Minimally Invasive Hip Surgery
Minimally invasive surgery of the hip, or MIS, infers that the hip replacement is being performed through a smaller incision and with less dissection.
It would seem reasonable that anyone requiring a total hip replacement would seek out the least invasive method. Proponents claim that MIS procedures result in less pain, less blood loss, a shorter hospital stay, and a quicker recovery. New techniques and instruments have been developed to perform these surgeries through smaller incisions. Even “new” prostheses have been created with this goal. Some surgeons are even advertising that they perform “MIS” as a way to attract patients and build their practices. Unfortunately, the performance of these new techniques and implants has not been studied over time.
In fact, many well-respected hip and knee reconstruction surgeons have expressed concern that MIS is overhyped and under proven. More and more well-designed, peer reviewed presentations and publications are now appearing that are not reporting less soft tissue trauma, less blood loss, or a faster recovery. Even the definition of what constitutes a minimally invasive surgery (MIS) is hotly debated. Some define MIS only by the length of the incision; some consider the incision as only the “window into the body” and what is really important is the amount of underlying soft tissue dissection that is performed. We are also seeing more reports on significantly higher complication rates after MIS surgery in the knee and the hip.
Poor component positioning in total hip and total knee surgery with MIS is more frequent. If the components are perfectly positioned, then minimal component wear and, hopefully, improved longevity will result. The ultimate goal of this surgery is to relieve pain, restore the ability to walk normally and be active, and create a construct that lasts many, many years. We all know that obesity continues to plague our population. It is therefore not surprising that more components are being placed in less than optimal positions because the surgeon is struggling through a tiny, deeper incision. One can also imagine that the surrounding tissues are being subjected to more stress and trauma to “make the small incision work.”
The positive repercussions from this MIS debate are that it has made nearly every surgeon who does hip or knee replacements re-question the length of their incision and re-question exactly what underlying structures need to be released or moved. Nearly all of these surgeons now perform the operation through a smaller incision and with less dissection than in years past. This has been positive, if the final outcome has not been compromised.
Whenever I’ve seen other surgeons as patients who’ve needed surgery, I’ve never been asked by them to perform the operation through a small incision. They invariably say, “just do a great job.” Personally, I want to perform the operation through as small an incision as reasonable, as long as the soft tissues are not traumatized and the result not compromised.
In my practice I always perform as minimally invasive a surgery as possible, but emphasize meticulous soft tissue handling, component positioning and balance, and wound closure. The final incision should look like a plastic surgeon closed it, but even more important is the attention to detail under the incision.
With MIS hip surgery, I also emphasize gentle soft tissue handling that preserves rather than cut / traumatize muscle. Critical is optimal component position, which translates to improved longevity and leg length equality; re-creating hip mechanics and an anatomic closure, which vastly improves hip stability.
My advice is to pick your surgeon based on reputation, experience, and the feeling of trust and personal connection you get. Though it is important to discuss new procedures and technology, in the end you need to have the trust that the surgeon you’ve chosen will choose what is best for you.
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I definitely made the right choice with Dr. Leone. His office team treats patients with amazing care and attention, and they all work to make the experience as gentle as possible. I was walking without a limp within 3 weeks. Margery Schwartz
