1. 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

2. There is a move to perform surgery through smaller incisions
Impetus-
lower infection rate?
less pain?
quicker rehab?
public demand
marketing
product companies

3. 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.

4. Arthroscopy Setup Uses: Knee- cartilage meniscus ligaments Shoulder-
rotator cuff
dislocation/instability
some arthritis
Hip labral tears anterior impingement

5. Arthroscopy Instruments

6. Shoulder Anatomy

7. Bone

8. Arthroscopic Photos
Shoulder

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

10. Knee Anatomy
Bones-
Femur
Tibia
Fibula
Patella

11. Tendons Rectus femoris Vastus Medialis Vastus lateralis obliquus
Patellar Ligament

12. ACL Ligament

13. Patellofemoral Chondromalcia

14. Knee Arthroscopy Meniscal Repair Meniscal Resection Synovectomy
Chondoplasty
Ligament Reconstruction
Cartilage Regeneration

15. Cartilage Regeneration
Arthroscopic Biopsy
Sent To Cambridge, Massachusetts
Grown in Petri Dish
Replace Deficit with open procedure
Near Future- arthroscopic replacement
tissue engineering

16. Cell Implantation

17. Hip Arthroscopy
Limited Indications
Impingement
Labral Tears

18. However, Joint Replacement can not be done arthroscopically
However, demand has pushed us to use smaller incisions and preserve anatomy

19. Osteoarthritis
This knee would not be amenable to arthroscopic intervention

20. 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

21. 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!!!!!!!!!!!!!!!!

22. Old Incisions

23. New Incisions

24. NEW INSTRUMENTS NATURAL-LITE
MIS – Knee instruments – 4” incision

25. Old New

26. 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

27. 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
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

28. 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

29. Small Incision
About 4 inches

30. Surgery

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