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Types of Minimally Invasive Orthopaedic Surgery

For the past 100 years, it has always been a fundamental surgical principle to minimize trauma on a patient during any surgical procedure. Recent technological development in the following areas have made this possible for certain areas of medical practice, including orthopaedics and traumatology.

1. Advance in fiber-optics: This allows light sources to be conducted to cavities, potential spaces or lumens in the body. In orthopaedics, various joint cavities, the pleural cavity in the chest as well as the peritoneal space in the abdomen can be distended (expanded) and illuminated for surgical procedures.

2. Operation microscopy: Procedures can be done with fine details under suitable magnification. 

3. Video-assisted procedures: Operations are performed with the help of a video-camera and instruments with extended operating arms.

4. Fluoroscopic monitoring: Manipulation of body parts, fracture reduction and fixation, introduction of implants and more procedures can be done under X-ray guidance without visual exposure of the injured body parts.

5. Key-hole Surgery: Operative procedures and placement of implants can be performed through small cut wounds on the skin. Examples are placement of intra-articular sutures, bone anchors, interlocking intramedullary nails, locking plates, and MIPO plates.

6. Some procedures can be achieved with the application of a thermal coil, a focused laser beam or other physical means through small puncture wounds on the skin without full exposure of the injured tissue.

7. Computer navigation: Instruments and implants are coupled with the images on body parts on a computer without exposing the entire surgical field for reference. The images on the computer can either be Fluoro, i.e. X-ray images or CT-based scans. Surgeons can follow the procedure with real-time images shown on the computer, resulting in a higher level of precision and accuracy.

Examples of minimally invasive surgery

For access

Arthroscopic procedures: Special pen-like surgical equipment with a light and a camera lens at the end, called “arthroscopes”, allows orthopaedic surgeons to approach some deeply seated target areas through small “key-holes”. This can minimise trauma related to surgical exposure. 

The orthopaedic procedure that uses the arthroscope to look inside a synovial joint without making a long surgical incision is called “arthroscopy”. Since the arthroscope is capable of capturing images inside a synovial joint, orthopaedic surgeons can “look inside the joint” through a high-definition monitor connected to the built-in camera on the arthroscope. 

Typical examples of orthopaedic surgeries that can benefit from arthroscopy are procedures involving synovial joints, including the knee, shoulder, elbow and ankle joints. With the use of arthroscopic instruments and specially designed implants, corresponding surgical procedures can be performed through “key-holes” in a minimally invasive manner. 

Common examples of arthroscopic procedures are:
Reconstruction of anterior cruciate ligament (ACL), repair of meniscus and arthroscopic synovectomy in knee joints.
Arthroscopic Bankart repair, arthroscopic acromioplasty and arthroscopic rotator cuff repair in shoulder joints. 

These are examples of “access surgery”, in which there is less iatrogenic surgical trauma through “key-holes” approaches .

For surgical target

New treatment principles are being developed for treating long bone fractures. 

With the help of corresponding outriggers and jigs and the use of fluoroscopy for guidance and monitoring, orthopaedic surgeons are now able to pass the locking plates and nails through tiny skin wounds, insert them under the skin or muscles and apply them on the surface or intramedullary space of long bones for fixation of long bone fractures. – a procedure known as minimally invasive percutenous plate osteosynthesis (MIPPO).

The fluoroscopy system enables orthopaedic surgeons to “see” through the surrounding soft tissues and to ensure proper reduction of the fracture and placement of the implant, without the need of making a long incision for a full exposure of the fracture site. It is an example of a “target surgery” in which new developments in management principles allow clinical applications in a minimally invasive approach. 

There are minimally invasive procedures emphasising both the “access” and “target” aspects of surgery, allowing surgical procedures to be done in a minimally invasive manner. Spinal decompression, fusion and instrumentation is an example of combining the access and surgical targets with a minimally invasive approach and instrumentation. 

Advantages

For patients, minimally invasive surgery may mean fewer surgical insults to the body, less blood loss and smaller surgical scars. Less post-operative pain medication may be required. Patients who have undergone this type of surgery may be able to leave the hospital sooner than if they were to undergo conventional open surgery.

Limitations

On the other hand, there are limitations associated with minimally invasive surgery.

First, not all orthopaedic conditions are suitable for minimally invasive surgery.

Second, minimally invasive surgery is not equivalent to minor surgery. In fact, a minimally invasive “major” surgery is still a major surgery, carrying definite risks.

Third, minimally invasive surgery is not completely safe. There are common complications, ranging from infection to death, similar to any open surgical procedure. There are also additional specific procedure-related complications. 

Fourth, these procedures require specific instruments, implants and equipment. This may result in higher costs compared with the corresponding open procedure. 

Fifth, minimally invasive procedures may take longer to perform than the corresponding open procedure. 

Sixth, some minimally invasive procedures require the use of the fluoroscopy system. This carries additional risks associated with an increased exposure to irradiation. 

Seventh, minimally invasive surgeries does not mean that only regional anesthesia is required. In fact, most of these procedures still require general anesthesia to be administered. 

Eighth, during any minimally invasive surgery, your orthopaedic surgeon may find open procedures to be more suitable, and will choose to continue with open techniques. 

Last but not the least, some minimally invasive procedures are still under scientific investigations and there is a lack of solid evidence on their long-term benefits. For example, only a few literatures have validated the long-term advantages of fixation with locking plates. Carefully conducted clinical trials in the coming years are necessary to provide scientific evidence. 

Conclusion

Certain considerations need to be reviewed carefully before offering any surgical procedure. Minimally invasive surgery may not be possible or suitable for your orthopaedic condition. It is of utmost importance to discuss in details with your orthopaedic surgeon what particular procedure is appropriate for you and your conditions.