Guest Editorial – Minimally Invasive Joint Replacement Surgery: Where Are We Now?

Guest Editorial

Case Report | Volume 7 | Issue 3 | JOCR May-June 2017 | Page 3-4 | Cheung Man Hong. DOI: 10.13107/jocr.2250-0685.778

Minimally Invasive Joint Replacement Surgery: Where Are We Now?

Authors: Dr. Cheung Man Hong

Department of Orthopaedics and Traumatology, Division of Joint Replacement Surgery, The University of Hong Kong, Hong Kong.


Since the establishment of joint replacement surgery, arthroplasty surgeons have been experimenting less invasive joint replacement procedures involving smaller incisions and novel approaches. Yet not until recent two decades the concept of MIS was introduced into the field of joint replacement surgery [1]. MIS joint replacement surgery is neither a single type of surgery nor a certain surgical approach. It is a concept which aims to achieve a smaller incision and, more importantly, less soft tissue trauma [2]. Through MIS approach joint surgeons hopefully can improve surgical outcome and patient’s satisfaction by reduction of blood loss, postoperative pain, improvement of cosmesis, accelerated discharge, and enhanced recovery.

Knee Arthroplasty
MIS total knee arthroplasty (TKA) was initially introduced to the orthopedic community in the early 1990s by Repicci and was originally designed for unicompartmental knee arthroplasty (UKA) [3]. Not until early 2000s, TKR surgeon started to apply the same concept to TKA. Four major approaches to MIS TKR have been developed: Quadriceps sparing, mini-midvastus, mini-subvastus, and mini-para-patellar [4, 5, 6]. Quadriceps sparing approach was coined by Alfred Tria in 2000 [7]. The skin incision was 10 cm in length and the arthrotomy extended from the superior pole of the patella to 2 cm below the tibial joint line over the medial side, without cutting through quadriceps tendon and muscle. His visit to Hong Kong in 2006 with his surgical demonstration had popularized this approach in this territory for as a MIS TKA approach for some time. Nevertheless, most of these MIS approaches require special instruments due to restricted operative field [8]. Moreover, to guarantee correct implant alignment, adjunctive technologies such as computer navigation [9, 10], patient specific instrumentation, or robotic-assisted surgery may be required in the same setting. All these factors will lead to prolonged operative time and extra difficulty in surgical training. It is not difficult to understand a long learning curve is required for arthroplasty surgeon to acquire the essential skill to perform MIS TKA [11].

Hip Arthroplasty
MIS total hip arthroplasty (THA) was introduced to orthopedic surgeons by pioneers including Richard Berger and Dana Mears since mid-1990s. The two common approaches to MIS include single-incision and two-incision approach. The former involves one single mini incision (usually defined as <10 cm) through either posterior, anterolateral [12], or posterolateral approach. The latter comprised of one anterior incision for preparing the acetabulum and cup insertion, and a second posterior incision for femur preparation and stem insertion [13]. Due to the limited visual field, intraoperative verification of stem and cup position commonly require fluoroscopic assistance [2]. Similar to MIS TKA, especially designed instrument including retractors, handle, reamers, and bone-shaping tool are needed in MIS THA due to limited surgical exposure.

Current Trend
A number of studies and meta-analysis have been published comparing the short-term result between MIS and conventional joint replacement. While the results are heterogeneous, it is generally agreed that current evidence does not demonstrate clear superiority of MIS toward conventional joint replacement [14, 15, 16, 17, 18, 19]. Moreover, there are modest evidence demonstrating inferior outcome of MIS joint replacement in terms of radiological component alignment [20, 21]. Other potential complications include increased risk of neurovascular injury, fracture, patella tendon disruption, soft tissue interposition at interfaces, bone over-resection, and retained cement [11]. Given the fact that there is no long-term data available, current evidence make the hypothetical benefits of MIS questionable. Combined with factors such as long operative time and long learning curve, the initial enthusiasm for MIS quieted and pendulum was then switched back to conventional approach. Currently, most arthroplasty surgeons apply the MIS approach to specific operation only (e.g. UKA).

While the concept of MIS is theoretically sound, scientific evidence to support its universality is lacking. Joint replacement surgeons who plan to use MIS in usual clinical practice should critically evaluate the procedure and pay extra attention in patient selection.


1. Berry DJ. “Minimally invasive” total hip arthroplasty. J Bone Joint Surg Am 2005;87(4):699-700.
2. Berry DJ, Berger RA, Callaghan JJ, Dorr LD, Duwelius PJ, Hartzband MA, 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, 2003. J Bone Joint Surg Am 2003;85-A(11):2235-2246.
3. Repicci JA, Eberle RW. Minimally invasive surgical technique for unicondylar knee arthroplasty. J South Orthop Assoc 1999;8(1):20-7; discussion 27.
4. Tria AJ, Scuderi GR. Minimally invasive knee arthroplasty: An overview. World J Orthop 2015;6(10):804-811.
5. Scuderi GR, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty. Clin Orthop Relat Res 2004;428:61-67.
6. Scuderi GR. Minimally invasive total knee arthroplasty: Surgical technique. Am J Orthop (Belle Mead NJ) 2006;35 7 Suppl:7-11.
7. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: Early experience. Clin Orthop Relat Res 2003;416:185-190.
8. Coon TM. Specialized instruments and modular implants for minimally invasive total knee arthroplasty. Am J Orthop (Belle Mead NJ) 2006;35 7 Suppl:12-17.
9. Chandrasekaran S, Molnar RB. Minimally invasive imageless computer-navigated knee surgery: Initial results. J Arthroplasty 2008;23(3):441-445.
10. Lüring C, Beckmann J, Haiböck P, Perlick L, Grifka J, Tingart M. Minimal invasive and computer assisted total knee replacement compared with the conventional technique: A prospective, randomised trial. Knee Surg Sports Traumatol Arthrosc 2008;16(10):928-934.
11. Aglietti P, Baldini A, Giron F, Sensi L. Minimally invasive total knee arthroplasty: Is it for everybody? HSS J 2006;2(1):22-26.
12. Berger RA. Mini-incision total hip replacement using an anterolateral approach: Technique and results. Orthop Clin North Am 2004;35(2):143-151.
13. Berger RA. The technique of minimally invasive total hip arthroplasty using the two-incision approach. Instr Course Lect 2004;53:149-155.
14. Imamura M, Munro NA, Zhu S, Glazener C, Fraser C, Hutchison J, et al. Single mini-incision total hip replacement for the management of arthritic disease of the hip: A systematic review and metaanalysis of randomized controlled trials. J Bone Joint Surg Am 2012;94(20):1897-1905.
15. Smith TO, Blake V, Hing CB. Minimally invasive versus conventional exposure for total hip arthroplasty: A systematic review and meta-analysis of clinical and radiological outcomes. Int Orthop 2011;35(2):173-184.
16. Unwin O, Hassaballa M, Murray J, Harries W, Porteous A. Minimally invasive surgery (MIS) for total knee replacement; Medium term results with minimum five year follow-up. Knee 2017;24(2):454-459.
17. McGrory B, Callaghan J, Kraay M, Jacobs J, Robb W, Brand RA, et al. Editorial: Minimally invasive and small-incision joint replacement surgery: What surgeons should consider. Clin Orthop Relat Res 2005;440:251-254.
18. Ranawat CS, Ranawat AS. Minimally invasive total joint arthroplasty: Where are we going? J Bone Joint Surg Am 2003;85-A(11):2070-2071.
19. Dorr LD, Maheshwari AV, Long WT. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. J Bone Joint Surg Am 2007;89(6):1153-1160.
20. Dalury DF, Dennis DA. Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop Relat Res 2005;440:77-81.
21. Chen AF, Alan RK, Redziniak DE, Tria AJ Jr. Quadriceps sparing total knee replacement. The initial experience with results at two to four years. J Bone Joint Surg Br 2006;88(11):1448-1453.

How to Cite This Article: Cheung MH. Minimally Invasive Joint Replacement Surgery: Where Are We Now? Journal of Orthopaedic Case Reports 2017 May-Jun;7(3):3-4

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