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Prof. P Aglietti Director of the First Orthopaedic Clinic University of Florence, Italy

MIS TKA today. Prof. P Aglietti Director of the First Orthopaedic Clinic University of Florence, Italy . Promises, promises ……. Less trauma Less pain Less blood loss Faster rehabilitation Better cosmesis. Mini-Subvastus vs Traditional Medial ParaPatellar .

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Prof. P Aglietti Director of the First Orthopaedic Clinic University of Florence, Italy

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  1. MIS TKA today Prof. P Aglietti Director of the First Orthopaedic Clinic University of Florence, Italy

  2. Promises, promises…… • Less trauma • Less pain • Less blood loss • Faster rehabilitation • Better cosmesis

  3. Mini-Subvastus vsTraditional Medial ParaPatellar Prospective, matched case-control study Implants: LPS (stemmed tibial component) Analgesia: femoral nerve block + PCEA Mini-Subvastus – 60 TKA Traditional Medial ParaPatellar – 60 TKA Boerger-Aglietti, CORR 2005

  4. Mini-Subvastus L-shaped capsular incision

  5. Limited blunt dissection over the septum

  6. Tibia first (in situ) Patella not everted

  7. Distal cut from medial

  8. Exposure of both condyles

  9. Complete preservation of VMO insertion

  10. Results: in favor of Mini-SV Less blood loss Less pain day 1 Earlier SLR 90° reached sooner (statistically significant)

  11. Disadvantages of Mini-SV • More tourniquet time • More complications (one each): • PT rupture • Lateral condyle fracture • Varus tibial component • Initial experience

  12. Limitations of MIS Inflammatory arthritis Restricted flexion (less than 80°) Patella infera (IS-R < 0.6) Morbid obesity (BMI > 35.0) Risk of ischemic skin complications Very severe deformities (more than 20°) Large muscular males

  13. Hypothesis Could we obtain the same MIS advantages with a shorter but more conventional approach, with less complications and more precision ?

  14. Limited ParaPatellar Quad incision 5 cm above patella No patellar eversion

  15. Femur first: distal cut from anterior (with downsized instrument)

  16. Femoral component sizing/rotation

  17. Femoral a/p cuts (downsized cutting block)

  18. Tibial cut with tibia subluxed forward (EM cutting jig)

  19. Complete tibial exposure for a variety of tibial implants

  20. Fluted High flex mobile RP Mini-keel TM

  21. Limited ParaPatellar vsMini-Subvastus approach Prospective matched case-control study Same implant (LPS) and multimodal pain management Limited ParaPatellar – 30 TKA Mini-subvastus – 30 TKA Sensi-Aglietti, submitted to KSSTA 2007

  22. Demographics

  23. Complications

  24. Clinical results Subjective

  25. Clinical results Objective

  26. Radiographic results

  27. Mini-SV radiographic “imperfections” Tibial medialization Retained cement

  28. 1. Conclusion The Mini-Subvastus had easier recovery but more complications and more tourniquet time than the Traditional Parapatellar approach.

  29. 2. Conclusion Less invasive TKA is not for everybody: it has many limitations or contraindications.

  30. 3. Conclusion The Limited ParaPatellar was only slightly inferior to the Mini-Subvastus in the first weeks after surgery, but with less tourniquet time and improved radiographic results.

  31. 4. Conclusion Outcome of TKA is multifactorial: • “Less invasive” surgical technique • Preop patient education with clear expectations • Postoperative pain control • Rehabilitation

  32. 5. Conclusion “Less invasive” technique: • Reduced QT incision • No patella eversion • No tibial subluxation ?

  33. 6. Conclusion The “less invasive concept” is here to stay. It has stimulated new technical solutions, with small smart instruments and new surgical skills.

  34. Risks and benefits Comfort zone for the surgeon

  35. The importance of being MIS Minimally IS Medium IS Maximally IS

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