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Johnson Dp. Mis Knee Replacement. What Are The Functional Benefits. Slide 1 18

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Johnson Dp. Mis Knee Replacement. What Are The Functional Benefits. Slide 1 18

  1. 1. MIS Knee Replacement: What are the functional benefits ? VOCA Lustrum Congress of Knee Surgery Norordwijk aan Zee 2007 David P. Johnson MB ChB FRCS FRCS(ORTH) MD The Bristol Orthopaedic and Sports Injury Clinic
  2. 2. MIS - Total Hip Replacement <ul><li>Berger RA Orthopedics. 2002 Mini-incisions: two for the price of one. </li></ul><ul><li>Wenz JF. 2002 Mini-incision total hip arthroplasty: a comparative assessment of perioperative outcomes. </li></ul><ul><li>Waldman BJ. J South Orthop Assoc. 2002 Minimally invasive total hip replacement and perioperative management: early experience. </li></ul>
  3. 3. MIS – Knee Replacement <ul><li>Repicci JA. J South Orthop Assoc. 1999 Minimally invasive surgical technique for unicondylar knee arthroplasty. </li></ul><ul><li>Murray DW. J Arthroplasty. 2001 Rapid recovery after oxford unicompartmental arthroplasty through a short incision. </li></ul><ul><li>Repicci JA. J Knee Surg. 2002 Minimally invasive unicondylar arthroplasty: eight-year follow-up. </li></ul>
  4. 4. MIS – TKA: Exposure <ul><li>Medial parapatellar approach </li></ul><ul><ul><li>Scuderi GR. et al CORR 2004 </li></ul></ul><ul><li>Medial parapatellar approach </li></ul><ul><ul><li>Tria AJ. et al CORR 2003 </li></ul></ul><ul><li>Mini-midvastus </li></ul><ul><ul><li>Laskin RS. CORR 2005 </li></ul></ul><ul><li>Quadriceps sparing </li></ul><ul><ul><li>Aglietti P. CORR 2006 </li></ul></ul>
  5. 5. Management of Postoperative Pain <ul><li>Burns et al Anesthesthia 1989 </li></ul><ul><ul><li>Pain is: </li></ul></ul><ul><ul><li>Cultural, nonlinear, subjective, </li></ul></ul><ul><ul><li>age and gender dependent </li></ul></ul><ul><li>Nuelle DG, J Arthroplasty. 2007 </li></ul><ul><ul><li>Multimodal pain management </li></ul></ul><ul><ul><li>Counseling and expectations </li></ul></ul><ul><ul><li>Pre-operative and pre-emptive </li></ul></ul><ul><ul><li>Cold therapy </li></ul></ul><ul><ul><li>Local / regional anaesthesia </li></ul></ul><ul><ul><li>NSAID’s </li></ul></ul><ul><ul><li>Oral analgesics </li></ul></ul><ul><ul><li>Opiates </li></ul></ul>
  6. 6. Management of Postoperative Pain <ul><li>Side effects of opioids </li></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Decrease cough reflex </li></ul></ul><ul><ul><li>Decrease GI motility </li></ul></ul><ul><ul><li>Increase biliary tract pressure </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>G-U retention </li></ul></ul><ul><ul><li>Pruritus/rash (Spinal) </li></ul></ul><ul><li>Side effects of regional analgesia </li></ul><ul><ul><li>Pruritus/rash (Spinal) </li></ul></ul><ul><ul><li>G-U retention </li></ul></ul><ul><ul><li>Urinary catheterisation </li></ul></ul><ul><ul><li>Delayed mobilisation </li></ul></ul>
  7. 7. MIS – Anaesthetic protocol <ul><li>Pre-operative counselling </li></ul><ul><li>Spinal anaesthesia </li></ul><ul><li>Regional / local nerve block </li></ul><ul><li>Post-operative opiates </li></ul><ul><li>Pre-emptive oral analgesia </li></ul><ul><li>NSAID’s </li></ul><ul><li>CPM </li></ul>
  8. 8. MIS – TKA Instrumentation <ul><li>Tria AJ. OCNA 2004 </li></ul>
  9. 9. MIS - Patellar subluxation <ul><li>Mobilise quadriceps </li></ul><ul><li>Resect patellar osteophytes </li></ul><ul><li>Resect femoral osteophytes </li></ul><ul><li>Excise fat pad </li></ul><ul><li>Release patello-femoral fold </li></ul><ul><li>Resect articular surface of patella </li></ul><ul><li>Abandon MIS </li></ul>
  10. 10. MIS – Size and obesity <ul><li>Size and weight </li></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Men / women </li></ul></ul><ul><ul><li>Flexibility </li></ul></ul><ul><ul><li>Choose incision </li></ul></ul>
  11. 11. MIS – Uni - Compartmental Knee <ul><li>Repicci JA, et al J South Orthop Assoc. 1999 </li></ul><ul><ul><li>700 Uni from 1992 </li></ul></ul><ul><ul><li>80% were 24 hr stay </li></ul></ul><ul><ul><li>Rehabilitation minimal </li></ul></ul>
  12. 12. Problems of MIS <ul><li>Shakespear et al Knee 2005 </li></ul><ul><ul><li>Oxford Uni-compartmental </li></ul></ul><ul><ul><li>Flexed femoral component 8 º </li></ul></ul><ul><ul><li>Varus tibial component 1.8 º </li></ul></ul><ul><ul><li>Posterior under-hang in 35% </li></ul></ul><ul><li>Kort et al: 2007 </li></ul><ul><ul><li>11% revision @ 2-7 years </li></ul></ul><ul><li>Hamilton WG et al J Arthroplasty 2006 </li></ul><ul><ul><li>Aseptic loosening 3.7% cv 1% </li></ul></ul><ul><ul><li>Reoperation 11.3% cv 8.6% </li></ul></ul>
  13. 13. Functional Outcome : MIS - Uni <ul><li>Muller et al: J Arthroplasty. 2004 </li></ul><ul><ul><li>Tibia varus and anterior </li></ul></ul><ul><ul><li>HSS 78 cv 92 </li></ul></ul><ul><ul><li>ROM 109 ° cv 113 ° </li></ul></ul><ul><ul><li>Extensor lag </li></ul></ul><ul><li>Carlsson et al 2006 </li></ul><ul><ul><li>MIS faster rehabilitation </li></ul></ul><ul><ul><li>Shorter hospitalisation </li></ul></ul><ul><ul><li>HSS 92 vs 96 </li></ul></ul><ul><ul><li>Limb alignment and migration equal </li></ul></ul><ul><li>Murray et al JBJS Br 2006 </li></ul><ul><ul><li>97% survival rate at 7 years. </li></ul></ul>
  14. 14. MIS – Total Knee Replacement <ul><li>Laskin RS. CORR 2004 </li></ul><ul><ul><li>Review of 32 cases with historical controlls. </li></ul></ul><ul><li>Hass SB. CORR 2004 </li></ul><ul><li>Aglietti P. CORR 2006 </li></ul><ul><ul><li>Mini midvastus </li></ul></ul><ul><ul><li>Quadriceps sparing incision. </li></ul></ul>
  15. 15. Functional Outcome : MIS - TKA <ul><li>Tria AJ et al JBJS Br 2006 </li></ul><ul><ul><li>Quadriceps sparing </li></ul></ul><ul><ul><li>Same knee scores </li></ul></ul><ul><ul><li>Longer MIS surgery </li></ul></ul><ul><ul><li>Inferior component placement </li></ul></ul><ul><li>King et al JBJS Am. 2007 </li></ul><ul><ul><li>Shorter hospital stay </li></ul></ul><ul><ul><li>Less rehabilitation </li></ul></ul><ul><ul><li>Less use of sticks at 2/52 </li></ul></ul>
  16. 16. MIS The Learning Curve <ul><li>King et al JBJS Am. 2007 </li></ul><ul><ul><li>First 25 cases </li></ul></ul><ul><ul><ul><li>Longer operation </li></ul></ul></ul><ul><ul><ul><li>Patellar tilt </li></ul></ul></ul><ul><li>Kolisek et al J Arthroplasty. 2007 </li></ul><ul><ul><li>First cases no difference </li></ul></ul><ul><li>Murray et al 2004 </li></ul><ul><ul><li>First 10 cases had lower HSS scores </li></ul></ul>
  17. 17. MIS - Economic advantages <ul><li>Bozic KJ, CORR 2007 </li></ul>
  18. 18. <ul><li>Wound 8 – 10 cm in extension </li></ul>

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