Frontiers in orthopaedic surgery

Orthopaedic surgeon Dr John O’Donnell is one of the earliest developers of arthroscopic FAI (femoroacetabular impingement) surgery, recently performing his 10,000th hip arthroscopy procedure — a reported world first for any surgeon performing this procedure.

Dr O’Donnell, how did your 10,000th hip arthroscopy compare with the first?

When I performed my first hip arthroscopy in 1992, we only had knee arthroscopy instruments, which were quite limited, and relatively rudimentary knowledge of the arthroscopic anatomy of the hip. Now we have sophisticated instruments that allow us to perform far more complex procedures.

We also have a greater understanding of the damage and problems that can be identified within the hip and how we can repair much of that damage. Understanding why these problems occur means we can address underlying issues to minimise the risk of symptoms recurring in the future. The surgery is far more complex than the simple debridement operations we used to do.

Dr John O’Donnell and his team. Image credit: SVPH East Melbourne.

How does the AMIS procedure compare with the procedures you performed earlier in your career?

AMIS is a method of performing anterior approach total hip replacement. The main difference between it and most other methods of performing hip replacement is that it avoids cutting muscles and minimises the risks of cutting major nerves, so I find the patients recover significantly more quickly than those where I used different approaches.

What are the advantages of minimally invasive surgery compared with procedures used in the past?

‘Minimally invasive surgery’ is a rather broad description. It may be used to describe arthroscopic (or keyhole) surgery, or it may be used to describe open surgery performed through smaller incisions. Arthroscopic surgery has the great advantage of minimising damage to unaffected tissues.

For example, if we were to use more invasive open surgery we would need large incisions (with associated large scars) and would need to cut muscles and dislocate the hip. This would significantly increase the risks of surgery and prolong recovery time.

Can you tell us about the patient that represented your 10,000th procedure, Catherine Norris?

Catherine is an active lady who works as a social worker in NSW. Over time her activities were severely limited by pain in her hip and groin so she had to largely stop exercising. She had been prescribed conservative treatments — painkillers, anti-inflammatories and physiotherapy — but these had not provided long-term relief.

Catherine was very keen to get relief from her pain and regain her previous level of activity, as she aims to walk the Camino del Santiago trail in Spain.

She came to Melbourne, believing that surgery provided the best possibility of pain relief and the chance to realise her goals.

What impact does the AMIS procedure have on patients’ lifestyles post surgery?

It is important not to confuse AMIS — a method for performing hip replacement — with hip arthroscopy, which is a method that uses telescopes and very fine instruments inserted through very small incisions for identifying pathology within the hip and repairing it. Both have the potential to relieve pain and restore function. In many patients, hip arthroscopy can restore a normally functioning hip and allow a return to all (even elite-level) activity.

Hip replacement is used for more severely damaged, arthritic hips that are beyond repair. It is a very reliable way to relieve pain and greatly improve function.

How important is technology in improving surgical procedures and outcomes for patients?

Technology is critical in improving outcomes for patients. The surgery we perform today would not be possible without the improved materials, instrumentation and diagnostic imaging that new technologies have delivered.

Improved CT and MRI scanning has allowed us to ‘virtually see’ the side of the hip and determine likely causes of hip pain. This allows more accurate diagnosis and potential non-surgical treatments in many cases.

Greatly improved optics in arthroscopes and digital imaging have allowed us to see with far greater clarity within the hip and to perform far more complex arthroscopic surgery.

How do you see orthopaedic procedures changing in the future?

No doubt orthopaedic procedures will change in ways we won’t be able to predict. It is likely that truly robotic procedures will be developed, especially for joint replacement surgery.

It is also likely that some of the image-guidance systems used in joint replacement now will be adapted to improve the accuracy of arthroscopic procedures.

Virtual reality will allow better teaching of techniques than the current, relatively crude machines, so surgeons will be better trained before operating on patients than they currently are.

And we are all looking forward to better biological, and perhaps genetic, treatments to restore damaged joints.

Top image credit: SVPH East Melbourne.