Services & Procedures

Dr. Gregory M. Martin is a board-certified orthopaedic surgeon who specializes in hip and knee arthritis and other painful disorders. Although Dr. Martin has extensive training and experience with state-of-the-art surgical options, he always recommends this as a last resort. He regularly treats patients with non-operative measures, including medications, physical therapy, and bracing. Dr. Martin also provides insight on nutritional supplements. The services and procedures provided by Dr. Martin include:

• Hip Injections
• Direct Anterior Hip Replacement
• Mini-Posterior Hip Replacement
• Revision Total Hip Replacement for failed hip implants
• FASTREC® Surgery
• Personalized Knee Replacement
• Concierge Medicine

When non-operative treatments fail, Dr. Martin discusses all available surgical options. He has extensive experience in less invasive hip and knee replacement (total and partial), arthroscopy, osteotomies, cartilage replacement, and joint preserving surgery.

About Your Hip

The hip joint is what is known as a “ball and socket” joint. It is a large joint made up of a ball (which is attached to the upper part of the thigh bone called the femur) and a socket (called the acetabulum, which is part of the pelvis). The hip joint is second only to the shoulder joint for allowing the most motion of all joints in our body. The hip joint is a true weight-bearing joint and often sees a load of about four times the weight of our bodies with normal daily activity. The joint is lined with a spongy material called cartilage, which cushions the joint. The hip is surrounded by strong muscles that work to move and support the joint.

Figure 1 shows a healthy-appearing hip joint.

Because the hip joint is so important – allowing us to walk, run, and jump – when we develop a problem with the joint, it can interfere with our quality of life and our ability to function and do the things we like or need to do.

What Can Go Wrong

When hip problems occur, they are often felt as pain in the groin area, the front of the thigh, or sometimes in the knee. Pain can be felt on the side of the hip as well. (Pain felt in the buttocks or the back of the leg is usually not a hip problem.) Hip problems also can cause stiffness, limping, and difficulty bending over to tie your shoes or get dressed. The following are the most common reasons we see people presenting with hip problems:

• Osteoarthritis: this is a mechanical condition where the cushion on the ends of the joints wears out.
• Hip fractures: these usually occur as a result of osteoporosis (weakening of the bones with aging) and a fall or a high-energy trauma. Inability to bear weight on the leg and significant pain are symptoms. If this is suspected, immediately go to an emergency room for evaluation. It is important to know that hip fractures do not always show up on X-rays, and sometimes an MRI or other imaging is necessary to diagnose a hip fracture.
• Inflammatory arthritis: this includes rheumatoid arthritis, psoriatic arthritis and others. The commonality here is that something systemic is going on where the hip joint is being attacked. Medical treatments are often effective in the early stages of disease.
• Bursitis and tendonitis: this is an inflammation around the joint either in the muscles or the bursa.
• Osteonecrosis (avascular necrosis): this is a condition where blood supply to the ball of the hip gets disrupted. This can occur with steroid use, alcohol use, trauma, or, in many cases the cause is unknown. Over time the bone can collapse and the joint can become arthritic.
• Other issues: certainly there can be other serious issues that can occur around the hip, such as tumors, nerve damage, etc. Symptoms should never be ignored and care should be obtained by a physician.

For more information on the hip and thigh, visit the American Academy of Orthopaedic Surgeons at http://orthoinfo.aaos.org/menus/hip.cfm.

Noninvasive Treatments

Surgery should be considered a last resort. There are some basic things that should always be tried prior to considering surgical intervention. These include:

• Weight loss (if needed): The hip joint bears the force of four times the weight of the body with most normal daily activity. So, if you are carrying around 50 extra pounds, it is experienced as 200 pounds of additional pressure on the joint. Lose the weight, and the joint will feel better. Even if it doesn’t, you will be in better health, feel better about yourself, and be a better candidate for surgery. Always consult a physician prior to changing your diet or attempting weight loss.
• Exercise: Numerous studies have demonstrated the beneficial effects of exercise for your hips. Strong muscles can support the joint and take pressure off it. Strong muscles can also help you walk and function better. Movement in the joint is important to keep it from getting stiff. Here is a hip conditioning program you can print out, http://orthoinfo.aaos.org/PDFs/Rehab_Hip_3.pdf  Always consult a physician prior to starting any new exercise program.
• Medications: Numerous medications, including acetaminophen (common brand: Tylenol), anti-inflammatories (common brands over the counter: Advil, Motrin, and Alleve; common brands by prescription: Celebrex, Voltaren, and Mobic), and tramadol (common brand: Ultram) all can be effective in controlling pain and symptoms associated with hip problems. Medications, even over the counter medicines, can be associated with significant risks, so you should always consult with a physician prior to taking any new medicine.
• Supplements: Several supplements, although controversial, may possibly alleviate the symptoms of hip arthritis and pain, with less of a risk than traditional medications. These include glucosamine sulfate (http://www.nlm.nih.gov/medlineplus/druginfo/natural/807.html) and tumeric/curcumin.
• Topical treatments: Numerous topical treatments may temporarily help, including menthol-based products, capsaicin, and others.

Hip Injections

Currently, hip injections are a way to alleviate symptoms and possibly delay the need for surgery. Injections to do not cure arthritis. Since the hip is deep, injections are generally done under image guidance (either with a fluoroscope/X-ray machine or with ultrasound. Numerous substances can be injected, including:

• Cortisone: this is a powerful anti-inflammatory injected right into the joint. It tends to work quickly with patients experiencing relief usually within a week. The time in which the effects last are variable, but a good result is considered to be 3 months or more.
• Hyaluronic acid: This substance, FDA approved for and commonly used in the knee, is not FDA approved for use in the hip. Its use is considered off-label and is not typically covered by insurance. It is used widely and approved in Europe, Canada, and Australia. Numerous studies support possible effectiveness in helping with hip symptoms. It does not cure arthritis or regrow cartilage.
• Platelet-rich plasma (PRP) and stem cells: These so-called biologic treatments are relatively new and untested. There is little science to support its use at this time and it are not covered by insurance. There is no convincing evidence that biologics alter the course of arthritis or regrow cartilage.

Direct Anterior Hip Replacement

If nonoperative treatments have failed and your hip needs to be replaced, there is good news. A new and innovative way of replacing the hip joint without cutting any muscle was developed and has been perfected. Direct anterior hip replacement using the innovative HANA table allows patients to get back on their feet almost immediately, without the usual restrictions and precautions and potentially less pain! The technique utilizes a 3- to 4-inch incision on the front (anterior) of the thigh. An interval is utilized between the muscles in order to limit soft tissue trauma. Not cutting these muscles potentially reduces the risk of dislocation and may allow for an accelerated recovery.

Figure 2 is a picture of the HANA table.

This high-tech table allows the patient to be lying on their back during the surgery, allowing a level of precision to be achieved, which is generally not possible while a patient is lying on their side.

The procedure allows the use of intra-operative X-ray to ensure the components are put in properly and that leg lengths are being matched to the opposite side.

Mini-Posterior Hip Replacement

Although direct anterior hip replacement using the HANA table has become Dr. Martin’s preferred method of hip replacement, it is not possible in all patients. Some patients with prior surgery and hardware, birth defects, and other issues require a posterior approach. Posterior-approach surgery remains the most common way hip replacement is performed in this country. For more than 10 years, Dr. Martin has performed a less invasive variant of posterior hip replacement, called mini-posterior hip replacement.

To better understand what is done with total hip replacement, see below.

To download a brochure on total hip replacement surgery, see below.

• English: http://patients.depuyorthopaedics.com/binary/org/DEPUY/doc/pt.com/0609-45-000r10.pdf
• Spanish: http://patients.depuyorthopaedics.com/binary/org/DEPUY/doc/pt.com/0610-76-000r4_SP_THR.pdf

Revision Total Hip Replacement

Dr. Martin has special expertise performing surgery on hips that have already been operated on. This is called revision total hip replacement and is required generally due to:

• Loosening of the implants
• Wear of the implants
• Infection
• Dislocation of the hip (the ball pops out of the socket)
• Fractures around the implants
• Allergic reactions
• Other issues

About Your Knee

The knee is the largest and one of the most complex joints in the human body. It is what is known as a “hinge joint.” It is made up of three bones: the lower part of the thigh bone (femur), the upper part of the leg bone (tibia), and the kneecap (patella). The ends of the bones are lined with a spongy material called joint cartilage that cushions the joint. There are also two meniscal cartilages that help protect the joint cartilage. There are numerous ligaments (tissue that connects bones) and tendons (tissue that connects muscle to bone). There are three parts to the joint: the medial, lateral, and patellofemoral joints.

Figure 1 shows a healthy-appearing knee joint and its three parts.

What Can Go Wrong

The knee joint is a weight-bearing joint and feels the force of four times the weight of the body with normal daily activity. The joint is surrounded by strong muscles that work to move and support the joint. The knee is so important in helping us walk, run, and jump that it can interfere with our quality of life and ability to do the things we want or need to do when not functioning properly.

Because the knee is so complex, you can imagine there is a lot that can go wrong. The following are the most common reasons we see people presenting with knee problems:

• Osteoarthritis: this is a mechanical condition where the joint cartilage wears out and the bone rubs against bone.
• Inflammatory arthritis: there are multiple diseases that can cause inflammatory arthritis, including rheumatoid arthritis, psoriatic arthritis, gout, and many others. The common factor here is that there is something systemic going on leading to damage to the joint.
• Meniscal tears: these are tears in the rubbery discs that sit between the ends of the bones on the inside (medial) and outside (lateral) parts of the knee.
• Patellofemoral pain/chondromalacia: This is a disorder, common in runners and people who use their knees a lot, where the cartilage behind the kneecap gets irritated.
• Trauma or microtrauma (including sprains, strains, fractures, ligament and tendon ruptures): this can include minor injuries up to severe fractures and your treatment options will vary greatly, depending on the cause.
• Other: less common but serious things like tumors or nerve and vascular issues can cause knee pain, so symptoms should never be ignored and should always be evaluated by a physician.

Figure 2 shows an arthritic knee.

For more information on the knee, visit the American Academy of Orthopaedic Surgeons website, http://orthoinfo.aaos.org/menus/leg.cfm.

Noninvasive Treatments

Surgery should be considered a last resort. There are some basic things that should always be tried prior to considering surgical intervention. These include:

• Weight loss (if needed): The knee joint bears the force of four times the weight of the body with most normal daily activity. So, if you are carrying around 50 extra pounds, that is experienced as 200 pounds of additional pressure on the joint. Lose the weight, and the joint will feel better. Even if it doesn’t, you will be in better health, feel better about yourself, and be a better candidate for surgery. Always consult a physician prior to changing your diet or attempting weight loss.
• Exercise: Numerous studies have demonstrated the beneficial effects of exercise for your knees. Strong muscles can support the joint and take pressure off it. Strong muscles can also help you walk and function better. Movement of the joint is important to keep it from getting stiff. Here is a knee conditioning program you can print out, http://orthoinfo.aaos.org/PDFs/Rehab_Knee_6.pdf  Always consult a physician prior to starting any new exercise program.
• Medications: Numerous medications, including acetaminophen (common brand: Tylenol), anti-inflammatories (common brands over the counter: Advil, Motrin, and Alleve; common brands by prescription: Celebrex, Voltaren, and Mobic), and tramadol (common brand: Ultram) all can be effective at controlling pain and symptoms associated with knee problems. Medications, even over the counter medicines, can be associated with significant risks, so you should always consult with a physician prior to taking a new medication.
• Supplements: Several supplements, although controversial, may possibly alleviate the symptoms of knee arthritis and pain, with less of a risk than traditional medications. These include glucosamine sulfate (http://www.nlm.nih.gov/medlineplus/druginfo/natural/807.html) and tumeric/curcumin.
• Topical treatments: Numerous topical treatments may temporarily help, including menthol-based products, capsaicin, and others. Although not cures, these treatments can help alleviate pain, without risking the potential side effects of systemic medicines.
• Support and compression sleeves/bracing: In the knee, there can be a role for support sleeves and occasionally for external bracing depending on the circumstances.

Knee Injections

Currently, knee injections are a way to alleviate symptoms and possibly delay the need for surgery. Injections to do not cure arthritis. Numerous substances can be injected, including:

• Cortisone: this is a powerful anti-inflammatory injected right into the joint. It tends to work quickly with patients experiencing relief usually within a week. The time in which the effects last are variable, but a good result is considered to be 3 months or more. Too much cortisone and local anesthetic injected into the joint can be counterproductive.
• Hyaluronic Acid: This substance is FDA-approved for and commonly used in the knee. It does not cure arthritis or regrow cartilage. It may lubricate the joint and have some anti-inflammatory properties. Hyaluronic acid is controversial and some recent studies have indicated it may not work as well as previously thought. It definitely does not help everyone. In Dr. Martin’s experience, for every three people injected, one gets significantly better, one gets somewhat better, and one has no benefit. These injections are generally safe, although there can occasionally be side effects. Dr. Martin uses two of these products that are made in a lab (as opposed to some made of rooster combs and other parts, which Dr. Martin generally does not use due to possible adverse reactions).
• Platelet-rich plasma (PRP) and stem cells: These so-called biologic treatments are relatively new and untested. There is little science to support its use at this time and it is not covered by insurance. There is no convincing evidence that biologics alter the course of arthritis or regrow cartilage. Dr. Martin continues to follow the evidence on these prior to recommending their use.

Arthroscopic Surgery

Arthroscopic surgery is a true minimally invasive form of surgery where several small incisions are made and miniature surgical instruments used to perform surgery within the knee.

Figure 3 illustrates portals used in arthroscopic surgery. Image borrowed with permission from Education4Knees, Star Group Publications 2014.

While arthroscopic surgery can be of tremendous benefit in a healthy knee with a damaged piece of meniscus cartilage or torn ligament, more and more evidence is showing that as the knee degenerates (which happens in most people over the age of 40), this surgery should probably be avoided. Individual cases should be discussed with an orthopedic surgeon.

Personalized Knee Replacement

Dr. Martin strongly believes people should pursue surgery only as a last resort. His new book, Education4Knees, tells people everything they need to know to potentially delay the need for surgery or to avoid it altogether. Despite best efforts to avoid it, surgery will be necessary for some. Fortunately, having completed all the appropriate steps to avoid surgery can help ensure the best possible outcome with surgery. The condition a patient is in prior to surgery has a lot to do with their result after surgery.

Traditional total knee replacement, where the joint is replaced with metal and plastic components that come in several different sizes, has been performed for about 40 years now with good success. However, there is room for significant improvement. Studies in the U.S. and Europe demonstrate that, from the patient’s perspective, about 1 in 5 who undergo traditional total knee replacement, are not satisfied with their outcome.

Dr. Martin also realizes that many people who underwent traditional total knee replacement, despite everything going well and without complications, were not satisfied. Patients are often dissatisfied because of persistent pain or because the knees do not feel natural. Because of this, Dr. Martin believes “cautious innovation” is required. We know from studies that implant size is important. Studies have demonstrated that an implant too big by just 3 mm (a very small amount) can double the risk of persistent pain after surgery. Because traditional implants are not shaped like a person's knee, it generally does not feel like the patient's own knee. No surgical technique or procedure will satisfy 100% of patients and no surgery will have perfect outcomes – but that doesn't mean we shouldn’t strive for the best outcomes possible.

Because of this, using shared decision making, Dr. Martin began to inform patients of personalized partial knee replacements in 2010 and personalized total knee replacements in 2011. People come in various shapes and sizes ... and so should their knee implants. Conformis, a company in the Boston, Massachusetts, area was founded with the idea that modern imaging technology and manufacturing techniques can be utilized to create better implants. Each implant is customized and individually made for the patient. In addition, all the instrumentation to help the surgeon place the implant is also made specifically for the patient. This allows the surgeon to implant the device correctly, with a less-invasive surgical technique (no hole is drilled in the thigh bone and less bone is removed, compared to traditional implants). Dr. Martin has one of the world’s largest series of personalized knee surgeries and is active in studying and presenting his data worldwide. Personalized implants have been utilized widely at many of the most prestigious institutions in America and Europe.

Dr. Martin believes that when it comes to surgery, never perform a bigger surgery than is needed. NOT EVERYBODY NEEDS A TOTAL KNEE REPLACEMENT! Because a CT arthrogram can be obtained as part of the process to make a patient-specific implant, the knee can be investigated further. Sometimes if only one or two parts of the knee are damaged, then only those parts of the knee need to be replaced.

Personalized Partial Knee Replacement

For patients who are found to have damage in only one or two of the three parts of the knee, there are numerous compelling reasons to consider a partial knee replacement:

• Less invasive surgical technique
  • No muscle cut
  • Minimal bone remove
• Less trauma to the body
  • Potential for less medical risk
• Potential for less painful recovery
  • Pain varies from patient to patient, but generally is less than total knee replacement
• Potential for quicker recovery
  • Typically done as outpatient surgery with quick return to a normal life
• Typically better range of motion
  • Knees generally bend easier with little physical therapy required
• Typically a more natural feel
  • Most people with a personalized partial knee say it feels natural
• Doesn’t burn bridges for future surgery
  • Nobody ever wants a second surgery, but the fact is that with either partial or total knee replacement, there are no guarantees
  • If a partial knee fails or the rest of the knee becomes arthritic, it can typically be converted to a total knee
  • If a total knee is performed rather than a partial knee, and the patient is not happy with the outcome, you can never turn back to a partial knee

The potential downsides of partial knee replacement are:

• Parts of the knee are left behind that could become arthritic and painful down the road, leading to the potential need for further surgery.
• Some studies have shown a higher early failure rate with partial knees versus total knees. However, recent studies with modern knee designs have demonstrated survival approaching total knees at 10 to 15 years of follow up.

Personalized Total Knee Replacement

For patients with significant damage to the knee that are candidates for total knee replacement, there are compelling reasons to consider a personalized total knee replacement:

• Prenavigated, single-use instruments for the surgeon
  • Instruments are made specifically for the patient
  • Helps surgeon align the knee without using time-consuming and somewhat unreliable conventional instruments, computer navigation, or robotics
  • Instruments are used only for you and then discarded (unlike traditional knee instruments, which are re-used and must go through sterilization process before each use)
• Less surgical trauma
  • No hole drilled in femur
  • Less bone removed (25% on average)
• Less blood loss and swelling
  • No hole drilled in femur
  • Implant covers all cut bone
  • Leads to reduced blood loss and swelling
  • Minimal risk of transfusion (1% compared with 10% to 20% for traditional total knee replacement)
• Potential for less postoperative pain
  • Less bleeding and swelling typically leads to less pain
• Potential for a quicker recovery
  • Less pain typically leads to a quicker recovery
• Potential for less of a chance of persistent pain
  • Customized implants have less of a chance of irritating soft tissues
• Potential for a more natural feeling with a total knee replacement
  • By recreating the normal anatomy, the hope is that the knee will feel more natural. Some early data has demonstrated this (see current research).

The potential downsides to a personalized total knee replacement are:

• Lack of intra-operative flexibility
  • Since the system is very conservative, if more damage is found than expected, there is a chance the technique may not be possible
• No long-term follow-up
  • Data is only out to three years and early failure rate is as good as or better than traditional total knee replacement
  • No data beyond this is available
  • Many existing designs for traditional total knees have data for more than 10 years, but many of these designs are being phased out in favor of newer implants that come in more shapes and sizes

Traditional Total Knee Replacement

For more than 10 years in practice and 5 years of residency and fellowship, Dr. Martin has performed traditional total knee replacement with mostly excellent results. He always discusses traditional total knee replacement as an option with his patients because it is the most time-tested procedure for the knee. Many cases with significant deformities, ligament injuries, knees with prior surgery, etc. are not candidates for personalized knee procedures and traditional total knee replacement is the only reasonable option.

Although the procedure helps most people, the main issue Dr. Martin has with total knee replacement is that approximately 1 in 5 patients who undergo the procedure are not satisfied with the outcome. That does not mean, in most cases, that the patients are not better off than they would have been without it (although that is possible with any surgery). It just means they are typically not as happy with the procedure as they thought they would be.

Figure 5 is a picture and X-ray of Depuy Sigma Rotating Platform Total Knee.

Revision Total Knee Replacement

Dr. Martin has special expertise in performing surgery on knee implants that have failed. This is called revision knee replacement and is required generally due to:

• Loosening of implants/mechanical failure
• Infection
• Instability
• Wear of the polyethylene liner
• Persistent pain
• Stiffness
• Fractures around the implants
• Patella (kneecap) problems
• Other issues

Dr. Martin co-authored the section on complications of total knee arthroplasty in UpToDate®, which is utilized worldwide. To read this professional level material, visit http://www.uptodate.com/contents/complications-of-total-knee-arthroplasty.

Although rare, complications and re-operations can and do occur. Close to 60,000 re-operations on total knee replacements occur each year in the United States. Studies have demonstrated approximately 6% of knees have required re-operation within the first five years and 12% within the first 10 years (this also means that close to 90% of total knee replacements done today will last 10 years or more).

Generally, revision total knee replacement is a higher risk operation, as tissue in the area has already be disrupted. Implants with stems and devices to obtain better fixation are typically utilized.

Figure 6 is a picture and X-ray of revision total knee components.

For more information on revision surgery from the American Academy of Orthopaedic Surgeons, visit http://orthoinfo.aaos.org/topic.cfm?topic=A00510.