Hip Arthroplasty with Minimally Invasive Surgery

Transcription

1 The Journal of Arthroplasty Vol. 21 No. 6 Suppl Hip Arthroplasty with Minimally Invasive Surgery A Survey Comparing the Opinion of Highly Qualified Experts vs Patients Javad Parvizi, MD, FRCS, Peter F. Sharkey, MD, Aidin Eslam Pour, MD, Venkat Rapuri, MD, William J. Hozack, MD, and Richard H. Rothman, MD, PhD Abstract: In recent years, there has been an increasing debate regarding the possible role of minimally invasive (MIS) total hip arthroplasty (THA). We conducted a questionnaire survey of the Hip Society members and compared the responses of the surgeons with those of patients who were being considered for THA. 80% of surgeons who completed the survey admitted to performing MIS THA, of whom two thirds defined MIS as small incision. Of surgeons, 74% had encountered some complication related to MIS THA; 67% of patients had not heard of MIS THA. The knowledge regarding MIS THA expressed by 80% of patients was either inaccurate or not substantiated by any studies. This survey highlights the inadequacy of our current understanding of MIS THA and lack of education on the part of the patients. Key words: total hip arthroplasty, minimally invasive total hip arthroplasty, survey, patients, orthopedic surgeons. n 2006 Elsevier Inc. All rights reserved. In recent years, the orthopedic community has witnessed a rapid emergence of bminimally invasive surgeryq for total hip arthroplasty (THA) [1-3]. The definition of minimally invasive (MIS) surgery still remains ambiguous. It may include performing the surgery through an alternative approach such as the 2-incision technique [4,5] or performing the procedure through a conventional approach but a smaller incision [6-10]. Although categorized under the same heading, bsmall-incisionq THA may not qualify as MIS THA by strict criteria because it From the Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, Philadelphia, PA. Submitted January 5, 2006; accepted May 1, No benefits or funds were received in support of the study. Reprint requests: Javad Parvizi, MD, FRCS, Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA n 2006 Elsevier Inc. All rights reserved /06/ $32.00/0 doi: /j.arth involves the same surgical approach and conceivably the same degree of soft tissue dissection. In any case, it is critical to make a distinction between the 2 categories of MIS THA. The advocates of MIS THA cite faster functional recovery, shorter hospital stay, less pain, better cosmesis, and better patient satisfaction as the appeal of MIS THA [5,11-17]. It has been recognized that MIS THA has brought with it the implementation of changes such as modified anesthesia and analgesia protocols, better patient education and preparedness for anticipated early discharge, and accelerated rehabilitation protocols [6,7,18,19]. Hence, it is not known what factor (s) exactly may confer these potential benefits to MIS THA. The critics of MIS THA, on the other hand, believe that randomized and comparative studies are needed before MIS THA can be embraced by the orthopedic community [3,10,17,20,21] because traditional hip replacement has been demonstrated to be one of the safest and most effective surgical procedures ever developed. Furthermore, although 38

2 Hip Arthroplasty with Minimally Invasive Surgery! Parvizi et al 39 address any problems that the patients may have encountered during the completion of the survey. The survey was completed by patients before their meeting with the surgeon. A reminder letter containing the survey was sent to all the Hip Society members who had not responded to the initial solicitation. The data from the completed questionnaires were entered into an electronic format and subjected to analysis. Results Fig. 1. The type of minimally invasive hip arthroplasty performed by the responding (45) members of the Hip Society. long-term results from MIS THA series are awaited, recent studies have refuted the potential benefits of MIS THA and have reported higher complication rates [3,8,11,17]. Despite the conflicted reports, MIS THA has received immense attention from both the orthopedic community and the general population. Patient demand for the MIS procedures has surged to high levels resulting in institutions, individual surgeons, and implant manufacturers to embrace this binnovation.q To better understand the patient and professional dichotomy of opinion regarding MIS, a group of recognized experts in hip surgery were surveyed to ascertain their opinions and experience related to this technique. In addition, a similar survey was administered to a group of patients who were candidates for THA and the responses were compared. Of 96 members of the Hip Society who were contacted, 45 returned the completed questionnaires. Completed surveys by 45 patients who had heard of MIS surgery were included in the final analysis. Type of MIS THA Although 36 responding members (80%) of the Hip Society performed bminimally invasive hip surgery,q the technique used varied. Of those responding affirmatively about using MIS methods, 36 (80%) of respondents used a small singleincision approach. The posterior approach was most commonly used (46%), followed by a direct anterolateral approach (32%). Twenty percent of surgeons performing MIS used a 2-incision technique (Fig. 1). When patients were asked regarding their perception of MIS THA, 67% had not heard of MIS THA. Of those who were familiar with the term, only 3.2% of patients thought that MIS involved a 2-incision surgical approach, whereas 35.5% felt that MIS was small-incision surgery. Others felt MIS THA was a procedure with better cosmesis (16.1%), or a safer type of THA (16.1%), Materials and Methods In 2004, all 96 members of the American Hip Society were sent a mail survey regarding MIS hip arthroplasty. The survey questionnaires consisted of 25 questions (Appendix A) developed with the assistance of the medical survey division of the Department of Epidemiology at our institution to capture the opinion and experience of these experts with regard to MIS THA. A similar survey (Appendix B) was also designed to capture the opinion and knowledge of patients who were candidates for THA. The survey was distributed to consecutive English-speaking patients presenting to an urban medical center for THA. A research fellow administering the survey was available to Fig. 2. The surgeons perspective regarding the complication rate of MIS THA compared with conventional THA.

3 40 The Journal of Arthroplasty Vol. 21 No. 6 Suppl. 2 September 2006 or a procedure that yielded more improved results (29%). Patients had several interesting observations about MIS; 18.1% of patients believed MIS was an arthroscopic procedure. The surgeons who performed MIS THA were asked specifically regarding what percentage of their patients bqualifiedq for MIS THA. Sixty-nine percent of surgeons performed MIS THA in a select population. In addition, 78% of surgeons had implemented changes in their routine protocols when performing MIS THA. Of note were changes in anesthesia technique (10.4%), pain management (13.5%), and rehabilitation protocols (11.5%). Complications. Fifty-four percent of the responding surgeons thought that MIS surgery was associated with more complications, whereas 22% were not sure if the procedure led to more complications or not. Twenty-four percent of surgeons did not think that MIS THA carried additional complications (Fig. 2). Seventy-four percent of surgeons had encountered complications related to MIS THA. The most common complication of MIS THA either performed by the surgeons or the others was periprosthetic fracture, followed by poor implant positioning, dislocation, and nerve injury. Nearly two thirds (a total of 25) of patients who developed complications after MIS THA and were treated by the responding surgeons required further surgical intervention. Treatment included revision surgery (n= 16), open reduction internal fixation (n = 5), nerve exploration (n = 3), and closed hip reduction (n = 1). Fig. 4. The surgeons and the patients perspective with regard to the amount of blood loss with MIS THA compared with conventional THA. In the cohort of patients who were surveyed in this study, 13.3% believed MIS was associated with complications, whereas 66.7% responded that it was a safer method for performing THA. Twenty percent of patients were not certain if MIS was more or less safe. Tissue Damage. Coinciding with the response to complications, 36% of surgeon respondents believed that MIS was associated with the same or more tissue damage, whereas 24% were unsure (Fig. 3). Forty percent indicated that less tissue damage occurred with MIS THA compared with conventional THA. The patients had a different perspective; 53.3% believed that MIS was associated with less muscle damage, whereas 46.7% were not sure. None of the patients believed MIS Fig. 3. The surgeons and the patients impression with regard to the degree of soft tissue damage incurred by MIS THA compared with conventional THA. Fig. 5. The surgeons and the patients response with regard to influence of MIS THA compared with conventional THA on functional recovery.

4 Hip Arthroplasty with Minimally Invasive Surgery! Parvizi et al 41 THA caused more soft tissue damage than conventional THA. Blood Loss. A specific question inquiring about the degree of blood loss during MIS THA compared with conventional THA was posed to both the patients and the surgeons. Thirty-four percent of surgeons vs 60% of patients believed MIS THA resulted in less blood loss (Fig. 4). None of the surgeons and the patients believed MIS THA resulted in more blood loss, whereas 25% of surgeons and 40% of the patients were unsure. Functional Recovery. The impression of both the surgeons and the patients were sought with regard to the influence of MIS THA on functional recovery; 45% of surgeons vs 47% of the patients believed that MIS was associated with faster functional recovery (Fig. 5). In addition, the surgeons were asked to remark on which, if any, aspect of MIS THA resulted in faster recovery. Twenty-eight percent believed less tissue damage was the reason for faster recovery, whereas 12.5% chose less blood loss, 2.5% chose reduced pain, and 26.6% selected placebo effect as the reason for the faster recovery. Hospital Length of Stay. The issue of possible shorter hospital stay after MIS THA was also surveyed; 40% of surgeons vs 73.3% of patients believed that hospital length of stay was shorter after MIS THA, compared with conventional THA. None of surgeons and patients felt that hospital length of stay was longer after MIS THA (Fig. 6). Pain. The issue of pain after MIS THA was also surveyed among patients and surgeons; 46.6% of surgeons vs 44.5% of patients felt that MIS THA resulted in less pain than conventional THA (Fig. 7). Fig. 7. The response of surgeons vs patients with regard to the degree of pain after MIS THA vs conventional THA. Drive for MIS THA. A specific question was posed to patients and surgeons to identify their belief with regard to the impetus for the launch and continuation of MIS THA in the orthopedic community. Most of the responding members of the Hip Society felt that marketing, either by orthopedic surgeons (43.5%) or implant manufacturers (29%), was a motivating force behind MIS. Only 13% believed that improved patient outcomes were driving this issue (Fig. 8). In contrast, only 5.6% of the patients believed that marketing was an influential force. A higher portion of patients (44.4%) felt that improved outcomes were the impetus for MIS THA. Other reasons selected by the patients included patient demand (27.8%), quicker recovery (11.1%), less scarring (5.6%), and reduced pain (5.6%). Fig. 6. The surgeons and the patients response with regard to the length of hospital stay after MIS THA compared with conventional THA. Fig. 8. Patients and surgeons perspective regarding the drive for MIS THA.

5 42 The Journal of Arthroplasty Vol. 21 No. 6 Suppl. 2 September 2006 Outcome. A specific question was presented to both groups asking if they believed the MIS THA had been proven to be effective. The response to this question from surgeon and patient perspectives varied widely. Of the responding members of the hip society, 87% believed that MIS THA had not been proven to be a safe and effective alternative to standard THA. Most responders were not certain if the early reported outcomes with MIS THA were real or biased. Seventy-five percent of the respondents indicated that the placebo effect was very important or somewhat important for being responsible for reported enhanced early results. Eighteen percent were unsure about the placebo effect, but only 7% thought it was not a factor at all associated with recovery. Interestingly, 53.3% of patients felt MIS was a proven and safe technique, 40% were not sure, but only 6.7% doubted the safety of MIS THA. Discussion Minimally invasive THA has become a popular issue because of the enormous implications associated with the concept, including market share (for surgeons, hospital, and implant manufactures), patient outcomes, and complications. The surgeons, administrators, and more importantly, the patients, have devoted immense attention to this issue in recent years. It has become common place for reconstructive orthopedic surgeons to face patients who speak about and possibly request MIS hip or knee arthroplasty. The orthopedic surgeons currently face 2 important challenges with regard to MIS joint arthroplasty. First, it is not known if MIS THA does indeed confer the cited benefits to the patients. Initial reports indicated that MIS THA was both safe and effective [5,10,22]. The advocates of MIS THA continue to report beneficial outcomes of MIS THA [4-6,16,22]. Most of the latter reports are by the originators of the MIS techniques [2,4-6,12,16,22] or come from centers with high surgical volume, where a better outcome for joint arthroplasty would be expected. An additional problem is that a small number of these studies are randomized and comparative in nature [1,3,10]. In recent years, there have been many published articles refuting the beneficial effects of MIS THA and attributing higher complications [8,17,21,23,24], poor cosmesis, and increased soft tissue damage [7,10,23] to this technique. Hence, the orthopedic community continues to face the uncertainty as to whether the noted benefits are real or biased in nature. An additional challenge that remains regarding these reported benefits of MIS is determining if these advantages relate to the actual surgical technique or the implementation of other changes in the routine protocols that include improved pain management, rehabilitation, or anesthesia techniques. The unresolved issues with regard to MIS THA provided the impetus for the current survey. The questionnaires, designed by a team with expertise in national surveys, intended to collect the beliefs and experiences of a group of highly qualified and academic surgeons, namely, the members of the Hip Society. The survey included questions to capture most pertinent information related to MIS THA, which included the definition of the actual term, blood loss, recovery, cosmesis, pain, and safety. The survey collected information, from both the surgeons and the patients, regarding the drive behind the MIS and also the economic issues surrounding MIS THA. Although the survey was not completed by all members of the Hip Society, it is hoped that the information collected is an accurate representation of the thoughts and early experiences of a highly respected group of opinion leaders in hip surgery. An equal number of consecutive patients who were in need of THA were also surveyed at our urban outpatient office. This study observed that a major dichotomy of opinion exists between surgeons and patients regarding MIS THA. Furthermore, the opinion of surgeons who perform MIS THA seemed to differ from that of non-mis performing surgeons. Most of the stated knowledge by the patients pertinent to MIS THA seemed to be inaccurate in clinical terms. For example, nearly one fifth of patients believed MIS THA was a type of arthroscopic procedure. One possible explanation accounting for the difference in the opinion of patients and surgeons is that the sources each group used to form the opinion differed. Surgeons most likely based their opinion on the knowledge gained from personal experience, discussion with colleagues, and reading of peer-reviewed publications or attendance to meetings. Patients, on the other hand, more likely formulated an opinion based on information obtained from the internet, advertisement, or conversation with other patients. The latter may explain why most of the beliefs and opinions held by the patients are inaccurate and reflect the lack of proper understanding of this concept. It is important to mention that the findings of this survey present a bbest case scenarioq because the participating patients were urban dwellers. There was a

6 Hip Arthroplasty with Minimally Invasive Surgery! Parvizi et al 43 good mix with regard to educational background and profession. By including a consecutive series of patients, we attempted to avoid sample bias. The process of data collection was overseen, but not interfered with, by a research fellow who was available to provide any help in the process. This also ensured the patients did not solicit the help of others in the process of questionnaire completion. This study suffers some shortcomings. First, as with any survey, the information obtained was influenced by the design and the type of field questions administered. We sought the advice of experts in the survey division at our institution to ensure the design of the survey was not affected by investigator bias or knowledge. The field questions were designed in a manner to accurately extract information from the different sample populations. The second, and perhaps the most important, limitation of this study relates to relatively small number of responders from the Hip Society. This was despite our continued attempts to increase the respondent pool by sending the survey and the reminder letters to the members of the Hip Society on more than 1 occasion. Again, the latter reflects a commonly recognized limitation of survey questionnaires and should not detract from the importance of the overall information that was obtained. Finally, this survey was not validated by testing its reproducibility. These findings of this study highlight the concerning gap in perception that exists between patients and surgeons. Some serious issues are currently in hand that relate to the role that orthopedic societies should play in overseeing the propagation of relevant and accurate educational facts among our patients. In addition, these findings underline the importance of regulation of promotional advertising and the need for a debate regarding how new surgical techniques should be introduced to the public. Recently, surgeons have expressed reservations about MIS, and the American Association of Hip and Knee Surgeons has published a policy statement recommending a cautious approach before widespread adaptation of these new surgical approaches. We applaud such a move and believe that it is crucial for MIS joint arthroplasty to receive the same vigorous and scientific questioning that the orthopedic community usually sets before adoption of any novel technologies. There is also a dire need for education of our patients regarding the MIS joint arthroplasty issue. This report should serve as a cautionary warning regarding wide-spread adoption of any MIS methods for THA before thorough investigation and peer-reviewed published investigations. Appendix A. Survey on MIS Hip Surgery for the Hip Society Members Survey on Minimally Invasive Total Hip Arthroplasty 1. What is your definition of MIS THA? 2. Do you perform minimally invasive (MIS) total hip arthroplasty (THA)? c. If no, why not? d. If no, go to question Which technique do you utilize to perform MIS THA? a. Single incision modified anterolateral b. Single incision posterior approach c. Two incision technique d. Other (Please describe) 4. If you perform MIS THA, in what percentage of cases do you use the technique? a. 1-10% b % c % d. N60% 5. Do you use additional imaging during MIS THA?, x-ray guidance b. Yes, computer assisted surgery c. No 6. Which type of anesthesia do you use for MIS THA? a. Spinal b. Epidural c. Nerve blocks d. General e. Other f. Combination (please list) 7. Have you implemented any changes in your routine practice when performing MIS THA? Circle all that apply. Please explain what the changes are., different surgical instruments b. Yes, anesthesia technique c. Yes, postoperative pain management d. Yes, DVT prophylaxis e. Yes, duration of antibiotic prophylaxis f. Yes, alternation in use of surgical drains g. Yes, postoperative blood management h. Yes, hip dislocation precautions i. Yes, rehabilitation protocol j. Yes, discharge planning k. Yes, other l. No.

7 44 The Journal of Arthroplasty Vol. 21 No. 6 Suppl. 2 September 2006 Explanation: 8. Do you think MIS THA is associated with more complications? 9. Have you encountered any complications from MIS THA performed by you or others?, please describe below and also list frequency....please go to question 12 Description: 10. Did the patient(s) receive additional treatment as a result of the above complication?, what 11. What was the outcome after this complication occurred? a. Did fine b. Will require further intervention. c. Other. 12. In your opinion, which of the following is the strongest driving force behind MIS THA? a. Patient care issues b. Marketing by orthopaedic surgeons c. Sales by implant manufactures d. Other. 13. Is there less or more damage to soft tissues during MIS THA? a. More b. Less c. Same 14. Which aspects of MIS THA allow for a bfaster recoveryq? (please circle all that apply) a. Less muscle damage b. Placebo effect c. Less blood loss d. Other what? 15. If patients do not ask bdo you talk about, or offer MIS THA?Q 16. Has the minimally invasive hip replacement surgery (MIS THA) been proven to be a safe and effective procedure by well-designed clinical trials? 17. How important is the placebo effect for so called improved results with MIS THA? a. Very important b. Somewhat important c. Not important 18. Can we safely teach residents and fellows small incision surgery? 19. Should surgeon payment be higher for MIS THA? 20. Are there certain patients that should not be offered MIS THA?, which ones? 21. In comparing conventional and MIS THA: a. There are less complications with MIS THA b. There are more complications associated with MIS THA c. The complications are the same for conventional and MIS THA 22. In comparing conventional and MIS THA: a. There is less pain associated with MIS THA b. There is more pain associated with MIS THA c. The pain associated with MIS and conventional THA is the same 23. In comparing conventional and MIS THA: a. There is less blood loss associated with MIS THA b. There is more blood loss associated with MIS THA c. Blood loss associated with MIS and conventional THA are the same 24. In comparing conventional and MIS THA: a. The speed of recovery is quicker with MIS THA b. The speed of recovery is quicker with conventional THA c. The speed of recovery associated with conventional and MIS THA is the same

8 Hip Arthroplasty with Minimally Invasive Surgery! Parvizi et al Length of hospitalization is: a. Shortened by use of MIS THA b. Lengthened by use of MIS THA c. Not influenced by type of THA performed Appendix B. Survey on MIS Hip Surgery for the Patients Survey on Minimally Invasive Total Hip Replacement 1. Have you heard about small incision/minimally invasive surgery (MIS) total hip replacement? c. If no, please do not complete the questionnaire. 2. What is MIS hip replacement? Circle all that apply. a. Small incision surgery b. Better cosmetic scar c. Outpatient hip replacement d. Two incision hip replacement e. Safer total hip replacement f. Total hip replacement with better results g. Other: 3. Is there less or more damage to muscles around hip during MIS hip replacement? a. More b. Less c. Same 4. Do you think MIS hip replacement is associated with more complications? c. No difference 5. Which of the following is true about MIS replacement? Circle all that apply. a. Less painful hip replacement b. Safer hip replacement c. Hip replacement with a quicker recovery d. With MIS hip replacement the long term results are better. 6. In comparing conventional and MIS hip replacement: a. There is less pain associated with MIS hip replacement b. There is more pain associated with MIS hip replacement c. The pain associated with MIS and conventional hip replacement is the same 7. In comparing conventional and MIS hip replacement: a. There is less blood loss associated with MIS hip replacement b. There is more blood loss associated with MIS hip replacement c. Blood loss associated with MIS and conventional hip replacement are the same 8. In comparing conventional and MIS hip replacement: a. The speed of recovery is quicker with MIS hip replacement b. The speed of recovery is quicker with conventional hip replacement c. The speed of recovery associated with conventional and MIS hip replacement is the same 9. Length of hospitalization is: a. Shortened by use of MIS hip replacement b. Lengthened by use of MIS hip replacement c. Not influenced by type of hip replacement performed 10. During conventional hip replacement (hip replacement with a regular incision), does the surgeon visually inspect the hip replacement to determine fit and orientation of the components? 11. During MIS hip replacement, the surgeon: a. Uses the same techniques as during conventional hip replacement b. Uses x-ray guidance to determine component position c. Uses computer assistance to determine component position d. Cannot see but uses his hands to determine component position e. Uses arthroscopy equipment to determine component position 12. Should surgeon payment be higher for MIS hip replacement? 13. In your opinion, which of the following is the strongest driving force behind MIS hip replacement?

9 46 The Journal of Arthroplasty Vol. 21 No. 6 Suppl. 2 September 2006 a. Patient desires MIS hip replacement b. Improved patient care c. Marketing by orthopaedic surgeons d. Sales by implant manufactures e. Other. 14. Has the minimally invasive hip replacement surgery (MIS hip replacement) been proven to be a safe and effective procedure by welldesigned clinical trials? 15. Long term success with MIS hip replacement compared to conventional hip replacement is: a. Better b. Worse c. Same References 1. Chimento GF, Pavone V, Sharrock N, et al. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty 2005;20: Sculco TP, Jordan LC, Walter WL. Minimally invasive total hip arthroplasty: the Hospital for Special Surgery experience. Orthop Clin North Am 2004;35: Wright JM, Crockett HC, Delgado S, et al. Miniincision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty 2004;19: Berger RA, Duwelius PJ. The two-incision minimally invasive total hip arthroplasty: technique and results. Orthop Clin North Am 2004;35: Berger RA. The technique of minimally invasive total hip arthroplasty using the two-incision approach. Instr Course Lect 2004;53: Berger RA, Jacobs JJ, Meneghini RM, et al. Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res 2004; 429: Berry DJ, Berger RA, Callaghan JJ, et al. Minimally invasive total hip arthroplasty. Development, early results, and a critical analysis. Presented at the Annual Meeting of the American Orthopaedic Association, Charleston, South Carolina, USA, June 14, J Bone Joint Surg Am 2003;85-A: de Beer J, Petruccelli D, Zalzal P, et al. Singleincision, minimally invasive total hip arthroplasty: length doesn t matter. J Arthroplasty 2004; 19: Hartzband MA. Posterolateral minimal incision for total hip replacement: technique and early results. Orthop Clin North Am 2004;35: Ogonda L, Wilson R, Archbold P, et al. A minimalincision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. J Bone Joint Surg Am 2005;87: Archibeck MJ, White Jr RE. Learning curve for the two-incision total hip replacement. Clin Orthop Relat Res 2004;429: Berger RA. Mini-incision total hip replacement using an anterolateral approach: technique and results. Orthop Clin North Am 2004;35: Berry DJ. bminimally invasiveq total hip arthroplasty. J Bone Joint Surg Am 2005;87: Howell JR, Masri BA, Duncan CP. Minimally invasive versus standard incision anterolateral hip replacement: a comparative study. Orthop Clin North Am 2004;35: Howell JR, Garbuz DS, Duncan CP. Minimally invasive hip replacement: rationale, applied anatomy, and instrumentation. Orthop Clin North Am 2004;35: Sculco TP. Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty 2004; 19(4 Suppl 1): Woolson ST, Mow CS, Syquia JF, et al. Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am 2004;86-A: Rittmeister M, Konig DP, Eysel P, et al. Minimally invasive approaches to hip and knee joints for total joint replacement. Orthopade 2004;33: Wenz JF, Gurkan I, Jibodh SR. Mini-incision total hip arthroplasty: a comparative assessment of perioperative outcomes. Orthopedics 2002;25: Bertin KC. Minimally invasive outpatient total hip arthroplasty: a financial analysis. Clin Orthop Relat Res 2005;435: Hungerford DS. Minimally invasive total hip arthroplasty: in opposition. J Arthroplasty 2004; 19(4 Suppl 1): Sculco TP, Jordan LC. The mini-incision approach to total hip arthroplasty. Instr Course Lect 2004;53: Fehring TK, Mason JB. Catastrophic complications of minimally invasive hip surgery. A series of three cases. J Bone Joint Surg Am 2005;87: Goldstein WM, Branson JJ, Berland KA, et al. Minimal-incision total hip arthroplasty. J Bone Joint Surg Am 2003;85-A(Suppl 4):33.