Transcript Slide 1

Major joint reconstructions
in day surgery
What is the limit?
John Fox (Australia)
From Any Lecture / Presentation
• You will only remember four
facts.
First Fact you will remember…is
From any lecture you will only remember
four facts… Three to go.
Background
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Orthopaedic surgeon in Sydney
Major Teaching Hospital Appointment - Westmead
8 years at the Cleveland Clinic, Cleveland Ohio
2 years in Boston, Massachusetts
Fellowship trained in major adult reconstructive surgery
(Major hip, knee, shoulder and elbow reconstructions)
Conceived, designed and with a number of other
colleagues am a shareholder of Castle Hill Day Surgery
• I have very much a vested interest in pushing the limits
of the Day Surgery within the bounds of safety and
appropriateness.
Major joint reconstructions in day
surgery – what is the limit?
What is a Major Joint ?
What is a Reconstruction ?
What is a Major Joint ?
Shoulder
Elbow
Hip
Knee
What is a ‘Reconstruction’ ?
Shoulder reconstruction =
ligament reconstruction or tendon repair
• Rotator Cuff Repair
• Capsular Shift
Rotator Cuff Repair
Capsular Shift
Shoulder Reconstruction
Shoulder reconstruction =
ligament reconstruction
• Rotator Cuff Repair
• Capsular Shift
Not Controversial !
Elbow Reconstruction
Elbow reconstruction
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Ligament reconstruction
Not Controversial !
Shoulder / Elbow
What about REPLACEMENT ?
•Shoulder Replacement
•Humeral Head Replacement
•Elbow Replacement
Not Controversial !
Total Shoulder Replacement
Humeral Head Replacement
Shoulder Elbow Replacement
•Shoulder Replacement
•Humeral Head Replacement
•Elbow Replacement
Not Controversial !
What is a Major Joint ?
Shoulder
Elbow
Hip
Knee
Primary Arthroplasty
USA
• Joint replacement is being done on an
ambulatory basis.
Australia
• Some selected cases / places
Total Hip
Replacement
Hip Resurfacing
HIP
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No hip ‘ligament’ reconstruction
Unipolar Replacement
Bipolar Replacement
Total Hip Replacement
Unipolar eg Moore’s
Hip Bipolar Replacement
Total Hip Replacement
Second Fact
Japanese Hornet
aka ‘yak-killer hornet’
Scientific name:Vespa mandarinia
Total Hip Replacement
• Paradox in the literature
“One of the most significant advancements in total
hip replacement is the recognition that the
procedure can be done with less invasive
techniques which allow the patient to recover
faster. This has even progressed to the point
that some patients are able to have their surgery
accomplished as an outpatient procedure. ”
Total Hip Replacement
• New implants designs
• New materials
– Metals
– Plastics
– Ceramics
• New biologically active coatings
Total Hip Replacement - Proponents
The less invasive approach
• minimally invasive techniques resulting in less trauma to the tissues
benefits for the patient
• most obvious, the scar is significantly smaller.
• faster recovery from surgery of “smaller” magnitude.
• Eg knee arthroscopic surgery, laproscopic cholecystectomy,
appendicectomy, hernia repair some more tumor operations.
• When joint replacement surgery is accomplished with smaller
incisions, the patients will require fewer blood transfusions, have
shorter hospital stays and will return to work or recreation sooner.
• Patients report that a joint replaced with these new techniques is
significantly less painful than with the previous larger surgical
exposures.
• Minimally invasive hip replacement can be performed either through
two incisions each 1½ to 2 inches long or one 3 to 3½ inch incision
Total Hip Replacement - Proponents
• The natural extension of minimally
invasive surgery is to do the operation on
patients as outpatients. In this situation,
the patient receives appropriate
education before surgery and then
comes to the hospital the morning of
surgery. After the operation, the patient is
able to leave the hospital on crutches and
be driven home to recover.
Total Hip Replacement - Proponents
Criteria:
• The patient is in a stable medical condition.
– Minor medical conditions should be well controlled: hypertension,
asthma, thyroid conditions, stomach or gastrointestinal problems.
• Contraindications: diabetes, altered mental function (dementia,
Parkinson’s disease), unstable cardiac status, renal failure, sleep
apnea, and significant prostate obstruction.
• The patient is willing to attend physical therapy before coming to the
hospital. The patient must learn the use of crutches and the
appropriate dislocation precautions before surgery.
• There is an appropriate caregiver to help take care of the patient at
home for the first few days after surgery.
• The patient desires to have the operation as an
outpatient. Obviously this would not be imposed on anyone.
Total Hip Replacement - Proponents
Total Hip Replacement - Proponents
Conventional
Minimally Invasive
Total Hip Replacement - Proponents
Conventional
Minimally Invasive
Total Hip Replacement - Berger
• Richard A. Berger, MD, Rush–Presbyterian
Chicago, Illinois
• 250 patients who had received total hip
replacements through his two-incision method.
• 100 have gone home the same day of surgery
• Total hip replacement surgery can be done
safely and consistently with two 1.5-inch
incisions, and most patients can go home the
same day
• Presented American Academy of Orthopaedic Surgeons.
Berger
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100 consecutive patients (74 men and 26 women)
92 patients discharged same day
the rest were sent home the following day
“In a press briefing” Dr. Berger said
only about 5% of hip replacements - less invasive
knows of no other surgeon doing it as a same-day
procedure.
• predicted that within five years, all hip replacements
would be done less invasively
• the shorter rehabilitation and more appealing scar
• "Right now, I could do it on 90% of the patients who walk
through the door."
Total Hip Replacement – Red Flags Rising
• David S. Hungerford, MD, Johns Hopkins University,
Baltimore,
– There are no rigorous data showing that less invasive surgery is
any better than procedures using a slightly longer incision.
– "For this to be widespread, you have to convince skeptics like
me," he said, adding that he was concerned that patient demand
was being driven by device manufacturers' "hype."
• Thomas P. Sculco, MD, Surgeon-in-chief at the Hospital
for Special Surgery, New York City
– cautioned that smaller incision hip replacement — especially on
an outpatient basis — required experience and carefully selected
patients and noted that Dr. Berger's patients were younger and
healthier than the average hip replacement patient.
Total Hip Replacement - Opponents
• Key factors
• Optimal fixation of the components is essential to the
long term success of the total hip arthroplasty.
• Optimal fixation provides patients with predictable and
durable results.
• The recent emphasis on minimally invasive surgery has
focussed attention on short term goals such as the rapid
rehabilitation and early discharge of the hospital.
• The ultimate goal of total hip arthroplasty however,
is the long term pain relief and function. Minimally
invasive surgery should not compromise long term
outcomes for short term achievements
Hozack
• Safe and adequate medical exposure is
required for proper component
placement and for obtaining optimal
fixation.
William Hozak- Professor of Orthopaedic Surgery
Rothman Institute, Thomas Jefferson University,
Philadelphia PA
Woolson
• “In the absence of evidence why
bother? A literature review of
minimally invasive total hip
replacement surgery”.
– Instructional Course Lectures from the
American Academy of Orthopaedic
Surgery
– Prof Woolson MD, Stanford University California
Woolson
• Is the small-incision total hip replacements
minimally invasive ?
A small skin incision requires the application
of high forces on the soft tissue for
exposure of the joint
Woolson
• A review of the literature provides no
convincing evidence of any significant
advantages of small incision THR
compared to a standard incision THR,
other than a shorter surgical scar.
Woolson
• The two incision technique have shown higher
rates of
– fracture
– nerve palsy
• “surgeons must weigh safety concerns against
patient demand in hospital economics in
deciding whether to use these procedures”
• “Patients should be informed about the few
documented advantages and possible higher
risk with the small incision technique.”
Literature
• Digioia, Ploksey, Levison, et al Mini incision technique for total hip
arthroplasty with navigation – J Arthroplasty
• De Beer Petrocelli, Alzal et al – Single incision minimally invasive
total hip arthroplasty. – J Arthroplasty.
• Chimento Provine et al – Minimally invasive total hip arthroplasty, a
respective randomized study – J Arthroplasty.
– No statistical significance between small and standard incision
total hip replacement in the specific clinical indicators for trauma,
invasiveness, post operative, narcotic requirement or length of
hospital stay.
– No difference in the transfusion requirements in these patient
groups.
– Two studies have showed evidence of more subcutaneous
tissue necrosis, poor wound healing after the mini incision
procedures.
Incidence of Fracture
• Burger Jacobs Meneghini et al reported
low risk of femoral fracture of 1%,
However
• Berry, Burger, Callahan 2.8%
• Archibeck and Pagano  7 – 9%
• There has been 4% early revision rate for
postoperative fractures
• Higher than average risk of lateral femoral
cutaneous nerve palsy (2.5-3.2%)
– Pagnano MW, Mayo Clinic,
Summary
• The literature does not show any
convincing evidence or significant
advantage of the small incision (either one
or two incision or the mini incision
techniques to standard techniques of total
hip replacement.
• The only advantage identifiable is the
smaller incision.
KNEE
• Ligament reconstruction
– Anterior Cruciate Ligament
– Posterior Cruciate Ligament
• Unicompartmental Replacement
• Total Knee Replacement
Unicompartment Replacement
MI TKR
MI TKR
MI TKR
MI TKR
Conventional
Minimally Invasive
Upper extremity
• Upper extremity reconstructions and
replacement are not controversial
• Overnight stay
Lower Extremity replacement
• Very Healthy
• Only minor medical conditions and well
controlled
• Pre-Admission Patient Education
– crutches education
– dislocation precautions
• The patient desires to have the operation as an
outpatient
Lower Extremity replacement
• Overnight stay + Rehab
– Total Knee Replacement
– Unicompartmental Knee Replacement
• Urge caution
– Total Hip Replacement
Knee Arthroscopy
Four Facts
• Four facts
• Vespa
• No convincing evidence for Minimally
Invasive Surgery of the hip
• Nurses are more observant then surgeons