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Recently, I have been bombarded by
questions from patients regarding the "new minimally invasive
surgery". Patients have brought in articles from various
newspapers and magazines regarding the new surgical procedure.
The new surgical procedure is being hyped by some as a
revolutionary procedure which provides the patient with
minimal pain, a shorter hospitalization, and better outcomes.
Others have been cautious to report that statistics have not
been clear in establishing the relative advantages of
minimally invasive surgery compared to standard surgical
techniques and total hip arthroplasty.
Let's start with the facts. Twenty
years ago, when I was a Fellow at the University of Southern
California, I had as my professors, three then-famous, hip
surgeons. All three severely criticized me at that point
because I was trying to proceed with a surgical approach to
minimize the standard 12-inch incision to 6 inches. I was told
at that time that this did not allow proper visualization of
the hip and, therefore, was inappropriate. At the same time
throughout the country, several separate institutions were
experimenting with surgical procedures as small as 3-1/2
inches and, in one case, two separate incisions of
approximately 2-1/2 to 3 inches. These procedures were
performed regularly on patients who qualified for the
procedure. The qualifications then were essentially thin
patients with no significant subcutaneous fat surrounding
their buttock and upper thigh, good bone stock, and relatively
young. The procedures were, without question, successful with
no higher complication rates than that noted with standard
total hip arthroplasties. The problem was that even with the
performance of the limited surgeries, the total
hospitalization and recuperation was the same as when compared
to a traditional total hip arthroplasty.
Over the course of the years, more
and more surgeons have concentrated on limiting the surgical
approach so that less trauma would be sustained by the soft
tissue surrounding the joint. The theory is obvious in that
the less soft tissue trauma, the less pain the patient would
sustain, and the less bleeding and other complications. The
problem once again was even though this appeared to be sound
theoretically, it was never proven to be statistically
significant in the reduction of the patient's overall
rehabilitation. Lately, there has been a dramatic publicity
campaign regarding the "new minimally invasive surgery"
utilizing two incisions. The surgeon that has been the biggest
proponent has published a series of fifty cases. In these
fifty cases, he has listed the patient's satisfaction rate to
virtually 100% with patients discharged within 24 hours. The
problem is that prior to these fifty cases, there was a
significant complication rate that has not been reported and
this entails fractures, malposition, dislocations, and other
common complications with total joint arthroplasty. The
statistics, therefore, are totally misleading to the public
and the widespread publication of this procedure has been
universally criticized amongst joint replacement surgeons in
the United States.
Now, don't get me wrong because I
started this article by telling you that I was a proponent of
minimally invasive surgery over twenty years ago. To this
date, I still am and will still continue to perform minimally
invasive surgery. The truth in the matter is that minimally
invasive surgery, if performed correctly, does indeed have
significant benefits to the patient. Since I participate in a
rehabilitation program at the Pinecrest Rehabilitation Center
(owned by Tenet Corporation), I am able to compare our
statistics to the national average. We have proven without any
shadow of doubt that our patients do better than the national
average. In fact, our patients perform one standard deviation
better than the national average. The results have been so
astounding, that the CEO of Tenet has come to Florida to try
to find out why our patients do so well. I am convinced that
the patients do so well because our surgical time on average
is 45 minutes, our blood loss is less than half the national
average, we mobilize the patients immediately, and have
perfected soft tissue techniques that minimize the trauma to
the tissues surrounding the hip. When all of these factors are
considered, the 4-inch incisions, or less, that we are
currently utilizing have definitely improved the immediate
postoperative recovery.
Now the next question is, at what
point should the patients be discharged from the hospital? It
is well known that on postoperative day No. 3, the highest
number of complications occur. On this day, there are higher
incidences of pulmonary emboli and cardiovascular
complications. The question, therefore, becomes, should the
patients be allowed to go home as early as postoperative day 3
or earlier? Now, we have to compare apples to apples and
oranges to oranges. You cannot compare a 50-year-old, healthy
male with an isolated, arthritic hip and no significant
medical problems to our average 70-year-old population in Palm
Beach County. To do so is totally misleading. Even our 40- and
50-year-old patients are not allowed to leave the hospital
within the first three days. These patients are able to walk
and function independently, but sound medical sense dictates
they should not go home at that point. In our average
70-year-old population, we are mobilizing the patients
immediately. The patients are walking earlier. They are able
to walk by day 1 and day 2. But even so, we know that by
sending them for a short-term course of rehabilitation, their
immediate perioperative period has less complications, they
return to their normal activities quicker, and they are
monitored in a safe and effective fashion.
It should also be noted that while
it is easy to say that minimally invasive surgery is the
current trend, it is not something that is suited for
everybody. Total body weight is not the major factor in
determining whether or not patients can undergo a small
incision. The size of their bone and the thickness of the
subcutaneous fat and underlying muscle must all be determined
so that no undue trauma will be imparted to the soft tissues
in an attempt to make the skin incision look smaller. It also
should be noted that minimally invasive surgery is a
technically demanding operation. It should not be performed by
the occasional hip surgeon, but rather experienced hip
surgeons with an experienced team assisting them. As my
patients know, my team consists of myself, two nurses and a
physician's assistant who operate on all patients together.
Without the aid of these assistants, performing minimally
invasive surgery would not only be more difficult, it would be
more traumatic to the patients, add on to the surgical time,
and most likely have an adverse effect on the excellent
results that we are now seeing.
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