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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. - PowerPoint PPT Presentation
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Hip and Knee ArthroplastyHip and Knee Arthroplasty
Presented by:Presented by:
Nicole M. Boyko, PT, MSNicole M. Boyko, PT, MS
MinimallyINVASIVE
OverviewOverview
Basics of Total Joint SurgeryBasics of Total Joint Surgery What is MIS?What is MIS? Benefits of MISBenefits of MIS Application of MIS to Hip Application of MIS to Hip
ReplacementReplacement Application of MIS to Knee Application of MIS to Knee
ReplacementReplacement Conclusion/Implication to PTConclusion/Implication to PT
IntroductionIntroduction
> 21 million people in the US have > 21 million people in the US have some form of osteoarthritissome form of osteoarthritis– By 2020, 20% of Americans will be By 2020, 20% of Americans will be
>65 y/o and at risk for OA>65 y/o and at risk for OA Annually this amounts to:Annually this amounts to:
– 152,000 THA surgeries152,000 THA surgeries– 299,000 TKA surgeries299,000 TKA surgeries
What is MIS?What is MIS? MIS= Minimally invasive solutionsMIS= Minimally invasive solutions
– Widely used in gynecological, cardiac, GI Widely used in gynecological, cardiac, GI surgery surgery
– Now being applied to orthopedic surgeriesNow being applied to orthopedic surgeries
Mini-incision vs Mini-invasiveMini-incision vs Mini-invasive– Mini-incision= operation through smaller holeMini-incision= operation through smaller hole– Mini-invasive adds to this 3 goals:Mini-invasive adds to this 3 goals:
Minimal disruption of physiologyMinimal disruption of physiology Minimal lifestyle interferenceMinimal lifestyle interference Avoidance of interference with future Rx or surgeryAvoidance of interference with future Rx or surgery
Benefits of MISBenefits of MIS
operation timeoperation time blood loss peri- blood loss peri-
and post-opand post-op hospital stayhospital stay costscosts risk of infectionrisk of infection Overall shorter Overall shorter
recovery timerecovery time
Smaller incisionSmaller incision tissue and tissue and
muscle traumamuscle trauma painpain 20-30% more 20-30% more
ROMROM Quicker, easier Quicker, easier
rehabrehab
Application of MIS to THAApplication of MIS to THA
Pioneered by Zimmer Holdings, Pioneered by Zimmer Holdings, Inc. of Warsaw, INInc. of Warsaw, IN– Global leader in design, development Global leader in design, development
and manufacture of reconstructive and manufacture of reconstructive orthopaedic implantsorthopaedic implants
Two TechniquesTwo Techniques– Mini Incision TechniqueMini Incision Technique– Two- Incision TechniqueTwo- Incision Technique
Zimmer (2002, 2003); Rodrigo (2002)
Mini Incision THAMini Incision THA
Utilizes 3-4” incision vs 8-10” with Utilizes 3-4” incision vs 8-10” with traditional THAtraditional THA
Cementless metal and plastic implantCementless metal and plastic implant 4-6 wk projected recovery period4-6 wk projected recovery period Two common proceduresTwo common procedures
– Top ½ of posterolateral approachTop ½ of posterolateral approach– Top 1/3 of anterolateral approachTop 1/3 of anterolateral approach
*In either approach, incision can be extended to *In either approach, incision can be extended to full length at any time during surgeryfull length at any time during surgery
Research: Wenz et al Research: Wenz et al (2002)(2002)
Results:Results: Mini-incisionMini-incision Direct Direct lateral lateral approachapproach
# Cases# Cases 124124 6565
OR timeOR time 40 min40 min 126 min126 min
Blood lossBlood loss 129 mL129 mL 602 mL602 mL
Incision Incision lengthlength
3.5 “3.5 “ 8”8”
D/C from D/C from hospitalhospital
60% by day 360% by day 3 47% by day 347% by day 3
Average LOSAverage LOS 3.8 days3.8 days 4.0 days4.0 days
D/C D/C PlacementPlacement
44% home44% home
50% rehab50% rehab
6% SNF6% SNF
38% home38% home
40% rehab40% rehab
22% SNF22% SNF
Zimmer (2002, 2003); Berger (2002)
Two Incision THATwo Incision THA
No mm are cut so < pain than mini No mm are cut so < pain than mini THATHA– One 1.5-1.75” ant incision over fem One 1.5-1.75” ant incision over fem
neck for excision of head of femur and neck for excision of head of femur and implantation of acetabular componentimplantation of acetabular component
– One 1-1.25” incision made as if IM fem One 1-1.25” incision made as if IM fem rod were being placed for insertion of rod were being placed for insertion of fem head componentfem head component
80% of 180% of 1stst 50 cases able to D/C same 50 cases able to D/C same day after 100 min OR procedureday after 100 min OR procedure
Application of MIS to Knee Application of MIS to Knee ReplacementReplacement
Unicondylar Knee ReplacementUnicondylar Knee Replacement– Uni-SpacerUni-Spacer– Repicci II UnicondylarRepicci II Unicondylar– Zimmer M/G Uni KneeZimmer M/G Uni Knee
Minimally Invasive TKAMinimally Invasive TKA– L-I ApproachL-I Approach– Zimmer ApproachesZimmer Approaches– Smith & Nephew and BrainLAB Smith & Nephew and BrainLAB
ApproachesApproaches
Unicondylar Knee Unicondylar Knee ArthroplastyArthroplasty
Involves reshaping only damaged Involves reshaping only damaged portion of joint portion of joint
Introduced in 1970sIntroduced in 1970s 5,000 performed annually in U.S. 5,000 performed annually in U.S. Newest innovation- minimally Newest innovation- minimally
invasive UKA or “mini-uni”invasive UKA or “mini-uni”– Introduced in late 1990sIntroduced in late 1990s– Same concepts but with 3-4” incisionSame concepts but with 3-4” incision
Ideal Candidates for UKAIdeal Candidates for UKA
45-65 y/o45-65 y/o Isolated non-rheumatoid OA with Isolated non-rheumatoid OA with
cartilage NOT bone losscartilage NOT bone loss Normal ligamentsNormal ligaments No significant patella problemsNo significant patella problems Best for non-obese patientsBest for non-obese patients
SulzerMedica (2002); St Croix Orthopedics (2002)
Popular Uni-KneesPopular Uni-Knees
Uni-SpacerUni-Spacer Manufactured by Sulzer Orthopedics, Inc.Manufactured by Sulzer Orthopedics, Inc. Cleared for use in US in Jan 2001Cleared for use in US in Jan 2001 > 2,500 successful surgeries to date> 2,500 successful surgeries to date Cobalt and chrome alloy prosthesisCobalt and chrome alloy prosthesis Fit b/t femur and tibia alleviates need for Fit b/t femur and tibia alleviates need for
cement or screwscement or screws Does not compromise conversion to TKA Does not compromise conversion to TKA
CBSnews.com (2002); Repicci et al (2003)
Popular Uni KneesPopular Uni Knees
Repicci II Unicondylar ProgramRepicci II Unicondylar Program Biomet prosthesis with 10 yr, 90% Biomet prosthesis with 10 yr, 90%
success ratesuccess rate 7-10 cm incision for medial rebalancing, 7-10 cm incision for medial rebalancing,
10-12 cm for lateral rebalancing10-12 cm for lateral rebalancing Burr rather than cut bone for implantBurr rather than cut bone for implant Freelance procedure relies on anatomy Freelance procedure relies on anatomy
not instruments to determine bone not instruments to determine bone removalremoval
Zimmer (2002, 2003)
Popular Uni KneesPopular Uni Knees
Zimmer M/G Uni KneeZimmer M/G Uni Knee Introduced in late 1990sIntroduced in late 1990s 2-3” incision to remove diseased portion 2-3” incision to remove diseased portion
of kneeof knee Can be done on outpt basisCan be done on outpt basis 5 wk recovery time with near full ROM5 wk recovery time with near full ROM > 20,000 implanted to date> 20,000 implanted to date
Bonutti.net (2002)
Minimally Invasive TKAMinimally Invasive TKA
L-I ApproachL-I Approach = Limited Incision TKA= Limited Incision TKA Invented by Dr. Peter Bonutti of Bonutti Invented by Dr. Peter Bonutti of Bonutti
Clinic in Effingham, ILClinic in Effingham, IL 3-4” incision, 60-75 min OR time3-4” incision, 60-75 min OR time Uses Scorpio Total Knee Instrumentation Uses Scorpio Total Knee Instrumentation
by Stryker Howmedica Osteonics (SHO)by Stryker Howmedica Osteonics (SHO) > 200 surgeries to date; research > 200 surgeries to date; research
results pending by SHOresults pending by SHO
CNET (2003); Zimmer (2002, 2003)
Minimally Invasive TKAMinimally Invasive TKA
Zimmer Mini-Incision TKAZimmer Mini-Incision TKA Pioneered by Dr. Luke Vaugh of Scripp’s Pioneered by Dr. Luke Vaugh of Scripp’s
clinic in La Jolla, CA, 1999clinic in La Jolla, CA, 1999 Comparison study of 60 MINI vs 66 Comparison study of 60 MINI vs 66
traditional:traditional:– Incision: 4.3-5.5” vs 7.8-12”Incision: 4.3-5.5” vs 7.8-12”– Hospital stay: 3.0 days vs 3.5 daysHospital stay: 3.0 days vs 3.5 days
Zimmer (2003)
Minimally Invasive TKAMinimally Invasive TKA
Zimmer Minimally Invasive Zimmer Minimally Invasive SolutionsSolutions Quad-Sparing TKA Quad-Sparing TKA
Avoids cut through quadsAvoids cut through quads Pioneered by Dr. Alfred Tria of St Pioneered by Dr. Alfred Tria of St
Peter’s Hospital in New Brunswick, NJPeter’s Hospital in New Brunswick, NJ 3” incision, LOS < 48 hrs, 18% > ROM3” incision, LOS < 48 hrs, 18% > ROM
– Uses Zimmer NexGen Complete Knee Uses Zimmer NexGen Complete Knee Solution LPS Flex ComponentsSolution LPS Flex Components
– Stealth Station optic image guidance techStealth Station optic image guidance tech
BrainLAB (2003), MedScape (2003)
Minimally Invasive TKAMinimally Invasive TKA
Smith & Nephew and BrainLABSmith & Nephew and BrainLAB April 2003: 1April 2003: 1stst mini TKR enhanced by high mini TKR enhanced by high
precision computer navigationprecision computer navigation Performed by Dr. John Lange & Dr. Paul Performed by Dr. John Lange & Dr. Paul
Schwartz of Shasta Orthopedics, Redding, Schwartz of Shasta Orthopedics, Redding, CACA
Utilizes 3.5” incision, Utilizes 3.5” incision, rehab by 2 morehab by 2 mo Accuracy of implant alignment extends lifeAccuracy of implant alignment extends life Tested in US, Europe, Japan, Canada, Tested in US, Europe, Japan, Canada,
AustraliaAustralia
Implication to PTImplication to PT
Requires modification of our Requires modification of our existing total joint protocolsexisting total joint protocols
In all cases, pts able to:In all cases, pts able to:– Walk soonerWalk sooner– Perform more aggressive ROMPerform more aggressive ROM– Tolerate more advanced Tolerate more advanced
strengtheningstrengthening– D/C to home earlierD/C to home earlier
Questions?Questions?
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