Torrance Orthopaedic & Sports Medicine Group
Physical, Hand & Aquatic Therapy
23456 Hawthorne Blvd.,
Torrance, CA 90505-4716
OPENING FALL 2017!
Glenn J. Huber, M.D. has been an orthopedic surgeon since 2001. He specializes in orthopedic sports medicine with a focus on knee arthroscopy, hip arthroscopy, and shoulder arthroscopy. He also performs hip replacements, shoulder replacements, and is a general trauma surgeon.
Below Dr. Huber discusses the hip repair and reconstruction surgeries of Jacqui, one of his patients, her recovery, and his own hip replacement surgeries. Click here to read Jacqui's interview. He also talks about what's current in orthopedic medicine and what patients should expect from their doctor if they're considering treatment for any knee, hip, or shoulder joint issues.
Why did you become an orthopedic surgeon?
My earliest influence was from my dad. He's an orthopedic surgeon as well. I played baseball, football, and soccer, and was active in life in general, and I think that all played into it. I used to shadow my dad on rounds. Someone close to me came down with Alzheimer's, so I started doing basic research in that area, which led me into medical school. Early on, though, I scrubbed in with my dad during orthopedic procedures, and I realized right away that I wanted to be a community-based doctor, in particular an orthopedic surgeon. So I switched my focus from research toward that.
Why are you passionate about being an orthopedic surgeon?
It's incredibly gratifying to be able to fix something that's broken, or something very painful, and give my patients immediate results. I get to see first-hand someone who's debilitated get back to a simple daily function like walking, or an athlete who can no longer perform their sport get back to a high level in that sport.
You had two hip replacements. How does that help you relate to your patients?
I achieved empathy for my patients through that because I was a patient myself. I understand how someone can be completely debilitated, depressed, and in severe pain, and then have an orthopedic procedure that brings them back to an active lifestyle. Skiing is my favorite sport and I'm able to do it again on a regular basis. So I can really relate with my patients now, especially when they come to me with really painful arthritis. We'll discuss their options, and some of them will tell me I don't really know what I'm talking about, but I actually know more than they do at that point because I've been through the whole spectrum of treatment, from arthroscopy to replacement.
So you had hip arthroscopy first?
I did. I had the same condition as many of my patients. It's called femoroacetabular impingement (FAI). I also had underlying arthritic change, which was inherited. FAI is where the bones of the hip are abnormally shaped. It happens during growth development in childhood, and while many people don't need to see an orthopedic doctor for decades, some have problems in the teen years. With FAI, bone spurs occur, which cause damage to the hip and surrounding tissues. Problems associated with this—sharp pain or aching in the groin area—can happen to very athletic people at younger ages who have the condition, just because they work their hip joints more vigorously.
After arthroscopy failed, you had hip replacements.
Yes. The arthroscopic procedure revealed that I had very unhealthy cartilage and that I was going to need hip replacements sooner than expected. Several months post surgery I'm very happy to have them replaced, and to be enjoying my family and active lifestyle again.
You treated a 48-year-old patient named Jacqui, who shared her experience about her hip repair and hip reconstruction surgery. Click here to read Jacqui's interview. What did you think when you first met Jacqui and heard about her orthopedic problems?
I remember she was almost on the verge of tears because she was in a lot of pain from her hips, especially her left one. Her x-rays and MRI showed that she had FAI with a large overhang of bone. It was affecting the way she played tennis, but by the time she came to see me (she's a very tough person) she was having difficulty just walking and getting out of a chair.
What I usually do and what I did for Jacqui was a special MRI called an MRI arthrogram, where we inject dye into the hip joint. I developed a special protocol with one of the radiologists at Little Company of Mary where we mix cortisone in with the dye so that if there's inflammation, it treats the pain, too. It's worth noting here that I don't treat an MRI or an x-ray, I treat a patient's symptoms. If they have no pain, I'll stay conservative and won't operate. Even though FAI is a condition that's known to cause more damage as time goes on, plenty of people can have it without pain, even though I can see it on their MRI or x-ray. I don't treat an asymptomatic patient.
Jacqui was in a lot of pain, though, so I treated her with conservative therapy first. She had already been to physical therapy for a year before seeing me, and that wasn't working any longer. Neither were reasonable doses of anti-inflammatory medication. I gave her a couple series' of cortisone injections to help with her pain, but those also had little effect. That means we failed conservative therapy. I always go through a stint of physical therapy and injections to see if a patient's condition can settle down, no matter what the pathology looks like. There's always a chance that surgery can wait, or that the patient can learn to adjust their lifestyle to cause themselves less damage and less pain, if that's how they want to proceed. I'm happy to help a patient work with that option.
Jacqui's case of FAI was so extensive, I wasn't 100% confident that she would get back to the level she did. With good physical therapy, though, and the surgery having gone as as well as possible, she's now playing tennis at a high level.
What was unique about Jacqui's case?
Her age was not unique, because FAI can present from the teenage years on. Jacqui had such an extensive overhang of the socket bone that I had to remove quite a bit more than I do in a more typical case. She actually had degenerated her soft cartilage so badly that in some areas it was not reparable on her left hip. I was able to repair it on her right hip.
That's actually a leading area of research, whether to reconstruct the cartilage. We do that in occasional cases, but the research still isn't there for the long-term results. Jacqui is a great example of success in this area because she's already made a full recovery.
Why is Jacqui such a success story, after having so much damage before surgery?
I think it's important to perform the surgery according to indications, and to take into account the type of patient. Jacqui is a very intense athlete with a lot of motivation to get back to a high performance level. I consider a patient's pain tolerance level, too, and hers is very high. Adding all those things together, she had the correct indications to have surgery. Her symptoms matched up with her exam, her x-rays, and her MRI findings. Her procedure was done addressing all those symptoms and indications. Expect better results when all those things match up.
Is it common, like in Jacqui's case, to be pain-free from a hip repair or reconstruction surgery after three months?
It's a range. I've treated people as early as six weeks post-op without any pain, all the way to four to six months. We'll tell a young athlete with no arthritic change in the joint that it's going to be four to six months until they're back competing at the same level they were before.
There's a very specific physical therapy protocol that we follow for each orthopedic procedure. A patient who has some knee cartilage removed in a partial meniscectomy surgery may be back to normal in as early as six weeks. The hip takes much longer. It's a minimum of six weeks just to complete basic healing of the hip capsule. After that's healed the patient does general strengthening from six to 12 weeks, followed by a more sports specific regimen of strengthening from weeks 12 to the four months to six months, after which there's a return to sports.
Jacqui did that faster than normal. She also did a lot of strengthening before her surgery, which helped shorten her post-surgery recovery time. She's the poster child for this type of procedure. It also helped that she was an occupational therapist and had medical knowledge.
Is hip arthroscopy highly successful, as in Jacqui's case?
In general it probably has around an 85% success rate as opposed to many other orthopedic procedures that have closer to a 95% success rate. Hip arthroscopy is still a really evolving field, and we're tightening up the indications and the procedures themselves. Just over these past 10 years, there's been a huge change in the type of procedures we're doing and when to do them.
What is it about the hip area that makes it statistically less successful to operate on than other areas of the body?
It's a difficult joint to operate in. It's very easy to put an arthroscope in a shoulder or knee, but the hip is a constrained joint with very thick, strong, ligaments and a lot of muscle around it. We actually have to distract the hip (pull the bones apart) on a special table, so the surgeon is under the limits of that traction time. Too much time in traction can cause sciatic nerve damage, so the doctor has to be cognizant of that. Being gentle while putting the surgical instruments inside the joint is also necessary, and once you're in the joint, it's difficult to move around. It takes years to feel comfortable doing the procedure.
What are some newer advances in the field of hip arthroscopy?
If there's exposed bone in certain areas where there's a cartilage defect, I'll do microfracture surgery, where holes are poked in the bone to stimulate new cartilage. I also do PRP (platelet rich plasma) injections, which are on the forefront of treatment in the field. PRP injection therapy involves taking blood from the patient, spinning it in a centrifuge to separate out the platelet-rich components, and re-injecting those components into the damaged area of the body. This stimulates the body's repair process.
Not too long ago surgeons in the field used to just remove damaged cartilage, but now we're repairing it in a lot more cases. I now use suture anchors and tie the cartilage back to the bone, and that's done all through the arthroscope. In arthroscopy I make two to three tiny one-centimeter incisions. Patients appreciate that because having smaller incisions shortens recovery time immensely.
Around 99% of my patients have same-day surgeries. They go home, come back in a week to have their sutures out, and a week after that they start physical therapy.
Are any two cases exactly alike?
They're usually not, but I do get a fair number of athletes that have FAI and who fit almost into a pigeon-hole diagnosis. They're very classic cases, but they're also the ones who typically have the best results. I just saw a patient who's only 18, who had an easily identifiable case of FAI. He's a track star who got to the point where he couldn't even do his basic workouts. I performed arthroscopy on both of his hips, which was a six-hour surgery. After three months he's now jogging and chomping at the bit to get back. Again, his symptoms dictated that he needed something done. Those are the cases that we're still waiting to see the 20-30 year results on, because we think we're going to prevent the progression to arthritis that this condition causes. That's what we're hoping.
One thing that's common is bilateral hip repair. One hip will go and then the other.
How is your field changing?
If your genes have the make up that you're going to come down with osteoarthritis no matter what, we can't prevent that yet. That will be the Nobel Prize, the person who can alter the genetic machinery or magically inject into the joint the stem cells that are going to recreate cartilage. That's what many researchers are working on now.
Right now we know that FAI is a mechanical condition that will progress to arthritis if it's severe enough. If I can treat the teenage to 20-something patients before they show arthritic change, remove the mechanical problem associated with the condition, there's hope that we'll prevent arthritis and prolong the lifetime of the hip, possibly preventing hip replacement like I had. There are other types of conditions, though, that if caught early, can be corrected with non-surgical treatments, avoiding surgery altogether.
A few years ago I used to get a number of patients referred to me with FAI, so many having been sent to psychiatrists. A lot of radiologists wouldn't even pick it up on the x-ray findings. The joint didn't have bad arthritis, but nobody even noticed either the overhanging spur or the acetabulum, or the big bump on the femur, and they would tell people that they're fine. It was usually the physical therapists that would know there was something going on in there, and there wasn't a widespread knowledge of the condition. I can think of two cases where patients actually broke down in tears when I told them it wasn't all in their head. I'd do an injection in their hip joint and they'd get better, even if it was temporary, and they would be relieved to finally have a diagnosis. Then after an arthroscopic procedure, they'd get better.
It's not as common now for the problem to be overlooked. We've done a good job educating the orthopedic community so that they'll more easily identify the problem. Now I'm not seeing as many patients who were bounced around to five or six different clinicians.
What would you say to patients who are in a similar situation as Jacqui?
I'd give them a whole spectrum of treatment. I'd start off conservatively with anti-inflammatory medication and advise them to try to avoid the activities that flare up the condition, if possible. There's a specific non-operative protocol for physical therapy that strengthens the core muscles and the posterior chain of muscles—the gluteal and hamstring muscles— to try to unload the front of the hip. Further conservative treatments may include viscosupplementation injections, such as Synvisc or Euflexxa, and PRP. I've even done stem cell therapy on a few patients, to see if we can settle the inflammation down and avoid surgery. If these things are not fixing the problem enough for the patient and their lifestyle is affected too adversely, whether a resumption of sporting activities or simple walking, then we entertain the idea of arthroscopic surgery if they're a candidate.
Torrance Orthopaedic & Sports Medicine Group has eight board certified orthopedic surgeons. How closely do you work with them?
We all specialize in different areas of the body but there's overlap among quite a few of us. Whenever we need to, we'll conference together with patients if they seem to be in a gray zone with minimal to mild arthritis. For example, if Dr. Shrader says he's not comfortable doing a total joint replacement, I'll see if the patient is a good candidate for an arthroscopic procedure. We've had some really good results by doing that. Patients appreciate when both of us will sit there and talk it out, and they'll get a better understanding of how no two cases are the same.
Jacqui focuses on tennis as her primary form of exercise. Does that singular focus make her more likely to have an orthopedic problem?
Yes. We're seeing a lot more overuse injuries in orthopedics because people are focusing on single sports, especially at the younger ages. Kids are all in club sports, which means they're playing just one sport year round. I usually have to have a conversation with the parents to let them know that even the pros take three months off. I also recommend having the kids cross-train, to let them play another sport they like and remove the heavy emphasis on one thing.
In Jacqui's case, she's a well-conditioned athlete with good technique, which is important, but she had this anatomical disadvantage that led to the pain. Now that we hope we've taken care of it, she can safely resume what she's passionate about.
Do most patients come to see you long after they should?
That varies. It comes down to how much pain the patient will tolerate before feeling like they need to see a doctor. Patients are also more knowledgeable now because of the internet, and they're focused on their conditions a lot more than in the past. Recreational sports are functioning at such a higher level than they used to. Athletes want to stay at that high level, and if something is preventing them from that, they want someone to address it. That's why there's a subspecialty of sports medicine.
Should patients come to you with less severe symptoms?
It's good if they do come in early so we can treat them with more conservative methods. If you can take a condition that's on its way to being pathological and surgical and intervene and fix it with physical therapy, that's a very desirable treatment route.
A perfect example would be a pitcher. We get a lot of throwing injuries. Young patients will come in with horrible arm pain. If I can identify that they have tightness of the posterior capsule of the shoulder, that can lead to the shoulder ball rubbing against the shoulder socket and causing a cartilage tear. Sometimes those tears need to be fixed surgically. If you can get the patient into a good strengthening and stretching therapy program, you can prevent a condition that would eventually require surgery. And surgery can end a career.
What percentage of your patients do you actually operate on?
A little less than 10%. The focus patients have on their injuries is one reason why. People are coming in earlier, so we can do a lot more for them because the field of physical therapy has progressed so much as well.
What kind of pain shouldn't people ignore?
Sharp, debilitating pain, or pain that keeps a person from their normal sporting activity is also enough to bring them in to see a doctor. If the pain is keeping you from comfortably doing the activity that you're trying to do, whether it's an activity of daily living or a sporting activity, then it shouldn't be ignored.
Should people see an orthopedic surgeon before seeing a physical therapist?
That's an important topic because some therapists want to both treat and evaluate. As orthopedic surgeons, we always at least get an x-ray. Even if your physical therapist has a good clinical handle on things, and you're both convinced that you probably just have something wrong with soft tissue, that may not be true. I've always been surprised about how much will show up on an x-ray. For example, something may seem like knee strain, but I've seen people come in, get an x-ray, and have bone-on-bone arthritis, which is a whole different diagnosis than a simple knee strain.
I think good physical therapists have a great clinical perspective on body function, but if they don't have diagnostic equipment on hand, they could treat a condition wrongly because they don't have the complete diagnosis. That situation can potentially make the problem worse. If a patient has a condition that needs some sort of diagnostic testing and it's not given, and someone either gets injured or God forbid the one-in-a-few-hundred-thousand cases where there's a tumor or some other condition that's not diagnosed, that patient didn't get the right care at the right time.
What would you say to people who think surgery is too risky?
I usually go over the risks in detail at first. I talk frankly with patients and I don't try to hide any of the literature that's out there. Usually, patients will be able to digest that knowledge. A patient who is initially frightful was typically that way because they didn't yet have the knowledge base about their condition or surgery. Once they hear everything spoken in very frank terms, they'll usually feel okay.
I always encourage second opinions. I think the surgeon who tries to prevent a patient from getting a second opinion is only setting up a potentially bad result. If a patient subjectively thinks something went wrong or they're not at the recovery level they expected, they may always wonder, should I have gotten that second opinion? That can really affect their outcome, regardless of how well the surgery went. When someone is hesitating or they seem like they feel like they're offending me, I encourage them wholeheartedly to go get that second opinion. They're usually very appreciative of that.
What's the difference in recovery outcomes for people who follow your prescribed post-op plans versus those who don't?
I generally see a lot of overuse type of injuries in my patients who try to do too much too soon after surgery. If the joint that I've operated on hasn't settled down enough, inflammation can recur, and some people will get tendinitis, or a swollen joint, which is a setback. Sometimes it will confuse the issue, too. It can be hard to tell if they reinjured what we repaired. That makes it difficult for the patient but also for the doctor to diagnose the new problem. If someone starts jogging too soon after hip arthroscopy and they come back with extreme pain, I don't know whether they have a stress fracture or just tendinitis. That can generate a lot of imaging studies or additional painful injections that might not have been necessary had they followed instructions. A lot can happen in those first six weeks after a hip scope if a patient overdoes it.
Are there any recoveries that do not fit into the category of normal?
Some patients have special risks or circumstances, which is why I always look at the general medical makeup of each one individually. Is the patient diabetic? Do they have hypertension? Are they obese? Are they athletic normally? Obviously, their age matters. This approach helps determine realistic expectations. A high-level, in-shape athlete is going to be more motivated to recover quicker than someone who's more sedentary and might have several medical co-morbidities. Someone is also at a higher risk of complications of they have other medical problems. We discuss these things with each patient.
For example, a diabetic who is getting a joint replacement does have some higher risks for infection and complications, so they need to be aware of that. I take that all into consideration as the surgeon, too.
Protocols are always changing for our athletes. We're pushing the envelope as much as we can. For Achilles tendon repairs on athletes, we used to immobilize them for extended lengths of time. Now as soon as the skin is healed and the swelling has settled down a bit, we're getting them back to earlier range of motion because basic orthopedic research revealed that tendons respond better to motion. The athletes heal quicker, stronger, and in a more functional manner, and they're happier because they can get back to their sport sooner.
Does age have anything to do with considering surgery?
I always tell patients to go by physiologic age and not chronologic age. I determine that by their medical well being during their preoperative examination. The decision to have surgery depends on the risk/benefit ratio. The benefits should well out-weigh the risks. If a patient has a high chronological age, I'll scrutinize them thoroughly, but I have patients in their nineties who are healthier than some of my patients in their sixties.
Is anyone too young?
There are guidelines in sports medicine. If a 12-year-old patient has an ACL tear, it's better to fix it, but you have to respect the growth plates. With hip arthroscopy we try to avoid any patients younger than 15. In general orthopedics, if the bones are broken and we need to fix them, we do. In pediatric patients, if they have specific types of fractures, they're what we call fractures of necessity. One type at the elbow can cause lifetime morbidity and dysfunction if it's not fixed. Those are cases where we have to operate on a young child, although they do heal well.