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Pioneering Surgery Helps Young Adults With Dying Hip Joints

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Duke Health News 919-660-1306

DURHAM, N.C. – Later this fall, Avery Ellsworth will put the
crutches away, and by spring, he should back playing Ultimate Frisbee
like any other 17-year-old. In the meantime, he is recovering from
unique hip replacement procedure developed at Duke University Medical
Center that should allow him to lead an active life throughout
adulthood.

The Landgrove, Vermont, native overshot a jump while
skiing last winter, landing on his left side, with his hip taking the
brunt of the fall.

"I spent the next six months with a somewhat
of a limp and I did experience some discomfort, but it didn't seem
really serious," Ellsworth said. "However, when my physical therapist
saw little improvement over time, she ordered a specialized MRI scan of
my left hip. It's very fortunate for me that we caught it early."

The
scan revealed the presence of a disorder known as avascular necrosis
(AVN), which occurs when there is a lack of adequate blood flow to the
ball joint attaching the leg to the hip. Without a supply of blood, the
bone dies, ultimately resulting in the collapse of the hip joint.

Ellsworth's
physician performed a literature search on AVN, which led to Duke and
James Urbaniak, M.D., Virginia Flowers Baker Professor of Orthopedic
Surgery, who developed a procedure which uses a portion of the lower
leg bone with its accompanying blood vessels to recreate a new and
living hip joint. The procedure is intended for young patients – the
average age of Urbaniak's hip patients is 33, with 50 being the oldest.

When
he underwent his surgery this summer, Ellsworth was the 2,000 patient
to be treated by Urbaniak for AVN with the unique surgery.

"This
procedure is particularly helpful for young people, because when they
receive artificial hips, which would be the only other option, the
joints need to be replaced two or three times during the course of
their life," Urbaniak continued. "Artificial hips last only about 15-20
years on average, and the more active the patients is, the faster the
hip artificial hips wear out."

The surgery is known as a free
vascularized fibular graft (FVFG) procedure. In the FVFG procedure,
surgeons insert a four-inch portion of the fibula, the smaller of the
two leg bones between the knee and ankle, into the hip to the ball
joint. Using microsurgical techniques, the blood vessels nourishing
this graft with blood are attached to other vessels in the hip, which
can arrest the degenerative process and stimulate new bone growth.

"As
in most surgical procedures, if you can perform reconstructions using
the patient's own tissue, the results will be better," Urbaniak said.
"The body will eventually reject all foreign implants. For me, the
significance of the procedure is that it represents the future of
reconstructive surgery because we are using the patient's tissue to
reconstruct diseased or damaged joints."

Since the fibula is not
a weight-bearing bone, patients suffer no adverse effects on their
subsequent mobility or activities. Recovering patients usually spend
six months on crutches as the joint heals, and then can gradually
resume weight-bearing activities.

When he first performed the
procedure in 1979, Urbaniak was planning to try it with five patients
and then watch how well they responded before performing more.

"The
first five did very well, so I decided to do 20 more and then follow
them for a few years," Urbaniak said. "It wasn't long before we were up
to 200. A five-year follow-up of the first 100 patients demonstrated a
success rate of 80 percent. Artificial total hip replacement procedures
in young patients currently have failure rates as high as 50 percent."

Today,
the success rate remains over 80 percent. Over the years, the procedure
has also become more streamlined. The first took ten hours to complete;
now, the operation is over in about three hours. In fact, over the
years Urbaniak has designed and refined a whole line of surgical tools
and instruments specifically for this operation.

There are four
general causes of AVN. The most common is the use of systemic steroids,
followed by excessive alcohol use. Both cause excessive fat build-up in
the bone marrow, which restricts the flow blood to the bone, Urbaniak
said. Trauma, as well as conditions which can cause blood to clot
improperly, are responsible for the rest of the cases.

"The
common element to all these factors is that the joint itself is not
receiving the proper supply of blood and nutrients," Urbaniak
explained. "It is interesting that the condition shows up in some
pregnant women. It appears that the growing fetus can press on a blood
vessel restricting flow to the hip.

"This procedure has been so
successful because in the process we remove all the dead tissue,
relieve the compression on the blood vessels in the bone, and provide
new support for the joint," Urbaniak said. "And the new blood vessels
keep the joint alive and stimulate new bone growth."

There are
currently fewer than a dozen centers world-wide that offer this
procedure, and the surgeons at those sites all trained under Urbaniak,
who has operated on patients from every state in the U.S. and eight
foreign countries.

"When I first heard how Dr. Urbaniak was going
to fix my hip, it sounded a little strange, but it has worked for so
many people," Ellsworth said. "I am progressing fine and I expect to be
sailing in spring and skiing next winter."

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