Minimally Invasive Surgery of the Knee, Shoulder
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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!
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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
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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.
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Arthroscopy SetupArthroscopy SetupUses:Knee- cartilage meniscus ligamentsShoulder- rotator cuff dislocation/instability some arthritisHip
labral tearsanterior impingement
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Arthroscopy InstrumentsArthroscopy Instruments
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Shoulder Anatomy
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Bone
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Arthroscopic PhotosArthroscopic Photos
Shoulder
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Shoulder ArthroscopyShoulder ArthroscopyRotator Cuff Tears
Dislocations/Subluxations
Biceps subluxation
SLAP Lesions
Impingement
Ac Joint resection
Osteoarthritis
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Knee AnatomyKnee Anatomy
Bones-– Femur– Tibia– Fibula– Patella
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TendonsTendons
Rectus femorisVastus Medialis
– obliquus
Vastus lateralis– Obliquus– Patellar Ligament
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ACL Ligament
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Patellofemoral ChondromalciaPatellofemoral Chondromalcia
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Knee ArthroscopyKnee Arthroscopy
Meniscal Repair
Meniscal Resection
Synovectomy
Chondoplasty
Ligament Reconstruction
Cartilage Regeneration
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Cartilage Regeneration
Arthroscopic BiopsySent To Cambridge, MassachusettsGrown in Petri DishReplace Deficit with open procedureNear Future- arthroscopic replacement
tissue engineering
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Cell Implantation Cell Implantation
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Hip Arthroscopy
Limited IndicationsImpingementLabral Tears
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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
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OsteoarthritisOsteoarthritis
This knee would not be amenable to arthroscopic intervention
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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
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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
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Old IncisionsOld Incisions
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New IncisionsNew Incisions
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NEW INSTRUMENTS NATURAL-NEW INSTRUMENTS NATURAL-LITELITE
MIS – Knee instruments – 4” incision
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OldOld NewNew
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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
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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
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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
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Small IncisionSmall Incision
About 4 inches
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SurgerySurgery
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SummarySummary
Patients like the scarLess painLess blood lossFaster rehabilitation