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Hip-replacement technique gets patients back on their feet sooner


TORONTO — Tim Heenan was in his teens when he injured his left hip in a four-metre fall while goofing around with some buddies. When his school hockey coach saw him favouring his leg before practice soon after, he said: "Just wait until you're older."

They turned out to be prophetic words.

Now 60, the construction worker from Innisfil, Ont., found the pain in his hip growing increasingly worse, especially in the last year.

"It was very difficult to get up and down a flight of stairs, up and down ladders," said Heenan, a married father of four and an avid sports enthusiast.

"If you were on the ladder all day long, it would get sore and that got me thinking that it could be time to get the ball rolling for a hip replacement."

Late last year, Heenan discussed making arrangements for a new hip joint with his family doctor, who subsequently called to say he had heard about an orthopedic surgeon at St. Michael's Hospital in Toronto, who was performing the operation in a new way that promised a speedier recovery.

Unlike more traditional hip replacements, with incisions to reach the joint through either a patient's side or back, Dr. Amir Khoshbin is performing the operation through the front and using a special surgical table to aid that approach.

The benefit is that patients begin recovering more quickly and are able to go home the same day as the surgery, instead of needing to be admitted for at least a day or two, as is usually the case.

"There's a different ideology," said Khoshbin, who was trained in the technique in New York. Same-day discharge surgery is still a novel approach but it's increasingly used by doctors in Canada.

"People used to think of hip replacements or knee replacements and you were in the hospital for four to five days," he said. "But now we're saying you're safe enough to go home."

That doesn't mean patients just hop off the gurney at the conclusion of the surgery, though the use of a spinal epidural to numb the lower extremities instead of going under general anesthetic means they are less groggy and not as prone to side-effects like nausea.

Once the epidural has worn off and a patient is feeling stable, the work of recovering mobility begins, with occupational and physical therapists getting the person on their feet and slowly moving with the aid of a walker.

But preparation for life after a hip replacement begins with a visit to the hospital prior to the surgery date, when therapists assess the patient's current mobility status and any equipment they will need at home to aid their recovery and assist them in daily activities like showering.

"That would include what walking aids they would need after surgery, as well as what assistive devices they might need in their home environment, particularly in their bathroom," said physiotherapist Ellen Newbold, who helped get Heenan back on his feet after he recently received his new titanium hip joint.

"So depending on their setup, whether they have a tub shower or a walk-in shower, we may recommend a (bath) seat or a bench to increase their safety there, and as well some individuals may benefit from a raised toilet seat," she said.

"Then the patient feels more prepared."

With Heenan, Newbold and occupational therapist Mary Van Impe began a series of simple exercises while he was still in a post-op bed on the ward, before having him progress to a walker and a short journey down the hallway to an exercise room. Once there, they taught him how to enter and exit a bathtub, walk up and down a short flight of stairs and perform some standing exercises to practise at home.

"I think he did very well," said Newbold. "He showed good tolerance, certainly to his pain. I think when he was demonstrating getting in and out of the tub, that was quite a high surface to lift over.

"He did sort of push through that."

Still, Heenan managed and then gamely made it up and down the few stairs — a necessarily slow process that requires careful steps that favour the leg with the hip replacement. "I feel great," he insisted, as his wife Carrie looked on.

The goal over time is to improve range of motion and strength around the hip joint and throughout the lower extremity, which will translate into improved mobility, explained Newbold, adding that patients are given a series of exercises to perform following discharge home.

Khoshbin said he and the surgical team have done about 15 to 20 rapid-recovery joint replacements since January, including six double, or bilateral, hip replacements, though the latter requires at least one overnight stay in hospital before rehab begins.

Adding this surgical approach to hip replacements took "a lot of changes from many different disciplines within the hospital," he said, noting that St. Mike's surgeons continue to perform more traditional methods of the operation.

Khoshbin points out, however, that the newer technique provides a cost-saving to the budget of about 20 per cent — or roughly $1,800 — because it does away with the overnight stay in the hospital

So is this method better?

"I wouldn't use the word better or easier," the surgeon said. "I do think if you look at the different approaches for hips, if you look at six months or a year, there's absolutely no difference with respect to outcomes. At one year, 90 to 95 per cent are doing very well.

"However, there might be a faster recovery and maybe a little less use of narcotics, being able to wean off the ambulatory aids, mainly within the very acute phases of two to six weeks.

"So it does help with the rapid recovery."

However, this form of surgery isn't applicable for every patient, he said. "But I do think there are people, for example people like Tim, who is very healthy and can be safely discharged."

For Heenan, the appeal of the same-day-discharge technique is the shorter healing time, which should mean he can resume working sooner and get back to his favourite activities.

"I played a lot of sports," he said, "so I'd love to be able to do that and be a little faster and more mobile, without all the pain."

 

— Follow @SherylUbelacker on Twitter.

Sheryl Ubelacker, The Canadian Press

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