Half a million Americans will get a new hip or knee this year, but fewer than 500 of them will be up and walking the same day. Of the nearly 20,000 orthopedists who perform hip and knee replacements, fewer than 30 use a technique Richard Berger, a 42-year-old Rush University Medical Center orthopedist, has developed–a muscle-sparing procedure that minimizes pain and drastically reduces recovery time. “On my own I can only help a few hundred patients a year,” he says. “But if these procedures become standard practice I can help hundreds of thousands.”
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All this cutting and tugging causes bleeding, swelling, and inflammation in the soft tissue, which releases chemicals that help it repair itself but also cause intense pain. Over the next few months new bone that’s exactly like the old grows into the prosthetic, stabilizing it. But the muscles, ligaments, and tendons replace damaged tissue with scar tissue, which is less flexible than the original. Recovery from both procedures is usually slow, painful, and sometimes incomplete, though after three months or so most patients function better and with less pain than they did before the surgery.
Surgeons try to minimize trauma, but Berger was the first to find a way to completely avoid cutting muscle, tendons, or ligaments. He’s been fascinated with the mechanics of things since he was a kid watching his father build complex moving figures for Macy’s Christmas windows in New York City. During his first year in the engineering program at MIT he began doing research with William Harris, the chief of hip and knee replacement at Massachusetts General Hospital, who’d pioneered hip-replacement surgery in the U.S. in 1960. “Surgeons have been trying to replace hips since ancient times, especially during the Civil War,” says Berger. “But no one really succeeded before 1960, when pioneers like Bill Harris first devised a prosthetic that lasts.”
In February 2001 Berger replaced the hip of his first live patient, one of a hundred people who’d volunteered for a pilot study at Rush. Over the next year he and a few other surgeons working with Zimmer operated on another 144 patients in 17 medical centers in the U.S. and Europe. “Our goal was a modest improvement in recovery,” says Berger. “We didn’t expect such dramatic change. We had assumed most pain was from the joint, not the soft tissue. But suddenly patients were clamoring to go home ASAP–even the same day.” Hospitals don’t let patients leave until they’re able to walk, get in and out of a bed and a chair, and go up and down stairs; 85 percent of the study’s patients qualified to go home the same day, the rest the day after. There were virtually no complications, and the end results were comparable to those following conventional surgery. Berger and his colleagues published the findings in Clinical Orthopaedics and Related Research in 2003 and 2004.
Operations using his procedures take longer, but the shorter hospital stays lower the total cost by up to 30 percent. Given that more than 250,000 hips and 300,000 knees are replaced every year in the U.S., the economic impact of fewer lost workdays alone could amount to billions of dollars. Berger’s technique is also a boon to people who can’t afford to spend weeks or months away from their jobs or taking care of their children, as well as people for whom any surgery is risky–those who are overweight or have other serious medical problems. The patients who’ve had the procedure seem happy–Berger is booked for months in advance, almost entirely through word of mouth. (My wife heard about him from someone at her health club.)
Pearl Katz, a cultural anthropologist at the Johns Hopkins School of Medicine and author of The Scalpel’s Edge: The Culture of Surgeons, agrees. “More than 20 years ago the Lancet called for an end to extensive shaving of patients before surgery, because it abrades the skin and increases risk of infection,” she says, “but many surgeons persist in shaving the operative site.” She thinks surgeons are reluctant to adopt new procedures that are difficult to learn and perform because that’s just not part of their culture. “They need to make life-and-death decisions quickly, so they value risk taking and quick learning,” she says. “They often rely more on their clinical experience than scientific evidence. They put an excessive value on their own competence, on what they can do well and quickly. They have to rely on their familiar motor and sensory skills, so are resistant to learning procedures like Berger’s that call for drastically changing those skills. And they are less concerned with aftercare than what they do in the operating theater. Since Berger’s procedures produce benefits in aftercare, it’s not surprising that surgeons would undervalue the contribution.”
