MIDDLEBURY — Porter Medical Center President Dr. Fred Kniffin recalled the day five years ago when the hospital’s orthopedic surgeons asked for a “Hana Table.”
“At the time, I had never heard of such a thing,” Kniffin said.
The Hana Table, a piece of medical equipment used in an alternative approach to hip replacement surgery, was expensive when Porter purchased it in 2013. But the device has come to fit well into the evolving way in which Americans pay for health care because it has proven to shorten the time patients stay in the hospital and speeded up their recovery from surgery.
The Hana Table, which is growing in popularity, makes it possible for surgeons to position a patient in a way that allows access to his or her hip from the front (anterior) of their body, as opposed to the more conventional “posterior” approach in which the hip is accessed through an incision in the gluteus maximus. This anterior approach, officials explained, makes for a more straightforward operation that can shave days off the patient’s hospital stay and subsequent recovery period, compared to the more conventional posterior approach that requires more invasive surgery.
Porter made an $80,000 investment in a Hana Table in 2013, thanks to successful fundraising by the Porter Auxiliary group.
“I am embarrassed to say we actually worried that with patients going home so fast we might lose money,” Kniffin said, referring to the fee-for-service system upon which Porter and other hospitals heavily based their revenue streams.
But the Hana Table is now looking like a great investment for Porter Medical Center and its patients, particularly in this new era in which hospitals are now being rewarded for a healthier patient population and shorter hospital stays.
“A great patient experience, the best possible outcomes, at the lowest possible cost; get people fixed and back to healthy lives as quickly as possible,” Kniffin said. “This is how specialty care fits into a population health world.”
Dr. Eric Benz of Porter Orthopedics is the point man for PMC’s hip replacement surgeries. He’d been doing about 50 hip replacements annually using the posterior approach when he switched to the anterior technique in 2013.
This year, he’s on pace to do 80.
Hip replacement involves two basic components, according to Benz: The hip socket and the “ball” joint of the femur.
“It’s quite easy to put the socket in through an anterior approach,” Benz said. “Prior to the development of the Hana Table and the new techniques, it was really challenging to put the ball in through that same incision. So the table facilitates being able to put the ball and socket in through the same incision.”
The Hana Table allows the physician to readily reposition the leg during the operation, whereas the posterior approach requires the patient to lay on his or her side; an assistant manipulates the leg during surgery.
With the anterior technique, the patient is laying on his or her back and the Hana Table allows for the patient’s leg to be automatically lowered — which then allows for easier insertion of the ball joint into the hip socket, according to Benz.
“We’re able to go between major muscles and part them like you’d part your hair,” Benz said of the new technique. “When we use the posterior approach, we split the fibers of the large muscles in the gluteus maximus (buttock) muscle. That generally makes more early pain.”
Patients who undergo hip replacements using the posterior approach typically spend two or three nights in the hospital, according to Benz. That’s generally whittled down to one or two nights with the anterior approach, he said.
And since there’s less muscle disruption, the anterior process usually results in shorter rehabilitation time for patients, Benz noted.
“Particularly in the first month, they reach milestones of walking without any aid, more quickly,” he said.
Anterior hip replacement also gives patients greater peace of mind and less risk for a setback during recovery, according to Porter officials. The posterior approach requires detaching several small muscles on the back side of the hip, thus raising concerns about the ball popping out of the socket, Benz noted.
“Even if you repair (the muscles), there’s a vulnerability that the ball could pop out of the socket very easily,” Benz said. “With the anterior approach, you don’t have to disrupt those muscles, so the worry for dislocation almost goes away completely.”
CASE STUDY
Julie Hebert, a worker at UTC Aerospace in Vergennes, had spent the past two years walking in pain. Afflicted with arthritis, Hebert had a hip that had severely deteriorated over time. There was no cartilage left in the joint.
She was put in touch with Benz, who replaced her hip on July 10.
Hebert came out of surgery on a Tuesday and began her physical therapy that Thursday.
“I was walking around the block within a week,” said Hebert, now 59.
She’s now at 100 percent mobility and pain-free.
“I’m glad I had it done,” she said of the operation. “I’m only sorry I waited so long.”
One would think that given its proven advantages, the anterior approach would now be the new standard for hip replacement. But it’s not a change physicians and hospitals can make overnight. There’s a lot of training and capital expense associated with the transition.
Benz spent an entire year learning the technique from other physicians, a tutelage that included visits to special courses in Miami, New York City and Boston.
“It’s gaining in popularity,” Benz said of the anterior approach, now increasingly adopted by physicians coming out of residency. “It’s used in about 20 percent of hip replacements at this point. That number is likely to climb yearly.”
That’s good news to Porter spokesman Ron Hallman and his colleagues.
“The whole concept of getting people out of the hospital sooner — trying to focus on providing the right care in the right setting at the right time — was still in the talking stages when we purchased this equipment,” Hallman said. “We had this vision we needed to do more to get people out of the hospital, even though in those days we were 100-percent fee-for-service …  Now, with population health and risk-based contracting, the investment we made continues to not only be good for the patient, it dovetails beautifully with our approach to health care delivery. We actually changed the delivery model before we changed the financial model.”
Benz continues to receive great feedback from his hip-replacement patients. And current state and local demographics suggest Porter’s Hana Table will continue to prove a well-used, wise buy. Vermont has one of the grayest populations in the nation. Addison County is home to two retirement communities and a nursing home. Those seeking hip replacements are typically older than 50.
“Certainly, I’ve seen many more patients walking without any aids within a week, which was not very common with the posterior approach,” he said.
“This has been truly impressive to see this evolve,” he added  “The patients have already decided it’s a better way to go.”
Reporter John Flowers is at [email protected].