Redefining minimally invasive joint replacement

Minimally invasive surgery is often thought to be surgery that simply minimizes surgical incisions to reduce trauma to the body. While the evolution of instrumentation over the past two decades has allowed for joint replacement to be performed using smaller incisions, that has not always resulted in the best outcomes for patients.

“Advancements in instrumentation led to a race to use the smallest possible incisions for joint replacement,” said Dr. Jeffrey Hodrick, orthopaedic surgeon with Southern Joint Replacement Institute (SJRI). “While it can be done successfully through very skilled hands, that wasn’t always the case and patients suffered as a result.”

“What we have learned is the size of the incision has nothing to do with the patient outcome,” he said.

According to Dr. Hodrick, the most important thing a surgeon can do during a joint replacement procedure to ensure an excellent long-term result is to put the implant in just the right place to ensure correct alignment, make sure the ligaments are balanced and the implant is reliably attached to the bone.

“We only make the size of incision necessary to perform the surgery well,” said Dr. Hodrick. “That incision is undeniably a lot smaller than it was 10-20 years ago. But we have learned that it is how we handle the soft tissue, rather than the length of the incision, that makes a surgery less invasive or minimally invasive.”

“When we are respectful of the soft tissue during the procedure it leads to less inflammation following the procedure which translates to less pain, faster mobility and quicker recovery,” he said. “For me the biggest evolution has been the robotic arm that helps me perform a very precise procedure without releasing as much soft tissue. Instruments have evolved, everything is much smaller and fit into a smaller area, so we don’t have to release as much soft tissue.”

Anterior hip replacement is a minimally invasive joint replacement technique that significantly reduces trauma to the soft tissue but allows visualization during the procedure to ensure implants are properly aligned. “It is minimally invasive in that we are not cutting though muscle or detaching tendons,” said Dr. Hodrick. “Patients experience less discomfort, less inflammation after surgery, so they move more and sooner following surgery, and recover faster.”

Several other factors contribute to joint replacement surgery that is less invasive and less intrusive. Advancements in anesthesia and pain management have led to significantly faster and less stressful recovery.

“It is certainly less invasive to have a spinal anesthetic rather than general anesthesia during joint replacement surgery,” said Dr. Hodrick. “Patients breathe on their own and do not require a ventilator because they are only mildly sedated during surgery. The sedation wears off about five to ten minutes after the surgery. That means we can mobilize them in about three to four hours and many patients go home the same day.”

According to Dr. Hodrick, surgeons at SJRI have also learned that patients typically do not require as much pain medication following surgery as previously thought. The most common side effects of pain medication—nausea, vomiting, loss of appetite, constipation, depression and sleep deprivation can be far worse that the discomfort experienced after joint replacement. Pain management protocols that require less medication is another way to ensure a less invasive joint replacement experience. 

Technology enables surgeons to be significantly less invasive during joint replacement surgery. “I perform robotic knee replacement that allows me to do surgery without putting instruments inside the bone and also allows me to cut less soft tissue during the procedure,” said Dr. Hodrick. Technology also allows me to have the perfect sized implant for that patient because I have a 3-dimensional model prior to surgery that lets me plan that surgery and map the joint replacement before making an incision.”

Partial knee replacement is an excellent option for patients who have arthritis in only one part of the knee and the other compartments of the knee have normal cartilage.  It is less invasive because it limits the amount of bone that must be removed and there is less blood loss.  Patients experience a shorter recovery still have an excellent and long-term outcome.

Surgeons at SJRI have a long established culture of continuous quality improvement and research that have led to their outstanding reputation for delivering the best patient outcomes and is helping advance minimally invasive techniques and protocols. The practice has an extensive database which is reviewed and evaluated each month that helps drive quality and outcomes to the best they can possibly be.

“In a world where we cannot achieve perfection, there is nothing wrong with trying,” said Dr. Hodrick. “At SJRI we are driven to figure out what is the best practice when it come to joint replacement. It is our culture of ongoing research, study and evidence-based medicine that drives excellence.”

“We look at every single thing we do for a patient and evaluate whether or not it is beneficial to the patient, and adjust our protocols accordingly,” he said. “It is an intellectual challenge to innovate on a local level, but the prize is our patients have better outcomes. We can relieve their pain, restore function and improve quality of life. Most days, that feels pretty close to perfect.”