Minimally Invasive Surgery of the Minimally Invasive Surgery of the Knee, ShoulderKnee, Shoulder

William F Bennett MDOrthopedic Surgeon

Bennett Orthopedics & SportsmedicineRegenerating the Youth in You!

There is a move to perform There is a move to perform surgery through smaller surgery through smaller

incisionsincisions

Impetus-lower infection rate?less pain?quicker rehab?public demandmarketingproduct companies

Arthroscopy vs ArthroplastyArthroscopy 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 SetupArthroscopy SetupUses:Knee- cartilage meniscus ligamentsShoulder- rotator cuff dislocation/instability some arthritisHip

labral tearsanterior impingement

Arthroscopy InstrumentsArthroscopy Instruments

Shoulder Anatomy

Bone

Arthroscopic PhotosArthroscopic Photos

Shoulder

Shoulder ArthroscopyShoulder ArthroscopyRotator Cuff Tears

Dislocations/Subluxations

Biceps subluxation

SLAP Lesions

Impingement

Ac Joint resection

Osteoarthritis

Knee AnatomyKnee Anatomy

Bones-– Femur– Tibia– Fibula– Patella

TendonsTendons

Rectus femorisVastus Medialis

– obliquus

Vastus lateralis– Obliquus– Patellar Ligament

ACL Ligament

Patellofemoral ChondromalciaPatellofemoral Chondromalcia

Knee ArthroscopyKnee Arthroscopy

Meniscal Repair

Meniscal Resection

Synovectomy

Chondoplasty

Ligament Reconstruction

Cartilage Regeneration

Cartilage Regeneration

Arthroscopic BiopsySent To Cambridge, MassachusettsGrown in Petri DishReplace Deficit with open procedureNear Future- arthroscopic replacement

tissue engineering

Cell Implantation Cell Implantation

Hip Arthroscopy

Limited IndicationsImpingementLabral Tears

However, Joint Replacement However, Joint Replacement can not be done can not be done arthroscopicallyarthroscopically

However, demand has pushed us to use smaller incisions and preserve anatomy

OsteoarthritisOsteoarthritis

This knee would not be amenable to arthroscopic intervention

Mini Incision/Quad SparingMini Incision/Quad Sparing TKR TKR

Smaller skin incisionDoes not disrupt the quadriceps tendon,

important for knee strengthLess time in hospitalQuicker to walk

Address all types of arthritic path.Address all types of arthritic path.

Approach both varus and valgus kneesApproach both varus and valgus knees

Provide early, exceptional analgesiaProvide early, exceptional analgesia

Allow early hospital discharge and rapid Allow early hospital discharge and rapid rehabilitationrehabilitation

The quality of the outcome not compromised by The quality of the outcome not compromised by length of incisionlength of incision

BUT NOT FOR ALL KNEES!!!!!!!!!!!!!!!!BUT NOT FOR ALL KNEES!!!!!!!!!!!!!!!!

Principles of MIS TKAPrinciples of MIS TKA

Old IncisionsOld Incisions

New IncisionsNew Incisions

NEW INSTRUMENTS NATURAL-NEW INSTRUMENTS NATURAL-LITELITE

MIS – Knee instruments – 4” incision

OldOld NewNew

MIS TKAMIS TKAIntra-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-Incision Hypothesis

Length 9-14cm1.5 - 2.0 cm Quad splitMuscle relaxationRelease lateral pat-fem ligament

PROM PTStraight leg raise on POD 1Ambulate POD 1Flex to 90 by D/C

< 3 days (Mean = 2.9)

Blood loss Tourniquet & OR timeDecreased morbidityQuicker return to ADLReduced pain (? significant)Cosmetic appeal

Standard TKA

ExposureLength 20-30cmExtensive quad violationPatellar eversionLateral release

PROM PTLeg raise by POD ?Ambulate POD 1

3 - 5 days (Mean = 3.6)

Blood lossMorbidity riskLengthy rehab

Mini TKA

Other Factors

LOS

Rehab

Reported by Dr. Luke Vaughan – Vail 2003

Quad-Sparing Hypothesis Quad-Sparing Hypothesis

Length 8-12cmNo VMO violationNo patella eversion

Early mobilizationLeg raise on day of surgeryFlex to 90 on day of surgeryAmbulation day of surgery

1 - 2 days

½ blood lossDecreased morbidityFaster return to ADLReduced pain Cosmetic appeal

Exposure

Rehab

Other Factors

LOS

Length 20-30cmExtensive quad violationPatellar eversion

PROM PTLeg raise by POD ?Ambulate POD 1

3 - 5 days

Blood lossMorbidity riskLengthy rehab

MIS TKA Standard TKA

Small IncisionSmall Incision

About 4 inches

SurgerySurgery

SummarySummary

Patients like the scarLess painLess blood lossFaster rehabilitation