We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures.

This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20⁰, using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years.

All patients in both operatively treated groups were corrected to under 10⁰ of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture.

The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%.

Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%.

MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible.

There was no loss of correction in either operatively treated groups.

The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction.

MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity.

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

Background. There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. Objective. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures. Methods. This is a prospective single-surgeon case series of 420 consecutive feet undergoing MICA surgery between July 2014 and November 2018. Primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, and complication rates. Results. Pre-operative and 2 year post-operative patient reported outcomes were collected for 334 feet (79.5%). At minimum 2 year follow-up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 43.9±21.0 reduced to 9.1±15.6 post-operatively (p<0.001), walking and standing; pre-operative 38.2±23.6 reduced to 6.5±14.5 post-operatively (p<0.001) and social interaction; pre-operative 47.6±22.1, reduced to 6.5±13.5 post-operatively (p<0.001). At 2 year follow-up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.3±22.4 to 8.3±16.2 post-operatively (p<0.001). 1–2 intermetatarsal angle (mean ± SD) reduced from 15.4°±3.5° to 5.8°±3.1° (p<0.001) and hallux valgus angle reduced from 33.1°±10.2° to 9.0°±5.0° post-operatively (p<0.001). Conclusion. Third-generation MICA showed significant improvement in clinical outcomes at 2 year follow-up and can be successfully used for correction of a wide range of hallux valgus deformities

Objectives. Minimally invasive surgery (MIS) has gained popularity for hallux valgus, compared to the traditional scarf osteotomy (OS). Though evidence suggests similar clinical outcomes, there is paucity of randomised controlled studies. This study aimed to assess the feasibility of conducting a randomised controlled trial comparing the patient recorded and clinical outcomes for the surgical management of Hallux Valgus between OS and MIS Chevron Akin (MICA). Methods. Patients suitable for surgical correction were invited to participate. Post-op rehabilitation was standardised for both groups. Patients completed a validated questionnaire (Manchester Oxford Foot questionnaire and EQ-5D-5L) pre-operatively and post-operatively at 6 months and 1 year. Radiological parameters and range of motion were measured pre-and post-operatively. Results. 31 patients were recruited between Dec 2017 and June 2022. 17 patients were randomised to MICA (15 female, mean age 51) and 15 to OS (14 female, mean age 51). Both groups had a significant improvement in all MOXFQ parameters at 6m and 12m, as well as radiological parameters. VAS improved for OS (p=0.048) and for MICA (p=0.059) at 6m. There was no significant improvement in EQ-5D in either group at 12 months and no significant difference in operative time (p=0.53). There was a higher number of complications in the MICA group with 5 removal of metalwork (29.4%) and 2 superficial infections (11.8%) versus none in the OS group. The dorsiflexion significantly improved in the OS group at 6months (p=0.04). Recruitment rate dipped during COVID. No patients were lost at follow up. Conclusion. Both surgical options show similar clinical results, but higher complication rates were seen with MICA. This study illustrates the feasibility to conduct a randomised control trial for the comparison between the two techniques. Challenges to recruitment included surgeon equipoise, patient preference, training requirement and the pandemic which could be mitigated in a larger study

Minimally invasive surgery for the restoration of bone tissues lost due to diseases and trauma is preferred by the health care system as the related costs are continuously increasing. Recently, efforts have been paid to optimize injectable calcium phosphate (CaP) cements which have been recognized as excellent alloplastic material for osseous augmentation because of their unique combination of osteoconductivity, biocompatibility and mouldability. The sol-gel synthesis approach appears to be the most suitable route towards performing injectable calcium phosphates. Different strategies used to prepare bioactive and osteoinductive injectable CaP are reported. CaP gels complexed with phosphoserine-tethered poly(ε-lysine) dendrons (G3-K PS) designed to interact with the ceramic phase and able to induce osteogenic differentiation of human mesenchymal stem cells (hMSCs) is discussed. Recently, attention has been given to the modification of hydroxyapatite with Strontium (Sr) due to its dual mode of action, simultaneously increasing bone formation (stimulating osteoblast differentiation) while decreasing bone resorption (inhibiting osteoclast differentiation). The effect of systems based on strontium modified hydroxyapatite (Sr-HA) at different composition on proliferation and osteogenic differentiation of hMSC is described. One more approach is based on the use of antimicrobial injectable materials. It has been demonstrated that some imidazolium, pyridinium and quaternary ammonium ionic liquids (IL) have antimicrobial activity against some different clinically significant bacterial and fungal pathogens. Here, we report several systems based on IL at different alkyl-chain length incorporated in Hydroxyapatite (HA) through the sol-gel process to obtain an injectable material with simultaneous opposite responses toward osteoblasts and microbial proliferation

Study design: Prospective study after minimally invasive anterior approach of the thoracolumbar spine in scoliosis correction. Objective: To describe the technique and first results after minimally invasive anterior approach of the thoracolumbar junction with insertion of double rod and double screw instrumentation. Summary of Background Data: Minimally invasive techniques are used at many areas of surgery nowadays. Minimally invasive surgery should have the same correction potential as with conventional approaches. Possible advantages of minimally invasive surgery are small incisions, less tissue damage, less morbidity and an improved cosmetic appearance. Methods: In this study we describe the technique and the preliminary results of minimally invasive open approach of the thoracolumbar spine with insertion of double rod and double screw instrumentation. A consecutive series of seven patients were included. All patients were female with a mean age of 16.7 years (range 10–28). The cause of thoracolumbar scoliosis was mixed. Results: The thoracolumbar curve was 59° preoperatively and 22° at six months follow up (63% correction). The unfused thoracic curve was 40° preoperatively and 29° at six months follow-up. In the sagittal plane of the fused levels Cobb angle was 61° of lordosis preoperatively and 35° of lordosis at six months follow up. Lumbar lordosis of the unfused spine was 16° preoperative and 5° at six months follow up. Thoracic kyphosis was 33° preoperatively and 24° at six months follow-up. The average time of surgery was 6.6 hours (range 5.5–7hours). The average estimated blood loss was 764ml (range 350–1200ml). Average hospital stay was 11 days (range 5–14days), and average stay at the intensive care unit was 1.7 days (range 0–3 days). One minor neurological complication with complete recovery was observed. Conclusions: Minimally invasive surgery has the advantage of less tissue damage, less morbidity and a better cosmetic appearance. With newer implants a good correction of the scoliosis can be achieved

Background. Treating fractures is expensive and includes a long post-operative care. Intra-articular fractures are often treated with open surgery that require massive soft tissue incisions, long healing time and are often accompanied by deep wound infections. Minimally invasive surgery (MIS) is an alternative to this but when performed by surgeons and supported by X-rays does not achieve the required accuracy of surgical treatment. Methods. Functional and non-functional requirements of the system were established by conducting interviews with orthopaedic surgeons and attending fracture surgeries at Bristol Royal Infirmary to gain first-hand experience of the complexities involved. A robot-assisted fracture system (RAFS) has been designed and built for a distal femur fracture but can generally serve as a platform for other fracture types. Results. The RAFS system has been tested in BRL and the individual robots can achieve the required level of reduction positional accuracy (less than 1mm translational and 5 degrees of rotational accuracy). The system can simultaneously move two fragments. The positioning tests have been made on Sawbones. Conclusions. The proposed approach is providing an optimal solution by merging the fracture reduction knowledge of the orthopaedic surgeon and the robotic system's precision in 3D. Level of Evidence. The current level of evidence is limited and based on the Sawbones testing. Acknowledgement. This is a summary of independent research funded by the NIHR's i4i Programme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

Background:. Morbidity of any surgical procedure is undefined. Major surgeries and minor surgeries have different morbidities but the morbidity after any surgical procedure is neither quantified nor defined in literature. Minimally invasive surgeries have evolved in all surgical branches and are known to have less morbidity after the surgery. There is no score or index to assess early recovery after any surgical procedure. Aim:. The objective of the study was to develop a scoring method to assess early post operative recovery of TKR patients. Materials and methods:. 50 consecutive total knee replacement patients were evaluated and scored at day 0, day 1, day2 and day3 post operatively. All the patients were operated upon by a single senior surgeon using minimally invasive approach. The scoring of the index consist of a questionnaire with 10 different questions regarding the general well being of the patient, wound condition, physical abilities and few other important parameters. The scores were judged from 0 to 3. Total score ranges from 0 to 30. The higher the score, the higher is the morbidity of the patient. Results:. The patients showed that the general morbidity decreases in great values from postoperative period to 24 h and 48 h after the surgery. Conclusion:. The morbidity index is a very reliable and precious way of assessing post operative condition of the patient in both surgeon's aspect and patient's aspect of view. Since there is no scoring method for early post operative assessment, this morbidity index may be important to measure the early surgical outcome of different surgeries

Aims. To determine whether there is any benefit using a minimally invasive trans-sartorial approach as described by Professor Søballe compared to the ilio-femoral for peri-acetabular osteotomy. Methods. 30 consecutive patients were operated on by a single surgeon. The first 15 underwent an ilio-femoral (I-F) approach whilst the following 15 had a trans-sartorial (T-S) approach. Fixation was achieved with 3 or 4 screws. All other aspects of surgery and rehabilitation were the same. Data was collected prospectively and included operation time, intra-operative blood loss and length of stay. Acetabular correction was measured using the sourcil and centre edge angle (CEA) on pre and post-operative radiographs. Results. Both groups had acceptable radiographic corrections with CEA improving from mean 14.5 to 38.7 degrees (T-S) and 14 to 39 degrees (I-F). The sourcil angle improved from mean 17.8 to 2 degrees (T-S) and 19.5 to −1.5 (I-F). Minimally invasive surgery reduced anaesthetic time by 62 minutes. Haemoglobin loss was reduced by 1 gram/L and there was no requirement for transfusion. Hospital stay reduced by 0.8 days. There were no major adverse complications although two partial femoral neurapraxias were noted early in the series. These fully resolved. Conclusion. We have found significant benefit from changing to minimally invasive PAO. Our patients have smaller wounds, a shorter operative time, reduced bleeding and a shorter length of stay. We found no adverse effects. The time savings have also corresponded to a cost saving for our institution. We recommend this technique although recognise that it has a learning curve and should be initiated by surgeons with previous PAO experience

Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care. Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme

Purpose: Minimally invasive surgery (MIS) knee replacement surgery has experienced a recent surge in popularity, driven by the patient concerns of a faster recovery time and a shorter, more cosmetic scar. However the evaluation of any new medical therapy must include a detailed evaluation of both efficacy and safety outcomes. The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive(MIS) and standard total knee replacement (TKR) approaches. Method: We reviewed randomized controlled trials comparing minimally invasive TKR to standard TKR. After testing for publication bias and heterogeneity, the data were aggregated by random-effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function Scores, and Knee Society Knee Scores. Results: We had a total of 9 studies evaluating our primary outcome. Average follow up time ranged from 3 to 28 months. There was no significant publication bias in our study. The combined odds ratios for complications for the MIS group and alignment outliers were 1.58 (95% CI: 1.01 to 2.47) p< 0.05 and 0.79 (95% CI: 0.34 to 1.82) p=0.58 respectively. The standard difference in means for Knee Society scores was no different between groups. Conclusion: The results of this meta-analysis demonstrate a statistically significant increase in complication rates with MIS TKR when compared to standard TKR. There were no significant differences in postoperative alignment or KSS at 3 months between the two groups. MIS knee surgery should be approached with caution

Technological advances and economic trends are shaping the future of orthopaedics, where a clinical solution encompasses all phases of surgery. Minimally invasive surgery (MIS) continues to become more popular and important in modern-day orthopaedics, but brings added complexity to the operating room. Computer assisted surgery (CAS) has the potential to provide greater reliability, repeatability, and control to orthopedic surgeries, although limitations in the technologies currently available for minimally invasive CAS procedures leave much to be desired. Despite new techniques and modern technologies, improvements are needed to achieve consistency of optimal patient outcomes in orthopaedic surgery. Healthcare markets are moving to emphasize the value of patient-specific intervention with reliable, custom solutions. We are developing a framework for orthopedic CAS which utilizes new technologies and a cohesive approach in providing a robust solution for the future of orthopaedics. Through the use of surgical preplanning, intra-operative guidance, and post-operative gait analysis, a full analysis and design cycle is used to ensure optimal patient outcome by focusing on the combination of the three surgical phases. In order to realize this comprehensive framework, a system-level design approach combined with cutting-edge technology is needed, catering to patient-specific anatomical reconstruction. In the pre-operative phase, X-ray images are used in the 3-D reconstruction of patient-specific models of the targeted anatomy. This is combined with automated morphometric measurements to provide automatic cutting plane alignment and a complete design suite for patient-specific implants. In the intraoperative phase, new wireless navigation technologies provide robust performance where optical and electromagnetic tracking systems fall short. MEMS capacitive sensor array technology provides accurate and real-time pressure sensing feedback for ligament balancing, and new software frameworks virtualize surgical protocols. Extensive gait analysis including X-ray fluoroscopy provides 3-D kinematic data in the post-operative phase to provide valuable feedback on implant performance for improved implant design

Background. Minimally invasive surgery is being widely used in the field of total hip arthroplasty (THA). The advantages of the direct anterior approach (DAA), which is used in minimally invasive surgery, include low dislocation rate, quick recovery with less pain, and accuracy of prosthesis placement. However, minimally invasive surgery can result in more complications related to the learning curve. The aim of this study was to evaluate the learning curve of DAA-THA performed by a senior resident. Methods. Thirty-three consecutive patients (33 hips) who underwent primary THA were enrolled in this study. All operations were performed by a senior resident using DAA in the supine position without the traction table. The surgeon started using DAA exclusively for all cases of primary THA after being trained in this approach for 6 months. Operative time, intraoperative blood loss, complications, and accuracy of prosthesis placement were investigated. Results. The mean intraoperative blood loss was 524 mL (range, 130–1650 m L). The mean operative time was 60 min (range, 41–80 min). Radiographic analysis showed an average acetabular anteversion angle of 17.0±3.3°, abduction angle of 37.8±4.3°, and stem alignment of 0±0.8°. Thirty-two (97%) of 33 cups were placed within the Lewinnek's safe zone. The overall complication rate was 12% (4 of 33 hips), including 1 proximal femoral fracture (salvaged with circumferential wiring), 1 temporary femoral nerve palsy (completely recovered in 2 weeks), 1 stem subsidence (5 mm), and 1 cup migration. Three of these complications were occurred in the first 10 cases. No revision surgery was required, No postoperative dislocation occurred. Conclusion. We investigated the learning curve of DAA-THA performed by a senior resident. We considered the first 10 cases as the learning curve, but concluded that with adequate training this procedure can be performed safely and effectively without increasing the risk of complications

Minimally invasive surgery (MIS) for total hip arthroplasty and hemiarthroplasty is performed through anterior or anterolateral approach from April 2006. Appropriate stem insertion is often difficult by conventional approach. Retractor for MIS stem insertion is used from February 2007 and initial stem position is measured. Forty-four hemiarthroplasty and 20 total hip arthroplasty were performed from April 2006 until December 2007 with mean age of 79.7. Retractor for MIS stem insertion has been used for 36 hips from February 2007. Stem was cemented for more than 13mm at femoral isthmus. Stem position was measured in rentogenographs of hip after operation about adduction or abduction, extension or flexion, and anteversion of stem in proximal femur. The average abduction/adduction was 1.75 degree abduction in conventional method and 1.38 degree abduction from February 2007. The average extension/flexion was 1.10 degree flexion in conventional method and 0.25 degree flexion from February 2007. The average anteversion was 30.3 degree in conventional method and 28.4 degree from February 2007. Two cases in conventional method and one case from February 2007 complicated femoral fracture during operation. In conventional method, cement cap in one case was undersized and proximal major trochanteric fracture was happened in one case. Ectopic ossification at medial gluteal muscle in one case was observed and one case was dislocated among conventionally operated cases during follow-up period. Care of femoral exposure though gluteal muscles is needed in anterior and anterolateral MIS. More exact and safe stem insertion procedure is available by using retractor for MIS of the hip

Introduction. The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires. Materials and Methods. Whilst positioned in the supine or lateral position, a routine supine anterior lumbar interbody fusion (ALIF), and/or antero-lateral ALIF (AL-ALIF) and/or lateral lateral interbody fusion (LLIF) is performed. The patient is then turned prone or kept in the single lateral position (SPL) for insertion of the posterior screws performed under robotic guidance. Intraoperative CT scan 3D images captured then are sent to the Robotic software platform for planning of the screw trajectories and finally use again at the end of the procedure to confirm screw accuracy. We identified 34 consecutive patients from October 2019 to January 2020 who underwent robotic assisted spine surgery. The demographic, intraoperative, and perioperative data of all these patients were reviewed and presented. Results. Of the 34 patients, 65 levels were treated in total using 204 screws. Of the 21 patients (60%) who underwent single-level fixation, 14 of them (67%) were treated at the L5/S1 level, 3 at L3/L4, 3 at L4/L5 and 1 at L2/L3 level. The remaining 13 patients (40%) underwent multi-level fixation, of which 4 were adult scoliosis. 15 underwent a supine ALIF approach, 1 underwent AL-ALIF, 8 patients underwent combined LLIF and AL-ALIF approach in a lateral decubitus, whilst 9 underwent pure LLIF approach (of which 3 patients were in the single position lateral) and one patient had previous TLIF surgery. The average estimated blood loss was 60 cc. The average planning time was 10 min and the average duration of surgery was 50 min. The average patient age was 54 years and 64% (22/34) were male. The average BMI was 28.1 kg/m. 2. There were no re-interventions due to complications or mal positioned screws. Conclusion. Minimally invasive spine surgery using robot-assisted navigation yields an improved level of accuracy, decreased radiation exposure, minimal muscle disruption, decreased blood loss, shorter operating theatre time, length of stay, and lower complication rates. Further follow-up of the patients treated will help compare the clinical outcomes with other techniques

Introduction: Minimally invasive surgery (MIS) presents challenges in achieving alignment for unicompartmental knee arthroplasty (UKA). Aim: Development and assessment of an image guidance system for MIS implanted Oxford UKA. Methods: The Surgetics platform which uses intra-operative data acquisition was chosen as the base system. Software was developed to determine height of tibial cut, image guidance of saws, alignment of components and assessment of ligament tension. The accuracy of component placement was assessed in vitro using matched pairs of knees randomised into navigated (NAV n=10) and standard manual (MAN n=10) procedures; standardised postoperative A-P and lateral radiographs were used. Pre and post-operative kinematics were assessed (NAV n=6, MAN n=7). The changes postoperatively over knee flexion and extension were calculated for tibiofemoral rotation (ΔROT) and ab/adduction (ΔABD). Results: Accurate component placement was achieved with both methods without significant differences. Tibial cut height was more accurately in the NAV group (re-cut rate: NAV 33%, MAN 50%). NAV femoral component placement was as accurate as MAN with intramedullary rod. For the flexing cycle mean ΔROT was −0.06° (range 6.08° to −3.93°) and mean ΔABD was −0.04° (range 3.39° to −5.72°). There were no observable differences between the NAV and MAN kinematics. Overall, no observable differences were found between pre and post-operative kinematics. Conclusions: Image guidance produces accurate placement through MIS approach and reduces the amount of tibial bone resection

Introduction: Minimally invasive surgery (MIS) has recently been proposed for unicompartmental arthroplasty to allow quick function recovery. The purpose of this study is to evaluate retrospectively the indications in which this technique would have been possible and successful. Methods: The requirements for the minimal invasive technique are: a pre-operative flexion of 100° and a lesion limited to one compartment of the knee. The preoperative status, operative findings and clinical outcome of 160 cases of unicompartmental knee arthroplasty (MG, Zimmer) were analyzed to determine whether the criteria for MIS would have been possible. Results: Preoperatively 12 knees had a flexion less than 100°. Postoperatively four of them had a limited flexion ranging from 90° to 100°. In 53 knees (33 %), peripheral osteophytes were removed on the opposite tibiofemoral joint. None of them were revised for progression of osteoarthritis. In 33 knees (21 %) a patelloplasty was associated to the procedure for peripheral osteophytes. Two of them were revised at 12 and 20 months for osteoarthritis progression. Discussion: Removal of peripheral osteophytes can be successfully associated to the unicompartmental procedure when using a conventional surgical approach. In 96 of the 160 knees (60 %) MIS was not recommended either for limited preoperative flexion or for peripheral osteophytes. In 2 knees unicompartmental arthroplasty itself was not the correct indication and total knee arthroplasty would have been the right solution. Finally, in 62 of the 160 knees (39 %) unicompartmental arthroplasty using MIS was indicated. In conclusion unicompartmental knee arthroplasty may be either performed by conventional or minimal approach based on the preoperative clinical and radiological evaluation

Minimally invasive surgery (MIS) for unicompartmental knee arthroplasty (UKA) has become increasingly popular. However, wound problems may be encountered with longitudinal skin incisions. This probably occurs because the skin is under excessively high tension during MIS. We have been using transverse incisions for MIS-UKA. We describe the surgical technique and an experimental study for assessing blood flow in the skin around the knee. A 5–7 cm transverse skin incision was made from the medial edge of the patella at the level of 1–2 cm proximal to the joint line. The capsule was incised along the medial parapatellar up to the proximal two-thirds of the patella, and a few cm were also cut along the distal end of the vastus medialis. Because skin on the anterior aspect of the knee is more flexible in the longitudinal direction, exposure is easy even with a small incision. Experimental study: We measured the direction of blood flow on the anterior aspect of the knee using laser flowmetry. Nine normal subjects were examined. A probe was attached to the skin on the medial parapatellar region, and two 7 cm long parallel depressors were applied bilaterally on the sides of the probe. The depressors were placed longitudinally or transversely under 30N of compression force, and then blood flow was recorded. Blood flow was markedly increased due to congestion when the depressor was placed longitudinally. On the contrary, changes in blood flow were significantly lower when the depressor was placed transversely. Transverse incision can lead to better exposure and permit an smaller incision. Moreover, transverse incisions are less invasive to the skin’s circulation and leave less distinctive scars than longitudinal incisions

Introduction: Recently there has been much interest in minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary program for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. Methods: The program involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was too early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d’Aubigne clinical rating system and Visual Analogue Pain Scores. Results: Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d’Aubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new program allows patients undergoing total hip replacement to be discharged after 1 night post operatively without compromising safety or quality of care. Conclusion: Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive program

Background. Minimally invasive surgery is an alternative therapeutic option for treating unstable spinal pathologies to reduce approach-related morbidity inherent to conventional open surgery. Objective. To compare the safety and therapeutic efficacy of percutaneous fixation to that of open posterior spinal stabilisation for instabilities of the thoraolumbar spine. Study Design. Comparison study of prospective historical cohort versus retrospective historical control at a tertiary care centre. Methods. Patients who underwent open or percutaneous posterior fixation for thoracic-lumbar instabilities secondary to metastasis, infection and acute trauma were included. Minimally access non traumatic instrumentation system (MANTIS) was used for percutaneous stabilisation. Outcome Measures. The differences in surgery-related parameters including operative time, blood loss, radiation exposure time, analgesia requirement, screw related problems and length of hospitalisation between the groups were analyzed. Results. There were a total of 50 patients with 25 in each group. There were no significant differences concerning age, sex, ASA, pathology causing instability, level and number of segments stabilised between the groups. There were significant differences between the MANTIS and open group in terms of blood loss (492 versus 925 ml, p<0.0001), post-op analgesia requirement (33 versus 45 mg/day of morphine, p<0.0004) and length of hospital stay for trauma sub-group of patients (6.2 versus 9.6 days, p< 0.0008). Average operative time of the MANTIS group was 190.2 minutes, not significantly longer to that of the conventional open group (183.84 minutes, p>0.05) Open group patients had less radiation exposure (average of 0.6 minutes) compared to MANTIS cohort (3.1 minutes). There were 2 patients with screw misplacements comprising one from each group that needing revision. Conclusion. Percutaneous spinal stabilisation using mini-invasive system is a good surgical therapeutic choice in thoracic-lumbar instabilities. It has the advantage of less trauma, quick recovery and shortened hospital stay with accuracy of screw placement as similar to those reported for other techniques. Indications and limitations of this technique must be carefully identified. Interest Statement. There was no commercial support or funding of any sort