Dr. Neal L. Rockowitz, M.D is a Board Certified Orthopaedic Surgeon who received a Bachelor of Science degree in Applied Biology from The Massachusetts Institute of Technology. Dr. Rockowitz then went on to earn his medical degree from McGill University Medical School in Montreal, Canada. A fellowship in joint replacement surgery with Dr. Richard Rothman was completed at Pennsylvania Hospital and Jefferson Hospital in Philadelphia, Pennsylvania.
Dr. Rockowitz opened a private practice in 1989 and has successfully treated patients from all over the world. He has contributed to the field of Orthopaedics by inventing several instruments to improve surgical techniques. Dr. Rockowitz also co-authored a leading textbook on the hip as well as publishing several articles. He has made many national and international presentations.
Dr. Rockowitz is considered an expert on the Anterior Total Hip Replacement Procedure by his peers and is well respected among his team of surgical experts, nurses, physical therapists and his patients. He sat down with The Western Medical Journal to provide some valuable insight into the surgical procedure.
Dr. Rockowitz, what is the most common cause of hip degeneration? Is it lifestyle induced or is it more a genetic condition?
Dr. Rockowitz: In my opinion, it's more typically genetic based. There are of course people who have injuries but it's hard to explain somebody who has bilateral arthritis symmetric without having some congenital component to it. I think the vast majority of arthritis is going to have a genetic component we just haven't figured out which gene is involved yet.
What kind of tests are performed to achieve a diagnosis?
Dr. Rockowitz: The best test is simply an X-Ray. Sometimes a weight bearing X-Ray. For hip arthritis it's the gold standard for diagnosis. MRI scans help sometimes but really to grade the amount of joint space narrowing an X-Ray is good enough.
Once a diagnosis is achieved do you offer different treatment options depending on the severity of the condition and where does the surgical option come into the picture?
Dr. Rockowitz: Typically to justify a joint replacement someone has to display not only severe looking X-Rays but also severe symptoms. Someone with mild arthritis or even moderate arthritis typically is not a candidate for joint replacement.
Somebody may have severe looking X-Rays but is hardly bothered by their hip, they don't need anything done. On the other hand someone with severe pain but mild looking X-Rays, you almost have to start looking elsewhere to their back or other areas to explain why they are having such severe complaints. For those patients joint replacement is typically not the answer either.
The early treatment for this condition would be activity modification, changing the type of exercises they do and taking anti-inflammatory medications such as ibuprofen, Aleve, drugs like that.
Could you explain the anterior hip replacement procedure and the advantages it offers?
Dr. Rockowitz: For decades the most common approach to doing a hip replacement was going in posterior fashion through the buttocks muscles and that involves going through the muscles and cutting some of the muscles. That's what hurts post-op and that's what takes time to heal and rehab.
The beauty of the anterior approach is that we go between muscles so there's no muscles that are cut. It takes some slick maneuvers in the operating room to get the exposure but the reality is we don't cut any muscle. You don't have to wait for the muscle to heal which is why it doesn't hurt as much and why the rehab is so fast.
Let's talk a little bit about the rehab process itself. How long does that generally take and what are the factors that determine the rate at which a patient recovers?
Dr. Rockowitz: A typical hip replacement where you are going through the back or the side and you cut muscle. You have to wait about six weeks before you can start exercising that muscle. You can start moving but you really can't stress the muscles that are operated through until they have had enough time to reattach or heal.
Since the direct anterior approach doesn't involve cutting muscle there's really no breaks on the kinds of exercise you can start doing right away. You really don't have to wait for any kind of muscle to heal so you can start moving in any direction, there's no precautions as far as protecting the muscle, you don't have to use walking aids and you don't have to use a walker. With this approach it is whenever the patient's pain level allows them to move. For instance, when you use an uncemented implant and the bone has to grow into the metal, it takes about six weeks for that process to occur. That's a biological rule.
So whether I do the surgery through the front, the side or the back you have to respect that biology. It takes six weeks for the bone to adhere to the metal. The implant is stable the day you put it in if the surgeon does the surgery properly. You still have to protect the hip somewhat, you can't be overly aggressive with sports and you can't pound the joint because you have to allow the bone to grow into the metal. The soft tissue is what hurts after surgery and since we don't disrupt that the pain level is minimal and that's why you don't have to protect the hip with walking aids. You just have to tone down your activity to allow the bone to grow into the metal.
How long can a patient expect a hip replacement device to last?
Dr. Rockowitz: The materials we are using now are made of titanium, plastic and cobalt chrome alloy and they're very durable, titanium and cobalt chrome alloy almost never break. Once the bone grows into the metal they almost never loosen as well. You're really looking at how long the plastic will take to wear out.
Some of the new plastics could literally last decades. For a given patient there are several different factors that come into play as far as how long an implant will last. How heavy is the patient, how active they are, how many years they will live. It's hard to pin down a defined time as to how long a device will last since there are a lot of variables.
We don't know because a lot of the implants we've used in the last decade haven't been in for thirty or forty years. We've tested them in labs but we don't know for sure if they're going to last that long. Some early evidence indicates they could last that long but there are some patient factors that could shorten or lengthen that amount of time.
Can a patient expect to resume or go back to the lifestyle they were accustomed to before they had the surgery?
Dr. Rockowitz: I tell patients they will feel good enough to do anything. They'll feel good enough to play tennis, they'll feel good enough to run but we still are a little hesitant to advocate high impact exercise because we just don't know how long these implants will last.
The re-dos are much harder than the first operation so if you want the implant to last your lifetime, I think if you avoided high impact exercise you'll give it a chance to last your lifetime. You can live a pretty normal life without playing full court basketball. I have patients playing golf, hiking, walking, swimming and biking. Some even play tennis. Most patients have given up high impact sports by the time they need their hip replaced so it's really not that much of a lifestyle change for the typical patient.
I have patients who are downhill skiers, I recommend they not go through the trees and not do bumps and not engage in risky behaviors where they could fall. Most are still quite active where they are participating in sports like that and if they are already good at it then they do well.
Dr. Rockowitz, what do you feel is the most important consideration someone should make when deciding on anterior hip replacement surgery?
Dr. Rockowitz: First off, it's a difficult technique for surgeons that are not experienced with it. This is a relatively new approach in the last decade and there's been several studies that have been recently published that show that if the surgeon doesn't have an interest in hip replacement and if he or she is not experienced with this approach then the complication rate is enormous.
The message to patients is pick your surgeon carefully, it should be someone who's done a lot of these and is trained to do it. Right now it's a minority of the surgeons in the world that are adept at this procedure. The majority are still doing the older technique. I would recommend that a patient search out surgeons that are specifically trained to perform the anterior replacement technique.
Doctor, thank you for your time today.
Dr. Rockowitz: You're very welcome.
Dr. Neal Rockowitz, MD is owner of The Rockowitz Orthopaedic Center (R.O.C.) in Phoenix. He can be contacted directly at 602-957-1233. His business website is rockowitzortho.com.
By Kevin Nimmo -
Kevin Nimmo, is a writer and online media strategist. He interviews subject matter experts and educates his readers based on information provided by experts in their respective fields. He is also Executive Editor of The Western Medical Journal.
Kevin Nimmo is a writer and Executive Editor of The Western Medical Journal. The Western Medical Journal features interviews with medical specialists who are experts on in their respective fields. From Chiropractic to Internal Medicine to Podiatry, we ask the questions most never get the opportunity to ask. Check us out at http://www.westernmedicaljournal.com
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