In their specialty update, "What's New in Hip Arthroplasty"
(2003;85:1852-64), Drs. Huo and
Brown included the development of a minimally invasive surgical technique for
total hip arthroplasty. We believe the technique of performing total hip
arthroplasty through smaller incisions should more properly be called
mini-incision arthroplasty.
Minimally invasive surgical techniques for total hip arthroplasty involve
different intermuscular surgical
planes1 than do
techniques involving smaller incisions, which are modifications of
conventional approaches.
We agree with the authors that marketing has stimulated enthusiasm for the
use of such mini-incision approaches for total hip arthroplasty, but we do not
agree that the literature lacks scientific data supporting the efficacy,
safety, and superiority of this approach compared with previously described
conventional approaches. The mini-incision arthroplasty that we
described2 has been
extensively analyzed with regard to the accuracy and reproducibility of
implantation, regardless of patient habitus. To our knowledge, our report is
the first to show that a mini-incision technique facilitates recovery after
total hip arthroplasty, decreases blood transfusion requirements without an
increase in complication rates or operative time, and permits earlier and more
vigorous postoperative physical therapy, which may shorten hospital stays and
reduce costs2. These
benefits and improved early surgical outcomes are the main goals of such an
approach.
Therefore, although controversy exists, as is appropriate for a new
technique, the focus of study should be the effect of a less invasive surgical
approach on early outcomes, as described in our paper. Our study showed that
the mini-incision surgical technique can be used without compromising the
accuracy and reproducibility of implantation in a demographically diverse
patient population and that it led to significantly improved early outcomes
when compared with a widely accepted conventional surgical
approach2. Although
we did not address long-term results as other investigators have
done3, our results
have led to the use of this technique as a standard approach for total hip
arthroplasty at our institution. Data on the long-term effects will be
forthcoming. With efficacy established, the issue focuses on the methodology
of training surgeons to perform the technique safely.
We appreciate the insightful letter from Drs. Wenz and Gurkan. We are
familiar with the article by Wenz et al. and regret that a reference to the
data from their
article2 was not
made in our review. Our paper was based on reports published in The
Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related
Research, and the Journal of Arthroplasty, as well as on
abstracts presented at the annual meeting of the American Academy of
Orthopaedic Surgeons, the annual meeting of the American Association of Hip
and Knee Surgeons, and the open and closed meetings of The Hip Society. These
sources of information have been the standard for writing this particular
review for the past three years.
The terminology used to describe this surgical technique is in a state of
evolution. We are unaware of any consensus in the literature as to which term
is preferable. Controversy exists with regard to whether this technique is a
modification of an existing procedure or should be considered an entirely
"new" procedure.
We agree with Drs. Wenz and Gurkan about the documented superior efficacy
of the mini-incision technique with regard to perioperative parameters and
short-term clinical outcome. These issues were specifically discussed on page
1858 (paragraphs 2, 3, 5, and
6) of our article. The data reported by DiGioia et
al.3 reflected the
superiority of the mini-incision technique in terms of several outcome
assessment parameters at six months, but no differences were observed at one
year.
We completely agree with Drs. Wenz and Gurkan that the major challenge is
to develop training methodologies for practicing orthopaedic surgeons and
resident physicians. We hope that newer navigation software, instrumentation,
and perhaps prosthetic designs all will contribute to reproducibly good
results in association with the use of this new surgical technique for total
hip replacement.
We look forward to reviewing Drs. Wenz and Gurkan's longer-term follow-up
data.