Watching Dr. Kusuma perform a live
I had the opportunity to watch a live BHR hip resurfacing
surgery at Grant Medical Center in Columbus, OH on Oct. 7,
2011. The story below is from a layman’s perspective
since I am not medically trained. I have written the story
so patients can understand the basic procedures during
surgery. I explain things so perspective patients can
understand them. I am not trying to write a technical
article on hip resurfacing surgery. It is my observations
about what was happening in the OR.
Watching a live surgery as an observer is quite different
than being a patient. As a patient, I never saw the inside
of an operating room. The special shot given to relax me
always put me to sleep before entering the OR. Being awake
and watching the staff the OR for a BHR surgery is very
interesting. The room is a beehive of activity. No one is
rushing but everyone is doing their job efficiently while a
little small talk occurs.
While the staff is preparing for the surgery, the Smith
and Nephew representative selects the proper sized BHR
device. He also selects one size larger and one size
smaller than the determined size to be used during the
surgery. A special room stores all of the Medical Devices
at the hospital. The representative from each medical
company keeps the shelves stocked for their own devices.
Once the patient is prepared, Dr. Kusuma, is ready to
begin. His staff is a very competent and obviously use to
working with him. His PA assists him in all of his
surgeries. The staff was aware I was observing the surgery
and was very helpful in placing the video cameras so I could
see everything that was happening.
Before surgery, Dr. Kusuma had studied the x-rays and
used his templating system to determine where the middle of
the neck of the femur bone was. He studied both the x-rays
and his drawings for the correct placement of the femur cap
on the center of the femur neck.
The BHR device was packaged in several sterile packages.
The first box was opened by the representative and handed to
an assistant. They opened the second package and handed it
to the surgery assistant. All checked carefully, that the
size was correct. There were many eyes checking many things
all through the surgery. Everyone paid close attention even
when they were not directly involved in the step being
Dr. Kusuma prepared to make the first incision to expose
the hip joint. He explained about the various muscles and
ligaments he was working with as he surgically cut into the
hip joint. I watched many surgeries on the Internet and at
hip resurfacing courses, but watching a live surgery was
quite different. I was able to see every step take place.
Usually the videos only included the major part of the BHR
component placements. Dr. Kusuma uses the posterior
approach with a large incision for best exposure.
He was very careful to preserve as much tissue around the
neck of the femur to help maintain a good blood supply.
When he uses the instrument to rotate around the femur neck
to determine its center and size, he uses a tighter fitting
setting than most surgeons use. This way he knows he is
Dr. Kusuma does the preliminary shaping of the femur ball
leaving enough bone to allow him to change the diameter of
the femur cap if needed after setting the acetabular cup.
As I watched him work and listened to his comments to me, I
realized once again, that hip resurfacing surgery is as much
an "art" as it is a skill. There is more involved than just
the information previously learned by the brain. There is an
inner knowledge or awareness of what seems right. It is
like any great athlete who just knows what to do without
thinking about it. It is that experience and skill acquired
throughout the years that also guides him along with his
conscious decisions. The experience of doing hip resurfacing
surgeries over and over helps him make the decisions without
having to think about every one of them as he moves from one
step to another.
The PA helps to rotate the leg and dislocate the joint to
expose the acetabular portion of the hip. Any of the bone
spurs or bony growths are removed from the joint very
carefully. They must be cleaned away so there is no
interference or impingement after the acetabular cup is set.
The cup depression is removed with a type of router, almost
like those used in woodworking. After the surgeon is happy
with the preparation, the acetabular test cup is put into
place. After testing and checking everything, the final
acetabular cup is help by a special tool and then pounded
into place. Dr. Kusuma prefers to hold the tool attached to
the cup while his assistant taps the component into place.
He feels this provides a better placement than when he tries
to hold and tap at the same time.
Once the acetabular cup is in place, he goes back to
finishing and shaping the ball of the femur. He placed
special draping cloths around the femur bone and neck to
protect it from all the small bone chips and fragments that
are removed with the shaping or routing tool. The drills
and routers all look very much like woodworking tools and
are battery operated. I am sure they cost much more than
normal woodworking tools! The femur ball is shaped to
accept the cup that will match with the acetabular cup
already placed in the hip.
The femur cap is placed on the femur with cement and
tapped for a forced fit. The cement operation is very
interesting. It has two components something like epoxy.
The cement must be timed because it has a reaction and then
sets – right now. I was able to feel a small amount in my
hand. As it gets ready to "fire" or set, it becomes warm
and quickly becomes very hard. This is a tricky part of the
surgery because everything must be timed correctly. Also
the right amount of cement must be added to the inside of
the femur cap. The amount of cement is critical because too
little will not allow good adhesion and too much can prevent
good bone growth. The pin of the femur cap is not cemented
and is only used to place the cap. The representative is
calling out the time so the surgeon and assistants know when
the cement is ready to set. The femur cap is also tapped
onto the properly shaped femur bone. A few extra holes are
drilled into the femur bone to allow the cement to
The leg is flexed and rotated to make sure that the
components are placed properly and there is no problem.
There should not be any impingement and everything should
move smoothly. This test is performed several times with
the test components and after the actual components are
After the femur cap has been cemented and tapped into
place, it is time to clean up the area. The sterile drape
is removed with all the pieces from the shaping and the
extra cement is also removed that has squirted out from the
cap. There is not much as I can tell, but the surgeon is
very careful to clean it all up. After everything is in
place, the whole area is washed with sterile fluids. After
that, everything is washed several times with
Dr. Kusuma does the initial stitching
when closing the incision. He does the first several
layers, then his PA closes the rest of the incision. The
outer layer is stapled closed.
An x-ray is taken right after surgery to
show the placement of the omponents. The x-ray showed the
femur cap pin to be in the middle of the femur neck and the acetabular component placed at an optimum angle.
I realized several things as I observed the live
surgery. Most importantly, the surgeon that is very
experienced is as much an "artist" and a surgeon. There are
instinctive moves and decisions made by the experienced
surgeon that he does not even have to think about. The
surgeon’s actions are like a pro athlete, musician or artist
meaning they are doing something they love and make many
intuitive decisions based on a great deal of experience and
I think the most important aspect of the live surgery
which impressed me is how much both the surgeon and all of
the staff in the OR cared about the patient. They are all
very attentive and treat the patient with respect and
kindness. I watched one person give the patient a gentle
pat on the leg as if to say "everything will be OK because
we are here and care about you." Everyone appeared to care
and want to be there, they were not counting the minutes or
hours until quitting time. I know they do this day in and
day out, but there was a feeling of caring and wanting to do
a great job.
I appreciate the opportunity Dr. Kusuma and Grant Medical
Center offered me to observe a live surgery. I learned more
about hip resurfacing and learned about the great staff at