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?