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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?

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Minimally Invasive Surgery of the Knee, Shoulder

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  1. 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. 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 • obliquus • 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 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

  28. Quad-Sparing Hypothesis MIS TKA StandardTKA 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

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