By Tom Nutile
Growing up in Newton, Dan Snyder saw the careers of two of his sports idols, Sandy Koufax and Bobby Orr, cut short by joint problems. An arthritic elbow forced the Los Angeles Dodgers pitcher to retire at the top of his game. The knees of the hockey defenseman blew out after he helped the Boston Bruins twice capture the Stanley Cup.
“As a kid growing up in Greater Boston, seeing Bobby Orr go out in his prime was fantastically disappointing,” says Snyder, a 54-year-old orthopedic surgeon who still lives in Newton.
Today, Snyder is the assistant director of the year-old Jim and Ellen Kaplan Center for Joint Reconstruction Surgery at Newton-Wellesley Hospital, where he is one of New England’s pioneers in less intrusive ways to repair hips and knees. The procedures leave patients with greater mobility while reducing hospital stays and recovery periods, according to the hospital. They are so effective that they have helped amateur athletes return to the marathon route, the hockey rink, and the basketball court. One patient is a national caliber World Pond Hockey player who is back on the ice following hip resurfacing.
The Kaplan Center, a collaborative effort with Massachusetts General Hospital, offers hip resurfacing, knee resurfacing, and custom-knee replacement. Snyder performed his first hip resurfacing here less than two years ago. The patient, a 50-year-old officer in a suburban fire department, had suffered for two decades with problems resulting from a fall on the job and injuries playing football. Today, the officer is pain free and playing basketball. “It was very exciting to see his progress,” Snyder says.
These procedures aren’t for everyone. Candidates are typically active adults under 60, although older people may benefit if they do not have severely damaged joints. Hip or knee resurfacing is not appropriate in cases where bones or sockets have been extremely deformed by arthritis. “It comes down to bone quality and a high activity level,” Snyder says. That Newton-Wellesley Hospital is in the forefront of offering these procedures is due in large part to Snyder. The young boy who was saddened to see his sports idols stricken became a jock himself. As a teen on the ski patrol at Killington in Vermont, he envied patrol members who were doctors because they could ski any slope they chose. The rank-and-file like himself—regardless of how accomplished—were assigned specific slopes, often those for beginning and intermediate skiers. Snyder half-jokingly vowed to attend med school in order to have the run of the mountain.
As it turned out, he did, earning his degree from Tufts University School of Medicine and completing his training at Bay State Medical Center in Springfield and Tufts New England Medical Center. He signed on as an orthopedic surgeon at Newton-Wellesley Hospital in 1986.He became involved in sports medicine, looking after the Boston Bolts, an American Soccer League team, and three high school football squads.
Back then in the United States, some surgical procedures, such as hip replacement, were so intrusive that patients rarely regained sufficient mobility to resume athletic activities at or near full strength. For years, European surgeons had been performing less invasive surgery. When the US approved a popular European hip resurfacing procedure in 2006, Snyder flew to Birmingham, England, to study at the McMinn Centre with Dr. Derek McMinn, who helped develop the technique. Snyder says he was the first surgeon to perform it in New England. (Surgeons from the West Coast and South Carolina were also among this initial wave.) Snyder has since performed some 300 hip resurfacings.
During standard hip replacement surgery, the ball of the hip and part of the bone below it are removed. Doctors then insert a metal ball—smaller than the real hip ball—that is attached to a metal shaft. This apparatus is connected to the upper leg bone. The ball fits into a plastic socket that replaces the real hip socket. If successful, the operation eliminates hip pain, but does not restore full mobility.
“In hip replacement surgery, you don’t have what is called proprioception, which is the awareness of your body in space—space and balance combined,” Snyder says. “Your body naturally balances when you walk because it has feedback from your body. Hip replacement has no proprioception.”
With hip resurfacing, the surgeon scrapes off the damaged part of the hip ball and replaces it with a thin metal cap. The cap is roughly the size of the original hip ball. Most of the hip ball and its attached bone are left intact, and fewer ligaments and tendons are removed. After recovery, patients walk more naturally and enjoy greater mobility than those who undergo the traditional surgery. Snyder estimates that the average hip resurfacing operation allows patient to have 95 percent of the mobility and 95 percent of the feel they had before the joint was damaged.
At the Kaplan Center, 60 percent of patients who have hip procedures are deemed candidates for resurfacing; the others receive a full hip replacement. Nationwide, 10 percent of patients receive the resurfacing procedure, compared with 90 percent who undergo full replacement, Snyder says. The reason for the disparity is unclear. Perhaps this region has more active adults who opt for minimally invasive work, or perhaps it is because other parts of the country have fewer surgeons who perform the procedure.
Patients are often working out on a stationary bike or an elliptical machine within two weeks of the procedure. At six weeks, skaters are back on the ice. By comparison, recovery from the far more intrusive hip replacement can take four to six months.
The cost of hip resurfacing is about the same as traditional hip replacement and is typically covered by medical insurance. Snyder has performed resurfacing to repair minor knee damage on about 200 patients over the past two years. “It used to be, remove all the ligaments. Then replace the knee with a mechanical accessory. If you were a robot or a machine, it would fit perfectly. But you wouldn’t be able to run a marathon or ski moguls after having this surgery,” he says. “Now we’re trying to preserve as much as we can of the ligaments and the bones and tendons.”
As with hip resurfacing, Snyder removes the damaged surface of the knee and replaces it with thin metal plates. “You have greater preservation of anatomy, which gives you two main things: preservation of function and bone conservation.” It also offers the prospect of running marathons and conquering ski slopes again. About half the candidates at Kaplan for knee repair receive resurfacing; the remainder get replacements.
For adults with greater damage to their knees, Newton- Wellesley and Kaplan offer a custom-fit replacement. The goal is still to remove as little bone and ligament as possible. The OtisKnee procedure, created by OtisMed Corp., involves matching the original knee as closely as possible; earlier operations used a “one-size-fits-all” replacement. “Instead of giving the patient a mechanical box and making it fit somehow, we’ll … make a plastic mold specifically for that person’s knee,” Snyder says.
Here’s how it works: An MRI is performed to take precise measurements of the patient’s arthritic knee. Then OtisKnee computer software creates a 3-D image of the knee and “corrects” the deformity on screen. That image is then matched to the appropriatesize knee replacement made by another company, Stryker.
Patients are usually out of the hospital in one to three days, which is a day or two earlier than in traditional knee replacement. OtisKnee patients report having less post-operative pain than patients who undergo the traditional operation. They also have greater mobility and a more “natural” feeling knee, Snyder says. For patients unable to have an MRI, he uses a different procedure.
Snyder is the only surgeon at the Kaplan Center who does the hip and both knee procedures. Dr. Alfred Hanmer performs knee resurfacing and hip resurfacing. And Joseph McCarthy, the center’s director and one of its founders, installs OtisKnee replacements. In all, nine doctors staff the center, which also offers pain management methods for joints; and treatment of ligament and tendon tears and soft-tissue injuries. The center was made possible in large part by a $1 million gift from Jim and Ellen Kaplan, Weston residents who were patients of Newton-Wellesley physicians. Jim Kaplan is a director of the Newton- Wellesley Hospital Charitable Foundation and serves on the Board of Overseers.
Snyder says the center is attracting patients from all parts of the country— people who are “desperate [but] not ready to give up” on their bodies. “It’s very rewarding and very satisfying to be able to do this for a living,” he says. “I never imagined, when I was younger, skiing and thinking of being an MD, that it would have worked out this way.”
For more on The Center for Joint Reconstruction Surgery, visit www.nwh.org, click on Clinical Centers, and scroll down to the link.
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