Minimally Invasive Surgery of the Knee, Shoulder 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 ligaments Shoulder- rotator cuff dislocation/instability some arthritis Hip labral tears anterior impingement

Arthroscopy Instruments

Shoulder Anatomy

Bone

Arthroscopic Photos Shoulder

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

Knee Anatomy Bones- Femur Tibia Fibula Patella

Tendons Rectus femoris Vastus Medialis Vastus lateralis obliquus Patellar Ligament

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 Length 20-30cm Extensive quad violation Patellar eversion Lateral release PROM  PT Leg raise by POD ? Ambulate POD 1 3 - 5 days (Mean = 3.6) Blood loss Morbidity risk Lengthy rehab Length 9-14cm 1.5 - 2.0 cm Quad split Muscle relaxation Release lateral pat-fem ligament PROM  PT Straight leg raise on POD 1 Ambulate POD 1 Flex to 90 by D/C < 3 days (Mean = 2.9)  Blood loss  Tourniquet & OR time Decreased morbidity Quicker return to ADL Reduced pain (? significant) Cosmetic appeal Exposure Rehab LOS Other Factors Reported by Dr. Luke Vaughan – Vail 2003

Quad-Sparing Hypothesis MIS TKA Standard TKA Length 8-12cm No VMO violation No patella eversion Early mobilization Leg raise on day of surgery Flex to 90 on day of surgery Ambulation day of surgery 1 - 2 days ½ blood loss Decreased morbidity Faster return to ADL Reduced pain Cosmetic appeal Length 20-30cm Extensive quad violation Patellar eversion PROM  PT Leg raise by POD ? Ambulate POD 1 3 - 5 days Blood loss Morbidity risk Lengthy rehab Exposure Rehab LOS Other Factors

Small Incision About 4 inches

Surgery

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