Giles R. ScuderiAlfred J. Tria Editors

Minimally Invasive Surgery in OrthopedicsSecond Edition

1 3 Reference

Minimally Invasive Surgery inOrthopedics

Giles R. Scuderi • Alfred J. TriaEditors

Minimally InvasiveSurgery in Orthopedics

With 1134 Figures and 56 Tables

EditorsGiles R. ScuderiOrthopedic Service LineNorthwell HealthNew York, NY, USA

Adult Knee ReconstructionLenox Hill HospitalNew York, NY, USA

Hofstra Northwell School of MedicineHempstead, NY, USA

Alfred J. TriaDepartment of Orthopedic SurgeryRutgers-Robert Wood Johnson MedicalSchoolNew Brunswick, New Jersey, USA

Department of Orthopedic SurgerySt. Peters University HospitalNew Brunswick, New Jersey, USA

ISBN 978-3-319-34107-1 ISBN 978-3-319-34109-5 (eBook)ISBN 978-3-319-34108-8 (print and electronic bundle)DOI 10.1007/978-3-319-34109-5

Library of Congress Control Number: 2016940964

# Springer Science+Business Media, LLC 2010# Springer International Publishing Switzerland 2016This work is subject to copyright. All rights are reserved by the Publisher, whether the whole orpart of the material is concerned, specifically the rights of translation, reprinting, reuse ofillustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,and transmission or information storage and retrieval, electronic adaptation, computer software, orby similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in thispublication does not imply, even in the absence of a specific statement, that such names are exemptfrom the relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in thisbook are believed to be true and accurate at the date of publication. Neither the publisher nor theauthors or the editors give a warranty, express or implied, with respect to the material containedherein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer NatureThe registered company is Springer International Publishing AG Switzerland

Preface

Since our first edition of Minimally Invasive Surgery in Orthopedics, therehas been a growing trend to perform more orthopedic procedures throughlimited surgical approaches with many using advanced technology to insureaccuracy. This second edition continues to cover all anatomic locations withcommonly performed procedures. Realizing the current trend towards fast-track surgery, we have expanded the book with sections on rapid recoveryprograms in joint arthroplasty and joint specific regional anesthesia. All thecontributors are experts in their field and have provided the reader withdetailed information on their innovative surgical techniques. It is expectedthat the clinical information and surgical techniques provided in this book,along with tips and pearls, should allow the reader to grasp a comprehensiveunderstanding of minimally invasive surgery. This information will hopefullyguide surgeons to perform the procedures safely and effectively with predict-able clinical outcomes. We believe this expanded second edition will continueto be a valuable reference for all orthopedic surgeons.

Giles R. ScuderiAlfred J. Tria

v

Acknowledgement

We would like to thank our families for supporting us through all outendeavors, while we continue to pursue our orthopedic dreams.

vii

About the Editors

Giles R. Scuderi, M.D., is Vice President of the Orthopedic Service Line inNorthwell Health in New York, an Associate Professor of Orthopedic Surgeryat Hofstra Northwell School of Medicine, Fellowship Director of Adult KneeReconstruction, and attending orthopedic surgeon at Lenox Hill Hospital.Following his residency at Lenox Hill Hospital, he was the Knee Fellowwith Dr. John Insall at the Hospital for Special Surgery. His practice focuseson adult knee reconstruction, total knee arthroplasty, and sports medicine.

Dr. Scuderi has published extensively in many medical and orthopedicjournals and continues to lecture worldwide on surgical reconstruction of theknee and total knee arthroplasty. He has edited several textbooks, including thefirst edition ofMinimally Invasive Surgery in Orthopedics. Dr. Scuderi is pastpresident of the Knee Society and continues an active role as the chairman ofthe Knee Society Knee Score Outcomes Committee. He is also a member ofthe American Association of Hip and Knee Surgeons and the ArthroscopyAssociation of North America.

His philanthropic contributions include being a board member of OperationWalk USA and the Arthritis Foundation New York Chapter.

ix

Alfred J. Tria was born in Brooklyn, New York, and graduated from HarvardCollege in 1968, and fromHarvardMedical School in 1972. He did his generalsurgery residency training at The Roosevelt Hospital, in New York City, anddid his orthopedic residency at The New York Orthopedic Hospital. Hecompleted a Knee Fellowship with Dr. John N. Insall, at The Hospital forSpecial Surgery, in 1979. He served in The United States Air Force from 1979to 1981. In 1981, he joined The Department of Orthopedic Surgery at Rutgers-Robert Wood Johnson Medical School in New Brunswick, New Jersey, andhas been on the faculty since that time. He has edited 14 textbooks on the kneeand published over 200 articles. He is a member of The Academy of Ortho-pedic Surgeons, The American Association of Hip and Knee Surgeons, andThe Knee Society. He is the father of nine children, collects wine, and is anavid pilot.

x About the Editors

Section Editors

Steven Beldner The New York Hand and Wrist Center of Lenox Hill,New York, NY, USA

Frances Cuomo Beth Israel Orthopaedics and Sports Medicine, New York,NY, USA

Fred Cushner Northwell Health Orthopaedic Institute, Hofstra UniversitySchool of Medicine, New York, NY, USA

Mark Easley Duke University Medical Center, Durham, NC, USA

Thomas Halaszynski Yale University School of Medicine, New Haven, CT,USA

Brian Harrington Department of Anesthesiology, Billings Clinic Hospital,Billings, MT, USA

Marc S. Kowalsky ONS Foundation for Clinical Research & Education,Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA

Adolph Lombardi Joint Implant Surgeons, Inc., New Albany, OH, USA

Nicola Maffulli Department of Musculoskeletal Disorders, University ofSalerno, School of Medicine and Surgery, Salerno, Italy

Joseph Marino Northwell Health system: Long Island Jewish Valley StreamHospital, New York, NY, USA

ThomasMauri Department of Orthopaedic Surgery, North Shore UniversityHospital/Long Island Jewish Medical Center, New York, NY, USA

Giles R. Scuderi Orthopedic Service Line, Northwell Health, NewYork, NY,USA

Adult Knee Reconstruction, Lenox Hill Hospital, New York, NY, USA

Hofstra Northwell School of Medicine, NY, USA

Alfred J. Tria Department of Orthopedic Surgery, Rutgers-Robert WoodJohnson Medical School, New Brunswick, New Jersey, USA

Department of Orthopedic Surgery, St. Peters University Hospital, NewBrunswick, New Jersey, USA

xi

Contents

Volume 1

Part I Rapid Recovery Programs for Joint Arthroplasty . . . . . . 1

1 What Is Minimally Invasive Surgery and How Do YouLearn It? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Aaron G. Rosenberg

2 Same-Day Unicondylar Knee Arthroplasty . . . . . . . . . . . . . . 13David A. Crawford, Keith R. Berend, and Adolph V. Lombardi Jr.

3 Outpatient Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . 23Michael B. Cross and Richard A. Berger

4 Same-Day Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . 27Gregg R. Klein, Harlan B. Levine, and Mark A. Hartzband

Part II Analgesic and Anesthetic Techniques . . . . . . . . . . . . . . . . 35

5 Regional Analgesia for Orthopedic Surgery . . . . . . . . . . . . . 37Peter J. Foldes, J. Wesley Doty, and Jinlei Li

6 Multimodal Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Brian Harrington, Thomas Halaszynski, and Joseph Marino

7 Regional Analgesia for Shoulder Surgery . . . . . . . . . . . . . . . 49Charles Luke, Uchenna Umeh, and Brian Harrington

8 Regional Anesthesia for Elbow and Hand Surgery . . . . . . . . 57Joel Barton and Sylvia H. Wilson

9 Regional Anesthesia for Hip Surgery . . . . . . . . . . . . . . . . . . . 63Thomas Halaszynski and Anna Uskova

10 Regional Analgesia for Knee Surgery . . . . . . . . . . . . . . . . . . 71Richa Wardhan and Qing Liu

11 Regional Anesthesia for Foot and Ankle Surgery . . . . . . . . . 79Emerson S. Conrad III, Paul B. Delonnay, andThomas Halaszynski

xiii

Part III The Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

12 Overview of Shoulder Approaches: Choosing BetweenMini-Incision and Arthroscopic Techniques . . . . . . . . . . . . . 91Leslie A. Fink Barnes, Bradford O. Parsons, and Evan L. Flatow

13 Mini-Incision Bankart Repair . . . . . . . . . . . . . . . . . . . . . . . . . 97Leslie A. Fink Barnes, Kenneth Accousti, Edward Lee, andEvan L. Flatow

14 Mini-Open Rotator Cuff Repair . . . . . . . . . . . . . . . . . . . . . . . 113W. Anthony Frisella and Frances Cuomo

15 Minimally Invasive Treatment of Greater TuberosityFractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Brian Magovern, Xavier Duralde, and Guido Marra

16 Mini-Incision Fixation of Proximal Humeral Four-PartFractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Leslie A. Fink Barnes, Jim C. Hsu, and Leesa M. Galatz

17 Mini-Incision Shoulder Arthroplasty . . . . . . . . . . . . . . . . . . . 147Sara L. Edwards, Ana Mata-Fink, John-Erik Bell,Chad J. Marion, Theodore A. Blaine, and Louis U. Bigliani

18 Arthroscopic-Assisted AC Joint Reconstruction . . . . . . . . . . 161Timothy G. Reish and Andrew B. Old

19 Arthroscopic Suprascapular Nerve Decompression . . . . . . . 173Rachel Harrison, David Lutton, and Frances Cuomo

Part IV The Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

20 Overview of Elbow Approaches: Small Incisions orArthroscopic Portals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Dave R. Shukla, Michael R. Hausman, andBradford O. Parsons

21 Minimally Invasive Approaches for LateralEpicondylitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Daniel Donovan, Leslie A. Fink Barnes,Bradford O. Parsons, and Michael R. Hausman

22 Minimally Invasive Treatment of Medial Epicondylitis . . . . 209Nathan T. Formaini and Jonathan C. Levy

23 Mini-Incision Medial Collateral Ligament Reconstructionof the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Christopher C. Dodson, Steven J. Thornton, andDavid W. Altchek

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24 Minimally Invasive Treatment of Valgus ExtensionOverload of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Sarah Black and Paul M. Sethi

25 Minimally Invasive Treatment of Lateral Ulnar CollateralLigament Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243Steven J. Lee and Matthew Mendez-Zfass

26 Minimally Invasive Treatment of Elbow ArticularCartilage Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255Marc S. Kowalsky

27 Mini-Incision Distal Biceps Tendon Repair . . . . . . . . . . . . . . 271Steven M. Andelman and Bradford O. Parsons

28 Minimally Invasive Approaches for Complex ElbowTrauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Raymond A. Klug, Jonathon Herald, andMichael R. Hausman

29 Minimally Invasive Treatment of Elbow Osteoarthritisand Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Robert Z. Tashjian

30 Minimally Invasive Treatment of Elbow Neuropathies . . . . . 315Christopher Chuinard

Part V The Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329

31 Overview of Wrist and Hand Approaches: Indicationsfor Minimally Invasive Techniques . . . . . . . . . . . . . . . . . . . . . 331Steve K. Lee

32 Minimally Invasive Surgical Treatment of Distal RadiusFractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Phani K. Dantuluri and Jarrad Barber

33 Minimally Invasive Fixation for Wrist Fractures . . . . . . . . . 353Louis W. Catalano III, Milan M. Patel, and Steven Z. Glickel

34 Minimally Invasive Techniques in Scaphoid FractureFixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365Steven Beldner and Daniel Polatsch

35 Minimally Invasive Metacarpal and Phalangeal FractureFixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373John W. Karl and Robert J. Strauch

36 Minimally Invasive Treatments for DupuytrenContracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393Gary M. Pess

Contents xv

37 Endoscopic and Minimally Invasive Carpal Tunnel andTrigger Finger Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415Mordechai Vigler and Steve K. Lee

Part VI The Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

38 Anterior Supine Intermuscular Approach in Total HipArthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441Andrew B. Richardson and Michael J. Morris

39 Anterior Approach Total Hip Arthroplasty with anOrthopedic Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453Navid M. Ziran and Joel M. Matta

40 Minimally Invasive Anterolateral (Watson–Jones) Approachin the Lateral Decubitus Physician . . . . . . . . . . . . . . . . . . . . . 473Stephen M. Walsh and Richard A. Berger

41 Minimally Invasive Anterolateral (Watson-Jones) Approachin the Supine Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485Eddie S. Wu, Jeffrey J. Cherian, and Ronald E. Delanois

42 Minimally Invasive Direct Lateral Approach . . . . . . . . . . . . 499David A. Crawford and Adolph V. Lombardi Jr.

43 Minimally Invasive Posterolateral Approach . . . . . . . . . . . . 515Christopher Pelt, Jill Erickson, and Christopher L. Peters

44 The PATH Direct Posterior Approach . . . . . . . . . . . . . . . . . . 525Brad L. Penenberg, Joshua Campbell, Matt Zapf, andAntonia Woehnl

45 SuperPATH and Micro-superior Total HipArthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541James C. Chow, Paul K. Della Torre, and David A. Fitch

46 Minimally Invasive Direct Anterior Approach forAcetabular Liner Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . 553Benjamin M. Frye and Keith R. Berend

Part VII The Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

47 MIS Unicondylar Arthroplasty: The Bone-SparingTechnique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569John A. Repicci and Jodi F. Hartman

48 Minimally Invasive Surgery for Unicondylar KneeArthroplasty: The Intramedullary Technique . . . . . . . . . . . . 585Richard A. Berger and Alfred J. Tria Jr.

49 The Extramedullary Tensor Technique for UnicondylarKnee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597Paul L. Saenger

xvi Contents

50 MIS Unicondylar Knee Arthroplasty with theExtramedullary Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 615Giles R. Scuderi

51 Mobile-Bearing Unicompartmental Knee . . . . . . . . . . . . . . . 623David A. Crawford and Keith R. Berend

52 MIS Patellofemoral Arthroplasty: Onlay Technique . . . . . . 637Jess H. Lonner and Andrew I.U. Longenecker

53 Bi-unicompartmental Knee Protheses . . . . . . . . . . . . . . . . . . 651Sergio Romagnoli, Matteo Marullo, Elena Stucovitz,Francesco Verde, and Michele Corbella

54 MIS Total Knee Arthroplasty with the Limited MedialParapatellar Arthrotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671Giles R. Scuderi

55 MIS TKAwith a Subvastus Approach . . . . . . . . . . . . . . . . . . 681Mark W. Pagnano

56 Mini-Midvastus Total Knee Arthroplasty . . . . . . . . . . . . . . . 689Steven B. Haas, Alberto V. Carli, Samuel J. Macdessi, andMary Ann Manitta

57 Minimally Invasive Total Knee Arthroplasty: SuspendedLeg Approach and Arthroscopic-Assisted Techniques . . . . . 701Peter Bonutti

58 Quadriceps-Sparing Total Knee Arthroplasty . . . . . . . . . . . . 711Rodney K. Alan and Alfred J. Tria

59 Minimally Invasive Quadriceps Sparing Total KneeReplacement Preserving the Posterior CruciateLigament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721Richard A. Berger and Aaron G. Rosenberg

60 Bicruciate Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . 733Bertrand W. Parcells, Jared S. Preston, and Alfred J. Tria Jr.

61 Cementless Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . 741Alexander J. Lampley, Lindsay Kleeman,Michael Bolognesi, and Aaron Hofmann

Volume 2

Part VIII The Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753

62 Arthroscopy of the First MTP Joint, Perspective 1 . . . . . . . . 755Nicholas Savva and Terry Saxby

63 Arthroscopy of the First MTP Joint, Perspective 2 . . . . . . . . 763Kenneth Hunt, Philip J. York, and T.H. Lui

Contents xvii

64 Arthroscopic Management of Disorders of the First MTPJoint, Perspective 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777A.C. Stroïnk and C.N. van Dijk

65 Minimally Invasive Management of Hallux Rigidus . . . . . . . 783Mariano De Prado, Manuel Cuervas-Mons,Virginia De Prado, and Pau Golanó

66 Arthroscopic-Assisted Correction of HalluxValgus Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803Samuel Ka Kin Ling and Tun Hing Lui

67 Minimally Invasive Hallux Valgus Correction,Perspective 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811Sandro Giannini, Roberto Bevoni, Francesca Vannini, andMatteo Cadossi

68 Minimally Invasive Hallux Valgus Correction,Perspective 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823Francesco Oliva, Rodrigo Buharaja, Alessio Giai Via, andNicola Maffulli

69 Arthroscopic-Assisted Correction of Lesser ToeDeformity: Plantar Plate Tenodesis . . . . . . . . . . . . . . . . . . . . 831Sally Hi-shan Cheng and Tun Hing Lui

70 Uniportal Endoscopic Decompression of the InterdigitalNerve for Morton’s Neuroma . . . . . . . . . . . . . . . . . . . . . . . . . 839Steven L. Shapiro

71 Closed Reduction and Internal Fixation of LisfrancFracture Dislocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847Anish R. Kadakia, Mark S. Myerson, and Milap Patel

72 Percutaneous Fixation of Proximal Fifth MetatarsalFractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855Jonathan R. Saluta, James A. Nunley, and Aaron Scott

73 Arthroscopic Subtalar Arthrodesis: Indications andTechnique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863Dominic S. Carreira and Pierce Scranton

74 Arthroscopic Triple Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . 871Chi Pan Yuen and Tun Hing Lui

75 Minimally Invasive Closed Reduction and InternalFixation of Calcaneal Fractures . . . . . . . . . . . . . . . . . . . . . . . 879J. Chris Coetzee and Fernando A. Pena

76 Minimally Invasive ORIF of Calcaneal Fractures . . . . . . . . . 885Juha Jaakkola and James B. Carr

77 Minimal Dual Incision ORIF of the Calcaneus . . . . . . . . . . . 895Michael M. Romash

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78 Endoscopic Plantar Fasciotomy . . . . . . . . . . . . . . . . . . . . . . . 913Steven L. Shapiro

79 Endoscopic Calcaneoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 921P. A. J. de Leeuw and C. Niek van Dijk

80 Arthroscopic Ankle Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . 929C. Christopher Stroud

81 Minimally Invasive Ankle Arthrodesis . . . . . . . . . . . . . . . . . . 939Jamal Ahmad and Steven M. Raikin

82 Percutaneous Supramalleolar Osteotomy Using theIlizarov/Taylor Spatial Frame . . . . . . . . . . . . . . . . . . . . . . . . . 949S. Robert Rozbruch

83 Percutaneous ORIF of Periarticular Distal TibiaFractures, Perspective 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967Michael P. Clare and Roy W. Sanders

84 Percutaneous ORIF of Periarticular Distal TibiaFractures, Perspective 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 977Francesco Oliva, Rodrigo Buharaja, Alessio Giai Via, andNicola Maffulli

85 Arthroscopic Repair of Chronic Ankle Instability . . . . . . . . 985Peter B. Maurus and Gregory C. Berlet

86 Minimally Invasive Management of SyndesmoticInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989Stefan Buchmann, Umile Giuseppe Longo,Nicola Maffulli, and Andreas B. Imhoff

87 Endoscopic Gastrocnemius Recession . . . . . . . . . . . . . . . . . . 997Amol SaxenaChristopher W. DiGiovanni

88 Percutaneous Repair of Acute Achilles TendonRupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005Nicola Maffulli, Alessio Giai Via, and Francesco Oliva

89 Minimally Invasive Achilles Tendon Repair . . . . . . . . . . . . . 1015Emilio Wagner, Pablo Wagner, Andres Keller,Diego Zanolli, and Cristian Ortiz

90 Minimally Invasive Stripping for Chronic AchillesTendinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025Nicola Maffulli, Alessio Giai Via, and Francesco Oliva

91 Tendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033Pim A.D. van Dijk, Peter A. J. de Leeuw, andC. Niek van Dijk

92 Computer-Assisted Surgery (CAS) in Foot andAnkle Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051Martinus Richter

Contents xix

Part IX The Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067

93 Minimally Invasive Spinal Surgery: Evidence-BasedReview of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069Max C. Lee, Kyle Fox, and Richard G. Fessler

94 Endoscopic Foraminoplasty: Key to Understandingthe Sources of Back Pain and Sciatica and TheirTreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077Martin Knight

95 Minimally Invasive Thoracic MicroendoscopicDiscectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103R. David Fessler, Kurt M. Eichholz, John E. O’Toole,Griffin R. Myers, and Richard G. Fessler

96 Minimally Invasive Cervical Foraminotomy andDecompression of Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 1109R. David Fessler, John E. O’Toole, Kurt M. Eichholz, andRichard G. Fessler

97 Minimally Invasive Treatment of Spinal Deformity . . . . . . . 1119Christopher M. Zarro and Baron S. Lonner

98 Percutaneous Vertebral Augmentation: Vertebroplastyand Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1129R. David Fessler, Richard L. Lebow, John E. O’Toole,Richard G. Fessler, and Kurt M. Eichholz

99 Minimally Invasive Transforaminal Lumbar InterbodyFusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145Alfred T. Ogden and Richard G. Fessler

100 Endoscopic Rhizotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157Victor M. Hayes, Farhan N. Siddiqi, andJacqueline MS. Romero

101 Intradiscal Stem Cell Implantation for Degenerative DiskDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171Farhan Siddiqi, Victor Hayes, Daniel Grande, andMohamad Hakim

Part X Innovative Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189

102 Computer-Assisted Surgery: Pros and Cons . . . . . . . . . . . . . 1191James B. Stiehl

103 The Utility of Robotics in Total Knee Arthroplasty . . . . . . . . 1199Mohanjit Kochhar and Giles R. Scuderi

104 Robotics in Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . 1203Werner Siebert, Sabine Mai, and Peter F. Heeckt

xx Contents

105 Minimally Invasive Total Knee Arthroplasty withImage-Free Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213S. David Stulberg

106 Electromagnetic Navigation in Total KneeArthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231Rodney K. Alan and Alfred J. Tria

107 Inertial Navigation in Total Knee Arthroplasty . . . . . . . . . . . 1239Jamie M. Grossman and Giles R. Scuderi

108 Use of Gyroscope-Based Instruments in TKA . . . . . . . . . . . . 1249David J. Mayman and Kaitlin M. Carroll

109 Patient-Specific Unicondylar Knee Arthroplasty . . . . . . . . . . 1259Fred Cushner and Jamie M. Grossman

110 Custom Unicompartmental Knee Arthroplasty . . . . . . . . . . . 1267Wolfgang Fitz

111 Robotic-Arm Assisted Unicompartmental KneeArthroplasty (MAKO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1281Frederick Buechel Jr, Frederick Buechel Sr, andMichael Conditt

112 Handheld Robotics for Unicompartmental KneeArthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1307Julie Shaner, Laura Matsen Ko, and Jess Lonner

113 Patient-Specific Total Knee Arthroplasty . . . . . . . . . . . . . . . . 1319James C. Chow and Paul K. Della Torre

114 Sensor Technology in Total Knee Arthroplasty . . . . . . . . . . . 1333Kenneth Gustke

115 Disposable Instruments in Total Knee Arthroplasty . . . . . . . 1349Steven B. Haas and Alberto Carli

116 Custom Total Knee Replacement . . . . . . . . . . . . . . . . . . . . . . 1357Jose A. Rodriguez and Marcel Bas

117 Computer-Guided Total Hip Arthroplasty . . . . . . . . . . . . . . . 1367James B. Stiehl and Robert Thornberry

118 Computer Navigation with Posterior MIS Total HipArthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1379Aamer Malik, Zhinian Wan, and Lawrence D. Dorr

119 Haptic Robotics in Total Hip Arthroplasty . . . . . . . . . . . . . . 1391Kenneth H. Jahng, Eli Kamara, and Matthew S. Hepinstall

120 Advances in Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . 1407Michael Nett and Germán A. Norambuena

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1419

Contents xxi

Contributors

Kenneth Accousti Fredericksburg Orthopaedic Associates, Fredericksburg,VA, USA

Jamal Ahmad Departments of Orthopaedic Surgery, Rothman Institute andThomas Jefferson University Hospital, Philadelphia, PA, USA

Rodney K. Alan Department of Surgery, Saint Peters University Hospital,New Brunswick, NJ, USA

Department of Orthopaedic Surgery, Institute for Advanced OrthopaedicStudy, The Orthopaedic Center of New Jersey, Somerset, NJ, USA

David W. Altchek Sports Medicine and Shoulder Service, Hospital forSpecial Surgery, New York, NY, USA

Steven M. Andelman Department of Orthopaedic Surgery, Mount SinaiHospital Icahn School of Medicine, New York, NY, USA

Jarrad Barber Department of Orthopaedic Surgery, Atlanta Medical Center,Atlanta, GA, USA

Leslie A. Fink Barnes Department of Orthopaedic Surgery, Temple Univer-sity School of Medicine, Philadelphia, PA, USA

Joel Barton Rockville, MD, USA

Marcel Bas Center for Joint Preservation and Reconstruction, Lenox HillHospital, New York, NY, USA

Steven Beldner New York Hand and Wrist Center of Lenox Hill, New York,NY, USA

John-Erik Bell Center for Shoulder, Elbow and Sports Medicine, ColumbiaUniversity, New York, NY, USA

Keith R. Berend Joint Implant Surgeons, Inc., New Albany, OH, USA

Richard A. Berger Department of Orthopedic Surgery, Rush–Presby-terian–St. Luke’s Medical Center, Chicago, IL, USA

Gregory C. Berlet Orthopedic Foot and Ankle Centre, Chief Foot and AnkleOhio State University, Columbus, OH, USA

xxiii

Roberto Bevoni School of Orthopaedics at Istituto Ortopedico Rizzoli,Bologna University, Bologna, Italy

Louis U. Bigliani Center for Shoulder, Elbow and Sports Medicine,Columbia University, New York, NY, USA

Sarah Black ONS Foundation, Greenwich, CT, USA

Theodore A. Blaine Center for Shoulder, Elbow and Sports Medicine,Columbia University, New York, NY, USA

Michael Bolognesi Department of Orthopaedic Surgery, Duke UniversityMedical Center, Durham, NC, USA

Peter Bonutti Bonutti Clinic, Effingham, IL, USA

Stefan Buchmann Department of Orthopaedic Sports Medicine, KlinikumRechts der Isar, University of Munich, Munich, Germany

Orthopaedisches Fachzentrum (OFZ), Weilheim, Germany

Frederick Buechel Jr Robotic Joint Center at The Stone Clinic, SanFrancisco, CA, USA

Frederick Buechel Sr South Mountain Orthopaedics, South Orange, NJ,USA

Rodrigo Buharaja Department of Orthopaedic and Trauma Surgery,University of Rome “Tor Vergata”, Rome, Italy

Matteo Cadossi School of Orthopaedics at Istituto Ortopedico Rizzoli,Bologna University, Bologna, Italy

Joshua Campbell Orthopaedic Surgery, Cedars-Sinai Medical Center,Beverly Hills, CA, USA

Alberto V. Carli Department of Orthopedic Surgery, Hospital for SpecialSurgery, Weill Medical College of Cornell University, New York, NY, USA

James B. Carr Department of Orthopedic Surgery, University of SouthCarolina, Palmetto Richland Hospital, Columbia, SC, USA

Dominic S. Carreira Orthopaedic and Sports Medicine Center, FortLauderdale, FL, USA

Orthopedics International, Kirkland, WA, USA

Kaitlin M. Carroll Joint Replacement and Sports Medicine, Hospital forSpecial Surgery, New York, NY, USA

Louis W. Catalano III Roosevelt Hand to Shoulder Center Ortho Manhat-tan, NYU Langone Medical Center, New York, NY, USA

Sally Hi-shan Cheng Department of Orthopaedics and Traumatology, Princeof Wales Hospital, Hong Kong, China

xxiv Contributors

Jeffrey J. Cherian Center for Joint Preservation and Replacement, RubinInstitute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore,MD, USA

James C. Chow Hedley Orthopaedic Institute, Phoenix, AZ, USA

Christopher Chuinard Shoulder and Elbow Surgeon, Great Lakes Ortho-paedic Center, Traverse City, MI, USA

Michael P. Clare Orthopaedic Trauma Service, Tampa General Hospital,The Florida Orthopaedic Institute, Tampa, FL, USA

J. Chris Coetzee Minnesota Orthopedics Sports Medicine Institute at TwinCities Orthopedics, Edina, MN, USA

Michael Conditt Holy Cross Hospital, Fort Lauderdale, FL, USA

Emerson S. Conrad III University of Pittsburgh Medical Center, Directorof Acute Pain and Regional Anesthesia UPMC Mercy Hospital, Pittsburgh,PA, USA

Michele Corbella Joint Replacement Department, Istituto Ortopedico“R. Galeazzi”, Milano, Italy

David A. Crawford Joint Implant Surgeons, Inc., New Albany, OH, USA

Michael B. Cross Hospital for Special Surgery, New York, NY, USA

Manuel Cuervas-Mons Department of Orthopaedics and Trauma Surgery,‘Gregorio Marañón’ University Hospital, Madrid, Spain

Frances Cuomo Division of Shoulder and Elbow Surgery, Department ofOrthopedics, Mount Sinai Beth Israel, New York, NY, USA

Beth Israel Orthopaedics and Sports Medicine, New York, NY, USA

Fred Cushner Northwell Health Orthopaedic Institute, New York, NY, USA

Phani K. Dantuluri Division of Shoulder, Elbow, and Upper ExtremitySurgery, Resurgens Orthopaedics, Atlanta, GA, USA

Peter A. J. de Leeuw Academic Center for Evidence Based Sports Medicine,Amsterdam, The Netherlands

Amsterdam Collaboration on Health and Safety in Sports, Amsterdam, TheNetherlands

Department of Trauma, Oxford University Hospitals, John Radcliffe HospitalOxford, Oxford, UK

Ronald E. Delanois Center for Joint Preservation and Replacement, RubinInstitute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore,MD, USA

Paul K. Della Torre Specialist Centre @ Sydney Olympic Park, SydneyOlympic Park, NSW, Australia

Paul B. Delonnay University of Pittsburgh Medical Center, UPMC MercyHospital, Boston, MA, USA

Contributors xxv

Christopher W. DiGiovanni Division of Foot and Ankle, Department ofOrthopedic Surgery, Brown University Medical School, Rhode IslandHospital, Providence, RI, USA

Division of Foot and Ankle Surgery, Massachusetts General Hospital andNewton Wellesley Hospital, Newton, MA, USA

Christopher C. Dodson Rothman Institute, Philadelphia, PA, USA

Daniel Donovan Department of Orthopaedics, Mount Sinai School ofMedicine, One Gustave Levy Place, New York, NY, USA

Lawrence D. Dorr Dorr Arthritis Institute, Los Angeles, CA, USA

J. Wesley Doty Medical University of South Carolina, Charleston, SC, USA

Xavier Duralde Section of Shoulder and Elbow Surgery, Loyola UniversityMedical Center, Maywood, IL, USA

Sara L. Edwards Center for Shoulder, Elbow and Sports Medicine, Colum-bia University, New York, NY, USA

Kurt M. Eichholz St. Louis Minimally Invasive Spine Center, St. Louis,MO, USA

Jill Erickson Department of Orthopaedic Surgery, University of Utah Schoolof Medicine, University of Utah Orthopaedic Center, Salt Lake City, UT, USA

R. David Fessler University of Cincinnati College of Medicine, Cincinnati,OH, USA

Richard G. Fessler Department of Neurosurgery, Rush University MedicalCenter, Chicago, IL, USA

David A. Fitch MicroPort Orthopedics Inc., Arlington, TN, USA

Wolfgang Fitz Brigham and Women’s Hospital, Boston, MA, USA

Evan L. Flatow Peter & Leni May Department of Orthopaedic Surgery,Mount Sinai Medical Center, New York, NY, USA

Peter J. Foldes Tulane University Medical Center, Iowa City, IA, USA

Nathan T. Formaini Holy Cross Orthopedic Institute, Fort Lauderdale, FL,USA

Kyle Fox Milwaukee Neurological Institute, Milwaukee, WI, USA

W. Anthony Frisella Division of Shoulder and Elbow Surgery, Departmentof Orthopedics and Sports Medicine, Beth Israel Medical Center, PhillipsAmbulatory Care Center, New York, NY, USA

Benjamin M. Frye Department of Orthopaedics, West Virginia University,Morgantown, WV, USA

WVU Medicine Center for Joint Replacement, Morgantown, WV, USA

LeesaM. Galatz Department of Orthopaedic Surgery, Mount Sinai School ofMedicine, New York, NY, USA

xxvi Contributors

Alessio Giai Via Department of Orthopaedic and Traumatology, School ofMedicine, University of Rome “Tor Vergata”, Rome, Italy

Sandro Giannini School of Orthopaedics at Istituto Ortopedico Rizzoli,Bologna University, Bologna, Italy

Steven Z. Glickel Roosevelt Hand to Shoulder Center Ortho Manhattan,NYU Langone Medical Center, New York, NY, USA

Pau Golanó

Daniel Grande Trinity Spine Center – Trinity Stem Cell Institute, Odessa,FL, USA

Jamie M. Grossman Northwell Health Orthopaedic Institute, New York,NY, USA

Kenneth Gustke Florida Orthopaedic Institute, Temple Terrace, FL, USA

Department of Orthopaedic Surgery, University of South Florida College ofMedicine, Tampa, FL, USA

Steven B. Haas Department of Orthopedic Surgery, Hospital forSpecial Surgery, Weill Medical College of Cornell University, New York,NY, USA

MohamadHakim Trinity Spine Center – Trinity Stem Cell Institute, Odessa,FL, USA

Thomas Halaszynski Department Anesthesiology, University of PittsburghMedical Center, Pittsburgh, PA, USA

Brian Harrington Department of Anesthesiology, Billings Clinic Hospital,Billings, MT, USA

Rachel Harrison Department of Orthopedics, Mount Sinai Beth Israel, NewYork, NY, USA

Jodi F. Hartman Joint Reconstruction Orthopedic Center, Buffalo, NY, USA

Mark A. Hartzband Hartzband Center for Hip and Knee Replacement,Paramus, NJ, USA

Michael R. Hausman Department of Orthopaedics, Mount Sinai School ofMedicine, One Gustave Levy Place, New York, NY, USA

Victor Hayes Trinity Spine Center – Trinity Stem Cell Institute, Odessa, FL,USA

Peter F. Heeckt Vitos Orthopaedic Center Kassel, Kassel, Germany

Matthew S. Hepinstall Department of Orthopaedic Surgery, Lenox HillHospital, New York, NY, USA

Pau Golanó: deceased

Contributors xxvii

Center for Joint Preservation and Reconstruction, Lenox Hill Hospital, NorthShore LIJ Orthopaedic Institute, New York, NY, USA

Jonathon Herald Orthoclinic Sydney, Sydney, NSW, Australia

Aaron Hofmann Center for Precision Joint Replacement, Hofmann ArthritisInstitute, Salt Lake City, UT, USA

Jim C. Hsu Department of Orthopaedic Surgery, Washington UniversitySchool of Medicine, St. Louis, MO, USA

Kenneth Hunt Department of Orthopaedic Surgery, University of ColoradoSchool of Medicine, Aurora, CO, USA

Andreas B. Imhoff Department of Orthopaedic Sports Medicine, KlinikumRechts der Isar, University of Munich, Munich, Germany

Juha Jaakkola Southeastern Orthopedic Center, Savannah, GA, USA

Savannah, GA, USA

Kenneth H. Jahng Arrowhead Orthopaedics, Redlands, CA, USA

Anish R. Kadakia Northwestern University – Feinberg School of Medicine,Northwestern Memorial Hospital, Chicago, IL, USA

Eli Kamara Department of Orthopaedic Surgery, Lenox Hill Hospital, NewYork, NY, USA

John W. Karl Columbia University Medical Center, New York, NY, USA

Andres Keller Foot and ankle surgeon, Orthopaedic Surgery department,Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

Lindsay Kleeman Department of Orthopaedic Surgery, Duke UniversityMedical Center, Durham, NC, USA

Gregg R. Klein Hartzband Center for Hip and Knee Replacement, Paramus,NJ, USA

Raymond A. Klug The Greater Long Beach Orthopaedic Surgical and Med-ical Group, Los Alamitos, CA, USA

Martin Knight The University of Manchester, Manchester, UK

The University of Central Lancashire, Preston, UK

The Spinal Foundation, Congleton, Cheshire, UK

Laura Matsen Ko Rothman Institute, Philadelphia, PA, USA

Mohanjit Kochhar Insall Scott Kelly Institute, New York, NY, USA

Marc S. Kowalsky Orthopaedic and Neurosurgery Specialists, Greenwich,CT, USA

Alexander J. Lampley Department of Orthopaedic Surgery, Duke Univer-sity Medical Center, Durham, NC, USA

xxviii Contributors

Richard L. Lebow Department of Neurological Surgery, Vanderbilt Univer-sity Medical Center, Nashville, TN, USA

Edward Lee Houston Methodist Orthopaedics and Sports Medicine,Houston Methodist, St. John Hospital, Nassau Bay, TX, USA

Max C. Lee Milwaukee Neurological Institute, Milwaukee, WI, USA

Steve K. Lee Hospital for Special Surgery, Weill Medical College of CornellUniversity, New York, NY, USA

Harlan B. Levine Hartzband Center for Hip and Knee Replacement,Paramus, NJ, USA

Jonathan C. Levy Holy Cross Orthopedic Institute, Fort Lauderdale, FL,USA

Jinlei Li Yale-New Haven Hospital, New Haven, CT, USA

Samuel Ka Kin Ling Department of Orthopaedics and Traumatology, NorthDistrict Hospital, Hong Kong, China

Qing Liu Pittsburgh, PA, USA

Adolph V. Lombardi Jr. Joint Implant Surgeons, Inc., New Albany, OH,USA

Andrew I. U. Longenecker Rothman Institute, Sidney Kimmel MedicalCollege at Thomas Jefferson University, Philadelphia, PA, USA

Umile Giuseppe Longo Department of Orthopaedic and Trauma Surgery,Campus Bio-Medico University, Trigoria, Rome, Italy

Baron S. Lonner NYU Hospital for Joint Diseases, New York, NY, USA

Department of Orthopedic Surgery, State University of New York, New York,NY, USA

Jess H. Lonner Rothman Institute, Sidney Kimmel Medical College atThomas Jefferson University, Philadelphia, PA, USA

T. H. Lui Department of Orthopaedics and Traumatology, North DistrictHospital, Hong Kong, China

Charles Luke Department of Anesthesiology, UPMC Passavant Hospital,Pittsburgh, PA, USA

David Lutton Washington, DC, USA

Samuel J. Macdessi Sydney Knee Specialists, Sydney, NSW, Australia

Nicola Maffulli Department of Musculoskeletal Disorders, School ofMedicine and Surgery, University of Salerno, Salerno, SA, Italy

Barts and the London School of Medicine and Dentistry, Centre for Sports andExercise Medicine, Mile End Hospital, Queen Mary University of London,London, UK

Contributors xxix

BrianMagovern Section of Shoulder and Elbow Surgery, Loyola UniversityMedical Center, Maywood, IL, USA

Sabine Mai Vitos Orthopaedic Center Kassel, Kassel, Germany

Aamer Malik Dorr Arthritis Institute, Los Angeles, CA, USA

Mary Ann Manitta Department of Orthopedics, Hospital for Special Sur-gery, New York, NY, USA

Joseph Marino North Shore Health System, Valley Stream, NY, USA

Chad J.Marion Center for Shoulder, Elbow and Sports Medicine, ColumbiaUniversity, New York, NY, USA

Guido Marra Section of Shoulder and Elbow Surgery, Loyola UniversityMedical Center, Maywood, IL, USA

Matteo Marullo Joint Replacement Department, Istituto Ortopedico“R. Galeazzi”, Milano, Italy

AnaMata-Fink Center for Shoulder, Elbow and Sports Medicine, ColumbiaUniversity, New York, NY, USA

Joel M. Matta Hip and Pelvis Institute, Saint John’s Health Center, SantaMonica, CA, USA

Peter B. Maurus Steindler Orthopedic Clinic Iowa City, IA, USA

David J. Mayman Joint Replacement and Sports Medicine, Hospital forSpecial Surgery, New York, NY, USA

Matthew Mendez-Zfass Department of Orthopeadics, NISMAT: NicholasInstitue of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, NewYork, NY, USA

Michael J. Morris Joint Implant Surgeons, Inc., New Albany, OH, USA

Griffin R. Myers Oak Street Health, Northwestern University, FeinbergSchool of Medicine, Chicago, IL, USA

Mark S. Myerson Mercy Medical Center, Baltimore, MD, USA

Michael Nett Dept Of Orthopedic Surgery, Southside Hospital of NorthwellHealth System, Bay Shore, NY, USA

Germán A. Norambuena Lenox Hill Hospital of Northwell Health System,New York, NY, USA

James A. Nunley Department of Surgery, Division of Orthopaedic Surgery,Duke University Medical Center, Durham, NC, USA

John E. O’Toole Rush University Medical Center, Chicago, IL, USA

Alfred T. Ogden Department of Neurological Surgery, Northwestern Memo-rial Hospital, Chicago, IL, USA

xxx Contributors

Andrew B. Old Hospital for Joint Diseases, NYU Langone, New York, NY,USA

Francesco Oliva Department of Orthopaedic and Trauma Surgery, Univer-sity of Rome “Tor Vergata”, Rome, Italy

Cristian Ortiz Foot and ankle surgeon, Orthopaedic Surgery department,Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

MarkW. Pagnano Department of Orthopedic Surgery, Mayo Clinic Collegeof Medicine, Mayo Clinic, Rochester, MN, USA

Bertrand W. Parcells PGY IV, Department of Orthopaedic Surgery,Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA

Department of Orthopaedic Surgery, Rutgers-Robert Wood Johnson MedicalSchool, New Brunswick, NJ, USA

Bradford O. Parsons Department of Orthopaedic Surgery, Mount SinaiHospital Icahn School of Medicine, New York, NY, USA

Milap Patel Department of Orthopedic Surgery, Northwestern University –Feinberg School of Medicine, Chicago, IL, USA

Milan M. Patel Lawrenceville, GA, USA

Christopher Pelt Department of Orthopaedic Surgery, University of UtahSchool of Medicine, University of Utah Orthopaedic Center, Salt Lake City,UT, USA

Fernando A. Pena University of Minnesota, Minneapolis, MN, USA

Brad L. Penenberg Orthopaedic Surgery, Cedars-Sinai Medical Center,Beverly Hills, CA, USA

Hip and Knee Institute of Los Angeles, Beverly Hills, CA, USA

Gary M. Pess Department of Orthopedic Surgery, Central Jersey HandSurgery, Drexel University School of Medicine, NJ, USA

Christopher L. Peters Department of Orthopaedic Surgery, University ofUtah School of Medicine, University of Utah Orthopaedic Center, Salt LakeCity, UT, USA

Daniel Polatsch New York Hand and Wrist Center, New York, NY, USA

Mariano De Prado Department of Orthopaedics and Trauma Surgery,‘Quirón’ Hospital, Murcia, Spain

Virginia De Prado Department of Podiatry, Quirón’Hospital, Murcia, Spain

Jared S. Preston PGY II, Department of Orthopaedic Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA

Department of Orthopaedic Surgery, Rutgers-Robert Wood Johnson MedicalSchool, New Brunswick, NJ, USA

Steven M. Raikin Departments of Orthopaedic Surgery, Rothman Instituteand Thomas Jefferson University Hospital, Philadelphia, PA, USA

Contributors xxxi

Timothy G. Reish Insall Scott Kelly Institute, New York, NY, USA

John A. Repicci Joint Reconstruction Orthopedic Center, Buffalo, NY, USA

Andrew B. Richardson Joint Implant Surgeons, Inc., New Albany, OH,USA

Martinus Richter II Chirurgische Klinik, Unfallchirurgie, Orthopädie undFußchirurgie, Klinikum Coburg, Coburg, Germany

Jose A. Rodriguez Center for Joint Preservation and Reconstruction, LenoxHill Hospital, New York, NY, USA

Sergio Romagnoli Joint Replacement Department, Istituto Ortopedico“R. Galeazzi”, Milano, Italy

Michael M. Romash Orthopedic Foot and Ankle Center of Hampton Roads,Chesapeake Regional Medical Center, Chesapeake, VA, USA

Jacqueline MS. Romero Organization Weill-Cornell University MedicalSchool Manhattans, New Port Richey, New York, NY, USA

Aaron G. Rosenberg Department of Orthopaedic Surgery, Rush MedicalCollege, Chicago, IL, USA

S. Robert Rozbruch Limb Lengthening and Deformity Service, Hospital forSpecial Surgery, New York, NY, USA

Clinical Orthopaedic Surgery, Weill Medical College of Cornell University,New York, NY, USA

Paul L. Saenger Blue Ridge Bone and Joint Clinic, Asheville, NC, USA

Jonathan R. Saluta Los Angeles Orthopaedic Center, Los Angeles, CA,USA

RoyW. Sanders Orthopaedic Trauma Service, Tampa General Hospital, TheFlorida Orthopaedic Institute, Tampa, FL, USA

Nicholas Savva Foot and Ankle Surgery, Brisbane Private Hospital,Brisbane, QLD, Australia

Terry Saxby Foot and Ankle Surgery, Brisbane Private Hospital, Brisbane,QLD, Australia

Amol Saxena Department of Sports Medicine, Palo Alto Division-PAMF,Palo Alto, CA, USA

Aaron Scott Department of Orthopaedic Surgery, Wake Forest UniversityBaptist Medical Center, Winston-Salem, NC, USA

Pierce Scranton Orthopedics International, Kirkland, WA, USA

Giles R. Scuderi Northwell Health Orthopaedic Institute, NewYork, NY, USA

Paul M. Sethi ONS Foundation, Greenwich, CT, USA

Julie Shaner Rothman Institute, Philadelphia, PA, USA

xxxii Contributors

Steven L. Shapiro Savannah Orthopaedic Foot and Ankle Center, Savannah,GA, USA

Dave R. Shukla Mount Sinai Hospital, New York, NY, USA

Farhan Siddiqi Trinity Spine Center – Trinity Stem Cell Institute, Odessa,FL, USA

Werner Siebert Vitos Orthopaedic Center Kassel, Kassel, Germany

James B. Stiehl St Mary’s/Good Samaritan Hospital, Centralia, IL, USA

Robert J. Strauch Columbia University Medical Center, New York, NY,USA

A. C. Stroïnk Department of Orthopaedic Surgery, Academic MedicalCenter, University of Amsterdam, Amsterdam, The Netherlands

C. Christopher Stroud Department of Surgery,William Beaumont Hospital-Troy, Troy, MI, USA

Elena Stucovitz Motion Analysis Laboratory, Istituto Ortopedico“R. Galeazzi”, Milano, Italy

S. David Stulberg Department of Orthopaedic Surgery, Feinberg School ofMedicine, Northwestern University, Chicago, IL, USA

Northwestern University Medical School, Chicago, USA

Robert Z. Tashjian Department of Orthopaedics, University of Utah Schoolof Medicine, Salt Lake City, UT, USA

Robert Thornberry Tallahassee Orthopaedic Clinic, Tallahassee, FL, USA

Steven J. Thornton Rothman Institute, Philadelphia, PA, USA

Alfred J. Tria Jr. Department of Orthopaedic Surgery, Rutgers-RobertWood Johnson Medical School, New Brunswick, NJ, USA

Department of Orthopaedic Surgery, St. Peter’s University Hospital, NewBrunswick, NJ, USA

Uchenna Umeh Department of Anesthesiology, Perioperative Care and PainMedicine, NYU Langone Medical Center, New York, NY, USA

Anna Uskova Clinical Assistant Professor, Department Anesthesiology,University of Pittsburgh Medical Center, Pittsburgh, PA, USA

C. Niek van Dijk Department of Orthopaedic Surgery, Orthopaedic ResearchCentre Amsterdam, Academic Medical Centre, University of Amsterdam,Amsterdam, The Netherlands

Academic Center for Evidence Based Sports Medicine, Amsterdam, TheNetherlands

Amsterdam Collaboration on Health and Safety in Sports, Amsterdam, TheNetherlands

Contributors xxxiii

Pim A. D. van Dijk Department of Orthopaedic Surgery, OrthopaedicResearch Centre Amsterdam, Academic Medical Centre, University ofAmsterdam, Amsterdam, The Netherlands

Academic Center for Evidence Based Sports Medicine, Amsterdam, TheNetherlands

Amsterdam Collaboration on Health and Safety in Sports, Amsterdam, TheNetherlands

Foot and Ankle Service, Department of Orthopaedic Surgery, MassachusettsGeneral Hospital, Harvard Medical School, Boston, MA, USA

Francesca Vannini School of Orthopaedics at Istituto Ortopedico Rizzoli,Bologna University, Bologna, Italy

Francesco Verde Joint Replacement Department, Istituto Ortopedico“R. Galeazzi”, Milano, Italy

Mordechai Vigler Department of Orthopaedic Surgery, Rabin MedicalCenter, Hasharon Hospital, Petach Tikva, Israel

Emilio Wagner Foot and ankle surgeon, Orthopaedic Surgery department,Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

Pablo Wagner Foot and ankle surgeon, Orthopaedic Surgery department,Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

Stephen M. Walsh Department of Orthopedic Surgery, Rush–Presbyterian–St. Luke’s Medical Center, Chicago, IL, USA

DownEast Orthopedics, Bangor, ME, USA

Zhinian Wan Dorr Arthritis Institute, Los Angeles, CA, USA

Richa Wardhan New Haven, CT, USA

Sylvia H. Wilson Anesthesia and Perioperative Medicine; Division ofRegional and Orthopedic Anesthesia, Medical University of South Carolina,Charleston, SC, USA

Antonia Woehnl Orthopaedic Surgery, Cedars-Sinai Medical Center,Beverly Hills, CA, USA

Eddie S. Wu Premier Orthopaedic Associates of Southern New Jersey,Vineland, NJ, USA

Philip J. York Department of Orthopaedic Surgery, University of ColoradoSchool of Medicine, Aurora, CO, USA

Chi Pan Yuen Department of Orthopaedics and Traumatology, Kwong WahHospital, Hong Kong SAR, China

Diego Zanolli Foot and ankle surgeon, Orthopaedic Surgery department,Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

Matt Zapf Orthopaedic Surgery, Cedars-Sinai Medical Center, BeverlyHills, CA, USA

xxxiv Contributors

Christopher M. Zarro NYU Hospital for Joint Diseases, New York, NY,USA

Spine Care and Rehabilitation Inc., Roseland, NJ, USA

Navid M. Ziran Hip and Pelvis Institute, Saint John’s Health Center, SantaMonica, CA, USA

Contributors xxxv

Part I

Rapid Recovery Programs for JointArthroplasty

What Is Minimally Invasive Surgeryand How Do You Learn It? 1Aaron G. Rosenberg

ContentsHow to Learn MIS: Practical Suggestions . . . . . . . . . 6Incremental Improvement Through Practice . . . . . . . . . 6

Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Criticism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Varied Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Avoid Multiple Learning Curves . . . . . . . . . . . . . . . . . . . 7

Visualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Debriefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Team Approach: Coaching . . . . . . . . . . . . . . . . . . . . . . . . . . 8

The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Innovation in surgery is not new and should not beunexpected. As an example, the history of totaljoint replacement has demonstrated continuousevolution, and the relatively high complicationrates associated with early prostheses and tech-niques eventually led to the improvement ofimplants and refinement of the surgical proce-dures. Gradual adoption of these improvementsand their eventual diffusion into the surgical com-munity led to improved success and increasedrates of implantation [1]. Increased surgical expe-rience was eventually accompanied by more rapidsurgical performance and then by the develop-ment of standardized hospitalization protocols,which eventually led to more rapid rehabilitationand return to function. These benefits are wellaccepted and can be seen as helping contributeto the establishment of a more “consumer-driven”and medical practice.

Most surgeons would agree that as experienceguides the surgeon to more accurate incisionplacement, more precise dissection, and moreskillful mobilization of structure, the need forwide exposure diminishes. Indeed, less invasive-ness appears to be a hallmark of experience gainedwith a given procedure. From a historical perspec-tive, this appears to be true of total hip replace-ment. The operation as initially described byCharnley required trochanteric osteotomy. Theosteotomy served several purposes: generousexposure, access to the intramedullary canal forproper component placement and cement pressur-ization, and the ability of the surgeon to “tension”

A.G. Rosenberg (*)Department of Orthopaedic Surgery, Rush MedicalCollege, Chicago, IL, USAe-mail: aarongbone@gmail.com

# Springer International Publishing Switzerland 2016G.R. Scuderi, A.J. Tria (eds.), Minimally Invasive Surgery in Orthopedics,DOI 10.1007/978-3-319-34109-5_1

3

mailto:aarongbone@gmail.com

the abductors to improve stability. However, overtime, it became apparent that trochanteric non-union and retained trochanteric hardware couldbe problematic. In attempts to minimize theseproblems, some worked to develop improvedtechniques for trochanteric fixation. However,others went in a different direction, eventuallydemonstrating that the operation could beperformed quite adequately without osteotomy.Many purists complained that this was not theCharnley operation and that the benefits of tro-chanteric osteotomy were lost. Yet the eventualacceptance of the nonosteotomy approaches byalmost all surgeons performing primary total hiparthroplasty (THA) in the vast majority of circum-stances would attest to the fact that osteotomy wasnot required to achieve the result that had come tobe expected.

These developments led to the popularity ofthe posterior approach to the hip for THA. Ini-tially, the gluteus maximus tendon insertion intothe posterolateral femur was routinely taken downto obtain adequate exposure of the acetabulum.Indeed, the generous exposure provided by thisrelease was needed to adequately control acetab-ular component position, to reduce bleeding forcement interdigitation, and to allow pressurizationof acetabular cement. However, this generousexposure was associated with a higher dislocationrate than was seen with the trochanteric osteotomytechnique. But with the advent of improved com-ponent design (offset) and better understanding ofcomponent positioning, as well as the introduc-tion of cementless techniques, less exposure wasneeded in the majority of cases. Eventually, care-ful closure of the posterior structures also led to asignificant reduction in the dislocation rate[2]. Seen in this example is a finding typicallynoted in the close examination of most evolution-ary processes: initial benefits are obtained at someexpense in the form of new or different complica-tions or alterations in the complication rate. Fur-ther modifications are then required to overcomethe new problems that arise from the adaptation ofthe innovation. The study of the factors that leadto the adoption (and alterations) of innovationshas been extensively studied by Rogers and is

well described in his landmark work, the Diffu-sion of Innovation [3].

The trend to less or minimally invasive pro-cedures has been noted in other specialties [4] andperhaps can be seen most dramatically in the fieldof interventional radiology [5].

It would be fair to say that almost all surgicaltechniques improve over time by leading to lessinvasive approaches, which are frequentlyadopted only reluctantly by the surgical commu-nity. For skeptics, it is instructive to review thecareer of Dr. Kurt Semm [6]. His reports of surgi-cal techniques were shouted down at professionalmeetings and his lectures were greeted with“laughter, derision, and suspicion.” He was for-bidden to publish by his dean, and his first paperssubmitted were rejected because they were“unethical.” The President of the German SurgicalSociety demanded that his license be revoked andhe be barred from practice. His associates at theUniversity of Kiel asked him to have psycholog-ical testing because his ideas were considered soradical. Despite this opprobrium, he invented80 patented surgical devices, published morethan 1,000 scientific papers, and developeddozens of new techniques. His obituary in theBritish Medical Journal hailed him as “the fatherof laparoscopic surgery.” Who today wouldchoose a standard open cholecystectomy overthe benefits of the laparoscopic approach?

Hip replacement is currently being performedby a variety of minimalist modifications of thestandard hip approaches as well as bynontraditional approaches. Knee replacement issimilarly being attempted through shorter inci-sions with various arthrotomy approaches. Theproponents of all call them minimally invasive,but this term has really become a catchall andhas no specificity or agreed-upon meaning.

The purported benefits of these techniquesinclude earlier, more rapid, and more completerecovery of function, less perioperative bleeding,and improved cosmesis. There has been, to date,few data by other than those proponents of spe-cific techniques to substantiate any of these poten-tial benefits. Of course, these purported benefitsmust be weighed against their potential to change

4 A.G. Rosenberg

the nature and/or incidence of complications thatmay arise secondary to the modifications of theseapproaches.

There is general consensus that adoption ofnew techniques initially results in a greater inci-dence of complications. This is the so-calledlearning curve [7, 8], well known to all surgeonslearning a new procedure. Whether this learningcurve is extended or contracted has been shown todepend on both individual and the systemic fea-tures of the operation [9].

It should therefore come as little surprise that,in the hands of those initially reporting thesemodified procedures (and presumably who havedeveloped their expertise gradually and over con-siderable time), the complication rates are compa-rable to those found in the standard approacheswhile others report a higher complication rate[10–14]. There has been insufficient time for thescientific evidence to accumulate in sufficient vol-ume to clarify the specific benefits and risks ofthese modifications in the hands of specialist sur-geons, let alone the generalist who performs theseprocedures.

Clearly, the modern era’s communication tech-nologies, coupled with more sophisticated mar-keting techniques, have dramatically influencedthe speed with which new techniques are recog-nized, popularized, and thus demanded by aneasily influenced public. However, continuedaccumulation of data through the performance ofappropriate studies will eventually determine themost appropriate role for these techniques in theorthopedic surgeon’s armamentarium [15]. Priorto that occurrence, what is the surgeon to do?

A purely prescriptive approach is prohibited bythe multifactorial nature of the surgical endeavor.The vast majority of surgeons who perform THAon a regular basis have already modified theiroperative approaches to incorporate less invasivetechniques. Each surgeon has an individual toler-ance for and willingness to undergo the strugglesinvolved in learning a new procedure, differinglevels of commitment to the change required forthe performance of the technique, as well as avarying ability to tolerate the potential complica-tions encountered while on the so-called learning

curve. Unfortunately, the removal of standardvisual, auditory, and tactile feedback cues duringthe performance of these “less” invasive proce-dures may require the development of alternatecues, which may not be readily available, wellestablished, or assimilated [11]. Thus, the overallcomplication rate may rise while familiarizationwith these cues (and the appropriate response tothem) matures or while alternate methods ofincorporating similar or comparable informationare developed. As attempts are made to limit theinvasiveness of surgical procedures, surgeonsmust be prepared to cultivate and take advantageof nontraditional sensory feedback and other alter-nate visualization methods to direct their efforts.As these evolve, it can be expected that surgicalintervention will continue to become lessinvasive.

The ultimate question implied in the title of thischapter, that is, how to learn a minimally invasivesurgery (MIS) technique, can only be answered byfirst understanding the current methods of surgicaltraining and their relationship to the practicerequirements of standard orthopedic procedures.Only then can we evaluate the way these methodsrelate specifically to the requirements of MIS andso answer the question: Do the specific surgicalrequirements of the MIS procedure require analteration in the manner in which we train sur-geons? An additional implied assumption is theperception, which appears to be correct but hasnot yet been rigorously established, that the per-formance of minimally invasive procedures in thetraining environment substantially alters the edu-cational experience for the learning surgeon. Aseries of linked questions is raised that deservesinquiry: (1) What are the performance require-ments for MIS surgery? (2) Do they differ sub-stantially from that of routine non-MIS surgery(begging the question of whether we really under-stand these!)? (3) What are the relationshipsbetween surgical training methods and patientoutcomes and do we understand these relation-ships sufficiently well to proceed to alter them ina meaningful fashion? (4) Does the routine adop-tion of MIS surgical procedures alter the currentteaching environment in a way that is deleterious

1 What Is Minimally Invasive Surgery and How Do You Learn It? 5

to the learning surgeon? (5) To what extent do theanswers to the proceeding questions demand thedevelopment of new methods for surgical teach-ing as regards the MIS procedures? And, finally,(6) what form might this take?

The old adage “It takes 1 year to teach someonehow to operate, 5 years to teach them when tooperate, and a lifetime to learn when not to oper-ate” seems to make the point that, in the surgeon’srepertoire, it is the psychomotor skills that are theeasiest and most readily taught. The implication isthat the psychomotor skills required in the oper-ating room are substantively different (and easierto teach) than the cognitive skills required. Butthis is clearly simplistic. Surgical performance isbased on a continuous feedback loop of psycho-motor performance intimately coupled with cog-nitive function. It is the continuous and ongoingmaking of decisions (albeit almost always at asubconscious level for the experienced) in themidst of physical performance that influences thequality of the surgical intervention.

To what extent the development of these cog-nitive and motor skills, and their interaction, gov-erns the eventual outcome is a complex problemthat has not yet been fully investigated andremains poorly understood. It has been said,“Many more surgeons have done a video analysisof their golf swing than have evaluated their oper-ative performance.” While there are few studiesthat have effectively evaluated real-time surgicalperformance characteristics in a meaningful way,even more fundamentally and unfortunately, thereis little research in the realm of surgical educationthat would help us determine the specific perfor-mance requirements for most surgical proceduresin general and of less invasive procedures in par-ticular. Additionally, there are few data on thepedagogical aspects of surgical procedure trainingfor either minimally or maximally invasive pro-cedures. A recent comprehensive review of expertperformance indicates that there has been moreattention directed to the study of musicians, ath-letes, pilots, and military commanders than tosurgeons [16]. Clearly, however, advances in sur-gical technology and technique have led to arenewed interest in these issues.

While the performance of arthroscopic proce-dures has resulted in a premium on specific three-dimensional spacio-visualization and psychomo-tor applications [8, 17], the same is not necessarilytrue for MIS-type joint replacement procedures.The simple answer to the question regarding theperformance skills requirements for MIS surgeryis that they are basically those that are found instandard surgical procedures but taken to a higherlevel. This arises from specific conditions thatappear to be inherent in MIS surgery [9].

1. In some respects, the ability to “protect” struc-tures in the standard fashion may be altered inspecific ways unique to the surgical procedure,and this may result in a directly proportionaldecrease in the margin of error for variousintraoperative maneuvers.

2. Small errors during the course of the operationmay be less easily recognized, and adjusted for,as the procedure progresses, and the implicationsof these small errors are potentially magnified.

3. Specific anatomic features that increase thedegree of difficulty encountered in the perfor-mance of a more “open procedure” (stiffness,deformity, poor tissue quality) may be magni-fied when the procedure is performed in aminimally invasive fashion.

4. Finally, and perhaps most importantly, thedevelopment of minimally invasive techniquesfrequently involves the removal or diminutionof traditional feedback signals that surgeonsnormally use and have come to rely upon tomake continuous adjustments to their perfor-mance. Thus, skills that are little needed, areinfrequently utilized, or have not been previ-ously recognized become of greater conse-quence. Indeed, the loss of standard cues mayneed to be compensated for in technique-specific ways. Ironically, in the hands of themore experienced surgeon, many of these feed-back signals are no longer “conscious,” havingbeen assimilated into almost automatic motorresponses; this can make the relearning processrequired more difficult.Training surgeons to perform these more diffi-

cult techniques, both with less room for error and

6 A.G. Rosenberg

with a different set of feedback signals, wouldtherefore seem to require the development ofboth traditional surgical skills and new ones inways that guarantee a more demanding perfor-mance level than has traditionally been required.

The questioned need for new training methodsimplies two separate factors that may be drivingthis concern. First, are current training methodsadequate to the task as currently envisioned? Sec-ond, does the conversion in the training environ-ment from standard open to MIS proceduresdegrade the training experience? The answerscan be found by evaluating the features of MISprocedures already noted:

1. Visibility of the surgical field is reduced,compromising visual feedback not only to theperforming surgeon but also to the learningsurgeon dependent upon observation and dem-onstration of anatomy and surgical pathology.

2. Lowered margins for error limit the opportuni-ties awarded to the less experienced trainee.

3. The decreased ability of the instructor to mon-itor trainee performance degrades the learningenvironment.

4. The alteration of traditional cues and theirreplacement withmore subtle and poorly definedfeedback signals are hallmarks of MIS tech-niques. Thus, the replacement of standard opensurgery by the MIS procedure would appear tosignificantly alter the training environment.Are the traditional residency education and

continuing medical education (CME) surgicaltraining methods capable of meeting this stan-dard? The system as currently constituted isderived (with little improvement and perhapseven development of some newer flaws) fromthe traditional systems of apprenticeship thatbegan sometime between the Dark Ages and thedevelopment of city-states in the Renaissance[18]. This pedagogical method, adapted by theGerman surgical schools of Kocher and Billroth,and modified in the United States by Halsted, haschanged relatively little over the years. Thus,training methodologies used to teach surgicalskills remain relatively primitive and haveenjoyed little improvement in either theory or

practice over the decades. Yet the specific techni-cal requirements of the surgical proceduresincrease steadily. The combined requirements ofresidency education, that is, service and educa-tion, frequently seem to serve the best interest ofneither. Even worse, depending on the specificsetting, current training methods may be appliedunevenly and randomly to the resident partici-pants [19]. The common cliché, see one, do one,teach one, seems to summarize the cavalierapproach to procedural teaching that has beenthe mainstay of surgical pedagogy. Moreover,when real patients are used for surgical teachingpurposes, increased morbidity, prolonged inter-vention times, and suboptimal results may beexpected [20]. It is clear that future technologies,whether they be traditionally surgical or otherwiseprocedurally interventional, will require more,rather than less, highly structured training andassessment methods. It has been demonstratedthat laparoscopic surgery adapts poorly to thestandard apprenticeship models for general surgi-cal training. Rather, standardized skill acquisitionand validation, performance goals, and a super-vised, enforced, skill-based curriculum that read-ily can be shared between trainee and instructorare thought to be needed to replace the observa-tion and incremental skill acquisition model usedin an open surgical environment [21].

Assuming no dramatic change in the nature ofour economy and the emphasis on health care, it isnot likely that the drive toward less invasive tech-niques will abate. As technology matures, newand improved techniques for vital structure pro-tection, component placement and positioning,and bone and soft tissue management will comeon line. As they do, the gradual development ofimproved skill levels in the performance of stan-dard procedures coupled with the cautious adop-tion of new practices as these skills mature iswarranted. An understanding of the ethical andmoral responsibilities of the operating surgeonmust be understood as they relate to training andsurgical performance [22]. An open mind alongwith a critical eye will be required. The followingsuggestions can be offered to the surgeon who hasyet to adopt these techniques.

1 What Is Minimally Invasive Surgery and How Do You Learn It? 7

How to Learn MIS: PracticalSuggestions

It has been demonstrated that domain-specific andtask-specific skills are not necessarily readilytransferred to new domains or tasks in the surgicalenvironment [23–25]. Surgeons, like other adults,learn best by doing, by practicing what they do,and by challenging themselves to take on increas-ingly difficult scenarios. Practice, in order to beeffective, requires deconstruction of the actualprocedure into key elements, each of which isrepeated until optimal results are achieved beforemoving onto the next element. The key ingredientto successful practice and ultimate self-improvement as a surgeon, as in other pursuits inlife, is that one be self-motivated and competitive,with a strong desire to improve coupled withappropriate practice routines that can lead toimprovement. This calls to mind the old joke,“Mister, How do I get to Carnegie Hall?” Theanswer, of course, is “practice.”

Incremental Improvement ThroughPractice

The literature on CME provides no support for thehypothesis that didactic CME improves eitherpractice patterns, skill levels, or patient outcomes– from this, one can infer that surgeons learn themore complex domain of surgical performancethrough repetition of procedures [26]. Willingnessto engage in repetitive attempts at improving thequality of what one is doing is crucial. One needsto define clearly the areas requiring practice andemploy a gradual, repetitive practice pattern; ulti-mately, one either improves or must change prac-tice habits. This is particularly important indeveloping an action plan for surgeons who maynot currently be performing any MIS procedures.

Practice

Correctpractice begins with the breakdown of theprocedure into its component parts, focusing per-formance-based exercise on those component

parts and acquiring and recognizing feedback,both during the performance in real time andafter. As an example, surgeons who are the mostexperienced in total knee replacementarthroplasty (TKA) frequently perform the vastmajority of the needed soft tissue releases to bal-ance the knee during the initial approachand exposure of the knee. Less experiencedsurgeons tend to make the soft tissue releases aseparate part of the technique, independent of theexposure, while the more experienced surgeonutilizes feedback throughout the procedure andemploys it to guide the degree of tissue theyare releasing during the exposure. In order tomaster the new skills that may be required inminimally invasive approaches, the surgeonmust reenter the mind of the learner that waspresent at an earlier stage of training. The basicsteps must be isolated, and renewed attentionmust be given to the details of procedure used toisolate those parts of the operation that requiremore attention, and there must be a detailedfocus on accomplishing the specific tasks requiredat each step of the procedure, specifically, on howthey present new or different challenges. Thosesteps that require the acquisition of new or refinedskills can then receive the appropriate attention.The use of computer guidance can aggressivelystrengthen feedback loops for surgical techniquethat might otherwise take years to develop. Theprecision of the technology provides objectiveand exacting criticism.

Criticism

Another contributor to effective practice is self-grading. Over time, one increases the pressure ononeself to perform, grades the result, and seeks toimprove. Self-grading requires measurement, andone needs to have some surgical goals in mind,such as tourniquet time, time to complete theprocedure, or specific objective characteristics ofoperative performance – cement mantle quality,component position, limb alignment, etc. Formore detail on this technique, see the Debriefingsection below.

8 A.G. Rosenberg

Varied Pressure

Surgeons can expand or contract the amount ofpressure experienced, because these less invasiveapproaches and the procedures themselves are, forthe most part, relatively extensile. Beginning aTKA as an MIS procedure does not lock thesurgeon into that pathway; if, at any point, thesurgeon deems the case too complex or the softtissue considerations are becoming unexpectedlydifficult, no harm is done by increasing the size ofthe incision to expand the exposure. Surgeons canliterally “push the envelope” by working theirway from the larger incision down to the smallerand, as a consequence, gradually increase thepressure on themselves. But the surgeon can alsoreduce that stress when desired or, more impor-tantly, when necessary to achieve the optimalsurgical outcome.

Avoid Multiple Learning Curves

It is essential to avoid combining multiple learn-ing curves when learning a new procedure. Theoutcome of any surgical intervention is clearlymultifactorial. Beyond the limitation of one’sown surgical skill set and one’s intuition, eachoperation encompasses a complex set of multiplefactors, some of which may remain below theradar screen of the most experienced surgeon.These factors include, but are not limited to, therelative contributions of our assistants, the char-acteristics of the specific operating room, and thetype of anesthesia being used. Multiple alterationsto such a complex system are much more difficultto assimilate than the incremental addition ofsmall changes approached one at a time. Forexample, it would be less than optimal to try anew technique or a new approach with new instru-ments, a new implant design, a new scrub techni-cian, and a new surgical assistant all at the sametime. Avoiding multiple learning curves is essentialin ensuring that the pressure you exert upon your-self represents a systematic increase and not anoverload; you can sequentially add more complex-ity and variation as you get better at what you do.

Visualization

Another important technique that has been wellpublicized in other areas of psychomotor skillacquisition and performance, but not as well pub-licized in surgery, is the use ofvisualization tech-niques. Great athletes will all admit to usingvisualization as an important part of their practiceregimen. Similarly, most high-performing sur-geons will also rehearse the operation, literally intheir “mind’s eye,” before proceeding with thecase. Most of us who perform complex surgeryhave the experience of repeatedly reviewing thesteps and sequences in a new operation before-hand, particularly when learning somethingcompletely new.

Visualization has been used in sports, musicalperformance, and in other forms of physical activ-ity, including dance and even acrobatic flying.Acrobatic pilots not only visualize the expectedsequence of flight maneuvers in their minds alongwith the control manipulation needed to achievethem but also assume the corresponding bodypostures, as if they are experiencing the forcesassociated with the acrobatic flight maneuver.This visualization technique combines psycho-motor and cognitive skill sets. One can similarlysee downhill ski racers mentally rehearsing therace course, accompanied by hand and bodymotion. In the same way, surgeons using similarvisualization might “think through” a particularoperation sequentially while imagining the poten-tial problems, structures at risk, and specific goalsof the procedure, while actually positioning theirhands as if they were grasping a specific instru-ment for a specific task during a surgicalprocedure.

Debriefing

Another self-improvement method involvesdebriefing, a more formal model for self, group,or mentor after-activity assessment [27, 28]. Theclassic role of debriefing is in the military, where ithas been used for generations to train and improvethe skills of warriors, particularly pilots.

1 What Is Minimally Invasive Surgery and How Do You Learn It? 9

Debriefing or after-action reviews involve themeticulous creation of a specific checklist of thegoals of any given performance followed by theruthless assessment of how those goals were actu-ally met during the performance. Debriefing tech-niques have applications in teaching residents andfellows as well as in improving one’s own perfor-mance. Such sessions have an important role inimproving performance at the step where you areat as well as in successfully ascending the ladderof surgical complexity [29].

Team Approach: Coaching

The MIS effort generally leads to an appreciationof the importance of teamwork and its impact onsurgical outcome. Perfect performance of theoperation without appropriate attention given toperioperative factors, such as pain control, reha-bilitation, etc., will not yield an optimal result.Similarly, increased coordination between assis-tants and surgeon is another requisite for thesuccessful performance of this more demandingtype of surgical procedure. Thus, a continuousfocus on the need for a team approach through-out, from preoperative considerations, to the sur-gical phase, and continuing through to thepostoperative environment, is a key determinantof optimal outcome. Every team needs a coach,and, in most cases, the responsibility will andshould rest with the surgeon. What do coachesdo? Their primary role is to create a feedbackloop; this is done by developing performanceexpectations, monitoring performance in a criti-cal way, and, finally, providing feedback thatleads to improvement and both motivates andempowers team members.

The Future

The characteristics that make up surgical perfor-mance include preoperative, intraoperative, andpostoperative factors. While the focus on surgicaltraining must be on all three arenas, it is mainly theintraoperative phase, where actual physical skillsare required, that is seen by most trainees as being

the area where there is the least opportunity todevelop experience. Experience is ideally gainedin an environment where feedback is immediateand mistakes are tolerated as part of the learningexperience. One of the things that have preventedsurgeons from acquiring greater levels of skill priorto entering practice or even during practice is thelack of such a practice environment.

The performance of surgery itself is dependenton performing multiple “subroutines,” most ofwhich have only been available for the surgeon toexperience during the performance of actual surgicalprocedures and therefore present the surgeon withno real opportunity to “practice” the psychomotorskills required during the procedure. In addition,there is little in the way of immediate informationavailable to the surgeon during the course of theoperation that would allow the surgeon to make thetype of adjustments that are based on cause-effects/feedback loops. As noted earlier, even in the perfor-mance of physical skills, there aremultiple cognitiveprocesses that must function correctly and effi-ciently to maximize surgical performance.

With modern technology, many of the factorsthat contribute to surgical performance can besimulated and repeatedly experienced with imme-diate feedback on the correctness of decisions andbehaviors. Development and utilization of thistechnology would be expected to result in anygiven surgeon moving more rapidly along thelearning curve, allowing the surgeon to performat a higher level during the actual surgical encoun-ter. Despite the obstacles present to the currentemployment of actual psychomotor skill simula-tion, these devices will eventually be part of thesurgical training environment. In the coming eraof virtual reality environments and surgical train-ing simulators, there is good reason to believe thatthe coupling of these technologies to assist thesurgeon in acquiring both motor and cognitiveskills will result in improved surgical performanceas well as improved patient outcomes as a result ofthe clinical encounter.

A current potential model for improving surgi-cal responsiveness and judgment can be obtainedby using the interactive video game as a model.Several features of the modern interactive videogame make it both compelling and popular. One

10 A.G. Rosenberg

PrefaceAcknowledgementAbout the EditorsSection EditorsContentsContributorsPart I: Rapid Recovery Programs for Joint Arthroplasty1: What Is Minimally Invasive Surgery and How Do You Learn It?How to Learn MIS: Practical SuggestionsIncremental Improvement Through Practice

PracticeCriticismVaried PressureAvoid Multiple Learning CurvesVisualizationDebriefingTeam Approach: CoachingThe FutureReferences

2: Same-Day Unicondylar Knee ArthroplastyIntroductionHospital Versus Surgery CenterA Multidisciplinary ApproachPain Management and AnesthesiaMinimizing TransfusionVenous Thromboembolism ProphylaxisPostoperative CareOutcomesSummaryReferences

3: Outpatient Total Knee ArthroplastyIntroductionPerioperative ManagementAnesthesiaApproachIntraoperative and Postoperative CarePostoperative Pain RegimenFeasibility and ResultsSummaryReferences

4: Same-Day Total Hip ArthroplastyRequirements for Outpatient THAPreoperative

IntraoperativePostoperativePost-discharge

ResultsConclusionReferences

Part II: Analgesic and Anesthetic Techniques5: Regional Analgesia for Orthopedic SurgeryIntroductionBenefits of Regional Anesthesia/Analgesia in Orthopedic SurgeryTechnical Aspects of Regional AnesthesiaNerve Localization TechniquesProlonging the Duration of Local Anesthetic (LA) Action

Issues and Concerns Regarding Regional AnesthesiaAnticoagulationPotential for Operating Room DelayWrong Side/Site BlockadeNerve InjuryRegional Anesthesia in Anesthetized or Heavily Sedated AdultsLocal Anesthetic Systemic Toxicity (LAST)Infectious Complications

ConclusionReferences

6: Multimodal AnalgesiaIntroductionPain Management in Orthopedic SurgeryMultimodal AnalgesiaNon-opioid Analgesic AdjuvantsNonsteroidal Anti-inflammatory Drugs (NSAIDs)Acetaminophen (More Widely Known as Paracetamol Outside of the United States)AnticonvulsantsN-Methyl-d-aspartate (NMDA) Receptor AntagonistsAlpha Receptor Agonist AgentsCorticosteroids

ConclusionReferences

7: Regional Analgesia for Shoulder SurgeryAnatomic ConsiderationsRegional Approaches for Shoulder SurgerySpecific Issues Concerning Regional Anesthesia for Shoulder SurgeryRelated IssuesReferences

8: Regional Anesthesia for Elbow and Hand SurgeryAnatomic ConsiderationsRegional Techniques for Elbow and Hand SurgerySpecific Peripheral Nerve Block ConsiderationsRelated IssuesReferences

9: Regional Anesthesia for Hip SurgeryAnatomical ConsiderationRegional Approaches for Hip SurgerySpecific Issues Concerning Regional Anesthesia for Hip SurgeryRelated IssuesReferences

10: Regional Analgesia for Knee SurgeryAnatomic ConsiderationsRegional Approaches for Knee SurgerySpecific Issues Concerning Regional Anesthesia for Knee SurgeryPatient FallsQuadriceps WeaknessNerve Injury InfectionFast Track Joint Replacement SurgeryLocal Infiltration Analgesia for Total Knee Arthroplasty

References

11: Regional Anesthesia for Foot and Ankle SurgeryAnatomic ConsiderationsRegional Techniques for Foot and Ankle SurgerySpecific Issues Concerning Foot and Ankle SurgeryRelated IssuesReferences

Part III: The Shoulder12: Overview of Shoulder Approaches: Choosing Between Mini-Incision and Arthroscopic TechniquesWhen to Choose Arthroscopy Over Other ApproachesThe Trend Toward ArthroscopyArthroscopy in Shoulder SurgeryReferences

13: Mini-Incision Bankart RepairAnatomy and BiomechanicsClinical FeaturesPatient HistoryPhysical Examination

Radiographic Featu