2. Hip and Knee Arthroplasty Presented by: Nicole M. Boyko, PT, MS Minimally INVASIVE

3. Overview n Basics of Total Joint Surgery n What is MIS? n Benefits of MIS n Application of MIS to Hip Replacement n Application of MIS to Knee Replacement n Conclusion/Implication to PT

4. Introduction n > 21 million people in the US have some form of osteoarthritis –By 2020, 20% of Americans will be >65 y/o and at risk for OA n Annually this amounts to: –152,000 THA surgeries –299,000 TKA surgeries

5. What is MIS? n MIS= Minimally invasive solutions –Widely used in gynecological, cardiac, GI surgery –Now being applied to orthopedic surgeries n Mini-incision vs Mini-invasive –Mini-incision= operation through smaller hole –Mini-invasive adds to this 3 goals: n Minimal disruption of physiology n Minimal lifestyle interference n Avoidance of interference with future Rx or surgery

6. Benefits of MIS n  operation time n  blood loss peri- and post-op n  hospital stay n  costs n  risk of infection n Overall shorter recovery time n Smaller incision n  tissue and muscle trauma n  pain n 20-30% more ROM n Quicker, easier rehab

7. Application of MIS to THA n Pioneered by Zimmer Holdings, Inc. of Warsaw, IN –Global leader in design, development and manufacture of reconstructive orthopaedic implants n Two Techniques –Mini Incision Technique –Two- Incision Technique

8. Zimmer (2002, 2003); Rodrigo (2002) Mini Incision THA n Utilizes 3-4” incision vs 8-10” with traditional THA n Cementless metal and plastic implant n 4-6 wk projected recovery period n Two common procedures –Top ½ of posterolateral approach –Top 1/3 of anterolateral approach *In either approach, incision can be extended to full length at any time during surgery

9. Research: Wenz et al (2002) Results:Mini-incision Direct lateral approach # Cases 12465 OR time 40 min 126 min Blood loss 129 mL 602 mL Incision length 3.5 “ 8” D/C from hospital 60% by day 3 47% by day 3 Average LOS 3.8 days 4.0 days D/C Placement 44% home 50% rehab 6% SNF 38% home 40% rehab 22% SNF

10. Zimmer (2002, 2003); Berger (2002) Two Incision THA n No mm are cut so < pain than mini THA –One 1.5-1.75” ant incision over fem neck for excision of head of femur and implantation of acetabular component –One 1-1.25” incision made as if IM fem rod were being placed for insertion of fem head component n 80% of 1 st 50 cases able to D/C same day after 100 min OR procedure

11. Application of MIS to Knee Replacement n Unicondylar Knee Replacement –Uni-Spacer –Repicci II Unicondylar –Zimmer M/G Uni Knee n Minimally Invasive TKA –L-I Approach –Zimmer Approaches –Smith & Nephew and BrainLAB Approaches

12. Unicondylar Knee Arthroplasty n Involves reshaping only damaged portion of joint n Introduced in 1970s n 5,000 performed annually in U.S. n Newest innovation- minimally invasive UKA or “mini-uni” –Introduced in late 1990s –Same concepts but with 3-4” incision

13. Ideal Candidates for UKA n 45-65 y/o n Isolated non-rheumatoid OA with cartilage NOT bone loss n Normal ligaments n No significant patella problems n Best for non-obese patients

14. SulzerMedica (2002); St Croix Orthopedics (2002) Popular Uni-Knees Uni-Spacer n Manufactured by Sulzer Orthopedics, Inc. n Cleared for use in US in Jan 2001 n > 2,500 successful surgeries to date n Cobalt and chrome alloy prosthesis n Fit b/t femur and tibia alleviates need for cement or screws n Does not compromise conversion to TKA

15. CBSnews.com (2002); Repicci et al (2003) Popular Uni Knees Repicci II Unicondylar Program n Biomet prosthesis with 10 yr, 90% success rate n 7-10 cm incision for medial rebalancing, 10- 12 cm for lateral rebalancing n Burr rather than cut bone for implant n Freelance procedure relies on anatomy not instruments to determine bone removal

16. Zimmer (2002, 2003) Popular Uni Knees Zimmer M/G Uni Knee n Introduced in late 1990s n 2-3” incision to remove diseased portion of knee n Can be done on outpt basis n 5 wk recovery time with near full ROM n > 20,000 implanted to date

17. Bonutti.net (2002) Minimally Invasive TKA L-I Approach n = Limited Incision TKA n Invented by Dr. Peter Bonutti of Bonutti Clinic in Effingham, IL n 3-4” incision, 60-75 min OR time n Uses Scorpio Total Knee Instrumentation by Stryker Howmedica Osteonics (SHO) n > 200 surgeries to date; research results pending by SHO

18. CNET (2003); Zimmer (2002, 2003) Minimally Invasive TKA Zimmer Mini-Incision TKA n Pioneered by Dr. Luke Vaugh of Scripp’s clinic in La Jolla, CA, 1999 n Comparison study of 60 MINI vs 66 traditional: –Incision: 4.3-5.5” vs 7.8-12” –Hospital stay: 3.0 days vs 3.5 days

19. Zimmer (2003) Minimally Invasive TKA Zimmer Minimally Invasive Solutions Quad-Sparing TKA n Avoids cut through quads n Pioneered by Dr. Alfred Tria of St Peter’s Hospital in New Brunswick, NJ n 3” incision, LOS ROM –Uses Zimmer NexGen Complete Knee Solution LPS Flex Components –Stealth Station optic image guidance tech

20. BrainLAB (2003), MedScape (2003) Minimally Invasive TKA Smith & Nephew and BrainLAB n April 2003: 1 st mini TKR enhanced by high precision computer navigation n Performed by Dr. John Lange & Dr. Paul Schwartz of Shasta Orthopedics, Redding, CA n Utilizes 3.5” incision,  rehab by 2 mo n Accuracy of implant alignment extends life n Tested in US, Europe, Japan, Canada, Australia

21. Implication to PT n Requires modification of our existing total joint protocols n In all cases, pts able to: –Walk sooner –Perform more aggressive ROM –Tolerate more advanced strengthening –D/C to home earlier

22. Questions?