Commentary & Perspective

Commentary & Perspective on
"Catastrophic Complications of Minimally Invasive Hip Surgery: A Series of Three Cases"
by Thomas K. Fehring, MD, and J. Bohannon Mason, MD
and on
"A Minimal-Incision Technique in Total Hip Arthroplasty Does Not Improve Early Postoperative Outcomes: A Prospective, Randomized, Controlled Trial"
by Luke Ogonda, MRCS, et al.

Commentary & Perspective by
Thomas P. Sculco, MD*,
Hospital for Special Surgery, New York, NY

The trend in surgical treatment over the past thirty years has been to reduce trauma to the patient by employing less invasive surgical approaches. This trend has produced substantial advances in general surgery with the widespread use of laparoscopic surgery for many abdominal procedures. Orthopaedic surgeons have also embraced less invasive surgery by the use of arthroscopic surgical procedures for many procedures that were previously performed open, particularly for upper extremity/hip and knee/ankle surgery. As an extension of these techniques, a less traumatic posterolateral approach to hip replacement was first employed by me almost eight years ago. The concept was not only to reduce the length of the skin incision but also to reduce deep dissection, thereby permitting preservation of the gluteus maximus tendon as well as most of the quadratus femoris. Special retractors and reamers were developed, and the procedure was made easier by the use of hypotensive epidural anesthesia, with its resultant reduction in operative bleeding, and a monoblock acetabular component.

A randomized trial of the less invasive approach compared with a conventional length incision demonstrated a significant reduction in blood loss and a trend toward a more rapid recovery at six weeks after operation on the basis of limp and the need for ambulatory support¹. In larger series since then, radiographic evaluation has demonstrated acceptable results both with regard to acetabular position and fixation and femoral positioning and fixation (unpublished data). This is corroborated by the prospective randomized study by Ogonda et al. in which radiographic results were comparable for their longer and minimal incision techniques. These authors did not find any differences with regard to recovery, although intraoperative blood loss was less in the minimal incision group. Although the authors stated that the patients were blinded to incision length, it is difficult to imagine how they were not aware of the length of the incision during dressing changes. It is unclear from the paper, but the deep dissection appears to have been similar in the two groups of patients, which is not the case in most minimal incision procedures. There is significantly less trauma to the external rotators and gluteus maximus tendon with the less invasive approaches. Additionally, the authors did not comment on patient satisfaction with incision length in the two procedures.

The paper by Fehring et al. presents three patients with major operative complications of minimally invasive hip replacement; a mini-incision technique was used in two of the patients, and a two-incision technique was used in the other. The latter patient had a surgical time of greater than nine hours and sustained an intraoperative fracture as well as probable abductor mechanism damage. The paper by Fehring et al. reinforces the idea that these procedures should not be performed by surgeons who are not well experienced in hip surgery. In the first case cited, the procedure was performed by a surgeon who performs fifteen total hip replacements per year. All patients had elevated body mass indices, based on the data presented, and were probably not ideal candidates for the procedure. It must be emphasized that minimally invasive procedures—particularly the posterolateral approaches—should be reserved for patients with a body mass index of <30.

The less invasive posterolateral approach through incisions of <10 cm must be reserved for well-experienced hip surgeons. Custom hip retractors and acetabular reamers and broaches are needed for these procedures. Regional hypotensive anesthesia will facilitate the procedure by reducing bleeding intraoperatively. Experienced assistants are needed to effect limb-positioning and exposures. Patient selection is key to this approach; thus, patients who are heavy, who have undergone multiple procedures, or who have severe hip dysplasia are not candidates for this approach. Visualization of the acetabulum and femur should be unobstructed so that proper component orientation is ensured. Extensile exposure should be performed if there is excessive retraction or skin pressure or if visualization is poor. The two-incision procedure requires specialized training and has a higher risk of femoral fracture and component malposition, and it is therefore recommended for use by only the most experienced surgeons with a dedicated interest in this approach.

Most surgeons are now performing hip-replacement surgery through smaller incisions and less aggressive and traumatic approaches. The use of 9 to 12-in incisions for straightforward primary hip arthroplasty is generally not needed for most patients and, I believe, has been abandoned by the majority of surgeons who perform total hip replacement today. The use of these less-invasive approaches is not for every surgeon. These approaches should be reserved only for the most experienced hip surgeons with an interest in this area. Complications, as Fehring has demonstrated, can be catastrophic and devastating and must be avoided. It is imperative that the end result of the hip arthroplasty must not be compromised by the surgical approach.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty. 2005;20:139-44.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.