By Michele Howe
In just two hours, a patient can go from days of pain and reduced mobility to a new lease on life.
Those people are among the more than 193,000 who undergo total hip replacement surgeries a year, says the American Academy of Orthopaedic Surgeons.
Imagine how completely life changing this two-hour investment is to those patients. It’s value? Irreplaceable. And it’s all thanks to a doctor and his surgical team who are precise and methodical in their work — testing and retesting the new, artificial joint until it fits perfectly.
When a patient requires a new hip, it is no minor problem to solve, but once the surgeon has removed what was damaged and fitted his patient with a brand new hip, the patient most certainly will be saying in a few short weeks’ time, “I don’t just feel better, I feel better than new!”
For most people, a hospital operating room is the last place they want to find themselves.
Not me.
While I prefer to not enter those swinging doors dressed in a gown that ties in the back and escorted in on a bed with wheels, there’s nothing like walking in on my own two feet because I want to be there — as an observer.
To me, reading about a medical procedure is interesting. Even watching an online video has its merits. But to my mind, there’s nothing better than to actually be there, in the flesh, studying a surgeon as he uses all his skills to bring renewed health and healing to a patient right before my eyes. From start to finish, the whole process is as amazing to watch as the result is for the patient.
I was reminded of that when I viewed a total hip replacement surgery performed at Flower Hospital in Sylvania, Ohio, by Dr. Christopher A. Foetisch, an orthopedic surgeon whose practice is located at the Toledo Clinic.
Moving around the room so I could get the clearest visual during each step of this intricate procedure, I watched, asked questions, took notes and inwardly marveled at what can be done to remake (and replace) such an essential part of the human anatomy.
PREPARATION FIRST
Here’s how it’s done, and it all starts with the preparation.
First, Dr. Foetisch and his assistant rub the antiseptic Avagard all over their hands and forearms at a simple sink area. They then enter the OR using their shoulders so as to not contaminate their hands and arms. An OR nurse helps them put on their head-totoe suits (think hazmat in appearance), complete with shielded helmet-like head coverings and rubber gloves. But long before the surgeon enters the room, his team of nurses, surgical technicians and a nurse anesthetist has been working hard to prepare the patient (getting her general anesthesia started and her body positioned correctly) and the surgical trays (the hardware and miscellaneous surgical tools) ready for the operation. Each person knows his or her role and performs it with skill, timing and exact execution.
Picture now the patient under the sway of anesthesia, lying on her side so her damaged hip is facing the ceiling. All the key players encircle her as the procedure begins. A circulating nurse “calls out” the patient’s name and what work is being done on her as Dr. Foetisch checks “his signature,” which he wrote on her hip just before she was wheeled into surgery.
The nurses then start disinfecting the entire hip and leg area. Completely draped and covered, only the patient’s hip and leg are exposed when they place Ioban (an antimicrobial adhesive drape that provides a sterile surface to the wound edge at the start of surgery and continuous antimicrobial activity throughout the procedure) all over the hip area.
THE FIRST CUT
The doctor measures, marks and then cuts open the hip with an incision about 8 to 10 inches long. He cuts through skin, fat, then fascia (connective tissue) to reach the hip socket itself. Using retractors, his assistants hold the area open (suctioning any blood or cartilage fragments out) as the surgeon inspects the hip closely.
Next, Dr. Foetisch dislocates the hip in one vigorous yet fluid movement and cleans the acetabulum using a reamer attached to a drill (the femoral head is removed before the acetabulum is reamed in order to gain access to the socket).
Now, the real tricky part begins as the surgeon must fit the largest replacement component that he can into this now empty hip socket. He places various trial sizes into this opening until he achieves the tightest fit possible to ensure this patient’s hip will enable her to move with comfort and stability for years to come.
As the doctor works to create that perfect fit, he taps the femoral cup into place with a metal instrument that is termed (hitting the floor) until he hears a change in pitch during the tapping and is satisfied with the result.
Once the surgeon determines the exact size of the acetabular component needed, he tells the sales representative what he requires. The rep locates the correct replacement part and “calls out” the size and number as the surgeon’s assistants continue to keep the open hip area clear with suctioning tubes.
Depending upon the patient, Dr. Foetisch sometimes will grind bits of the damaged femoral head into small pieces, mixing these tiny bits in a cup and then packing the new acetabular component with them to help promote ongoing bone growth once it is placed into the hip socket.
This metal component then is pressed into place as the surgeon checks and rechecks numerous angled positions before snapping the liner into the cup and securing it.
The canal is cleaned again, this time, however, Dr. Foetisch does the job by hand, rather than power, using a broach.
MAKING THE FIT
Next, the surgeon begins manipulating and moving the leg and hip into different positions before fitting the new metal femoral component into place.
He checks and rechecks the patient’s legs to ensure the correct sized femoral component is used so that they will be the same length after surgery as before.
Reduction is the process of putting the hip back in socket after it is dislocated and is called a “trial” as Dr. Foetisch meticulously examines various trial balls, inserting them, removing them, until, once again, he locates the perfectly sized component to fit his patient’s specifications. The hip is actually dislocated each time during trialing; this is how the different sized heads are placed to determine leg length and hip stability.
The selected femoral component then is “called out” by the sales rep and he hands it to the surgeon who places it into the femur and pounds it into position.
Once Dr. Foetisch gets it exactly right (and he doesn’t stop until he is perfectly satisfied the fit is “perfect”), he moves the component into place and the replacement process is finished.
The surgeon then starts to “close up” the wound site, going through the same multi-layered process as when he opened up, only in reverse. Working from the inside out, he sutures the fascia, then the fat and finally the outer skin area before assistants remove the Ioban adhesive drape, disinfect the area and begin applying the special bandages as the patient is readied to move into the recovery area.
There’s something just short of miraculous happening every day in operating rooms around the country and my most recent visit to the OR convinced me of this fact yet again.
The AAOS calls total hip replacement surgery “one of the most important surgical advances of the last century.” It’s development since 1960 has helped millions of people enjoy their everyday activities once again.
Michele Howe is a LaSalle resident and author of “Burdens Do a Body Good.”
