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Cedars-Sinai orthopedic surgeon specializes in arthroscopic procedure that allows many patients to avoid total hip replacement

Cedars-Sinai Medical Center

LOS ANGELES (January 17, 2000) - Orthopedic specialists in Michigan told Lynette Snauwaert she likely would need several major hip operations to repair a cartilage tear she suffered in January 1999. Mikayo Langhofer, a resident of London, England, was anticipating - or more accurately, dreading - the prospect of hip replacement surgery to treat arthritis and a hip socket that had been defective since birth.

Instead, both women came to Los Angeles last December for arthroscopic hip procedures that relieved most of their pain immediately and delayed the need for major surgery for years, possibly for the rest of their lives. Rather than finding themselves unable to resume their active lifestyles for months - as is typical after open hip surgery - they spent several days relaxing in Southern California before heading home to pick up their usual schedules where they left off.

Snauwaert and Langhofer found one of a very few surgeons who perform hip arthroscopy, Robert Klapper, M.D., medical director of Cedars-Sinai Orthopedic Associates and attending orthopedic specialist at the hospital. A pioneer in the field, Dr. Klapper holds nine patents on the tools that make the procedure possible. He has published papers in orthopedic journals, recently wrote a chapter for an orthopedic textbook, and teaches courses for other orthopedic surgeons.

Unlike knees and shoulders, for which arthroscopic tools and procedures have been available for years, the hip is situated deep within muscle and other fragile tissue, limiting access. But with his angled telescope and specially designed tools, Dr. Klapper can see and work directly at the site of the joint, entering through two small puncture holes. He can view the degree of inflammation, smooth damaged cartilage and vacuum out debris and joint fluid that has become "corrosive" through the inflammatory process of arthritis.

"For many patients, this is a very nice way to avoid a hip replacement," said Dr. Klapper, who serves as orthopedic consultant to the TV show "ER" and has been performing hip arthroscopy for about nine years. "When arthroscopy first came about, the comment from a lot of traditional orthopedic surgeons was, 'Why look through a keyhole when you can open the whole door?' Well, I don't want to open the door. It's a lot easier for the patient to recover from an arthroscopic procedure."

In many cases, arthroscopy may allow a patient to avoid major hip surgery altogether. Other times, it is seen as a long-term stopgap, providing quick relief from pain and giving patients time to wait for new generations of science and technology that may improve hip replacement surgery or do away with it entirely.

Before finding Dr. Klapper, both Langhofer and Snauwaert happened upon a book he co-wrote with Lynda Huey, an athlete and coach who has developed water workout rehabilitation programs. Langhofer saw an ad for the book, "Heal Your Hips: How to Prevent Hip Surgery - and What to Do If You Need It," in a science magazine. Snauwaert noticed an article written by Dr. Klapper in a health magazine.

"In the article, it said groin pain is a sign of cartilage problems within the hip. That's how I heard of him. At the bottom, it said that he wrote a book, and I thought, 'Well, he's the only other doctor who seems to understand what the problem is. I'll give him a call,'" said Snauwaert, 34, a nurse anesthetist from Fair Haven, Mich., about 40 miles north of Detroit.

"The last few months, I couldn't even make it through a work day. I would go to work and I would have to be chained to the sofa or a chair for the rest of the night because I couldn't physically move any more," said Snauwaert, who enjoys hunting moose in her spare time.

Although she does not know how her cartilage injury occurred, Snauwaert said her hip started hurting last January. "With an MRI with contrast, they diagnosed the problem in Michigan but they wanted to take my hip apart, clean it up inside, put two nails in it and put it back in place. Probably in a year, I'd have a 50 percent chance of having them go back in and take the hip apart, take the hardware out and put the hip back together again, which I thought was very aggressive. I'm 34 years old, so I didn't think it would be something I'd really want to try as a first resort," Snauwaert said.

Her orthopedic specialist in Michigan and Dr. Klapper both agreed that if the injury were not repaired, she probably would need a hip replacement in the future. The arthroscopic procedure probably allows this decision to be postponed by at least six years, possible more, depending in part on how regularly Snauwaert participates in physical therapy.

Dr. Klapper said Snauwaert's surgery lasted about 45 minutes on Dec. 17 and she was discharged from the hospital two days later.

"I've been to physical therapy three times already. I'm walking. I have less pain than when I started and I feel amazingly good. I'm shocked," Snauwaert said five days after the arthroscopy.

Langhofer reported similar results five days after her operation. She had been born with a hip socket that was too shallow. Because the ball at the top of the femur did not fit properly into the socket, the joint was prematurely wearing away, resulting in inflammation and pain. Dr. Klapper inspected the joint, cleaned out the inflammation and debris, and gave Langhofer several years to ski, climb, scuba dive and hike before undergoing implant surgery.

"My hip had started to get very bad arthritis," said the 40-year-old biologist who used to live in Los Angeles but now enjoys exploring the forts and castles of England. "When I'd seen doctors in the United Kingdom about it and even on the East Coast in the U.S. - I have friends who are orthopedic surgeons - what they told me is that I should just reconcile myself to hip replacement surgery, and until I actually need the hip replacement surgery, there's nothing that can be done."

Dr. Klapper performed Langhofer's arthroscopy on Dec. 10. "The procedure went beautifully," she said. "It's just amazing because they didn't give me any pain killers after the surgery and there was less pain with the surgery than I had had before."

Dr. Klapper cautions that arthroscopy is not the best solution for every patient with hip problems. In fact, of the more than 150 hip surgeries he does a year, only an average of 30 to 40 are performed arthroscopically.

"I'm very picky about who I will do it on," he said. He insists, for example, that patients be willing to participate in the recommended therapeutic exercises and to make other lifestyle alterations that may be necessary to ensure successful rehabilitation of their hips. He said he encourages patients to follow a very conservative approach, exhausting all other options before employing any surgical procedure.

"Many people get into a negative spiral that begins when they first feel pain or limited movement in a hip," he said. "To avoid the pain, they move the hip less often. They may cut back on their normal physical activities."

Unfortunately, the cartilage within joints is not fed by a blood supply but is nourished by the regular inward and outward flow of the fluid that resides within the joints. Therefore, instead of relieving the problem, the reduced activity begins to starve the joint of nourishment, causing further constriction and inflammation. Next, the muscles begin to shrink and weaken, and the tendons around the joint become brittle.

"My goal is to break this negative spiral early, prevent further damage, preserve the healthy cartilage that still exists, and help the patient avoid invasive surgery," said Dr. Klapper.

Not only is total hip replacement surgery traumatic, requiring a long period of recovery, but implants eventually wear down and often need to be replaced again in a few years. The prosthesis is made of material that is actually harder than the bone into which it is cemented, requiring surgeons in the past to use hammers and chisels to break out the old prosthesis to implant a new one.

"It was eight hours of surgery, ripping the bone apart, wiring it and bone-grafting it back together," said Dr. Klapper. "It's not going to last very long if you're not leaving the patient with much to work with."

To solve this problem, Dr. Klapper designed a tool that produces an ultrasound frequency specific for reducing cement to a chewing gum consistency while leaving the bone unscathed. This technology has been used for about 10 years in about 500,000 surgeries worldwide. Although hammers and chisels are still used in some locations, the ultrasound technique has become the standard of practice.

Dr. Klapper expects hip arthroscopy to become much more prevalent in the future also. "Hip problems, these ailments that used to affect older patients, are occurring in epidemic proportions in our young, active, baby-booming population. We really would rather avoid putting an implant in these patients if possible."

Lynette Snauwaert, the Michigan nurse and moose hunter, was enjoying a shopping trip with her mother in Beverly Hills five days after arthroscopic surgery. "The other surgery that they wanted to do, my only other alternative, would have been a minimum of a five-day hospital stay and six months off work," she said.


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