Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Mark W. Pagnano, MD*,
Mayo Clinic, Rochester, Minnesota
Posted September 2007
Minimally invasive total hip arthroplasty continues to be an
area of substantial interest to patients and orthopaedic surgeons alike. From
the time that the technique was initially extolled in the mainstream media in
2002, various groups of clinical investigators have scrutinized the scientific
underpinnings of early claims of rapid recovery with this procedure. The
earliest reports stressed the importance of the surgical technique, whether that
technique included the use of one small incision or the so-called two-incision
approach, but it soon became clear that substantial changes in the way patients
were selected and the way in which they were managed perioperatively also
played a role in determining early outcome. It remains relatively unclear
whether good outcomes can be attributed to the minimally invasive surgical
technique itself or if they are due to the combined effects of patient
selection, advanced anesthesia protocols, multimodal analgesia protocols,
patient-education interventions, and rapid rehabilitation protocols. In reporting
the results of their well-designed randomized controlled trial, Pour et al. bring
some clarity to this issue by examining which factors—preoperative education,
perioperative pain management, accelerated rehabilitation, or incision size—are
influential in improving early functional outcome after total hip arthroplasty.
In this study, ninety-four of 100 enrolled patients were
randomized into four groups on the basis of incision size (a standard incision
of >10 cm compared with a small incision of ≤10
cm) and perioperative management (conventional compared with advanced). The
advanced perioperative management groups received additional preoperative counseling,
a preemptive analgesia protocol, and an accelerated rehabilitation protocol.
The authors found that the patients who received the
advanced perioperative management could walk farther, were more likely to walk
independently at the time of hospital discharge, were discharged from the
hospital sooner, were more likely to go home rather than to a skilled
rehabilitation facility, scored higher on the mental health component of the
SF-36 score, and scored better with regard to energy level, quality of life,
and daily activity subscores of the linear analog scale assessment test. The
incision size made no difference in any of the functional parameters measured
in this study.
An important limitation of the study is that the authors
chose to vary only the size of the skin incision and not to alter the deep-tissue
dissection. This leaves open the question of whether alternative minimally
invasive surgical approaches that purportedly cause less damage to muscle and
tendon offer further advantages with regard to the early functional results for
patients after total hip arthroplasty. What the authors of the present study
have clearly defined, however, is that substantial patient benefits accrue from
relatively straightforward changes in perioperative management. While changes
in surgical technique may demand substantial surgeon training and may be
associated with a learning curve during which the prevalence of complications
is increased, the changes in perioperative management implemented by the authors
of this study are simple and straightforward and come with a low risk of
unanticipated complications. This study thus changes the dynamics of the
intellectual debate surrounding minimally invasive surgery. The burden now
shifts back to the surgeon-advocates of minimally invasive techniques to prove
that a clinically important marginal value is directly attributable to those
more complex techniques and is not just the result of either the advanced
perioperative management strategies, as outlined in this study, or patient-selection bias.
Most surgeons would be well served to take advantage of the
substantial gains that have been made over the past several years in the
perioperative management of pain after total joint replacement. A variety of
multimodal pain management approaches have been advocated, each of which has at
its core the goal of minimizing the use of parenteral opioid medications during
the postoperative period. Some strategies are more complex and may provide more
complete pain relief, such as those that make use of peripheral nerve blocks1,
while others are quite straightforward, such as those that make use of local
anesthetic injections around the surgical site2 but that may not
provide quite the same extent or duration of pain relief. What is clear,
however, is that minimizing the use of parenteral opioid medications
substantially decreases narcotic-related side effects, such as nausea,
vomiting, somnolence, and disorientation, and facilitates early mobilization of
patients after total joint arthroplasty. Similarly, most surgeons would benefit
from adoption of some form of a rapid rehabilitation protocol for their
patients after total joint arthroplasty3. When the prosthetic components
are judged to be stable at the time of surgery, then most patients will benefit
from early mobilization and progression to weight-bearing as tolerated.
Clearly, however, there are instances in which accelerated
rehabilitation is not in the best interest of the patient. These instances
include when the patient has marked osteopenia or has had an intraoperative
complication or when there is a very high risk of dislocation. Nevertheless,
for many patients, the results of contemporary total hip arthroplasty can be
improved by participation in an accelerated rehabilitation protocol.
The debate surrounding the techniques used to perform minimally
invasive total hip arthroplasty will continue for the foreseeable future as
surgeon-advocates make the case for one approach or another, but this article
by Pour et al. has clearly delineated the gains attributable to advanced
perioperative management strategies alone. Future studies that support one
surgical approach over another will now need to control for the effects of
these advanced perioperative management strategies in addition to controlling
for patient selection. Such studies will need to demonstrate the marginal
benefit attributable to the surgical technique alone but also acknowledge the
marginal cost of those techniques as measured by additional surgical training,
additional surgical time, and additional complications.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block. J Am Acad Orthop Surg. 2006;14:126-35.
2. Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am. 2006;88:959-63.
3. Peak EL, Parvizi J, Ciminiello M, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study. J Bone Joint Surg Am. 2005;87:247-53.
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