Minimally Invasive Total Joint Surgery in the United States
Andrew H. SCHMIDT
University of Minnesota

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What is MIS joint surgery? In North America, several pioneering surgeons have been performing "muscle-sparing" total hip replacements for over a decade using an anterior approach (Matta, Keggi). Mears pioneered (and patented with Zimmer) a novel two-incision technique. With the additional impetus of aggressive marketing campaigns, so-called minimally invasive surgery has exploded in the U.S. in the last 2-3 years. In North America, orthopedic implant companies advertise the perceived benefits of such surgery directly to patients and the Internet is full of doctor's web pages, patient testimonials, and other information. Potential patients in the US often have the impression that MIS hip and knee replacement is now the standard of care and is possible in all circumstances.

Facts about MIS:

It is possible to perform hip and knee surgery through smaller incisions.

It is possible to perform outpatient hip and knee replacement surgery.

Are these related? Perhaps, but not completely.

Properly performed joint replacement surgery should be minimally invasive. For example, the iliotibial band does not need to be divided for THA and the patella does not need to be inverted for TKA. Avoiding these additional surgical insults allows the patient to have less pain and to recover strength more rapidly. These lesser approaches do not require as extensive an incision, but MIS is not about the skin incision itself; it is a philosophy about the total approach to the procedure.

Even patients that have an MIS procedure will not go home the same day without significant pre-op education and aggressive perioperative anesthetic management. Many "early adopters" of MIS surgery are patients who are highly motivated and educated. These may be more important factors for reducing the length of stay than the size of the incision.

Published Literature: There are very few comparative articles that document the advantages of MIS compared to traditional surgery. Fisher et al found that minimally invasive unicompartmental knee replacement was less accurate than open UKR using traditional instrumentation. Woolson et al compared 50 cases of MIS THA to 85 cases done through a standard incision. There were no differences in operative time, blood loss, transfusions, length of hospital stay, or the patients disposition. The MIS group had a higher rate of wound complications (P=0,02), more common acetabular malposition (p=0,04), and poor fit and fill of the femoral stem (p=0,0036).

Fisher DA et al, J Arthroplasty 2003;18(7 Suppl 1):2-8

Woolson ST et al, J Bone Joint Surg 2004;86A:1353-8.

 

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