Bennett Orthopedics & Sportsmedicine
Regenerating the Youth in You!
Minimally Invasive Surgery of the
Knee, Shoulder
William F Bennett MD
Orthopedic Surgeon
There is a move to perform
surgery through smaller
incisions
Impetuslower infection rate?
less pain?
quicker rehab?
public demand
marketing
product companies
Arthroscopy vs Arthroplasty

Arthroscopy-The use of a fiber
optic device and mirrors to project
an image onto a television screen
 Arthroplasty- replacing defective
joints with implants, or other
techniques to remodel the joint
surface.
Arthroscopy Setup
Uses:
Knee
cartilage

meniscus

ligaments
Shoulder
rotator cuff

dislocation/instability

some arthritis
Hip
labral tears
anterior impingement
Arthroscopy Instruments
Shoulder Anatomy
Bone
Arthroscopic Photos

Shoulder
Shoulder Arthroscopy
Rotator Cuff Tears
Dislocations/Subluxations
Biceps subluxation
SLAP Lesions
Impingement
Ac Joint resection
Osteoarthritis
Knee Anatomy

Bones– Femur
– Tibia
– Fibula
– Patella
Tendons

Rectus femoris
 Vastus Medialis
– obliquus

Vastus lateralis
– Obliquus
– Patellar Ligament
ACL Ligament
Patellofemoral Chondromalcia
Knee Arthroscopy
Meniscal Repair
Meniscal Resection
Synovectomy
Chondoplasty
Ligament Reconstruction
Cartilage Regeneration
Cartilage Regeneration
Arthroscopic Biopsy
Sent To Cambridge, Massachusetts
Grown in Petri Dish
Replace Deficit with open procedure
Near Future- arthroscopic replacement
tissue engineering
Cell Implantation
Hip Arthroscopy
Limited Indications
Impingement
Labral Tears
However, Joint Replacement
can not be done
arthroscopically

However, demand has pushed us to
use smaller incisions and preserve
anatomy
Osteoarthritis

This knee would not be
amenable to
arthroscopic
intervention
Mini Incision/Quad Sparing
TKR

Smaller skin incision
 Does not disrupt the quadriceps tendon,
important for knee strength
 Less time in hospital
 Quicker to walk
Principles of MIS TKA
Address all types of arthritic path.
Approach both varus and valgus knees
Provide early, exceptional analgesia
Allow early hospital discharge and rapid
rehabilitation
The quality of the outcome not compromised
by length of incision
BUT NOT FOR ALL KNEES!!!!!!!!!!!!!!!!
Old Incisions
New Incisions
NEW INSTRUMENTS NATURALLITE

MIS – Knee
instruments – 4”
incision
Old
New
MIS TKA
Intra-operative
– Minimizes interruption of N/V tissue
– Minimizes dissection -muscles, tendon,lig .
– Avoids quadriceps disruption
– Avoids disruption of the suprapatellar pouch
– Eliminates patella eversion
– Reduces incision length to 7 to 10 cm
– Decreases blood loss
Post-operative
Faster return to activities of daily living (ADL)
Greater range of motion (ROM) during first six months
Leg raises and flex the knee within 6 hours
Reduced pain
Mini-Incision Hypothesis
Mini TKA
Length 9-14cm
Exposure
1.5 - 2.0 cm Quad split
Muscle relaxation
Release lateral pat-fem ligament
Standard TKA
Length 20-30cm
Extensive quad violation
Patellar eversion
Lateral release
Rehab
PROM  PT
Straight leg raise on POD 1
Ambulate POD 1
Flex to 90 by D/C
PROM  PT
Leg raise by POD ?
Ambulate POD 1
LOS
< 3 days (Mean = 2.9)
3 - 5 days (Mean = 3.6)
Other
Factors
 Blood loss
 Tourniquet & OR time
Decreased morbidity
Quicker return to ADL
Reduced pain (? significant)
Cosmetic appeal
Blood loss
Morbidity risk
Lengthy rehab
Reported by Dr. Luke Vaughan – Vail 2003
Quad-Sparing Hypothesis
MIS TKA
Exposure
Rehab
LOS
Other
Factors
Length 8-12cm
No VMO violation
No patella eversion
Early mobilization
Leg raise on day of surgery
Flex to 90 on day of surgery
Ambulation day of surgery
Standard TKA
Length 20-30cm
Extensive quad violation
Patellar eversion
PROM  PT
Leg raise by POD ?
Ambulate POD 1
1 - 2 days
½ blood loss
Decreased morbidity
Faster return to ADL
Reduced pain
Cosmetic appeal
3 - 5 days
Blood loss
Morbidity risk
Lengthy rehab
Small Incision

About 4 inches
Surgery
Summary
 Patients
like the scar
 Less pain
 Less blood loss
 Faster rehabilitation