Bennett Orthopedics & Sportsmedicine Regenerating the Youth in You!

Minimally Invasive Surgery of the Knee, Shoulder William F Bennett MD Orthopedic Surgeon

There is a move to perform surgery through smaller incisions Impetus lower infection rate?

less pain?

quicker rehab?

public demand marketing product companies

Arthroscopy vs Arthroplasty  Arthroscopy-The use of a fiber optic device and mirrors to project an image onto a television screen  Arthroplasty- replacing defective joints with implants, or other techniques to remodel the joint surface.

Arthroscopy Setup  Uses:  Knee  cartilage  meniscus   Hip ligaments  Shoulder  rotator cuff  dislocation/instability  some arthritis labral tears anterior impingement

Arthroscopy Instruments

Shoulder Anatomy

Bone

 Shoulder Arthroscopic Photos

Shoulder Arthroscopy Rotator Cuff Tears Dislocations/Subluxations Biceps subluxation SLAP Lesions Impingement Ac Joint resection Osteoarthritis

Knee Anatomy  Bones – Femur – Tibia – Fibula – Patella

 Rectus femoris  Vastus Medialis – obliquus  Vastus lateralis – Obliquus – Patellar Ligament Tendons

ACL Ligament

Patellofemoral Chondromalcia

Knee Arthroscopy Meniscal Repair Meniscal Resection Synovectomy Chondoplasty Ligament Reconstruction Cartilage Regeneration

Cartilage Regeneration

Arthroscopic Biopsy Sent To Cambridge, Massachusetts Grown in Petri Dish Replace Deficit with open procedure Near Future- arthroscopic replacement tissue engineering

Cell Implantation

Hip Arthroscopy

Limited Indications Impingement Labral Tears

However, Joint Replacement can not be done arthroscopically  However, demand has pushed us to use smaller incisions and preserve anatomy

Osteoarthritis  This knee would not be amenable to arthroscopic intervention

Mini Incision/Quad Sparing TKR  Smaller skin incision  Does not disrupt the quadriceps tendon, important for knee strength  Less time in hospital  Quicker to walk

Principles of MIS TKA

Address all types of arthritic path.

Approach both varus and valgus knees Provide early, exceptional analgesia Allow early hospital discharge and rapid rehabilitation The quality of the outcome not compromised by length of incision BUT NOT FOR ALL KNEES!!!!!!!!!!!!!!!!

Old Incisions

New Incisions

NEW INSTRUMENTS NATURAL LITE  MIS – Knee instruments – 4” incision

Old New

MIS TKA Intra-operative – Minimizes interruption of N/V tissue – Minimizes dissection -muscles, tendon,lig .

– Avoids quadriceps disruption – Avoids disruption of the suprapatellar pouch – Eliminates patella eversion – Reduces incision length to 7 to 10 cm – Decreases blood loss Post-operative Faster return to activities of daily living (ADL) Greater range of motion (ROM) during first six months Leg raises and flex the knee within 6 hours Reduced pain

Mini-Incision Hypothesis

Mini TKA Standard TKA Exposure

Length 9-14cm 1.5 - 2.0 cm Quad split Muscle relaxation Release lateral pat-fem ligament Length 20-30cm Extensive quad violation Patellar eversion Lateral release

Rehab

PROM  PT Straight leg raise on POD 1 Ambulate POD 1 Flex to 90  by D/C PROM  PT Leg raise by POD ?

Ambulate POD 1

LOS

< 3 days (Mean = 2.9) 3 - 5 days (Mean = 3.6)

Other Factors

  Blood loss Tourniquet & OR time Decreased morbidity Quicker return to ADL Reduced pain (? significant) Cosmetic appeal Blood loss Morbidity risk Lengthy rehab Reported by Dr. Luke Vaughan – Vail 2003

Exposure

Quad-Sparing Hypothesis

MIS TKA

Length 8-12cm No VMO violation No patella eversion

Standard TKA

Length 20-30cm Extensive quad violation Patellar eversion

Rehab

Early mobilization Leg raise on day of surgery Flex to 90  on day of surgery Ambulation day of surgery PROM  PT Leg raise by POD ?

Ambulate POD 1 1 - 2 days

LOS

3 - 5 days

Other Factors

½ blood loss Decreased morbidity Faster return to ADL Reduced pain Cosmetic appeal Blood loss Morbidity risk Lengthy rehab

Small Incision  About 4 inches

Surgery

Summary

 Patients like the scar  Less pain  Less blood loss  Faster rehabilitation