Minimally Invasive Total Knee replacement

There is a move over all branches of surgery to achieve operations through small incisions, so-called "minimally invasive surgery". The aim is less pain, less time in hospital and quicker rehabilitation. In knee replacement the drive for this has come from the Usa, where in a shop driven healthcare economy, patients gravitate towards surgeons with progressive and therefore "better" techniques.

Manufacturers of knee replacement components have realised that they can shop directly to patients by using the internet. A visit to the websites of Zimmer or Biomet illustrates the point. Both have leading "patient information" areas which extol the virtues of minimally invasive knee replacement. They are very effectively exploiting one of the basic principles of marketing. Generate a inquire and then fulfill it. There is essential confusion as to exactly what is meant by "minimally invasive". This may be partly intentional for reasons I will interpret later.

As you are probably aware arthritis of the knee can be treated by replacing whether personel bearings of the knee (medial, lateral or patellofemoral) or by total knee replacement. Which is done depends to an extent on the degree of damage to the joint, but there is more to it than that. In the Usa it has been former to replace the whole knee, on the principle that nothing less will do.

This means that very many patients are given total replacements when partial ones would do.

In my institution in the Uk for example 50% of replacements have been partial. In America roughly all patients still receive total replacement. The theorize for development the disagreement between total and partial replacement is that it is uncomplicated to implant small components through small incisions, but implanting the larger components of a total knee through a small hole is very tricky and time-consuming.

Now there is a small group of American surgeons who have made it their mission to push the boundaries of the big component/tiny incision concept. And very well rewarded financially for doing so, I should add. Their clinical sense has been small and the follow-up short, although you wouldn't think this if you type "minimally invasive knee replacement" into "Google". It is as yet unproven that patients go home earlier, get best movements or have literal, surgery. Many other surgeons have tried this coming and find it too difficult. Hence the confusion of the definition.

Implant manufacturers have introduced "mini" or "reduced" incision surgery, and these too have been loosely termed minimally invasive (which has been used by surgeons to fee a price premium), so anyone can claim to do it if they make their incision a bit smaller. These mini incisions are exiguous distinct from that used by the majority of knee surgeons, especially if the inpatient is thin!

The shop for partial knee replacement is dominated by just one company Biomet, the remaining manufacturers therefore have to make the case for using a total replacement in as many patients as possible, hence the thought of " minimally invasive replacement". If the incision is small, then logic decrees that it is a small operation.

The principle here should be to do the literal, doing for every patient. The size of the incision should be large adequate to achieve surgery safely and accurately. This does not mean development an incision a yard long for every patient. As many patients as inherent should undergo partial knee replacement through truly minimally invasive incisions. The remainder of severely damaged knees may need a wider exposure.

Cramming large pieces of metal through tiny holes seems to me to be a triumph of technique over reason. Admittedly in many of the illustrations I have seen of the minimally invasive technique published in the American literature, the damage to the knee hardly justifies partial, let alone total replacement. There are major issues about accuracy of implantation of the components, as foresight is so limited. It has been estimated that up to 25% of components are badly aligned. Components that are poorly aligned may give rise to early failure of the knee replacement.

So in a nutshell if you are considering a knee replacement and the topic of minimally invasive surgery comes up, find out what exactly your surgeon means by this. Ask what proportion of your surgeon's patients have partial replacement, as this can be done safely and accurately through small incisions and the clinical results are ordinarily classic to total knee replacement with just as good long-term results.

As ever in orthopaedics, seldom are things what they seem. Produce of joint replacements is a worldwide multi-billion dollar industry, subject to the same competing drive as any other.

Read more

Minimally Invasive Coronary Bypass surgical operation

Minimally Invasive Coronary Bypass surgery techniques have changed the way we cure cure coronary artery disease. In spite of all the enthralling enlarge in the field of interventional cardiology (stents and angioplasties), many patients are best treated with minimally invasive coronary bypass surgery to enjoy a durable and trustworthy explication to their problems and a much best quality of life. One of my popular analogies about choosing the right options in heart disease comes from the field of dentistry. If you have a toothache and a literally rotten tooth you might reconsider two basic choices.......

Choice #1: The Diy Cheap Way Out.

You might determine to go to the local drug store and get yourself some strong toothache medication to feel best for a while. Unfortunately, we all know what happens next. This remedy won't last too long and chances are that you will end up losing your tooth and/or experiencing the misery of a tooth abscess.

Choice #2: The Permanent Fix

....Or you might determine to see what a dentist can do to help. Chances are that our good dentist will suggest a root canal. It goes without saying that none of us particularly enjoys the expectation of needle sticks and gruesome drilling in the dentist's office. We can expect, though, to save our tooth and get a crown on it. Bottom line: the pain is gone, the tooth is saved and we are happy again. That's more like it!!

Let's go back to coronary disease. A lot more than a tooth is at stake but a great deal of patients are still in denial and will try any easy way out rather than facing their condition. Some of them are unsuccessfully treated with curative therapy and/or stents and show up again with the same or more chest pain, shortness of breath, profound weakness or even worse...a heart assault and/or a much weaker heart. In many cases these same patients subject themselves to a radical, often exaggerated decrease in their corporal and collective operation to avoid their symptoms of chest pain, palpitations or shortness of breath. Some others get more and more stents in spite of the fact that they are obviously not working for them. I recall the extreme example of a 58-year old coronary patient with multiple stents saying, and I quote: "I'm fine. I only get chest pain when I walk!!" I heard once this line: "Insanity is doing the same thing over and over again, expecting a separate outcome each time".

All coronary patients should be strongly encouraged to consult with a heart surgeon and get a balanced view of their options in the medicine of their disease. It is not unusual to see patients that had been insisting on non-surgical therapies that are not working and can eventually cause more problems and effectively take their quality of life away. I am always amazed by how little information is offered to patients and their families when they are "shopping" for their best options. You should always feel free to ask as many questions as you like to your primary care physician and to the heart devotee about your choices in treatment. Our low-impact and minimally invasive coronary bypass techniques have dramatically improved our results and have shortened the rescue time after surgery. The remarkable majority of coronary patients in my assistance return to their homes two-three days after their minimally invasive coronary bypass surgery. Even frail and older patients can enjoy these exquisite results and get their "permanent fix" instead of the "Diy cheap way out"

What is a Coronary Artery Bypass? Coronary bypass surgery is one of the most oftentimes performed surgical procedures in the U.S.. To put it in plain plumbing terms, this policy deals with badly clogged pipes (the coronary arteries). We associate a new pipe (a bypass) between the aorta (the equivalent of the main water supply) and the coronary artery segment downstream from the blockage (the "clogged pipe"). This coronary bypass serves the purpose of bringing back a normal flow of oxygenated blood to the quantum of heart muscle supplied by the blocked coronary artery (see photo below).

The primary way to perform this execution involved the use of a heart-lung machine and a midline incision straight through the breast bone (median sternotomy). A more modern development that has revolutionized the way we perform this policy is the beating heart surgery technique. In other words, we are now able to perform a coronary artery bypass while the heart is beating, with no need for a heart-lung machine. In devotee hands, this technique allows exquisite results and a shorter and less involved postoperative course, especially in the older and higher risk patient population. By avoiding the use of the heart-lung machine, we are also able to perform a minimally invasive coronary bypass procedure. Clinical studies are beginning to show that this technique is associated to much less bleeding and very few patients require transfusions. It is best tolerated by the lungs and kidneys, which is a great advantage in patients with emphysema and/or renal insufficiency. It might also be useful in patients that have carotid artery disease (bad circulation to the brain). For all these reasons, it is my personal preference to use this minimally invasive coronary bypass technique in the remarkable majority of my patients. The execution is carried out by connecting the aorta to a small chance in the segment of coronary artery beyond the blockage. The relationship is created with saphenous veins harvested from the leg, mammary arteries from the chest wall, radial arteries from the forearm or other arteries from the abdomen. See pictures in my website.

Which grafts? The first coronary artery bypasses were performed only with leg veins. In the 70's the internal mammary artery (Ima) was introduced in clinical practice. It was soon discovered that the disposition use of this artery for bypass can warrant long term results that are far classic to using only leg veins. Numerous clinical studies have in fact shown that even after 10 years over 96% of the Ima grafts are still open and function well. The use of the Ima to bypass the coronary artery that feeds the front of the heart has been proven to give our patients the many survival advantage over any other intervention in modern medicine. This the presuppose why the left Ima is now carefully the graft of first choice all over the world, often in relationship with other grafts if more than one bypass is necessary. The exquisite results we observed with the use of the Ima lead us to believe that the preferential use of more arterial grafts instead of veins might improve the duration and quality of the useful effects of the bypass operation. In expanding to both Ima's (right and left), other arterial grafts such as the radial arteries from the forearm, the right gastroepiploic artery from the stomach, the inferior epigastric artery from the abdominal wall, etc. Have been successfully used. It is again foremost to point out that every patient gets an personel estimation to determine which single policy and grafts suit him or her best.

Midcab stands for Minimally Invasive Direct Coronary Artery Bypass. This technique truly represents the extreme minimally invasive coronary bypass technique in the field of heart surgery because it is carried out straight through a small incision And does not require the use of the heart-lung machine. This execution is performed on the beating heart and instead of the primary big midline incision, a 3" long transverse incision is all that is considerable to access the heart. The incision in a Midcab is right on the skin fold underneath the left breast to insure an invisible scar.

During a Midcab the Left Internal Mammary Artery is harvested from the chest wall and ready for relationship to the blocked coronary in the front of the heart. A mechanical stabilizer (that two-pronged fork) is used to immobilize the quantum of the heart face where the blocked coronary vessel is and allow the surgeon to associate the left internal mammary artery to it. The wound is then complete with plastic surgery techniques and the scar will be effectively private in the skin fold underneath the left breast. This Midcab arrival can basically afford our patients a scarless and often painless minimally invasive heart surgery operation

After this Midcab minimally invasive coronary bypass operation, our patients contact minimal pain with a small surgical scar and can often go home within the next 48 hours with a left internal mammary artery graft. Once again, this mammary graft is by far the best life insurance that modern medicine can offer to coronary patients!!! Ask your cardiologist about it. It is foremost to remember, though, that each patient needs to get an personel estimation by the heart surgeon in order to determine if he or she is a suitable candidate for a minimally invasive coronary bypass operation.

Read more