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Evan F. Ekman, MD: Well, let's advance to the fun part of the night and our first talk is going to be entitled, "Improving Patient Satisfaction Through Technique" and we're going to learn about a minimally invasive approach to total knee arthroplasty. It is an absolute pleasure to introduce Dr. Peter Bonutti and I'm sure you all have heard his name before; he's the founder of the Bonutti Clinic. He's an Associate Clinical Professor at the University of Arkansas and one thing that I learned about him that's absolutely amazing to me is I think he holds something like over 170 patents -- a pretty impressive number. So myself as well as everyone else here is looking forward to hearing him. Thank you very much.
Peter M. Bonutti, MD, FAAOS, FACS: Thanks very much. We'll talk a little bit more about technique, which is probably a little closer to my heart than some of the pharmaceutical options, although the pharmaceutical options are very, very important. Let's see what we've got.
Our goal with this, with minimally invasive technology, was really to look at issues that patients had, to try and address patient satisfaction and patient-related issues. I think it's real important as we look at knee arthroplasty in general, we need to understand not just what surgeons consider important factors -- survivorship and success rates -- but what patients really are concerned about.
Here's a patient who decided to undergo bilateral total knee replacements by a well-respected surgeon. His neighbor tells him he had his knee replaced and he said the first 4 weeks are hell. And here's the patient at 3 weeks after surgery; he states that he's moaning and crying and despite narcotics and icing, his knees are killing him. And the article finishes by stating: I'm still waiting for the blissful day when I can walk better than I did before surgery, get through the day without multiple pain pills, and sleep without pain medication. Now, again, this is just a case, but this was what's published recently in The New York Times, suggesting that patients' experience with knee arthroplasty is significantly different than what surgeons look at.
Again, this is the same patient, another article, kind of making us look not so good as orthopedic surgeons, taking OxyContin and 10 Percocet a day -- I don't think I've ever prescribed that in my life! And then the severity of his pain had him crying and no surprise that his pain was unrelenting. He said: I know of an orthopedic surgeon in New Jersey who won't see his patients for 2 months after surgery because he doesn't want to see them when they're suffering. And then the final quote -- this is again The New York Times! -- as it turned out, my internist knew more about treating pain than my surgeon. So again, it makes us in a little bit of a bad light and it suggests that we may need to revisit knee arthroplasty, especially from the patient's perspective.
But then you look at these scars and patients compare these scars with the standard total knee replacement, they look at that and they go: This must hurt, and they're very afraid of this. And the question is: Is this best for the patient? And I would propose there needs to be some alteration in our technique that may help patients.
That pretty daunting statistic says maybe we don't understand what our patients care about, and this might be mirrored by a recent study at last year's Academy by Esler looking at the British Knee Registry on 4600 knees. And he found that only 80% met expectations and 30% had problems with a significant amount of pain in these patients, even after successful knee arthroplasties.
Trousdale looked at a very interesting paper trying to assess patients' fear before hip and knee arthroplasty and what he found, if you look at the patient's perspective, their two greatest concerns were pain and length of recovery. And I think that's important; we need to understand what patients want from us.
And Bullens, looking at patients' success rate in Knee Society scores, found that the concerns and priorities of patients and surgeons differ, that our scoring systems may not be accurate assessment of what patients really care about. And the conclusion of the article is that surgeons are more satisfied than patients. Well, that's worrisome; I think we should be as satisfied as our patients are or maybe be as honest to ourselves as patients.
On the functional side, I think we also have a problem. Mont, at this Academy, has presented a paper soon to be published on his patients with a high Knee Society score, over 90, minimum 6-month follow-up, and only 35% of patients said they could do everything they wanted to. And in the younger subgroup under 60, only 13% of patients said they had no restrictions in their activity, which means not only do we have issues of pain and satisfaction, but our patients may not be doing the activities that they want to do.
This was recently presented in Orthopedics Today by the Insall Scott Kelly Institute; they talked about how total knee arthroplasty can be an option for the young, active patient, yet he tells the patients you'll never kneel on this knee comfortably, so gardening and descending stairs may be a problem. And in their study, only 24% of their patients remained active, so this is kind of an interesting study.
Ormonde Mahoney working with Tom Schmalzried looked at a different study trying to do a simple test of getting out of a chair without using your arms.
Improved Extensor Mechanism Function With the Scorpio Total Knee Replacement
He called that "unassisted chair rise" and he found that 3 months after surgery, only 40% with traditional knees could get out of a chair and at 6 months, only 64% could, which means that quadricep is significantly affected.
Improved Extensor Mechanism Function With the Scorpio Total Knee Replacement
And here's one of our patients, a standard patient 3 weeks after his minimally invasive knee arthroplasty. But the patient basically has a very simple unassisted chair rise, is able to use his quad function reproducibly. He's got good strength and this man was back to farming and climbing his tractor and working on his combine 2.5 weeks after his knee replacement. Pretty normal gait and this patient is satisfied; he's back to his life 3 weeks after surgery and that's what's driving us.
Now there's also marketing issues and issues about what's going on with direct patient marketing and trends in medicine, and the trends in medicine are suggesting that currently only a small percentage of joints are being done with minimally invasive surgery. They predict, however, in the next 5 years it will be the most common approach for hip and knee arthroplasty.
This is mirrored somewhat in the unicompartmental knee literature where you look, and the unicompartmental knees prior to 2000, only comprised 1% of the knee arthroplasty market. Yet if you look in 2004, over 10% of the knee arthroplasty market is uni's and that's in large part due to minimally invasive techniques, I believe. So it's a big, big jump in the sector of the market and patients are looking at and demanding some of this MIS.
Now I will propose MIS is patient-driven and we need to listen to our patients. Cosmetics are an issue; we can't avoid that. Pain recovery, we don't know issues, however, about long-term function, but clearly the goal is to reduce the overall soft tissue trauma -- not just simply a smaller incision; we need to look at what's inside.
And so we recommend looking at an evolutionary approach to looking at these techniques, gradually downsizing your incision, evolving into a lower, smaller incision, deciding where your incision precisely should be, and maybe whether a multi-incision approach. Remember that you can always extend your incision any time during surgery, but you cannot shorten it.
Basically these are the quadriceps exposures and you can see the median parapatellar effects. When you cut into that, it affects all four of the quadriceps muscles. The quad saving approach really is a modification of the median parapatellar, then we do a midvastus variation of the VMO snip or mini midvastus, subvastus, or lateral approaches; these are the approaches that have been described. But I'll propose to you that this is not the main reason why patients go home faster or have less pain; it is one of the variables.
We do navigated approaches and lateral approaches; some of them are quite challenging and I would caution you to approach these very carefully because you have significant patient preselection. The navigated approaches, Bill Hozack will talk about later I think, certainly has some advantages and he'll talk about those.
We found that a number of studies, both Dalury and White and others, have found that it offers early advantages and less pain and faster recovery, and all came up with the same conclusions. And Cooper found that as an extensile approach, you can split the VMO up to 8 cm safely without any neurovascular injury.
And here you can see the snip in the musculature; it's not extensive, okay, and you can see it's about, in this position, about the 10 o'clock position on the patella. We've not gone to the superior equator of the patella and that's basically our approach. The trick is how to get the patella out of the way and this is probably the most useful slide; we go into full extension and it's very useful to release the fat pad and anterolateral attachments of the lateral meniscus to this fat pad. And you say it's daunting; I can't get the patella out of the way. But if you release this down to the tibial tubercle, down to the patellar ligament, and release this fat pad over and then combine this with a superior release -- see, I can put my finger all the way to the anterolateral tibia -- then that allows us to mobilize our patella and slide it out of the way.
Now with the patella slid out of the way, you have easy access with these downsized instrumentation. Here, we elevate the quad muscle; we don't cut into it and our knee is only flexed about 50-60 degrees and then we would pin this in position, setting our rotation. I use an anterior referencing approach but you can also use a posterior referencing approach and look at a number of soft signs. The drawback is we cannot see our epicondyles, so it makes it very difficult to set up the rotation if you're epicondylar-based rotation, but we use other soft signs as the tibial cut, white sides lined, the anterior femur, the grand piano sign, and the tibial cut in that inflexion. You can see here most of our surgery is done in about 45 degrees of knee flexion; when you flex the knee further, there's more tension on the skin and the quad mechanism and it tears more. So if you decrease the flexion, it allows more mobility of the muscle, it slides it out of the way, and with these downsized instruments, you can make your bone cuts in a very reasonable and reproducible fashion.
The biggest issue is the tibial keel or tibial fixation and this is the first time we're delivering the tibia anterior to the femur; it's what we call in situ bone cuts and so you want to make sure that you have adequate exposure for the tibial keel and cement pressurization. This can be difficult; you need excellent muscle relaxation from anesthesia. And here you'll see how we pull the muscle out of the way; we use this Goulet retractor, which is very muscle friendly, and you can see sequentially you have adequate exposure.
You have to have good cement technique, good pressurization, so we can hopefully have the same long-term survivorship. We're trying to do the same technique with sparing the muscle and downsizing the approach. And then here we impact this, making sure that the implant is in good position, not flexed, and have a good cement mantle all around the entire implant. The biggest pain, however, is removing all the cement, especially laterally. You have to spend a lot of attention to detail getting all the cement out because it can be a very big problem and a source for complications.
This is our pop test to test that the patella is tracking well, and here you can see that you don't have undue soft tissue trauma if you pay attention to details and learn the position of your leg from flex and extension. Our muscle is not macerated and it's a very reasonable approach and it can be done in all patients. A simple post-op x-ray.
But here are the great advantages -- not some highly preselected patient; this is a typical patient I see in my practice, a small town in Illinois. And this patient is a typical what I call a two-gown patient because it takes two gowns to get around her! But she's the one who really needs that quad function and look at her as she is able to actively flex and extend her leg 36 hours after surgery. She's had one physical therapy session prior to this and you can see she has good active control of her quadriceps muscle. And this is even more difficult, getting out of a chair and getting back into bed and this lady, although she's limping, she is not normal; she is able to do it without an assisted device and she's able to bear full weight on that leg, so she can start to navigate. When she goes home, she will be using the cane and she has excellent muscle control. And I would suggest that this is not purely an analgesia issue; these are patients who have better quadriceps function, which is what they're really looking for.
Here's another patient, simultaneous bilateral total knees, 4 weeks after surgery. He has excellent quad function, you can see here with this unassisted chair rise, even tougher on tall patients. Good quad function. He was able to get back to his life and this individual, when he saw us, he's got a little bit of a limp but not too bad. And here he is, he was already golfing at his 4-week visit, which I think is very impressive with bilateral knees.
M.W. 65 Y/O WM -- 6'4" 250 lbs: Simultaneous Bilateral MIS TKA 4 Wks Post-Op
Again, tibiofemoral alignment; are we putting these in as good as traditional knee arthroplasty? I can tell you we do have some outliers; you can see that 0, 1, 2 degree, we need to eliminate those; we're working on improving the instruments. But again, these were with our first-generation instrumentation.
And here were our open reoperations. We did have two component revisions, one because of poor cement technique on the tibia and one because I probably overhang, I put too large a tibial component and they had lateral tibial overhang. We had one hematogenous infection, not surgical-related, one chronic effusion, and one patient who did have traumatic laxity. Most of these were in our very, very early procedures.
We also had a subgroup of patients who had standard knee on one side (24 patients), and minimally invasive on the opposite side, a minimum 1-year follow-up. All 24 patients recovered, by their own standards and chart reviews, 4-8 weeks faster when we compared it to their standard knee arthroplasty. Twenty-two of the 24 preferred the MIS approach, one didn't really care at follow-up, and one actually preferred the standard approach; so not everybody likes this.
And here's another patient with a standard total knee 5 years after surgery and minimally invasive 6 months after surgery; the right knee was 15% stronger than the left standard knee. But we're following this up; we'll hopefully present this at next year's Academy but we're seeing some hard data now that suggests quadricep strength is affected, and that by doing some of these muscle sparing techniques and noneverted patella, we may help these patients.
But one caution is that too many people equate minimally invasive without patient surgery. And I want to stress that we need to look at this because Ottenbacher did a study looking at decreasing length of stay with orthopedic and neurology patients, and they found when they decreased the stay, the mortality rate increased significantly. And this was actually picked up and was front page in our local newspaper, so it's something to be aware of. Sending patients home too early from these big surgical procedures has medical as well as surgical risks.
And if you're sports medicine-trained like I am, we know that steroid injections, especially Depo-Medrol, into an arthroscopic wound has a significantly greater risk of infection, published in two separate studies. So intra-articular steroids with total knee arthroplasty I think is a big risk and should be avoided.
This is kind of where the future is going so I thought I'd throw a few slides up on this, just a lateral incision. We open this up; we do not denervate the skin. The incision is directly lateral. We remove the bone laterally, slide this out with in situ bone cuts, and don't affect the quad mechanism at all. Slide the tibial and femoral components in; it does require a new type of implant and it can be fairly exciting. Here's one of our surgical pictures, so we think that the future may be going this way as well.
So evolution vs revolution: We need to understand this is a complex difficult procedure. We recommend evolving into this; you need to understand anesthesia will optimize muscle relaxation, and you have to take your time and pay attention to detail, gradually becoming comfortable and then downsizing your instruments.
And here's a patient who I did; it's something new we're doing with minimally invasive revisions as well and primary MIS totaling 3 days after simultaneous bilateral surgery. And the patient states that he went home from the hospital on Saturday and he went dancing with his wife the day of discharge. And he said he's been dancing ever since. And here's a patient for his follow-up checkup and you can see, with even a revision on one side and a primary in the other, he's getting pretty reasonable function. And this patient is what we're really looking for; it makes us gratified to spend the extra time and effort.
So, in summary, MIS really is an attempt to address patient goals, not surgeon goals, and trying to address pain, rehab, and function. I think it should be done in evolutionary fashion and make sure it's safe and effective. Thank you.
Dr. Ekman: Well, Dr. Bonutti, thanks so much. I'll tell you, I love that video of your last patient. I think that the smile on his face, it probably has everything about what it is to be an orthopedic surgeon; really, it is an opportunity to make a difference in people's lives.