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Some doctors warn of hype in hip surgery ads

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Sep. 19--On websites and television, hospitals and surgeons are promoting what they call a dramatically better way to treat painful hips: "minimally invasive surgery" that allows patients to recover quickly and with less pain. Hundreds of patients who aren't willing to endure the arduous months-long recovery from a conventional hip replacement are eagerly volunteering.

But behind the scenes, in medical journals, at conferences, and in private exchanges, a growing number of surgeons are warning that colleagues are overselling the procedure.

Some surgeons have even abandoned the operation, which requires one or two incisions, just 1 1/2 inches to less than 4 inches long, compared with incisions of 6 inches or more for standard surgery. Other surgeons have accused colleagues of overly optimistic marketing to patients, particularly as reports of serious complications such as dislocated hips have emerged.

"There is a lot of hype about minimally invasive surgery that is not based on any data at all," said Dr. Jay Lieberman, an orthopedic surgeon at UCLA Medical Center in Los Angeles.

For one, evidence does not yet exist that artificial joints placed through small incisions, which provide less visibility for the surgeon, last as long as those implanted through the longer cuts of conventional hip surgery, one of medicine's most successful operations. Researchers have not completed head-to-head comparison trials, and the newer operation is technically challenging, so the highly touted results of a few experienced surgeons who pioneered it may be atypical.

Fueling the controversy has been a lack of agreement about exactly what constitutes minimally invasive hip surgery. Hospitals and surgeons advertise a range of surgical techniques as minimally invasive, some involving only a smaller incision, others also sparing more muscle and tendons. And even traditionalists have shortened their incisions over the past several years.

Unlike with prescription drugs, the federal government does not regulate the safety and effectiveness of surgery -- or the accuracy of advertising -- although it must approve the devices that surgeons implant. Surgeons experiment with new techniques they believe will improve care for patients. As a result, many new surgeries, including minimally invasive hip surgery, become popular before researchers have studied them fully in clinical trials. This was true of laparoscopic gallbladder removal, which turned out to be a major advance, and of off-pump cardiac bypass surgery, which some surgeons have abandoned because of mixed results.

More than 300,000 Americans had a hip replacement in 2003, a 20 percent jump in five years, propelled in part by minimally invasive techniques, according to the American Academy of Orthopaedic Surgeons; the group does not know how many of those operations were minimally invasive.

Mount Auburn Hospital in Cambridge has run television ads touting minimally invasive hip surgery as resulting in less pain and faster recovery and with implants that "last longer than ever before." Beth Israel Deaconess Medical Center promotes minimally invasive surgery on the radio, and numerous hospitals have put patient and surgeon testimonials on their websites. The surgery is lucrative, but hospitals and surgeons also worry they will lose patients to competitors if they don't offer the minimally invasive technique. Zimmer, an implant manufacturer based in Indiana, advertises the procedure on its website and allows patients to search for a company-trained surgeon in their hometown.

Dr. James Bono, an orthopedic surgeon at New England Baptist Hospital, said that because recovery from traditional hip surgery can be a challenge, "there are a lot of Americans who suffer from arthritic conditions who are not ready to have a joint replacement. The advertising is designed to drive these people on the sidelines to say, 'Now is the time to do it.' "

Surgeons who do minimally invasive hip surgery are convinced that at least the short-term results are better. Patients stay in the hospital an average of two days, compared with four days for standard surgery, according to the orthopedic surgeons organization.

At Massachusetts General Hospital, Dr. Andrew Freiberg said his patients have had excellent results from two types of minimally invasive hip surgery. He performs one of the most hotly debated types of surgery, because of the size and location of the cuts, which some of his own colleagues shun. The operation involves making a 1 1/2-inch cut in the front of the hip, through which he slips the socket portion of the joint, and another 1 1/2-inch cut behind the hip for the new end of the femur, which fits into the socket. Rather than cutting muscles and tendons to access bone, he parts the muscles with instruments and his fingers. X-rays help guide him.

Freiberg said his patients do remarkably well; only one of his first 100 needed a second operation to correct a problem, and none has suffered infections or other complications after one to two years; 95 percent went home in one day. He also does a single-incision surgery with a slightly longer cut, which more doctors do because it's easier.

But Freiberg said he recognizes the need for a long-term clinical trial comparing minimally invasive surgery to the traditional operation, and he and several Mass. General colleagues have applied to the federal government for a major grant.

In this case, patients' excitement over the procedure has hindered doctors' ability to study it; Freiberg said he could not convince patients to enroll in a randomized clinical trial comparing traditional and minimally invasive surgery in 2003 because they did not want to risk being assigned to the group that would get traditional hip surgery.

Charles Kendrick, 63, of Andover, a commercial real estate developer and serious skier, said he did not want traditional hip surgery because he did not want to miss work for several weeks. He spoke to another skier who had the two-incision operation in the fall and was skiing by winter. Kendrick went to Freiberg for a right hip replacement in January. He walked out the day after surgery on crutches. Three weeks later, he was driving and flying in airplanes. Two months later, he was working out twice a week at the gym.

"The short-term recovery difference is substantial," Kendrick said. "That's not based on a study -- it's based on many conversations with people who have had hip operations."

Dr. Richard Berger, who popularized the two-incision surgery at Rush University Medical Center in Chicago, said he has had remarkable results; 296 of his last 300 patients have gone home the day of their surgery, and none has developed a skin infection. "Most of my patients are back to work in a week," Berger said.

But other surgeons report not-so-sterling results. Some, including Dr. Lawrence Dorr of Centinela Hospital Medical Center in California and an international leader in minimally invasive joint replacement, believe the newer technique may excessively stretch the skin, damaging it and leading to infections.

In the April issue of the Journal of Bone and Joint Surgery, a group of Irish researchers found no difference in pain, blood transfusion requirements, or walking ability among patients at their hospital who were randomized to have either traditional (6-inch cut) or minimally invasive hip surgery (less than 4-inch cut) and then were followed for six weeks. In a separate article, doctors from the Charlotte Hip and Knee Center described three patients who had catastrophic complications after minimally invasive hip surgery, all of whom were transferred to the Charlotte hospital for corrective surgery. In one case, surgeons damaged the femur of a 67-year-old woman while operating through a 3 1/2-inch incision.

One North Shore orthopedic surgeon, who did not want his name used because he does not want to alarm patients, said he trained at Zimmer and did 30 two-incision operations. But he found one patient had developed a skin infection and several others limped after surgery -- complications he never experienced with traditional surgery. "I just can't afford any complications with my patients," he said. "I abandoned it."

But patients are not ready to.

Marjorie Douglas, 80, of Southborough, was already considering a hip replacement when the woman who delivers her newspaper had the operation. Douglas, who visited the patient, said she was "blown away" by the tininess of the woman's scar, and that sold her on minimally invasive surgery. She asked for her friend's surgeon's name.

That surgeon, Dr. Paul Pongor, works at Marlborough Hospital, which promotes his minimally invasive technique on its website. He said he has had excellent results using a 2 1/2-inch to 3-inch incision and cutting less muscle. He said patients are happier with the incision, which is "covered by their underwear and bathing suit, and they do tend to rehab quicker." But he added: "I would be wrong to tell them it's much better than traditional surgery. You can do a great hip with the old approach."


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