chirurgia protesica mis - ettore sabetta · “mis uka was not as accurate as open uka in a-p...
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Arcispedale Santa Maria Nuova Reggio Emilia
S.C. Ortopedia e Traumatologia Direttore: Ettore Sabetta
E. Sabetta
Chirurgia Protesica MIS
Luci e Ombre
CITTA’ DI PARMA, 23 GIUGNO 2008
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L’impianto di una protesi di ginocchio richiede:
• Adeguata visione • Adeguato spazio lavoro
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Adeguata visione
• Visione minima indispensabile • Visione senza visione
Adeguato spazio di lavoro
• Esperienza • Protesi e strumentario
ESPERIENZA
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Quindi le vie di accesso mini-invasive richiedono
• Esperienza per vedere senza vedere • Esperienza per lavorare in spazi ristretti • Protesi e strumentari dedicati
Non sono per tutti i Chirurghi, né per tutte le protesi
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Cos’è una via accesso mini-invasiva ?
• Una via di accesso nuova • Una via accesso tradizionale, ma più piccola (?)
Mantenere gli stessi risultati della tecnica standard
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Cos’è la M.I.S. ?
• Piccola incisione cutanea • No eversione rotula • Rispetto app. estensore • Rispetto sfondato quadricipitale • Rispetto canale midollare • Rispetto legamenti crociati • Minima resezione ossea • Minima perdita ematica • Recupero funzionale rapido • Ricovero breve
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M.I.S.
(Piccola) incisione cutanea con massimo rispetto dell’apparato estensore e dello sfondato quadricipitale
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M.I.S.
•! L’inserzione del VMO è sempre sul 3° prossimale della rotula •! La violazione del VMO altera la propriocettività
PAGNANO M. 22 Annual Interim Meeting of the Knee Society, Feb 2005
Impossibile impiantare una PTG in modo mini-invasivo
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M.I.S.: dubbi
• Tensione sui tessuti molli • Tensione sull’osso (rotula, osteoporosi) e sulle inserzioni legamentose e tendinee (t. rotuleo) • Accuratezza nell’impianto (osteofiti, reperi anatomici, resezioni ossee, bilanciamento, taglia e rotazione componenti) • Cementazione • Durata dell’intervento • Complicazioni • Durata del ricovero
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“MIS UKA was not as accurate as open UKA in A-P tibial placement or postoperative limb alignment” Fisher, J Arthroplasty 2003
“At 5 years MIS UKA have over 2 times greater revision rate than standard UKA” Swedish Register - Bonutti, AAOS 2005
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M.I.S.: Indicazioni
• Paz. in buone condizioni (intervento > 90’) • Varo < 10° • Valgo < 15° • Flesso <10° • ROM ≥ 110° • No rotula bassa • No grave osteoporosi • No obesità o grande diametro della coscia • No grave deformità artrosica • No Revisioni
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Vie Accesso Mini-Invasive
• Quad-sparing • Mini-midvastus • Mini-subvastus • Limited parapatellar
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Quad sparing
• Artrotomia pararotulea mediale senza incidere il vasto mediale ed il tendine quadricipitale fino alla TTA • Rispetto app. estensore • Strumentario dedicato • Sempre protesizz. rotula • No cementazione • Componente tibiale senza fittone
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Quad sparing
• Asportazione Hoffa • Taglio rotuleo in estensione, a mano libera, per aumentare lo spazio • “Finestra dinamica” • Strumantario dedicato
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Mini-Midvastus
• Antero-mediale, dal bordo sup-med rotula incisione del VM per 2-3 cm parallela alle fibre • Distalmente fino alla TTA come nella pararotulea standard
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Mini-Midvastus
• Flessione progressiva del ginocchio • Lussazione laterale app. estensore senza eversione rotula • Strumentario dimensioni ridotte
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Mini-Midvastus
• Arteria genicolata discendente • Nervo per il vasto mediale (dal n. femorale)
Incisione < 4-5 cm.
n. per il vasto mediale (dal femorale)
n.safeno
ramo infrapatellare del safeno
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Mini-Subvastus
• Artrotomia mediale a “L” • Dissezione smussa del VM dal setto < 10 cm (a. genicolata sup-med) • Lussazione laterale app. estensore senza eversione rotula • Strumentario dimensioni ridotte
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Mini-Subvastus
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Mini-Subvastus: vantaggi
• < danno vascolare (rispetto a. genicolata discendente) • < dolore • < problemi malallineamento apparato estensore • precoce recupero estensione e forza quadricipite (nessuna differenza dopo 1 anno) Chang 2002
Faure 1993, Gustilo 2000, Roysam Oakley 2001, Chang 2002
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Limited Parapatellar
• 3 cm. prossimale al polo superiore della rotula • No eversione della rotula • Strumentario dimensioni ridotte • Rispetto alla mini-midvastus non c’è il rischio di “snippaggio” del VM
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73 anni, 162 cm., 83 kg
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12,5 cm.
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RISULTATI M.I.S.
• Migliore recupero funzionale fino a 3 mesi • Stessi risultati a 6-12 mesi
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217 PTG Mini-Midvastus vs Standard • tempo chirurgico uguale (6 minuti in più) • minore perdita ematica dal drenaggio (non significativa) • minore dolore post-operatorio • più rapido recupero flessione 80° 2 gg con M-Mid, 4 gg con St • flessione equivalente a 6 sett., 3 e 6 mesi • più rapida ripresa deambulazione e fare le scale senza bastoni
Laskin, Clin Orthop 2005
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217 PTG Mini-Midvastus vs Standard • uguale accuratezza (posizione, bilanciamento, RX) • no significative differenze per deformità, peso, altezza, età e sesso • più breve degenza ospedaliera • più rapido ritorno alle comuni attività • stessi risultati a 6-12 mesi • 1 necrosi cutanea (guarita spontaneamente) • 6 split del VM durante la flessione
Laskin, Clin Orthop 2005
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60 PTG Subvastus • > tempo laccio • 3 lateral release • 1 frattura condilo femorale laterale • 1 rottura tendine rotuleo • 1 malallineamento tibiale (3° varo) 60 PTG Standard • 2 lateral release • nessuna complicanza • nessun malallineamento
Aglietti, Clin Orthop 2005
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69 PTG M.I.S. • 1 paralisi temporanea SPE • 1 lussazione traumatica rotula dopo 1 anno • nessun malallineamento 49 PTG Standard Scuderi, Clin Orthop 2005
20 PTG M.I.S. • 2 componenti femorali flesse
Bonutti, Clin Orthop 2005
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30 PTG M.I.S. • 4 componenti tibiali in varo (<87°) • 3 tilt laterale rotula 30 PTG Standard • nessun malallineamento
Dalury, Clin Orthop 2005
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PTG QS: vantaggi • ROM migliore a 3 mesi • precoce recupero funzionale • < perdite ematiche • < dolore post-op • < degenza post-op • cicatrice molto piccola • stessi risultati a 6-12 mesi Tria, AAOS 2004
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249 PTG QS: 5 casi ampliamento accesso • 1 obeso • 1 sanguinamento • 3 posizionamento femore Aumento tempo chirurgico del 50% Tria, AAOS 2005
450 PTG QS: • aumento tempo chirurgico > 10 min. (is this a risk factor for increased complications, such as infection, skin injury, or ischemia ?) • 1 infezione acuta • 2 casi con varo tibiale 7° • 3 casi scollamento tibiale dopo 2-3 anni Tria, Orthopedics 2006
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Aumento complicanze mediche nel post-op (degenza post-op 4 gg.)
Tria, Clin Orthop 2003
Aumento della mortalità con il diminuire della durata di ricovero
Ottenbacher, Jama 2004
Dimissione precoce ?
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“It appears that controlling pain after total joint surgery is a more important variable for the early recovery of function than the length of the incision or soft-tissue trauma”
Ranawat, AAOS 2006
E se la vera M.I.S. fosse un’altra cosa ?
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It is our belief the next great advance in total joint surgery will not be with MIS procedures, but rather improved peri-operative pain management techniques.
- Local Pain Control - Pre-operative patient education - Advanced Physical therapy - Reduced Tissue Trauma Surgery (RTTS)
Ranawat, AAOS 2006
E se la vera M.I.S. fosse un’altra cosa ?
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Chandrasekaran S et al. Minimally invasive imageless computer- navigated knee surgery: initial results. The Journal of Arthroplasty, 23,3;2008
Seon JK et al. Comparison of minimally invasive unicompartmental knee arthroplasty with or without a navigation system. The Journal of Arthroplasty, 2008, article in press
Kilian P et al. New visualization tools: computer vision and ultrasound for MIS navigation. Int J Med Robotics Comput Assist Surg, 4:23-31, 2008
PubMed 2008
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100 Pazienti in attesa di eseguire PTG Scelta su CAS, MIS, Ceramica; prima e dopo completa informazione • 42% di quelli che avevano scelto CAS prima dell’informazione, dopo ha preferito la tecnica convenzionale • Nessuno di quelli che avevano scelto no-CAS prima ha cambiato idea • 60% di quelli che avevano scelto MIS prima ha cambiato idea • Nessuno di quelli che avevano scelto no-MIS prima ha cambiato idea
RAGIONI DELLA SCELTA CAS: “not proved yet” (88%) MIS: “higher complication” (50%) “lower accuracy” (43%)
Patient’s perspective on controversial issues in total knee arthroplasty: Kim TK, Choi J, Shin KS, Chang CB, Seong SC Knee Surg Sports Traumatol Artrosc 2008, 16:297-304
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• La M.I.S. ha avuto il merito di insegnare ai Chirurghi a limitare il trauma chirurgico all’essenziale • I limiti della M.I.S. sono: visione, spazio di lavoro, modello protesico, strumentario • Visione e spazio di lavoro sono funzione dell’esperienza del Chirurgo • Ogni paziente ha la sua M.I.S.
CONCLUSIONI
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• Il controllo del dolore post-op. è determinante ai fini della M.I.S. • Il futuro della M.I.S. sembra essere sempre più legato alla navigazione • La corretta informazione al paziente in molti casi risolve i dubbi e facilita il lavoro del Chirurgo
CONCLUSIONI
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GRAZIE