1David P Johnson MIS & Function

David P. JohnsonDavid P. JohnsonMB ChB FRCS FRCS(ORTH) MDMB ChB FRCS FRCS(ORTH) MD

The Bristol Orthopaedic The Bristol Orthopaedic andand

Sports Injury ClinicSports Injury Clinic

MIS Knee Replacement:MIS Knee Replacement:

What are the functional benefits ?What are the functional benefits ?

VOCA Lustrum Congress of Knee SurgeryVOCA Lustrum Congress of Knee SurgeryNorordwijk aan Zee 2007Norordwijk aan Zee 2007

2David P Johnson MIS & Function

MIS - Total Hip ReplacementMIS - Total Hip Replacement

Berger RA Orthopedics. 2002 Berger RA Orthopedics. 2002 Mini-incisions: two for the price of one.Mini-incisions: two for the price of one.

Wenz JF. 2002 Wenz JF. 2002 Mini-incision total hip arthroplasty: a comparative Mini-incision total hip arthroplasty: a comparative assessment of perioperative outcomes. assessment of perioperative outcomes.

Waldman BJ. Waldman BJ. J South Orthop Assoc. 2002 Minimally J South Orthop Assoc. 2002 Minimally invasive total hip replacement and perioperative invasive total hip replacement and perioperative management: early experience.management: early experience.

3David P Johnson MIS & Function

MIS – Knee ReplacementMIS – Knee Replacement

Repicci JA. J South Orthop Assoc. 1999 Repicci JA. J South Orthop Assoc. 1999 Minimally invasive surgical technique for unicondylar Minimally invasive surgical technique for unicondylar knee arthroplasty.knee arthroplasty.

Murray DW. J Arthroplasty. 2001 Murray DW. J Arthroplasty. 2001 Rapid recovery after oxford unicompartmental Rapid recovery after oxford unicompartmental arthroplasty through a short incision.arthroplasty through a short incision.

Repicci JA. J Knee Surg. 2002 Repicci JA. J Knee Surg. 2002 Minimally invasive unicondylar arthroplasty: eight-Minimally invasive unicondylar arthroplasty: eight-year follow-up. year follow-up.

4David P Johnson MIS & Function

MIS – TKA: ExposureMIS – TKA: Exposure

Medial parapatellar approachMedial parapatellar approach Scuderi GR. et al CORR 2004Scuderi GR. et al CORR 2004

Medial parapatellar approachMedial parapatellar approach Tria AJ. et al CORR 2003Tria AJ. et al CORR 2003

Mini-midvastusMini-midvastus Laskin RS. CORR 2005Laskin RS. CORR 2005

Quadriceps sparing Quadriceps sparing Aglietti P. CORR 2006 Aglietti P. CORR 2006

5David P Johnson MIS & Function

Burns et al Anesthesthia 1989Burns et al Anesthesthia 1989Pain is:Pain is: Cultural, nonlinear, subjective, Cultural, nonlinear, subjective, age and gender dependentage and gender dependent

Nuelle DG, J Arthroplasty. 2007 Nuelle DG, J Arthroplasty. 2007 Multimodal pain managementMultimodal pain management Counseling and expectationsCounseling and expectations Pre-operative and pre-emptivePre-operative and pre-emptive Cold therapyCold therapy Local / regional anaesthesiaLocal / regional anaesthesia NSAID’sNSAID’s Oral analgesicsOral analgesics OpiatesOpiates

Management of Postoperative PainManagement of Postoperative Pain

6David P Johnson MIS & Function

Management of Postoperative PainManagement of Postoperative Pain

Side effects of opioidsSide effects of opioids Nausea/vomitingNausea/vomiting Decrease cough reflexDecrease cough reflex Decrease GI motilityDecrease GI motility Increase biliary tract Increase biliary tract

pressurepressure BradycardiaBradycardia G-U retentionG-U retention Pruritus/rash (Spinal)Pruritus/rash (Spinal)

Side effects of regional analgesiaSide effects of regional analgesia Pruritus/rash (Spinal)Pruritus/rash (Spinal) G-U retentionG-U retention Urinary catheterisationUrinary catheterisation Delayed mobilisationDelayed mobilisation

7David P Johnson MIS & Function

MIS – Anaesthetic protocolMIS – Anaesthetic protocol

Pre-operative counsellingPre-operative counselling Spinal anaesthesiaSpinal anaesthesia Regional / local nerve blockRegional / local nerve block Post-operative opiatesPost-operative opiates Pre-emptive oral analgesia Pre-emptive oral analgesia NSAID’sNSAID’s CPMCPM

8David P Johnson MIS & Function

MIS – TKA InstrumentationMIS – TKA Instrumentation

Tria AJ. OCNA 2004Tria AJ. OCNA 2004

9David P Johnson MIS & Function

MIS - Patellar subluxationMIS - Patellar subluxation

Mobilise quadricepsMobilise quadriceps Resect patellar osteophytesResect patellar osteophytes Resect femoral osteophytesResect femoral osteophytes Excise fat padExcise fat pad Release patello-femoral fold Release patello-femoral fold Resect articular surface of patellaResect articular surface of patella Abandon MISAbandon MIS

10David P Johnson MIS & Function

MIS – Size and obesityMIS – Size and obesity

Size and weightSize and weight ObesityObesity Men / womenMen / women FlexibilityFlexibility Choose incisionChoose incision

11David P Johnson MIS & Function

MIS – Uni - Compartmental KneeMIS – Uni - Compartmental Knee

Repicci JA, et al Repicci JA, et al J South Orthop Assoc. 1999J South Orthop Assoc. 1999 700 Uni from 1992700 Uni from 1992 80% were 24 hr stay80% were 24 hr stay Rehabilitation minimalRehabilitation minimal

12David P Johnson MIS & Function

Problems of MISProblems of MIS

Shakespear et al Knee 2005Shakespear et al Knee 2005 Oxford Uni-compartmentalOxford Uni-compartmental Flexed femoral component 8Flexed femoral component 8ºº Varus tibial component 1.8Varus tibial component 1.8ºº Posterior under-hang in 35%Posterior under-hang in 35%

Kort et al: 2007Kort et al: 2007 11% revision @ 2-7 years11% revision @ 2-7 years

Hamilton WG et al J Arthroplasty 2006Hamilton WG et al J Arthroplasty 2006 Aseptic loosening 3.7% cv 1%Aseptic loosening 3.7% cv 1% Reoperation 11.3% cv 8.6%Reoperation 11.3% cv 8.6%

13David P Johnson MIS & Function

Functional Outcome : MIS - UniFunctional Outcome : MIS - Uni

Muller et al: J Arthroplasty. 2004Muller et al: J Arthroplasty. 2004 Tibia varus and anteriorTibia varus and anterior HSS 78 cv 92HSS 78 cv 92 ROM 109 ROM 109 °° cv 113 cv 113°° Extensor lagExtensor lag

Carlsson et al 2006Carlsson et al 2006 MIS faster rehabilitationMIS faster rehabilitation Shorter hospitalisationShorter hospitalisation HSS 92 vs 96HSS 92 vs 96 Limb alignment and migration equalLimb alignment and migration equal

Murray et al JBJS Br 2006Murray et al JBJS Br 2006 97% survival rate at 7 years.97% survival rate at 7 years.

14David P Johnson MIS & Function

MIS – Total Knee ReplacementMIS – Total Knee Replacement

Laskin RS. CORR 2004Laskin RS. CORR 2004 Review of 32 cases with historical Review of 32 cases with historical

controlls.controlls. Hass SB. CORR 2004Hass SB. CORR 2004 Aglietti P. CORR 2006Aglietti P. CORR 2006

Mini midvastusMini midvastus Quadriceps sparing incision.Quadriceps sparing incision.

15David P Johnson MIS & Function

Functional Outcome : MIS - TKAFunctional Outcome : MIS - TKA

Tria AJ et al JBJS Br 2006Tria AJ et al JBJS Br 2006 Quadriceps sparingQuadriceps sparing Same knee scoresSame knee scores Longer MIS surgeryLonger MIS surgery Inferior component placementInferior component placement

King et al JBJS Am. 2007 King et al JBJS Am. 2007 Shorter hospital stayShorter hospital stay Less rehabilitationLess rehabilitation Less use of sticks at 2/52Less use of sticks at 2/52

16David P Johnson MIS & Function

MIS The Learning CurveMIS The Learning Curve

King et al JBJS Am. 2007 King et al JBJS Am. 2007 First 25 casesFirst 25 cases

Longer operation Longer operation Patellar tiltPatellar tilt

Kolisek et al J Arthroplasty. 2007 Kolisek et al J Arthroplasty. 2007 First cases no differenceFirst cases no difference

Murray et al 2004Murray et al 2004 First 10 cases had lower HSS scoresFirst 10 cases had lower HSS scores

17David P Johnson MIS & Function

MIS - Economic advantagesMIS - Economic advantages

Bozic KJ, CORR 2007Bozic KJ, CORR 2007

18David P Johnson MIS & Function

Wound 8 – 10 cm in extensionWound 8 – 10 cm in extension