed. That kind of immediate activity, Miller said, can cut rehabilitation time to weeks instead of months.
It's a hugely different scenario from the early days of hip and knee replacements, in the 1960's, when patients might spend three to four months in the hospital and then many more months recovering full function.
With newly-designed instrumentation that allows less damage to muscles, through that smaller incision, the kind of fast recovery Heuck experienced is now possible. "Healthy, younger patients can go home the morning after," Miller said. "The goal is to get people healed quicker so they can get back to work and get back to life."
The smaller incision surgery is more technically demanding, Miller said. "You have to know how to look at things, to know what you're looking for. You have to have lots of experience and specific training with hips and knees before you do small incision replacements."
Less fuss, less pain
Before his surgery, Heuck and his wife, Janie, had to attend a pre-surgery class, of sorts, to learn what to expect. Heuck said he was surprised at first because he was 20 years younger than everyone else. Then, as the class continued and the instructor was explaining about drains and bandages, Heuck said, she kept turning to him and saying, "Oh, you won't have that with Dr. Miller," Heuck began to appreciate how his hip replacement might be different from most.
"I don't think I had a full appreciation of how wonderful it was going to be," said Janie Heuck. "It was all new to us." She visited her husband in the recovery room immediately after surgery and expected to say hello and leave. "I thought he would be loopy, and he was completely coherent!"
It's changed our quality of life, for sure.
Heuck told Miller he never felt any pain at all.
They left at 11 am the next day, less than 48 hours after he emerged from the operating room. Heuck's surgery was on a Thursday; he stopped taking pain medications on Monday evening. And, Wednesday, he went back to work, which brought those colleagues to wonder if he'd skipped the surgery. Six weeks after the surgery, Miller gave him the okay to play golf again, albeit sensibly, and Heuck went out onto the course for a bit. "It felt great," he said.
"My son is excited for his daddy to be able to run with him and I'm excited because he'll be able to exercise with me," Janie Heuck said. "It's changed the quality of our life, for sure."
About Stanford Hospital & Clinics
Stanford Hospital & Clinics, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Hospital & Clinics is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Hospital & Clinics: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.