Halifax Health Presents: Total Hip Replacement

Transcription

1 Halifax Health Presents: Total Hip Replacement Halifax Health Florida June 28, 2011 I am your guest host. I am your guest hose, Dr. Scott Klioze, and we ve got a wonderful program planned for you guys tonight. But before we get started, I want you to do me a favor. Go out and gather up the family, get the kids off the Xbox and the Wii and bring them into the computer room. Go find your teenagers and pull those little Smart Phones out of their hands, give their little texting thumbs a rest and do something you probably haven t done in a long, long time, have a quality learning experience all together, free of charge, courtesy of Halifax Health. Because like I said, this is going to be a great program, but what s going to make it absolutely fantastic is going to be your participation. You re going to have an opportunity to ask questions. We re going to teach you how to do that in just a moment. The best part about all of this is that it s being broadcast on the World Wide Web, so if you ve got your grandson in California maybe interested in a medical career or your grandfather is over in Kentucky and he s considering some sort of orthopedic procedure, they can log on and watch the same thing that you re watching live, so come Christmas Break, Thanksgiving Break, at the end of the year you got something to talk about besides the weather. So while you guys, and I don t want you to leave, just pick one individual to go gather up the family members and bring them into the room, and I m going to go ahead and talk about our introductions here, introduce our stars of our show. To my left, I have Dr. Albert Gillespy. He is going to be our commentator for tonight, surgical commentator. In the other room, the Grand Poobah, the chief, in the main ring, the center ring is going to be Dr. Mark Gillespy. Welcome, gentlemen. Thank you very much. Thank you very much, Dr. Scott. And Dr. Gillespy is now -- on the screen right now showing us what he s going to be doing. And if you noticed when I introduced them, they have the same last name, and that s not a coincidence. They are brothers. Dr. Albert is the older of the two brothers; is that correct? That is correct. That s correct. So he is going to be basically commenting on what his younger brother is doing in the other room. And he s basically showing us everything you taught him over the years. Not everything, but most everything. Most everything. But that s what big brothers are for. So we re going to go over to Dr. Mark for a moment here and just find out a little bit about the patient that he s selected for tonight s program. Well we re online now in the room, folks. This gentleman just turned 45 years of age. He s a big fella. He s, you know, very muscular, large boned. He has a condition that developed that s called avascular necrosis. That means that the blood supply to the ball and ball and socket of the hip has died. So, you know, just like you stop the blood supply to anything else in the body, that tissue over time deteriorates, and has developed a very rapid arthritic condition, extremely painful condition of the hip. So we talked to

2 him, and he has volunteered to be a patient tonight to help instruct people who are watching this live broadcast, and we really welcome you to him. He s 45 years of age, and we re doing an exposure for his right hip or total right hip replacement. And this is my team of people that we work with us. It s 7:00 o clock at night, so we thank them all for taking time out of their very busy schedules and personal lives to help be a part of this instruction. Thank you. Scott. All right. And we re going to back over to me and Dr. Albert. Dr. Albert Gillespy and me, are going to be commenting on the procedure tonight. Now, again, just a little bit of history about you guys in the Daytona area, the world s most famous beach. You ve been doing orthopedics here for about how many years? Well I came to town 24 years ago, and my brother, Mark, joined the practice five years after I did. Actually, my father, Dr. Therman Gillespy, started the practice here in 1961, which is 50 years ago this month. 50 years ago, fantastic. 50 years ago this month. That s right. Yeah, the name Gillespy has become synonymous with orthopedics here in the town, and we all refer to you as the Gillespy Group, but that s not entirely true anymore; is that? No. There s probably more non Gillespys than Gillespys. That is correct. We have actually nine physicians in our group, in which Dr. Gilbert Martin, who is also one of the founding partners of the group is in our group, in addition to my brother, Mark and myself. Then there s Dr. Bryan, James Bryan, Dr. Gottlich. Dr. Brian Hatten, Dr. Jeff Martin who s no relation to Dr. Gilbert Martin, and Dr. Todd McCall. All these guys have their own little specialty areas of orthopaedics. I would assume you go through the same training, you go through the orthopedic training, and then some guys like to do some procedures more than others; is that correct? That is absolutely correct. My brother, Dr. Mark, and I, we have special interest in total joint replacements and also in spine procedures involving the cervical spine and lumbar spine. Our other partners -- actually all of our partners do total hip replacements and total knee replacements. Two of our partners are fellowship trained in sports medicine, which has to do with arthroscopic surgery and ligamentous reconstructions of the knee and the shoulder joint. And our youngest partner, Dr. McCall, all he does is trauma. And Halifax Medical Center is a level-two trauma center, extremely busy emergency room, and Dr. McCall, all he does is orthopedic trauma with fractures and injuries. Yeah, you are working Dr. McCall like a dog. I saw him on the way in. He s still in the OR doing cases tonight. Yes, he is. As we speak, as we re having fun, watching Dr. Mark do his procedure tonight. So as Dr. Mark alluded to, we are going to do a total hip, and are we ready to go back to you, Dr. Mark, and just see what we got at this point. Yeah, I guess so. And I think the question is, did you want to show any video footage at all? 2

3 Sure. We can go ahead and we can talk about some of the normal anatomy. I think that s going to be a great way to introduce everything. So if we can, we can bring up that first image, the first video image, and Dr. Albert can go ahead and commentate as we bring that video up. This is a video image of the hip joint. The hip joint consists of the femoral head, the acetabulum, which is the socket of the hip joint itself, the thigh bone, which is called the femur. And what Dr. Mark is getting ready to do, he already has done a surgical exposure to the hip itself, and the first portion of the hip surgery is to make the exposure down into the hip joint and then to actually remove the ball portion out of the socket or what we call dislocation of the hip. And I think what we can do is finish up there. We ll come in and we ll pan to what we re doing in here. I m not sure -- I don t have a camera of what you re looking at. But at any rate, this is a right person s hip. This is toward the patient s head, as I m pointing. This is toward the patient s foot. This is the front. This is the back toward me. So we started just a few minutes before we got going online here. This the muscle part of the hip abductors that help you to walk properly. The bone is right underneath there. What we can do is we re going to actually -- we ve released the muscles. We re going to twist this leg in a way that we can now actually dislocate the hip out of the socket. Outer retractor. We re going to put retractors in here that allow us a little bit better exposure, holding the tissues out of the way so we can do what we need to do. So let s hold this up straight, Joe. I m really happy to have Joe here today. Bovie, please. He s very strong, and this patient being very large in size, I m really happy to have him helping me here. So he s holding the leg. My physician assistant, Jessica, is helping on the other side. Dr. Mark, can you hear me while you re in there? Yes, I sure can. Can you just point to the femoral head there, where the top of the head is? Yeah. What s happened, as you can see here -- And just that point -- that s perfect. -- that round area there is the femoral head. And that s the actual bone that we re looking at. That s correct. And that s the cartilage over it, which, actually, the cartilage looks pretty good. We ll show later, though, where it s been damaged. And then this is the bone, and the tissue is out of the way. Bo I m getting ready to make a mark where we re going to cut the bone here. Okay. Because we re going to actually -- in this situation because of his disease condition, we re going to remove the whole head. We re going to resurface it. We re going to do a complete replacement. Exactly. Okay. If we could come back to us for a moment, we just want to clarify some of that anatomy. And Dr. Albert is holding an actual femur in his hand, so you re going to be able to see what the femur looks like outside the body. If you could just zoom in here a little bit more me, please. This right here is a plastic bone model. This is the thigh bone looking at the front of the thigh. This is the back of the thigh. This is the femoral head. And what my brother, Mark, is doing right now is that he s actually removing this part of the femoral neck from the femoral head in order to get exposure into the hip joint itself. Right here. Okay. Right here. This is the head he was pointing to previously. 3

4 That s correct. So when he had the hip joint in through here, the hip joint was like this. He was able to dislocate the hip out posteriorly and now is actually removing -- Can you see in here what we re doing? -- the bone in through here in order to get exposure to the cup. All right. Let s cut on back to the OR there, and we can see that he s removed the femoral head. You did that quickly. I didn t even get to see that. Yeah. Now let me show you guys something very interesting about this. Now if you look at this, this is cartilage, which is nice and smooth. It really looks beautiful. But look at the ripple here, and what s happened is that that bone underneath there is dead and it has died. Do you have a knife? And that ripple there is like a crack in the foundation that has dropped down that becomes extremely painful. It s almost like having a hole in the enamel of your tooth. We could actually cut this away, and if we had enough time, we could cut through there. We shouldn t be able to do this normally, but that underneath there, that whole area there is dead. That whole section there has collapsed, and that s why this patient s hip has become very, very painful. Boy, that is great stuff. I see that radiographically all the time, but, you know, I rarely get a chance to see it live. Now, you know, this gentleman is fairly young, Dr. Albert, 45 years old. What causes something like this? How do you end up with avascular necrosis at a fairly young age? Well, you know, Albert, you can talk about this, but there s many etiologies. The most common, we don t know. You know, there s so many different factors that can effect younger people. Some of it is social issues, some of it has to do with medications, and some of it has to do with recreational sports or certain sports such as scuba diving, which repetitive bearing can lead to it. But the most common is we really don t know. Bovie, please. Now the most common reason for hip replacement, I m assuming, is going to be from osteoarthritic changes; is that correct? Or trauma, something in that order, or most of the cases you see avascular necrosis? I would say that the most common reason for a patient requiring to have a total hip replacement has to do with primary osteoarthritis involving the hip joint. That s what I would think as well. Other secondary causes are osteonecrosis or avascular necrosis that is in this patient here, the causes of osteonecrosis or avascular necrosis in this patient and what my brother, Mark, alluded to. The most common cause is what we call idiopathic, and I kid with my patients; that means the doctors are idiots and not really sure -- Right. We don t know what s going on. What happened. -- as to why it occurs. But about 50% of patients who do have osteonecrosis of the hip, we really don t know the reason why. The other causes are more commonly related to patients who have very high dosages and low dosages of corticosteroids. Absolutely. For patient who have a tissue transplants like kidneys or liver transplants are commonly seen with those patients. Other causes are related to alcohol intake. The patient might drink too much alcohol, and for some reason that can lead to osteonecrosis of the femoral head. And we re not sure why that is too. 4

5 Some people can drink a lot of alcohol and nothing ever happens to the hips, and some patients can drink small amounts of alcohol and it affects them. So it s sort of individually -- The problem is you don t know until after the damage is done; right? That s correct. So you don t want to push the limit, I think, with any of that. Okay. Let me go back here just want to let you know -- we re not sure what the viewers are seeing, whether they re looking at me or you. They re looking at you right now, Mark. Okay. So we have finished exposure to the cup area. And let me start with, if you could have your camera in your room point to the view box behind you, we ve made a plan here, which is in blue and red. The red is the stem. The blue is the cup area. So we re going to work on the cup part first, and we have templated this. We, actually, in our office, these are from our office. These are digitized X-rays. You see the round ball on the bottom. We know that is a given size, and we can size all of the bony tissues, and then we actually have a very complicated computer system of taking a look at what we call templates, which are what we think the size of the components are going to be, so we have a plan ahead of time. And we are planning on a 62, probably 60 or 62 millimeter component. That s very large. Normally it would be about 52, 54 millimeters. And we re going to start reaming. Let s start with a 54 reamer. Dr. Mark, before you show that, actually, is it possible we can show a little video to show the audience and idea of what we re working at? Absolutely. I m going to get working. You can do that. Okay. This is a type of power reamer. I m going to get working on that a little bit. Okay. Why don t you go do that, and then we ll come back. Okay? Sounds good. We ll clarify what you re doing right now. I d like to go ahead and cue up the next video and just show some normal hip anatomy if we could do that. And basically, Dr. Albert, what we re looking at here is the pelvis and we got the hip, and this a ball and socket joint. Correct. That s correct. And it allows a lot of freedom of motion. One of the penalties, of course, of walking upright is there is a lot of pressure on certain joints, our spine, our hip, and our knees, and our hip usually takes the brunt of our weight, especially if we re carrying a lot of that extra weight. So when I look at this, this is a still image of the actual pelvis, if you liken it to a ham hock or like my wife who cooking up a lamb every year, and you put that -- you take that hip out of there and you actually see the glistening cartilage on top of that ball, which we haven t seen yet, except what Dr. Mark showed us when he dislocated the hip there. And that s what wears away over time; correct? That is absolutely correct. When you take a look at -- okay. When you take a look at that last image that we had in through there is that on top of the bone, which is not seen through here, is the bearing surface, which is called hyaline articular cartilage, and arthritis is actually where there is damage done to that particular tissue. And in the hip joint itself, it s the ball portion of the femoral head and the socket portion, which is the acetabulum, and there is actual wear that s on that tissue, the hyaline articular cartilage, and 5

6 then in this surgery right now, we re at the stage to where we re going to do the reaming of the acetabulum, which is the cup portion of the hip. Perfect. And we can have a video of that. It actually shows that procedures, if we could bring up the next video, please. Don, what size do we go to with a 36? And this is that animation, Dr. Albert, if you d like to comment on what we re seeing in here. Yeah. This is the exposure to the acetabulum itself, and then we actually get powered reamers. That s the same device Dr. Mark just had. That s exactly right. We just saw it in his hand. And then we ream it to certain sizes, and then we have the cup, the metal cup, that actually fits that area, and I ll show you an example of that. Okay, can we pan in here real quickly. Real quickly we re going to show this, and then we re going to pan back to the OR. But go ahead and show it Doctor. Let me just show you this right through here. So this is the acetabulum that was prepared, and then there s a metal cup that actually fits into the reamed acetabulum or that portion of the cup. And then inside the bearing surface of that cup is this plastic that we use in through here so that when the hip articulates, it articulates like that. Beautiful. All right. Let s take a quick look back in the OR and see what Dr. Mark is doing over there because I think he s at that point. We ve used this reamer. We go up by one millimeter in size. We re templating to about a 60 or 62, but, really, at 57/58, he feels pretty good. So he s a young person, so instead of removing too much bone, we ll go down a size. I have a trial in there. So, Mark, right now is putting in a trial component. This is 57 millimeters in diameter. My real component is probably going to be 58. We want to see how this feels. Let s have an alignment guide. We use geometry in the room. This is a 45-degree angle. This is an angle about 30 degrees to the patient s anatomy. Hold that back there, Jessica. That s good. Joe, go ahead and knock that in for me. I m going to hold it where I want it, and he s going to knock it on in. Good. Okay. So I really like this, you know. It looks like it wiggles, but that s actually the attachment. The actual metal piece that is in there is not moving at all. I can t move it. I m going to be very happy with this. What we re going to do -- that s a 57 millimeter component in a 57-millimeter hole, which I m almost having a hard time getting out. That s good. Good solid bone. We re going to ream it up to 58 partially. Let s ream it on up to 58, no hole cup. So we re going to put in a solid course-coded cup that s going to fit into the bone. The bone will grow into the edges of cup and hold it rigidly. We re going to under ream this just a little bit so that when it goes in it s a really firm fit so I m real happy. That 58 reamer. 6

7 That s some impressive equipment there, Dr. Mark. That s not for the wimpy that you re using right there, hammers and big old metal components. It looks like something you could fix at my car with at the end of the procedure. Now Dr. Klioze, this is orthopedic surgery now. We clean them thoroughly before we bring them into the OR. Okay. So we have partially reamed the 58. I ve really reamed it about 57-and-a-half. The 58 component is probably a smidge bigger than the 58 and a half, so I m going to have a press fit of a good millimeter or a little bit more. It really looks good. The bone preparation here, I m very pleased with, so let s irrigate this. Wash this out, please. So, really, to me, this operation is in multiple steps, one is exposure, two is doing the cup, three is doing the stem, and then finally is really getting it balanced right to make sure you ve done everything right. You ve got to make sure the length is correct. Make sure that the offset side so it s stable, doesn t want to come out of the joint, and we like to irrigate here because we don t want any infections, obviously. Seven and a half. Dr. Mark, do you have an opportunity to take a question from me? Yeah, go ahead. You know, what we didn t get to see was the exposure itself, and going back to that, you know, leg of lamb, you know, when I ve gotten down to bone itself and the joint, it takes a lot of work. There s a lot of muscle, soft tissue around there. Obviously you can t just cut down on that like we would for the Easter dinner. You ve got to preserve function, the muscles, and all that. How do you actually get down and make this exposure? What do you do? Do you have to cut the muscle itself? Can you go in between the muscles and the ligaments? What we do is release some the muscles, but you know as time has gone on, we find that we release fewer and fewer muscles and we go in some natural tissue plains. The muscle that is we do release, we repair them, but we actually have to release some of the ligaments, you know, that hold bone to bone, some of the ligaments of the joint itself called the capsule, and so we release it partially, and then we really leverage certain tools. It s not for, you know, small people. You have to be strong. We re ready for that, Sara. Yeah, it s interesting you bring that up, because I don t -- you know, not to be chauvinistic or anything, but I don t see a lot of small women in the orthopedic OR. I don t remember ever seeing a lot of that. You have to have some strength to do this, I believe. Most of the smaller women in orthopedics are enhancers. Oh, I do know one. That s exactly right, our own Dr. Clancy. She s right here in our own community. But, yeah, these bigger bones this is, again, not for the weak. Here s what we re doing. We re looking very carefully now, Scott. And we want this not quite level. That s 45 degrees. I like it about 5 degrees down. This is a critical thing, this alignment, this pin here, which is in line with the body, is about 25/30 degrees. I like this position here. I think this is going to be very, very suitable for this patient s bone. Joe, let s knock this in. And we might find that we have to go to a bigger hammer. Go ahead. Man, bigger than before? That was a pretty big one. So actually what Dr. Mark is doing now is actually putting in the implant itself. This is not the trial anymore. This is the final implant. So this is what we saw in the video. This is the implantation. 7

8 That s correct. So I m pretty happy here. I think we re right about where we want to be. I m right at about 45 degrees. And that s 45 degrees relative to the pelvis itself? Relative to the floor. To the floor. Okay. And, actually, what happens is, when the person standing up, it tilts away from center is 45 degrees, and I think we re right about where we want to be. I m feeling here because my index finger still is better than anything. I think I m just about perfect. I like this. We re going to keep this. We re good. Very nice. Very nice. Okay. So I ve disconnected that. Let s have the hole eliminator. I m going to put a little screw in the bottom where that came from. It actually seals the bottom of this cup in a way that over time no issues develop. I m pleased with this. This looks great. We re going to go ahead and put in a 36 liner, John. Dr. Mark, while you are doing all that, I want to take a break and actually ask some questions. I ll tell you what I m going to do. I m going to take two seconds. I m going to put this liner in. Okay. Then I have to sort of rearrange myself and that will give us time to do that. Is that okay? Perfect. All right. Go ahead and show us all that and we ll go from there. You know, it looks like a simple piece of plastic. It s extremely difficult to penetrate very hard plastic, designed and manufactured to last probably 15 to 20 years, you know. So the body is a salt environment. So we re going to put this in here, and we re going to impact it into the right location. This is a special way of fitting in there. This now becomes the bearing surface of the cup. If my hand is the metal cup, this fits inside it, and then the metal part of the head that fits inside there or the ceramic part that we use today will now actually fit into this bearing. So that s the equivalent of the cartilage that Dr. Albert talked about earlier. This is now the artificial cartilage; right? That is exactly right. Okay. Perfect. And to show, again, as a close-up on this, this right here is the metal cup that Dr. Mark Gillespy just put into the bony acetabulum. So that s fixated to the bone itself. And if you take a look even a little bit closer through here, the preparation on the backside of this cup is made in a manner that the bone itself will actually grow into the cup itself to get good bony fixation. And then what he did was that after the appropriate positioning into this metal cup into the bone, then we put in the bearing surface, which is the plastic entry here that s then assembled into here so that after we have the femoral side together then that actual articulation will be like this, just like that. Okay. Nice and smooth. While Dr. Mark gets ready to do the next step, we re going to take a couple of questions here. I just want to clarify, we ve been using the terms Dr. Albert and Dr. Mark, and just to let you guys know where that comes from, that s not some cutesy thing we re doing for the show tonight. You guys are actually affectionately known as Dr. Albert and Dr. Mark right here in our own community because Dr. Gillespy is your dad. 8

9 That is correct. Right? And we ve never called you guys Dr. Gillespy. No. Ever. So this is not something we re just doing for the show tonight. You are Dr. Albert and that is Dr. Mark. That is correct. If Dr. Gillespy walked in right now, we would all put our suit and ties on and salute him. I call him Dr. dad, but everybody else calls him Dr. Gillespy. That is exactly right. I would call him Dr. Gillespy because he s not my dad. Okay. So Loretta from Tennessee asked, Could someone explain to me the difference between a partial and total hip replacement? And also, I would like to know what determines if you can have the minimally-invasive laparoscopic rather than the traditional open procedure? And I want to take the first part, Loretta, because laparoscopic means that they re going into your belly. Okay. So no one in the orthopedic arena is going to be doing a laparoscopic procedure, because if they are, then you are in the wrong OR. So it s not laparoscopic, it s arthroscopic, and I m going to pass it on over to Dr. Albert who is going to answer the rest of your question for you. Well the answer to the first question is the difference between a partial hip replacement and a total hip replacement is that a partial hip replacement is usually performed on patients who have sustained a fracture to the hip itself. Again, looking here at this plastic model of the hip, an intracapsular capture is one that involves -- a fracturing involving femoral neck. And in certain patients, if there is either significant thinning of the bone with osteoporosis and/or significant displacement of that fracture, it probably is best managed by what we call a partial hip replacement. And what we do on those patients is that we replace the hip by removing the remaining portion of the femoral neck and then we place a prosthesis like this within the femur, but we do not do any preparation of the acetabular part. That is called a partial hip replacement. The total hip replacement is what we re doing here today, and that s where there is preparation on both the cup portion, the acetabulum, which consists of the reaming and the replacement of the acetabulum with the preparation of the femur with the femoral prosthesis. Perfect. Now in arthroscopic surgery, arthroscopic surgery is a very common surgical procedure that is performed on the knee join, the shoulder joint, elbow joint, and sometimes the wrist joint for hand surgeons. But hip replacement surgery is not done arthroscopically. That s where there s a small tube that we are able to look inside the joint, but we do not do joint resurfacing or hip replacements using arthroscopic instruments. Fantastic. Do we have time for another question, Dr. Mark, or are you ready to talk? Actually, yeah, we re just moving right along, and, actually, in answer to that also a little. You know, minimally invasive hip surgery, we use, you know, the traditional incision. When my father started this many years ago, it was about a 15-inch incision. Today we ve made this a bit larger than my normal incision for everybody to be able to see here a little bit and because he s really very large boned. 9

10 Yeah. It s really interesting watching the evolution of the medical field, especially like orthopedic surgery, over the year. I know, you know, before the advent of casting and traction and that kind of stuff, there was really nothing you could do. You have a deformity for the rest of your life. Right. And, actually, orthopedic surgery is one of the few things that has actually benefitted from warfare. You know, warfare patients have come in, they have had their legs blown apart, and there predecessors actually went out and put these guys back together and learned a lot from that arena. Well actually that is correct. The father of intramedullary rod fixation for long bone fractures of the arm and of the thigh and of the leg came from a German orthopedic surgeon called Kunchner. Kunchner. And what he would do is that on his pilots that would have fractures and would survive the crashes, he was able to manage those fractures with a metal rod that would go down the middle of the femur, and that was the genesis of the ion fixational intermedullary fixation for fractures of femurs, tibias, and humari. That s great. Dr. Scott, are we back in the room right now or with you? We are with me, but we re actually looking at you and listening to us. Okay. But we can listen to you right now. Go ahead, Dr. Mark. But what I was just going to say, let me show you that last reamer. What we ve been doing here, we opened up the canal of the femur. We have special tools holding this to see this. I think the camera is in a great position. And so under power we use these special reamers. These are conical reamers that go down inside the bone. I predetermined I thought it would be probably an eight or a nine, so I m pushing for probably about an eight size. They re all different sizes. So I have started, and the very first broach here is a number five, and mallet, please. You re just sizing at this point; is that correct? I m just basically removing enough bone to be able to do a good job to get the prosthesis in there. Okay. Dr. Mark, we got a great video of this. And before you get too far in, I d like to show that to the audience exactly where you re coming from. Okay. You go ahead and show that, and I m going to keep working my way up a little bit. How does that sound? Absolutely. So we ll cue that up right now, and Dr. Albert will give us some commentary on that video. Yeah. This is a video example of that, and what you re doing through here is that he s preparing the proximal femur of the thigh bone. He s going to remove a little piece of the bone right through here with a Rongeur and a curette, and then he actually gets -- here is the curette and the Rongeur, and then he s actually preparing the inner part of the femur. That s this tool right here. That s actually reaming out the inner part of the bone marrow and the femur through there that will perfectly fit this prosthesis that he s 10

11 doing through here. So as you can see what Dr. Mark is doing through here is you go back and forth, back and forth, preparing the inner surface of that femur. Man, that is some delicate surgery. That is impressive. If you can maybe bring that back here a little bit, I want to just show you an example of what he s doing through here. So what I m doing now -- Hold on one second, Mark, okay? Okay. Uh-huh. We ll get back live here to the studio. I heard your big brother step on you, Mark. I heard you. He told you to just hold on. So actually what Dr. Mark is doing right now is that the reamers that he has are actually perfectly reproducing the shape of this prosthesis, so that when this prosthesis goes down into the bone it perfectly fits the hole in the bone that he has created so that when you get fixation of this prosthesis, that it s not going to get loose in the bone. If you look over through here onto the X-ray, right over in through here, this area of the X-ray, this is the preoperative X-ray, this is the template that he right now is perfectly replacing this bone with that reamer so that he will get this exact size prosthesis to fit exactly in the area that we want to fit into the bone so that when you get this prosthesis in that position through here and where all these little red lines in through here, this is where the bone ingrowth is going to occur so that you don t get loosening of the prosthesis. And this is the normal cavity of the bone itself. That s correct. That sticks into the bone cavity? That is the inside part of the femur. Not to step in front out of you here, but again -- Let me explain what we re doing here. Go ahead. Sorry. I appreciate that. We now have a number seven prosthesis in here. Based on my pre-op templating, I want the top of that prosthesis to be 9.9 millimeters from the top of this bone. But the problem is, the top of this bone has muscle on it, so I have designed a special type of measuring device that goes through the muscle, down to the bone, and I think that right now I think my stem is down a little too far, so that s a number seven, so what I m going to want to do is I want to broach up. I want to go to an eight, so it s going to be a little further up the canal. So this is -- we re getting close to where we want to be. It s probably going to be an eight prosthesis. You know, like everything else, we re trying to press this into the bone. We don t want to break the bone, and it can happen. You can get a little hairline crack. So we have to be very careful. We re getting real close to where it s going to be, but I want to get a little bigger prosthesis in, so I m going to machine this down just a little bit further, and we re going to have an eight reamer. I m going to go back with my conical reamer. I want to make sure I ve got the clearance I need, because this conical reamer removes bone down deep in the canal. This other reamer removes it mostly up in the top 11

12 of the femur. I want to make sure. So this reamer is designed that the eight mark is right where this corner of the bone is. We want to make sure we get down far enough, and we re really right there. I think it s going to be good. Let s have an eight broach. So you could see they re getting bigger, and I tell you, this is a big stem. For a big man. We ve got to be very careful. Yeah. Again, we don t want to hurt anything. We want to get it in their solidly. And the real prosthesis, the real one I put in there is going to be a little bigger than this one, just by a little bit, but we re getting really close, I think. Okay. I want to ask another question while you re sizing that up, Dr. Mark. Steve from Daytona asked, Can you explain the space suits, quote, space suits, they are wearing, and what is a clean-air OR." I lost my ear. Sorry. The space suits that we wear here are clean air suits, and this is done very specifically for artificial joints, total joint replacements, and the room itself is a laminar flow room, so these are all devices that we have here to make the operating room environment extremely sterile and extremely clean. If you look at the statistics of infections of a total joint, that it s about one-third to one-half of one percent on our rooms that are used with the clean-air environment and the space suits that you can see here on the images. Okay. Mike wants to know, What is it like being a surgeon? Dr. Albert? It s great. I think that the rewards of being a physician and a surgeon, especially in orthopedics, are absolutely tremendous. There are so many of our patients that are just extremely painful, disabled. Their condition is painful. There condition is very painful like this gentleman here, a very arthritic hip. He s in his mid-40s. It s really a shame to see somebody at such a young person like that so disabled like that that he has a hard time walking, you know, from the kitchen to the front door because of the pain in his hip, and then when you replace their hip or do orthopedic surgeon on them, the pain that they have is gone, and it s just very rewarding to be a surgeon. Yeah, I think in general just being in medicine itself, I couldn t imagine doing anything else. That s right. I mean when you can help somebody out and make them better, the rewards are unbelievable, so I couldn t agree with you more. If we have time for another question, Dr. Mark, can I go ahead? Yeah, absolutely. Go ahead. If they re looking at what we re doing right now, we re putting a -- we have the stem in. I think it s right in the right spot. I have it at about 11 millimeters down. My real stem is going to be just a little higher, so I need to be careful. And I m trialing it now. I have different pieces that attach to this, like you build it up, and then when we open the real prosthesis, it matches what we re doing here. Okay. Good. So what I m doing now is we re trialing different things. We want to make sure we re very close to our original plan. Joe, let s take that out. We re going to actually slide this right into the socket here. Pull and rotate, please. Relax. Okay. That looks great. Thanks. So he s going to let me have the leg now. We have the hip back into the socket. One of the first things I check is my leg length. I think I m really close to where I started. I might be about a millimeter or two long. Okay. I don t want to be short. I certainly don t want to be long. Now what s your marker there? Mark, what are you using? 12

13 What I have underneath the drapes here, I have the other knee positioned in a very special way that I can measure that. And we measured that before we started. Oh, great. And we have it -- actually the bottom leg is locked in a position. I m feel thing kneecap. So under the drapes I m feeling the kneecap, and it feels like we re really close. Now I have to realize this hip is a little short to begin with because of his arthritic condition. Sure. So lengthening him just a little bit is okay, but I don t want to do it too much. I m about a few millimeters long right now I think. And you can get millimeter accuracy with that technique that you re using. Well we re trying to get it very close. Now here I m testing stability, so I m flexing the hip and rotating the leg, and it just starts coming out at about, it looks like about 60 degrees. I m very well happy with that. I m pulling him into full extension. I m testing to make sure he doesn t come out the front. He doesn t. I think we re really close. But I think that I have to be careful. This is the shortest neck length that we have, which is a plus 1.5, and my stem is probably right where it s supposed to be. I m going to have to work hard to get it down a little bit further so when I put the real stem in it s going to be perfect. So we re going to work for a few more minutes if you want to talk about something else. We re going to get it just right. Yeah. Just to carry on a little bit more with what Dr. Mark was talking about through here, what he s doing at this stage is he s using trial components. These are not the real components that go into the patient other than the cup, the acetabular cup. So the stem that he was working on and the femoral neck that he was working on and the femoral head that he was working on, those are all trial components to see if everything that we re going to put in is going to be the right size to fit it. Couldn t be better, because, you know, I used to do construction every summer when I was in college, and you always measure twice and you cut once. That s correct. You can t take back a cut. That right. So, you know, measuring multiple times I think is a fantastic idea. Measure three times, cut once. I m going to go ahead and ask another question. Michele, When I was 18 I was in a very serious car accident. I broke my pelvis in three places. Couldn t have the surgery until three weeks after my accident. I am now 27. I have pain much of the time due to having metal in my pelvis, screws and bolts. Also, there are bone spurs on my left hip, ball, and piece of calcium growing off the back of my pelvis. Will a hip replacement be inevitable for me? I guess me means she has bone spurring off the femoral head. Well first of all, a fractured pelvis, it sounds like that she had, is a very serious horrible injury that can occur. And it s not uncommon when patients have significant pelvis injuries like that that they actually do not survive the injury. Right. 13

14 There s actually a fairly high mortality rate survived by that. In terms of surgical management of those fractures, very commonly, they are managed with plates and screws to reconstruct the hip. Unfortunately, some people that have that injury, they can develop bone that forms in the muscles around the hip, which is called heterotopic ossificans, and that can lead to some pain in the hip and some restriction and range of motion of the hip, and also patients can develop a condition that this patient has through here. Sure. Avascular necrosis, because of the nature of the injury, it can actually affect the blood supply to the femoral head and it can die, and then the patient can end up with a painful hip. Can the patients themselves ever have discomfort from the side plates themselves, the screws, all of that that you use to secure the pelvis? Is there ever a reason to remove that hardware at some point in time? The answer to the question is that usually hardware that s within a pelvis injury is positioned in a manner that is not painful. Hardware that we use like around the elbow joint, the ankle joint, not uncommonly can be painful after the surgery. But usually the hardware that s within the pelvis itself is usually not pain I feel. Dr. Scott, let me tell you what we ve done here just real quickly. Those are great comments, and that was a great question by the person who sent that question in. I think we re just right. Okay. I went ahead and put that same broach. I went down about another three millimeters, maybe four. The real stem is going to be up about two millimeters from where I thought it was going to be. I think I m going to be right on the money, so I think it s good here. Dr. Mark, can we just see, or the camera person in the OR, let s see that shot again and just give us an orientation of where we re at. We re actually looking down at the femur itself. That s correct. Yeah, let me help you here, and I ll show you. Okay. So if you look at the picture right now, at about 12:00 o clock is looking right straight down the thigh. The knee is bent up at 90 degrees with the foot coming up towards the ceiling, so you re looking at the back part of the hip. The back part of the hip, and that s the femur itself. It s very disorienting to some people, but right now this is the backside of the hip area. This is the front side. The leg is turned actually almost upside down from normal. Okay. Wow. It goes back almost 90 degrees so we can work on it. And that goes back to the question that you asked, Dr. Klioze, you know, how can we do this without distorting things? Well we release the tissues on one side, allow them to open in one way that we can work on them, and then put them back together. We haven t touched any of the tissues on the front. So this is the broach that we have, we pulled out. We re very happy with this. I do want to show you. I ve got new gloves on here. I want to take a look at the real stem. I don t let my personnel touch it. We worry about infections. Absolutely. We re very fortunate. We ve been so lucky. I mean, you know, if I had wood I d knock on it. But nonetheless, this stem, if we can get a picture of this stem, this is a very high performance type of stem. This is a polished titanium-type stem. This is a special coating that s on here. It s called hydroxylapatite. That s a material the bone is very friendly with. It grows into it. And literally what will happen, we re going to press this into the bone, it s going to be very rigidly in there, but over a period of about six weeks, that bone s going to grow right into it, and hook onto it permanently, literally permanently. Once that bone has grown into this, it won t let it go. So I always check. She said she gave me an eight standard, and it says, eight standard, so I believe her. So that s perfect. I believe her. 14

15 So we re going to very carefully slide this in here. All right, just like that. We have a device that allows that to go in. Now this is what we call a taper fit, so I m not putting real hard because it s going to be all tight at one time, and we don t want to go too far, and that s really, really hard bone. Now let s get our measuring device, please. Remember, I want today be between nine and ten millimeters up. Now that looks like you meant to be there. It is. And you know what, look at this the, guys, you probably can t see it, but I m right at -- You re right on it. I m right on the money. I think I m right on the money. I think it s just perfect, so we re going to go ahead and trial that again. We re going to just slide this out real carefully. We don t want to scratch anything. We re going to get trial plus 1.5, make sure we re happy with everything, and then we re probably going to open up a ceramic head. Pull and rotate, Joe. And rotate. Dr. Mark, if we can come back to us for a in a moment, I just want to kind of clarify what you were doing with Dr. Albert s assistance. And this is the device that we just put into the femur; correct? That is correct. And, you know, what s interesting, before we get into too into that, is that we don t have the head actually attached to this device; right? That is correct. In the old device like you see right here, the head is attached to the device itself. That s right. So if you ever had to replace this, this whole thing had to come out. That s correct. Now with the new device, it s modular, it s a component. So you have this, this part. Oh, my God, I have the wrong piece here. This part slips : One of you slips on here like that and then that fits into the cup. That s correct. So I had a buddy of mine who had a traumatic hip injury, just like the previous question, the girl that asked the previous question. Yes, Michele. Michele. And he had a hip replacement probably 15 years ago. He had to have everything changed out after about 15 years. That s correct. He said it was nothing. I mean you know, I heard the nightmares about patients going in and having to have their hip replaced, and, you know, you put it off as long as you possibly can because these things have a limited lifespan. It s not a normal part of the body, it s going to wear out. But he said because of the modular design of the newer hips, they just went in and put in a new head. Unbelievable. And basically not only put in a new head but what we usually do on that is that we actually have to replace the liner. That s right. Put the liner in, the cartilage. 15

16 That is correct. And he said that was -- his convalescence was a couple of days. That was it. So you guys must have done that, it was so well done. Tell me when we re back in the room. Back in the room right now. So we have -- this is the ball. It s a very highly polished. It s a pretty color, but it s a highly-polished ceramic head, okay, the ball or the ball and socket. Now we put the cup in. We put that plastic liner in the cup. We put the stem downright in the canal, right down the femur. Now we need to finish the bearing surface. This what we call ceramic on plastic. This is machined in a way that the inside of it has a taper fit, and so it will actually go on top of that stem and will lock on it with a couple taps, to the point that it s actually very difficult to get back off. And it s machined perfectly. And I want to be very careful here. I don t want to drop it. I don t want to scratch it. So we re going to go ahead and put this on. We already sized our components. We re happy with that. We re going to clean this off real good here. Help me a little bit, Jessica. We re going to slide this right in place. We don t want to scratch anything. We don t want to injure anything. Let me have a lap sponge, please. So it s sitting right onto the stem. Bring the leg and this way just a little bit. There we go. Thank you, Joe. Impacter. Even though this is plastic, I like to put a little piece of cloth there to make sure I don t injure it. And we have knocked that on. I can t get that off if I had to. Now, Joe, good pull, one rotation, one time in. Okay. It looks excellent. Perfect. So we have it. We trialed everything. We put the components in. I think our component position is very good. I come into full extension. I rotate it and then come out the front. I bring it up in flexion. I rotate this leg, and it s just now starting to come out, and I d say that probably 65 degrees or so. That s a very good number. Anything over 45 degrees is good. I pull on it. It kind of slides out about three or four millimeters, maybe a little bit more. That s perfect. I put my legs together where it was, and you know what, guys, I am right on the money. Great. It is perfect. I m very happy with this. Good job. Basically the job is done. We just need to wash and wash and wash. We might put a little drain in to drain any blood. We ll repair the tissues that we took apart, and this person will be out of bed tomorrow. He ll be walking full weight bearing with a walker. Fantastic. Fantastic Dr. Mark. That s one of our questions actually. But before we get to the last few questions, I d like to go to our last video. If you guys could cue that up for us, it show it is completed hip placement, and Dr. Albert can comment on that and show how the hip actually functions after placement. Yeah. That s placement going into flexion, back into extension, and you can see where the articulation is now in terms of having a full flexion of 150 degrees. And this is what we were talking about when Dr. Mark was talking about, degrees of flexion, extension, so on and so forth. That is correct. So that is actually a nice representation of exactly what the artificial hip joint looks like in a person who is standing and walking. 16