The selling of MIS TJR may obscure satisfaction benefits and complications

Low-volume surgeons may feel undue pressure from patients, media to use new techniques.

Issue: February 2007

The major pros and cons of performing minimally invasive total joint replacement surgery remain significant enough to continue dividing orthopedic surgeons.

But they now may be starting to see eye-to-eye. Those opposing the technique contend that total joint replacement (TJR) surgery performed with smaller, less invasive incisions may be associated with higher surgical risk. And those risks may be multiplied if untrained or inexperienced surgeons perform the minimally invasive procedures.

According to proponents of these new techniques, in the right surgeon's hands, minimally invasive surgery (MIS) may be the optimal method for getting a patient out of the hospital quickly and back to a more active lifestyle. Research results set to be published soon are expected to support that philosophy.

John M. Cuckler, MD [photo]
John M. Cuckler

In the presentation "The ugly underbelly of the MIS movement," at the annual Current Concepts in Joint Replacement winter meeting, two orthopedic surgeons debated the pros and cons of MIS for TJR. However, they realized in the midst of their discourse that whether MIS TJR surgery is good or bad is merely a matter of perspective.

John M. Cuckler, MD, affirmed that the "underbelly" of MIS for TJR is big, ugly and getting increasingly more revolting as the push to perform more and more MIS TJR procedures escalates.

The selling of MIS

Lawrence D. Dorr, MD, opposed Cuckler and mainly favored MIS surgery for its restorative benefits. The subject remains controversial because there are few randomized studies that show the benefits of these procedures, Dorr said.

Lawrence D. Dorr, MD [photo]
Lawrence D. Dorr

"My concern is that the selling of MIS techniques has gone beyond reason," Cuckler said in his presentation. He called for an objective evaluation of industry's push to promote these less-invasive techniques and how surgeons have responded to that. There is a need to "look at these early complications and ask ourselves: Have we gone too far in the selling of this technique?"

The push for MIS surgery has certainly struck a chord with patients. They now come into Cuckler's office and those of other TJR surgeons around the country armed with reams of information about MIS procedures downloaded from the Internet.

Although what they have collected is not necessarily scientific, it still increases their awareness of some perceived benefits and reduced complications from having a knee or hip joint replaced with MIS techniques, which include less muscle and ligament damage and lower hospital costs.

Despite that belief, "I'm not aware of any data that say we've reduced the risks or the complications with MIS technique. This is just false advertising," Cuckler pointed out.

Complications, cosmesis

Cuckler admits patients are attracted to the procedure because it is gentler on the body or may produce a more appealing cosmetic result. But they do not realize "that 80% of all surgeries in the United States for total joints are done by surgeons who do 20 or less [procedures] per year," Cuckler said.

He worried that any good results now being achieved through MIS surgery might be compromised when low-volume TJR surgeons perform the procedure. "I'm concerned that the marketing pressure is forcing the surgeon, and bringing the patient, to do things that may compromise the outcome of these otherwise wonderful procedures that we offer for hip and knee replacement."

To resolve this issue and perhaps encourage physicians in both camps to meet somewhere in the middle, Cuckler urged surgeons, not industry, to continue to develop better techniques for less invasive surgery and work together to reduce the overall tissue trauma in all TJR procedures. "But, let's use peer review and not marketing pressure to achieve these goals," he said.

Satisfaction mean success

Dorr argued in favor of performing MIS procedures on many of his patients not only because they can experience improved pain and function postoperatively, but because they become satisfied patients during the recovery process which helps the healing.

He cited a recently published study by Pamela L. Hudak, MD, of Toronto, who credited patient satisfaction and not feeling self-conscious as being highly integral to the patient recovery process. Achieving greater independence has also become closely linked to a successful recovery.

"The patients credit MIS surgery because they have that as objective evidence of their great result," Dorr said. "And that is the beauty of the MIS operation. It makes patients feel good about themselves and their operation because it helps restore their self-esteem."

MIS joint replacement surgeries are safe and durable techniques, Dorr added, saying there are 19 citations in the literature in randomized prospective studies showing that MIS is equal to long incisions in terms of safety.

The fact that researchers used identical components in both arms of those randomized, comparative studies suggests the MIS procedures are durable, Dorr said.

Short-term pain relief

Reported pain relief following MIS is at least equivalent to that achieved with traditional TJR surgery, and in the short-term, the pain-relieving power of MIS TJR may actually exceed that of traditional TJR-based on results of a randomized, blinded study Dorr and colleagues conducted, he said. They expect the results will be published this year.

"Patients with a small incision had less pain at discharge, more discharge by 48 hours [postop], and more discharge on a single assistive device," Dorr said.

The science is equal between MIS and traditional surgery, Dorr said. "Patients can get a safe and durable operation with either incision. But the satisfaction is not equal because satisfaction for some patients means the success of their operation," Dorr said.

For more information:
Cuckler JM. The ugly underbelly of the MIS movement — Affirms. #6. Presented at the 23rd Annual Current Concepts in Joint Replacement Winter 2006 Meeting. Dec. 13-16, 2006. Orlando, Fla.
Dorr LD. The ugly underbelly of the MIS movement — Opposes. #7. Presented at the 23rd Annual Current Concepts in Joint Replacement Winter 2006 Meeting. Dec. 13-16, 2006. Orlando, Fla.
Hudak PL. Dialogue on the nature of patient satisfaction. Journal of Clinical Epidemiology. 2004;57(2):218.
John M. Cuckler, MD, 510 S. 20th Street, FOT 930, Birmingham, AL 35294-3409; 205-934-4668 john.cuckler@ortho.uab.edu. He indicated he has no relationship with any products or concepts presented. Lawrence D. Dorr, MD, 501 E. Hardy Street, Suite 300, Inglewood, CA 90301-4058; 310-695-4838. He indicated he is a consultant and independent contractor to Zimmer.