Minimally invasive knee replacement surgery : Minimally invasive knee replacement surgery is a technique sensitive surgery which is now possible in India at a fraction of cost as compared to that in the western countries. With advancing age, a huge percentage of population gets affected by knee problems like knee pain and discomfort due to arthritis. Minimally invasive knee replacement surgery is a modification of the traditional knee replacement surgery. These modifications are meant to reduce the tissue trauma during the surgery. The main purpose of minimally invasive knee replacement is to relieve pain, improve quality of life and maintain or improve knee function with an advantage of reduced post-operative complications and speedy recovery. This technique also called quadriceps-sparing knee replacement, uses an incision that is typically only 3-4" in length and the recovery time is much quicker, often permitting patients to walk with a cane as early as third day of the surgery.
Treatment Option-Treatment alternatives to knee replacement include:
- Nonsurgical treatment for osteoarthritis/arthritis include: Physical therapy, Analgesics and anti-inflammatory medications and suitable drugs in cases of infections of the joints,Knee bracing or shoe inserts which help in knee alignment and balancing of weight on the knee joints,Visco supplementation injections for lubricating the joint to make the joint movement less painful.
- Surgical alternatives include:
- Arthroscopy is a minimally invasive procedure where small incisions are done to repair the damage with arthroscopy.
- Osteotomy is a surgical procedure where the involved leg bone is cut, realigned, and allowed to heal. It is useful for patients older than 60 with inflammatory arthritis.
- Partial knee replacement involves replacing only the part of the knee joint that is damaged or arthritic.
- Traditional total knee replacement that involves the conventional knee joint replacement.
- Minimally Invasive knee replacement including both total and partial knee replacement.
Types of approaches used in minimally invasive knee replacement include-
- Quadriceps sparing approach - It is less invasive technique and also called as subvastus approach. As the name implies, it spares the quadriceps muscle from being cut and thus eliminate the risk of trauma and injury to the thigh muscle. A 3 to 4 inch of small incision is made and the knee joint is entered by cutting the fibrous layer of the tissue, upper in the thigh that is attached to the quadriceps muscle called as retinaculum. The quadriceps muscle is then lifted away from the way instead of cutting it to proceed and insert the replacement implant in place.Using special instruments, the bone is prepared for implant. As there is little or no damage to the quadriceps muscle, this approach fastens the rehabilitation process making it easier for the patient to resume walking even earlier with reduced pain and minimal scarring.
- Lateral Approach Knee Replacement -This procedure involves entering the knee joint from the lateral part. The incision is made on the lateral side of knee joint, and hence the knee cap and corresponding muscles are not manipulated. This approach eliminates the chances of muscle injury and improves the knee cap mechanism. However, this is a rarely used technique.
Cervical spine surgery: The cervical spine is summation of seven vertebrae. Each of these vertebrae is separated by shock-absorbing discs. These discs allow the spine to be flexible and help us to move and bend. Cervical spine surgery is indicated for people who have pain that extends (radiates) from the neck to the shoulder, arms or back of scapula or breast, pain that interferes with daily activities, weakness of arms or hands, patient had physiotherapeutic and medication input, but that hasn't helped.
Treatment Option - The treatment of cervical spine dysfunctions is mainly done through two procedures - Decompression and Fusion, which can be done through either Anterior, Posterior or Combined approach.
- Anterior approach-Cervical discectomy with or without fusion, Corpectomy, Disc arthroplasty, Transoral approach.
- Posterior approach-Laminectomy, Laminectomy with fusion, Laminoplasty, Foraminoplasty, Posterior discectomy, Upper cervical fusion.
- Combined approach
Lumbar spine surgery: Lumbar spine problems are most often caused by herniated inter-vertebral discs, anomalous developments on the vertebral bodies (osteophytes), which apply pressure on the spinal nerves that leads to narrowing of the spinal column around the spinal cord. The most popular and important procedures done in lumbar Spine Surgery are decompression and fusion. Lumbago, also known as low back pain is one of the most prevalent spinal problems in adults. It affects individuals of all genders equally. The reason for such persistent back pain is the presence of pathological problem in the lumbar spine, which makes the last five vertebrae of the spine.
Treatment Option-Lumbar spine surgery is indicated for people who have pain that extends (radiates) from the back to the buttocks or back of thigh, pain that interferes with daily activities, weakness of legs or feet, numbness of legs, feet, or toes, loss of bowel of bladder control, had physiotherapy and medication treatment, but that hasn't helped.The lumbar spine surgery is performed using either of the following technique:
- Decompression: Lumbar spine decompression surgery is performed to relieve the pressure over nerves by removing the diseased discs, ligamentum flavum and bone which is pressing over the nerve. The surgery is generally recommended in cases of spinal stenosis caused by thickened joints, loosened ligaments, bony growths, or disc herniation i.e. there is not enough space for the nerves to breath.The surgery entails removing a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and provide a better healing environment.Various procedures used for Decompressing Lumbar spine are:
- Laminotomy or Laminectomy
- Port Hole Decompression
- Foraminotomy or Foraminectomy
- Osteophyte removal
- Fusion : Lumbar fusion surgery is designed to create solid bone between the adjoining vertebrae, eliminating any movement between the involved bones. The goal of the surgery is to reduce pain and nerve irritation. During the surgery, diseased discs are excised and replaced with spacer device, pedicle screws and rods are attached to the back of the vertebra and an interbody fusion spacer is inserted into the disc space from one side of the spine.Lumbar fusion surgery has two individual approaches. The most common process used is the posterior approach, where the surgery is done from the back. The three main Posterior fusion techniques are:
The anterior approach involves placing the bone directly into the section between the vertebrae where the shock-absorption disc had been situated. Using special instruments, the bone is prepared for implant. As there is little or no damage to the quadriceps muscle, this approach fastens the rehabilitation process making it easier for the patient to resume walking even earlier with reduced pain and minimal scarring.
- Postero lateral gutter fusion surgery
- Posterior lumbar Interbody fusion (PLIF) surgery
- Transforaminal lumbar Interbody fusion (TLIF) surgery
Total Hip Replacement: Surgery replaces the upper end of the thighbone (femur) with a metal ball and resurfaces the hip socket in the pelvic bone with a metal shell and plastic liner. Total hip replacement surgery replaces damaged cartilage with new joint material in a step-by-step process.
ACL (Anterior Cruciate Ligament) Surgery: ACL reconstruction is an arthroscopic surgery to rebuild the torn ACL ligament using the grafts that are harvested from the tendon stationed at some other part of the knee.ACL surgery is indicated in ligament injury that occurs most frequently with the sudden over extension or twisting movement at the knee joint as a result of mostly the combative sports like soccer, basketball, football etc. The main purpose of ACL reconstruction surgery is to restore the knee stability and function of the injured ligament.
Treatment options-ACL injury/tear can be managed by either of the following options-
- Conservative Management: Acute sprains or partial ligament tears can be managed conservatively with the appropriate rest and protection to the joint with limited mobility.
- Rehabilitation Program: This is to regain normal range of motion, strengthening your muscles to support and stabilize the joint during your daily living activities.
- Protective Bracing: Use of custom fitted knee braces to decrease the stress on healing ligaments.
- Surgical-ACL tear can be treated surgically with two different techniques that includes:
- Surgical Repair of ACL : It is a rare choice of surgery which is accomplished by reposing and suturing the torn ligament. This technique is indicated only when the ligament is torn off from its attachment but still intact and is not stretched out or when there is an avulsion. The repair of ACL is less recommended due to less desirable outcomes and possibility of recurrent ligament injury.
- Reconstruction Surgery : ACL reconstruction is the primary choice and the leading aid of surgically managed ACL injuries. It is performed arthroscopically or endoscopically causing less tissue destruction and faster recovery. During ACL reconstruction, a tissue graft is used to replicate the function of injured ligament thereby stabilizing the knee.
The tendon graft can be harvested from two different tissue that includes:
- Patella tendon graft : If patella tendon graft is selected, the small graft is taken along with the small bone plugs attached at each end from front of the patient's knee, allowing the graft to fix very rapidly with bone.
- Hamstring tendon graft: It is the most popular and highly successful method. The semitendinosus-gracilis tendon graft is harvested from the insertion of the muscle. It has an advantage of less donor site discomfort than patellar tendon graft.
Slip Disc Treatment: A slipped disc is also known as a prolapsed or herniated disc. It is a condition when the inner soft part of the disc (known as nucleus pulposus) bulges out through the weakened or ruptured part of the disc pressing on the structures close to it (nerves coming out off the spinal cord) resulting in numbness, tingling sensation or even pain in the area. Slipped disc or disc herniation can happen at any level, but usually occurs in the lumbar region. The extent of the prolapsed and herniation can vary from person to person, the larger the prolapse the severe the symptoms.
Treatment Option-Treatment options for a slipped disk include rest with pain medication, physical therapy or sometimes further treatments like injections and surgery.
- Medications and lifestyle changes-Nonsteroidal anti-inflammatory medications are given for pain control andnarcotics are prescribed in cases of severe pain non-responsive to NSAIDs. Muscle relaxants are given for back spasms. Overweight individuals are recommended diet and exercise. Physical therapy helps in strengthening the spine muscles and give flexibility to the spine and legs.
- Injections-Steroid injections control pain and swelling in the herniated disk for several months with several other symptoms.
- Surgery-Surgery is the treatment option for cases where the above treatments have not worked. Various surgical techniques of herniated disc surgery include:
- Discectomy or open discectomy involves removing herniated disc material which is pressing the nerve root or spinal cord resulting in pain and other symptoms.
- Percutaneous discectomy is done for for bulging discs and discs that have not ruptured into the spinal canal.
- Laminotomy and laminectomy - Laminotomy involves removing a part of the lamina to relieve the pressure over the nerves, while laminectomy involves removing the entire lamina. Lamina is the thin part of the vertebrae which forms an arch over the spinal cord to protect it.
The Hip Resurfacing: The Hip Resurfacing -In hip resurfacing, the femoral head is not removed, but is instead trimmed and capped with a smooth metal covering. The damaged bone and cartilage within the socket is removed and replaced with a metal shell, just as in a traditional total hip replacement Spinal Disc Replacement.
Minimally invasive Spine Surgery: Minimally invasive Spine Surgery is also known as Minimal Access Spine Surgery or Endoscopic/Keyhole Spine Surgery. The foremost goal of minimally invasive spine surgery (MISS) like the conventional surgery, is to stabilize vertebrae and decompress the pinched nerves to ease pain and to eliminate painful symptoms by decreasing the pressure on nerves caused by herniated discs, spinal stenosis, bone spurs or tumours. The minimally invasive spinal surgery, however is a faster and safer alternative with reduced recovery time. The interventional trauma to the surrounding muscles and other adjacent tissues is greatly reduced
Treatment Option-Surgery is often the last resort and is advised in patients where symptoms have not settled in six weeks of conservative treatment like medication, injections and physiotherapy. The aim of the surgery is to remove the prolapsed part of the disc releasing pressure from the spinal cord. Various techniques of herniated disc surgery includes:
- Discectomy removes herniated disc material that presses on thespinal cord or a nerve root.
- Percutaneous discectomy is used for bulging discs and discs that have not ruptured into the spinal canal.
- Laminotomyand laminectomy- "Laminotomy" removes a portion of the thin part of the vertebrae that forms a protective arch over the spinal cord (lamina). "Laminectomy" removes all of the lamina on selected vertebrae and also may remove thickened tissue that is narrowing the spinal canal.
- Minimally Invasive Spinal (MIS) Fusion - This spinal surgery is performed to remove the lamina and the disc with introduction of graft to fuse the vertebrae. The surgery can be performed using both the anterior or posterior approaches.The most common process used is the posterior approach, where the surgery is done from the back. The three main Posterior fusion techniques are:
The anterior approach involves placing the bone directly into the section between the vertebrae where the shock-absorption disc had been situated.
- Postero Lateral Gutter Fusion Surgery
- Posterior Lumbar Interbody Fusion (PLIF) Surgery
- Transforaminal Lumbar Inter body Fusion (TLIF) Surgery
- Spinal decompression - This procedure is done torelieve spinal stenosis caused by narrowing vertebral column and compressed nerves with associated symptoms. Lateral Approach Knee Replacement-This procedure involves entering the knee joint from the lateral part. The incision is made on the lateral side of knee joint, and hence the knee cap and corresponding muscles are not manipulated. This approach eliminates the chances of muscle injury and improves the knee cap mechanism. However, this is a rarely used technique.
Spinal Disc Replacement: Spinal Disc Replacement-The use of an artificial disc to replace a damaged spinal disc that is generating chronic back pain. There are a wide variety of new products, procedures and techniques currently in development to enhance spine surgery, and many spine surgeons believe that artificial disc technology holds real promise for significantly improving the standard of care for many patients.
Spinal Fusion: Spinal fusion is surgery to join together two bones (vertebrae) in the spine. Fusion permanently joins two bones together so there is no longer movement between them. Spinal fusion is usually done along with other surgical procedures of the spine.Spinal fusion surgery is a procedure that fuses two or more spinal vertebrae permanently to eradicate the movement between them, thus bringing stability to the vertebral segments and eliminating the pain associated with them.
Treatment Option-Different types of spinal fusion surgeries are commonly available, like
- Posterior lumbar inter-body fusion (PLIF) creates space between two vertebrae and induces bone in that space. This procedure is done from the back
- Posterolateral gutter fusion
- Anterior lumbar inter-body fusion (ALIF) is the same as PILF. The only difference is that the spine is approached from the front
- Trans-foraminal lumbar inter-body fusion (TLIF)
- Extreme Lateral Inter-body Fusion (XLIF) procedure is done from the side
- Multilevel Spinal Fusion : Lumbar spinal fusion surgery is the most effective procedure for problems involving one segment of spinal vertebra as the movement improves with this.For some cases of pain, two levels can be fused though it places lot of pressure on the remaining joints. Three or more levels of fusion are done in cases of scoliosis and lumbar deformity. Multilevel spinal fusions are used to treat lower back pain and lumbar degenerative disc diseases
- ACDF : Anterior Cervical Discectomy and Fusion is used to relieve cervical disc herniation symptoms like spinal cord and nerve root pressure and associated numbness, pain, and tingling. The disc is removed with the fusion surgery in the ACDF procedure. It can also bedone for cervical degenerative disc disease and for more levels of cervical spine.
Abnormal curvature of the spine (Scoliosis): Abnormal curvature of the spine (Scoliosis),Injury to spinal vertebrae,Slipped disc,Weak or unstable spine caused by Infections or tumors,Spinal stenosis,Spinal Tumors, Herniated Disc. Scoliosis is the lateral curvature in a normal straight spine mostly occurring during the child's growing years. A side view shows convexity in upper back and concavity in lower back though it looks normal from front or back view. It can be seen in 3 shapes:
- Single curve on left/ C shaped/ levo-scoliosis
- Single curve on right/dextro-scoliosis
- Two curves/ S shaped
Treatment Option-The aim of the scoliosis surgery in India or scoliosis treatment in India is threefold:
- Safely straighten the spine as much as possible
- Balance the torso and pelvic areas, 3)Maintain the correction for long term.
This is done by two methods-
- Spinal Fusion - fusing the vertebrae along the curve
- Supporting the spine - with rods and screws till the fusion takes place.
The surgery is done by two approaches:
Posterior (done through back) or Anterior (through sides) approach. Both have their own merits and demerits. The surgery for treatment of scoliosis in India is done under general anaesthesia and can take anywhere between 4-12 hours depending on the curve and how much spine needs to be fused. Hospital stay of about a week is required after the surgery to make sure you are on the right healing path.