Michael Pagliaro, left, laughs with Paul Scattaretico at the Muzic Store Inc. in Dobbs Ferry, N.Y., as Pagliaro picks up instruments for his rental business. Before Pagliaro had a hip replacement, pain made it difficult to work.
Michael Pagliaro, left, laughs with Paul Scattaretico at the Muzic Store Inc. in Dobbs Ferry, N.Y., as Pagliaro picks up instruments for his rental business. Before Pagliaro had a hip replacement, pain made it difficult to work. Maggie Starbard/NPR
Every year more than a quarter of a million Americans have total hip replacement surgery. It's almost always a successful operation that frees patients from what's often described as disabling pain.
But in recent years, there's been lots of discussion on the Internet about "anterior approach" hip replacement, a surgical technique that's different than the standard procedure. It's one that proponents say can lead to quicker recovery, three to four weeks compared to six to eight weeks for typical surgery.
Some people have been willing to give it a try, even though there's no conclusive research showing it's better than other approaches.
Take the case of Michael Pagliaro, 52, who lives in Scarsdale, N.Y., and runs a company that rents and sells musical instruments to schools. He's an active man, has a personal trainer, rides horses and works hard. So when his hip started hurting last year, he says, he "got very sad."
When he walked, the pain from his hip made his knee buckle. He was diagnosed with avascular necrosis – blood was not adequately flowing to the hip joint, causing the bone to degenerate. Doctors told him he needed surgery to replace the damaged bone and cartilage in his hip with an artificial ball and socket.
"He explained that it's a very eventful surgery, that I'd be incapacitated for six weeks, have to sleep with a pillow between my legs, can't do this, can't do that," says Pagliaro. That, he says, was a "real buzz kill."
Each year about 332,000 people get a hip replacement, making it one of the most commonly performed surgeries in the United States.
Doctors recommend a total hip replacement when the hip joint is damaged by arthritis or other conditions, making it painful to walk and be active.
In the surgery, the damaged head of the femur is cut off. A metal stem is put in the center of the femur. It's topped with a metal or ceramic ball.
Cartilage inside the hip joint socket is removed, and a metal socket is installed. A plastic liner between the ball and socket lets the hip move smoothly.
Serious complications happen less than 2 percent of the time. They include joint infection, blood clots, and dislocation of the joint.
Sources: American Academy of Orthopedic Surgeons, Centers for Disease Control and Prevention, National Institutes of Health
Overwhelmed by what sounded like a difficult recovery period, Pagliaro searched for alternatives. He tried physical therapy and avoided certain activities. But the pain persisted, and he came to realize that surgery was inevitable. When he searched online, he discovered a surgical approach to hip replacement that sounded a lot less overwhelming than what the doctor described.
Soon Pagliaro found his way to Michael Alexiades, an orthopedic surgeon at the Hospital for Special Surgery in New York City. Alexiades is one of the surgeons responsible for the recent resurgence of interest in what's called the anterior approach. In this case, surgeons enter the hip joint from the front of the thigh, rather than the more conventional posterior approach, from the back.
"When I did the anterior approach, it was dramatic how quickly the patients were getting up and walking and how quickly they were ready to leave the hospital," says Alexiades. "They were leaving the hospital a lot quicker than my posterior approach patients." He says the anterior approach cut recovery time in half for some patients.
The fast recovery may have to do with less muscle being cut and stretched during the anterior procedure, Alexiades says. Patients also reported less pain with this approach. Michael Pagliaro was sold, had the surgery and was out of the hospital in two days. "I was at home having lunch at my favorite restaurant with my friend and my wife; everyone said it was amazing. 'Didn't you just, eh eh eh......?'"
Pagliaro had a cane for support but didn't really need it. The following Monday, just one week after surgery, he was back on the job. And not even taking pain medication, just aspirin as needed. (But he's still not back to riding horses.)
According to Alexiades, "I would think probably nine out of 10 people who need a straightforward total hip replacement for the first time are good candidates for an anterior approach."
But there are patients who aren't good candidates. That includes those with major bone deformities since birth or those getting a 're-do,' a second or third replacement surgery, or patients who are obese.
In these more complicated cases, surgeons can actually see better using the posterior technique. It also takes less time and, according to orthopedic surgeon Thomas Sculco, also at the Hospital for Special Surgery, offers other benefits. "There's less blood loss, no need for X-ray during procedure, and in my experience, the recovery is as quick as with the anterior approach," he says.
Pagliaro chose a less common form of hip replacement surgery, called the anterior approach, because he thought it would allow a faster recovery time. He was back at work after a week.
Pagliaro chose a less common form of hip replacement surgery, called the anterior approach, because he thought it would allow a faster recovery time. He was back at work after a week. Maggie Starbard/NPR
In over 35 years of practice, Sculco has performed over 10,000 hip replacements and like most surgeons today, relies on the posterior approach for hip replacements for most of his patients. "I'm slow to change to something else unless I can see some real advantage to changing," he says. "And I really don't see any advantage to changing in this case, either in terms of outcomes or in terms of recovery."
Patients looking for clinical trials that directly compare complication rates, pain, and recovery time for the two techniques are going to be frustrated. There aren't any. A 2004 review of studies on both techniques found there wasn't enough evidence to say which was better.
There is a lot of research on the posterior approach, which has been used since the 1960s, but much less on the anterior approach. Small trials that have been done on the anterior procedure have found a higher rate of bone fractures during surgery. But it's unclear if those results come from the fact that many surgeons aren't experienced with the procedure or from other issues.
There's also no data on how often the anterior approach is performed. The American Academy of Orthopedic Surgeons says that about 20 percent of their members know how to perform the surgery.
Critics say the increased interest in anterior approach surgery may be more due to marketing from doctors, hospitals and companies that sell specialized operating tables and other gear rather than any benefits to patients.
Clinical trials comparing the two methods are underway at the Mayo Clinic and at the Hospital for Special Surgery, but it may well be five years before that data is available.
In the meantime, doctors says it's important to look at the big picture.
Today "most healthy patients recover quickly, no matter which surgical technique is used," says orthopedic surgeon Mark Pagnano with the Mayo Clinic.
Claims that less muscle is cut when entering from the front of the thigh for the anterior approach isn't true for most patients, Pagnano says. "Small muscles often end up being cut in both procedures," he says, as surgeons work to stretch and move muscles in order to get into the joint.
So why all the Internet hype about the anterior approach? Something that sounds new and different is appealing, says Pagnano, and many procedures are promoted on the Web as new. That doesn't necessarily make them better, he adds.
Michael Pagliaro pedals on a stationary bike in the warehouse of his business in Dobbs Ferry, N.Y. Working out is fun again now that his hip doesn't hurt.
"What patients really need is knowledge," says Pagnano, "the Internet is great for providing information, but it lacks a context in which to interpret that."
How does a patient sift through all the information and make an informed decision? Dr. Joshua Jacobs, president of the American Academy of Orthopedic Surgeons, says patients should investigate information on a reputable website like the academy's website, which can also help them find a surgeon.
One key question to ask an orthopedic surgeon is about the number of times he or she performs this procedure in a year. Like most things in medicine, practice makes perfect. And being expert, says Jacobs, means performing a surgery at least 100 times a year.
Once patients have found a doctor, they should talk the physician which technique is best, given the patient's history and preferences.
Jacobs emphasizes that all techniques have gotten better over the years, with fewer complications and faster recovery times.
"All approaches to hip replacement have gotten less invasive over time because of our understanding of anatomy, more sophisticated surgical tools and instruments that allow better access with a smaller incision," he says. "All the surgical approaches are less invasive than they were seven to 10 years ago."