The goal of minimal invasive surgery (MIS) is to reduce surgical trauma and shorten recovery. The scope of MIS in orthopaedics and traumatology is very wide. The current article is a brief overview of the status of MIS in fracture repair, spine surgery, joint replacement surgery, sport and arthroscopic surgery. Such goal is not always achieved in all clinical scenarios.

The use of modern intramedullary nails and sub-muscular plating has revolutionized orthopaedic trauma care in the past two decades. There is much evidence supporting routine use for lower limb fractures. In the upper limb fractures, evidence still supports open surgery to play a large role. For joint replacement surgery of the knee and hip, evidence has pointed out the lack of benefit, steep learning curve and higher risk of complications and is therefore not widespread. For spine surgery, MIS has a recognized role in spine trauma, degenerative lumbar conditions, spinal metastasis and deformity correction with some limitations to overcome. For sports surgery, arthroscopic treatment is becoming the standard of care of intraarticular conditions involving large joints, with indications expanding to smaller joints. Advancement in computer navigation, intraoperative advanced imaging and 3D printing is enabling new horizons for MIS in orthopaedics.

The benefits of MIS are realized via technological innovations and proficient surgical skills. For most conditions, MIS is performed depending on surgeon preference, and clear indications for routine use remains to be defined by high quality clinical studies.

: Fang CX, Kwan KYH, Yuen SCP, Cheung MH (2017) The Current Role of Minimal Invasive Surgery in Orthopaedics– A General Overview. Ann Musc Disord 1(1): 1003

The role of minimal invasive surgery (MIS) in orthopaedics is substantial. The goal is to decrease surgical trauma, bleeding, recovery duration and hospital length of stay and postoperative morbidities. Scarsare cosmetically more appealing without compromising surgical objectives. MIS may offer expanded treatment options. We present a current overview of MIS on fracture repair, spine surgery, joint replacement, and sports surgery.

Fracture repair by MIS is widespread. The principle is to minimize further trauma to the compromised soft tissue, and minimally disrupt the fracture hematoma and periosteal blood supply. The fracture is stabilized internally and patients can mobilize early without the need for external bracing or casting. In many instances, patients are encouraged to perform self-care chores and bare weight soon after surgery. Healing is promoted by callus formation. Wound complication is significantly reduced in areas with thin soft tissue envelope such as the tibia and calcaneus [1]. When needed, implant removal can follow the same minimal invasive route.

Closed reduction and minimal invasive fixation

The two most established MIS techniques for fracture repair in long bones are by intramedullary (IM) nailing and minimal invasive plate osteosynthesis (MIPO).Pioneered by Küntscher in 1939, IM nails are standard treatment for long bone shaft fractures in the femur and tibia. In the elderly, IM nails have become routine in managing fragility intertrochanteric fractures. Open fractures are manageable by early IM fixation with less worry of exposed hardware. Titanium elastic nails (TEN) are common treatment for paediatric long bone and adult clavicular fractures with reduced wound complications [2]. Current generation of IM nails have improved locking mechanisms that offer improved fixation in and extended indications in the periarticular regions.

MIPO is evolved from open reduction internal fixation by plating, popularized by Krettek in the 90s. MIPO is indicated for periarticular and metaphyseal fractures at the proximal humerus [3] distal femur [4] and both ends of tibia [5]. Minimal incisions are used and plates are ‘slid’ under the sub-muscular plane with screws placed through stab incisions. Modern low contact, anatomically shaped plates with angular stable locking screws have reduced prominence and considerably improved anchorage in osteoporotic bone. Because of superior mechanical stability in cancellous bone, MIPO is more applicable to fractures at metaphyseal and periarticular areas.

External fixation is popular for treating high energy fractures and comminuted intra-articular fractures that are not reliably managed by conventional open technique, these being respectively common for the tibia and the distal radius. Minimal incisions are used and major fragments are stabilized with pins or cross-wires and the fracture ‘bridged’ externally by a stable frame. Although strictly classified as a minimal invasive technique, patients are arguably less tolerant to the cumbersome frame and infection of pin tracts remains problematic. External fixation is therefore generally reserved for patients with severe soft tissue trauma and used as temporary method of stabilization.

Percutaneous screw osteosynthesis is commonly applied ton on-displaced or readily reducible fractures near joints. For example, the percutaneous screw technique introduced by Zadravecz for the calcaneusis associated with a low risk of wound complications and good outcomes [6].

In above situations, fracture reduction is carried out indirectly under fluoroscopic control. The operator must ensure accurate fracture reduction and correct implant placement. Ample surgical and anatomical knowledge is mandatory in preventing neurovascular injuries [7] Surgeons and operation room staff are unfortunately at additional risk of radiation exposure. Incorrectly performed minimal invasive surgery has risks of poor reduction, malunion and non-union. As the main aim of operative treatment remains to be fracture reduction, stabilization and early rehabilitation, open or ‘mini-open’ surgery is still required for displaced fractures with compromised articular congruity.

Future direction

Arthroscopic assisted fracture repair is viable for fractures that involves medium to large size joints, advocated for improved reduction, less radiation and reduced surgical trauma. High-tech percutaneous MIS techniques by 3D computer navigation or CT guided fixation is increasingly popular for treatment of pelvic ring and acetabular fractures [8]. The concept of pre-operative navigation is realized via 3D printed guides, with early evidence validatingits role in management of post-traumatic deformities [9].

There is robust evidence to support the routine use of minimal invasive fracture repair. Techniques will undoubtedly evolve in a direction where surgical trauma further reduced with improved fracture reduction and stability. There will be continued debate on the best choice of approaches and implants. For example, routine use of IM nails in the humerus is disputed to have slightly higher complications than plating [10] due to shoulder joint impingement and lack of rotational control. More evidence will better define standard treatment indications.

Figure 1 minimal invasive plate osteosynthesis of a distal tibia fracture.

Figure 1 Minimal invasive plate osteosynthesis of a distal tibia fracture. A long plate is inserted sub-muscularly using a larger medial distal incision and stab wounds for screw placement. Fracture reduction is monitored under fluoroscopy by the surgeon.

A long plate is inserted sub-muscularly using a larger medial distal incision and stab wounds for screw placement. Fracture reduction is monitored under fluoroscopy by the surgeon.

Minimally invasive spine surgery (MISS) is relatively novel that has emerged in the latter half of the last century. The scope of MISS has expanded rapidly, and MISS techniques can now be applied in complex spinal pathologies and in patients with comorbidities that would make open surgeries challenging [11].

Spine trauma

Fractures of the thoracic and lumbar spine are indicated for surgical intervention in the presence of instability, deformity, neurological compromise, intractable pain with or without non-union. The simplest form of intervention is vertebroplasty, which utilises a percutaneous transpedicular approach for polymethylmethacrylate (PMMA) cement injection into the vertebral body under fluoroscopic guidance. Clinical evidence for the use of vertebroplasty has changed throughout the years, with two initial randomized controlled trials (RCTs) showing minimal benefit when compared with placebo, [12] more recent RCTs have demonstrated clinical benefit for pain relief and hospital length of stay [13]. The ability to restore vertebral height is further augmented with kyphoplasty, whereby an inflatable balloon or stent is placed transpedicularly to improve the sagittal alignment before PMMA cement is introduced. MIS instrumentation and fluoroscopic techniques now allow more complex interventions with the use of percutaneous fixation with pedicle screws to stabilize the spinal column.

Degenerative lumbar conditions

Prolapsed intervertebral disc (PID) and spinal stenosis with or without associated instability are the commonest indication for surgical intervention in the lumbar spine. MISS techniques can be applied using tubular retractors and assisted by microscope or endoscope to decompress the spinal canal and perform discectomy. The surgical approach can be via the more traditional posterior route, or a transforaminal approach using a percutaneous endoscope. The learning curve for these procedures is variable and maybe associated with higher complication rates, particularly with low-volume practices [14]. MISS decreases surgical trauma and postoperative pain, which leads to improved recovery and decreased hospital length of stay, although there is still a paucity of high quality evidence to support this, and its cost-effectiveness is still undetermined [15] (Figure 2).

Figure 2 Microendoscopic view of lumbar discectomy for prolapsed intervertebral disc

Symptomatic spinal metastases

Palliative surgery for symptomatic spinal metastases can relieve neurological compression, pain and stabilize the spine. Traditional open techniques may not be suitable for this group of patients with multiple morbidities and shorter life expectancies, but MIS techniques means some of these surgical interventions can be performed under local anaesthesia or with less surgical dissection and intraoperative blood loss. Long segment stabilization using percutaneous screw fixation and small surgical wounds for decompression at the site of spinal cord compression have led to satisfactory surgical outcomes [16]

Spinal deformity

Perhaps one the most significant developments in MISS is the use of lateral access approach for anterior column reconstruction and sagittal profile realignment in adult spinal deformity (ASD). Open anterior surgeries require extensive incisions and muscle dissections with considerable postoperative complications. Lateral access approach uses a smaller wound with the assistance of retractors and intraoperative neuromonitoring for interbody fusions that lead to more powerful deformity correction in the coronal and sagittal planes. Several studies have now shown that MISS in ASD can achieve good clinical outcomes [17], and may be more suitable for the elderly who cannot undergo large reconstructive surgeries. However, there is still controversy amongst spine surgeons as to the best indications for MISS in ASD corrections (Figure 3)

Figure 3 (a) Preoperative CT of a patient with vascular tumor of L1 with kyphotic deformity. (b) Postoperative radiograph after embolization, correction by anterior cage via MIS lateral approach and cement augmented percutaneous posterior spinal instrumentation.

Limitations

Careful patient selection and understanding the limitation of each MISS technique in addressing the specific pathologies are paramount in achieving a good clinical outcome. There is evidence that decompression of the central canal and lateral recess is not always achievable with lateral interbody fusion [18], and not all deformities can be corrected adequately using MISS [19]. Robust evidence is also lacking whether MISS techniques are translated to improved clinical outcomes for lumbar disc herniation compared with conventional microdiscectomy [20]. Moreover, the costs for MISS are higher in most instances, and its cost-effectiveness remains unproven [15].

In summary, there are new and confirmatory evidence that MISS advancements can be applied in different spinal conditions safely and effectively. Responsible applications with appropriate choice of MISS techniques in carefully selected patients are key to success. Continual evolution and refinement of our knowledge, techniques in MISS and more high-quality studies to support its use will lead to more widespread use and improved patient care.

MIS joint replacement surgery had been developed since early 1990s. The premise is to adopt a smaller incision and reduce soft tissue trauma while maintaining the high standard and efficacy of the procedure. If properly performed, arthroplasty surgeon can reduce postoperative pain, enhance recovery and achieve shorter hospital stay and better patient satisfaction [21]

Knee arthroplasty

MIS arthroplasty was first introduced in 1990s by Repiccifor the Unicompartmental Knee Arthroplasty (UKA) [22]. Since then similar concept was adopted in total knee arthroplasty (TKA). A number of approaches to MIS TKA has been developed: Quadriceps sparing, mini-midvastus, mini-subvastus, and minipara-patellar approach [23,24]. Each approach has their own advantage and specific technical difficulty. The mini-midvastus approach is the most popular approach since it give a better exposure, does not require major instrument modification and permit extension of the arthrotomy for more difficult cases [23].

Hip arthroplasty

MIS THA (total hip arthroplasty) was introduced by Richard Berger and Dana Mears in mid 1990s. Currently two approaches to MIS are usually adopted: single-incision and two-incision approach. The former involves one single mini incision (8cm – 10cm, some surgeons up to 12cm) through either posterior, anterolateral [25] or posterolateral approach. For two incision approach, a 4-6cm anterior incision is made directly over femoral neck for acetabulum exposure and cup insertion, and a second posterior incision in line with femoral canal for femur preparation and insert the femoral component [26].

In both MIS TKA and MIS THA the exposure is usually limited due to reduced length in skin incision. As a result, specially designed instruments [retractor, broach holder, curve reamer] are often required in such restricted operative field [27]. In MIS THA intra operative fluoroscopy is commonly required for verification of implant position [28].

Current evidence and limitations

A number of studies and meta-analysis has been published comparing the result between MIS and conventional joint replacement. So far there’s no clear evidence to show that MIS do better in terms of patient’s satisfaction and outcome in shortterm and mid-term [21,29,30]. Moreover, there are modest evidence and reports describing various potential problem of MIS approach including radiological outliers, fracture, soft tissue invagination at interfaces and suboptimal bone resection [31- 33]. Before concrete long term data become available, current evidence seems does not favor the hypothetical benefits of MIS.

Furthermore, adjunctive technologies like computer navigation [34,35] patient specific instrumentation [36] or robotic assisted surgery are often required in MIS setting to ensure proper implant component orientation. Combined with the inherent difficulty of the surgical approach in MIS, long learning curve is expected for surgeon to perform MIS safely and efficiently [33].

While MIS TKA and THA has their potential benefit, this technique should be reserved to dedicated arthroplasty surgeons with considerable experience in joint arthroplasty surgery [21,33]. Careful patient selection, a comprehensive training program, sufficient learning time and a well-trained surgical team are all key elements for successful MIS joint arthroplasty surgery.

Innovation in arthroscopic surgery in the last century has fundamentally changed the standard of care for much intraarticular and peri-articular pathology, especially in the field of sports medicine. Sometimes seen as synonymous with minimal invasive orthopaedic surgery, the endoscope is in-reality only a tool. Its utility in complex procedures is driven by advancements in technology and skills. Arthroscopes as small as 1.3mm gives satisfactory vision in small joints. Arthroscopic implants, suture anchors, electro-surgery devices have seen rapid proliferation along with improved techniques and training.

The knee

Watanabe developed the first truly working arthroscope and performed the first recorded arthroscopic partial meniscectomy in 1962. Since then, knee arthroscopy is very common. The American Academy of Orthopaedic Surgeons estimates 636,000 such procedures each year in the United States, with more than half performed for meniscal pathologies. The benefits of knee arthroscopy are well documented. Open menisectomy and open anterior cruciate ligament reconstruction is now nearly obsolete.

Arthroscopic knee surgery is therapeutically indicated for meniscal, ligamentous, patellofemoral, neoplastic, loose body, arthritic, cartilage conditions, and fractures, at the same time providing diagnostic value for additional lesions. Meniscal procedures can be menisectomy or repair. Anterior and posterior cruciate ligament reconstruction is a standard procedure supported by evidence with clearly defined indications. Patellofemoral procedure is mainly for patellar instability. Chondral procedure including debridement, micro-fracture and osteochondral transplantation have weaker evidence of support for degenerative conditions [37-40] (Figure 4)

Figure 4 Application of knee arthroscopy

(a) Longitudinal meniscal tear.

(b) Bucket-handle meniscal tear.

(c) Meniscal repair with all-inside suture technique (asterisk).

(d) ACL reconstruction with satisfactory tension of the graft.

The shoulder

Arthroscopic shoulder surgery is popular. Advocates claim better visualization of the glenohumeral joint and the subacromial space, and more thorough releases of deeper tendon and capsular contractures. For rotator cuff repair, open shoulder surgery and arthroscopy demonstrated similar results [41]. Provided adequate skills, arthroscopic management of recurrent shoulder instability, impingement syndrome, bicep tenodonitis and acromioclavicular joint pathology is considered a standard alternative to open surgery [42] while open or mini-open surgery is reserved for complex or revision situations.

The ankle

Anterior ankle, posterior ankle and subtalar joints are accessible by arthroscopy, providing both therapeutic and diagnostic value in articular structural repair, reconstruction or fusion. Arthroscopic ankle fusion is a standard treatment option forend-stage ankle arthritis and successfully applied to subtalar and midfoot joints. Under arthroscopic view, the articular cartilage and subchondral bone is removed with by curettage and burr. Two or three percutaneous cannulated screws are placed across the joint under fluoroscopic guidance to achieve gap compression and fusion. Evidence have demonstrated shorter recovery and improved union rates [43]. Specific arthroscopic techniques are developed for the management of talar osteochondral lesion, ankle synovitis, post-traumatic impingement, anterior osteophyte or ostrigonum excision, and repair or reconstruction of lateral ankle instability [44,45]

Apart from arthroscopy, endoscopic and tendoscopic procedures have become more widespread. Endoscopic calcaneoplasty for Haglund’s disease and endoscopic plantar fasciotomy for recalcitrant plantar fasciitis have been reported to be safer then open procedure [46]. Tendoscope in the foot and ankle region is mainly for posterior tibial tendon dysfunction, being both diagnostic and therapeutic [47]. Minimal invasive Achilles tendon repair have reduced wound complications and similar functional outcome when compared to open repair (Figure 5).

Figure 5 Application of ankle arthroscopy.

(a) Osteochondral lesion of talus with full-thickness cartilage flap (asterisk).

(b) Debridement and micro-fracture stimulates subchondral bleeding and development of a fibrin clot (arrows).

(c) Pre-operative XR showed significant talar dome chondral defect with subcondral sclerosis.

(d) Satisfactory chondral remodelling occurred in 4 months post-operatively

The wrist

Wrist arthroscopy was first described by Chen in 1979, [48] with initial application limited to partial evaluation of the joint surface. With better distraction techniques and precise portal placement, treatment indications have expanded exponentially. While open arthrotomy is suboptimal in visualizing subtle pathologies, wrist arthroscopy allows magnified visual examination of the articular surfaces and wrist ligaments. For diagnosis, wrist arthroscopy is an accurate complement to ordinary examination. It is useful in patients with interosseous ligaments tears, carpal instability, Kienbock’s disease, and scapholunate or lunotriquetral dissociations [49].

Wrist arthroscopic intervention is indicated for loose body removal, synovectomy, debridement, intra-articular adhesion release, tears of the triangular fibrocartilage complex, ganglion excision, distal radius and scaphoid fracture fixation, and radialstyloidectomy [50,51]. Recently, more advanced arthroscopic procedures, such as proximal row carpectomy, limited carpal resection or fusion, and scaphoid non-union have been reported [52].

The elbow 

Elbow arthroscopy was originally used for diagnostic procedure or removal of loose bodies [53] With advancement in technique, the indications for arthroscopic treatment have extended to tennis elbow, posttraumatic contracture capsular release, synovectomy, osteochondral lesions and intra-articular (capitellar and coronoid) fracture fixation [54,55].

The hip

Hip arthroscopy was first described in 1931 [56]. However its role was limited until 1980s when several authors started to advocate hip arthroscopy as a result of advancements in portal location, traction technique, surgical equipment and experience [57]. Hip arthroscopy is used in diagnosis and treatment of labral tears, removal of loose bodies, management of femoroacetabular impingement, degenerative arthritis, cartilage damage, synovial lesions and avascular necrosis of the femoral head [58].

Small joints

With precise and fine arthroscope and instruments, the clinical application of small joint arthroscopies (metatarsophalangeal joint, Lisfranc joint, Chopart joint, and interphlangeal joint) in the foot has seen significant advancements. Arthroscopic techniques for large joint pathologies is being exploited correspondingly in small joints. Early studies have found comparable results for arthroscopic soft tissue procedures and arthrodesis of the small joints when compared with open approach [59]

. In conclusion, arthroscopy is just another tool in the surgeon’s armamentarium. The benefits are appealing for a broad range of pathological conditions. Treatment must be decided on an individual case-by-case basis. Appropriate use of such tools should lead to improved patient outcome.

The benefits of MIS are realized via technological innovations, skills and correct surgical indications. We have provided a brief overview of the numerous surgical options for the musculoskeletal system. Because it is less likely that any single orthopaedist can master all of them, subspecialized training and a sound patient referral system will be important future foundations. Evidence based medicine will continue to help us define the most appropriate treatment indications

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