Minimally Invasive Minimally Invasive Surgery in Surgery in

OrthopaedicsOrthopaedics

Dr. Anshu SharmaDr. Anshu Sharma

Moderator: Dr. A.K MathurModerator: Dr. A.K Mathur

IntroductionIntroduction

A minimally invasive surgical procedure should A minimally invasive surgical procedure should be defined as one that is safe, performed with be defined as one that is safe, performed with least soft tissue damage and is associated with a least soft tissue damage and is associated with a lower postoperative patient morbidity compared lower postoperative patient morbidity compared with a conventional approach for the same with a conventional approach for the same operation.operation.

HistoryHistory

First procedure performed: Cystoscope to look First procedure performed: Cystoscope to look into and treat lesions of the bladder.into and treat lesions of the bladder.

In 1931,Takagi of Tokyo redesigned the In 1931,Takagi of Tokyo redesigned the cystoscope and produced an arthroscope.cystoscope and produced an arthroscope.

Marski Watanable, a student of Takagi, further Marski Watanable, a student of Takagi, further improved the arthroscope, and in 1957, based improved the arthroscope, and in 1957, based on extensive experience in performing on extensive experience in performing arthroscopy, he published an Atlas of arthroscopy, he published an Atlas of Arthroscopy. Arthroscopy.

Basic principle:-Basic principle:-

-Effectively treat pathology with minimal -Effectively treat pathology with minimal disturbance of normal anatomy.disturbance of normal anatomy.

-Leaving “the smallest footprint.”-Leaving “the smallest footprint.” Advantages:Advantages:

-Minimal tissue trauma,-Minimal tissue trauma,

-Minimal post- operative pain and morbidity,-Minimal post- operative pain and morbidity,

-Minimal hospital stay,-Minimal hospital stay,

-Early and better recovery. -Early and better recovery.

MIS Techniques In OrthopedicsMIS Techniques In Orthopedics

In Orthopedics Minimal Invasive surgical In Orthopedics Minimal Invasive surgical techniques are used in following areas:-techniques are used in following areas:-

1)Minimally invasive Spine Surgeries,1)Minimally invasive Spine Surgeries,

2)Arthroscopy,2)Arthroscopy,

3)Minimally invasive surgeries for fracture 3)Minimally invasive surgeries for fracture management,management,

4)Minimally invasive Arthroplasty.4)Minimally invasive Arthroplasty.

Minimally Invasive Spinal SurgeriesMinimally Invasive Spinal Surgeries(MISS)(MISS)

Spine surgery is traditionally done as “open Spine surgery is traditionally done as “open surgery”.surgery”.

Minimally invasive techniques are beginning Minimally invasive techniques are beginning to be used for a wider range of spine to be used for a wider range of spine procedures, and have been used for common procedures, and have been used for common procedures like decompression and spinal procedures like decompression and spinal fusion since the 1990s.fusion since the 1990s.

Traditional open surgeries of spine requires Traditional open surgeries of spine requires an incision that is 5 to 6 inch long and an incision that is 5 to 6 inch long and retraction of the muscles in order to see the retraction of the muscles in order to see the spine or deeper structures.spine or deeper structures.

Retraction of muscles and soft tissue for Retraction of muscles and soft tissue for prolonged period leads to their damage and prolonged period leads to their damage and increased post operative pain and morbidity.  increased post operative pain and morbidity. 

In MISS procedures (such as diskectomy, In MISS procedures (such as diskectomy, laminectomy and spinal fusion) are laminectomy and spinal fusion) are performed with special tools called tubular performed with special tools called tubular retractors.retractors.

During the procedure, a small incision is During the procedure, a small incision is made and the tubular retractor is inserted made and the tubular retractor is inserted through the skin and soft tissues down to through the skin and soft tissues down to the spinal column.the spinal column.

In order to see where to place the incision In order to see where to place the incision and insert the retractor, the surgeon is and insert the retractor, the surgeon is guided by fluoroscopy.guided by fluoroscopy.

The tubular retractor holds the The tubular retractor holds the muscles open and is kept in muscles open and is kept in place throughout the place throughout the procedure.procedure.

Any bone or disk material that Any bone or disk material that is removed exits through the is removed exits through the retractor, and any devices retractor, and any devices necessary for fusion — such as necessary for fusion — such as screws or rods — are inserted screws or rods — are inserted through the retractor.through the retractor.

Some surgeries require more Some surgeries require more than one retractor.than one retractor.

A small instrument is inserted through the tubular retractor to remove a herniated disk.Screws to support the fusion are placed in the bone through both retractors .

Indications of MISS:-Indications of MISS:- -Posterior cervical lamino-foraminotomy and -Posterior cervical lamino-foraminotomy and

discectomy,discectomy,

-Thoracic discectomy and laminectomy,-Thoracic discectomy and laminectomy,

-Lumbar disecctomy and laminectomy,-Lumbar disecctomy and laminectomy,

-Tumors of the Thoraco-Lumbar spine, -Tumors of the Thoraco-Lumbar spine,

-Interbody Fusion-Interbody Fusion

-Kyphoplasty/Vertebroplasty.-Kyphoplasty/Vertebroplasty.

Contraindications of MISS:-Contraindications of MISS:- --Systemic:Systemic: -Recent systemic/local infection,-Recent systemic/local infection, -Uncorrected bleeding diathesis,-Uncorrected bleeding diathesis, -Insufficient cardiopulmonary health,-Insufficient cardiopulmonary health, --Local:Local: -Fracture related canal compromise,-Fracture related canal compromise, - Severe spinal canal stenosis,- Severe spinal canal stenosis, -> 2 level disc,-> 2 level disc, -Bony bridging of interlaminar space. -Bony bridging of interlaminar space.

Complications of MISS:-Complications of MISS:- -Hemorrhage,-Hemorrhage, -Dural Tear,-Dural Tear, -Bowel Perforation,-Bowel Perforation, -Infection,-Infection, -Hardware failure,-Hardware failure, -Adjacent level vertebral body collapse,-Adjacent level vertebral body collapse, -Venous embolism,-Venous embolism, -Cement migration.-Cement migration.

Limitations of MISS:-Limitations of MISS:- -There is a learning curve to using the system -There is a learning curve to using the system

efficiently and safelyefficiently and safely

-Complications like dural tear, if occur can be -Complications like dural tear, if occur can be difficult to repair,difficult to repair,

-Delicate instruments with risk of instrument -Delicate instruments with risk of instrument failure.failure.

ArthroscopyArthroscopy ArthroscopyArthroscopy is a minimally invasive surgical  is a minimally invasive surgical

procedure on a joint in which an examination procedure on a joint in which an examination and/or treatment of damage is performed using and/or treatment of damage is performed using an an arthroscope.arthroscope.

This word arthroscopy came from Greek,This word arthroscopy came from Greek, “ “Arthro" (joint) And “Skopein"(to look).Arthro" (joint) And “Skopein"(to look).

Arthroscope:Arthroscope: A thin flexible A thin flexible fiberoptic scope which is fiberoptic scope which is introduced into a joint space introduced into a joint space through a small incision in through a small incision in order to carry out procedures order to carry out procedures within the joint.within the joint.

Fitted withFitted with Mini camera,Mini camera, Light source,Light source, Surgical tools.Surgical tools.

Shoulder ArthroscopyShoulder Arthroscopy

Indications:-Indications:- -Rotator Cuff Tears-Rotator Cuff Tears -Recurrent Dislocations,-Recurrent Dislocations, -Biceps subluxation-Biceps subluxation -SLAP Lesions-SLAP Lesions -Impingement-Impingement -Ac Joint resection-Ac Joint resection -Osteoarthritis-Osteoarthritis

Beach-chair position,Beach-chair position, -Anatomical position,-Anatomical position,

-Easy to Convert to Open -Easy to Convert to Open surgerysurgery

-Able to Move arm.-Able to Move arm.

Posterior Labral TearBankart Tear

Bony Bankart

SLAP Tear Rotator Cuff Tear

Pathological LesionsPathological Lesions

www.shoulderdoc.co.uk

Knee ArthroscopyKnee Arthroscopy

Indications:-Indications:- -Meniscal Repair,-Meniscal Repair, -Meniscal Resection,-Meniscal Resection, -Ligament Reconstruction,-Ligament Reconstruction, -Cartilage Regeneration,-Cartilage Regeneration, -Removal of loose bodies,-Removal of loose bodies, -Removal of synovium for-Removal of synovium for -Partial Synovectomy,-Partial Synovectomy, -Biospy,-Biospy, -Lavage of infected joint .-Lavage of infected joint .

Hip ArthroscopyHip Arthroscopy Limited Indications:Limited Indications: - Femoroacetabular - Femoroacetabular

Impingement,Impingement, -Labral Tears,-Labral Tears, -Loose bodies.-Loose bodies.

Ankle ArthroscopyAnkle Arthroscopy

Indications:-Indications:--Articular injury,-Articular injury,-Soft-tissue injury,-Soft-tissue injury,-Bony impingement,-Bony impingement,-Arthroscopic-assisted -Arthroscopic-assisted fracture fixation,fracture fixation,-Synovitis,-Synovitis,-Loose bodies,-Loose bodies,-Osteophytes,-Osteophytes,-Osteochondral defects,-Osteochondral defects,-Arthrodesis.-Arthrodesis.

Contraindications of Arthroscopy:-Contraindications of Arthroscopy:-

-In a minimaly deranged joints where -In a minimaly deranged joints where conservative method may response,conservative method may response,

-When risk of joint sepsis from a local skin -When risk of joint sepsis from a local skin infection,infection,

-Major collateral ligament & capsular disruption.-Major collateral ligament & capsular disruption.

-Partial or complete ankylosis (relative).-Partial or complete ankylosis (relative).

Complications of Arthroscopy:-Complications of Arthroscopy:- -Damages to related structures,-Damages to related structures, -Hemarthrosis -Hemarthrosis (most common postop.),(most common postop.), -Thrombophlebitis,-Thrombophlebitis, -INFECTION -INFECTION – as for any surgery but very less,– as for any surgery but very less, -Tourniquet paresis,-Tourniquet paresis, -Synovial herniation & Fistulas,-Synovial herniation & Fistulas, -Instrument breakage.-Instrument breakage. COMPLICATIONS RELATED TO COMPLICATIONS RELATED TO

ANESTHESIAANESTHESIA

Limitations of Arthroscopy:-Limitations of Arthroscopy:-

-Very few Surgeons,-Very few Surgeons,

-Technically demanding-Technically demanding

-Specialized equipments required-Specialized equipments required

-Needs excellent psychomotor-Needs excellent psychomotor

co-ordination.co-ordination.

Minimally Invasive Surgeries For Minimally Invasive Surgeries For Fracture ManagementFracture Management

MIS with a small incision results in minimal injury to MIS with a small incision results in minimal injury to soft tissue and bone which has a great biological soft tissue and bone which has a great biological advantages for fracture healing.advantages for fracture healing.

The best example is closed IMN of diaphyseal fractures The best example is closed IMN of diaphyseal fractures and bridge plating for fractures of the epiphysis or and bridge plating for fractures of the epiphysis or metaphysis extending into the shaft.metaphysis extending into the shaft.

Reduction is done by indirect closed percutaneous Reduction is done by indirect closed percutaneous length usually.length usually.

MIS consists of small soft tissue window, MIS consists of small soft tissue window, through a small skin incision, which allow allows through a small skin incision, which allow allows insertion of implants or instruments.insertion of implants or instruments.

MIS causes minimal additional injury to the soft MIS causes minimal additional injury to the soft tissue and fracture fragments.tissue and fracture fragments.

Use of indirect reduction or a gental direct Use of indirect reduction or a gental direct reduction.reduction.

Following implants are used for MIS technique Following implants are used for MIS technique of fracture management:of fracture management:

-Closed IM Interlocking Nailing,-Closed IM Interlocking Nailing,

-Minimally invasive plate osteosynthesis,-Minimally invasive plate osteosynthesis,

-External fixator,-External fixator,

-Percutaneous K-wire or screw fixation.-Percutaneous K-wire or screw fixation.

Indications:-Indications:-

-IMIL Nailing:-IMIL Nailing:

-Closed diaphyseal fractures.-Closed diaphyseal fractures.

MIPO:MIPO:

-Intra-articular # (distal femur, proximal & distal -Intra-articular # (distal femur, proximal & distal tibia, proximal humerus),tibia, proximal humerus),

-Comminuted metaphyseal or diaphyseal #.-Comminuted metaphyseal or diaphyseal #.

External fixator:External fixator:-Open metaphyseal -Open metaphyseal or diaphyseal # with or diaphyseal # with soft tissue damage.soft tissue damage.

Minimally InvasiveMinimally InvasiveArthroplastyArthroplasty

Minimally Minimally invasive Knee invasive Knee Replacement,Replacement,

Minimally Minimally invasive Hip invasive Hip Replacement.Replacement.

Minimally Invasive Minimally Invasive Knee ReplacementKnee Replacement

Heavily developed since 1991.Heavily developed since 1991. 6-8 cm incision results in less 6-8 cm incision results in less

damage to tissue.damage to tissue. A smaller incision results in A smaller incision results in

faster recovery and less narcotic faster recovery and less narcotic use for patients.use for patients.

Anesthesia times average Anesthesia times average approximately 2 hours and 30 approximately 2 hours and 30 mins.mins.

Comparing Incision SizesComparing Incision Sizes

Minimally Invasive Traditional TKR

Traditional TKR MIS TKRTraditional TKR MIS TKR

Study of Minimally Invasive Knee Study of Minimally Invasive Knee Replacements (Richard Laskin)Replacements (Richard Laskin)

58 TKR were performed via minimally 58 TKR were performed via minimally invasive approach with a control group (42 invasive approach with a control group (42 TKR) who had traditional knee replacement TKR) who had traditional knee replacement surgery .surgery .

Proposed that a minimally invasive Proposed that a minimally invasive approach would limit soft tissue disruption, approach would limit soft tissue disruption, speed recovery time, diminish blood loss, speed recovery time, diminish blood loss, and decrease post-operative pain.and decrease post-operative pain.

Pain was reported to be considerably lower in the Pain was reported to be considerably lower in the minimally invasive group than in the traditional minimally invasive group than in the traditional knee replacement group. knee replacement group.

Total use of morphine by the minimally invasive Total use of morphine by the minimally invasive group was 55 mg versus 118 mg by the traditional group was 55 mg versus 118 mg by the traditional group.group.

Interestingly, blood loss was greater in patients Interestingly, blood loss was greater in patients undergoing minimally invasive surgery at 713 ml undergoing minimally invasive surgery at 713 ml compared to 573 ml in the traditional knee compared to 573 ml in the traditional knee replacement group. replacement group.

Minimally invasive Hip ReplacementMinimally invasive Hip Replacement

Traditional THRTraditional THR Proven in clinical studies and Proven in clinical studies and

successfully performed for successfully performed for decades.decades.

Allows surgeon full Allows surgeon full visualization of operative area.visualization of operative area.

Larger incision (8-10 inches).Larger incision (8-10 inches). More disruption of muscles More disruption of muscles

and tissues.and tissues. Average hospital stay is five Average hospital stay is five

days.days. Average recovery time of Average recovery time of

approx. 3 months (individuals approx. 3 months (individuals will vary)will vary)

Minimally Invasive Minimally Invasive THRTHR

Long-term effects and success Long-term effects and success are not established.are not established.

Restricted visualization of Restricted visualization of operation area.operation area.

Smaller incisions (2-4 inches)Smaller incisions (2-4 inches) Potentially less disruption of Potentially less disruption of

muscles and tissues.muscles and tissues. May lead to a shortened May lead to a shortened

hospital stay, less than 5 days.hospital stay, less than 5 days. May reduce recovery timeMay reduce recovery time

Traditional VS Minimally Invasive Hip Traditional VS Minimally Invasive Hip Replacement SurgeryReplacement Surgery

Traditional Hip Traditional Hip Replacement SurgeryReplacement Surgery

Minimally Invasive Hip Minimally Invasive Hip Replacement SurgeryReplacement Surgery

Minimally Invasive Hip TechniquesMinimally Invasive Hip Techniques

Two-IncisionTwo-Incision 2 incisions2 incisions Approximately 2 inches Approximately 2 inches

in lengthin length On both front and rear On both front and rear

of thighof thigh Fluoroscopy may be Fluoroscopy may be

used.used.

Mini-IncisionMini-Incision 1 incision1 incision Approximately 3 to 4 Approximately 3 to 4

inches in lengthinches in length Either front or rear of Either front or rear of

thighthigh Fluoroscopy is not usedFluoroscopy is not used..

MI THR Techniques:MI THR Techniques:Two Incision vs Mini IncisionTwo Incision vs Mini Incision

Two-IncisionTwo-Incision Mini-IncisionMini-Incision

ConclusionConclusion

Patients report near equal satisfaction rates Patients report near equal satisfaction rates with both types of Knee and Hip with both types of Knee and Hip replacement.replacement.

Reduction of cost, hospitalization, post-op Reduction of cost, hospitalization, post-op pain, and a decrease in the length of pain, and a decrease in the length of rehabilitation will push further development rehabilitation will push further development of minimally invasive procedures.of minimally invasive procedures.

Longer anesthesia times and increased Longer anesthesia times and increased blood loss with minimally invasive blood loss with minimally invasive procedures are a concern.procedures are a concern.

New procedures present learning curve to New procedures present learning curve to surgeons.surgeons.

Thank you….Thank you….