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"MIS" — Minimally Invasive vs. Minimal Incision: What you should know.

Know what you are asking for.
Know what you are getting.
Know the pros and cons.

A topic of much discussion by surgeons during the past few years has been the concept of minimally invasive procedures. Shrewd entrepreneurial surgeons have blurred the distinction between two very different concepts: minimal incision surgery and minimally invasive surgery. Both go by the acronym “MIS”, but they share little similarity beyond that.

There is general acceptance among surgeons that minimally invasive surgery is a good thing. Minimally invasive joint replacement means less cutting and stretching, and less trauma to the joint and to the surrounding soft tissue as the implants are inserted. As I tell my patients, “We don’t take you apart as much as we once did to put these pieces in.”

By using this surgical technique, the patient heals more quickly, so in general there is less pain and a more rapid return to a high level of function.

Most research studies note the major differences between the so-called standard and the minimally invasive procedures occur in the first few weeks after surgery, with the two groups doing equally as well three to six months following the surgery. And while most surgeons who do minimally invasive surgery have shortened their incisions (I have as well), there is no study that directly ties a better outcome to a shorter incision.

In fact, shortening the incision excessively has been shown in many studies to lead to an increased likelihood of problems such as poor wound healing and infection from stretching of the edges and corners of the surgical wound, unintentional damage to surrounding soft tissue such as ligaments, nerves and arteries (because they are harder to see), and malpositioning of the components.

This latter problem is perhaps the most important because malpositioning of the components leads to early failure of the joint implant. Last summer Dr. Robert Barrack’s group at Washington University School of Medicine in St. Louis published a study suggesting that minimal incision surgery was a risk factor leading to the need for early revision surgery.

While I might be dating myself with this analogy, I see the concept of minimal incision surgery as comparable to someone offering to change my car’s spark plugs through the grille. While it certainly may be possible, and while that mechanic might deserve incredible style points, who do you think is more likely to do the job correctly and with less likelihood that the car will need to come back for additional repairs: the mechanic who works through the grille, or the one who opens the hood?

If the goal of joint replacement is to provide a patient with more than two decades of comfortable life of the joint, my vote is to open the window well enough to do a good job and ensure the patient the greatest opportunity to achieve that goal with the least chance of complication. While you may want to look for a surgeon who uses minimally invasive techniques, don’t necessarily tie that to the size of the incision.

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