Small Incision (Minimally Invasive) Joint Replacement Surgery

The minimally invasive surgery movement has grown over the past decade and has changed what is possible for patients and surgeons alike. With the proper training and specialized equipment, surgeons can now safely replace hip and knee joints through skin incisions as small as 3-4 inches. But minimally invasive surgery is not defined by the length of the incision. The important difference for the patient, is the care taken to limit the disruption of muscles, ligaments, and tendons under the skin. 

If less is cut at the time of surgery, the patient has less to heal after surgery and can make a quicker recovery. When combined with advancements in pain control techniques, physical therapy programs, and cutting edge surgical instruments, a less invasive surgical technique can help a patient recover from a joint replacement in weeks instead of months.  

The first priority is to safely and accurately reconstruct the damaged joint to allow for a long lasting pain relief and improved function. To accomplish this goal, pioneering surgeons redesigned the instruments and techniques used to perform joint replacement surgery. This new way of approaching joint replacement surgery has been shown in the scientific literature to reduce the patients' pain and use of narcotic pain medications, decrease the length of hospital stay, decrease blood loss, and accelerate the entire rehab process.

Advances in regional anesthesia (spinal or nerve blocks and local anesthetics around the joint) allow a patient to undergo a pain free surgery without many of the risks of a general anesthetic. When combined with moderate sedation, the patient can comfortably sleep through the surgery without the need for a breathing tube in most cases. The pain relieving effects of the anesthetics administered during surgery allow the patient to begin participating with physical therapy that same day of surgery. Patients are able to walk with their therapist the same day, or the morning after surgery with little or no pain.

As the anesthetic blocks wear off over the next day, a combination of pain medication are used to minimize the patient's discomfort. The better the pain control, the more the patient is able to participate with therapy and accomplish the goals necessary to go home safely. 

Early, active participation in physical therapy has contributed greatly to the accelerated recovery of patients undergoing less invasive joint replacement. With appropriate pain control, patients work on transferring in and out of bed, walk with a walker or cane, and climb stairs before going home. These goals can be met safely by many patients as quickly as one day, allowing for a shorter hospital stay and a quicker return to their normal routines.

After discharge from the hospital, home physical therapy is coordinated to facilitate this transition for the first two or three weeks. At the first follow up visit, 2 weeks after surgery, most patients can transition to walking with a cane, or no assist device at all.  

Frequently Asked Questions: Joint Replacment

Am I a candidate for less invasive hip or knee replacement?

Because of advancements in instrumentation and surgical technique, a vast majority of patients can elect to undergo a small incision joint replacement. There is no weight or size limit, nor an age limit for these procedures. The size of the incision is, to some degree, driven by the size of the implants that are placed at the time of surgery.

Larger bones require larger replacement implants and longer incisions. Obese patients may require larger incisions for exposure of the joint that is being replaced, but the same care is taken to minimize the disruption of soft tissue structures at the joint level.

How long will I need to be in the hospital?

Depending on your medical conditions and your level of physical fitness before surgery, typically patients undergoing less invasive joint replacement stay 1-2 days before going home. Dr. Miller believes it is usually necessary to stay one night after joint replacement surgery for medical observation for even the most fit and health patients.

Despite our many advancements in recent years, less invasive joint replacement is still a major orthopaedic surgery and can have significant complications that your medical team will be watching for during your hospital stay. The majority of these complications are observed in the first 1-3 days after surgery.

How long before I can drive?

Most patients can drive safely in as few as 2-6 weeks after surgery. Each patients recovery is different after joint replacement. To be able to safely drive, the patient must discontinue narcotic pain medication and have the strength and reaction time to safely operate their vehicle without endangering others.

How long will my incision be?

As long as it needs to be for your surgeon to safely and accurately perform your surgery. Using less invasive techniques and instruments, the incision is usually 3-4 inches in length. However, if this length of incision does not allow adequate visualization to do the surgery appropriately, the incision is lengthened. 

More complicated hip and knee replacements with significant joint deformity, re-do or revision joint replacements require larger incisions. The length of the incision for a traditional approach to hip or knee replacement is 8-12 inches.

What are the risks or downsides of less invasive, or small incision joint replacement?

It is widely accepted that less invasive approaches to joint replacement are more difficult to perform correctly than standard approaches to hip and knee replacement. It is important to select a surgeon with appropriate training and experience performing these procedures. Specific modifications to surgical instrumentation and technique must be made to safely and reproducible perform a less invasive approach. Simply making a shorter incision without significant adaptations can result in poor surgical results and severe complications. 

Without appropriate surgical exposure or visualization, errors in alignment and sizing of components, damage to nerves and arteries, and poor soft tissue balancing can compromise the end result for the patient. It is important to talk to your surgeon about their training and experience performing minimally invasive procedures.

What are the results of less invasive joint replacements?

Currently there are no long-term studies of minimally invasive joint replacements as the techniques and instruments used to perform these surgeries have been evolving over the last ten years. The orthopaedic literature shows that patients who undergo a less invasive joint replacement enjoy a faster recovery in the first 2-4 weeks after surgery. 

Studies have documented less blood loss at the time of surgery, less pain and pain medication usage, shorter hospital stays, faster return to walking with a cane or no assist device, and faster return to work. These early advantages are only significant in the first 6-12 weeks after surgery. 

By 3 months, joint replacement patients have achieved 90% of their ultimate recovery regardless of the approach used at the time of surgery. Long term success of a hip or knee replacement depends on the appropriate selection, sizing, and alignment of the implants. 

With appropriate instruments and surgical training, this can be achieved through a minimally invasive or traditional approach to the procedure. Current studies of long-term results of hip and knee replacement suggest a 90-95% survivorship of the reconstructed joint at 20 year follow-up.

What are the goals of less invasive surgery?

The goal is to safely and accurately reconstruct your hip or knee while disrupting as little normal tissue around your joint as possible. This results in faster relief of pain and restoration of normal function, getting you back to life, back to work, and back to the activities that you enjoy most.

Why aren't all joint replacements done using small incision techniques?

A less invasive approach to hip or knee replacement is a much more technically demanding procedure than traditional approaches. Without appropriate training and equipment, and an experienced surgical team, complications can occur that effect the long term function of the reconstructed joint. In addition, most revision (or re-do) replacements and some primary (first time) joint replacements require significantly more exposure of deep joint structures than can be safely accomplished using minimally invasive techniques. Your surgeon can describe what is needed for your specific procedure.

Do you use an anterior approach for hip replacements?

There are many approaches a surgeon can take to a hip replacement. When done properly by an experienced hip surgeon, both anterior and posterior approaches to hip replacement should have a less than 1% risk of dislocation. Unfortunately, marketing efforts have implied that there is no need for hip precautions after an anterior approach and that the risk of complication is lower. This is not supported by medical evidence.

While trained in anterior, antero-lateral, direct lateral, and posterior approaches to the hip joint, Dr. Miller performs a mini-posterior approach for almost all primary hip replacements. No matter what approach is used, all patients undergoing a total hip replacement need to avoid specific movements for a period of 6 weeks to avoid dislocations while the soft tissue about the hip heals. 

After this time, most patients can return to full range of motion activities without worry of dislocation. It is important that your surgeon choose an approach that he or she is experienced in performing and is completely comfortable using for each patient.

What questions should I ask my surgeon before undergoing less invasive hip or knee replacement?

Where were you trained to complete small incision hip and knee replacements? These procedures are fundamentally different than traditional joint replacements in both technique and instrumentation. This technique is not something a surgeon can learn at a weekend course and immediately incorporate into their practice.

Without appropriate training, the surgery can lead to poor outcomes with serious complications. I completed an additional year of training at Rush University Medical Center to learn this technique from the innovators of the procedures. 

How is your less invasive technique different than a traditional approach to joint replacement, specifically?

Many surgeons advertise minimally invasive approaches, but change nothing but the size of the skin incision. What really matters for the patient is what is done with the soft tissue (muscles, tendons, ligaments) under the skin. To safely and reproducibly complete these new approaches, a whole new set of instruments and techniques have been developed.

How many less invasive hip and knee replacements have you performed?

Dr. Miller has performed over 3,500 orthopaedic surgeries. More than 1,000 have been less invasive hip and knee replacements.

What kind of anesthesia do you use with patients undergoing hip or knee replacements?

We use a spinal anesthetic when possible, combined with regional techniques that allow patients to participate with therapy right after surgery.

What kind of implants will you be using to replace my damaged joint?

Dr. Miller chooses a family of implants with a proven track record of clinical success. He routinely uses a knee prosthesis that has one of the lowest rates of revision in large total joint registries. The hip implants Dr. Miller selects are based on individual variations in anatomy. These are fine tuned to adjust for gender differences and patient size to best recreate a patient's anatomy. The less invasive techniques he uses do not influence the selection of the correct implant for each patient.

Sources:

1. Early Pain Relief and Function after Posterior Minimally Invasive and Conventional Total Hip Arthroplasty, JBJS 2007, Dorr et al
2. Minimally Invasive Total Hip Arthroplasty, JBJS 2005, Chimento et al
3. Rapid Rehabilitation and Recovery with Minimally Invasive Total Hip Arthroplasty. Clin Orthop Relat Res. 2004, Berger et al
4. The Economic Impact of Minimally Invasive Total Hip Arthroplasty, Journal of Arthroplasty, epub 11/8/10, Duwelius et al
5. The Early Dislocation Rate in Primary Total Hip Arthroplasty Following the Posterior Approach With Posterior Soft-Tissue Repair, Journal of Arthroplasty 2003, Weeden, Paprosky, Bowling

Frequently Asked Questions: Arthroscopy

What injuries or conditions are treated with arthroscopy?

Arthroscopic surgery is a minimally invasive surgery most often used to treat a sports injury to a joint. The majority of the surgery is done with the assistance of a microscopic camera that is placed into the joint through a small incision. This allows your physician to both see and evaluate the entire joint while treating any injured parts, such as the ACL (anterior cruciate ligament) or meniscus in the knee, the labrum or rotator cuff in the shoulder, and pain due to a FAI (femoroacetabular impingement) or a labral tear in the hip.

Is arthroscopic surgery right for me?

It is important that you thoroughly discuss any discomfort, pain or injuries with your physician. Together, you and your trained orthopaedic surgeon will be able to determine the best course of treatment. The most critical step to take before beginning any treatment is ensuring that you have the proper diagnosis. Keep in mind that not all injuries require surgery and not all surgical procedures can be done arthroscopically.

However, if a qualified orthopaedic specialist determines that there is serious damage to your joint, or if you are experiencing pain that prevents you from engaging in your normal level of activity, arthroscopic surgery may be a good option for you.

What are the benefits of arthroscopic surgery?

Arthroscopic surgery offers several key benefits to patients who need a damaged or injured joint repaired. Years ago arthroscopy was used only to diagnose a joint injury and help plan for open surgery. Advances in technology now allow surgeons to view, evaluate and operate on injured joints simultaneously, so there are fewer procedures for a patient to endure.

Arthroscopy is generally an outpatient procedure. Depending on the location and extent of the injury, the surgery generally takes about 1 to 2 hours to complete. Patients can typically return home to begin their recovery the same day as their surgery. In addition to a faster procedure and shorter hospital stay, people usually recover from arthroscopic surgery much faster than open joint surgery.

What are the risks of arthroscopic surgery?

There are risks associated with any surgery, including the risk of infection, complications from anesthesia and bleeding. Arthroscopy is less invasive than open surgery and, when performed correctly by a trained orthopaedic surgeon, it is often extremely successful.

When can I expect to return to my normal level of athletic activity?

Rehabilitation takes place over the course of several months. Your recovery and rehabilitation time can vary based on the surgeon, surgical technique, kind of graft used and type of activity you are trying to resume. Because of this variability, the timing of surgery is often very important for many athletes to be able to return to play in a timely manner. 

What Should I Ask My Physician?

Do you have specific training in minimally invasive surgery or arthroscopic surgery?

Minimally invasive surgical procedures are fundamentally different than open surgery in both technique and instrumentation. This technique is not something a surgeon can learn at a weekend course and immediately incorporate into their practice. Without appropriate training, the surgery can lead to poor outcomes with serious complications.

Dr. Miller completed an additional year of training at Rush University Medical Center to learn minimally invasive orthopaedic surgical techniques from the innovators of the procedures.  

Dr. Vaughn completed a fellowship for subspecialty training in Sports Medicine at Stanford University, where he received extensive training in minimally invasive and arthroscopic surgical techniques. This included experience in arthroscopy of the hip, knee, shoulder, elbow, ankle and wrist.

How many minimally invasive surgeries have you performed?

The amount of experience a physician has with minimally invasive and arthroscopic surgeries can directly impact the success of the surgery, as well as the comfort and recovery time for the patient. Additionally, as the number of cases a surgeon performs grows, the more reliable patient outcome data will be.

Dr. Miller has performed more than 3,500 orthopaedic surgeries. More than 1,000 have been minimally invasive hip and knee replacements. 

Dr. Vaughn has performed more than 3,000 orthopaedic surgeries, the majority of which are arthroscopic surgeries.

What kind of anesthesia do you use with patients?

For many years, general anesthesia was the most commonly administered form of anesthesia for orthopaedic surgeries. One drawback to general anesthesia is that it can take patients longer to recover from general anesthesia than it would to recover from a local or regional anesthesia, delaying the start of physical therapy and ultimately prolonging your overall recovery time. 

At the Stanford Orthopaedic Surgery Clinic – Los Gatos, we use a spinal anesthetic when possible for our joint replacement surgery, combined with regional techniques that allow patients to participate with therapy right after surgery. For arthroscopic surgery, a very limited general anesthetic is often given. This limited general anesthetic allows for the surgery to take place effectively and with minimal risk of common side effects from prolonged deep general anesthesia.

What kind of implants will you be using to replace my damaged joint?

It is important that your surgeon chooses implants with a proven track record of clinical success. Your surgeon should have access to registries that demonstrate which implants have the best outcomes.

At our Clinic, we routinely use a knee prosthesis that has the lowest rate of revision in large total joint registries. The hip implants we select are based on individual variations in anatomy. These are fine tuned to adjust for gender differences and patient size to best recreate a patient's anatomy. The arthroscopic implants are highly variable and will depend upon the specific requirements of your injury. These can be discussed in detail with you during the planning of your surgery.

What will my recovery look like? How long will I need to be in the hospital?

Arthroscopic surgeries are usually performed on an outpatient basis—you will be able to return home and begin your recovery on the same day as your surgery.

Patients undergoing minimally invasive joint replacement stay in the hospital 1-3 days before going home. The length of stay depends on your medical conditions and your level of physical fitness before surgery.  Usually, even the most fit and healthy patients need to stay at least one night after joint replacement surgery for medical observation. Despite advancements in recent years, minimally invasive joint replacement is still a major orthopaedic surgery and can have significant complications that your medical team will be watching for during your hospital stay. The majority of these complications are observed within the first 72 hours after surgery.  

How long before I can drive?

This is highly variable based on the type of surgery performed. It may be as quickly 1 day after surgery, but may be several weeks.Most patients can drive safely in as few as 2-6 weeks after minimally invasive joint replacement surgery. Each patient's recovery is different after joint replacement. To be able to safely drive, you must discontinue narcotic pain medication and have the strength and reaction time to safely operate a vehicle without endangering others.

How long will I need to be in physical therapy?

Rehabilitation takes place over the course of weeks or months. Your recovery and rehabilitation time will vary depending on the surgeon, surgical technique, kind of graft or implant used and type of activity you are trying to resume.