I was in my study this morning, reviewing some of the articles in my inbox on orthopaedic problems and knee pain, when I came across an article in the October 14th Wall Street Journal by Thomas H. Burton. He was writing about one of the latest trends in arthritis surgery of the joints, called minimally invasive surgery, often referred to as an acronym — MIS.
 
Like the name suggests, this is a technique in which prosthetic joint replacement, mainly of the hip and the knee, is performed through a smaller (shorter) incision than normal. This means that sometimes the incision is much shorter, like only 3 to 4 inches, when the normal length may be as much as 8-12 inches, usually depending on the weight of the patient–fatter people need longer incisions (a hole has to be bigger at the top than the bottom and the fatter a person is, the deeper the hole is going to be).
 
The theory is that a smaller incision maintains the integrity of the big muscles around the joint and allows for less pain, faster healing and quicker return to full function. But here’s the problem. Because of the more limited vision into the joints allowed by the smaller incisions, the chance of complications is higher, sometimes much higher, than with more traditional approaches. It makes sense if you think about it.
 
In this respect, a MIS is as good as a mile;-) While it is true that a perfectly done MIS can heal faster, with less tissue damage, the poor visualization it affords the surgeon makes its risks much higher. So, is it worth it? Well, yes and no.
 
Yes, but only if you can find a very experienced surgeon in the technique. Total hip and knee replacements are highly technique-dependent surgeries. That means that the best results tend to come from the best trained, most experienced surgeons. This is even more true for the MIS.

No, because if you don’t get one of those best trained, most experienced surgeons, then your risks of complications is greatly increased. These would include soft tissue injuries, from stretching the smaller incision so the surgeon can see; incorrect bone cuts with incorrect angles, simply because the surgeon just can’t see enough of the bones to make accurate cuts; debris left in the joint, because the small incision obscures the joint so the surgeon can’t see to remove it. Also included are fractures of the bones, when attempting to impact the implants into place, malposition of the implants, often leading to dislocations, or joint instablity; and nerve injuries from traction, again in an attempt to see better through the small incision.
 
As you can see, the trade off is a chance for faster healing versus higher risks for multiple complications. All of these, the good and the bad, are a consequence of the smaller incision.
 
Funny thing is, my teachers always said to make a larger incision, because 1. you can see what you’re doing and all the anatomy and 2. there is less tension and therefore less trauma to the tissues, less edema (swelling) and 3. you can see and stop any bleeding blood vessels (“It heals from side to side, not end to end...”). 
 
But the MIS is in vogue right now–despite NO long term evidence that its results are as good as standard surgical approaches. You didn’t know that there are actual fashions in surgery? Oh, yes. Very much so. 
 
I’ve seen this before. At first, there’s a rush of enthusiasm and the public (who only know about the supposed benefits) DEMAND the new, in vogue procedure. Then, as its indications are expanded and surgeons, who are NOT as experienced, feel pressured to do the new procedure (or risk losing patients), the complications begin to emerge. As the problems begin to mount, and some true disasters are reported, the enthusiasm wanes and finally everyone goes back to the traditional approaches, or at least modifies the indications for the “new” technique.
 
As if you needed another reason to stay OUT of the operating room…. Or, you can try one of a number of proven, reliable, simple, non-surgical treatments that can help you AVOID SURGERY. It’s your choice. There are lots of cases in which surgery is UNNECESSARY. You lose nothing by trying one of the conservative, non-operative treatments I teach in HOW TO AVOID KNEE SURGERY. See it here at http://drbillsclinic.com/avoid_knee_surgery.html
 
If you want to see treatments to relieve knee pain and specially modified exercises to restore function, using conventional, alternative and complimentary methods from across the entire medical spectrum, go NOW to http://drbillsclinic.com/avoid_knee_surgery.html
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill 
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
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