December 18, 2018

St. Vincent Charity surgeon's approach to hip replacement reduces pain and recovery time

Michael Maniche of Willoughby, Ohio, knew for almost a year he needed a total left hip replacement. But having gone through a recent left knee replacement, he dreaded what he believed would be months of painful rehabilitation. He did some research and met with his previous orthopedic surgeon, but it wasn’t until he talked with Dr. Amar Mutnal, an affiliated surgeon of St. Vincent Charity Medical Center’s Spine and Orthopedic Institute, that he knew he was ready to take the leap to hip replacement.

Michael chose Dr. Mutnal because of his specialized approach to total hip replacement surgery. Dr. Mutnal combines the latest in surgical techniques and technology – a minimally invasive anterior approach, digital templating technology and intra-operative x-ray.

“By combining these elements, I see my patients up walking a few hours after surgery and virtually all patients go home the day after,” Dr. Mutnal said. “It also reduces the use of narcotic pain medicines, which I have found the vast majority of my patients seldom need.”

Anterior approach
Dr. Mutnal is a strong proponent of the anterior approach to hip replacement, through which the implants are placed through an incision in front of the patient’s hip, after learning from masters of the technique as a research fellow.

As opposed to the more common posterior approach, in which the surgeon places the implant through the back, the anterior approach avoids cutting through muscle fibers and detaching muscles from bones, and requires a smaller incision. The anterior approach does not require any of the cumbersome post-surgical restrictions required following the posterior approach (no crossing legs, no bending at the hips, and having to place a pillow between the legs at night) that patients typically must endure for six weeks.

“Because I am not cutting through major muscles, patients have less post-operative pain and they are up walking around unassisted more quickly and with easier range of motion,” Dr. Mutnal said. “My priority as a surgeon is to always get patients back to their daily activities as quickly, yet safely, as possible.”

Because it does not significantly disturb the muscles and soft tissue structures around the joint, the anterior approach itself carries a lower rate of dislocation, the major cause of re-operation following total hip replacement. The most common way the hip dislocates is posteriorly (or out the back), and since the approach is anterior, those stabilizing posterior structures are not violated as they are in the posterior approach.

Digital templating technology
To ensure better long-term results for patients, Dr. Mutnal also employs digital templating to plan every surgery. After taking x-rays of a patient both standing and lying down, he utilizes digital technology to map out the surgery, identifying the proper-sized implant and the optimal orientation at which the implant should be placed. Poor cup position is another major factor that contributes to dislocation. So, Dr. Mutnal takes advantage of both the protective effect of the approach itself and the latest technology that ensures proper cup position to minimize that dislocation risk. To date, Dr. Mutnal has not had a dislocation in any anterior hip patient.

“This takes the guesswork out of the surgery. I know before I walk into the operating room exactly what I am going to do,” Dr. Mutnal said. “By ensuring the components are going into the proper location, the leg feels more stable and the life of the implant is extended.”

Dr. Mutnal’s surgical approach also avoids complications related to differences in a patient leg lengths – a leading cause of poor outcomes following a hip replacement surgery. If one leg is too long, it changes the angle of the patient’s pelvis, tilting the cup of the implant and potentially altering the mechanics and longevity of the implant. This can lead to increased pain, restricted motion and even excessive wear of the implant that can lead to it not lasting as long as it could. With the use of x-ray and surgical planning, Dr. Mutnal is able to restore a patient’s leg lengths to typically equal or, at worst, within a few millimeters, which is not discernable to the patient.

Intra-operative x-ray
Once the plan is in place and the surgery is under way, Dr. Mutnal utilizes x-ray to ensure proper alignment, angle of the implant and to confirm equal leg lengths for the patient.

“I have real-time information so I can adjust right in the operating room,” Dr. Mutnal said. “It eliminates some of the preventable things that can happen and allows for consistent results. The anterior approach, combined with surgical planning and use of X-ray in the OR, dramatically improves outcomes for patients.”

Michael’s success with his surgery, including the fact he never needed any pain medicines, has made him a strong advocate for Dr. Mutnal and his surgical approach. Within days of his surgery, Michael was walking unassisted without a cane or walker and was easily going up and down stairs. Less than two weeks after surgery, he was riding a bike and performing chores in his yard. Based on his experience, he wonders why hip replacement surgeries are performed any other way.

“Once Dr. Mutnal explained his approach, I knew he was meticulous, was going to get it right and give me the care I needed,” Michael said. “I tell everyone that needs a hip replacement to go to him. Why go through all that pain and suffering when you don’t need to?”


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