Surgeon uses TV cameras to see inside incisions

PITTSBURGH

Dr. Marc Philippon's first patient is wheeled into the operating room by 7 a.m. on this July day to receive general anesthesia.

Philippon is pioneering a form of arthroscopic surgery that can keep patients from having to have hips replaced later. He has refined the procedure since 1998, and now is doing hundreds per year. One of Philippon's goals is to cut down on the 300,000 Americans who opt for hip-replacement surgery each year.

But there is little glamour in the setup. Cables are plugged into a television monitor. The patient's gown is pulled back around the right hip area, revealing a flank where two small incisions will allow insertion of a fiber-optic camera, or "scope," mounted on a rod to transmit the TV images. Later, Philippon will insert relatively non-invasive flexible instruments to perform the surgery.

The 52-year-old suburban Pittsburgh woman with chronic hip pain from psoriatic arthritis is about torso level to the surgeons.

At 8:20, Philippon and assisting surgeon Dr. Srino Bharam scrub up. Bharam is in the final days of a one-year fellowship with Philippon and only a week away from joining an orthopedic practice in New York. While scrubbing, the surgeons greet an observing doctor from China. Orthopedic surgeons from many states and countries visit regularly to observe Philippon's techniques.

"Turn all of the lights off, please," Philippon says as the surgery begins. "All of the lights." That's a switch, but Philippon's eyes will be glued to the TV screen during the procedure. The tiny lens with its own tiny lights will illuminate plenty.

"Bring the TV closer to me," Philippon says to a surgical nurse. Within minutes of the entry incisions, the doctor is using one of the tools he invented to shave the torn labrum, or loose cartilage, in the hip. Foot pedals help him drain blood and fluids from the hip. Other instruments at his disposal -- thanks to his own ingenuity -- include a ligament chisel and a full-radius shaver that can trim and suck up the loose cartilage with one squeeze of the trigger.

"The torn labrum tissue looks like crab meat," Philippon says.

The first surgery goes smoothly. As he finishes, Philippon explains he got the idea of doing arthroscopic hip surgery by watching a friend perform a relatively simple shoulder repair.

Within weeks, Philippon collaborated with executives from Oratec Interventions, a medical technology firm now owned by conglomerate Smith & Nephew. The patented instruments bend and curve to allow Philippon to reach parts of the hip joint that previously were thought inaccessible. Just as important, the surgeon's work is easier and less invasive for the patients.

Another big plus is Philippon's ability to use a heat-producing probe on the entire hip joint. It shrinks the hip capsule and stabilizes the joint.

The second of three patients will be the recipient of one of Philippon's most innovative procedures. She has a "pretty big cartilage tear from 2 o'clock to 9 o'clock" in the joint. Philippon first trims the torn tissue, then he and Bharam actually tap a hammer on a chisel to make small holes in the hip ball (the top of the femur bone). This procedure causes some bleeding, which is good because it means stem cells are coming to the surface. These cells will form a layer of fibrocartilage to cushion the connection between the ball and socket (the pelvic bone). The fibrocartilage will take about six weeks to heal.

The surgery concludes with cauterizing or heating the entire joint. Philippon also has released tension in the 41-year-old woman's right hip by making small strategic cuts into an inflamed tendon.

As the third and final surgery gets under way, Philippon is explaining what visitors are seeing on the screen. He points out torn cartilage and bone in the 24-year-old former field hockey player's right hip, but, honestly, what Philippon sees in great detail is visual gibberish to untrained eyes.

As the procedure moves into its second hour -- and about 20 minutes after Philippon says he is almost done -- the surgeon is flexing the patient's knee to make sure no loose cartilage or other matter remains.

Philippon, who is married and the father of three young children, explains his thoroughness: "She is young. I want her to forget she ever had hip pain."