From the orthopedic surgeon’s perspective
Hip Replacement Surgery and Unequal Leg Length
By William A. Leone, M.D., F.A.C.S.
The Leone Center for Orthopedic Care at Holy Cross Hospital, Fort Lauderdale, Florida
Recently I treated Judith Burganger, a concert pianist and professor at Florida Atlantic University, who long had suffered from one of the most common complications after having a total replacement: one leg now was longer than the other. As a result, she experienced worsening scoliosis, sciatica, and loss of balance. She could not walk without holding on and had to use a pillow when sitting. She found it impossible to practice or perform concerts. By the time Judith visited my office, she was in total despair.
Unfortunately, unequal leg length frequently occurs due to poorly positioned prosthetic hip cups. When implanting the acetabular component, most surgeons attempt to implant it into a specific position. This positioning is based on each surgeon's specific surgical approach, technique, prosthesis used and experience. Dr. George Lewinnek, an orthopedic surgeon in Worcester, Mass., published a study and popularized the concept of a "safe zone" for cup positioning. Based on his own specific surgical goal, he found that if the cups were placed within a range of 10 degrees plus or minus his goal, then the rate of dislocation was significantly less (1.5% dislocation) compared to those cups that were outside of the desired range (6.2% dislocation).
Another important study, which recently was published and won the coveted Charnley Award for 2010, describes risk factors associated with cup mal-positioning. It reports on the experience of seven surgeons at Massachusetts General Hospital in Boston. Cup position was analyzed on the postoperative X-rays of 2,061 patients who had undergone total hip replacements. The study found that only 47% of the cups were in the "desired range."
I use a devise that I invented called the Pelvic Alignment Level™ (PAL) which allows the surgeon to measure cup position and leg length. I designed the PAL specifically to improve outcomes and consistency for hip replacement surgery. When cups are optimally positioned, it reduces the chance that a leg length difference will occur and increases implant longevity. Independent evaluators analyzed the postoperative X-rays of 250 consecutive total hip replacement patients on whom I operated on from March to November 2009. Cup position was analyzed by same parameters that were measured in the studies I cited above. My successful "safe zone" results were 99.2 percent for abduction, 91 percent for version and 90.6 percent for both abduction and version.
By the time I saw Judith, she needed a revision on her left hip and a full replacement of her right hip. She did beautifully. Despite her severe scoliosis, both legs now feel equal; she can walk and sit normally and is teaching again. She also is working toward being able to give piano concerts again. In January, twelve weeks after both surgeries, she wrote to me, "You have given me my life back." Those words are music to a surgeon's ears.
Reading about PET scans led to a speedy diagnosis and life saving treatments for this Bahamian patient
In June we wrote an article for The Punch, Bahamas’ largest newspaper, titled Pet-CT Scans hold promise in diagnosis and treatment of disease. Based on the many questions we receive from patients we felt this sophisticated test was not fully understood by all, so we tried to explain in print some of the basic characteristics of the combined Pet and Ct scans.
Shortly after the article appeared, we received a call from Mrs. Lorna Taylor a 38 year old woman from Nassau who felt she needed a PET scan and some other studies to figure out what was going on with her right breast. Her symptoms had begun with hardening of her breast and a rash and itchiness 1 month before. Thinking that it was perhaps an allergy to the soap she was using to wash her clothes, she did not really think very much about it. Now her breast was getting swollen, and at times appeared to be harder. Mrs. Taylor explained that her breast did not hurt, and to her knowledge there was no history of breast cancer in her family.
Typically imaging scans, like other tests, require a physician prescription in to order for the test to be performed. Mrs. Taylor had not visited a physician in a few years, so we encouraged her to go see Dr. Todd Pinder a trusted Family Practice physician in Nassau. Dr. Pinder was courteous enough to see her right away in his office, and upon examining her recommended she get a breast MRI, a mammogram and possibly ultrasound and breast biopsy. He shared his initial observations about her condition with ORNOA: inflammatory breast cancer
Inflammatory Breast Cancer (IBC) is a very aggressive form of cancer and can quickly spread to other parts of the body. It is a killer disease, which is often ignored by women because of its subtle symptoms. IBC is also rare and can be mis-diagnosed by physicians not familiar with it. We knew time was of the essence, so we asked Mrs. Taylor to come to South Florida right away and began to plan her appointments. On the day of her arrival, she along with her ORNOA Patient Navigator visited the Miami Breast Institute where Dr. Elsy Cabot-Flores, Breast Radiologist, examined her and she received a mammogram, ultrasound, and breast MRI. She also went to Physicians Imaging Center in Hollywood to do a PET/CT. The next morning all of the results of these tests were given to Dr. Carlos Suarez, Oncology Surgeon for his review. Dr. Suarez indicated the reports signaled the likelihood of cancer on her right breast but he wanted some biopsies of her breast, neck and axila so that tissue could be examined. The next day Mrs. Taylor returned to the Miami Breast Institute where she underwent a needle-core biopsy. The tissue was rushed to the pathology laboratory for confirmation of Inflammatory Breast Cancer.
Results: positive
Mrs. Taylor was clearly distraught at the news confirming her cancer but was reassured by her doctors that they would do “everything in their powers to save her life.” Mrs. Taylor next consulted with Dr. Lisa Reale, Medical Oncologist from Advanced Medical Specialties in Miami, who reviewed her case and all the test results and in consultation with Dr. Cabot-Flores (Radiologist) and Dr. Suarez (Surgeon) developed her treatment plan for the next several weeks.
Mrs. Taylor has begun targeted (specific mix of medications for her condition) chemotherapy sessions. This is to be followed by a mastectomy of her right breast. Depending on her progress, her treatment process will be completed when she finishes 3 weeks of external beam radiation, an added measure to ensure that no cancerous cells remain, and attach to her chest wall.
Time is important in fighting Inflammatory Breast Cancer: from the time of her first phone call to ORNOA and her confirmed diagnosis - 2 days. From diagnosis to 1st day of treatment- 3 days. In the span of one week, Mrs. Keller has begun comprehensive and coordinated treatments for her disease and is confident in the team of oncology experts who understand IBC and are focusing on her well being.
Her prognosis: very good
Early detection is crucial to surviving Inflammatory Breast Cancer. If you have 1 or 2 of these symptoms, please seek medical help as soon as possible.
Source: Inflammatory Breast Cancer Research Foundation