Hip and Knee Arthroplasty

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Hip and Knee Arthroplasty
INVASIVE
Minimally

• Presented by
• Nicole M. Boyko, PT, MS

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Overview

• Basics of Total Joint Surgery
• What is MIS?
• Benefits of MIS
• Application of MIS to Hip Replacement
• Application of MIS to Knee Replacement
• Conclusion/Implication to PT

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Introduction

• gt 21 million people in the US have some form of
  osteoarthritis
• By 2020, 20 of Americans will be gt65 y/o and at
  risk for OA
• Annually this amounts to
• 152,000 THA surgeries
• 299,000 TKA surgeries

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What is MIS?

• MIS Minimally invasive solutions
• Widely used in gynecological, cardiac, GI surgery
  
• Now being applied to orthopedic surgeries
• Mini-incision vs Mini-invasive
• Mini-incision operation through smaller hole
• Mini-invasive adds to this 3 goals
• Minimal disruption of physiology
• Minimal lifestyle interference
• Avoidance of interference with future Rx or
  surgery

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Benefits of MIS

• ? operation time
• ? blood loss peri- and post-op
• ? hospital stay
• ? costs
• ? risk of infection
• Overall shorter recovery time

• Smaller incision
• ? tissue and muscle trauma
• ? pain
• 20-30 more ROM
• Quicker, easier rehab

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Application of MIS to THA

• Pioneered by Zimmer Holdings, Inc. of Warsaw, IN
• Global leader in design, development and
  manufacture of reconstructive orthopaedic
  implants
• Two Techniques
• Mini Incision Technique
• Two- Incision Technique

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Mini Incision THA

• Utilizes 3-4 incision vs 8-10 with traditional
  THA
• Cementless metal and plastic implant
• 4-6 wk projected recovery period
• Two common procedures
• Top ½ of posterolateral approach
• Top 1/3 of anterolateral approach
• In either approach, incision can be extended to
  full length at any time during surgery

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Research Wenz et al (2002)
Results Mini-incision Direct lateral approach
Cases 124 65
OR time 40 min 126 min
Blood loss 129 mL 602 mL
Incision length 3.5 8
D/C from hospital 60 by day 3 47 by day 3
Average LOS 3.8 days 4.0 days
D/C Placement 44 home 50 rehab 6 SNF 38 home 40 rehab 22 SNF
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Two Incision THA

• No mm are cut so lt pain than mini THA
• One 1.5-1.75 ant incision over fem neck for
  excision of head of femur and implantation of
  acetabular component
• One 1-1.25 incision made as if IM fem rod were
  being placed for insertion of fem head component
• 80 of 1st 50 cases able to D/C same day after
  100 min OR procedure

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Application of MIS to Knee Replacement

• Unicondylar Knee Replacement
• Uni-Spacer
• Repicci II Unicondylar
• Zimmer M/G Uni Knee
• Minimally Invasive TKA
• L-I Approach
• Zimmer Approaches
• Smith Nephew and BrainLAB Approaches

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Unicondylar Knee Arthroplasty

• Involves reshaping only damaged portion of joint
• Introduced in 1970s
• 5,000 performed annually in U.S.
• Newest innovation- minimally invasive UKA or
  mini-uni
• Introduced in late 1990s
• Same concepts but with 3-4 incision

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Ideal Candidates for UKA

• 45-65 y/o
• Isolated non-rheumatoid OA with cartilage NOT
  bone loss
• Normal ligaments
• No significant patella problems
• Best for non-obese patients

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Popular Uni-Knees

• Uni-Spacer
• Manufactured by Sulzer Orthopedics, Inc.
• Cleared for use in US in Jan 2001
• gt 2,500 successful surgeries to date
• Cobalt and chrome alloy prosthesis
• Fit b/t femur and tibia alleviates need for
  cement or screws
• Does not compromise conversion to TKA

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Popular Uni Knees

• Repicci II Unicondylar Program
• Biomet prosthesis with 10 yr, 90 success rate
• 7-10 cm incision for medial rebalancing, 10-12 cm
  for lateral rebalancing
• Burr rather than cut bone for implant
• Freelance procedure relies on anatomy not
  instruments to determine bone removal

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Popular Uni Knees

• Zimmer M/G Uni Knee
• Introduced in late 1990s
• 2-3 incision to remove diseased portion of knee
• Can be done on outpt basis
• 5 wk recovery time with near full ROM
• gt 20,000 implanted to date

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Minimally Invasive TKA

• L-I Approach
• Limited Incision TKA
• Invented by Dr. Peter Bonutti of Bonutti Clinic
  in Effingham, IL
• 3-4 incision, 60-75 min OR time
• Uses Scorpio Total Knee Instrumentation by
  Stryker Howmedica Osteonics (SHO)
• gt 200 surgeries to date research results pending
  by SHO

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Minimally Invasive TKA

• Zimmer Mini-Incision TKA
• Pioneered by Dr. Luke Vaugh of Scripps clinic in
  La Jolla, CA, 1999
• Comparison study of 60 MINI vs 66 traditional
• Incision 4.3-5.5 vs 7.8-12
• Hospital stay 3.0 days vs 3.5 days

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Minimally Invasive TKA

• Zimmer Minimally Invasive Solutions Quad-Sparing
  TKA
• Avoids cut through quads
• Pioneered by Dr. Alfred Tria of St Peters
  Hospital in New Brunswick, NJ
• 3 incision, LOS lt 48 hrs, 18 gt ROM
• Uses Zimmer NexGen Complete Knee Solution LPS
  Flex Components
• Stealth Station optic image guidance tech

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Minimally Invasive TKA

• Smith Nephew and BrainLAB
• April 2003 1st mini TKR enhanced by high
  precision computer navigation
• Performed by Dr. John Lange Dr. Paul Schwartz
  of Shasta Orthopedics, Redding, CA
• Utilizes 3.5 incision, ? rehab by 2 mo
• Accuracy of implant alignment extends life
• Tested in US, Europe, Japan, Canada, Australia

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Implication to PT

• Requires modification of our existing total joint
  protocols
• In all cases, pts able to
• Walk sooner
• Perform more aggressive ROM
• Tolerate more advanced strengthening
• D/C to home earlier

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Questions?