We would agree with Drs. Schafroth and Eijer that minimally invasive surgery of the hip is not a type of operation but rather a technique. Complications can occur with open techniques, as well as minimally invasive techniques. It was the catastrophic nature of these complications in thin patients with normal anatomy, which we felt merited their review and case report.

It should be noted that these patients were referred to our center after their complications. Consequently, we are unable to comment on the complication rates of the surgeons who performed the index procedures. We agree with Drs. Schafroth and Eijer that changing the technique of probably the best operation there is, should be done with care. We also agree that optimization of surgical techniques and performance should be the goal for all surgeons.

J. Bohannon Mason, M.D.

Thomas K. Fehring, M.D.

To the Editor:

We were surprised to read the statements made in the article of Fehring and Mason, “Catastrophic Complications After Minimally Invasive Hip Surgery" in which the authors state that they experienced some catastrophic complications due specifically to minimally invasive (MIS) hip arthroplasty.

Although at first sight interesting news, we are disappointed with the form of the publication. In our experience, all of the described complications can also occur in conventional total hip arthroplasty, and none is specific for MIS surgery. There are a many publications indicating the importance of correct positioning of components to avoid dislocations; intraoperative fractures of the greater trochanter still happen; and discontinuity of the abductor muscle is also common, although not visible on x-ray.

Minimally invasive surgery is not a type of operation. It is rather a way of performing an operation. It would be interesting to know how many complications the authors had before they changed their technique. Indeed, their published performance wasn‘t very good, but an operating time of 9 hours for a trochanteric fracture tells the story.

The theoretic advantages of MIS surgery are mostly common sense, albeit now often industry driven. Changing the technique of probably the best operation there is, should be done with care. Rather than shorten the incision and calling it minimal incision surgery, one should think about optimising ones operative technique and thus performance. This would mean optimising preoperative procedures and information, soft tissue handling, anaesthesia and rehabilitation.

To the Editor:

I applaud Drs. Fehring and Mason for their early reporting of complications from minimally invasive total hip surgery. I would confirm that I have also consulted on similiar cases that presented with all three of these scenarios, ie. pelvic discontinuity, reaming away the anterior column of the pelvis, and placing the cup with very high inclination.

Unfortunatly, I believe that they have drawn attention to the tip of the iceberg. For most of us, making a smaller incision for hip replacements has been facilited by better lighted retractors and a few basic skills that enhance this exposure. After that, the operation remains identical to what I have tried to do for the past 20 years. The authors point out that a steep learning curve may accompany certain MIS techniques and the surgeon must gradually gain this skill over a significant number of cases until it becomes easy.

However, there are techniques where serious complications may occur even after significant experience; these are the ones that will fall by the wayside. This case report does not discourage the use of MIS total hip replacement, but only heightens the awareness of potential problems that we may create.

Jemes B. Stiehl, MD

We are responding to Dr. Brennan’s inquiry concerning our revision volume and the percentage of these that we would consider catastrophes.

Since 1986, we have performed over 1500 hip revisions. Last year at our center, we performed 96 revisions from which these three cases came. We would consider any arthroplasty failure within five years a significant disappointment for patient and surgeon alike. We previously evaluated such early failures and reported our results from our referral revision practice. We found that 40% of patients referred for revision hip surgery failed within five years of their index arthroplasty,(1) and 63% of patients referred for revision knee surgery failed within five years of their index arthroplasty.(2) While these are alarming statistics, we do not consider every failure within five years a catastrophic failure. In the World Book dictionary a catastrophe is defined as “a sudden extraordinary disaster”. We would consider creating a segmental defect in the acetabulum during a routine primary arthroplasty or shattering a greater trochanter beyond repair during a nine-hour minimally invasive surgery true catastrophes in thin patients with normal anatomy. The fact that we encountered these significant complications in the same calendar year following surgeon champion and industry marketing efforts regarding minimally invasive surgery stimulated us to submit these cases to the Journal of Bone and Joint Surgery to provide a balanced opinion. While undoubtedly we see complications from standard incisions on a routine basis, we rarely see catastrophic complications of this magnitude in such straightforward cases.

References:

1. Dobyzniak MA, Fehring TK, Odum S, Griffin WL, Mason JB, McCoy TH: Early Failures in Total Hip Arthroplasty, poster presentation at Annual Meeting of American Association of Hip and Knee Surgeons, Dallas, TX, 2003.

2. Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M: Early Failures in Total Knee Arthroplasty. Clin Orthop. 2001; 392: 315-318.

The Editor replies:

Your letter raises some important points with regard to the manuscript review, manuscript selection, and editorial practices of The Journal. The process necessarily begins with manuscripts, the subject matter of which is determined by our authors. With the help of a large team of volunteer reviewers and an expert editorial board, I select the articles to be published, and my sole criterion is that they will be of benefit to orthopaedic patients and/or the orthopaedic community. The positioning of articles within The Journal is determined by me and is largely based on the desire to deliver a relevant and useful issue each month to our readers.

Because of the incredible enthusiasm for minimally invasive surgery of the hip, we anticipated that we would receive objective, scientifically conducted studies evaluating this new procedure. Unfortunately, few manuscripts have been forthcoming. With regard to the two articles published in the April issue, my reviewers and deputy editors thought that both convey an important message for our readers; thus, they were selected for publication. Because of the popular nature of the subject, I chose to publish them back to back and to tie them directly to the editorial by Dr. Berry, which clearly places both articles in clinical context.

The Journal eagerly awaits the submission of objective confirmation of the benefits of minimally invasive total hip arthroplasty. Such a report would be of great benefit to the orthopaedic community and our patients, and it certainly would be published.

The layout of every issue of The Journal does reflect my bias. I hope that this bias is not in favor of, or in opposition to, any particular procedure but rather favors quality care for our patients because that is my true agenda as Editor.

James D. Heckman, MD Editor-in-Chief The Journal of Bone and Joint Surgery

To The Editor:

I was quite surprised to find an article such as “Catastrophic Complications of Minimally Invasive Hip Surgery. A Series of Three Cases” (2005;87:711-4), by Fehring and Mason, receiving such attention from The Journal’s editorial staff as to find its way to being the second article in the April issue.

While the three reported cases are indeed catastrophic complications, there is no basis on which to consider this information. I might assume that the center from which these cases were reported receives a large number of “catastrophic” referrals. What percentage of their overall “catastrophies” do these cases represent? Or do they not see complications from standard incision surgery? Albeit lacking in scientific value, the article does have merit. The Journal’s decision to give the article second billing, following an article with top billing shedding poor light on minimally invasive hip surgery, demonstrates to me that the editorial staff has bias against minimally invasive hip surgery.

This article belonged, at best, in the case report section. The layout of the April issue undermines the credibility of your publication and demonstrates an agenda on the part of the editorial staff.

John J. Brennan, MD Hampton Orthopedics and Sports Medicine