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Giles R. ScuderiAlfred J. Tria Editors
Minimally Invasive Surgery in OrthopedicsSecond Edition
1 3 Reference
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Minimally Invasive Surgery inOrthopedics
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Giles R. Scuderi • Alfred J. TriaEditors
Minimally InvasiveSurgery in Orthopedics
With 1134 Figures and 56 Tables
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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
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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
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Acknowledgement
We would like to thank our families for supporting us through all outendeavors, while we continue to pursue our orthopedic dreams.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Part I
Rapid Recovery Programs for JointArthroplasty
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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: [email protected]
# 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
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mailto:[email protected]
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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
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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
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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
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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.
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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.
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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.
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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
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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