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I need a knee replacement and am trying to decide between a minimally invasive operation(MIS TKR) and a traditional one. Does the incision size really matter??

Posted by Dr Jayant Arora on February 24, 2012 at 1:25 PM

The traditional operation involves an incision that’s about eight inches long that goes down the front of the knee and leg. With the minimally invasive operation, the incision is about half as long. But the traditional and the minimally invasive operations have more in common than not. The surgeon still cuts away portions of the femur (thighbone) and the tibia (shin bone) that form the knee, and it still involves replacing them with a prosthesis that is designed to restore movement and decrease pain.

Some people find minimally invasive surgery appealing for cosmetic reasons—and it does result in a smaller scar. But the main selling points are less pain after the operation and a speedier recovery, so the benefits of knee replacement are experienced sooner and the recovery is quicker approximately by one month. Joint replacement is a big money maker that engenders a lot of competition for patients among surgeons and hospitals. Touting minimally invasive surgery as a suitable procedure for every patient is a way of drumming up business and borders on being unethical. I have come across a few patients with failed knee implants within 2-3 years after a MIS knee surgery due to poorly positioned implants

Minimally invasive surgery should be able to deliver on these promises: a smaller incision does mean less tissue damage. And proponents of the operations can point to some studies that have shown some advantages, such as shorter hospital stays and less blood loss. But replacing a knee isn’t like taking out a gall bladder. A device has to be implanted into the body. The jury is still very much out whether replacements done through smaller incisions will last as long and be as stable as those done through the larger incision… and this would only become clearer in coming 10 years.

As a surgeon who has done knee replacements using both approaches, I think that the surgeon should get clear view of the joint through an incision of “Sufficient Length” for proper placement of the prostheses and avoiding surgical complications. Now whether that incision is 4, 5 or 8 inches is irrrelevant and depends on the patient’s needs. Any day, I would not like to be struggling to properly place the implants through a tight smaller incison, just because I had promised a patient who is not suitable for MIS knee surgery. Such patient typically include obese patients especially short obese ladies, severe deformed legs like bowing and knock knees and in my practice there is no dearth of such patients, infact approximately 60% of patients that come to me for a knee replacement surgery are not suitable candidate for a MIS procedure.

There are other ways to reduce postoperative pain and speed recovery besides making a smaller incision. They range from injections of long-acting painkillers into the joint and surrounding tissues, to cold wraps around the joint, to “constant passive motion” machines that can be used in the days right after surgery to exercise the knee gently, keeping down swelling and stiffness.

I don’t think minimally invasive surgery is the kind of “disruptive technology” that is going to revolutionize total knee replacement, which is already a safe, effective, time tested operation. The gains, if any, are likely to be marginal, and I think these other approaches to postoperative care can probably match them. So my advice to the patients is to not to focus on the length of the incision because it will be irrelevant within 2-3 months of surgery! What would really matter in the long term would be the position of their implants !!!

MIS surgery has a definitive advantage in a small selected group of patients as recovery from knee replacement is painful — and always requires a lot of hard work. Anything that makes it easier for patients is welcome. As surgeons, it is important that rather than resorting to lure the unsuspected patients with a small incision surgery, we maintain sight of the ultimate goal to safely perform a reliable surgery to improve the quality of lives of our patients than to try and make an easy operation difficult!!

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2 Comments

Reply Michael
10:37 PM on March 29, 2012 
My wife just recently had a MIS knee replacement and it didn't pan out the way we had hoped. We're now looking for a walkin tub to make her life a little easier and less dangerous. Considering a Safe Step Walk in Tub. Anyone have any experience in these, or recommendations?
Reply http://www.benendenhospital.org.uk/TreatmentAndServices/Knee-Replacement/your-knee-replacement-surgery.aspx
5:10 AM on April 8, 2013 
It's important to mention that, even if the worst comes to the worst and you need surgery, medical advancements have made treatments on areas such as this routine procedures, often without requiring an overnight stay. so there's no reason to be nervous or apprehensive. You're in good hands.
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