Shane J. Nho, MD, MS, an Orthopedic Surgeon for Midwest Orthopaedics at Rush, talks about a potentially different option for patients considering a total hip replacement surgery.
Interview conducted by Ivanhoe Broadcast News in May 2017.
How did they find you?
Dr. Nho: Femoral-Acetabular Impingement (FAI) and Hip Arthroscopy, it’s a relatively new procedure. And the experiences from patients vary quite a bit. Patients have a support network that they’ve been able to create online. So there’s a huge social media presence for FAI and Hip Arthroscopy, but other orthopedic procedures as well. I’m in tune with FAI because that’s a lot of what I treat. Patients communicate with one another, asit gives them an opportunity to speak about their experiences. It also gives them a sounding board withother patients to relate to and talk about how they’re doing and how they’re progressing. Does it sound normal to them, is there something amiss, is there something else going on?
Are there any other countries or certain populations that have found you?
Dr. Nho: Yes. We do provide complimentary review of imaging studies for patients, so they’ll send us clinical information and we receive a couple of inquires a week. And they come from all over the country, they also come from Canada, Caribbean, Europe, and Asia. Their reasons for reaching out to us differs for each patient. In some situations, they’re looking for a free consultation; in other situations they’re actually looking for someone to treat it. It depends on which physicians are in their local community; we get a lot inquiries domestically. Certain parts of this country do not have a provider that does a lot of hip procedures, so we get a lot from central and southern Illinois and the Pacific Northwest. Our radius for referrals, is a five hour radius from Chicago.
Why is it such a difficult procedure, why is it so rare, why aren’t more doctors doing this?
Dr. Nho: It’s only been performed in high numbers in the past ten or fifteen years. And so the problem is that it requires more intensive training for surgeons as it is technically difficult to perform. In some cases, a surgeon who is used to doing open surgery for a long time, and then asking them to perform the most difficult procedure in orthopedic surgery right now. Anybody can perform the procedure if they want to, but it depends on what their level of training, level of experience level, and proficiency. Also, the field is changing rapidly so what we’re doing today is very different than what we were doing when I finished my fellowship. If you’re not either keeping up with the latest research and the outcomes, then you’re not performing the most up to date technique. Part of what I do as well as a handful of other surgeons in the country, is that we contribute a lot to the literature in terms of both basic science research and clinical research and that allows us to evolve our practices. We’re constantly kind of refining what we’re doing. It’s a moving target and I think that’s what makes it all so difficult. The other reason why it’s not more widely performed is a lot of surgeons that are learning it are learning it in their training as a resident or fellow. Every year as more residents and fellows graduate and go out to different locations, and those are the ones that will start to pick it up. But their lead time in terms of having a busy practice may take several years. And even in our market there’s a couple of guys that do a lot of procedures, but there’s a lot of surgeons that do a low volume. It’s one of those procedures that patients understand that it’s not just something that you can go to the most convenient orthopedic surgeon, but this is a procedure that you need to seek out more specialized care.
What’s the name of the procedure?
Dr. Nho: Hip Arthroscopy for Femoral-Acetabular Impingement (FAI). FAI is essentially a developmental condition that might be in part hereditary. What happens is that a lot of these patients that we’re seeing are very active in their junior high, high school or college years in terms of athletic activities. What happens is that during the patient’s growth spurt the bones actually very subtly change shape. The ball and socket changes shape in response to the repetitive activities and loadings the joint is being exposed. Over time the ball and socket start to engage one another, if it doesn’t quite fit right together from a geometric perspective, the cartilage and labrum can be injured or torn. The labral tear sounds the alarm creating pain and inflammation in the joint. Some patients we see in high school and college, and most of those patients are very competitive athletes. Then, we see other patients kind of further on down the line in their twenties, thirties, forties, and fifties who may become more active. Sometimes it may be traumatic, and other times it may just be from everyday life. Everybody presents somewhat differently, but the procedure that we do for FAI is performed with arthroscopy; which means that we do it through very small incisions. We use two or three incisions, and we place the camera inside the ball and socket joint itself. Labrum and cartilage can be repaired, and most importantly, we have to shave down the bone deformities so that the ball and socket articulate more smoothly. Removing the impingement will allow friction-less movement between the ball and socket.And the porcedure usually takes about an hour and a half; it’s more technically difficult asthe hip joint is much deeper than your knee and shoulder. There’s less room for error, and that’s why the people that do a high volume end up doing more, because patients recognize that if it’s not being done on a proficient level that sometimes the outcomes can be somewhat variable.
How do you compare to other physicians doing this?
Dr. Nho: We do a lot of Hip Arthroscopy for Femoral-Acetabular Impingement. Amongst other surgeons in the country, there are a handful of us that probably do more than four or five hundred hip procedures a year. This is mostly for the treatment of FAI, mostly for young patients who are active without any evidence of osteoarthritis. The other thing that differentiates a lot of us that do the high volume of this procedure is that we are also very involved in the research and the education behind it. We’re doing things in the lab, we’re following our patients after surgery, so we’re constantly either changing how we do things from a technical level by understanding the disease process and the pathology better. In addition, selecting the right patients is extremely important too. There are certain patients that we won’t necessarily operate on even if they have pain, because we don’t think that they’ll have a good outcome. We recently published a study in which followed our outcomes in terms of patient age and gender. The goal was to understand why is it that some patients do very well and why is it there are other patients don’t do as well. These are kind of real world applications of some of the research that we implement in our everyday office. We’ll tell patients, this is the study we published and you’re in this category that suggests you should do very well, and that’s why we recommend this procedure. Whereas, other patients may fall in a category where they may not do very well, and they should be informed so that they understand what the procedure entails. The other thing that we try to educate patients about is that it’s not a small procedure even though it’s being done through very small incisions. It’s actually a very big procedure. I tell most patients that it’s really going to be like a six month to twelve month recovery period before they’re back to their activities. Everybody is different; some patients will go back in a few months while other patients may take a couple of years. There is a lot of variability in terms of their post-operative course as well, which kind of creates more of the confusion. A lot of it is education and expectations from a patient perspective that we try to tell them up front as much as we can.
What advice do you give to patients after this procedure? In terms of their expectations.
Dr. Nho: I think the patients that do best are the ones that have pain, problems in terms of their daily life activity such as sitting, squatting and other types of activities, inability to participate in recreation or sporting activities. If it’s just kind of vague pain, sometimes it may not necessarily be the right procedure for them. The patients that have higher functional demands are more able to tolerate the procedure than other patients. Again, it’s not a small procedure, a lot of work that’s being done in the joint. Any procedure that you’ve undergone, the joint won’t be the same. There may be a little bit of discomfort that some patients may feel, even despite having surgery and having a good outcome, but most of the time it’s not entirely pain free. That’s one of the things that some people think; that you fix it, like you fix your car, you fix your house; once it’s fixed you don’t have to deal with it again. But that’s not the case; this is our body, this is what we have for our entire life. We’re always trying to make educated and shared decision; in terms of is this right for you; is this going to help you? In some situations we’ll say, give it a little bit more time, maybe try some physical therapy. In other situations we’ll say, I think kind of given what your demands are and the level of pain that you have, that the surgery probably makes most sense at this point. Part of the decision making in terms of when patients are best treated with surgery is not black and white.
What recommendations do you have to somebody that has this condition?
Dr. Nho: Most patients with hip joint pain usually feel it in the groin, but there are some people that can have other types of pain locations; including back pain, pelvic pain, buttocks pain, it’s not always straight-forward. That creates some of the difficulties that make it sometimes hard to pin down. Is it coming from the hip joint, is it coming from tendinitis, is it coming from the low back, is it coming from the sacrum? There are a lot of structures that are in this section of the body that creates some of that confusion. From our perspective we want to try to isolate the joint as best as we can. That’s based on patient’s history, x-rays, MRI, and in some situations we’ll perform injections. The injections are a good way to help understand is it actually coming from the joint itself. In terms of seeking treatment, if you’ve undergone a series of treatment already and you feel like you’re not getting down to the source of the problem, really you want to see someone that treats a lot of these conditions. If you’re having ongoing complaints of pain that just doesn’t seem to be improving or isn’t making much functional gains, you should really seek someone that treats a lot of hip problems and performs a lot of hip arthroscopy procedures. Because those are the ones that will be able to differentiate, is this a hip joint problem or is it something outside the joint.
You were saying these new fellows were coming up but they haven’t done the volume. How are you keeping up with all these new procedures?
Dr. Nho: Myself and a handful of other surgeons in this country are the ones that are pushing the envelope in terms of treating them the best that we can and implementing kind of newer ideas and technologies from research into a lot of what we do. Some of it is common sense orthopedics that we’ve applied from other parts of the body, and part of it is you kind of have to make do with what you have and basically see what you have from a joint perspective and treat it with whatever tools you have on hand.
So it’s like each patient is different and they need individualized treatment?
Dr. Nho: Right and everybody is different, not just in terms of the way they present but also everybody’s hip is very different. There are some hips that are more minimal than let’s say an arthroscopic procedure and there are other patients where maybe Hip Arthroscopy is not the right procedure for them, or maybe they don’t need a procedure. In some situations sometimes they need more of an open procedure and more invasive procedure; potentially the arthroscopy may not be the right treatment for them. A lot of that goes back to kind of understanding the pathology and the disease process, understanding Femoral-Acetabular Impingement, understand hip dysplasia and understanding what is the best treatment for them especially if they have already gone through a previous procedure already.
What research is exciting for you in the field of FAI, what are you working on that really excites you?
Dr. Nho: The thing that excites me the most about treating patients with Femoral-Acetabular Impingement with Hip Arthroscopy is that it is a new field, it is evolving and it’s changing quite a bit. Every month there are new studies coming out as far as what are the best techniques to be performed, what is the best in terms of mechanically trying to stabilize a joint or improve a joint movement, and articulation from a very basic science level. What excites me the most is understanding which patients are the ones that are going to do the best and how to predict that. The patients that we know who are going to do well, what is it that allows us to understand that before we actually bring it to the operating room. So that both the patient and myself kind of understand and have a realistic expectation and are on the same page as far as this is your problem. This is what we think is going on and given our best information available this is what we think we can expect following surgery and things like that.
Are you doing a study like that?
Dr. Nho: Yeah, we’re looking through our database of patients and basically trying to pair down which are the factors both in terms of patient demographic issues as well as any sort of other co-morbidities or co-pathologies that they may have that may allow us to understand and predict if this patient is going to do well or if this patient is not going to do well. So that we can be prepared for it before we go into it. Because there are some patients that we know are going to do well and there are other patients that we know will be better, but they’re not going to be let’s say as good as we had hoped for. But I think that if patients understand that and understand this may not be sort of the final thing that you do, but this may be kind of a bridge for another procedure then I think patients will understand better and be more accepting of that.
In terms of new studies, this new study that you just discussed in doing; that had a lot to do with outcome and also sex and age. Can you explain what you found out?
Dr. Nho: What we have found in a recent study that we published in the Journal of Bone and Joint Surgery on Femoral-Acetabular Impingement, looking at patient demographic factors such as patient gender and age, is a couple surprising things. One is that most orthopedic surgeons believe in the treatment of Femoral-Acetabular Impingement, it is a good procedure for very young male patients. Meaning, high school male athletes, if you perform a hip scope on them that they’re going to do exceedingly very well. The study proved that was the case, the young patients; under the age of forty five males do very, very well. There are other surgeons that believe females don’t do as well. For a variety of reasons we may or may not understand. One of the main findings that we described in this paper is that young females under forty five do just as well as young males under forty five. And so there is no discrepancy in terms of males and females in terms of how we expect them to do. If we find the right patient, whether male or female, who have let’s say a symptomatic labral tear and FAI without arthritis, we know that those patients regardless of their gender should do very, very well. The final thing that we found was that once we get past let’s say forty or fifty that both patients, males and females, don’t do as well as those who are under forty five or fifty. That makes sense and I think most of us have seen this. Some situations it might be related to a little bit further degeneration in their joint or a little bit of arthritis in their hip. Just like in the knee, providing procedures for arthritis tends not to be a very successful surgery. The degree of arthritis can be very minimal in some patient and so some of these patients may have at first glance a fairly normal looking x-ray in terms of arthritis, but when you look at their MRI they may have other signs of degeneration that may make them a lesser quality candidate for surgery. Those are the patients that we have to understand what is their goal in terms of having this; is it pain relief, is it going back to playing tennis or running and things like that? If we understand where they’re coming from and what they want to accomplish, that’s when sometimes we’ll say, this is what you can expect from this procedure. You’ve got a little bit of arthritis and it may not be necessarily as predictable as you’d hope. Sometimes the hardest thing is to say no to a patient and say this is not going to help you, and that you should consider alternative treatments. Or at some point consider a joint replacement.
Back to package pricing in general, why did Midwest Orthopedics start going in this direction?
Dr. Nho: I think the beginning of this was really patient demand. We’d see patients who were having problems and looking for higher quality care. Obviously with a change in the healthcare market most payers and patients are looking for more value. Value is not necessarily cheaper, but a higher quality at a more affordable price. The benefit of this is that we can provide all these services in one bundle so that patients are able to know what they’re getting it for. Just like when we’re shopping for retail goods or anything online these days, we can compare different venders and so forth. We’re probably one of the first to have done this and just like purchasing other goods you can as a consumer decide is this the right provider and is this the right procedure for you. I think the package pricing is great for patients who fall under a few different categories. One is the international patients that we talked about. Domestically, as well, we also see a demand for it. Also for patients who have either high deductable plans or patients who don’t have insurance, which is becoming more rare these days. But in some situations your deductible is so high, you’ll actually find that performing some of these procedures may actually fall underneath your deductable. So you may pay less for a package price Knee Arthroscopy, Shoulder Arthroscopy or Hip Arthroscopy than what your total deductible is. The last situation is when you have a narrow network plan or an ACO or HMO type plan where you’re really restricted in terms of who you can see. In this situation you don’t have the choice that you want and so you may have to treat with whoever falls within their plan unless you really don’t want to. I think all of us don’t really want to be forced to choose among people that we don’t think are going to provide the best care for us. In this situation it gives patients the ability to choose, let’s say a surgeon that is very well qualified, very reputable that can provide this at a cost that is much cheaper than what they would get either within their existing plan or whatever they would have to pay out of pocket if they had to pay for everything individually.
Anything new in the mobility lab that you’re doing, any new studies?
Dr. Nho: In our gait lab we are tracking our patients both before and after surgery. The interesting thing from the gait lab is understanding the neuromuscular envelope surrounding the hip and the pelvis. And I think this is probably something that is very difficult to understand because we just don’t have a great way of looking at it. The gait lab gives us more ability to look at the muscle activation of a lot of the muscles that surround the joint. We can understand why is it that patients have snapping with their hip, why is it the patients have atrophy in some of their muscles and how does that change after surgery? What we’re finding is that before surgery, and this is part of why patients develop so much weakness and wasting in their muscles is that for whatever reason, the signaling to their local muscles and muscular skeletal environment just changes. We usually see that some of these muscles essentially turn off and atrophy. But once you treat the problem the joint issues related to labral and cartilage tear as well as the impingement, a lot of these muscular problems and weaknesses actually improve. So it does happen but like I said it can happen sometimes very quickly or sometimes it may take many months or even years. That kind of goes back to understanding the process that’s going on and also understanding why is it that some patients do well right out of the gates and some patients take a long time to get better.
It helps you modify the treatment for them in the future.
Dr. Nho: Right, and also sometimes if their progress is a little bit slower than others we have to understand that is it something we can change, you know is there any rehab or therapy or injections that may help to kind of speed them up or you know augment them a little bit and make them a little bit better. That’s another area that we’re looking at as well. I think the rehab and the physical therapy just like the orthopedic surgeons can vary quite a bit. What’s being done in each physical therapy provider and our clinic is variable. We try to provide a very specific protocol for healthcare providers to follow. Now, sometimes patients don’t really follow that because they’re just a little bit different. And there are some patients that are just a little bit more difficult. There’s a lot of different issues going on with the care for some of these patients that just makes it very difficult.
Basically what you’re doing it helping a lot of these people to hold off from having hip replacement. Are you giving them an extra twenty years, is there anything like that going on? Or do these people sometimes just get better and never have to have hip replacement?
Dr. Nho: What happens long term after Hip Arthroscopy, for FAI is something that we don’t really have the data to answer. The procedure has only been around for about ten or fifteen years. The actual first report of Femoral-Acetabular Impingement in the medical literature was only in 2003, only thirteen years ago. So we don’t have the ten year, twenty year, thirty year data on patients in terms of which ones are going to result in a hip replacement and at what point in time. Some patients will result in a hip replacement depending how far along their disease process is. I think there are some patients that if you didn’t treat them and they just kind of went along in life without it that you would argue they would end up with a Hip Replacement at an earlier age. So in some situations we believe that if we can treat the problem earlier, this may delay the progression disease. In some rare situations you may be able to prevent it. If we get it soon enough where there’s no soft tissue problems or cartilage problems, in some situations we may have prevented someone who may have resulted in a joint replacement surgery at the age of forty or fifty and maybe they won’t have one in their lifetime. Or maybe we’ll delay it for ten, fifteen or twenty years from where they probably would have gotten it. Some of these patients we know that their hips are not going to last very long and we see a lot of patients in their forties that end up with hip replacements because of either Femoral-Acetabular Impingement or dysplasia or some other mechanical deformity. Some of those patients we’ll see in their teenage years. So if we treat those patients earlier are they going to result in a joint replacement at the age of forty or are we actually going to be able to prolong their need for a hip until they reach their fifth, sixth or seventh decade. I think that unfortunately we just don’t have the data for that but that’s kind of the Holy Grail in our field is that if we can prove that we can either delay or prevent the onset of joint arthritis then I think this would be a significant benefit. Not just for individual patients but also for the population at large.
END OF INTERVIEW
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