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No bones about it: minimally invasive orthopedic surgery

I've read about athletes suffering knee injuries and then resuming play within a couple of weeks. I'm aware of major surgery to treat broken bones, but are there less invasive methods?

In the past, many orthopedic injuries required extensive surgery, large incisions, lengthy hospital stays, and prolonged recovery periods. Today, the use of arthroscopic surgery and other minimally invasive surgical procedures has revolutionized how joint injuries are treated.

Using an arthroscope -- a small, fiber-optic instrument made up of a tiny lens, light source, and video camera -- an orthopedic surgeon can diagnose and surgically correct a vast array of joint problems. Most people are familiar with knee arthroscopy, but the procedure is also common with shoulder, ankle, wrist, elbow, and hip injuries. Arthroscopy can be used to catch bone chips floating in a knee, shave or smooth ragged areas caused by arthritis or a fracture, cut tight ligaments, remove bone and tissue for biopsy, and repair torn ligaments.

Most patients who undergo arthroscopic surgery return home the same day the procedure is done. Patient recovery time is greatly reduced because the small incision does not damage surrounding muscle and tissue, which take longer to heal. Many patients who have knee arthroscopy are walking without assistance within a few days.

Although most patients with fractured bones undergo invasive surgery in which plates and screws are inserted to stabilize the joint, surgeons are now beginning to use minimally invasive techniques to repair fractures.

Paul Tornetta III, M.D., professor of orthopedic surgery at Boston University School of Medicine and the director of orthopedic trauma at Boston Medical Center, has had success performing minimally invasive surgery on selected patients with joint fractures and other orthopedic surgeons around the country have followed his lead. Rather than using both screws and plates for ankle fractures, Tornetta uses only screws to stabilize fractures, a procedure that requires a smaller incision and less hardware. Patients encounter fewer postsurgical complications.

"More than 60 percent of patients with plates in their ankles complain of pain after surgery," says Tornetta. "In over 50 patients in whom we've done this minimally invasive surgery, only one has complained of pain after walking." Tornetta uses the same screws that are used with plates, but he places them in areas of the bone where they rarely cause pain.

In addition, Tornetta uses a dynamic fluoroscopic stress test to determine if a fracture requires surgery. Fluoroscopic images are taken of the patient's joint as it is placed in various stress positions. Joints are considered stable if the relationship between the two sides of the joint remains unchanged throughout the range of stress. This technique, which Tornetta says requires further investigation, gives a more accurate assessment of joint stability than either a physical examination or plain X rays. In a study using the dynamic stress test on 41 acetabular fracture patients, Tornetta found that only 3 required surgical treatment. In 38 patients, surgery was avoided with excellent results.

"Historically, most trauma treatment has been aggressive," says Tornetta. "What we're trying to do is determine what we don't have to fix. By having a much clearer definition of injury patterns through the use of special X rays and stress tests, we can reduce the number of patients who need surgery to repair fractures, or minimize the surgery that is required."

From the patient's perspective, the benefits of the stress test and X rays are obvious -- they can avoid surgery because another option will achieve the same result. If surgery is necessary, Tornetta says, minimally invasive procedures have distinct advantages over conventional surgery, including less scarring, a quicker recovery time, and fewer postsurgical complications such as pain and infection.

"This approach requires the involvement of the patient throughout," he says. "We have to understand the patient's requirements -- does he or she need to use the limb for work or to care for children, for example -- and tailor a treatment program that is right for the patient. This requires more thought on the physician's end, but the bottom line is whether it's right for the patient."

"Health Matters" is written in cooperation with staff members of Boston Medical Center. For more information on orthopedic surgery or other health matters, call 617-638-6767.

7 September 2001
Boston University
Office of University Relations