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Surgical Technology International XXI contains 40 articles with color illustrations.

 

Universal Medical Press, Inc.

San Francisco, September, 2011

ISBN: 1-890131-17-2

 

1 year Institutional Subscription 

both electronic and print versions.

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STI XXI - Orthopaedic Surgery

 

Alignment in Total Knee Arthroplasty: Where Have We Come From and Where Are We Going?
Aaron J. Johnson, MD, Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Steven F. Harwin, MD, FACS, Chief of Adult Reconstructive Surgery and Total, Joint Replacement, The Center for Reconstructive Joint Surgery, Beth Israel Medical Center, New York, New York, Kenneth A. Krackow, MD, Professor of Orthopaedics, State University of New York at Buffalo, Department of Orthopaedics, Orthopaedic, Research Laboratory, Buffalo, New York, Michael A. Mont, MD, Co-Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland

 

  • Abstract
    • Numerous reports have linked malaligned total knee arthroplasty (TKA) components with increased wear, poor functional outcomes, and possibly early failure due to component loosening. Consequently, proper alignment is critical to a successful outcome. This article will review: the normal mechanical alignment of the knee, classical alignment in TKA, anatomic alignment in TKA, intraoperative reference points for alignment, and the potential for new alignment schema based on the kinematic axes of knee movement. Along with our increased understanding of how the knee functions, modern total knee arthroplasty has evolved to restore a neutral mechanical axis when prostheses are implanted. Although historically the goal has been to aim to be within 3 degrees of this axis, recent reports have challenged the validity of the claim that outliers have an increased risk for revision. In addition, new alignment schemes have been developed based on the kinematic axes, but as yet we await verification of results to determine whether they increase the ability of total knee arthroplasty to provide a better-functioning and longer-lasting knee for the patient.

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Excellent Clinical Outcomes in Total Knee Arthroplasty Performed Without a Tourniquet  

D. Alex Stroh, BS, Medical Student, MSIV, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Aaron J. Johnson, MD, Orthopaedic Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Peter M. Bonutti, MD, Director, Bonutti Clinic, Effingham, Illinois

 

  • Abstract
    • Although tourniquet use is the standard protocol for total knee arthroplasties it may lead to postoperative complications including thigh pain, compressive soft-tissue problems, and thromboembolic events. The purpose of this study was to explore the perioperative and clinical outcomes of total knee arthroplasty performed without a tourniquet. Thirty consecutive total knee arthroplasties were performed in 30 patients without a tourniquet and compared with 30 procedures (30 matched patients) performed with a tourniquet. Tourniquet patients had statistically lower mean intraoperative blood loss, total blood loss, and change in hematocrit, but these did not have any clinical impact or change the transfusion rate between the groups. At a mean follow-up of 3 years, both groups achieved excellent mean Knee Society scores with similar improvements between groups. There were no complications or radiographic abnormalities in either group. Total knee arthroplasty performed with or without a tourniquet yields similar intraoperative surgical and postoperative clinical outcomes.

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A Comparison Study of Two  Cruciate-Retaining Total Knee Designs:  A Preliminary Report   
Frank R. Kolisek, MD, Surgeon, OrthoIndy, Indianapolis, Indiana,  Michael A. Mont MD, Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,  Christopher R. Costa MD, Orthopaedic Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,  Charles E. Jaggard, RA, Research Coordinator, OrthoIndy, Indianapolis, Indiana,    Aaron J. Johnson MD, Orthopaedic Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland

 

  • Abstract
    • Cruciate-retaining total knee arthroplasties have had high success rates. The purpose of this study was to compare a newer cruciate-retaining design to a previously used implant to determine if there were any changes in clinical or functional outcome. A total of 461 patients (553 knees) were identified who had total knee arthroplasty with this newer design. At latest 2-year follow-up, the mean range of motion was 121 degrees (range 105 to 140 degrees), the mean Knee Society pain score was 91 points (range, 57 to 100 points) and the functional score was 76 points (45 to 100 points). The comparison group of 211 patients (225 knees) had a mean range of motion of 119 degrees at 2 years (range, 90 to 142 degrees) with Knee Society pain and functional scores of 95 and 85 points, respectively (ranges 57 to 100, and 0 to 100, respectively). The use of the newer cruciate-retaining total knee arthroplasty showed comparable results to the previously used design at short-term follow-up. The cruciate-retaining design used in this study had no early failures, though further study is needed to make assessments regarding longer-term functional results and outcomes.

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Evaluation of Primary Total Knee Arthroplasty Incision Closure with the Use of Continuous Bidirectional Barbed Suture
Scott Stephens, MD, Resident Physician, Mount Carmel Medical Center, Columbus, Ohio, Joel Politi, MD, Department of Orthopedic Surgery Teaching Staff, Mount Carmel Medical Center, Columbus, Ohio, Ben C. Taylor, MD, Trauma Fellow, Grant Medical Center, Columbus, Ohio

 

  • Abstract
    • The purpose of this study is to determine whether operative time for primary total knee arthroplasty can be decreased with the use of a continuous barbed suture. Five hundred patients were retrospectively reviewed and divided into groups based on whether incision closure utilized a continuous barbed suture or an interrupted biodegradable suture. We identified additional variables to determine their relationship to operative time, including body mass index, age, gender, and side of replacement. The results demonstrated a decrease in operative time by an average of 4 minutes (P < .001) with the use of barbed suture, without an associated increase in complications. Statistically significant relationships were found between operative time and variables such as body mass index, age, and gender, but not side of replacement.

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Surgical Techniques for Staged Revision of the Chronically Infected Total Knee Arthroplasty
Steven J. Fitzgerald, MD, Assistant Professor, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, Arlen D. Hanssen, MD, Professor of Orthopedic Surgery, Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota

 

  • Abstract
    • Infection after total knee arthroplasty is a rare yet devastating complication requiring multiple hospitalizations, operations, and outpatient visits placing a significant burden on both patient and treating surgeon. Two-stage exchange protocols for the treatment of the chronically infected total knee arthroplasty remain the standard of care in the United States. Thorough debridement, use of antibiotic spacers, treatment with parenteral antibiotics, and delayed reimplantation have resulted in treatment success rates greater than 90%. The use of antibiotic cement spacers has led to increased range of motion, preservation of the joint space, and maintenance of cleaner soft tissue plains making surgery at the time of reimplantation less arduous. This article describes our current surgical technique used for two-stage revision of the chronically infected total knee including: (1) exposure, (2) implant removal and debridement, and (3) construction of both static and mobile antibiotic spacers.

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Fixation Strategies in Total Knee Arthroplasty
Shane Guerin, MCh, MEng, FRCSI (Tr & Orth), Arthroplasty Fellow, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada, Chris Jones, MB, BS, FRACS (Orth), Arthroplasty Fellow, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada, R. Michael Meneghini, MD, Director of Joint Replacement, Indiana University Health Saxony Hospital, Assistant Professor of Clinical Orthopedic Surgery, Indiana University School of, Medicine, Indianapolis, Indiana, Michael J. Dunbar, MD, FRCSC, PhD, Professor of Surgery, Professor of Biomedical Engineering, Professor of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada

 

  • Abstract
    • There are three broad strategies for component fixation in total knee arthroplasty (TKA): cemented, cementless, and hybrid (cemented tibia, uncemented femur). Cemented TKA remains the current gold standard, with reliable long-term results. National joint registry data indicates that uncemented tibial components have the highest revision rates, and clinical and RSA studies suggest this is the result of lower initial stability when compared with cemented tibial components. However, young, active, high-demand patients may warrant a consideration of accepting the slightly increased risk of early failure for the potential benefit of long-term osseointegration, which may result in the, as yet elusive, "knee replacement for a lifetime."

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Neuromuscular Adaptations in Gluteus Medius Activity Following Resurfacing and Total Hip Arthroplasty   
Manoshi Bhowmik-Stoker, PhD, Motion Analysis Lab Manager, BSHRI-CORE Orthopedic Labs, Banner Sun Health Research Institute, Sun City, Arizona,  Christopher A. Buneo, PhD, Assistant Professor, School of Biological & Health Systems Engineering, Arizona State University, Tempe, Arizona,  Michael Wade Shrader, MD, Orthopaedic Surgeon and Director of Research, Department of Orthopaedic Surgery, Phoenix Children's Hospital, Phoenix, Arizona,  Marc C. Jacofsky, PhD, Vice President of Research and Development, The Core Institute, Phoenix, Arizona

 

  • Abstract
    • In middle-aged patients, the choice between resurfacing and total hip arthroplasty may be difficult given recent studies showing differences in functional outcomes. Success of clinical outcomes, defined by a greater range of motion and reduced pain following surgery, are dependent on a return in function of incised muscle groups. To identify neuromuscular recovery following hip arthroplasty, hip abductor activity was assessed throughout the first year of recovery. Analysis focused on characterization of the temporal activity of the gluteus medius during activities of daily living. Adaptation in muscle firing and biomechanical outcomes was revealed in both groups, though more pronounced in the THA cohort with increasingly difficult activities. Differences between groups should be considered by clinicians when considering the best treatment options for their patients.

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Modern Dual Mobility Cups for Total Hip Arthroplasty   

Nitin Goyal, MD. Adult Reconstruction Fellow. Thomas Jefferson University Hospital & The Rothman Institute. Philadelphia, Pennsylvania.  Mohan S. Tripathi. Medical Student. Jefferson Medical College. Thomas Jefferson University. Philadelphia, Pennsylvania.  Javad Parvizi, MD. Professor of Orthopaedic Surgery. Thomas Jefferson University Hospital & The Rothman Institute Philadelphia, Pennsylvania

 

  • Abstract
    • Dislocation after total hip arthroplasty remains a primary concern among orthopaedic surgeons. Endeavors to decrease the incidence of dislocation, while maintaining limb function and mobility, have been painstakingly undertaken. Since their advent in the 1970s, dual mobility cups have proven again and again to be effective in reducing dislocation following total hip arthroplasty. The dual mobility cup enables the surgeon to treat patients with an increased risk for dislocation, while maintaining hip stability, favorable wear properties, and an acceptable rate of dislocation. Disadvantages are related to the potential increased wear and surgeon error. With advances in engineering and design, dual mobility cups have proven useful in providing lower dislocation rates for several pathological conditions. As a result, dual mobility cups have moved into the forefront of total hip arthroplasty.

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The Use of Dual-Mobility Bearings in Difficult Hip Arthroplasty Reconstructive Cases
Michael A. Mont, MD, Co-Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Kimona Issa, MD, Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Qais Naziri, MD, Fellow, Center for Joint Preservation and Replacement , Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Steven F. Harwin, MD, Chief of Adult Reconstructive Surgery and Total Joint, Replacement, Adult Reconstruction Service, Beth Israel Medical Center, New York, New York, Ronald E. Delanois, MD, Orthopaedic Surgeon, Center for Joint Preservation and Replacemen, Rubin Institute for Advanced Orthopedics, Sinai Hospital, of Baltimore, Baltimore, Maryland, Aaron J. Johnson, MD, Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland

 

  • Abstract
    • This report includes a series of eight cases in which a dual-mobility prosthesis was utilized for difficult acetabular reconstructive hip arthroplasty cases. Most of the patients described had multiple reasons for hip instability (including prior multiple surgeries, abductor muscle insufficiency, prior infection). All patients were successfully managed with this device and this report includes a brief description of its use compared with other surgical reconstruction methods for instability.

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Fixation Strategies in Total Hip Arthroplasty
Rudolph G.T. Geesink, MD, PhD, Emeritus Professor of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands

 

  • Abstract
    • Substantial progress has been achieved in cementless arthroplasty in the recent decades where cementless arthroplasty has evolved from pressfit implantation to porous-coated and later HA-coated implant fixation as its ultimate current state-of-the-art incarnation. Key factors for success are adequate primary stability of the device in the bone supported by design and surface structure variables that together with optimal implant biocompatibility result in durable osseo-integration of the device. Excellent survival rates past 20 years are documented in both literature and registries with quantitative studies confirming the excellent implant stability and bone quality. Elderly, younger, or medically compromised patients may require specific attention to avoid problems, but in general, every patient can be given the benefit of modern cementless hip arthroplasty. With an optimal consideration for patient-related factors as well as anatomic reconstruction of the arthroplasty, modern cementless arthroplasty provides every patient an outlook on both excellent long-term functionality and survival.

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The Use of Modularity in Total Hip Arthroplasty
Paolo Cherubino, MD, Professor and Chief, Orthopedics and Trauma Clinic, Department of Biology and Life Sciences, University of Insubria , Varese, Italy, Michele F. Surace, MD, Associate Professor, Orthopedics and Trauma Clinic, Department of Biology and Life Sciences, University of Insubria, Varese, Italy

 

  • Abstract
    • Modularity is defined as separation of a system into independent parts or modules that can be treated as logical and may be separated and recombined. Historically, the modularity represents the evolution of the concept of "low friction arthroplasty" developed by Sir J. Charnely in 1960. The disadvantage of a one-piece stem is the difficulty of restoring the biomechanical feature of the hip. Thus, the natural evolution was the introduction of modularity on both sides, the acetabulum and the femur. Modularity allows the surgeon to accurately match the anatomic characteristics of each patient to obtain improved range of motion, joint stability, abductor strength, and leg length equality. Disadvantages are related to the introduction of different interfaces, which could be sites of wear and corrosion. In accordance with the most recent literature, in primary total hip arthroplasty (THA) the modularity can be reduced to the head and the acetabular component, while a one-piece stem can manage the majority of cases. On the other hand, we believe that during revision surgery, a complete modularity is necessary.

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A Prospective, Randomized Study of Component Position in Two-Incision MIS Total Hip Arthroplasty: A Preliminary Study   
R. Michael Meneghini, MD, Director of Joint Replacement, IU Health Saxony Hospital, Indiana University Health Physicians, Assistant Professor of Clinical Orthopaedic Surgery, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, Shelly A. Smits, RN , Indiana University Health Physicians, Indianapolis, Indiana

 

  • Abstract
    • Controversy exists regarding the ability to position the implants reliably in minimally invasive surgery (MIS) total hip arthroplasty (THA). This study compared the ability to accurately position components in the MIS two-incision versus single-incision approaches. Twenty-four patients were randomized to THA through one of three approaches, including the two-incision approach. Component position was measured with computed tomography. The mean deviation from the target acetabular anteversion was 14.8 degrees in the two-incision MIS group versus 6.4 degrees in the other two approaches (p = 0.006). A mean of 9.8 degrees deviation from the target femoral anteversion in the two-incision MIS approach group was observed compared with 5.3 degrees in the single-incision groups (p = 0.05). These results suggest there is a decreased ability to accurately position the components in the two-incision approach.

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Total Joint Arthroplasty in Patients with Obstructive Sleep Apnea: Strategies for Reduction of Perioperative Complications   

James Cashman, MD, Arthroplasty Fellow,  Orhan Bican, MD, Research Fellow,  Ravi Patel, BS, Research Fellow, Christina Jacovides, BS, Research Fellow,  Chelsea Dalsey, BS, Research Fellow,  Javad Parvizi, MD, FRCS, Professor Of Orthopedics,  Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

 

  • Abstract
    • Obstructive sleep apnea (OSA) has been associated with increased risk for medical complications following total joint arthroplasty. Our institution employs postoperative precautions for OSA patients in an effort to minimize the impact of postoperative complications in this group. We performed this study to assess the effect of careful monitoring on postoperative complication rates in OSA patients. We identified patients with a clinically suspected or objective diagnosis of OSA who received total joint arthroplasty between January 1998 and January 2008. 1016 cases in 792 OSA patients were matched to 1016 cases in 993 control patients to compare complication rates. There were no differences between OSA and control patients in cardiovascular and respiratory complications following TJA. Patients with OSA experienced increased rates of postoperative acute renal failure when compared with controls (p = 0.02) and experienced mild desaturations (Hb O2 < 92%) (p = 0.002), but not severe desaturations (Hb O2 < 88%) (p = 0.2). We conclude that our postoperative monitoring protocols are successful in reducing postoperative complications most commonly associated with OSA. We were interested to note the increased risk for OSA patients to develop postoperative acute renal failure and believe that future study is warranted to explore the link between OSA and renal failure.

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Post-traumatic Vertebral Compression Fracture Treated with Minimally Invasive Biologic Vertebral Augmentation for Reconstruction
John C. Chiu, MD, DSc, FRCS, Director, Department Neurospine Surgery, California Center for Minimally Invasive Spine Surgery, California Spine Institute Medical Center, Newbury Park, California, Ali M. Maziad, MD, MChOrth, Orthopedic Surgery Specialist, Spine Surgery and Surgical Informatics Fellow, California Spine Institute - IPILAB, University of Southern California, Los Angeles, California

 

  • Abstract
    • In the United States, there is a high incidence of motor vehicle and sports injuries among the active population causing symptomatic post-traumatic vertebral compression fracture. At our institution, 28 cases of painful post-traumatic vertebral compression fractures (PPT-VCFs) were successfully treated with percutaneous vertebral augmentation (VA) for stabilization and reconstruction with intravertebral polyethylene mesh sac (OptiMesh®, Spineology, Inc., Stillwater, MN) and biological morcelized bone graft. The surgical approach provides an efficacious and controlled minimally invasive delivery mechanism to stabilize and reconstruct VCFs, as well as avoiding serious complications from Polymethylmethacrylate (PMMA) of vertebroplasty and kyphoplasty. The construct for biological bone graft/vertebral augmentation is osteoconductive and osteoinductive, and is used to create biologic vertebral stabilization and reconstruction. The adjacent vertebra integrity is protected by the construct with similar elasticity and physical characteristics of the biologic morcelized bone, more matched to that of adjacent bone than PMMA. The surgical techniques are described herein.

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Joimax
Joimax

Percutaneous Posterolateral Transforaminal Endoscopic Discectomy: Clinical Outcome, Complications, and Learning Curve Evaluation   

Shay Tenenbaum, MD,  Resident, Department of Orthopedic Surgery Sheba Medical Center, Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Harel Arzi, MD, Spine Fellow University of Kansas Medical Center Department of Neurosurgery Kansas City, Kansas  Amir Herman, MD,  Resident, Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Alon Friedlander, MD, Senior Surgeon, Spine Deformity Unit Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Moshe Levinkopf, MD, Senior Surgeon, Spine Deformity Unit  Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Paul M. Arnold, MD, Professor of Neurosurgery Department of Neurosurgery University of Kansas Medical Center Kansas City, Kansas  Israel Caspi, MD, Senior Surgeon, Spine Deformity Unit Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel

 

  • Abstract
    • Ongoing technological development combined with better understanding of endoscopic anatomy has made posterolateral endoscopic discectomy an appealing surgical option for the management of herniated lumbar disc. We evaluated clinical outcomes, complication rates, and surgical learning curve with the percutaneous posterolateral transforaminal endoscopic discectomy technique (PPTED). PPTED was performed on 150 patients from 2004 to 2008. And 124 patients were available for follow-up. Data regarding pain, postoperative complications, neurological status, operation time, and subjective patient satisfaction were recorded. A satisfactory clinical outcome as reflected in the VAS (mean 3.6) and ODI improvement (mean 21%) scores was reported; 20.9% of the patients required additional surgery. Learning curve assessment showed a significant difference (p = 0.043) for fewer revision surgeries as surgeons became more experienced. Patients who had endoscopic discectomy as a primary surgery achieved significantly lower VAS (p = 0.04) and ODI improvement (p = 0.004) scores compared with patients having transforaminal endoscopic discectomy as revision surgery. The complication rate was 1.6%, including one case of post-surgery hypoesthesia and one deep wound infection. The percutaneous posterolateral transforaminal endoscopic discectomy technique has a satisfactory clinical outcome with a low complication rate. Results for endoscopic surgery for revision or recurrent disc herniation are comparable to those of open revision surgery; the steep learning curve can be overcome with training and suitable patient selection.

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Full-endoscopic Operations of the Spine in Disk Herniations and Spinal Stenosis   

Sebastian Ruetten, MD, Head of the Department of Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology, St. Anna Hospital Herne, Herne, Germany

 

  • Abstract
    • Degenerative constrictions of the spinal canal with compression of neural elements arise as a result of bony, disk, capsular, or ligament structures. The most frequent causes are disk herniations and spinal stenoses. The lumbar and cervical spine is the most prominent cause. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical, microscopically assisted decompression is regarded as the standard procedure for disk herniation and spinal stenosis in the lumbar region, while in the cervical spine microsurgical, microscopically assisted anterior decompression and fusion are standard. Both procedures demonstrate good clinical results but present problems associated with the operation. Decompressions in the area of the spine must be carried out under continuous visualization and must entail the possibility of adequate bone resection. Taking this into account, completely new endoscopes and instrument sets were developed for full-endoscopic operations in tandem with the development of the lateral transforaminal and interlaminar approaches for the lumbar spine and the posterior and contralateral anterior approaches for the cervical spine. The possibilities and results of comparable, established standard procedures were used as a benchmark in the course of clinical validation. The development of surgically created approaches and the new rod lens endoscopes combined with appropriate instrument sets have laid the technical foundations for full-endoscopic operation in the lumbar spine on all primary and recurrent disk herniations inside and outside the spinal canal and on spinal stenoses. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the relevant approaches depends on anatomical and pathological inclusion and exclusion criteria. The clinical results of standard procedures are achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of EBM criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with reduced traumatization, improved visibility conditions, and positive cost benefits. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

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Richard Wolf
R.Wolf

In-vivo Endoscopic Visualization of Patho-anatomy in Symptomatic Degenerative Conditions of the Lumbar Spine II: Intradiscal, Foraminal, and Central Canal Decompression
Anthony T. Yeung, MD, Executive Director, International Intradiscal Therapy Society, Associate, Desert Institute for Spine Care, Phoenix, Arizona, Satishchandra Gore, MS, Spine Endoscopist, Mission Spine, Pune, India

 

  • Abstract
    • The patho-anatomy in an aging spine is partly defined by Rauschning's anatomic cryosections. Theories of pain generation and principles of minimally invasive spine surgery are suggested by close examination of these specimens. If the visualized patho-anatomy can be studied in vivo in a partially sedated patient by spinal probing, spinal pain can be better understood, and rational endoscopic treatment options may then evolve. A 1997 IRB-approved study provided evidence that endoscopic transforaminal surgery was feasible for the treatment of a wide spectrum of degenerative conditions in the lumbar spine. The technique incorporated evocative chromo-discography to correlate reproduction of pain with in-vivo probing of patho-anatomy. Laser and radiofrequency ablation augmented mechanical decompression to obtain pain relief. Endoscopic visualization of patho-anatomy ranging from annular tears to spondylolisthesis and stenosis provided clinical evidence that foraminal decompression, ablation, and irrigation could effectively treat these visualized painful conditions with minimal morbidity. This resulted in a better understanding of the pain generators in the lumbar spine, opening up options for surgical pain management. The procedure does not burn any bridges for more traditional surgical techniques. The learning curve may be steep for some and long for others, but results are very good, concomitant with each individual surgeon overcoming his personal learning curve.

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