Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for (1) clinical and (2) functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether (3) minimally invasive approaches are superior to conventional approaches for clinical outcomes. All studies comparing MI approaches to conventional approaches were eligible for analysis. The PRISMA guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: ‘minimally invasive’, ‘muscle-sparing’, ‘THA’, ‘THR’, ‘hip arthroplasty’ and ‘hip replacement’. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the EU clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation). Twenty studies were identified. There were 1,282 MI THAs and 1,351 conventional THAs performed. (1). There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (p=0.959), aseptic revision (p=0.894), instability (p=0.894), infection (p=0.669) and periprosthetic fracture (p=0.940). (2). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (p=0.38). (3). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in the rate of aseptic revision (p=0.461) between both groups. Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim

Background:. Previous attempts at small incision hallux valgus surgery have compromised the principles of bunion correction in order to minimise the incision. The Minimally Invasive Chevron/Akin (MICA) is a technique that enables an open modified Chevron/Akin to be done through a 3 mm incision, facilitated by a 2 mm Shannon burr. Methodology:. This is a consecutive case series performed between 2009 and 2012. This includes the learning curve for minimally invasive surgery. All cases were performed by a single surgeon at two different sites, one centre where minimally invasive surgery is available and the other where it is not. The standard procedure in both centres is a modified Chevron osteotomy. Regardless of whether the osteotomy was performed open or minimally invasive two-screw fixation was performed. Retrospective analysis includes the IMA, HVA, M1 length, forefoot width and forefoot: hindfoot ratio. Clinical outcomes include the MOXFQ, AOFAS, and assessment of complications. Results:. There were 70 cases in each arm. Follow-up was 4 years to 6 months. The radiological outcomes were similar in both groups. There was an increased rate of screw removal in the MICA group. There were also cases of hallux varus, these occurred in the cases with severe pre-operative IMA angles that also had a lateral release and an Akin. There was high satisfaction in both groups. Conclusion:. This is the only comparison of minimally invasive and open techniques that has been performed, providing a direct comparison of the utility of a burr compared to a saw. These early results demonstrate the efficacy of a Minimally Invasive Chevron/Akin in terms of achieving radiological correction. The clinical outcomes are excellent but there is a learning curve and this needs to be managed

Purpose: There is great interest recently,among Orthopaedic surgeons about Minimally Invasive Surgery (MIS) in knee arthroplasty.We present a retrospective,randomized review of 50 patients,who had their knees replaced during a period of a year and show our experience in indications,surgical technique,early results and comparison to conventional surgery. Method: Using regional anaestesia and an incision of about 9cm (7–11cm), the components are placed without patellar eversion.We briefly describe regional anatomy in relation to surgical technique.We compare early results using MIS to standard procedure,regarding pain,function and rehabilitation and describe pros and cons of the method. Results: Early results show faster recovery time, less post-operative pain and effusion and quicker return to normal activities.There were no skin problems. 96% of the knees that recieved MIS had good to excellent KSS and KS scoring Systems score.We certainly need longer results and better experience because the method is technically challenging. Smaller surgical tools are also needed in order the technique becomes better and easier for the surgeon

Introduction: The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and to analyse the reported surgical outcomes. Material and Methods: A comprehensive search of databases using various combinations of the keywords: minimally invasive total knee arthroplasty, mini-incision total knee replacement and minimally invasive arthroplasty was performed. 28 studies published from January 2003 to June 2008 meeting the inclusion criteria were evaluated using the Coleman Methodology Score (CMS). Results: AT A mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased post operative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short term gain) and shorter hospital stay in comparison to patients undergoing standard total knee arthroplasty. These benefits however need to be balanced against the incidence of increased tourniquet time and increased incidence of component malaligment in the MITKA group. Conclusion: Evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow ups are needed to justify the long term advantages of MITKA over standard total knee arthroplasty

Background. Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after Minimally Invasive Plate Osteosynthesis (MIPO) of stress fracture through femoral tracker is unique in orthopaedic literature. We are reporting this unique presentation of periprosthetic fractures after MIPO for stress fracture involving femoral pin site track in computer assisted total knee arthroplasty, treated by reconstruction nail (PFNA). Methods. A 75-year old female, who had computer navigated right total knee replacement, was admitted 6 weeks later with increasing pain over distal thigh for 3 weeks without trauma. Prior to onset of pain, she achieved a range of movements of 0–105 degrees. Perioperative radiographs did not suggest obvious osteoporosis, pre-existent benign or malignant lesion, or fracture. Radiographs demonstrated transverse fracture of distal third of femur through pin site track. We fixed the fracture with 11-hole combihole locking plate by MIPO technique. Eight weeks later, she was readmitted with periprosthetic fracture through screw hole at the tip of MIPO Plate and treated by Reconstruction Nail (PFNA), removal of locking screws and refixation of intermediate segment with unicortical locking screws. Then she was protected with plaster cylinder for 4 weeks and hinged brace for 2 months. Results. Retrograde nail for navigation pin site stress fracture entails intraarticular approach with attendant risks including scatches to prosthesis and joint infection. So we opted to fix by MIPO technique. Periprosthetic fracture at the top of MIPO merits fixation with antegrade nail in conjunction with conversion of screws in the proximal part of the plate to unicortical locking screws. Overlap of at least 3cms offers biomechanical superiority. She made an uneventful recovery and was started on osteoporosis treatment, pending DEXA scan. Conclusion. Reconstruction Nail (PFNA), refixation of intermediate segment with unicortical locking screws constitutes a logical management option for the unique periprosthetic fracture after MIPO of stress fracture involving femoral pin site track in computer assisted total knee replacement

A major limiting factor for the accuracy in Computer Assisted Surgery (CAS) is the system’s positional knowledge of the patient’s anatomy, derived through the process of registration. In computer assisted Minimally Invasive Surgery (MIS) the registration process is made more difficult by the lack of direct access to a large portion of the surface to be registered. Current experience with a hands-on robotic surgery system, which uses a set of points measured with a mechanical digitiser on the exposed surface of the bone and a surface reconstructed from computer tomography (CT) data, has shown that accurate and robust registration is still possible through an MIS approach. The registration method described here, which was originally developed for robotic assisted total knee arthroplasty (TKA), has successfully been adapted for robotic assisted unicompartmental knee arthroplasty (UKA) and computer assisted hip resurfacing (HR). Results show that good registration can be achieved by registering the bone surfaces through conventional surgical incisions, with two additional stab-wounds required for the UKA procedure. However, experimental results suggest that, because of the limited access resulting from a smaller incision, a good correspondence between the point-set and surface measurements (i.e., better than one millimeter) is necessary for registration accuracy better than two degrees and two millimeters. This degree of correspondence can be expected for a good surface model and an appropriate intra-operative setup, but poses an important constraint on the requirements for a system suitable for this type of procedure, if a registration method based on anatomical features is to be used without the need for additional access

Introduction: In the last few years minimally invasive surgery in hip replacement is becoming more popular among orthopaedic surgeons because of less morbidity and faster rehabilitation. However several complications have been reported expecially in the so called “learning curve” (first twenty cases). The purpose of this study is to evaluate the learning curve of three different minimally invasive approaches.

Methods and Materials: In this study three different surgical approaches of THA were evaluated: lateral mini incision (GroupA), minimally invasive anterior approach (GroupB) and minimally invasive antero lateral approach (GroupC). The first twenty cases of each surgical approach were selected and compared with a control group (GroupD) of 149 total hip replacement operated using a lateral standard approach (> 12 cm) in the same period by the same experienced surgeon.

In all cases a specialized dedicated surgical instrumentation was used. Inclusion criteria to enter the study group (A-B-C Groups) were:BMI< 30, diagnosis of primary osteoarthritis, age< 75 years.

Following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional outcomes (HHS, WOMAC) at six weeks.

Results: No dislocations, infections and early aseptic loosening were detected in groups A, B and C. No significant differences were detected regarding the length of hospital stay in all groups. In group B the time of surgery was significantly higher than in group D. The total blood loss of group A, B and C was statistically lower than group D. Clinical outcomes at six weeks in groups B and C were significantly better that in group A and D. The following complications were detected:

Group A: two sciatic nerve palsy (one transient and one permanent), one greater trochanter fracture, one femoral stem malposition.

Group B: one greater trochanter fracture, one proximal femoral fracture, one rupture of tensor fasciae latae, two haematomas.

Group C: no complications were detected.

In control group D (149 patients) the following complications were observed: one proximal femoral fracture, one case of cup malposition and one infection.

Conclusions: The main advantages of all MIS approaches seem to be the reduced total blood loss, even in the learning curve. However during learning curve the minimally invasive approaches seem to have a higher rate of complications than the standard procedures even in selected patients. In muscle sparing approaches (anterior and antero lateral) the early functional outcomes are better than other approaches (standard and mini incision). Among the evaluated minimally invasive procedures, the antero lateral approach seems to be safer and less demanding than others.

Background. Total Shoulder Arthroplasty (TSA) has been shown to improve the function and pain of patients with severe degeneration. Recently, TSA has been of interest for younger patients with higher post-operative expectations; however, they are treated using traditional surgical approaches and techniques, which, although amenable to the elderly population, may not achieve acceptable results with this new demographic. Specifically, to achieve sufficient visualization, traditional TSA uses the highly invasive deltopectoral approach that detaches the subscapularis, which can significantly limit post-operative healing and function. To address these concerns, we have developed a novel surgical approach, and guidance and instrumentation system (for short-stemmed/stemless TSA) that minimize muscle disruption and aim to optimize implantation accuracy. Development. Surgical Approach: A muscle splitting approach with a reduced incision size (∼6–8cm) was developed that markedly reduces muscle disruption, thus potentially improving healing and function. The split was placed between the infraspinatus and teres-minor (Fig.1) as this further reduces damage, provides an obvious dissection plane, and improves access to the retroverted articular surfaces. This approach, however, precludes the use of standard bone preparation methods/instruments that require clear visualization and en-face articular access. Therefore, a novel guidance technique and instrumentation paradigm was developed. Minimally Invasive Surgical Guidance: 3D printed Patient Specific Guides (PSGs) have been developed for TSA; however, these are designed for traditional, highly invasive approaches providing unobstructed access to each articular surface separately. As the proposed approach does not offer this access, a novel PSG with two opposing contoured surfaces has been developed that can be inserted between the humeral and scapular articular surfaces and use the rotator cuff's passive tension to self-locate (Fig.2). During computer-aided pre-operative planning/PSG design, the two bones are placed into an optimized relative pose and the PSG is constructed between and around them. This ensures that when the physical PSG is inserted intra-operatively, the bones are locked into the preoperatively planned pose. New Instrumentation Paradigm: With the constraints of this minimally invasive approach, a new paradigm for bone preparation/instrumentation was required which did not rely on en-face access. This new paradigm involves the ability to simultaneously create glenoid and humeral guide axes – the latter of which can guide humeral bone preparation and be a working channel for tools – by driving a short k-wire into the glenoid by passing through the humerus starting laterally (Fig.3). By preoperatively defining the pose produced by the inserted PSG as one that collinearly aligns the bones’ guide axes, the PSG and an attached c-arm drill guide facilitate this new lateral drilling technique. Subsequently, bone preparation is conducted using novel instruments (e.g. reamers and drills for creating holes radial to driver axis) powered using a trans-humeral driver and guided by the glenoid k-wire or humeral tunnel. Conclusion. To meet the expectations of increasingly younger TSA patients, advancements in procedural invasiveness and implantation accuracy are needed. This need was addressed by developing a novel, fully integrated surgical approach, PSG system, and instrumentation paradigm, the initial in-vitro results of which have demonstrated acceptable accuracy while significantly reducing invasiveness

Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

Introduction. Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

Background: The combination of imageless computer aided navigation and minimally invasive surgery for total knee arthroplasty (TKA) has not been reported. Computer Aided Surgery (CAS) of the knee has demonstrated more reproducible component alignment compared to standard instrumentation. Minimally Invasive Surgery (MIS) for total knee arthroplasty allows for quicker rehabilitation and less post-operative pain. However, MIS has been associated with a higher complication rate, including component malalignment, compared to a conventional operative approach. Both MIS and CAS have been demonstrated to have a learning curve. Aims: This study presents the initial 30 procedures in which imageless CAS was combined with MIS for TKA by the senior author. Specifically, we examined the accuracy of coronal alignment and the learning curve associated with the combined technique. Between 6 and 12 weeks full length weight bearing radiographs were taken when patients could achieve full extension. Coronal alignments of the tibial and femoral components were calculated relative to the mechanical axis. The goal for both femoral and tibial component alignment was within 30 of 900 to the mechanical axis. The results were verified by an independent observer. Analysis of sequential tourniquet times, complication rates and component alignment were used as measure of the learning curve for the technique. Component position was acceptable for all implants. The mean coronal tibial alignment was 90.35 degrees (range 88 to 92 degrees) and the mean coronal femoral alignment 90.10 degrees (range 88 to 93 degrees) to the mechanical axis. Tourniquet time averaged 90 minutes (range 60 to 118 minutes). There was no significant reduction in tourniquet time with increasing familiarity with the technique. Our results demonstrate that CAS combined with MIS for TKA maintains the accuracy of component alignment despite the minimally invasive approach. These initial results demonstrate no significant learning curve associated with the technique

Introduction: The value of arthroscopy, fluoroscopy, and e-learning courses (focusing on minimally invasive surgical techniques) for the treatment of intra-articular distal radius fractures (I-ADRF), remains controversial. This study compares the outcomes after fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures, with or without concomitant arthroscopic evaluation. Materials and Methods: Forty-seven patients with I-ADRF underwent FA external fixation and percutaneous pinning. Among them 23 had additional arthroscopic evaluation of their wrist. For teaching purposes procedures with the use of fluoroscopy and arthroscopy were recorded and adapted as a course for the On-line Performance Support Environment for Minimally Invasive Orthopaedic Surgery (“OnLineOrtho” EU- sponsored project). The context of these courses was incorporated in an intelligent medical performance support environment. The duration of the procedure, the surgical findings and the outcomes were recorded. Results: The follow-up period ranged from 24 to 62 months and the patients were evaluated at 3, 6, 12 and 24 months. The addition of arthroscopy prolonged the procedure by 25 minutes but diminished the number of images obtained by the image intensifier by 5. After arthroscopic evaluation the placement of subchon-dral pins was changed, because of step-off, in 11 of 23 patients. Also tears of the TFCC (14 of 23 patients), perilunate ligaments (16) were depicted. Patients who underwent additional arthroscopic evaluation had significantly better supination, extension and flexion at all time points than those who had only fluoroscopically assisted surgery. The value added by e-courses and the online performance support system is highlighted through the recognition of the systems effectiveness in e-training. Discussion: During reduction and fixation of I-ADRF, arthroscopy is a very useful tool for the inspection of the articular surface, the ligaments and the TFCC. Long-term evaluation revealed that patients with additional arthroscopy returned to their previous activities in shorter periods and had better supination, flexion, and extension than patients with FA procedures. Fluoroscopy is essential for the minimally invasive surgical treatment of intra-articular distal radius fractures, whereas arthroscopy is an additional valuable tool that improves the outcome, and e-courses are useful adjuncts for teaching purposes

Introduction: Recent studies have shown that Minimally Invasive Total Hip Replacements (MISTHRs) have not reduced hospital stay. We seek to demonstrate the importance of infrastructure allowing early mobilisation and discharge thereby gaining the full benefits of MISTHRs. We compared the early outcomes of 2 units where MISTHRs were carried out by the same surgical teams but had 2 different infrastructure set-ups. In the first unit a “Short Stay Programme” (SSP) was in place. This involved early pre-operative assessment by medical, physiotherapy and occupational therapy teams. Post-operative analgesia was augmented with the use of a pain pump administering local anaesthetic as a continuous infusion. Patients were mobilised at 4 hours after surgery and were supported in the community by an “Outreach Team”. In the second unit the patients had MISTHRs without changes to the conventional infrastructure. Methods: One surgeon carried out all operations, at 2 different hospitals using a mini-posterior approach with specific minimally-invasive instrumentation. Uncemented ABG II prostheses were used. Hospital discharge was only achieved after specific criteria were fulfilled. Discussion: A significant reduction in the length of stay of MISTHRs patients is achieved by the Short Stay Programme, with no difference in complications. The full advantages of MISTHRs are achieved only if the whole aim of the care pathway is to facilitate early, supported discharge. Trouble-shooting pre-operatively, effective analgesia and post-operative support are the key elements of this programme

Various reports confirm that elevations in serum markers associated with skeletal muscle injury exist and can occur after orthopaedic surgery in the absence of overt clinical manifestations of myocardial injury. The purpose of this study is to measure the influence surgical approach on these serum markers following primary Minimally Invasive THA. Consecutive enrollment of 30 patients into three different groups of 10 was performed. The MIS Modified Watson Jones THA is an approach using an inter-muscular plane, the Mini Posterior is a trans-muscular approach with some muscle detachment and repair, while the MIS II Incision THA is an inter-muscular approach anteriorly and a trans-muscular approach posteriorly. Blood samples for total creatine kinase (CK), creatine phospho-kinase (CPK), and serum myoglobin were obtained at screening and the morning before surgery as a baseline, immediately post-operatively in the recovery room and 8, 16, 24, 36, 48, and 72 hours post-operatively. Hemoglobin and hematocrit was obtained pre-operatively, 16, 36, and 72 hours (±6 hours) post-operatively. Cardiac troponin-I was measured the morning before surgery (pre-operatively) and 16 hours following surgery to monitor any contributory effect of myocardial injury. We report measurable and reproducible trends in serum enzyme levels consistent with skeletal muscle damage due to THA. Troponin-I remained normal in all but one case throughout the entire study indicating no myocardial contribution to measured serum enzyme levels. While these trends may have slight correlation with surgical approach, they were not statistically significant. We conclude that all three procedures do affect serum enzyme markers and are safe from this standpoint, but no surgical approach appears to affect the degree of muscle trauma more or less than another

Increasing incidence of osteoporosis, obesity and an aging population have led to an increase in low energy hip fractures in the elderly. Perceived lower blood loss and lower surgical time, media coverage of minimal invasive surgery and patient expectations unsurprisingly have led to a trend towards intramedullary devices for fixation of extracapsular hip fractures. This is contrary to the Cochrane review of random controlled trials of intramedullary vs extramedullary implants which continues recommends the use of a sliding hip screw (SHS) over other devices. Furthermore, despite published literature of minimally invasive surgery (MIS) of SHS citing benefits such as reduced soft tissue trauma, smaller scar, faster recovery, reduced blood loss, reduced analgesia needs; the uptake of these approaches has been poor. We describe a novel technique one which remains minimally invasive, that not only has a simple learning curve but easily reproducible results. All patients who underwent MIS SHS fixation of extracapsular fractures were included in this study. Technique is shown in Figure 1. We collated data on all intertrochanteric hip fractures that were treated by a single surgeon series during period Jan 2014 to July 2015. Data was collected from electronic patient records and radiographs from Picture Archiving and Communication System (PACS). Surgical time, fluoroscopy time, blood loss, surgical incision length, post-operative transfusion, Tip Apex Distance (TAD) were analyzed. There were 10 patients in this study. All fractures were Orthopaedic Trauma Association (OTA) type A1 or A2. Median surgical time was 36 minutes (25–54). Mean fluoroscopy time was similar to standard incision sliding hip screw fixation. Blood loss estimation with MIS SHS can be undertaken safely and expeditiously for extracapsular hip fractures.

Periacetabular osteotomy (PAO) has been established as an effective technique to treat symptomatic hip dysplasia in young patients. Its role in treating borderline dysplasia and acetabular retroversion is evolving.

The aim of this study was to:

Examine the prospectively collected outcomes following a minimally invasive PAO in a large cohort of patients

This is a single-surgeon review of patients operated in a high-volume centre with prospectively collected data between 2013 and 2020, and minimal followup of six months. PAO was performed using a minimally invasive modified Smith Peterson approach. 387 patients were operated during the study period and 369 eligible patients included in the final analysis. Radiographic parameters were assessed by two authors (GS and KB) with interrater reliability for 25 patients of 84–95% (IntraClass Coefficient). Patient reported outcome measures (i-HOT 12, NAHS, UCLA and EQ-5D) were collected prospectively. Case note review was also performed to collate complication data and blood transfusion rates.

Radiological parameters improved significantly after surgery with Lateral centre-edge angle (LCEA) improving by 16.4 degrees and Acetabular index (AI) improved by 15.8 degrees.

Patient reported outcome measures showed significant improvement in post-op NAHS, iHOT and EQ5D at 2 years compared to pre-op scores (NAHS=30.45, iHOT=42, EQ5D=0.32, p=0.01). This significance is maintained over 2 years post procedure (p=0.001). There was no significant difference between the three groups (severe dysplasia, borderline dysplasia and acetabular retroversion).

Clinical outcomes showed an overall complication rate n=31, 8.3% (Major complication rate: n=3, 0.81%). Non-union rate: n=11, 2.96% of which 3 required fixation (0.81%). Hip arthroscopy post PAO: n=7, 1.9%. Conversion to THR: n=4, 1.1%. Blood transfusion requirement: n=46, 12.5%. No patient developed a major neurovascular injury.

In this large single-centre study, patients had radiological and reported outcome improvements following surgery. Overall, there was a low complication rate, providing further evidence of the safety and efficacy of PAO for ameliorating pain and long-lasting results in the management of symptomatic hip dysplasia.

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.

The anterolateral MIS-THA approach can be divided into the Modified Watson-Jones approach (MWJ) performed in the lateral position and the Anterolateral Supine method (ALS) performed in the supine position. Femoral preparation is flexible in stem selection in the MWJ method. On the other hand, the ALS method is more stable for placement on the acetabular implant.

Now we introduce novel anterolateral MIS approach named AL60, it makes use of the merits of both MWJ and ALS methods.

First metatarsophalangeal joint (MTPJ) arthrodesis plays a significant role in the management of symptomatic hallux rigidus. Several open and very few percutaneous techniques have been described in the literature. The authors present a new minimally invasive technique along with patient reported outcome, radiological parameters and a discussion on this novel technique.

A total of fifteen cases of first MPTJ arthrodesis were included in this prospective continuous series from September 2011 to June 2012. Mean age was 56 years and the indication for surgery was hallux rigidus in 13 of 15 cases. All patients underwent the same minimally invasive procedure by the same primary surgeon (AHS), 13 of 15 as day cases. Clinical outcome and patient satisfaction were assessed by the Manchester-Oxford Foot Questionnaire (MOXFQ) preoperatively and at most recent follow up. Radiographic and clinical evaluation of fusion was also assessed. No patients were lost to follow up and all scores were collected by an independent surgical practitioner to avoid bias. Mean follow up was six months (range 1 to 9 months).

The MOXFQ score for cases where fusion was achieved (n=14) improved from a mean 40/64 preoperatively to a mean 15/64 at last follow up (p=0.001). Patient satisfaction was overall very good.

This minimally invasive technique for first MTPJ arthrodesis is simple and can achieve results similar or better than open techniques in experienced hands. Further cases are needed to expand this series and evaluate for further complications.

Background

Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years.

Unicompartmental knee arthroplasty has been in use since the 1970s. In spite of early enthusiasm, the procedure soon fell into disfavour, particularly in the USA. Early failures were a result of improper indication, poor technique and in some cases and poor prosthetic design.

A new instrument system for use with the MG unicompartmental knee arthroplasty has been designed, with guides for accurate and reproducible alignment, sizing and resection. Potential benefits include early mobilisation, rapid rehabilitation, improved range of motion and shortened hospital stay.

This paper briefly reviews the literature and discusses indications and surgical techniques.

Introduction

A new surgical approach for minimally invasive hip resurfacing is described with early results.

Introduction

The periacetabular osteotomy (PAO) improves hip joint mechanics in patients with symptomatic dysplasia. As a consequence of the multi-planar acetabular re-orientation, the course of the iliopsoas tendon over the hip may be affected, potentially resulting in iliopsoas tendon-related pain. At present, little information regarding the incidence of iliopsoas-related pathology following PAO exists.

We aimed to identify the incidence of iliopsoas-related pain following PAO. Secondarily, we aimed to identify any risk factors associated with this pathology.

minimally invasive surgery is a concept well known in medicine – In orhotpedic surgery the advent of arthroscopic techniques has given a dramatic change in clinical and surgical approach. Total knee replacement (TKR) is a well established procedure. Good result have been widely documented. Nevertheless wide surgical approach, the post op. pain, the lenght of hospitalization, the rehabilitation program are still long and heavy for the patient.

Minimally invasive procedure consist in a new way of approaching the surgical intervention in TKR, riducing the lenght of the incision, minimizing the soft tissue thrauma, sparing as much as possible the extensor mechanism. This new approach has brougt to a change also in instruments design.

This is a new technique and we don’t have statistically significative data. We rely upon data from authors like Tria and the clinic results of our cases

We can affirm that minimally invasive techniques in TKR permits a lower level of post op. pain and bleeding, shorter lenght of hospital admission time, faster rehabilitation

Mini-incision total hip arthroplasty seeks to eliminate some complications of traditional extensile exposure and also facilitates more rapid post-operative rehabilitation. Posterior approach has been associated with increased risk of posterior dislocation. Thus, a modified mini-incision lateral approach of Hardinge was described not only to overcome this problem by preserving the posterior capsule, but also allows adequate access for orientation of the implant. The author has modified the Hardinge approach by a V-shaped incision where the apex is centered over the tip of the greater trochanter with the one limb extending proximally along the fibers of the gluteus medius muscle and the distal limb extending across the proximal part of vastus lateralis. This innovative surgical approach is described in this article.

Minimally invasive total knee arthroplasty is growing in popularity. It appears to reduce blood loss, reduce hospital stay, improve post-operative quadriceps function and shorten post-operative recovery. We show our experience of minimally invasive TKA with a computer navigation system.

The first series compared forty MICA TKA and forty conventional computer assisted total knee arthroplasties (CATKA). Component positioning was assessed radiographically with long leg Maquet views. Knee Society Scores (KSS) were recorded pre-operatively and at 6, 12, 18 months. Length of stay and recovery of straight leg raise was also recorded. A second series of fifty MICATKA patients were assessed post-operatively for component alignment using long leg Maquet views. Twenty-two of these patients had assessment of femoral rotation using CT.

In the first series pre-operative KSS showed no significant difference between the two groups. Post-operatively the mean femoral component alignment was 89.7 degrees for MICATKA and 90.2 for CATKA. The mean tibial component alignment was 89.7 degrees for both. KSS at 6, 12, 18 months were statistically better in the MICATKA (p<000.1). Straight leg raise was achieved by day one in 93% of the MICATKA compared to 30% of the CATKA. Length of stay for MICATKA was a mean of 3.25 days with CATKA a mean of 6 days. In the second series the mean femoral component varus/valgus angle was 89.98 degrees, the mean tibial component varus/valgus angle was 89.91 degrees and the mean femoral component rotation was 0.6 degrees of external rotation.

MICATKA is a safe procedure with reproducible results. Alignment is equivalent to CATKA. It gives statistically significant improvement in KSS compared to the open procedure. The length of stay and time to straight leg raise are also reduced. At 2 years follow-up we have seen no revisions and no evidence of loosening radiographically.

We performed 82 primary unicompatental, medial knee replacements in patients under the age of 50, using a fixed bearing, metal backed tibial design and a conforming anatomic femoral component. Patients were followed prospectively for a minimum of 2 years (range, 24 to 48 months). All patients were rated both clinically and radiographically using Knee Society Scores, SF-36 and standard radiographic instruments. Patients also completed a validated questionnaire that examined activity level, functional outcomes and ability to return to sports.

Methods: The senior author performed all procedures using a minimally invasive technique with subvastus approach to the medial aspect of the joint. Inclusion criteria were patients under 50 with documented, medial compartment osteoarthritis and a retained ACL. All patients received the same fixed bearing, metal backed design implanted with cement. All patients had osteophytes removed from the medial border of the patella if present.

Results: At last follow up, the mean Knee Society functional score was 96. There was one early infection that was converted to a total knee replacement without further complication. There were no fractures, thromboembolic events or other major complications in this group. Patients reported excellent pain relief and few activity limitations. There was no loss of radiographic alignment or signs of loosening on the most recent radiographs.

Conclusion: Unicompartmental medial knee arthroplasty in a younger patient population can be performed with excellent results. Functional outcomes were superior to total knee replacement designs previously reported in this patient population. The authors can recommend this design in younger patients with medial osteoarthritis that is resistant to non-operative treatment, but full evaluation of this prosthesis will require longer-term results.

Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard of care provides open reduction and internal fixation (ORIF) through differentiated surgical approaches which have been associated with relatively high complications rate such as haematomas, superficial and deep infection, and neuro-vascular lesions. Moreover these procedures need long operative times with significant blood loss. To avoid these general and local complications, that sometimes compromise the functional outcome of the operation and the possibility to perform a future arthroplasty, some authors advocated a minimally invasive percutaneous osteosynthesis (MIPO). This approach can also be considered a valid alternative to ORIF in all those cases in which the standard approaches are contraindicated as in open fractures, comminuted fractures in osteoporotic patients or fractures in high risk patients.

Between 2001 and 2006 we performed MIPO techniques for acetabular fractures in 15 patients; the reduction has been evaluated with fluoroscopy during the operation and with CT after the operative procedure. In almost all the cases the reduction has been achieved and maintained using an ileo-femoral external fixator according to the ligamentotaxis technique. The frame is applied in distraction bridging the joint from the contra-lateral iliac wing to the omolateral femoral shaft associating whenever possible percutaneous cannulated 4 mm. screws to optimise the reduction and obtain fragment fixation. The fixator is left in place from a minimum of 20 days to a maximum of 40 days in relation to the comminution of the fracture and/or the quality of the bone.

Following this strategy is possible to achieve good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. According to the radiological and clinical results obtained the best reduction can be achieved when the treatment is carried out early and the best stability when we associate to the fixator 1 or 2 cannulated screws. The use of external fixation has never compromised the range of movement of the knee (secondary to quadriceps transfixion) and we have never had deep infection related to pin tract problems in the 3 to 6 weeks treatment period.

Total knee arthroplasty (TKA) has evolved over the past 40 years to a point where it now is a routine treatment with fairly predictable outcomes. However, TKA is an end-stage treatment which frequently is used when only one or two compartments in the knee are damaged. Ideally, treatments for earlier stage and isolated disease would be available to provide the same high level of outcome predictability, but provide for isolated treatment of the affected compartments, greater levels of postoperative physical activity and the shorter convalescence demanded by younger, more active, and often employed patients. One approach to a compartment-by-compartment treatment regime is the utilization of discrete condylar unicompartmental prostheses and a patellofemoral prosthesis in any combination. This approach has been practiced in some European clinics for decades with good reported outcomes. However, it remains a major surgical challenge to optimally place multiple discrete arthroplasty components using conventional tools and small incisions. This lecture will present a detailed overview of a unified approach to minimally invasive, modular knee arthroplasty using haptic robotic instrumentation and implants designed specifically for robotic installation in a customized modular treatment regime.

Haptic robotics provide a ‘virtual cutting guide’ capability permitting precise sculpturing of bone surfaces using near-zero-visibility minimally invasive incisions. The use of a single-multifunctional tool eliminates many of the instrument trays commonly needed for these procedures. The surgeon has complete control in manipulating the bone cutting tool within the desired bone-removal area, but the haptic robotics prohibit the cutting tool from removing bone outside the planned bone removal volume. Precise bone sculpturing has the potential to minimize bone removal and optimize the alignment and fixation of the prosthetic components.

Haptic robotic cutting tools obviously can be used with off-the-shelf prosthetic components, but this approach would fail to fully take advantage of the precision surfaces that can be achieved using robot assisted bone sculpting. Instead, a purpose built system of modular knee components can be defined that work in any combination (medial or lateral unicompartmental, bi-unicondylar, medial or lateral plus patellofemoral, or tricompartmental), require minimum bone removal, can be placed through very small incisions, give great flexibility to customize implant placement to fit the patient’s anatomy, and take advantage of the types of fixation features which easily are created with a robotically controlled bone cutting device.

The current treatment implementation and implant design will be presented. Clinical results for unicompartmental procedures and in vitro results for multiple-compartment procedures will be presented and discussed.

Short scarf osteotomy (SSO) retains the versatility of standard scarf in treating moderate and severe hallux valgus deformity with the added benefit of less invasiveness translated into less soft-tissue stripping, reduced exposure, less metalwork, less operative time and reduced cost. We present our medium-term clinical, radiographic and patient satisfaction results.

All patients who underwent SSO between January 2015 and December 2017 were eligible (98). Exclusion criteria were: follow up less than a year, additional 1st ray procedures, inflammatory arthropathy, infection, peripheral vascular disease and hallux rigidus. Eighty-four patients (94 feet) were included: 80 females / 4 males with average age of 51-year-old (24–81). Minimum follow up was 12 months (12–28). Weight-bearing x-rays and AOFAS score were compared pre- and postoperatively. Non-parametric Mann-Whitney U test assessed statistical significance of our results.

Hallux valgus angle (HVA) improved from preoperative mean of 30.8° (17.4°–46.8°) to 12° (4°–30°) postoperatively (p=0.0001). Intermetatarsal angle (IMA) improved from preoperative mean of 15.1° (10.3°–21.1°) to 7.1° (4°–15.1°) postoperatively (p=0.0001). Average sesamoid coverage according to Reynold's tibial sesamoid position improved from average grade 2.18 (1–3) to 0.57 (0–2) (p=0.0001). Average AOFAS score improved from 51.26 (32–88) to 91.1 (72–100) (p=0.0001). Ninety percent of patients were satisfied and 83% wound recommend the surgery. No troughing phenomenon or fractures. Four overcorrections were found 3 of which did not require surgery. One recurrence at 18 months was treated with standard scarf.

We believe that this technique offers a safer, quicker and equally versatile way of dealing with Hallux Valgus.

There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach.

This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterized as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals.

A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years.

Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.

Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard approach provides open reduction and internal fixation (O.R.I.F.) through a variety of surgical approaches which have been associated with relatively high complications rate such as haematomas, deep infection, and neuro-vascular lesions. These procedures need long operative times with significant blood loss.

Many authors have demonstrated the feasibility of closed reduction and percutaneous fixation (C.R.P.F.) for minimally or non displaced acetabular fractures; this technique can be considered a valid alternative to O.RI. F. in order to decrease the morbidity related to surgical approaches.

Between 2001 and 2006 we performed C.R.P.F. for acetabular fractures in 15 patients; the reduction has been controlled with fluoroscopy during the operation and with CT scan after the operative procedure. The osteosinthesis has been performed with cannulated screws and In more complex cases the reduction has been achieved and maintained with ileo-femoral external fixation (ligamentotaxis technique).

Fractures were classified according to AO classification. Clinical and functional results have been evaluated according to Harris Hip Score on the base of post-operative CT scan and on x-ray films at last follow-up.

According to our experience the use of external fixation in the treatment of acetabular fractures must be reserved for very selected cases in which for general or local condition the joint the distraction associated with minimal internal fixation can guarantee good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. The best reduction can be achieved when the treatment is carried out early while the best stability is achieved with the association of percutaneous cannulated screws. The use of external fixation has never compromised the range of movement of the hip.

Purpose of the study: The aim of this work was to study the functional and radiological results as well as any complications obtained after minimally invasive treatment of bimalleolar fractures.

Material and methods: The series included 100 fractures in 100 patients who underwent surgery between 1998 and 2000: 52 men and 48 women, mean age 47.1 years (range 17–96 years). According to the AO classification, the fractures were A:18, B:62, C:20. Osteosynthesis of the lateral malleolus was achieved with a Rush nail in 95 cases and with a K-wire in six. Closed osteosynthe-sis was achieved in 67 cases, an open procedure being used for 33 cases. Osteosynthesis was performed on the medial malleolus in 73 patients, 65 with a 3.5-mm screw, a K-wire for five, and a tutor-wire in two, all during an open procedure. The functional outcome was assessed at last follow-up using the Olerund and MOlander and the AOFAS scores.

Results: Mean follow-up was thirteen months (range 3–54 months). All fractures healed at mean eight weeks (range 6–24 weeks). At last follow-up, 90 ankles were radiographically anatomic. Mean function scores were: Olerund and Molander 73.5/90; AOFAS 85.8/100. Clinical outcome (Olerund and Molander) was excellent or good in 86 patients, poor in 12 and very poor in two. According to the AOFAS score, clinical outcome was excellent or good in 90 patients, poor in 9 and very poor in one. Considered by gender and type of reduction of the lateral malleolus, there was no difference in the distribution of the clinical outcome. There was however a strong correlation between the quality of the anatomic result and the functional outcome since poor anatomic results gave poor functional results in 80% of cases. The type of anatomic fracture had a certain importance since excellent and good results were obtained for type A fractures (94%) and type C fractures (90%) but 70% of the poor results were observed in type B fractures. There were few complications: two superficial infections, four cases of reflex dystrophy, and one thromboembolic event.

Conclusion: Compared with other operative techniques, the advantages of this method are basically linked to the ability to respond to all the different forms of bimalleo-lar fracture, irrespective of the anatomic type. The operative protocol is well established. The procedure is easy to perform and rapid and provides excellent results.

Introduction

Rapid recovery protocols after joint replacement have been implemented widely to decrease hospital length of stay (LOS). Minimally-invasive total knee arthroplasty (MIS-TKA) may facilitate rapid recovery for patients. Increased complications and LOS have been documented in morbidly obese TKA patients. The objective of the current study was to retrospectively evaluate the impact of morbid obesity on MIS-TKA patients.

Introduction: Increasing experiences in determining the indication for UKA and improvements in design and materials of the prosthesis led to better results. The AMC-Uniglide has an unconstrained mobile bearing with congruent area contact. This ensures complete freedom to rotate and slide upon one other with physiologic kinematic and low intrinsic stability.

Material and Methods:

Minimal-invasive technique 30 patients with minimal-invasive AMC-Uniglide implantation technique were compared with 30 conventional implanted AMC’s and 30 total knee replacements in regard to rehabilitation and accuracy of implantation.

361AMC-Uniglides 361 consecutive patients were investigated after AMC-Uniglide implantation. The mean duration of follow-up was 5.5 (2.3-12.5) years. Patients were reviewed using the American Knee Society Rating System. The roentgenographic analyses were performed with the American Knee Society Evaluation System.

Results:

Minimal-invasive technique The comparison of 30 minimal-invasive UKA with 30 conventional UKA and 30 total knee replacements show an advantage of minimal invasive technique with regard to a reduced time of rehabilitation. The accuracy of implantation was comparable between the conventional and the minimal-invasive technique.

361 AMC-Uniglides Ninety-five percent of patients had no pain or slight pain at the latest follow-up, ninety-two percent had good or excellent clinical outcome. Three knees were revised for mobile bearing dislocation after medial UCA and three for lateral mobile bearing dislocation after lateral UCA. Five revisions because of component loosening were performed and there was one case of deep infection.

Conclusion: The clinical results of the investigated patients demonstrate that the AMC-Uniglide is a successful concept with a safe anchorage of the prosthesis and a good durability of the mobile bearings. An advantage of minimal invasive technique with regard to a reduced time of rehabilitation was found. The accuracy of implantation was comparable between the conventional and the minimal-invasive technique.

Purpose

Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury.

In orthopaedic spine surgery pedicle screw systems are used for stabilisation of the spine after injuries or disorders. With an percutaneous operation method surgeons are faced with huge challenges compared to an open surgery, but it's less traumatic and the patient benefits with a faster rehabilitation and less traumatic injuries. The screw positions and the required rod dimensions for the stabilising connection between the screws are hard to define without an open view on the operating field. Because of these facts a new smart device based system for rod shape determination was invented. Therefore, an application was developed, which integrates a localiser module to get the position data of the pedicle screws, with help of rigid bodies placed on top of the pedicle screws down-tubes. An algorithm was developed to choose the best fitting rod to connect the pedicle screws with help of calculating the rod length and the rod radius. The system was tested in a test scenario where four pedicle screws were drilled into a wooden plate. The positions of the screws were adjusted to fit a curved and a straight rod. In the test scenario the application chose always the rod correctly.

Introduction THR is a successful procedure with excellent long term results. With many patients requiring the procedure there is some advantage in rapid recovery and early discharge. This may require a change in the surgical approach and peri-operative management. We report the first series of a new minimally invasive surgical approach for THR.

Methods A two incision approach for THR has been developed after extensive cadaver tests. This consists of an anterior muscle splitting incision to insert the cup and a posterior incision for the stem insertion. The authors have undergone cadaver training and clinical surgery before embarking on clinical trials. Patients included in this study are those people awaiting THR who were selected for a cementless prothesis and who would benefit from early rehabilitation. Patients with previous surgery, hip dysplasia and significant obesity were excluded. An initial study group are presented with an average age of 59, average height 168 cms and average weight 71 kg.

Results Average length of stay was 3.7 days with an average operative time of 90 minutes. Average blood loss 505 mls with an average blood usage of 1.1 units. Early complications include lateral cutaneous nerve of thigh palsy (50% resolution at three months), two stable trochanter fractures, one infection and one anterior dislocation at eight weeks with a ceramic implant.

Conclusions The approach is technically difficult and initially time consuming. It does enable quicker mobilisation and appears to result in less need for analgesia post-operatively. We believe it is important to present the early results so the technique can be discussed and potential problems avoided. A randomised, prospective trial with clinical and RSA follow-up is underway.

This paper reports the authors’ experience of over 850 unicompartmental knee replacements beginning in 1985 with the MG2 uni and then the LCS uni in 1995, and more recently with the Allegretto, Oxford and PFC minimally invasive uni.

Minimally invasive unicompartmental knee arthroplasty (MIU) offers the knee arthritis patient significant benefits compared with total knee arthroplasty. Some of these are especially important for Asian patients, in particular range of movement and ability to squat.

The ideal indications for the MIU are not yet fully established but are becoming clearer. Contraindications are also clearer.

These issues will be discussed in detail. The results in 100 cases of unicompartmental arthroplasty will be presented and discussed along with the complications in these patients. Special considerations and recommendations for the commencement of MIU will also be discussed.

This recent and popular procedure also presents the knee surgeon with significant challenges. However, there are also disadvantages which will be outlined.

The surgical technique of the MIU will be shown in detail. The paper closes on a brief discussion into recent developments by an 8 member international group of knee surgeons of a new MIU offering a choice of fixed or mobile bearing MIU, with precise instrumentation of both the femoral and tibial sides, and the early result of the first 18 procedures in 15 patients (3 bilateral).

Introduction: Satisfactory ten-year survival statistics from the Swedish Arthroplasty Register, combined with new minimally-invasive surgical implantation techniques, have seen a resurgence in interest in unicompartmental knee arthroplasty (UKA).

Aim: To compare unicompartmental component positioning following minimally invasive and open implantation.

Methods: The radiographs of patients with UKAs implanted using a minimally invasive technique were retrospectively compared with a similar number of UKAs implanted using an open technique. Optimal component positioning and methods of determining this from radiographs will be presented.

Results: Twenty-three consecutive Ripicci UKAs (21 patients) were implanted using a minimally invasive technique. Radiographs were compared with an equivalent number of Marmor UKAs implanted using an open technique. All patients derived from a single surgeon’s practice. Preliminary results indicated that tibial tray positioning was satisfactory, and that variations in the femoral component positioning were due largely to the design modifications of the Ripicci UKA.

Unicompartment knee arthroplasty (UKA) was proven to be one of the standard treatments of medial compartment osteoarthritis. The key to success was restoration of pre-operative alignment. Overcorrection of coronal (AP) alignment may predispose to early osteoarthritis in the contralateral compartment, change in post-operative tibial slope may predispose to proximal tibial bone collapse and loosening of tibial prosthesis. Minimally invasive surgery (MIS) in UKA was developed quickly in the last ten years. However, MIS has limited access to visualize the surgical field and limb alignment. Computer navigation may help the surgeon to place the component in more accurate position. We aim to study the radiological alignment of computer assisted MIS UKA.

Eighteen patients with UKA (PreservationTM, all poly tibia, DePuy Orthopaedics Inc, Warsaw, IN) implanted using MIS technique were studied prospectively. The CiTM system (DePuy International Ltd, Warsaw IN) were used for computer navigation. Five male and 13 female patients were studied. The mean age of the patients was 58.2 (range, 45 to 70). All patients had medial compartment osteoarthritis with varus deformity. The postoperative coronal (AP) alignment and tibial slope of the operated limb were compared with the pre-operative alignment for any significant difference.

The mean pre-operative and post-operative radiographic coronal (AP) alignment of the operated limb were 8.4° varus (range, 2° to 12°) and 7.2° varus (range, 1° to 15°) respectively, the difference was not significant (p = 0.537). The mean pre-operative and post-operative tibial slope were 6.8° (range, 3° to 11°) and 5.8° (range, 3° to 10°) respectively, the difference was not significant (p = 0.066). The post-operative tibial slope correlated well with the intra-operative tibial slope recorded by computer after bone cut was made (Cronbach’s Alpha = 0.771). The mean tourniquet time was 124 minutes (range, 94 to 140 minutes).

There was no significant difference in pre-operative and post-operative coronal alignment of the operated limb. Computer assisted MIS UKA could reproduce the pre-operative coronal alignment and tibial slope. Restoration of the pre-operative limb alignment in coronal plane and tibial slope was crucial to the survival of UKA. Computer navigation could help the surgeon to position the component during minimally invasive surgery. However, the learning curve of computer assisted MIS UKA was steep.

PURPOSE

To validate the efficacy and accuracy of a novel patient specific guide (PSG) and instrumentation system that enables minimally invasive (MI) short stemmed total shoulder arthroplasty (TSA).

Background

In this study, we investigated the long-term clinical results and survivorship of minimally invasive unicompartmental knee arthroplasty (UKA) by collecting cases that have been implanted for >10 years ago.

Purpose

The minimally invasive surgery (MIS) approach has been popularised as an alternative to the standard open approach in acute Achilles tendon ruptures. Advocates of this technique suggest earlier functional recovery, due to less injury to the surrounding tissues. However, the critics argue that due to the reduced exposure risk and complications of such surgery are higher in comparison to the open technique.

About ten years ago we introduced sophisticated instrumentation and an increased range of component sizes for the Oxford unicompartmental knee replacement (UKR) to facilitate a minimally invasive surgical (MIS) approach. The device is now routinely implanted through an incision from the medial pole of the patella to the tibial tuberosity. This has resulted in a more rapid recovery and an improved functional result. As the access to the knee is limited there is a concern that the long term results may be compromised. The aim of this study was to determine the 10 year survival.

A prospective follow up of all Phase 3 minimally invasive Oxford UKR implanted by two senior authors (DWM & CAFD) has been undertaken. So far 1015 UKRs have been implanted for anteromedial osteoarthritis. All patients received a cemented implant through a MIS approach and were followed up prospectively by an independent observer. The data was collected prospectively regarding pre-operative status, complications and clinical as well as functional outcome at predetermined intervals.

The average age of patients was 66.4 years (range: 33 – 88) with mean Oxford Knee Score 41 (SD: 7.9) at the time of last follow up, Knee Society Score (objective) of 84 (SD: 13) and Knee Society Score (functional) of 83 (SD: 21). At ten years the survival of this cohort is 96%. There were 22 revisions including 7 for progression of arthritis, 5 for infection, 5 for bearing dislocation, 4 for unexplained pain and one for rupture of ACL secondary to trauma.

We conclude that the Oxford Knee can be implanted reliably through a minimally invasive approach, giving excellent long term results.

The two-incision technique uses strategically located incisions to insert the prosthesis components in to specific intermuscular or internervous planes in an effort to minimize damage to these tissues. Even though there are many reports about safety and benefits of bilateral simultaneous total hip arthroplasty (THA), none of them has reported about either one-incision or two-incision bilateral simultaneous minimally invasive (MI) THA. This study aimed to assess the feasibility of bilateral simultaneous MI two-incision THA in terms of clinical, radiological and functional outcomes.

Sixty two patients, in the age of 24 to 69 years were operated for bilateral simultaneous THA using modified two-incision technique and followed for average 41 months. In the technique of two-incision THA described by Mears, they used modification of Smith Peterson approach for insertion of acetabular component and femoral component is inserted through a small incision situated between greater trochanter and iliac crest, centered directly in line with the femoral shaft. We modified this technique and used part of Watson Jones approach for insertion of acetabular component with patient in lateral position. The posterior incision for insertion of femoral component is through intermuscular interval between gluteus medius and piriformis.

The average Harris Hip score improved from 41.8 (range 10 to 59) preoperatively to 95.3 (range 73 to 100) postoperatively (P < 0.05). WOMAC score improved from median of 66.2 (range 31 to 96) preoperatively to 5.0 (range 0 to 19) postoperatively (P < 0.05). Forty-nine (79.03%) patients were pain-free at the time of first follow up (6 weeks after surgery) and remained pain-free till the last follow up, while remaining 13 (20.97%) had only slight pain. Out of those 13, 3 patients complained of occasional mild pain at last follow up. Fifty (80.64%) patients were walking without limp, while remaining 12 (19.35%) had only slight limp at 6 months. Out of those 12, 2 patients had persistent limp at final follow up. Fifty-eight (93.53%) patients were walking without support, 56 (90.32%) were able to walk unlimited distance and 55 (88.70%) were able to climb stairs without using a railing. Walking with walker was started on average 3.7 days (range 1 to14 days) and walking with crutches was started on average 10.3 days (range 1 to 49 days) postoperatively. Patients were able to walk without support on an average 48 days (range 14 to 120 days) and use stairs without support and without any discomfort on an average of 50 days (range 5 to 150 days). The average lateral opening angle of acetabulum was 40 ° and anteversion was 12 °. All femoral components were implanted in neutral to 5 ° valgus position. None of the femoral component showed subsidence of more than 3 mm. The filling of the femoral canal by the prosthesis was excellent in all cases. Post-operative periprosthetic fracture occurred in 2 patients and delayed infection occurred in 1 patient.

In conclusion, bilateral simultaneous two-incision minimally invasive THA gives satisfactory clinical and radiological results in comparison with conventional THA. It is safe in experienced hands, without any additional risk of complications. It provides excellent functional outcome and patient satisfaction.

Fractures of the proximal humerus can offer a difficult surgical challenge particularly if they occur in elderly patients and/or are a complex fracture configuration. Much of the morbidity of the surgery relates to the extensile delto-pectoral approach traditionally used for operative treatment of these fractures.

A minimally invasive technique for approaching these fractures has was developed using a proximal deltoid split approach at the anterior edge of the deltoid and sliding a precontoured proximal humeral locking plate submuscularly after provisional fracture reduction. This technique was tested in a cadaver model to identify “safe” and “at risk” holes in the plate for percutaneous fixation in relation to the axillary nerve.

A case series of eighteen patients who had surgery using this technique were reviewed. All patients achieved acceptable reductions and went on to unite without any signs of AVN or implant failure. One patient had a transient sensory disturbance in an axillary nerve distribution post op. One patient has asymptomatic fibrous union of the greater tuberosity.

Minimally invasive plate fixation using a lateral deltoid split approach is technically possible with excellent results. The danger zone around the axillary nerve has been identified and should be avoided with percutaneous fixation utilising this procedure. A jig to allow accurate MIPO fixation has been developed.

Objectives: The direct anterior approach (DAA) is a distal portion of Smith-Peterson approach to the hip joint. Independent from the length of skin incision, no muscular dissection has to be done for total hip arthroplasty (THA). We have developed minimally invasive THA using DAA on the standard surgical table. The purpose of this study is to present the clinical results of 162 THAs with this approach and to know whether DAA can be safely performed on a standard surgical table.

Patients and Methods: Between August in 2004 and June in 2006, 189 primary THAs in 167 patients were performed through DAA in our hospital. We excluded patients with severe developmental dysplasia (12 hips) and with previous hip surgery (7 hips). The severity of dysplasia was graded according to the Crowe classification. We excluded Crowe type 3 or 4 osteoarthritis which requires a modified procedure to cope with the difficult anatomic situation and a different rehabilitation protocol, although it was possible to perform THA with DAA. In order to assess the recovery rate and safety of a rapid rehabilitation protocol after surgery, we also excluded patients with walking disability of uninvolved lower limb (8 hips). Thus, the results included 162 hips in 149 patients (125 women and 24 men). They were followed for at least 3 months postoperatively. The mean age was 62.6 years. The mean BMI was 23.1. The preoperative diagnosis was osteoarthritis in 142 hips, avascular necrosis of the femoral head in 11 hips, femoral neck fracture in 7 hips and rapid destructive cox-arthrosis in 2 hips. In patients with osteoarthritis, 136 hips (95.7%) are secondary to developmental dysplasia (Crowe 1: 112 hips, Crowe 2: 24 hips). Only 5 hips (5.4%) were primary osteoarthritis. The Bicontact total hip stem was used in 135 hips, the CentPilar system in 21 hips and others in 6 hips.

Results: Mean surgical time was 70.1 (range: 45 to 150) minutes. Mean operative blood loss was 368 (range: 73 to 1053) ml. Patients were able to walk over 50 meters with T-cane an average of 4.7 (1~30) days after surgery. Complications included one cup migration, one traumatic dislocation, one transient femoral nerve palsy, one heterotopic ossification and one asymptomatic stem subsidence (4 mm) in the early period postoperatively. The cup migration occurred 1 month after surgery and required re-surgery through the same incision. The radiographic analysis showed a mean cup inclination of 42.1 ± 7.1 degrees and a mean anteversion angle of 16.9 ± 4.3 degrees. The femoral component coronal alignment was within 3 degrees of neutral position in 159 hips. Varus alignment of more than 3 degrees was found in 3 hips.

Conclusion: We confirmed that the direct anterior approach was a safe and reproducible technique on the standard surgical table and allowed the prosthesis to implant correctly with no muscular dissection and no risk of denervation.

Introduction: High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods: This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, post-operative pain and wound healing.

Results: The mean intra-operative blood loss in the ultrasonic scalpel group was 242mls compared with 319mls in the electrodiathermy group. This is statistically significant (p < 0.05). The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant (P< 0.01). There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion: The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma. The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

From 1980–2004 a total of 928 uni knees were performed using the link “St. Georg” and “Endo-Modell” as well as the “Allegretto” device. Our last follow up concerning the first group 1980–1984 revealed an average survival rate of more than 15 years for 94,6 % of the patients, including cases of 24 years without any complaints. Since 2001 the uni knee also was performed as 1-day-surgery in out-patients. Is there any benefit in comparison with In-patients having the same surgery?

Since 2001 53 patients got a uni knee as out-patients. Exclusion criteria: body overweight, cardio-respiratory disease, diabetes, coagulopathy, allergy, malposition of the patella and insufficiency to use crutches. Socially excluded were patients with deficits in emergency supply, home care, personal compliance, local rehabilitation network and insurance problems. Our standards of the surgical procedure: Tourniquet, no cutting guides, antibiotic single shot, general anaesthetica, cemented components, heparine, compression stockings and a controlphone in the evening. At the first ambulatory follow up the second day after surgery we changed the compression stockings after removal of the drainage and started physiotherapy with lymphatic drainage and a special movement splint for exercise at home 3hours/day.

X-ray results and clinical investigation did’nt show a siginificant difference between In- and Out-patients. Out-patients had an average postoperative stay at the unit of 4,7 hours. 24 patients left by wheelchair and 29 by crutches. 46 used a private car for the transport and 7 an ambulance. At the beginning we saw only two “out-patient-specific-complications” in form of drainage disconnections, however without any consequences for the patients. We got 17 emergendy calls because of postoperative pain within the first 28 hours.

The follow up comparison of In- and Out-patients performing minimally invasive unicondylar knee prosthesis did not reveal benefits for ambulatory surgery concerning blood loss, pain, recovery, infections, thrombosis, personal care and surgical procedure. Insurance savings, however, were tremendous: 3800,- EUR for general insured patients and 7900,- EUR for private insurance.

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 Minimally invasive lumbar discectomy using the METRx™ System (MAST discectomy) has been advocated as an alternative to open microdiscectomy for symptomatic posterolateral lumbar disc herniation. This paper presents a quality assurance dual surgeon retrospective study with independent observer minimum twelve month follow-up.

Methods This study was approved by the Ethics Committee of the Princess Alexandra Hospital prior to commencement. All patients who underwent MAST discectomy using the METRx™ System for the management of radiculopathy caused by posterolateral lumbar disc herniation under the care of two surgeons (AN and RK) more than twelve months prior to the commencement of assessment were included in the study. The patient demographic data was collected contemporaneously, operation performance data was collected retrospectively from hospital databases and outcome data was collected by telephone interview by independent observers (PL, SO and JP) a minimum of twelve months after discharge from hospital.

Results 101 patients (53 males, 48 females) (average age 43 years, range 17 to 83 years) underwent 102 procedures between July 2001 and December 2004. Surgery was performed on the right side in 63 cases and was either at L4/5 (30%) or more commonly L5/S1 (70%). 21 were public patients and 80 private patients with 59 episodes of surgery occurring in a public hospital. 46 operations were performed with the METRx™ MED System and 56 with the METRx™ MD System. The average duration of surgery for patients at the Princess Alexandra Hospital (n = 48) was 88 minutes with an average length of post-operative hospital stay of 22 hrs 35 mins. 16 of these cases were performed as day surgery. Perioperative complications were: conversion to open (3), urine retention (7), nausea and vomiting (3), durotomy (5), wound haematoma not requiring surgery (1) and incorrect level surgery identified and rectified during surgery (1). The average length of time from surgery to independent follow-up was 679 days (range: 382 to 1055) with 78% successful contact. On the Modified McNabb Outcome Scale, 83% reported an excellent or good outcome, 9% reported a fair outcome and 8% a poor outcome. The time until return to work was identified as less than two weeks in 28% and between 2 weeks and 3 months in 39%. Patients whose surgery was funded by Workers Compensation were over-represented in both the poor outcomes and delayed return to work. 4 patients reported progressive severe low back pain, 10 patients reported ongoing lower limb pain (severe in 1 and mild in 9) and 1 patient underwent surgery for a recurrent disc prolapse. Further disc prolapse at different sites was identified in five patients.

Discussion The retrospective data in this study forms class IV evidence for efficacy. As a quality assurance exercise it suggests an acceptable level of safety and efficacy to allow further technique development and study. A prospective randomized controlled study is proposed. The high incidence of urine retention early in the series of one surgeon is considered to be related to the practice of placing depot morphine in the operative bed. The reduction in complications in general and the improvement in duration of surgery over the series is evidence of the learning curve for this procedure.

Purpose: We use a minimally invasive surgical technique (MIS) when performing cementless total hip arthroplasty (THA). Because, it is difficult to put the implant correctly through the small incision, we have used a computed tomography (CT)-based navigation system navigation system since 2005. The current study is a preliminary report of the results.

Materials and Methods : We performed MIS-THA with an antero-lateral approach, in treating 10 osteoarthritis (OA) cases by navigated MIS-THA (Navi group) and compared them with the 10 OA cases treated without navigation (non-Navi group). Follow-up periods ranged from 6–9 months. All of the implants were AMS HA cup with a PerFix stem. The patient’s preoperative CT data in DICOM format was used in the work station for preoperative planning. Appropriate angle and the positions of cup and stem were decided preoperatively on the 3D model of pelvis and femur. The factors evaluated were operation time, blood loss, the inclination and the cup anteversion angle on post operative radiographs and CT images.

Results: The mean operation time and mean amount of blood loss were 110 minutes versus 80 minutes, and 417 ml versus 260 ml in the Navi and the non-Navi groups, respectively. The differences were significant. The differences between the planned and postoperative angles were lower in the Navi group than in the non-Navi group. However, the differences between the groups were not significant. There were no major complications, nerve palsy, or fracture in either group.

Conclusion: Our findings were similar to previous reports. The increase of operation time and the amount of blood loss were caused by lengthy registration and adjustments to the system. Although the navigation system increased implantation accuracy, improvements are necessary to reduce blood loss and operation time.

Introduction High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, postoperative pain and wound healing.

Results The mean intraoperative blood loss in the ultrasonic scalpel group was 156mls compared with 295mls in the electrodiathermy group. This is highly statistically significant. The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant. There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma.

Conclusion The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

The accuracy of component implantation is an important factor affecting long term results of unicompartmental knee replacement (UKR), particularly, since overcorrection of the leg axis has been associated with an inferior patients outcome. This problem is aggravated when using a minimally invasive approach with a limited view.

In a prospective study, two groups of 40 UKR each were operated either using a non-image-based navigation system or the conventional technique. Radiographic assessment of postoperative alignment was performed by postoperative long-leg coronal and lateral x-rays.

The results revealed a significant difference between the two groups in favour of navigation with regard to the mechanical axis, as well as the coronal femoral and tibial alignment. In the computer assisted group 38/40 (95%) of UKR were in a range of 4 Degree to 0 degree varus (mechanical axis) compared with 29/40 (72,5%) in the conventional group. There was no significant difference between the groups concerning postoperative range of motion, blood loss and pain score.

The only inconvenience was a lengthening of the operation time (20 min). Due to the limited exposure in minimal invasive unicompartmental TKA the navigation system is helpful in achieving a more precise component orientation. The danger of overcorrection is diminished by real time information about the leg axis at each step during the operation. This improvement could be related to a longer survival rate.

Aims: To determine the feasibility and short-term outcome after Total Hip Arthroplasty through a limited anterior approach.

Methods: Done between April 2003 and August 2004, 100 patients (102 hips) requiring primary total hip arthroplasty comprise this study. A modification of the Smith-Peterson anterior approach developed by Robert Judet was used requiring a special fracture table (Pro-Fx, OSI) but no unique surgical instruments. A single incision was used; the natural interval between the sartorius and rectus muscles medially and the tensor muscle laterally was developed. SL-Plus stems and Plus-MPF or Encore cups were used in all cases.

This series is entirely unselected: no patients were excluded because of size or body habitus. One third of the patients had a Body Mass Index greater than 30 (obese); the maximum BMI was 45.6. One third had type C bone and nearly one tenth were category 3 anesthetic risks. Average age was 72 (range 39 to 90). A naive definition of “minimally invasive” is met: the average incision length was 9.5 centimeters (range 6.5 to 13).

Result: Time for the surgical procedure reduced from three and one half hours for the first arthroplasty to 70 minutes between the 15th and 20th operation. Previously, hospital stay averaged over 5 days using a conventional posterior approach; average stay with the “minimal” approach was less than 3 days. Only 20% of these patients required an intermediate care facility prior to returning home.

There have been three complications requiring readmission: 1 dislocation, 1 unstable acetabulum, and 1 superficial wound breakdown. There has been a total of 3 dislocations-all within 4 days of surgery, none recurrent. One DVT has been detected.

Conclusions: The early experience, “learning curve” and technical complications of the modified Smith-Peterson anterior approach are emphasized. Given the consistently reported 95% to 98% success rate of conventional hip arthroplasty it is imperative to make any change with foresight and then to document the consequence of that change. Surgical technique should not absolutely dictate implant choice. This report sheds light on the very early result of a change only to the surgical approach to total hip arthroplasty.

Introduction and Aims: A number of ‘minimally invasive’ approaches have been described which are essentially a standard approach through a smaller incision: the term ‘mini-incision’ is more appropriate. We describe a new technique that is truly soft-tissue sparing and report our early results.

Method: Following Malchau’s principles we performed cadaver studies to familiarise ourselves with the approach before conducting a pilot study. The approach involves a 6–8cm oblique incision over the posterior aspect of the greater trochanter. Care is taken to preserve piriformis and gluteus maximus. Meticulous capsular repair is performed through drill holes into bone at the end of the procedure to reconstruct the posterior envelope. There are no restrictions to mobility post-op.

Patients were scored pre-operatively and followed up prospectively. The only special instruments required are two large curved Hohmann retractors and an angled cup introducer.

Results: One hundred and one consecutive routine primary total hip replacements were performed via the ‘piriformis-sparing minimally invasive approach’ by a single surgeon. Marked on-table stability was noted in all hips prior to capsular repair.

Forty-two percent of patients were male. Mean age was 68.9 years (42–90) and BMI 26 (14–39). Average operation time was 64.1 minutes and anaesthetic time 92.5 minutes. Mean fall in haemoglobin in the first 24 hours was 2.3g/dl. Mean incision length was 7.4cm.

Follow-up was a minimum of one year (range 12–29 months). There was a highly statistically significant improvement in WOMAC and SF-36 scores at three and 12 months post-operatively (p< 0.0001). Early medical complications occurred in 12 patients, including two superficial infections, all of which resolved. There were no peri-prosthetic fractures and importantly, no dislocations. There were two re-operations: one revision for cup displacement and one washout for deep infection.

Conclusion: We believe that the marked stability that we achieve on-table is only possible by sparing piriformis and careful capsular repair. As with all new procedures however, there is a learning curve for both surgeon and assistant. Preliminary results from our pilot study may be interpreted with guarded optimism.

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive (MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure

BACKGROUND & AIM

Most previous studies found that the rate of dislocation following primary THA was 2 to 3 % on average. It is expected that minimally invasive (MI) THA has fewer dislocations after surgery because it causes less muscle damage. To ascertain the risk factors of dislocation, we conducted a retrospective study of the occurrence of dislocation after MI-THA in Japanese patients.

There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach.

This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterised as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals.

A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years. There were no dislocations.

Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive(MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure.

Prospective study of 47 patients. 22 patients had MIS cheilectomy between March 2009 and September 2010. We compared the outcome with a matched group (25 patients) who had open cheilectomy. Functional outcome was assessed using the Manchester Oxford Foot and ankle questionnaire (MOXFQ). The MOXFQ is a validated 16-item, patient-generated questionnaire designed to be self-completed and used as an outcome measure for foot surgery. It comprises three domains foot pain, walking and standing problems and social interaction. Total score ranges from 0 (best score) to 64 (worst score). Patients completed preoperative and postoperative questionnaires. Patients’ satisfaction and complications were recorded.

In the MIS group, the median follow up was 11 months (4–23. The median preoperative MOXFQ score was 34/64(23) and the median postoperative score was 19/64 (p value <0.02) In the open group the median follow up was 17 months (9–27). The median preoperative MOXFQ score was 35/64 and the median postoperative score was 7.5/64 and this difference was statistically significant (<0.0001). There were three failures in the open group (Fusion) compared to none in the MIS.

MIS cheilectomy is an effective alternative procedure with satisfactory functional outcome and high patient satisfaction. Results are comparable to the standard open cheilectomy with a lower apparent failure rate. The results of our randomised controlled trial comparing MIS cheilectomy to open cheilectomy are awaited.

Nowdays bicompartmental arthritis of the knee in patients younger than 60 still remains a challenge for the orthopaedic surgeon. In these selected cases, the authors present their experience in performing a minimally invasive bi-unicompartmental knee replacement assisted by computer navigation.

From January to December 2003, the authors treated seven patients (seven knees) with bicompartmental arthritis of the knee. The mean age was 66 and in all the cases an arthritis deformity was present but with no ligament deficiency and a pain-free femur-patella joint. The Orhophilot (4.0 version) navigation system was used during the surgery to assist prosthesis placement. In all the cases a minimally invasive surgical approach was used (7- to 9-cm skin incision). The patients were assessed using a UKR dedicated outcome score (GIUM Score), pre-operatively and at the latest follow-up. Pre-operatively the mean GIUM score was 49.1 (range 26–63)

At the lastest follow-up the mean GIUM score was 80.2 (range :75–94). The average femoral-tibial angle was 179° (range 177°–181°). In all the cases a good ligament balancing was achieved using a computer-assisted spreader device. All the patients were satisfied and had returned to their previous occupation soon.

The authors underline how the computer navigation system supports ligament balancing and correct prosthesis alignment. They did not register any fracture of the tibial intercondylar eminence because of wrong balancing and incisions. They emphasise this truly minimally invasive surgical approach to the cure of knee arthritis, above all in young patients with post-traumatic deformities.

Purpose: Implantation of a unicompartmental knee pros-thesis (UKP) via a short incisiosn was proposed to improve rapid postoperative recovery. But it is known that long-term survival is highly dependent on implantation quality. The purpose of this study was to evaluate the influence of implantation quality assessed radiographically and that of rapid recovery after unicompartmental arthroplasty using the conventional or minimally invasive approach.

Material and methods: A continuous series of the first 25 cases of UKP implanted using the minimally invasive approach (group 1) was compared with a homogeneous group of matched knees in a series of 145 UKP implanted with the same approach as used for total knee arthroplasty (group 2). The groups were comparable for age, gender, weight, and height. The same medial cemented UKP with a metallic tibial base plate was implanted in both groups. Postoperative radiographic measures included the overall mechanical axis, the femoral and tibial implantation orientations, and the posterior tibial slope.

Results: There was no significantly different between groups 1 and 2 for mechanical axis (3.6° and 4.7° respectively), tibial implantation angle (87° and 88°), or posterior tibial slope (2.6° and 2°). The femoral implantation angle was also comparable (2.3° and 2.9°) with the exception of one knee (9°) in group 1. Hospital stay, use of crutches and resumed activity were significantly shorter in group 1. Blood loss (222 and 244 ml respectively), postoperative pain (visual analogue scale), and full flexion at one year were comparable between the groups.

Discussion: The basic difference between the two approaches is the absence of patellar eversion and rupture of the extensor system with the minimally invasive method. This probably explains the more rapid recovery of function and activity in this group. The one case of significant femoral deviation noted in this group points out the need for greater care in positioning the specific guides for the short incision approach. To evaluate the long-term results of UKP implanted with the minimally invasive approach, the same criteria for patient selection and prosthetic implantation should be used.

Introduction Minimally invasive total knee arthroplasty has gained interest among total joint surgeons across the USA. It remains, however, somewhat unclear how to define minimally invasive. Small incisions may be a focal point of the surgery, but unless one is performing “limited incision surgery”, the skin does not define minimalness. The techniques and instrumentation for performing a minimally invasive total knee arthroplasty are presented.

Methods The principles of a minimally invasive total knee arthroplasty procedure include: a small incision, a vastus-medialis split, mobilization of the patella without eversion, and the use of modified instruments that have been designed for use with standard implants. The implantation instruments are downsized versions of a standard system and are easily applied to the routine arthroplasty patient.

Results The mid-vastus split appears to protect the quadriceps’ function and promote early recovery relative to the more traditional para-patellar arthrotomy. By avoiding patellar eversion altogether or only everting for a limited period, in extension, at the end of the case, elongation of the quadriceps fibers is avoided. These two measures appear protective and may promote early muscle recruitment during the post-operative recovery phase. The miniaturization of the familiar easier. Early review of post-operative radiographs has not revealed detriment to implant positioning.

Conclusions While only developmental, this technique appears amenable to navigation systems that may further the minimalization by avoiding violation of the femoral and tibial canals. Minimally invasive total knee arthroplasty needs to be defined as a concept and as to what role it should play in a surgeon’s armamentarium. While in its infancy as a technique, the new instruments and refined surgical approach appear to allow rapid rehabilitation and patient satisfaction without sacrificing positioning or outcome.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

I consider the term ‘minimally invasive surgery’ (MIS) to represent a wide range of techniques directed at achieving a surgical objective with less collateral tissue damage. The surgeon choosing to employ such techniques may aspire to achieve improved or more consistent outcome for their patients but is this so? What are the complications? In certain areas of surgery the concept of MIS is well established (e.g. knee and ankle arthroscopy). In forefoot surgery the concept has been met with interest but also skepticism. Much of this skepticism pivots around concerns that the loss of direct vision (maintained in arthroscopic techniques) may increase the risk of complications. In other words, there is a concern that due to the loss of direct visualization (replaced by intra-operative xray imaging), any benefit that might arise from the less invasive technique of the operation will be negated by either poorer quality of surgical correction or higher risk of injury to adjacent structures. All surgery is associated with a degree of risk and in considering the complications specifically associated with MIS of the forefoot we must try to separate out those complications related to the specific MIS technique involved and those that are not. In other words, we need to identify whether the complication has occurred as a result of incorrect surgical planning (e.g. wrong choice of osteotomy/flaws in surgical objective), poor execution of the surgical technique, or as a result of the MIS instrumentation/equipment. I will discuss the above in relation to my experience of complications encountered whilst employing minimally invasive surgical techniques in the treatment of forefoot pathology over the last 2 years.

Introduction

We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals.

Aim

The aim of this study was to compare a single-incision minimally invasive (MI) posterior approach with a standard posterior approach in a double-blind prospective randomised controlled trial.

Introduction

Most Japanese patients who receive total hip arthroplasty (THA) are osteoarthritic and 70% have development dysplasia of the hip. Their stature is shorter than average and their sizes (acetabular cup and femoral stem) are smaller. The Taperloc Microplasty (BIOMET) is a short femoral stem. It was launched on July 2012 in Japan (extended on January 2013). It is essentially a shortened version of the Taperloc stem (35mm shorter than the standard stem).

Purpose

This study aims to report the radiological corrections achieved and complication profile of Peri-Acetabular Osteotomy (PAO) undertaken through the minimally invasive approach.

Patient Specific Instruments (PSIs) are becoming an increasingly common method to provide surgeons with assistance in accurately performing procedures; however, to our knowledge, these new instruments have only been applied to traditional, highly invasive surgical approaches. However, PSIs have the potential to decreased surgical invasiveness by reducing the surgeon's need to clearly visualise anatomical landmarks. Therefore, we designed and evaluated a novel PSI for minimally invasive shoulder arthroplasty.

The proposed minimally invasive approach prevents en face access to the articular surfaces and thus the PSI was designed to guide the accurate placement of a trans-humeral bone tunnel which would permit surgical steps to be conducted. To accurately create this tunnel and place a guide pin in the glenoid, the PSI was designed as a two sided guide that incorporates unique anatomical features from both bones, which would lock the two bones in a predefined pose relative to one another. Proper registration of the PSI is aided by the joint's passive compression force, which is not disrupted due to the soft tissue sparing approach. Once the bones are locked together, a guide pin could be passed through the humeral head – creating a bone tunnel to guide later humeral bone preparation – and into the glenoid to guide reaming and drilling. By designing the guide in this way, it is possible to avoid the need to perform surgical steps with a clear en face view.

The PSI was created by loading 3D reconstructed CT models of the humerus and scapula into a CAD package, aligning the desired humeral and scapular guide axes such that the bones' relative pose is fully defined, and finally constructing the guide itself between and around the articular surfaces, such that sufficient anatomical features are incorporated to provide complete physical registration with the bones. This PSI was subsequently customised, based on a cadaveric specimen and fabricated using a 3D printer. The PSI's usability and accuracy in achieving the pre-operative plan were then assessed using optical tracking and surface based registration procedure.

Results of the evaluation demonstrated that the designed PSI is capable of accurately registering the two bones to within 5mm and 14° of the intended pre-operative plan, while also effectively reducing the invasiveness of the surgical procedure. Therefore, this novel PSI may represent a new avenue to improve the clinical impact of CAOS systems, by achieving good surgical accuracy, but with a greatly reduced invasiveness.

Introduction and Objectives: During the last few years there has been a trend towards minimally invasive total knee replacement (TKR). The advantages described for minimally invasive surgery (MIS) are diverse; however, some disadvantages have also been described such as the difficulty of adequately calculating the dimensions of the components. Assessment of the tendency to use an undersized femoral component in MIS.

Materials and Methods: We studied two multi-center cohorts (Grupo Scorpio España and Grupo Scorpio-MIS España) of patients in whom the same model of prosthesis was implanted surgically, in one group using conventional techniques and in the other using minimally invasive surgery. Using conventional techniques, 371prostheses were implanted in 14 centers, and using MIS, 130 prostheses were implanted in 10 hospitals. The tibial component is easier to measure and has been used as a reference. We assessed the differences between femur and tibia size in both groups of patients, the conventional surgery group and the minimally invasive surgery group.

Results: Using this model of prosthesis, in the conventional group, 45% of the femur components were a size larger than the tibial components, whereas this was seen in 30% of the MIS group (p=0.001956). A smaller size femur component was implanted in the same percentage of cases in both groups (6%). No differences were seen based on the group body mass index.

Discussion and Conclusions: With the data from this multicentric study, in which the same model of prosthesis was used, we confirmed, by means of a significant difference, that there is a tendency to use an undersized femoral component in MIS in comparison with conventional surgery procedures.

Introduction and Objectives: Our aim was to study the clinical and work-related results of minimally invasive athrodesis in the treatment of severe calcaneus fractures.

Materials and Methods: A total of 50 fractures (42 patients) with intraarticular calcaneus fractures were treated by means of a minimally invasive primary arthrodesis using the VIRA^® (Biomet, Valencia, Spain) system with a minimum follow-up of 12 months and a mean follow-up of 21 months. Mean age was 41 years of age. Eight procedures were bilateral and 3 open. According to Sanders classification 74% were type IV. We performed a prospective study with clinical and radiographic assessment (AOFAS scale) 12 months after surgery.

Results: The mean AOFAS score was 76.6 points (SD: 13.97): 26% were very good, 62% good and 12% fair to poor. There was no statistical variation of AOFAS in Sanders type of fracture, whether or not the lesion was bilateral and whether or not there was an associated lesion. We found an association (p=0.06) between the AOFAS score and the previous health status of the patient. Böhler’s angle improved slightly, although significantly (p=0.05), and there was seen to be correspondence with the postoperative AOFAS scale. Subtalar arthrodesis was achieved in 48 cases (96%) at 3 months.

Discussion and Conclusions: Primary arthrodesis using minimally invasive systems is a valid option for the surgical treatment of severe fractures of the calcaneus. It provides good clinical and radiological outcomes with minimally aggressive surgery and a low complication rate.

[Introduction]

One of the modern design total knee arthroplasty (TKA) system, the NexGen Legacy posterior-stabilized (LPS) Flex prosthesis, has been in use at our hospital since 2001. Between 2006 and 2011, NexGen LPS-Flex primary TKA were mainly performed in combination with a cemented short-keeled minimally invasive version tibial tray (MIS tibial component) instead of the traditional NexGen stemmed tibial tray. We observed some cases required early revision of isolated tibial component in primary TKA performed in this period. Therefore, our objectives were to report the series of this revision cases and to consider this failure mechanism.

Despite initial enthusiasm for minimally invasive total hip replacements (THR), there has been a marked paucity of level 1 evidence studies assessing it.

100 patients fulfilling the inclusion criteria were randomised in theatre to a standard posterior or muscle-sparing short incision (MIS) approach. A hybrid hip replacement was used routinely. Post-operative management was the same. Follow-up occurred at 2, 6 and 12 weeks. Patients, as well as functional and radiographic assessors were blinded.

50 patients were recruited to each group. There was no difference in demographics Mean incision length was 12.8cm and 19.1cm respectively. There was no statistically significant difference in operation time, post-op functional recovery (ILOA score) or length of stay. Pain (VAS) was similar post-operatively, and at 6 and 12 weeks. There was no significant difference in 10 metre walking speed or 6 minute walking distance at 2, 6 or 12 weeks; nor was there a difference in Oxford hip score, patient satisfaction with surgery (VAS), or SF-12 score at 6 or 12 weeks. Blood loss, fall in haematocrit, transfusion rate and CRP rise were similar. There was no significant difference in cementation of the stem (Barrack) or cup position (Dorr). There was one death from PE in the MIS group and one deep infection in the standard group. There was one dislocation in the standard group. The only statistical difference between the groups was less dependence on walking aids at 2 and 6 weeks in the MIS group; there was no difference at 12 weeks.

MIS surgery is safe, and may allow earlier independent mobility after THR. However, the claims of significantly reduced pain, less morbidity, better function and improved patient satisfaction appear to be unfounded.

The purpose of this study was to determine the complications after Bernese periacetabular osteomy (PAO) performed by one experienced surgeon using a minimally invasive modified Smith-Petersen approach.

Between May 2012 and December 2015, 224 periacetabular osteotomies (PAO) in 201 patients were performed. The perioperative complications were retrospectively reviewed after reviewing clinical notes and radiographs. The mean age was 28.8 years with 179 females and 22 males. The most common diagnosis was acetabular dysplasia with some cases of retroversion. The average lateral centre edge (LCE) angle was 16.5°(−18–45) and mean acetabular index (AI) 16.79° (−3–50).

Postoperatively the mean LCE angle was 33.1°(20–51.3) and mean AI 3.0°

(−13.5–16.6). There were no deep infections, no major nerve or vascular injuries and only one allogenic blood transfusion.

Nine superficial wound infections required oral antibiotics and two wounds needed a surgical debridement. There was one pulmonary embolus and one deep vein thrombosis. Nine (4%) cases underwent a subsequent hip arthroscopy and three (1.3%) PAO's were converted to a total hip arthroplasty after a mean follow-up of 22 months (3–50).

Lateral femoral cutaneous nerve dysaesthesia was noted in 64 (28.6%) PAO's. In 55 (24.5%) an iliopsoas injection of local anaesthetic and steroid for persistent iliopsoas irritation during the recovery phase was given.

The minimally invasive modified Smith-Petersen approach is suitable to perform a Bernese periacetabular osteotomy with a low perioperative complication rate. Persistent pain related to iliopsoas is a not uncommon finding and perhaps under-reported in the literature.

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.

Introduction

The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery.

Aim

This study presents the early results of a novel procedure, both in timing and surgical technique, aimed to treat those cases of congenital hip dysplasia that present late or fail conservative treatment.

We present a prospective, randomised, single-centre, multi-surgeon, controlled trial comparing minimally invasive (MIS) and standard approach total knee arthroplasty (TKA).

86 patients undergoing 92 total knee replacements were recruited. 46 operations were randomised to the MIS treatment arm, 46 to the standard control arm. Data collected included postoperative blood loss, length of stay and complications. Patients underwent surgery via a quadriceps sparing or standard medial parapatella approach. All operations were performed using MIS instruments and an identical postoperative care pathway.

The MIS group had a significantly shorter length of stay (1.4 days, p=0.004) and fewer complications (p=0.003). Demographics, operative time blood loss and radiographic alignment were comparable between the groups. There were no deaths, pulmonary emboli or surgical site infections. 1 patient developed DVT and 1 required revision for pain and failure to regain flexion within 9 months of surgery, both in the control group. Nine percent of MIS patients versus 35% controls suffered a complication delaying discharge, of which 2% and 17% related to surgical site problems respectively.

MIS resulted in a shorter admission and fewer complications, whilst achieving satisfactory component alignment. We discuss the potential economic implications.

Objective: To critically appraise the use of hindfoot nailing as an alternative treatment for fragility fractures of the ankle.

Summary of background data: Ankle fractures are common. The peak incidence now lies in women between the ages of 75 and 84. These fractures are inherently unstable and it is known that anatomical reduction and stable fixation leads to a rapid return of function. Although this is usually achieved by open reduction and plate and screw fixation, in older patients poor bone quality and compromised wound healing can lead to unacceptably high complication rates. Conservative management of these patients also has its problems with anatomical congruity being difficult to achieve and maintain.

Method: We reviewed 13 patients who underwent minimally invasive intramedullary nailing to fuse the tibiotalocalcaneal joint as primary or revision treatment for an ankle fracture. Olerud and Molander Scale, and SF36 were used as outcome measures.

Results: There were 12 females and 1 male with a mean age of 81.5 (range 64 to 93). One nail was revised after 22 days due to valgus deformity and one patient suffered a minor wound (breakdown / infection). Half of the patients were discharged in the first two weeks after the operation. They all achieved pain free full weight bearing on the fractured ankle and gained a comparable function to their pre-operative state. The mean follow up period was 9 months (range of 2 – 62 months).

Conclusion: Minimally invasive tibiotalocalcaneal fusion is a very useful and successful way of restoring function following a fragility fracture of the ankle. We recommend its use in the cases of fragility fracture of the ankle with poor soft tissue.

Introduction We believe minimally invasive surgery should be defined by the extent of soft tissue dissection rather than incision length. We describe a new technique that is truly soft-tissue sparing and report our early results.

The surgical approach The landmarks for the incision are identified and an incision is made over the posterior aspect of the greater trochanter. Piriformis is preserved. A capsular repair is performed through drill holes into bone. There are no restrictions to mobility. No specialised instruments are required.

Method The standard posterior approach (group 1) was compared with the PSMI approach (group 2) in a prospective cohort study of 200 consecutive patients over 60 years of age. Patients were scored pre-operatively and followed up prospectively, by a blinded observer.

Results Mean operation time was about 1 hour in both groups. Mean incision length was 21.5 cm in group 1 and 8.4cm in group 2. Mean blood loss in group 1 was significantly higher than group 2 (P< 0.0001). Mean inpatient stay was significantly higher in group 2 (P< 0.0001).

Minimum follow-up was 3 years in group 1 and 1.5 years in group 2. There were 3 dislocations in group 1, and none in group 2. There were 2 re-operations in both groups. The relative improvement in WOMAC scores was significantly greater in group 2 at 3 months and 1 year (P< 0.05).

Conclusion: This is the first study to suggest the benefits of minimally invasive surgery may be prolonged. Cosmesis is a by-product rather than primary objective.

Introduction and aim: In order to harness existing surgical skill and expertise of the operator trained in conventional total hip arthroplasty (THA) it would be advantageous to adopt a mini-incision surgery (MIS) THA technique that is similar. It would also make economic sense for MIS THA to be performed using existing conventional instrumentation available in every elective orthopaedic unit. The aim of this retrospective comparative study was to verify safety, efficacy and durability of this MIS THA technique via a modified anterolateral approach developed in our hospital by the senior author. This technique utilises standard instrumentation and does not require the use of an image intensifier.

Materials and Methods: The implants used in the study were the SL-Plus (Plus Endoprothetik AG, CH-Rotkreuz) and the EPF cup (Plus Endoprothetik AG, CH-Rotkreuz). We report on our experience of a consecutive series of 111 patients operated for osteoarthritis of the hip joint.

Results: Fifty-nine patients (53.2%) were implanted using MIS technique; the remainder (52 cases, 46.8%) were operated using conventional THA via traditional anterolateral approach. In patients undergoing MIS technique a skin incision averaging 8 cm (range 7.5 to 9 cm) was made over the greater trochanter with two thirds lying superior to its tip. The surgical procedure lasted forty minutes on average, and no excessive retraction was needed. The small incision can be extended with ease if access proves difficult, but this proved unnecessary in any of our cases.

The mean follow-up for the MIS THA group was 22.9 months compared to 33.1 months for the conventional THA group. All our MIS patients had less postoperative blood loss, needed less post operative painkillers, and mobilised earlier. There was however no significant difference in the duration of postoperative hospital stay between the two patient groups. We have had no incidence of dislocation and continue to use this technique during routine THA.

Discussion and conclusion: A review of the MIS THA literature is provided to compare this technique with those described by other authors. The authors believe this to be a safe, cost effective alternative to MIS THA techniques that require special instrumentation and the use of the image intensifier.

Introduction We believe minimally invasive surgery should be defined by the extent of soft tissue dissection rather than incision length. We describe a new technique that is truly soft-tissue sparing and report our early results.

The surgical approach The landmarks for the incision are identified and a 6–8cm oblique incision is made over the posterior aspect of the greater trochanter. Longer incisions are required in more difficult cases. Piriformis and the proximal insertion of gluteus maximus are preserved. After implant insertion, meticulous capsular repair is performed through drill holes into bone to reconstruct the posterior envelope. There are no restrictions to mobility. No specialised instruments are required.

Method The standard posterior approach (group 1) was compared with the PSMI approach (group 2) in a prospective cohort study of 200 consecutive patients over 60 years of age. In the standard approach the external rrotators were dettached. The capsule was repaired to bone, and the piriformis tendon reattached to the Gluteus Medius tendon. Routine restrictions to mobility were imposed. Patients were scored pre-operatively and followed up prospectively, by a blinded observer.

Results Demographics and functional scores were similar. Mean operation time was about 1 hour in both groups. Mean incision length was 21.5 cm (range 15 – 25) in group 1 and 8.4 cm (range 6 – 16) in group 2. Mean blood loss in group 1 was significantly higher than group 2 (P< 0.0001, 95%CI 191–547). Mean inpatient stay was 8.0 days in group 1, and 4.8 days in group 2 (P< 0.0001, 95%CI 3.4–6.0).

Minimum follow-up was 3 years in group 1 and 1.5 years in group 2. There were 3 dislocations in group 1, and none in group 2. There were 2 re-operations in both groups. The relative improvement in WOMAC scores was significantly greater in group 2 at 3 months and 1 year (P< 0.05).

Conclusion The PSMI approach to the hip is truly soft-tissue sparing. It is safe and relatively easy to perform. The stability and minimal morbidity allow early mobilisation. This is the first study to suggest the benefits of minimally invasive surgery may be prolonged. Cosmesis is a by-product rather than primary objective.

Objective To describe the initial clinical and radiological results of a minimally invasive technique of lumbar fusion

Study Design Prospective review of 16 consecutive patients with degenerative lumbar disease who underwent a mini posterior lumbar interbody fusion using the operating microscope and B- twin expandable cages and titanium facet screws and facet fusion .

Subjects 16 patients with degenerative lumbar disease, average age 41(33–48) 5 male 11 female. This was the primary procedure in 11 patients , 5 had previously had a microdiscectomy . 14 patients L5/S1 level 2 patients 2 level L4/L5 L5/S1

Outcome Measures Oswestry disability index and VAS of back and leg pain were perfomed pre-operatively and at 3/12, 6/12, 12/12 Average follow up was 8.1 months (3–17).

Results 1 patient had persistent bone graft donor site pain ,no other complications. Preoperative mean ODI 55 (40–76) Post operative ODI 33 (2–64) Pre op back pain 7.1 (0–8) post op at last follow up 3.7(0–6) Pre op leg 3.9 (0–8) 1.6(0–5) All patients who had reached 12 months follow up had evidence of bone formation at the level in question. All patients improved in terms back pain and leg pain scores and all but 1 patient had a significantly improved ODI score.

Conclusions This has proved to be a safe method of achieving a 360degree stabilisation and probable fusion. It maximally preserves the paraspinal muscles and their innervation in contrast to posterolateral fusion and conventional PLIF using pedicle screws .The small diameter of the implant prior to expansion minimises the degree of neural retraction required .

The authors describe a new, original technique of intra-medullary nailing (originally designed for the Gamma nail system, now also suitable for other nailing systems) for the management of pertrochanteric and subtrochanteric fractures using a minimally invasive approach to the proximal femur. In this approach, the intramedullary nail is placed using a percutaneous Kirschner wire as a guide, so that the procedure has been called “Percutaneous Nailing System” (PNS).

The entry portal is selected at the proximal femur using the Kirschner wire, then a series of cannulae is placed through a small cutaneous incision (15 mm). This dilatator system protects the soft tissue during the reaming procedure (usually only necessary in the proximal femur, not in the diaphysis) and the insertion of the femoral nail.

From April 2001 to January 2004, 120 patients were treated with this new technique. They have been followed up and retrospectively compared to 60 patients operated with the standard technique. The comparison between the two groups was based on the surgical procedure (operation time and total blood loss) and the post-operative period (complications, length of hospitalisation).

With the minimally invasive technique the operation time was on average 15 min and the blood loss, measured as the difference in pre- and postoperative haemoglobinaemia, was on average 1 point, with no need for blood transfusion: these values were less than half in comparison to the standard technique.

The study shows the advantages of this minimally invasive technique, which can also be applied to fractures of the femoral diaphysis.

Introduction: The use of minimal incision THR is increasing. The purpose of this study is to determine the effects of a change in operative technique from a standard incision to a minimally invasive incision at primary THR on peri-operative blood loss, analgesia requirement, length of stay, and complication rate. Two consecutive groups are compared.

Materials and methods: All patients who underwent a primary THR (posterior approach) by the senior author during a 3month period before and after a change in technique from a standard to a minimal incision were identified. 202 patients were analysed: 105 standard incisions and 97 minimal incisions. A retrospective chart review was used to collect age, height, weight, BMI, diagnosis and length of stay for each patient. Estimated peri-operative blood loss in units of blood was calculated by a validated formula. Morphine usage by PCA in the first 24hours post-operatively was recorded. Complications were identified.

Results: There was no significant difference in the mean age, height, weight or BMI between the 2 groups. Predominant diagnosis was primary osteoarthritis. Mean wound length for the standard incision was 16.6cms. Mean wound length for the minimal incision was 11cms. There was no difference in length of stay, mean 5.4days. There was no difference in morphine usage by PCA in the first 24hours, mean 39.4mgs.

Average estimated peri-operative blood loss for the standard incision group was 3.45 units and for the minimal incision group was 3.05 units (statistically significant, p-value 0.039, 95%CI). One patient after minimal incision had a superficial wound infection, which responded to oral antibiotics. There was one dislocation (standard incision).

Conclusions: Peri-operative estimated blood loss was less with a minimal incision but there was no difference in length of stay or analgesia requirement. A prospective RCT is now underway to determine the clinical efficacy of minimally invasive THR.

Introduction

Following bone tumour resection, lower limb reconstruction results in leg-length discrepancy in skeletally immature patients. Previously, minimally invasive endoprostheses have been associated with a high risk of complications including joint stiffness, nerve injury, aseptic loosening and infection. The purpose of this study was to examine the outcome of the Stanmore non-invasive extendible endoprostheses used in our institution between 2002 and 2009 and compare them with implants used in the past.

Purpose

Posterior lumbar fusion using minimally invasive surgical (MIS) techniques are reported to minimise postoperative pain, soft tissue damage and length of hospital stay when compared to the traditional open procedure.

Introduction: The Oxford medial unicompartmental arthroplasty (UCA) is now routinely performed through a short incision without Dislocation of the patella. The aim of this study was to assess the one-year results of this new technique to determine whether it enhances the quality of outcome, as well as the speed of its achievement.

Method: The first 88 consecutive Oxford UCA’s (Phase 3) implanted into 75 patients by two consultant surgeons were scored pre-operatively and at review with the American Knee Society Score. The average age of the patients was 68.1 years; the male to female ratio was 0.9 to 1.

Results: At review, one patient (one knee) had died and one knee had been revised for infection. The other patients (86 knees) were examined at a mean of 1.3 years from surgery. The average ‘knee score’ improved from 37 points to 95 and the average ‘functional score’ from 51 points to 93. Average maximum flexion improved from 117° to 132°. The ‘knee score’ outcome categories at review were 87% excellent, 8% good, 2.5% fair and 2.5% poor.

Conclusions: Historical comparison of these results with the best results of the Oxford UCA, performed through an open approach with dislocation of the patella, suggest that the minimally invasive approach, in addition to faster recovery, improves the quality of outcome at one year.

Purpose We report the long term outcome of a minimally invasive technique avoiding the risks associated with open reduction and bone grafting in paediatric lateral condyle fracture non-unions.

Methods The Toronto Hospital for Sick Children's radiology database was searched to isolate all those who sustained a lateral condyle elbow fracture and had developed a non-union between the years 1998 and 2008. This identified 16 patients who had undergone percutaneous fixation for the treatment of their non union. Each individuals clinical notes and radiographs were reviewed from presentation to final follow-up.

Results Median age at injury was 5.1 (3.2, 7.2) in the successful and 2.8 (2.1, 4.7) in the unsuccessful groups (p=0.18). 11 patients (68.7%) had been initially managed non-operatively. Median time from injury to non-union diagnosis was 15.7 weeks in the successful, and 225.5 weeks in the unsuccessful group (p=0.039).

Mean time to union post fixation was 16.2 weeks (+/- 6.74) and mean time to surgery was 5.2 weeks (+/- 4.11). Surgery was successful, defined as radiological and clinical union, in 12 of 16 patients (75%). 43.8% had metalwork removal and no cases of avascular necrosis were reported.

Conclusion We have demonstrated this technique to be successful in those non-unions addressed within 16 weeks from initial injury to diagnosis. We had 4 failures, these occurred in patients whose non-unions were diagnosed more than 31 weeks from the time of injury (31; 68; 383; 427 weeks). Each of these failures had been managed non-operatively as part of their primary treatment plan.

Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed significantly later. There was a trend towards successfully treated patients being younger.

Minimally invasive plate osteosynthesis is a technically feasible surgical alternative to treat displaced diaphyseal fractures of the tibia. In recent years, this technique has evolved in response to the poor results following tibial fracture stabilization using the traditional open method of plate fixation. Devascularisation with periosteal stripping of bone fragments using open reduction and internal fixation to ensure adequate fracture visualisation led to a substantial percentage of complications including deep infection, delayed union or non union, and refractures after plate removal. Using the technique of minimally invasive plate osteosynthesis, fracture management is achieved with closed reduction followed by stabilisation using a subcutaneous epiperiosteal LC-DC-plate.

Twenty-four patients with 25 tibial fractures were treated by minimally invasive plate osteosynthesis at the Kantonsspital, Fribourg, Switzerland, between 1997 and 1999. These cases were retrospectively reviewed.

There were 11 male and 13 female patients with a mean age of 41 years (range 16 -64). Nineteen tibial diaphyseal fractures (7 type A, 11 type B, and 1 type C) and six tibial epiphyseal-metaphyseal fractures (4 type A, 1 type B, and 1 type C) were surgically treated. Three fractures were open (grade I). Twenty-four fractures were treated using a 4.5 mm titanium LC-DC-plate, and in one fracture a 4.5 mm stainless steel DC-plate was used for tibial fixation. Open reduction and internal fixation of the fibula was necessary in eleven fractures, nine of which were stabilized with a one-third tubular plate and two with a 3.5 mm LC-DC-plate. The postoperative regimen included partial weight bearing for eight weeks followed by progressive and protected weight bearing until fracture union was achieved. Fracture union was confirmed with radiographs obtained at six to eight weeks, twelve to sixteen weeks, and at final follow-up. The mean time to final follow-up was eighteen months.

All fractures had solidly united within four months postoperatively. Radiographically, healing was characterised by callus formation located on the lateral and posterior aspects of the tibial diaphysis, and was similar to that which is usually seen after stabilisation of tibial fractures using an intramedullary rod. Both ankle and knee range of motion were similar to the uninjured side by final follow-up. There were eight cases of residual valgus malalignment of less than five degrees, and were associated with distal third tibial diaphyseal fractures with concomitant fibula fractures which were not rigidly stabilised. Postoperative complications included two deep wound infections and one postoperative compartment syndrome.

Overall good results were obtained by using minimally invasive plate osteosynthesis of diaphyseal fractures of the tibia. Although this technique is more technically demanding than standard open reduction and internal fixation of tibial diaphyseal fractures, preservation of the soft tissue envelope and periosteal blood supply is beneficial for fracture healing. Surgical indications for minimally invasive plate osteosynthesis of the tibial diaphysis include a narrow tibial medullary canal as well as distal and proximal metaphyseal fractures not suitable for intramedullary rodding, and associated intra-articular tibial fractures. Minimally invasive plate osteosynthesis should be considered as a surgical alternative for the treatment of displaced diaphyseal fractures of the tibia.

Despite multiple published reviews, the optimum method of correction and stabilisation of Blount's disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. This technique was developed to minimise cost in a context of limited resources.

This study was conducted between 2016 and 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32tibiae) who had correction of late-onset tibia by proximal tibial osteotomy and Ilizarov external fixator. All cases were followed up to 2 years.

The mean proximal tibial angle was 65.7° (±7.8) preoperatively and 89.8° (±1.7) postoperatively. The mean mechanical axis deviation improved from 56.2 (±8.3) preoperatively to 2.8 (±1.6) mm postoperatively. The mean femoral-tibial shaft angle was changed from – 34.3° (±6.7) preoperatively to 5.7° (±2.8) after correction. Complications included overcorrection (9%) and pin tract infection (25%). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity.

This simple procedure provides secure fixation allowing early weight bearing and early return to function. It can be used in the context of health care systems with limited resources. It has a relatively low complication rate. Our results suggest that acute correction and simple circular frame fixation is an excellent treatment choice for cases of late-onset tibia vara, especially in severe deformities.

Objective

Computer-assisted minimally invasive total knee arthroplasty (CAMI-TKA) has gained increasing interest from orthopaedic surgeons due to its advantages in improving accuracy of component placement combined with benefits in postoperative recovery due to a smaller incision. However, long-term clinical and radiographic outcomes are lacking. The purpose of the present study is to compare the long-term radiographic features and functional outcomes between patients who underwent CAMI-TKA and those who underwent conventional TKA.

Introduction: The stress-response to surgery, known as a variety of well-characterized hormonal, metabolic, haematological and immunological changes, may be smaller in less invasive operations. Decreased blood loss, less soft tissue damage and inflammation leading to fast recovery are arguments used in promoting minimal invasive surgery (MIS).

Purpose: Does MIS TKR with the subvastus approach lead to less inflammation and muscle damage than conventional TKR with the medial parapatellar approach?

Material and Methods: Inflammation parameters (IL-6, IL-8 and IL-10, and CRP), muscle damage parameters (myoglobin, CK) and Hb values were determined preoperative and at 5 moments postoperative in 41 patients. Twenty patients operated through a MIS subvastus approach were compared to 21 patients with the standard medial parapatellair approach.

Results: Average age in was 69.2 yrs in conventional TKR (contr) versus 68.9 yrs in MIS. The Hb levels were 13.9 g/dl preoperative and decreased to 10.8 g/dl (contr) and 11.6 g/dl (MIS) 72 hours postoperative.

The mean IL-6 concentration increased from 6.8 (contr) vs 1.3 (MIS) pg/ml to 68.8 (contr) vs 45.1 (MIS) pg/ml 6 hours postoperative. The mean myoglobin concentration increased in TKP group from 47.7 ug/l pre-operative to 90.1 ug/l 6 hours postoperative, the values for MIS were 27.8 μg/l preoperative and 202.3 ug/l 6 hours postoperative, with significant differences at 2, 4, 6 hrs and day 1 post-operative.

Conclusion: Haemoglobin levels show no significant differences between conventional and MIS approach. Inflammation parameters were not significant different between the two groups. Myoglobin was the only muscle damage parameter with significant differences on several time points between both approaches. This may be explained by the used forces on surrounded tissues. The retractors are necessary to visualise the knee joint in MIS. These results show a trend towards more muscle damage compared to conventional TKR.

The purpose of this study was to develop a novel, minimally invasive therapy for nucleus pulposus augmentation without the need for major surgical incision.

Two optimum patented self-assembling peptides based on natural amino acids were mixed with glycosaminoglycans (GAGs) to form reversible, tunable hydrogels that mimic the vital biological osmotic pumping action and aid in swelling pressure of the intervertebral disc (IVD). Separate peptide and GAG solutions can be switched from fluid to gel upon mixing inside the body. The gels were analysed using a series of complementary techniques (FTIR, TEM & rheometry) to determine their cross-length scale structure and properties. Approaches to developing a clinical product were then developed including the incorporation of a fluorescent probe and a CT contrast agents to aid visualization of the gels, and a semi-automatic syringe driver rig, incorporating a pressure sensor, for the delivery of the solutions into the intervertebral discs. The efficacy of the procedure in restoring disc height and biomechanics was examined using chemically degenerated bovine caudal samples.

It was found the presence of the GAGs stabilized the peptides forming stiffer gels, even upon injection through a long (∼10cm) small gauge needle. The injected gels were easily visualized post injection by microCT and by eye during dissection under visible and UV light. It was also noted that following injection, the disc height of the degenerated samples was restored to a similar level of that observed for native discs.

A hydrogel has been developed that is injected through a narrow bore needle using a semi-automatic delivery rig and forms a self-assembled gel in situ which has shown to restore the disc height. Further tests are now underway to examine their biomechanical performance across more physiological time periods.

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Methods: The minimally invasive technique used involves reduction of the fracture by ligamentotaxis with the use of the traction table and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction where necessary was performed using an ankle arthroscope and a probe introduced through stab incisions anteriorly. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. Locking screws were then inserted percutaneously. All significant anterior or posterior distal tibial fragment were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of foot and ankle outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively, by orthopaedic surgeons blinded to the treatment modality. The mean of the two scores was then recorded. It has been previously demonstrated that the functional outcome in pilon fractures improves for approximately 2 years after injury.

Results: We observed a much higher incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5% of the formal open reduction and fixation group.

Conclusion – The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, in the form a medial locking plate with or without additional percutaneously inserted antero-posterior screws represents a valuable method of treating the most complex of closed pilon fractures.

There are several techniques in minimally invasive total hip arthroplasty. One of the possible advantages of these techniques is early functional recovery. The purpose of the study was to evaluate possible differences in functional recovery patterns after three different techniques of minimally invasive total hip arthroplasty.

Patients and methods: Two hundreds and eighty-eight hips were recruited for this study. All operations were done without cement in all institutes. Acetabular components were Trilogy and femoral components were VerSys (Zimmer, Indiana, USA) in all hips. Mini-incision antero-lateral approach was used for 112 hips (Mini-AL group), mini-incision postero-lateral approach for 53 (Mini-PL group), and muscle sparing antero-lateral approach was used for 123 hips (MS-AL group). There were no significant differences among the three groups for age. All patients were encouraged to walk with full weight-bearing as soon as possible. Early functional outcome was assessed by the attainment of functional milestones, including the number of days post-op to walk 100m with a T-cane and to put on socks. We also analyzed pain during resting and walking, and evaluated muscle strength for abduction before surgery, at one, three, five, seven and 14 days after surgery. Pain was assessed using a visual analog scale. Muscle strength was assessed using a hand held dynamometer (MicroFET-2) in supine position. The post-pre-operative strength ratio was calculated and defined as the recovery ratio. For continuous variables, a Kruskal-Wallis test was used. For comparison among all three groups, the level of significance was set at p< 0.05. For the three multiple comparisons, the level of significance was calculated using the Bonferonni adjustment and was set at p< 0.0165.

Results: Mean of the post-op days to walk 100 meters with a T-cane was 4.09 days for MS-AL group, 4.82 for Mini-AL group, and 5.57 for Mini-PL group. MS-AL group showed a significantly earlier recovery than Mini-AL group. Mean of the post-op days to put on socks was 5.86 days for MS-AL group, 7.37 for Mini-AL group, and 9.9 for Mini-PL group. MS-AL group showed a significantly earlier recovery than Mini-AL and Mini-PL groups. There were no differences for resting pain or walking pain at any days among the three groups. There were no differences for recovery ratio of muscle strength for abduction at 3 postoperative days. At 5 days, Mini-AL showed a lower ratio than MS-AL. And at 7 and 14 days, Mini-AL showed a lower ratio than both the MS-AL and Mini-PL group.

Conclusion: Muscle sparing antero-lateral technique showed earlier recovery for walking and putting on socks than those using mini-incision techniques.

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Materials and Methods: The minimally invasive technique used involved reduction of the fracture by ligamentotaxis and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction was performed using an ankle arthroscope and a probe introduced through stab incisions. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. All significant anterior or posterior distal tibial fragments were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively.

Results: We observed a far greater incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5 % of the formal open reduction and fixation group.

Conclusion: The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, represents a valuable method of treating the most complex of closed pilon fractures.