What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway?
ABSTRACT Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway.
An English language literature search was performed using the MEDLINE and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review.
The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay.
There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.
- SourceAvailable from: Andre F Steinert[show abstract] [hide abstract]
ABSTRACT: The development of minimal-incision techniques for total hip replacement with preservation of soft tissue is generally associated with faster rehabilitation, reduction of postoperative pain and increased patient comfort. The aim of this study was to compare a minimal-incision anterior approach with a transgluteal lateral technique for hip replacement surgery with respect to postoperative pain, consumption of rescue medication, length of hospital stay and time to reach a defined range of motion. In this retrospective cohort study we investigated 100 patients with a minimal-incision anterior approach (group I) and 100 patients with a transgluteal lateral approach (group II) retrospectively undergoing unilateral hip replacement. The study variables were pain at rest and during physiotherapy, amount of rescue medication, the time to reach a defined flexion and time in hospital. The patients of group I consumed less rescue medication (19.6 ± 6.9 mg vs. 23.6 ± 11.3 mg; p = 0.005) and experienced less pain on the day of surgery (1.3 ± 1 vs. 2.3 ± 1.3, p = 0.0001) and the first postoperative day (0.41 ± 0.8 vs. 0.66 ± 1.1, p = 0.036). The time to reach the defined range of motion (6.4 ± 2 days vs. 7.4 ± 2.1 days; p = 0.001) and the length of hospital stay were shorter (10.2 ± 1.9 days vs. 13.4 ± 1.6 days; p = 0.0001) for group I. However, pain during physiotherapy was higher on the third and sixth through ninth days after surgery in comparison to group II (p = 0.001-0.013). The implantation of a hip prosthesis through a minimal-incision anterior approach is successful in reducing postoperative pain and consumption of pain medication. Time to recovery and length of hospital stay are also influenced positively. Pain increases during physiotherapy, and may be mitigated by adopting limited weight bearing during the early postoperative period.International Orthopaedics 05/2011; 36(3):491-8. · 2.32 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Minimization of soft-tissue damage is one of the primary purposes behind the application of minimally invasive surgery (MIS) in total knee arthroplasty (TKA). A consecutive series of 147 TKAs were enrolled in the present study, with 96 MIS-TKAs using 11 quadriceps-sparing, 46 subvastus, 32 midvastus, and 7 parapatellar approaches and 51 conventional TKAs using 22 subvastus, 9 midvastus, and 20 parapatellar approaches. Serum levels of creatinine phosphokinase, myoglobin, aldolase, lactate dehydrogenase, glutamic oxaloacetic transaminase, and creatinine were measured on postoperative days 0, 1, 2, 4, 7, and 14. Postoperative rising index (RI) was expressed as a proportion of the preoperative value. When RIs were compared between MIS-TKA and conventional TKA, no significant differences were found for any enzymes. Interestingly, the midvastus approach displayed the highest RIs for creatinine phosphokinase and myoglobin between the 4 vastus-splitting approaches. Consequently, degree of muscle damage was equivalent between MIS-TKA and conventional TKA, whereas types of vastus-splitting approach appeared closely related to muscle damage.The Journal of arthroplasty 09/2008; 24(4):499-504. · 1.79 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Enhanced surgical techniques and instrumentation enable surgeons to perform total hip arthroplasties through minimally invasive approaches. Using incisions typically less than 10 cm in length, surgeons can achieve adequate visualization of the surgical site while minimizing trauma to deep soft tissues. Associated reductions in morbidity should allow for improved rehabilitation and recovery. Although these techniques have been met with some controversy, a number of recent studies appear to attest to their safety and efficacy. Many of these studies have concentrated on a posterior single-incision technique for total hip arthroplasty. Favorable results for such outcomes as operative times, complication rates, pain, functional recovery, and blood loss have been reported, and patient satisfaction has been high. If surgeons and their patients are to achieve maximum benefit from minimally invasive total hip arthroplasties, it will be necessary to design effective educational tools that address the learning curve associated with these approaches.International Orthopaedics 09/2007; 31 Suppl 1:S1-5. · 2.32 Impact Factor