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Less and minimally invasive surgery (Hip and Knee)

Background:

Less and minimally invasive surgery (L/MIS) have emerged as recent alternatives to traditional hip and knee replacement surgery in select patients. These procedures are in high demand by the public because of claims that L/MIS allows for quicker recovery, less pain, fewer complications and a smaller surgical scar. However, not every patient is a candidate for L/MIS and because these techniques are so new, evidence-based medicine has not yet proven their efficacy.

Statistics:

  • to the National Center for Health Statistics, there were more 402,000 total knee replacements and 217,000 total hip replacements performed in 2003.
  • is no ICD-9 code to specify whether or not a joint replacement was performed using L/MIS or traditional surgery, so there is currently no data on how many L/MIS procedures are performed each year.
  • surgeons who routinely perform L/MIS report that only 17-20 percent of their patients are candidates for this procedure.
  • to a study by the Mayo Clinic, L/MIS lends itself to higher complication rates both during and after surgery than do traditional procedures and requires more anesthesia, longer operative time and causes just as much – if not more – muscle damage than conventional hip replacement surgery.

Talking Points:

  • newer procedures are not for everyone. Only the surgeon performing the procedure should recommend which procedure is best, based on his or her experience and each patient’s individual circumstances.
  • profile of today’s average knee replacement patients has shifted from sedentary individuals in their late 60s and early 70s, to active adults in their 50s. Even older patients in their 60s and 70s are remaining more active than previous generations, which drives patient demand for L/MIS.
  • younger, and in some cases older, active patients come to surgeons’ offices with dramatically higher expectations than previous generations – particularly as it relates to the function of the new hip or knee.
  • procedures are performed by only a small percentage of orthopaedic surgeons.
  • need to realize that these techniques are still in development and require further analysis to assess their true role.
  • are no long-term outcome studies on L/MIS, and only evidence-based studies will determine its true place in reconstructive surgery.
  • certain to discuss with your physician the possible complications during and after surgery, options for pain management, recommended therapy/rehabilitation programs, a timeline for recovery and what types of activities you can participate in post-joint replacement.
  • well-done traditional joint replacement is far better than L/MIS performed incorrectly.
  • orthopaedic surgeons who do not perform L/MIS are incorporating some of the newer instruments and techniques into their standard surgical approaches. This has resulted in smaller incisions for standard total joint replacements, as well.

Potential Media Questions:

Q: How do less and minimally invasive procedures differ from traditional joint replacement, by definition?

A: Less-invasive surgery calls for performing the traditional joint replacement technique through a smaller skin incision, of approximately one-half the size of conventional procedures. In traditional knee replacement, the incision averages 8 inches to 10 inches long. Minimally invasive total knee arthroplasty is a different way of performing the surgery, using an incision that is only 4 inches to 6 inches long, meaning that potentially there will be less damage to the tissue around the knee. Total hip procedures performed using MIS can be attempted through two incisions, as small as two-inches in length.

Q: What are some of the possible advantages of L/MIS?

A: The reported possible short-term advantages of L/MIS differ from patient to patient, and typically occur in the first few weeks or months post-surgery. These include:

  • incision length (more cosmetic scar)
  • discomfort (immediate post-operative pain)
  • blood loss (fewer blood transfusions)
  • hospitalization
  • rehabilitation
  • return to work

Many of the perceived advantages of L/MIS may stem from the new anesthesia techniques developed for procedures designed to diminish nausea and get the patient moving in a shorter amount of time and out of the hospital faster. Many orthopaedic surgeons are now applying those same anesthesia techniques to patients undergoing standard total joint replacements, and are seeing faster recovery times.

Q: What are some of the possible disadvantages of L/MIS?

A: The reported possible advantages of L/MIS relate to the difficulty of performing surgery within a restricted visual field as well as issues related to learning and typically occur in the first few weeks or months post-surgery. These include:

  • of skin/soft tissues, leading to a less cosmetic scar
  • more restricted visual surgical field
  • duration of surgery
  • nerve injury in hip surgery with the anterior incision
  • of bone during implant insertion
  • implant choices

Q: What should I ask my orthopaedic surgeon when considering a total joint replacement of any kind?

A: Among the questions you should ask your orthopaedic surgeon when considering total joint replacement – via L/MIS or the traditional approach – are:

  1. are the major and/or most frequent complications of surgery?
  2. the surgeon more important than the device, procedure or approach?
  3. you give me any information on your outcomes and complication rates?
  4. I do not have surgery, what is the risk? Are there other options besides surgery?
  5. device would you want put in your hip or knee, if you needed a hip or knee replacement now, and why?
  6. much pain can I expect, and how will it be managed in the hospital and after I go home?
  7. long will the device last, and what can I do to make it last as long as possible?
  8. are the pros and cons of 'mini-incision' surgery? Does it really make a meaningful difference in the result, or does it pose unnecessary risks? Am I a candidate?
  9. I trust what I see on TV or read in the ads in magazines? Where can I go for reputable information about L/MIS?
  10. will I be able to do/not do after my hip or knee replacement?
  11. therapy necessary after surgery?
  12. long will I be in the hospital?
  13. many total hips or knees do you, and your hospital, perform a year?
  14. I be able to reach you after the surgery if I have a question or problem?

Q: What are some initial studies showing in terms of patient outcomes, post MIS?

A: Several early studies of MIS knee surgery have shown some benefits such as less blood loss, shorter hospital stays and better motion, while others have shown a higher rate of complications, suboptimal positioning of the knee implants and no real difference in the recovery. Unfortunately, we won't know if these new techniques affect the long-term function and durability of the knee replacement for 10 to 15 years. Long-term durability is much more important than whether you were in the hospital for two days or four days after surgery.

Q: Do you see L/MIS becoming the standard joint replacement technique, in the future?

A: While we as orthopaedic surgeons want to develop techniques that will permit joint replacements to be done less invasively with improved accuracy and precision, we also must ensure these procedures are performed safely and effectively, without jeopardizing patient safety. Currently, only a handful of orthopaedic surgeons perform L/MIS. Despite the initial “hype,” any new clinical technique or technology must be critically examined as they relate to patient outcomes in order to see what is working well and what surgeons still need to adopt. Orthopaedic surgeons will move towards using L/MIS techniques based on evidence-based data published in peer review journals, not because of market demand for such surgeries.

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