Half a million Americans will get a new hip or knee this year, but fewer than 500 of them will be up and walking the same day. Of the nearly 20,000 orthopedists who perform hip and knee replacements, fewer than 30 use a technique Richard Berger, a 42-year-old Rush University Medical Center orthopedist, has developed--a muscle-sparing procedure that minimizes pain and drastically reduces recovery time. "On my own I can only help a few hundred patients a year," he says. "But if these procedures become standard practice I can help hundreds of thousands."
Roy Houff, a flower wholesaler, had conventional surgery on his left knee in 2003. "With the traditional operation the muscle is cut, so rehab is hard," he says. "I couldn't walk for days and was in the hospital five days with a morphine pump. Physical therapy was tough because the muscle was weakened." Berger did his right knee last year. "There was no cane or crutch," Houff says. "I was driving after 6 days and golfing after 30. There's a better range of motion in my right knee--I can bend it much further, because the muscle wasn't cut." Richard Levy, an attorney whose second knee surgery was done by Berger, says, "After the first surgery it was eight weeks till I had pretty good mobility and three months till I was done. The second was an outpatient surgery. I had three days' pain, was back at work in six days and playing tennis four weeks later."
Conventional surgery traumatizes the muscles that hold hips and knees in place. When replacing a hip joint the surgeon makes a single incision, usually 8 to 12 inches long, that slices through abductor and rotator muscles and the associated ligaments and tendons. Retractors forcibly hold the cut tissue out of the surgeon's way, making it possible to see the entire hip area at once and limiting the chances of a mistake. The surgeon then breaks the hip apart, pulling the ball from the socket and further traumatizing the soft tissue. The ball and socket are cut off, the ends of the bones reamed out, and a prosthetic joint inserted. Then the soft tissue is stitched back into place. In a conventional knee replacement the surgeon cuts the quadriceps muscles that hold the knee in place, separates the ends of the bones, cuts off the joint, reams out the bone ends, and inserts a prosthetic joint.
All this cutting and tugging causes bleeding, swelling, and inflammation in the soft tissue, which releases chemicals that help it repair itself but also cause intense pain. Over the next few months new bone that's exactly like the old grows into the prosthetic, stabilizing it. But the muscles, ligaments, and tendons replace damaged tissue with scar tissue, which is less flexible than the original. Recovery from both procedures is usually slow, painful, and sometimes incomplete, though after three months or so most patients function better and with less pain than they did before the surgery.
Surgeons try to minimize trauma, but Berger was the first to find a way to completely avoid cutting muscle, tendons, or ligaments. He's been fascinated with the mechanics of things since he was a kid watching his father build complex moving figures for Macy's Christmas windows in New York City. During his first year in the engineering program at MIT he began doing research with William Harris, the chief of hip and knee replacement at Massachusetts General Hospital, who'd pioneered hip-replacement surgery in the U.S. in 1960. "Surgeons have been trying to replace hips since ancient times, especially during the Civil War," says Berger. "But no one really succeeded before 1960, when pioneers like Bill Harris first devised a prosthetic that lasts."
Berger worked throughout his undergraduate years at Harris's human motion laboratory and gradually shifted his focus from engineering to surgery. After earning his engineering degree he went on to medical school at nearby Tufts, and in 1995 he migrated to Rush to do a fellowship with two of Harris's former colleagues. One of them, Jorge Galante, had invented prosthetics that didn't need cement because he'd figured out how to get bone to grow into them. He's widely credited with making Rush a leading orthopedic center.
Berger says that after he arrived at Rush his focus shifted again, from the prosthetics to the procedure for implanting them. "For 35 years orthopedists had been refining the mechanics of hip replacements, but the actual operation hadn't changed much," he says. "Patients would come to me complaining of pain and reduced functioning, and all I could offer them was a procedure that involved severe pain and a prolonged period of being disabled."
In 1998 he began experimenting on cadavers, eventually operating on more than 40 of them. He also worked with engineers he knew at Zimmer, the world's largest manufacturer of orthopedic implants, to design tools that were easier to use in small spaces, testing them on the cadavers, then refining them. "Conventional surgery began looking analogous to ripping out an engine block to replace an oil filter," he says.
In the hip-replacement procedure Berger developed, the surgeon makes two incisions that are typically just an inch to an inch and a half long, and neither cuts through any muscle or other soft tissue. The opening is too small to allow the surgeon to cut off the whole joint at once; instead it's sliced up and removed in pieces. The small openings limit what surgeons can see, but they use a fluoroscope, an instrument that allows real-time X-ray imaging, to supplement what they can see directly, and the new tools help: rounded, illuminated retractors that hold the muscles out of the way less forcefully than conventional ones, cutting reamers for removing the joint that are half the size of traditional ones, and a bent device for implanting the prosthetic that's easier to maneuver in the limited space. The titanium and plastic replacement joints are the same as those used in conventional surgery.
In February 2001 Berger replaced the hip of his first live patient, one of a hundred people who'd volunteered for a pilot study at Rush. Over the next year he and a few other surgeons working with Zimmer operated on another 144 patients in 17 medical centers in the U.S. and Europe. "Our goal was a modest improvement in recovery," says Berger. "We didn't expect such dramatic change. We had assumed most pain was from the joint, not the soft tissue. But suddenly patients were clamoring to go home ASAP--even the same day." Hospitals don't let patients leave until they're able to walk, get in and out of a bed and a chair, and go up and down stairs; 85 percent of the study's patients qualified to go home the same day, the rest the day after. There were virtually no complications, and the end results were comparable to those following conventional surgery. Berger and his colleagues published the findings in Clinical Orthopaedics and Related Research in 2003 and 2004.
Meanwhile Berger had teamed up with Fred Tria, a New Jersey surgeon who'd been working with Zimmer on a similar approach for knees. Together they developed a procedure that used a smaller incision--about three and a half inches instead of eight--and designed new tools, notably a cutting guide that holds the knee in various positions and makes each step of the procedure easier. (In conventional surgery the knee remains either fully extended or fully flexed.) Of the 50 patients in their pilot study, 48 went home the same day. They published their findings in the Journal of Arthroplasty in 2005 and the Journal of Knee Surgery in 2006.
People who get conventional surgery typically spend five days in the hospital, and many spend as much as another week in a nursing home. The data Berger has published on hundreds of surgeries using the new procedures show that almost all the patients go home the same day or the day after. (Berger replaced my wife's hip last July; she went home within two days.) Berger's patients also stop using narcotic painkillers within days instead of weeks. They typically set aside their crutches and start driving within six days, and usually return to work in eight days instead of four to eight weeks.
The complication rates for Berger's procedures and conventional ones are similar. The risk of severing a nerve in either is slight: the sciatic nerve is two inches from the hip--a comfortable distance for a surgeon--and the peroneal nerve is almost as far from the knee. In rare cases soft-tissue swelling and dislocation can stretch a nerve, leading to "foot drop"--the patient can walk but not lift the foot. The prosthetic can be installed incorrectly and then not function well, sometimes even breaking the bone, though Berger says using a fluoroscope makes this less likely. Patients who've had both types of surgery often report that Berger's procedures have given them greater mobility.
Operations using his procedures take longer, but the shorter hospital stays lower the total cost by up to 30 percent. Given that more than 250,000 hips and 300,000 knees are replaced every year in the U.S., the economic impact of fewer lost workdays alone could amount to billions of dollars. Berger's technique is also a boon to people who can't afford to spend weeks or months away from their jobs or taking care of their children, as well as people for whom any surgery is risky--those who are overweight or have other serious medical problems. The patients who've had the procedure seem happy--Berger is booked for months in advance, almost entirely through word of mouth. (My wife heard about him from someone at her health club.)
Two of Berger's partners at Rush recently began using the technique on some of their patients, but the three surgeons are the only ones in Chicago using it. Of the more than 3,000 procedures tracked by Zimmer since 2001, Berger has done nearly two-thirds. Of the remainder, nearly half were done by surgeons in Europe, Australia, and Asia.
Berger has helped develop a program with Zimmer to teach other surgeons the new procedure: the Zimmer Institute opened in April 2003 and it now offers weekend training in 22 locations worldwide that includes practice with a cadaver. Last year Berger also spent 100 days on the road making presentations at orthopedic conferences. The procedures are difficult to master--a presentation or a weekend's training only gets surgeons started. Then they have to watch Berger perform multiple surgeries over the course of many visits; around 120 surgeons watched him last year. Next they have to spend months practicing on cadavers at their own hospitals. When Berger thinks they have the necessary technical skills he supervises them while they do several surgeries in their own hospitals. The surgeons aren't compensated for the time they spend observing operations and practicing on cadavers, and they pay their own transportation costs, though Zimmer does give the new tools to anyone who buys its implants. Berger, who isn't compensated for supervising surgeries or for his transportation costs, has finished training half a dozen surgeons nationwide along with his two colleagues at Rush.
Berger says surgeons often are interested in using techniques that are less traumatic for patients. "Many are using shorter incisions, better pain control, and other measures to help patients recover faster," he says. A review of the professional and trade literature indicates that no one in the field seems to have anything critical to say about his procedures, at least in print, and clearly orthopedists know about his work, since he publishes in the journals they read. But one young orthopedist at a prominent Chicago teaching hospital, who has sterling credentials and an impressive publishing record, stammered and was hard to pin down when asked about the procedures. He cautioned that surgeons should make "judicious use of new technologies" and when reminded that patients could go home the same day said there are always "many factors at play in recovery."
Berger doesn't think his procedures require anything unusual beyond lots of practice, though he's still trying to make the surgery easier to do. He plans to design new instruments and prosthetics, refine the techniques, and develop ways to use computers to help visualize the process. He understands that the learning curve is steep and that it's not easy to spend so many hours working uncompensated. But he also thinks surgeons get complacent, comfortable with the techniques they already know.
Pearl Katz, a cultural anthropologist at the Johns Hopkins School of Medicine and author of The Scalpel's Edge: The Culture of Surgeons, agrees. "More than 20 years ago the Lancet called for an end to extensive shaving of patients before surgery, because it abrades the skin and increases risk of infection," she says, "but many surgeons persist in shaving the operative site." She thinks surgeons are reluctant to adopt new procedures that are difficult to learn and perform because that's just not part of their culture. "They need to make life-and-death decisions quickly, so they value risk taking and quick learning," she says. "They often rely more on their clinical experience than scientific evidence. They put an excessive value on their own competence, on what they can do well and quickly. They have to rely on their familiar motor and sensory skills, so are resistant to learning procedures like Berger's that call for drastically changing those skills. And they are less concerned with aftercare than what they do in the operating theater. Since Berger's procedures produce benefits in aftercare, it's not surprising that surgeons would undervalue the contribution."
Berger sees the obstacles to converting surgeons to his methods, but he's in it for the long haul. "The orthopedic community, like any well-evolved institution, is slow to change," he says. He believes it's ultimately up to patients to be more knowledgeable about their options. "Surgeons will change procedures they know to be successful only if patients demand it."
Art accompanying story in printed newspaper (not available in this archive): photos/Jon Randolph.