Notas / Notes - Active Congress.......

MIÉRCOLES / WEDNESDAY
52
this the “forgotten hip,” which means that the patient has forgotten
that he had an operation. Our data with the posterior MIS
indicate that this can be found in 80% of these patients. 15
The short-term benefits of MIS include earlier satisfaction
with the operation, better initial confidence in the outcome,
and a more rapid early recovery because of higher expectations,
less anxiety, and greater optimism. 13-15,18,19 Patients
expect that they will more quickly regain control of their
independence and be able to manage themselves and their
world. Both of these expectations, when fulfilled, are of highest
importance in patients achieving satisfaction with their
operation. 20-21
Improved satisfaction is of no benefit if the complication rate
of the patient is increased. Woolson and coworkers 22 suggested
that a posterior mini-incision was not safe. These data
have never been confirmed, and all randomized 2,7,23 and
other comparative studies have reported that it is a safe operation.
The lead surgeon in the Woolson study was Christopher
Mow, who is now an advocate of the operation (personal
communication). There has never been any confirmation of
the Woolson data that posterior MIS operations are not safe,
and therefore these operations should be considered safe.
There are 19 citations in the literature that document safety
of the posterior mini-incision operation.
The primary complication reported with small-incision
operations, whether posterior, anterior, or two-incision, has
been femoral fracture. 22,24-26 What is not established is
whether this fracture rate is greater than with long incisions.
In published randomized series, there is no difference in
fracture occurrence. 2,7,23 In comparative studies of both
posterior and anterior approaches, a difference has been
found only in the Woolson study. 22 Only Pagnano and
coworkers 27 and Duwelius et a 18 have compared two-incision
to posterior mini-incision procedures, with no significant
differences in fractures (although Pagnano only had fractures
with the two-incision procedure). The percentage of fractures
in small-incision series must be compared with the percentage
that occurs with traditional incisions. Berend and coworkers 28
reported 1.3% fractures in 1959 uncemented hips with posterior
long incisions and 6.3% in 476 hips with uncemented
stems with anterior long incisions. These data would suggest
that mini-incision operations do not have an increased fracture
rate. Likewise, other complications, such as infection and
dislocations, have not shown statistical difference; Kim 29
suggests increased infection on a single case without any
statistical scientific data.
HOW IMPORTANT IS MIS?
The new process of THR includes changes in incisions, pain
management, and recovery patterns. The author believes
most surgeons credit the pain management program for the
improved patient benefits. It has a huge contribution to the
improved outcomes. Patients could not go home the same
day of surgery without pain control. Patients could not participate
in an active physical therapy program without avoi-
dance of nausea, vomiting, and lethargy caused by parenteral
narcotics. So, physicians who credit the pain management
program may well be correct. Patients, however, in the author’s
experience credit the small incision, because it is objective,
visual evidence to them that their body was minimally
injured, and they credit this confidence to their improved
recovery. 15 Therefore, the small incision is an integral “team
member” of the success of the new process for THR. There
has not yet been any reported success with outpatient THR
using long incisions.
The success of the pain management program is founded
on the avoidance of parenteral narcotics. Berger and coworkers
4 initiated this idea. Our success with our modifications
of this program reports low pain scores, near elimination
of emesis, and elimination of severe complications of respiratory
depression, cognitive changes, gastrointestinal ileus,
and a low rate of urinary retention. 30 The keys to success
with this program are preemptive oral medications (elimination
of patient-controlled analgesia and epidural opiates) and
the intraoperative wound injection. Pain scores of 2 to 3 on
an analog scale of 0 to 10 emphasize the success of this
program for patients. 30 In our randomized study of posterior
mini versus long incisions, using this pain program, patients
with a small incision had statistically lower pain scores. 7 We
now have the experience of sending 200 patients home the
day of surgery (using the posterior mini approach we have
described 31 ) without a single readmission or complication
from this same-day discharge.
Recovery is accelerated by the use of an active rather than
a passive physical therapy program. 7 A passive physical
therapy program treats all patients the same, and an active
physical therapy program tailors the progress of the patient
according to the capability of that individual. The use of passive
physical therapy programs has been a weakness of randomized
and comparative studies in attempting to differentiate
between the effects of small and long incision. We used
an active physical therapy program in our randomized study
of posterior incisions, and patients with small incisions outperformed
those with long incisions by earlier discharge and
more patients going home on a single assistive device. 7 The
new process of THR provides improved patient care, and MIS
has been an important contributing factor to this process.
SUMMARY
MIS operations will continue to increase in popularity of use
among surgeons. Increasing data have overcome the fears
of decreased safety. When the operation is performed
correctly, just as when long-incision operations are performed
correctly, the outcomes are the same 2,7,23 In the author’s
experience, when the two other parts of the new process of
THR are used (pain management without parenteral narcotics
30 and an active recovery program 7 ), patients with
posterior MIS have better in-hospital recovery. A psychological
study 15 shows the mental benefits of MIS are strongest at
6 weeks postoperative and, although less so, remain influential
to patients at 6 months to 1 year.