Novato Living

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Novato Community Surgery

Wednesday, May 2, 2007 3:21 PM PDT

Story by Rob Mitchell

A day with Dr. Raymond Bonneau

On Tuesday, April 17, Paul Magistretti went to sleep at 8:09 a.m. and woke up later that day with a new hip.

The hip, courtesy of Dr. Raymond Bonneau and the surgery team in Operating Room 3 at Novato Community Hospital, is part titanium, part polyethylene. Bonneau, who has performed about 10,000 surgeries and about 2,500 hip and knee replacements, is compact, with broad shoulders, immaculately combed silver hair and a broad smile. “You can't be perfect. But you try to stay in the narrow area around perfect,” he said. “You don't want outliers beyond that area.”

The titanium hip prosthetic, which looks like a stainless steel cue ball at one end of a rod and a steel bullet at the other, is buried deep into the shaft of Magistretti's femur, or thigh bone.

It costs between $4,000 and $6,000, depending on the size, according to the manufacturer, Zimmer, Inc. - installation not included. Joint replacements happen every week, right here in Novato at Novato Community Hospital. Last year Dr. Bonneau replaced 163 hips and knees, a small part of more than 2,570 surgical procedures performed at the hospital in 2006.

Bonneau, who has practiced in Novato since 1988, says the hospital's surgery unit does almost everything that the more famous hospitals in San Francisco and the Peninsula do, and just as well. He did his medical school and residency at the University of San Francisco.

“There's no place that does anything better than this one,” he said. “What we have is state of the art.” Knee and hip replacements are becoming more common - there were about 282,000 hips and 428,000 knees replaced nationwide in 2003-2004, according to the National Health Report issued by the Department of Health and Human Services in 2006.

That's up from 128,000 hips and 166,000 knees in 1992-1993. People are staying active longer, and the Baby Boomers are getting older, Bonneau explained. And prosthetic technology has gradually improved to the point where an implant in a typical 60-year-old can be expected to last out that person's life. The replacements cost a combined $24.1 billion in 2003, the report said, at an average cost per surgery of about $35,000. It's worth every penny, said Magistretti 10 days after his hip surgery. “It seems to be working,” he said. “The one that wasn't operated on is the most painful one.”

He's recovering so well that he expects to get his left hip replaced later this summer, he said. After years of pain, the right one had deteriorated so far he had trouble walking.

Bonneau made the incision in Magistretti's hip, a 6-inch cut with a scalpel, at 8:47 a.m.

The operating room is kept at a cool 60 degrees, and Bonneau and Cooper both wear cooling vests that circulate chilled water to keep them cool as they work.

But Magistretti had to be kept warm, said anesthesiologist Dr. Cooper Chao.

“Under anesthesia, your body loses the ability to thermoregulate,” he said.

Patients who are under anesthesia flop like dead fish. They lie exactly the way they are placed, cutting off circulation or nerves, and can even die, unless the surgical staff takes great care.

So Dr. Chao layers on a heating blanket and sits by Magistretti's head, monitoring computer readouts on his vital signs. Before the cut, Bill Beckman, 52, an operating room tech, and Sheila Habib, 51, the operating room nurse, had prepped Magistretti.

They positioned him on his side, right hip to the ceiling, and began to create the ultra-sterile operating field. They unpacked layers of sterile blue surgical cloth and laid it over his body, and Habib scrubbed his hip and leg with a powerful antimicrobial for three minutes.

Beckman and Habib help Bonneau and Cooper into blue sterile smocks and gloves over their scrubs. They bantered back and forth.

“I had a nice pastrami sandwich on rye, with a glass of milk for dinner last night,” Beckman said. He lives in Novato with his German Shepherd puppy. “I was asleep in 10 minutes flat.”

Beckman opened a package of Ioban, an orange-tinted antimicrobial barrier that clings to the skin like Saran Wrap, and plastered it over the operating area.

The man Magistretti became just an orange hip in a sea of blue.

Bonneau told a story about his daughter visiting New York City to look at colleges.

“I call her, and ask her if she's sitting in on a class, you know,” he said, wrapping some gauze around Magistretti's leg. “And no, she's in Bloomingdale's.”

With the preparation done, the surgery began and the room grew quiet. The only sound was the steady beep of the heart rate monitor, the hiss of the respirator, and Bonneau's quiet comments and requests.

After the initial cut, Bonneau sliced his way down to the bone, using an electric knife that cauterizes capillaries as it goes. Small puffs of smoke wafted up from the wound.

Bonneau used a pneumatic saw to take off the “ball” end of Magistretti's femur.

It looked like the flat skull of a Neanderthal when Dr. Bonneau pulled it out of the hip at 9:10 a.m. that Tuesday.

He held it up to the light, examined it, and said in a matter-of-fact way: “This should be perfectly round. You can see it's all worn down.”

The worn-down bone had been rubbing, scratching, tearing at the socket until Magistretti was in constant pain. He felt stabbing knives in his thigh; he felt burning rods from his hip down to his toes. He woke up at night in pain. The Neanderthal-skull hip ball was the cause.

After prepping the socket and the femur, Bonneau began testing different-sized prosthetic combinations. “One of the advantages of doing this all the time is that you've got all the specialized equipment,” he said, pointing to stacks of trays of ‘tester' prosthetics.

OR tech Beckman stood ready at a tray as Bonneau called out for different sized sockets until he found the right one. With that in place, he finds the correct femur prosthetic. He tests three different sizes, snapping the hip into place and putting the leg through a broad range of motion. It's still too loose. He pauses to think. “Hmmmm. What do we do here?” he asks, looking at the wall. He tests one last combination. It works. He rattles off a list of specifications for Habib, who brings the prosthetic in shrink-wrapped boxes and pops them out into the sterile field. It's the ‘moment of truth': at 10:24 a.m. Bonneau fixed the real polyethylene socket and liner into the pelvis, then tapped in the shiny titanium ball segment into the femur. He popped the ball into its socket, tested the range of motion, and smiled. “This one took a little more fitting than usual,” he said. Bonneau's second patient of the day, Beth Gobbin, had proof of the advances in joint replacement technique etched into her left knee.

In 2001, Bonneau performed a knee replacement on that leg, leaving a fading scar that ran from her shin to well up her thigh. Six years later, using a new technique where he holds the quadriceps muscle to the side, Bonneau performed almost the same surgery with a relatively small 6-inch cut. Beckman scrubbed out, and 23-year-old OR tech Dana Andersen takes over for the knee. He is brash, confident and precise, with thick earrings.

“I look great,” he says. “No you don't,” Habib told him. A Mill Valley resident, she's worked with Bonneau in Novato for 15 years, and is constantly in motion, counting, cleaning, checking, anticipating. They brought Gobbin into the sterile field: the 64-year-old Novato resident became just a knee in the middle of blue. Her husband calls assistant surgeon John Wayne Cooper “Cowboy,” and she has lost almost completely her Kentucky accent since she moved to Novato 43 years ago. Her knee hurt so much she couldn't stand long enough to cook dinner. Bonneau opens her knee at 12:34 p.m. He moved the kneecap aside and fixed it in place, preserving the quadriceps muscle. To prepare the bottom end of the femur and the top end of the tibia, they had to saw the bone in a precise pattern using metal guides that are screwed into the bone.

The team became a six-handed machine; Bonneau calling out for different-sized guides, Cooper bracing retractors and maneuvering the knee, Andersen wielding a drill and mixing the special cement that will hold the prosthetic in place. The first try - again using tester prosthetic pieces - was too tight. “We've got it down, the leg is lined up right, but it's too tight, she can't flex it,” Bonneau said. “So we have to shave a little more off the tibia.” He took off about 2 millimeters more, tapped the testers back in place, and bent and unbent the knee. “Perfect,” he said. “The real test is when you put on rollerblades,” said Cooper. Habib selects the correct permanent prosthetics and pops them out of their packaging, then starts collecting and counting the sponges used in the surgery. They cement the prosthetics in place - a shiny titanium end on the femur, a polyethylene and titanium cap on the tibia - and begin to clean up and close the wound. It is 2:12 p.m. They have two more surgeries - arthroscopies - left, but the hardest part of the day is over. “Three to four months to be back to normal, in six months it's great - it's usually changed their life,” Bonneau said. “You can often see the difference in their faces. That's kind of the reward of doing this kind of surgery.”

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