Medical Minute 6-8: Hip Surgery Hope

By: Vanessa Welch Email
By: Vanessa Welch Email

Walking is something Marci Ybarra must work at.

"Every step you take, that's like baby steps to me."

After a staph infection ate away her hip cartilage and part of her pelvic bone 26 years ago

"The doctor came in and said, 'Well, you no longer have a hip,'" said Marcia Ybarra.

She's faced a long road to recovery.

"I could be laying in my sleep, and I'd turn over, and my hip would dislocate, and I'd have to go to the emergency room."

That's happened 42 times. Then -- something no doctor had seen before.

"I had a vaginal fistula. Nobody's ever had that in the world either. That's where I don't mean to sound gross, but one of the pins came loose and went through my vagina wall."

Marci was then referred to Doctor Henry Finn of the Chicago Center for Orthopedics at Weiss Memorial Hospital.

"Even though I was just a bodily mess, he was my hero!"

Doctor Finn treated her fistula and would ultimately change her life with a pins and cement procedure he pioneered -- a technique borrowed from bone cancer survivors and now being used to treat other patients like Marci, who after a dozen hip surgeries, has very little of her own bone left.

"They come from long distances away. They've had multiple revisions, infections and have had massive bone loss, and sort of, they are looking for a last hope," said Henry A. Finn, M.D., F.A.C.S., Chicago Center for Orthopedics at Weiss Memorial Hospital/University of Chicago.

Think of it like a road project.

"When someone is laying a road, they use wire mesh or steel bars to keep the concrete from breaking up, and that same mechanical principal is utilized here to reconstruct this patient's pelvis."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: Today, more than 193,000 total hip replacements are performed each year in the United States. Other similar surgical procedures are performed on other joints in the body including the knee, shoulder, and elbow. The first hip replacement surgery was performed in 1960. Since then, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of a total hip replacement. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are common causes of hip pain and loss of hip mobility.
(Source: American Academy of Orthopaedic Surgeons)

THE PROCEDURE: Patients are usually admitted to the hospital the day of their surgery. The surgery typically takes a few hours. The surgeon removes the damaged cartilage and bone and then positions new metal, plastic or ceramic joint surfaces to restore the alignment and function of the hip. Many types of designs and materials are currently being used for artificial hip joints. They consist of two basic components: the ball component and the socket component.

REVISIONS: About 10 percent of patients who undergo total hip replacement surgery will need a revision for their implant. "We are seeing patients from 20 and 30 years ago who had their first joint replacement. They either have had a complication such as wear of their bearing or secondary osteolysis and destruction of bone. They may have had an infection. They had the hip removed and replaced multiple times, and each time that occurs, there is loss of bone," Henry Finn, M.D., from the Chicago Center for Orthopedics at Weiss Memorial Hospital and the University of Chicago, told Ivanhoe.

NEW HELP: Dr. Finn has pioneered a pins and cement procedure. It's a technique borrowed from patients with metastatic bone cancer and is now being used on patients who have very little of their own bone left. Dr. Finn used the procedure on a patient with a hip-vaginal fistula who had a dozen hip surgeries. He says this technique offers hope to patients who have run out of options, but it's not for everyone. "This should not be touted as first-line treatment," Dr. Finn told Ivanhoe.

FOR MORE INFORMATION, PLEASE CONTACT:
Catherine Gianaro
Director, Marketing & Public Relations
Weiss Memorial Hospital
cgianaro@weisshospital.com
(773) 564-7285

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THE FOLLOWING IS AN IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE.

Henry A. Finn, MD, FACS, from the Chicago Center for Orthopedics at Weiss Memorial Hospital and the University of Chicago tells us about a new hip surgery.

You were going to start off talking about cancer patients of the past who have had pelvic reconstruction and hip replacement for metastatic disease and how that is now providing hope for non-cancerous patients with the durability of future revisional surgery in the non-cancerous patients.

Dr. Henry Finn: We learned when we started to do limb salvage for bone tumors that, where we would remove major segments of bone, we had to find a method to replace those segments of bone. Attempts have been made with cadaver bones, attempts have been made with all kinds of custom and off the shelf metallic replacements and many of them have worked well and many of them have failed. But we have learned over the last 25 years how to reconstruct major significant defects in cancer patients who have bone removed, or who have bone destroyed by metastatic cancer. What I have been focusing on lately is the patient who has massive bone stock deficiency associated, usually around the knee or the hip and pelvis, which may be from conditions that aren’t related to cancer. And these patients have a greater concern because their longevity is greater. Many of the things that we developed in orthopedic oncology now have evolved into helping patients with massive bone stock deficiencies who don’t have cancer. Initially, when we did these procedures, we weren’t sure how durable they would be, particularly the ones that were non-biological reconstructions. But, as time has gone on, we have seen that some of these reconstructions for cancer patients, if the patients survive, are very durable and can be used for patients in the worst situations, who do not have cancer.

Tell us a little about the x-rays and this is an example of what you are able to do.

Dr. Henry Finn: This patient had a reconstruction of her pelvis and upper femur. Her whole upper femur is metal and her pelvis had a hip socket. If you look at this x-ray, this is a perfect example of a young patient without cancer who’s had multiple surgeries and has had major loss of bone. The obvious loss is this upper femur, which we’ve replaced with a metal femur. But one of the last frontiers is reconstructing massive losses of the acetabulum in the pelvis, which is your hip socket. You can see on this x-ray from here to here she has no bone whatsoever. This was a reconstruction that failed and she was referred to me.

Ok, so that failed and she was referred to you and you were able to come up with the pin and cement procedure to reconstruct her pelvis and hip socket?

Dr. Henry Finn: If you look at this x-ray you’ll notice the pins. What we did was take technology that was used to reconstruct the pelvis when it was riddled with metastatic cancer with threaded steal dowels or pins in multiple directions that connect the upper and lower half of the pelvis as well as transfer weight into the lower spine and drill these pins into the remaining bone and then put a hip socket component with bone cement which is like an epoxy. Initially, the bone cement is in a doughy malleable state, and when it hardens it sets up like concrete. An analogy would be when someone is laying a road they use wire mesh or steel bars to keep the concrete from breaking up and that same mechanical principle is utilized here to reconstruct this patient’s pelvis. We’ve learned from patients, whom we have performed this on, who survive for a long time after cancer, that indeed this type of reconstruction can be very durable.

Marcia is a pretty unique patient, wouldn’t you say?

Dr. Henry Finn: She is a unique patient, I would say, overall in orthopedics but not a unique patient to me. I see patients like this almost every week. They come from long distances. They have multiple revisions or infections and have had massive bone loss. They are looking for a last hope.

Why are other doctors not doing this?

Dr. Henry Finn: Typically, these types of problems would be taken care of by a specialist in joint replacement called an adult reconstruction surgeon. Now many of these problems are being referred to tertiary referral centers such as the University of Chicago where I work, where we do things that are a little atypical and not the standard that you might see in a smaller community hospital. As part of trying to advance the field, we’ve been able to adapt orthopedic oncologic techniques into adult reconstruction techniques for some of the worst problems that occur in orthopedic adult reconstruction.

So, you’re able to take this pin and cement procedure and put your little twist on it in order to make it work for Marcia? Is this a specially designed procedure?

Dr. Henry Finn: I think the twist is that this procedure was designed and developed for a patient with metastatic cancer who had a very poor prognosis and may have had less than a year or two to live. And often they didn’t live; but at least during that period of time they were pain free and ambulatory. We’ve now found that with the patients that did survive their cancer, these reconstructions have remained durable and the twist is that we are applying this to a patient who has a massive bone stock deficiency, just like the cancer patient, but who doesn’t have cancer, and these techniques wouldn’t traditionally have been used. In the worst situations we can use this pins and cement technique where there would be no hope otherwise.

Has this proven to be a very durable procedure?

Dr. Henry Finn: I wouldn’t say yet that it is proven. I would just say that we have one case, for example, that we just published in the Journal of Arthroplasty, of a patient with larger bone stock deficiency than this patient, who has survived her cancer for over 17 years and her reconstruction has remained durable. We didn’t know that this possibility existed. I have other patients that are out five or 10 years from cancer that also have remained durable. So, we think, with a great deal of caution, if there is no other possibility for a patient, this is a reasonable attempt to reconstruct even a patient without cancer who may have a long life to live.

People are living longer and longer, and this technique may provide a potential solution for catastrophic failure after an initial hip replacement or more than one?

Dr. Henry Finn: Well, we are seeing patients from 20 and 30 years ago who had their first joint replacement. They either have had a complication such as wear of their bearing and secondary osteolysis, or destruction of bone; they may have had an infection. They had the hip removed and replaced multiple times and each time that occurs there is loss of bone. And as years go on and patients get older, we don’t know what their survival is, but there are situations where there is nothing left and we might resort to this type of reconstruction as a last resort. I would not consider this a first line procedure for most patients. Joint replacement is growing very rapidly. We expect within five years there will be 1.5 million hip replacements done a year. And when that keeps cumulating into the fold of hip replacement patients and as they age, these problems are becoming more and more common when the hips wear out and when they’ve lost significant bone stock. We hope that some of the more contemporary technology with hip replacement is going to last longer. We are really treating the patients from two and three decades ago when they had their first hip replacement and now face loss of their hip function due to catastrophic failure or multiple revisions.

So, that’s what the pin and cement procedure is for? More for those who need to have their hip revised not the ones who need a hip replacement for the first time?

Dr. Henry Finn: Exactly. It’s for patients again for whom it would not be the first treatment option, but for patients who have had multiple revisions or infections or loss of bone from osteolysis and there doesn’t seem to be any other contemporary revision technique. We believe, based on the durability we’ve seen in our oncology patients, that this can be a salvage option for noncancerous patients, this technique of pins and cement reconstruction.

Do you have an estimate of the numbers of people that would, or could be, patients needing this option?

Dr. Henry Finn: Well, it certainly is a problem that is growing, but I can’t give you numbers. It’s not someone you see in your office everyday even as a revision surgeon. What you have to remember is that we are treating people who had hip replacements done 20 to 30 years ago that have failed. That is growing and then more and more hip replacements are being put in and they’re going to eventually fail. It’s only in very extreme situations where this technique is considered. It is not a first line technique for revision. It’s only for the patient who has no other hope because of failure of other revision techniques.

In the book here, this is the original patient from 17 years ago. Could you talk about that?

Dr. Henry Finn: This is a patient from more than 17 years ago who had a solitary myeloma, which is usually metastatic cancer, but in her case it wasn’t. Her pelvis and entire hip socket was being destroyed. The CAT Scan is very demonstrative in defining the tumor and catastrophic bone loss. This would be the wall or the dome, of her hip socket and you can see that it is completely gone. Her options would be to live in pain on a morphine drip and die very quickly, or to attempt reconstruction of her pelvis. And this is after these pins have been placed up into the lower spine called sacrum and other pins have been placed that connect the bottom to the top of the pelvis. There is some significant risk because these pins, if misplaced, can go into the spinal cord, they can go into the pelvis and damage a variety of organs that are in the pelvis or go into the intestine.

This is a diagrammatic example of how we keep our finger in the sciatic notch to guide the pins that go up into the lower spine and then we take x-rays in the operating room to determine that the placement is correct.

This diagram shows the pins that are connecting the lower and upper half of the pelvis.

And then this shows when the cup for a conventional hip replacement or acetabular component is actually cemented into place and the bone cement amalgamates all this together into one solid construct, bypassing the defect.

Is there anything that we missed?

Dr. Henry Finn: This should not be touted as first line treatment. We are not touting this technique as a first line treatment for a patient with bone stock deficiency in their pelvis and acetabulum. We are only saying in elderly patients with osteoporosis and with massive bone stock deficiencies that had failure of the contemporary techniques such as allografting and/or a cup-cage construct. This is a last chance situation, to reconstruct this pelvis and make up for this major and the surrounding osteoporotic bone where it pulls it all together and has greater strength by all these interconnections that are amalgamated into the bone cement, pins and acetabular components.


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