This document provides an overview of minimally invasive surgery techniques in orthopedics. It discusses the history and basic principles of minimally invasive surgery. Key areas where minimally invasive techniques are used include minimally invasive spine surgery using tubular retractors, arthroscopy of joints like the shoulder, knee, hip and ankle, minimally invasive surgeries for fracture management using techniques like IM nailing and MIPO, and minimally invasive joint replacements like knee and hip arthroplasty. Benefits of minimally invasive surgeries include minimal tissue trauma, reduced pain and morbidity, shorter hospital stays and faster recovery.

1. Minimally InvasiveMinimally Invasive
Surgery inSurgery in
OrthopaedicsOrthopaedics
Dr. Anshu SharmaDr. Anshu Sharma
Moderator: Dr. A.K MathurModerator: Dr. A.K Mathur

2. IntroductionIntroduction
 A minimally invasive surgical procedure shouldA minimally invasive surgical procedure should
be defined as one that is safe, performed withbe defined as one that is safe, performed with
least soft tissue damage and is associated with aleast soft tissue damage and is associated with a
lower postoperative patient morbidity comparedlower postoperative patient morbidity compared
with a conventional approach for the samewith a conventional approach for the same
operation.operation.

3. HistoryHistory
 First procedure performed: Cystoscope to lookFirst procedure performed: Cystoscope to look
into and treat lesions of the bladder.into and treat lesions of the bladder.
 In 1931,Takagi of Tokyo redesigned theIn 1931,Takagi of Tokyo redesigned the
cystoscope and produced an arthroscope.cystoscope and produced an arthroscope.
 Marski Watanable, a student of Takagi, furtherMarski Watanable, a student of Takagi, further
improved the arthroscope, and in 1957, basedimproved the arthroscope, and in 1957, based
on extensive experience in performingon extensive experience in performing
arthroscopy, he published an Atlas ofarthroscopy, he published an Atlas of
Arthroscopy.Arthroscopy.

4.  Basic principle:-Basic principle:-
-Effectively treat pathology with minimal-Effectively treat pathology with minimal
disturbance of normal anatomy.disturbance of normal anatomy.
-Leaving “the smallest footprint.”-Leaving “the smallest footprint.”
 Advantages:Advantages:
-Minimal tissue trauma,-Minimal tissue trauma,
-Minimal post- operative pain and morbidity,-Minimal post- operative pain and morbidity,
-Minimal hospital stay,-Minimal hospital stay,
-Early and better recovery.-Early and better recovery.

5. MIS Techniques In OrthopedicsMIS Techniques In Orthopedics
 In Orthopedics Minimal Invasive surgicalIn Orthopedics Minimal Invasive surgical
techniques are used in following areas:-techniques are used in following areas:-
1)Minimally invasive Spine Surgeries,1)Minimally invasive Spine Surgeries,
2)Arthroscopy,2)Arthroscopy,
3)Minimally invasive surgeries for fracture3)Minimally invasive surgeries for fracture
management,management,
4)Minimally invasive Arthroplasty.4)Minimally invasive Arthroplasty.

6. Minimally Invasive Spinal SurgeriesMinimally Invasive Spinal Surgeries
(MISS)(MISS)
 Spine surgery is traditionally done as “openSpine surgery is traditionally done as “open
surgery”.surgery”.
 Minimally invasive techniques are beginningMinimally invasive techniques are beginning
to be used for a wider range of spineto be used for a wider range of spine
procedures, and have been used for commonprocedures, and have been used for common
procedures like decompression and spinalprocedures like decompression and spinal
fusion since the 1990s.fusion since the 1990s.
 Traditional open surgeries of spine requiresTraditional open surgeries of spine requires
an incision that is 5 to 6 inch long andan incision that is 5 to 6 inch long and
retraction of the muscles in order to see theretraction of the muscles in order to see the
spine or deeper structures.spine or deeper structures.
 Retraction of muscles and soft tissue forRetraction of muscles and soft tissue for
prolonged period leads to their damage andprolonged period leads to their damage and
increased post operative pain and morbidity. increased post operative pain and morbidity.

7.  In MISS procedures (such as diskectomy,In MISS procedures (such as diskectomy,
laminectomy and spinal fusion) arelaminectomy and spinal fusion) are
performed with special tools called tubularperformed with special tools called tubular
retractors.retractors.
 During the procedure, a small incision isDuring the procedure, a small incision is
made and the tubular retractor is insertedmade and the tubular retractor is inserted
through the skin and soft tissues down tothrough the skin and soft tissues down to
the spinal column.the spinal column.
 In order to see where to place the incisionIn order to see where to place the incision
and insert the retractor, the surgeon isand insert the retractor, the surgeon is
guided by fluoroscopy.guided by fluoroscopy.

8.  The tubular retractor holds theThe tubular retractor holds the
muscles open and is kept inmuscles open and is kept in
place throughout theplace throughout the
procedure.procedure.
 Any bone or disk material thatAny bone or disk material that
is removed exits through theis removed exits through the
retractor, and any devicesretractor, and any devices
necessary for fusion — such asnecessary for fusion — such as
screws or rods — are insertedscrews or rods — are inserted
through the retractor.through the retractor.
 Some surgeries require moreSome surgeries require more
than one retractor.than one retractor.
A small instrument is inserted
through the tubular retractor to
remove a herniated disk.
Screws to support the fusion
are placed in the bone through
both retractors .

9.  Indications of MISS:-Indications of MISS:-
-Posterior cervical lamino-foraminotomy and-Posterior cervical lamino-foraminotomy and
discectomy,discectomy,
-Thoracic discectomy and laminectomy,-Thoracic discectomy and laminectomy,
-Lumbar disecctomy and laminectomy,-Lumbar disecctomy and laminectomy,
-Tumors of the Thoraco-Lumbar spine,-Tumors of the Thoraco-Lumbar spine,
-Interbody Fusion-Interbody Fusion
-Kyphoplasty/Vertebroplasty.-Kyphoplasty/Vertebroplasty.

10.  Contraindications of MISS:-Contraindications of MISS:-
--Systemic:Systemic:
-Recent systemic/local infection,-Recent systemic/local infection,
-Uncorrected bleeding diathesis,-Uncorrected bleeding diathesis,
-Insufficient cardiopulmonary health,-Insufficient cardiopulmonary health,
--Local:Local:
-Fracture related canal compromise,-Fracture related canal compromise,
- Severe spinal canal stenosis,- Severe spinal canal stenosis,
-> 2 level disc,-> 2 level disc,
-Bony bridging of interlaminar space.-Bony bridging of interlaminar space.

11.  Complications of MISS:-Complications of MISS:-
-Hemorrhage,-Hemorrhage,
-Dural Tear,-Dural Tear,
-Bowel Perforation,-Bowel Perforation,
-Infection,-Infection,
-Hardware failure,-Hardware failure,
-Adjacent level vertebral body collapse,-Adjacent level vertebral body collapse,
-Venous embolism,-Venous embolism,
-Cement migration.-Cement migration.

12.  Limitations of MISS:-Limitations of MISS:-
-There is a learning curve to using the system-There is a learning curve to using the system
efficiently and safelyefficiently and safely
-Complications like dural tear, if occur can be-Complications like dural tear, if occur can be
difficult to repair,difficult to repair,
-Delicate instruments with risk of instrument-Delicate instruments with risk of instrument
failure.failure.

13. ArthroscopyArthroscopy
 ArthroscopyArthroscopy is a minimally invasive surgical is a minimally invasive surgical
procedure on a joint in which an examinationprocedure on a joint in which an examination
and/or treatment of damage is performed usingand/or treatment of damage is performed using
an an arthroscope.arthroscope.
 This word arthroscopy came from Greek,This word arthroscopy came from Greek,
““Arthro" (joint) And “Skopein"(to look).Arthro" (joint) And “Skopein"(to look).

14.  Arthroscope:Arthroscope: A thin flexibleA thin flexible
fiberoptic scope which isfiberoptic scope which is
introduced into a joint spaceintroduced into a joint space
through a small incision inthrough a small incision in
order to carry out proceduresorder to carry out procedures
within the joint.within the joint.
 Fitted withFitted with
 Mini camera,Mini camera,
 Light source,Light source,
 Surgical tools.Surgical tools.

15. Shoulder ArthroscopyShoulder Arthroscopy
 Indications:-Indications:-
-Rotator Cuff Tears-Rotator Cuff Tears
-Recurrent Dislocations,-Recurrent Dislocations,
-Biceps subluxation-Biceps subluxation
-SLAP Lesions-SLAP Lesions
-Impingement-Impingement
-Ac Joint resection-Ac Joint resection
-Osteoarthritis-Osteoarthritis

16.  Beach-chair position,Beach-chair position,
-Anatomical position,-Anatomical position,
-Easy to Convert to Open-Easy to Convert to Open
surgerysurgery
-Able to Move arm.-Able to Move arm.

17. Posterior Labral TearBankart Tear
Bony Bankart
SLAP Tear Rotator Cuff Tear
Pathological LesionsPathological Lesions
www.shoulderdoc.co.uk

18. Knee ArthroscopyKnee Arthroscopy
 Indications:-Indications:-
-Meniscal Repair,-Meniscal Repair,
-Meniscal Resection,-Meniscal Resection,
-Ligament Reconstruction,-Ligament Reconstruction,
-Cartilage Regeneration,-Cartilage Regeneration,
-Removal of loose bodies,-Removal of loose bodies,
-Removal of synovium for-Removal of synovium for
-Partial Synovectomy,-Partial Synovectomy,
-Biospy,-Biospy,
-Lavage of infected joint .-Lavage of infected joint .

21. Hip ArthroscopyHip Arthroscopy
 Limited Indications:Limited Indications:
- Femoroacetabular- Femoroacetabular
Impingement,Impingement,
-Labral Tears,-Labral Tears,
-Loose bodies.-Loose bodies.

22. Ankle ArthroscopyAnkle Arthroscopy
 Indications:-Indications:-
-Articular injury,-Articular injury,
-Soft-tissue injury,-Soft-tissue injury,
-Bony impingement,-Bony impingement,
-Arthroscopic-assisted-Arthroscopic-assisted
fracture fixation,fracture fixation,
-Synovitis,-Synovitis,
-Loose bodies,-Loose bodies,
-Osteophytes,-Osteophytes,
-Osteochondral defects,-Osteochondral defects,
-Arthrodesis.-Arthrodesis.

23.  Contraindications of Arthroscopy:-Contraindications of Arthroscopy:-
-In a minimaly deranged joints where-In a minimaly deranged joints where
conservative method may response,conservative method may response,
-When risk of joint sepsis from a local skin-When risk of joint sepsis from a local skin
infection,infection,
-Major collateral ligament & capsular disruption.-Major collateral ligament & capsular disruption.
-Partial or complete ankylosis (relative).-Partial or complete ankylosis (relative).

24.  Complications of Arthroscopy:-Complications of Arthroscopy:-
-Damages to related structures,-Damages to related structures,
-Hemarthrosis-Hemarthrosis (most common postop.),(most common postop.),
-Thrombophlebitis,-Thrombophlebitis,
-INFECTION-INFECTION – as for any surgery but very less,– as for any surgery but very less,
-Tourniquet paresis,-Tourniquet paresis,
-Synovial herniation & Fistulas,-Synovial herniation & Fistulas,
-Instrument breakage.-Instrument breakage.
 COMPLICATIONS RELATED TOCOMPLICATIONS RELATED TO
ANESTHESIAANESTHESIA

25.  Limitations of Arthroscopy:-Limitations of Arthroscopy:-
-Very few Surgeons,-Very few Surgeons,
-Technically demanding-Technically demanding
-Specialized equipments required-Specialized equipments required
-Needs excellent psychomotor-Needs excellent psychomotor
co-ordination.co-ordination.

26. Minimally Invasive Surgeries ForMinimally Invasive Surgeries For
Fracture ManagementFracture Management
 MIS with a small incision results in minimal injury toMIS with a small incision results in minimal injury to
soft tissue and bone which has a great biologicalsoft tissue and bone which has a great biological
advantages for fracture healing.advantages for fracture healing.
 The best example is closed IMN of diaphyseal fracturesThe best example is closed IMN of diaphyseal fractures
and bridge plating for fractures of the epiphysis orand bridge plating for fractures of the epiphysis or
metaphysis extending into the shaft.metaphysis extending into the shaft.
 Reduction is done by indirect closed percutaneousReduction is done by indirect closed percutaneous
length usually.length usually.

27.  MIS consists of small soft tissue window,MIS consists of small soft tissue window,
through a small skin incision, which allow allowsthrough a small skin incision, which allow allows
insertion of implants or instruments.insertion of implants or instruments.
 MIS causes minimal additional injury to the softMIS causes minimal additional injury to the soft
tissue and fracture fragments.tissue and fracture fragments.
 Use of indirect reduction or a gental directUse of indirect reduction or a gental direct
reduction.reduction.

28.  Following implants are used for MIS techniqueFollowing implants are used for MIS technique
of fracture management:of fracture management:
-Closed IM Interlocking Nailing,-Closed IM Interlocking Nailing,
-Minimally invasive plate osteosynthesis,-Minimally invasive plate osteosynthesis,
-External fixator,-External fixator,
-Percutaneous K-wire or screw fixation.-Percutaneous K-wire or screw fixation.

29.  Indications:-Indications:-
-IMIL Nailing:-IMIL Nailing:
-Closed diaphyseal fractures.-Closed diaphyseal fractures.

30.  MIPO:MIPO:
-Intra-articular # (distal femur, proximal & distal-Intra-articular # (distal femur, proximal & distal
tibia, proximal humerus),tibia, proximal humerus),
-Comminuted metaphyseal or diaphyseal #.-Comminuted metaphyseal or diaphyseal #.

32. External fixator:External fixator:
-Open metaphyseal-Open metaphyseal
or diaphyseal # withor diaphyseal # with
soft tissue damage.soft tissue damage.

33. Minimally InvasiveMinimally Invasive
ArthroplastyArthroplasty
 MinimallyMinimally
invasive Kneeinvasive Knee
Replacement,Replacement,
 MinimallyMinimally
invasive Hipinvasive Hip
Replacement.Replacement.

34. Minimally InvasiveMinimally Invasive
Knee ReplacementKnee Replacement
 Heavily developed since 1991.Heavily developed since 1991.
 6-8 cm incision results in less6-8 cm incision results in less
damage to tissue.damage to tissue.
 A smaller incision results inA smaller incision results in
faster recovery and less narcoticfaster recovery and less narcotic
use for patients.use for patients.
 Anesthesia times averageAnesthesia times average
approximately 2 hours and 30approximately 2 hours and 30
mins.mins.

35. Comparing Incision SizesComparing Incision Sizes
Minimally Invasive Traditional TKR

36. Traditional TKR MIS TKRTraditional TKR MIS TKR

37. Study of Minimally Invasive KneeStudy of Minimally Invasive Knee
Replacements (Richard Laskin)Replacements (Richard Laskin)
 58 TKR were performed via minimally58 TKR were performed via minimally
invasive approach with a control group (42invasive approach with a control group (42
TKR) who had traditional knee replacementTKR) who had traditional knee replacement
surgery .surgery .
 Proposed that a minimally invasiveProposed that a minimally invasive
approach would limit soft tissue disruption,approach would limit soft tissue disruption,
speed recovery time, diminish blood loss,speed recovery time, diminish blood loss,
and decrease post-operative pain.and decrease post-operative pain.

38.  Pain was reported to be considerably lower in thePain was reported to be considerably lower in the
minimally invasive group than in the traditionalminimally invasive group than in the traditional
knee replacement group.knee replacement group.
 Total use of morphine by the minimally invasiveTotal use of morphine by the minimally invasive
group was 55 mg versus 118 mg by the traditionalgroup was 55 mg versus 118 mg by the traditional
group.group.
 Interestingly, blood loss was greater in patientsInterestingly, blood loss was greater in patients
undergoing minimally invasive surgery at 713 mlundergoing minimally invasive surgery at 713 ml
compared to 573 ml in the traditional kneecompared to 573 ml in the traditional knee
replacement group.replacement group.

39. Minimally invasive Hip ReplacementMinimally invasive Hip Replacement
Traditional THRTraditional THR
Proven in clinical studies andProven in clinical studies and
successfully performed forsuccessfully performed for
decades.decades.
 Allows surgeon fullAllows surgeon full
visualization of operative area.visualization of operative area.
 Larger incision (8-10 inches).Larger incision (8-10 inches).
 More disruption of musclesMore disruption of muscles
and tissues.and tissues.
 Average hospital stay is fiveAverage hospital stay is five
days.days.
 Average recovery time ofAverage recovery time of
approx. 3 months (individualsapprox. 3 months (individuals
will vary)will vary)
Minimally InvasiveMinimally Invasive
THRTHR
Long-term effects and successLong-term effects and success
are not established.are not established.
 Restricted visualization ofRestricted visualization of
operation area.operation area.
 Smaller incisions (2-4 inches)Smaller incisions (2-4 inches)
 Potentially less disruption ofPotentially less disruption of
muscles and tissues.muscles and tissues.
 May lead to a shortenedMay lead to a shortened
hospital stay, less than 5 days.hospital stay, less than 5 days.
 May reduce recovery timeMay reduce recovery time

40. Traditional VS Minimally Invasive HipTraditional VS Minimally Invasive Hip
Replacement SurgeryReplacement Surgery
Traditional HipTraditional Hip
Replacement SurgeryReplacement Surgery
Minimally Invasive HipMinimally Invasive Hip
Replacement SurgeryReplacement Surgery

41. Minimally Invasive Hip TechniquesMinimally Invasive Hip Techniques
Two-IncisionTwo-Incision
 2 incisions2 incisions
 Approximately 2 inchesApproximately 2 inches
in lengthin length
 On both front and rearOn both front and rear
of thighof thigh
 Fluoroscopy may beFluoroscopy may be
used.used.
Mini-IncisionMini-Incision
 1 incision1 incision
 Approximately 3 to 4Approximately 3 to 4
inches in lengthinches in length
 Either front or rear ofEither front or rear of
thighthigh
 Fluoroscopy is not usedFluoroscopy is not used..

42. MI THR Techniques:MI THR Techniques:
Two Incision vs Mini IncisionTwo Incision vs Mini Incision
Two-IncisionTwo-Incision Mini-IncisionMini-Incision

43. ConclusionConclusion
 Patients report near equal satisfaction ratesPatients report near equal satisfaction rates
with both types of Knee and Hipwith both types of Knee and Hip
replacement.replacement.
 Reduction of cost, hospitalization, post-opReduction of cost, hospitalization, post-op
pain, and a decrease in the length ofpain, and a decrease in the length of
rehabilitation will push further developmentrehabilitation will push further development
of minimally invasive procedures.of minimally invasive procedures.
 Longer anesthesia times and increasedLonger anesthesia times and increased
blood loss with minimally invasiveblood loss with minimally invasive
procedures are a concern.procedures are a concern.
 New procedures present learning curve toNew procedures present learning curve to
surgeons.surgeons.

44. Thank you….Thank you….