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Hip and Knee Arthroplasty

INVASIVE. Minimally. Hip and Knee Arthroplasty. Presented by: Nicole M. Boyko, PT, MS. Overview. Basics of Total Joint Surgery What is MIS? Benefits of MIS Application of MIS to Hip Replacement Application of MIS to Knee Replacement Conclusion/Implication to PT. Introduction.

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Hip and Knee Arthroplasty

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

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

  3. Introduction • > 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 • Annually this amounts to: • 152,000 THA surgeries • 299,000 TKA surgeries

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

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

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

  7. Mini Incision THA • Utilizes 3-4” incision vs 8-10” with traditional THA • Cementless metal and plastic implant • 4-6 wk projected recovery period • 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 Zimmer (2002, 2003); Rodrigo (2002)

  8. Research: Wenz et al (2002)

  9. Two Incision THA • 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 • 80% of 1st 50 cases able to D/C same day after 100 min OR procedure Zimmer (2002, 2003); Berger (2002)

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

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

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

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

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

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

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

  17. Minimally Invasive TKA Zimmer Mini-Incision TKA • Pioneered by Dr. Luke Vaugh of Scripp’s clinic in La Jolla, CA, 1999 • 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 CNET (2003); Zimmer (2002, 2003)

  18. Minimally Invasive TKA Zimmer Minimally Invasive Solutions Quad-Sparing TKA • Avoids cut through quads • Pioneered by Dr. Alfred Tria of St Peter’s Hospital in New Brunswick, NJ • 3” incision, LOS < 48 hrs, 18% > ROM • Uses Zimmer NexGen Complete Knee Solution LPS Flex Components • Stealth Station optic image guidance tech Zimmer (2003)

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

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

  21. Questions?

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