1David P Johnson MIS & Function

Functional Outcome of Knee ReplacementFunctional Outcome of Knee Replacement

Patient orientated functionPatient orientated function Self care, sticks, stability, ADL, walking Self care, sticks, stability, ADL, walking Stairs, work, sport, longevityStairs, work, sport, longevity

Objective functionObjective function Speed, quadriceps power, enduranceSpeed, quadriceps power, endurance

ExpectationsExpectations AgeAge PainPain FlexionFlexion Fixed FlexionFixed Flexion

2David P Johnson MIS & Function

Functional OutcomeFunctional Outcome

McClelland et al Knee 2007McClelland et al Knee 2007 Gait analysis of patients Gait analysis of patients

following total knee following total knee replacement.replacement. Post TKA gait is not normalPost TKA gait is not normal Less flexionLess flexion Quads avoidanceQuads avoidance

3David P Johnson MIS & Function

MIS – TKA elderlyMIS – TKA elderly

72 years old72 years old 36 hours post-op36 hours post-op

0-1000-100°° 1 stick1 stick

Cuckler JM: CORR 2007: Cuckler JM: CORR 2007: ““The ugly underbelly of the MIS movement”The ugly underbelly of the MIS movement”

4David 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 ?

5David P Johnson MIS & Function

Minimally Invasive SurgeryMinimally Invasive Surgery

Arthroscopy 1975Arthroscopy 1975 Power arthroscopic instruments 1985Power arthroscopic instruments 1985 Arthroscopic carpal tunnel release 1992Arthroscopic carpal tunnel release 1992 Total hip replacement 2001Total hip replacement 2001 Uni-compartmental knee replacement 2002Uni-compartmental knee replacement 2002 Total knee replacement 2004Total knee replacement 2004

6David P Johnson MIS & Function

Management of Postoperative PainManagement of Postoperative Pain

Nuelle DG, J Arthroplasty. 2007 Nuelle DG, J Arthroplasty. 2007 Minimal incision protocols for anesthesia, pain Minimal incision protocols for anesthesia, pain management, and physical therapy with management, and physical therapy with standard incisions in hip and knee standard incisions in hip and knee arthroplastiesarthroplasties

7David P Johnson MIS & Function

MIS – Medial collateral ligamentMIS – Medial collateral ligament

MCL at riskMCL at risk

8David P Johnson MIS & Function

Wound closureWound closure

1 Drain1 Drain Vicryl in layersVicryl in layers Clips to skinClips to skin DressingsDressings

9David P Johnson MIS & Function

MIS – Total Knee ReplacementMIS – Total Knee Replacement

Advancements in minimally invasive total Advancements in minimally invasive total knee arthroplasty.knee arthroplasty.Tria AJ Jr Orthopedics. 2003 Aug;26(8 Tria AJ Jr Orthopedics. 2003 Aug;26(8 Suppl):s859-63 Suppl):s859-63

Minimal incision total knee arthroplasty: Minimal incision total knee arthroplasty: early experience.early experience.Tria AJ Jr, Coon TM Clin Orthop Relat Tria AJ Jr, Coon TM Clin Orthop Relat

Res. 2003 Nov;(416):185-90Res. 2003 Nov;(416):185-90

10David P Johnson MIS & Function

MIS - Skin incisionMIS - Skin incision

Mark skinMark skin Medial boarder of tibial Medial boarder of tibial

tuberositytuberosity Medial boarder of patellaMedial boarder of patella Upper margin of patellaUpper margin of patella

11David P Johnson MIS & Function

Modified sub-vastus incisionModified sub-vastus incision

12David P Johnson MIS & Function

Computer Assisted Navigation in MISComputer Assisted Navigation in MIS

Keene GKeene G.et al 2006.et al 2006 Alignment improved 2.8Alignment improved 2.8°° cv 0.9 cv 0.9°° +/- 2 ° improved from 60% to 87%+/- 2 ° improved from 60% to 87%

Kim YH. JBJS Br 2007Kim YH. JBJS Br 2007 CAN made no difference to alignmentCAN made no difference to alignment

Bauwens K JBJS AM 2007Bauwens K JBJS AM 2007 23% longer surgery23% longer surgery CAN fewer outliersCAN fewer outliers No functional difference.No functional difference.

13David P Johnson MIS & Function

General discreditingGeneral discrediting

Cuckler JM: 2007: Cuckler JM: 2007: ““The ugly The ugly underbelly of the MIS movement”underbelly of the MIS movement”

Hungerford DS: “Smaller is not Hungerford DS: “Smaller is not necessarily better and, when it is necessarily better and, when it is worse, worse, it will be the "smaller" that it will be the "smaller" that is held accountableis held accountable.” .”

14David P Johnson MIS & Function

MIS – Anatomy of the medial retinaculumMIS – Anatomy of the medial retinaculum

Pegnamo NW. CORR 2006Pegnamo NW. CORR 2006 The VMO inserts to the The VMO inserts to the

midpole of the medial patella.midpole of the medial patella. The VMO inserts at an angle The VMO inserts at an angle

of 50of 50°°

15David P Johnson MIS & Function

MIS – Uni - Compartmental KneeMIS – Uni - Compartmental Knee

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%

16David P Johnson MIS & Function

17David P Johnson MIS & Function

Preservation of the Supra-patellar pouchPreservation of the Supra-patellar pouch

Sub-vastus releaseSub-vastus release

18David P Johnson MIS & Function

Management of Postoperative PainManagement of Postoperative Pain

Principles of pain management:Principles of pain management: Reduce “sundowning”Reduce “sundowning” Improve daytime sensorium to Improve daytime sensorium to

speed rehabilitationspeed rehabilitation Reduce effects of pain stress, i.e., Reduce effects of pain stress, i.e.,

chest painchest pain Reduce side effects: respiratory Reduce side effects: respiratory

depression, constipation, urinary depression, constipation, urinary retention, pressure sores, etc.retention, pressure sores, etc.