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2013: Important Dates for UCSF Orthopaedic Surgery

Larry Kufel’s surgeon, Dr. Joseph T. Moskal, used the anterior technique for his hip replacement. Mr. Kufel said he was back at work the second week after the operation.

Larry Kufel had always been an active man, tall and rangy, who worked out regularly and picked up basketball games at the gym. But age was taking a toll on his joints, and it had become clear that he needed a hip replacement.

“It got to the point, if I did any exertion, even getting out of a chair, it felt like the muscle was tearing away from the bone,” he recalled.

Still, Mr. Kufel, 63, a financial controller in Roanoke, Va., worried that conventional hip replacement surgery would mean a long, painful recuperation. Instead, his doctor proposed an alternative that is gaining popularity across the country, an operation that many surgeons say helps patients recover more quickly.

Mr. Kufel was amazed by the results. “I was back to work the second week after the operation,” he said. “By the fourth week, I was doing a spin class at the athletic club.” A year later, he’s cycling, lifting weights, and even playing racquetball.

“I feel like I never had surgery,” he said.

The procedure that Mr. Kufel received is called anterior hip replacement. The surgeon makes the incision at the front of the hip instead of through the buttocks or the side of the hip. This approach permits the doctor to reach the hip socket without cutting through major muscle groups. Proponents claim that the procedure results in less pain and fewer complications for patients than standard hip replacement.

“We’re seeing more and more data that patients recover quicker, discontinue use of a cane or walker sooner, and have a quicker return to a normal gait,” said Dr. Joseph T. Moskal, chief of orthopedic surgery at Virginia Tech Carilion School of Medicine and Research Institute, who was Mr. Kufel’s surgeon.

Surgeons have used an anterior approach to perform emergency hip repairs for decades. Anterior hip replacements were first introduced in the United States about 10 years ago and have gradually gained popularity. No one knows how many surgeons currently use the new approach, but at a recent meeting of hip and knee surgeons, an informal survey suggested that as many as 20 percent of hip surgeons are now performing anterior hip replacements, according to Dr. Moskal — up from “less than a handful” in 2005. With more than 400,000 total and partial hip replacements performed each year in the United States, a change in technique would eventually affect millions of Americans.

Proponents note that because the operation spares muscles, patients don’t need to limit their movements during the recovery period.

“You can bend over,” said Dr. Robin N. Goytia, an orthopedic surgeon in Houston. “You can reach down to the floor. You can cross your legs — all things that patients with a posterior approach have to be careful about for a while because they can dislocate the hip.”

Surgeons who perform the procedure also say the anterior position makes it easier for them to use fluoroscopy, a real-time X-ray technique that allows doctors to precisely position the implanted artificial hip. That, in turn, may allow artificial hips to last longer.

And since the major muscle groups of the hip are left untouched, there appears to be a lower risk that the artificial joint might pop out, or dislocate, said Dr. Francis B. Gonzales, an orthopedic surgeon and assistant clinical professor at the University of California, San Diego.

Conventional hip replacement techniques have a dislocation rate of about 1 percent. Preliminary studies suggest that the rate following anterior surgery may be less than one-third of that.

Yet reports of the benefits are mostly anecdotal, based on surgeons’ experience. No large randomized studies have been done comparing the outcome of anterior surgery with other approaches. And there are downsides.

Anterior hip replacement often takes longer to perform and can result in more blood loss. Some patients experience temporary numbness in the thigh afterward.

Because the operation is tricky to perform, there is a steep learning curve for physicians, which partly explains why it hasn’t been taught as widely as other approaches in medical schools. Special operating tables have been designed that make the surgery easier to perform, but many medical centers don’t have them.

Even surgeons who perform the new procedure are quick to say that it isn’t “minimally invasive,” the term often used in marketing materials.

“We can do any of these approaches through a small incision, but it’s a little like assembling a ship in a bottle,” Dr. Goytia said. “If you’ve ever seen a hip replacement, it’s not a tissue-friendly surgery. We have to do a lot of bone work and cuts, and we use a lot of power tools.”

Despite a rising chorus of support, not all orthopedic surgeons are convinced that anterior hip replacement offers significant advantages over the traditional approaches.

“As far as we can tell from the data, it doesn’t appear that the surgical procedure is as important to recovery as the pain management protocol, the rehabilitation protocol, and a patient’s baseline pain and functional status,” said Dr. Kevin J. Bozic, professor and vice chairman of orthopedic surgery at the University of California, San Francisco.

In the end, he said, a surgeon’s skill and experience are by far the most important factors. Doctors who do hundreds of hip replacements a year typically have very low complication rates, no matter what approach they favor.

“Most surgeons become comfortable with a single surgical approach and they perfect that over time,” Dr. Bozic said. “You definitely don’t want to go to a surgeon trained in the posterior approach and insist on an anterior approach.”

His advice? “Find an experienced surgeon and a medical team you trust and feel comfortable with, and leave the technical issues up to them.”

A version of this article appeared in print on 03/19/2013, on page D5 of the NewYork edition with the headline: New Approach to Hip Surgery.

By PETER JARET

Recipe for Relevance: Blend Digital Health Developers and Clinical Providers

I wanted to capture a few quick top-of-mind reactions to a much-needed, well-executed event I attended Tuesday night, a “Meeting of the Minds,” co-sponsored by the digital health incubator Rock Health and the UCSF Clinical and Translational Science Institute (CTSI). The goal: bring together healthcare providers who have specific pain points with technologists eager to develop solutions.

This event happened to showcase several of my favorite themes: the importance of “field discovery” (i.e. innovation driven by practitioners, as described by MIT Professor Eric von Hippel), the need to create more useful digital health companies (vs more trivial apps); and the need to crowdsource problems not just solutions.

The organizers – particularly UCSF surgeon Aenor Sawyer – clearly put a lot of effort into selecting the handful of healthcare speakers, and in guiding them to succinctly describe their key problems.

The result was a captivating, diverse series of presentations highlighting key challenges with which various folks at UCSF were actively struggling:

- Ralph Gonzales, an internist and epidemiologist with an interest in health systems, discussed the increasing use of specialists, and the associated impact on healthcare costs; his specific question was whether alternative approaches (perhaps technology-enabled) could reduce the need for follow-up visits with specialists.

- Christine Ritchie, a geriatrician, discussed the increasing use of potentially dangerous opioids to manage chronic pain in the elderly, and asked whether there were approaches that could permit the more comprehensive monitoring of such patients between visits.

- Kate Possin, a researcher in UCSF’s Center for Memory and Aging, discussed the rising incidence of dementia, and emphasized the need for improved assessment tools for early cognitive impairment, tools both sensitive and efficient.

- Kirby Lee, a faculty member of UCSF’s School of Pharmacy, provided an overview of the remarkably complex challenges of medication adherence; he highlighted some of the solutions already available, and emphasized that an effective solution might bring together existing tools in a creative way.

- Christine Kennedy, a researcher and pediatric nurse, discussed the need for health applications that are relevant in the community, where the degree of “health literacy” may be appreciably lower than most developers appreciate. In particular, she highlighted the need for greater use of images and videos, and tools that help “regular” people (i.e. not QS fitness freaks [my phrase not hers]) increase activity in their daily lives.

- Michael Turken, a thoughtful fourth year med student at UCSF, reviewed the existing process of medical training, and pointed out a number of specific areas where technology-enabled approaches might be helpful.

Is tonight’s forum going to lead to the next (some wags would say first) great digital health company? Who knows. But I was delighted and heartened by the approach, which in many cases surfaced opportunities that those outside of healthcare might never have known about, or conceptualized correctly.

I was also pleased by the range of topics; while perhaps a bit heavy on the operational improvement side, you could also see how some solutions (e.g. to the improved assessment of early cognitive impairment) might lead to profound basic scientific insights as well.

If some of the presentations today were flawed, it was in their vision of their problem, a perspective that (understandably) tended towards the immediate and pragmatic. For example, during the discussion of how technology might be used to help med students memorize anatomy, metabolic pathways, and differential diagnoses, all I could think (not for the first time) was how pointless – especially given our access to technology — so much of this rote memorization is. As Clay Christensen might say, we might want to take a more careful look in some of these areas at the underlying problem that truly needs to be solved.

Given the size, energy, and motivation of the developer community, and the number of challenges healthcare providers contend with every day, I can imagine that it might make sense for Rock Health and UCSF’s CTSI program to consider repeating this event, virtually – bringing together geographically dispersed developers to address discrete pain points described succinctly by similarly dispersed providers and researchers.

True, provider/technologist meetups – whether live or virtual – are unlikely to provide a panacea for our nation’s healthcare challenges; however, they could easily spark ideas and establish connections, and lead to new approaches to medically-relevant questions.

David Shaywitz, Contributor

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PBS NewsHour followed up with some of their favorite stories from the past year and asked them what they see in the year to come. Dr. Richard Coughlin was among their favorite interview subjects from the past year and was asked he hoped to see in the next 12 months.  Read his commentary here.