Time heals all wounds. Of course, those who spend months recovering from spinal surgery or a knee replacement operation may not necessarily see it that way.

But the use by many Iowa orthopedic surgeons of minimally invasive surgical techniques has allowed thousands of patients to leave the hospital in much better shape than they would have found themselves in 10 years ago.

“When patients voice their concerns before they come into the hospital, what it boils down to is ‘When can I get back to my previous level of functioning? When can I get back to my job? How much pain am I going to be in?’” said Dr. Craig Mahoney, a surgeon at Iowa Orthopaedic Center P.C. “So even though some of these techniques may not directly correlate, I think the whole concept of minimally invasive surgeries in orthopedics has been beneficial to patients because we’re listening to patients.

“Unfortunately, in any industry, you feel you have to keep up with the Joneses, so to speak. Someone says, ‘Well I had a minimally invasive surgery in Davenport,’ and any self-respecting surgeon is going to say, ‘I have to do that, too.’”

Minimally invasive surgeries, depending on their application, can provide numerous advantages to patients. Many of these procedures allow for smaller incisions, limiting the amount of initial pain. Surgeons are typically able to limit the amount of disruption to surrounding tissues, leading to fewer healing complications, and the risk of infection is often reduced. Some patients can even avoid a night in the hospital.

An ongoing evolution in instrumentation and minimally invasive techniques and a greater appreciation for those post-surgical benefits have made these types of surgeries far more common, though most have been slower to catch on in the Midwest. But one of the major drivers has been the successful use of the arthroscope, a tiny camera lens attached to a flexible tube, in sports medicine.

“Because of the success of that in the sports medicine world, it’s branched off into other areas of orthopedics and total joints, as well as the spine,” said Dr. Scott Meyer, a surgeon with Iowa Orthopaedic Center specializing in sports medicine and arthroscopic surgeries.

“It’s not easy to jump on the bandwagon every time a new technique comes along,” Meyer said. “But for the surgeon, once you’ve gotten past the initial learning curve, you prefer to do it arthroscopically.”

Arthroscopic techniques to repair anterior cruciate ligament tears, one of the most common sports-related injuries, were introduced in the late 1980s and became the most popular choice for surgeons in the 1990s. “It went from being a technique that used two small incisions to now mostly one small incision,” Meyer said. Today, about 97 percent of sports medicine surgeons perform ACL surgeries arthroscopically.

“It was a huge improvement because they had less pain, they could get going with their range of motion faster, they had less scarring, which can be a significant delay in recovery,” he said. “You’re not damaging structures that don’t need to be damaged to get the procedure done, so there potentially will be fewer healing complications, and most arthroscopic techniques have lower infection rates.”

As the instrumentation and knowledge base has improved, use of the arthroscope has expanded to where it can now be placed in most joints for small procedures. Today, even complex shoulder surgeries such as rotator cuff repairs and stabilization procedures are beginning to see greater use of the arthroscope.

“Even five years ago I was not using it as much myself for rotator cuff repairs,” Meyer said. “Now that is more the norm.”

Some procedures, such as “Tommy John surgery” (which involves replacing a ligament in the elbow with a tendon from elsewhere in the body) and repairs to the medial or lateral cruciate ligaments in the knee, still require open procedures because of anatomical limitations that make it difficult for the surgeon to see the injured area. “I would suspect the elbow would potentially have some arthroscopic applications in the future, but that’s a few years down the road,” he said.

Mahoney, who specializes in hip and knee replacement surgeries, said some of the buzz about minimally invasive surgical techniques has been hype. But he has incorporated a few techniques into his practice, one of which has become quite common in knee replacement surgery.

Typical knee replacements require the surgeon to make an incision in the quadriceps tendon, which connects the quadriceps muscle to the patella. Through a minimally invasive procedure known as a quad-sparing knee replacement, the surgeon avoids making an incision in the quadriceps tendon and instead separates the muscle fibers on the inside of the knee and bypasses the tendon altogether.

“The range of motion I see after surgery is statistically better than it was beforehand,” Mahoney said. “People have less pain, they are able to get up more quickly and really, I think, get back to their previous level of functioning more quickly than in the past.”

Mahoney, who learned the procedure during a fellowship in New York City and introduced it at the Iowa Orthopaedic Center when he joined the staff 3 1/2 years ago, uses it with about 70 percent of his knee replacement patients. Those with large, heavily muscled legs are not considered good candidates for the procedure, nor are those who have large deformities or who have had previous knee operations (scar tissue often makes minimally invasive procedures more difficult to perform).

And the procedure isn’t for every surgeon, either, he said.

“I think physicians are concerned about it because they’re still very comfortable with conventional approaches, and the conventional approach is still a very successful approach,” Mahoney said. “So I don’t want people to think that if they don’t get this they didn’t get something they should have, because that’s not necessarily true.”

Mahoney has encountered some minimally invasive techniques for hip surgeries, “but in my hands,” he said, “most of the techniques involve making a smaller incision, but the actual act of doing the surgery beneath the skin, which is really the most important thing, is the same.” Few of those techniques have produced a significant improvement in recovery, and one technique, which uses X-rays intraoperatively, has been shown to produce a higher rate of complications.

Spine surgeons have been among the last to adopt the minimally invasive techniques because, for years, few in the medical field thought they could be applied to the spine. Cassim Igram, a spine specialist at Iowa Orthopaedic Center, said it has caught on among surgeons in his subspecialty in recent years, largely because of the success of minimally invasive surgery techniques in other subspecialties.

“I think once people saw that the instrumentation was out there, the techniques were being refined, I think it caught on,” he said.

Surgeons at universities and larger referral hospitals have been performing minimally invasive spine surgeries for about seven to eight years, Igram said, and the practice is slowly making its way into the Midwest. He first performed a minimally invasive surgery nearly three years ago, and said he now sees a mixed bag of spine surgeons: those who perform minimally invasive surgeries and those who choose to stick with traditional methods.

“There are different ways to safely and effectively perform an operation, and it really depends on your preference,” he said.

Minimally invasive spine surgeries, Igram said, are “essentially achieving the same result (as open procedures), but with a lot less trauma.” Rather than making a large incision and disrupting many soft tissues surrounding the spine, minimally invasive procedures allow the surgeon to make a smaller incision with less disruption of the soft tissues.

When repairing a herniated disk using traditional methods, the surgeon makes a 1/2- to 2-inch incision, peels the soft tissues away from the spine to see the opening in the spinal canal, and then removes the ruptured disk. The procedure takes about 45 minutes and the patient is hospitalized overnight.

However, when using a minimally invasive technique, the surgeon makes a 3/4-inch incision and, rather than peeling the soft tissues away from the spine, the tissues are split apart using a series of concentric tubes. The surgeon operates through the 22-milimeter opening in the smallest tube to remove the disk and then removes the tube, allowing the soft tissue to return almost entirely to its natural state. The surgery takes about 45 minutes and, for patients with early-morning surgeries, they’re home in time for lunch.

For the patient, a smaller incision, less blood loss and less disruption of the soft tissue result in a shorter hospital stay – if one is needed at all – and less risk of infection, Igram said. Because there is less pain from the incision, he has found that patients tend to feel better more quickly than those who undergo traditional surgery. “If a person does office work, it wouldn’t be unusual for them to go back perhaps on a part-time or full-time basis in about seven days or so,” he said.

But, like with other minimally invasive surgeries, there are factors that prohibit some patients from being eligible for this type of procedure. A previous spine surgery may have left scar tissue that makes it more difficult for the surgeon to perform minimally invasive surgery. For some overweight patients, the instrumentation – a mere 9 centimeters long – may be a limiting factor. “But for somebody who’s really skinny, that makes minimally invasive surgery a breeze,” Igram said.

The surgeons expect to see continued improvements in minimally invasive techniques and instrumentation. Meyer expects more applications to be found for the arthroscope. He hopes new techniques will be developed for long-term cartilage injuries as well as for elbow surgeries.

The near future holds new challenges related to computer-assisted surgery, which will likely begin to emerge next year. Kevin Ward, CEO of Iowa Orthopaedic Center, compares it to graduating from Ford Model T to a four-wheel-drive Jeep.

“It’s not just a system,” Ward said. “It’s a methodology of practice.”

Mahoney expects to see “tremendous improvements” in the development of computers for surgical purposes, but, like with the evolution of home computers, it’s difficult to know how the technology may evolve.

“In the long run, that will continue to improve and help us,” he said.

Surgeons and hospitals have voiced concern the added time – about 30 minutes – required for computer-assisted surgeries, as well as the added cost of equipment. Meyer said one computer, which would be used for hip and knee replacements, would cost at least $50,000.

But the greatest evolution in orthopedics, the surgeons said, will come through the development of growth factors. Researchers have been working for decades to identify and isolate proteins within the body that will trigger the formation of bone and tissue, which are far more durable than metal or plastic implants.

“Bone and soft tissues have somewhat of a limiting capacity to heal,” Meyer said. “It’s going to be growth factors that will speed up that healing time.”

Igram pointed to spine fusion surgery, which has always been a challenge for surgeons because bone fusion does not occur naturally within the body.

“If a person breaks their arm, there is a healing response where the bones heal themselves together,” he said. “We’re trying to induce the same thing with the spine, but we’re choosing to do that. So you need to put something in there that will cause bone to form and trigger that cascade of events.”