Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

Introduction: Total hip arthroplasty preformed with the use of minimal incision surgery has received tremendous attention recently. Various surgical approaches have been introduced to minimize surgical trauma to the soft tissues. The mini invasive Modified Watson-Jones approach have been selected to decrease the perioperative complications associated with other mini invasive approaches that has been described.

The anterolateral mini incision is a new innovative approach using the intramuscular plan between the gluteus medius and the tensor fascia lata. This intermuscular interval through a small incision provides good exposure and preserves muscle integrity. Moreover, preserving the muscle integrity provides a very stable joint after implantation such that no restrictions is giving to the patient during the rehabilitation period.

Materials and Methods: Between July 2004 to September 2005, we used this approach on 60 sequential patients. Fifty patients were enrolled in this prospective study. Patients were evaluated preoperatively, immediately postoperatively, and at 3-month and 6 month follow-up according to operating time, intraoperative blood loss, subcutaneous drains blood loss, post op pain control drugs requirements, short form 36 patient questionnaire (SF-36) scores and the Harris Hip Score (HHS). 4 patients had previous THA on the contralteral side.

Results: The average operation time was 137min (range 90–200min), there were no dislocations, the mean post operation blood transfusion requirements was 1.64, the mean subcutaneous drains blood loss was 241.9ml (range 20–620ml), there was significant improvement in function, pain, SF-36 and Harris Hip Score (HHS) at the 3-month and 6-month follow-up examination. The average length of the incision was under 12cm. We had one reoperation due to deep infection. All four patients with bilateral THA preferred their last operation due to lack of post operative restrictions and due to shorter recovery of muscle strength.

Conclusion: We think that using mini invasive Modified Watson-Jones approach in total hip replacement surgeries is a preferable option. There are several advantages of using this approach compared with the more traditional techniques. Such a technique should help reduce morbidity and complication rates for those patients undergoing a total hip replacement.

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

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

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. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Currently, fibrin glue obtained from fibrinogen and thrombin of human and animal blood are widely investigated to use as injectable hydrogel for tissue engineering which contributes to minimally invasive surgery, superior biodegradability, cell attachment, proliferation and regenerating new tissue. However, most of them fail to achieve to be used for tissue engineering application because of a risk of immune response and poor mechanical properties. To overcome the limitation of fibrin glue and to reduce the usage of products from human and animal blood, the artificial fibrin glue materials were developed. Recently, cellulose nanofiber (CNF) as reinforcing agent has been explored for many tissue engineering applications such as bone and cartilage due to its impressive biological compatibility, biodegradability and mechanical properties. CNF was extracted from cassava pulp. PEO-PPO-PEO diacrylate block copolymer is a biodegradable synthetic polymers which is water insoluble hydrogel after curing by UV light at low intensity. To enhance the cell adhesion abilities, gelatin methacrylate (GelMA), the denature form of collagen was used to incorporate into hydrogel. The aim of this study was to develop the artificial fibrin glue from CNF reinforced PEO-PPO-PEO diacrylate block copolymer/GelMA injectable hydrogel. CNF/PEO-PPO-PEO diacrylate block copolymer/GelMA injectable hydrogels were prepared with 2-hydroxy-1-(4-(hydroxy ethoxy) phenyl)-2-methyl-1-propanone (Irgacure 2959) as a photoinitiator. The physicochemical properties were investigated by measuring various properties such as thickness, gel fraction, mechanical properties and water uptake. At optimal preparation condition, CNF reinforced injectable hydrogel was successful prepared after curing with UV light within 7 minutes. This hydrogel showed gel fraction and water uptake of 81 and 85%, respectively. The cytotoxicity, cell adhesion and proliferation of CNF reinforced injectable hydrogel was presented. Cellulose nanofiber from casava pulp was successfully used to prepare injectable hydrogel as artificial fibrin glue for tissue engineering. The hydrogel showed good physical properties which can be applied to use for tissue engineering application

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

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

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

The April 2012 Spine Roundup. 360. looks at yoga for lower back pain, spinal tuberculosis, complications of spinal surgery, fusing the subaxial cervical spine, minimally invasive surgery and osteoporotic vertebral fractures, spinal surgery in the over 65s, and pain relief after spinal surgery

Background. Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the five-year clinical and radiological outcomes following third-generation MIS hallux valgus surgery. Methods. A retrospective observational single surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous Chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60 month clinical and radiographic follow up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) pre-operatively, 6 months and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, Euroqol-5D Visual Analogue Scale and Visual Analogue Scale for Pain. Results. Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA. The mean follow up was 68.8±7.3 (range 60–88) months. There was a significant improvement in radiographic deformity correction; IMA improved from 13.0±3.0 to 6.0±2.6, (p < 0.001) and HVA improved from 27.5±7.6 to 7.8±5.1. There was a statistically significant but not clinically relevant increase of 1.2±2.6° in the HVA between 6 month and ≥60 month radiographs. There was an increase in IMA of 0.1±1.6º between 6 month and ≥60 month radiographs which was not statistically or clinically significant. MOXFQ Index score at ≥follow up was 10.1±17.0. The radiographic recurrence rate was 2.6% at final follow up. The screw removal rate was 4.0%. Conclusion. Radiological deformity correction following third-generation PECA is maintained at a mean follow up of 68.8 months with a radiographic recurrence rate of 2.6%. Clinical PROMs and patient satisfaction levels are high and comparable to other third-generation studies with shorter duration of follow up

Implant removal is necessary in up to 25% of patients with plate osteosynthesis after proximal humeral fracture. Our new technique of arthroscopic implant removal offers all advantages of minimal invasive surgery. Additionally treatment of concomitant intraarticular lesions is possible. This study outlines the first results after arthroscopic implant removal in comparison with those of open implant removal. A prospective series of 40 consecutive treated patients had implant removal and arthrolysis after plate osteosynthesis of proximal humeral fracture. Implant removal was carried out due to limitation in range of movement, secondary implant dislocation and implant impingement. 30 patients (median age 63 (30–82) years) had arthroscopic, ten patients (median age 53 (34–76) years) had open implant removal. Median 10 months after implant removal subjective patient satisfaction, Constant Murley Score (CMS) and Simple Shoulder Test were determined. Arthroscopic implant removal showed comparable first results as open implant removal. There was no significant difference between CMS of both groups. The active shoulder abduction, flexion and external rotation improved significantly after arthroscopic and open implant removal. The simple shoulder test outlined advantages for the arthroscopic technique. After arthroscopic implant removal patients showed higher subjective satisfaction as well as faster pain reduction and mobilization. Analysis of perioperative data showed less blood loss in the group with arthroscopic implant removal. In 85% of patients with arthroscopic implant removal concomitant intraarticular lesions were observed and treated. The arthroscopic implant removal after plate osteosynthesis of proximal humeral fractures offers all advantages of minimal invasive surgery and comparable first results as the open implant removal. The subjective and objective satisfaction of patients is high. The technique can be applied and established by all arthroscopic trained shoulder surgeons

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

Introduction. Injectable hydrogels via minimally invasive surgery offer benefits to the healthcare system, reduced risk of infection, scar formation and the cost of treatment. Development of new treatments with the use of novel biomaterials requires significant pre-clinical testing and must comply with regulations before they can reach the bedside. In the European economic area (EEA) one of the first hurdles of this process is attaining the CE marking which protects the health, safety and environmental aspects of a product. Implanted materials fall under the class III medical device EU745 regulation standards. To attain the CE marking for a product parties must provide evidence of the materials safety with an investigational medicinal product dossier (IMPD). Methods and Results. We have been working to develop a new thermoresponsive injectable biomaterial hydrogel (NPgel) for the treatment of intervertebral disc (IVD) disease. A large part of the IMPD requires information on how the hydrogel physical properties change over time in bodily conditions. We have been studying 6 batches of NPgel over 18 months, tracking the materials wet/ dry weight, structure and composition. To date we have found that NPgel in liquids more similar to the body (with protein and salts) appear to be stable and safe, whilst those in distilled water swell and disintegrate over time. Subtle long-term changes to the material composition were found and we are currently investigating its ramifications. Conclusion. The study highlights the need to test materials in detail in physiologically representative environments before approaching the bedside and demonstrates promise for NPgel as a suitable CE candidate. Conflicts of interest: CS and CLM are named inventors on the patent for NPgel/BGel. Funded by the Medical Research Council and Versus Arthritis UK: SNiPER

Aims. The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (. sd. 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications. Patients and Methods. We prospectively collected the data of 70 consecutive patients with AIS treated with MIS using three incisions and a muscle-splitting approach by a single surgeon between June 2013 and February 2016 and these were retrospectively reviewed. There were eight male and 62 female patients with a mean age of 15 years (. sd. 4.5 ) with a mean body mass index of 19.8 kg/m. 2. (. sd. 5.4). The curves were classified according to Lenke; 40 curves were type 1, 15 were type 2, three were type 3, two were type 4, eight were type 5 and two were type 6. Results. The mean primary Cobb angle was corrected from 58.9° (. sd. 12.6°) pre-operatively to 17.7° (. sd.  10.2°) post-operatively with a mean correction of 69% (. sd. 20%, p < 0.001). The mean kyphosis at T5 to T12 increased from 24.2° (. sd. 12.2°) pre-operatively to 30.1° (. sd. 9.6°, p < 0.001) post-operatively. Peri-operative (30 days) complications occurred in three patients(4.2%): one subcutaneous haematoma, one deep venous thrombosis and one pulmonary complication. Five additional complications occurred in five patients (7.1%): one superficial wound infection, one suture granuloma and three delayed deep surgical site infections. The mean ORT was 337.1 mins (. sd. 121.3); the mean EBL was 345.7 ml (. sd. 175.1) and the mean LOS was 4.6 days (. sd. 0.8). Conclusion. The use of MIS for patients with AIS results in a significant correction of spinal deformity in both the frontal and sagittal planes, with a low EBL and a short LOS. The rate of peri-operative complications compares well with that following a routine open technique. The longer term safety and benefit of MIS in these patients needs to be evaluated with further follow-up of a larger cohort of patients. Cite this article: Bone Joint J 2017;99-B:1651–7

Navigation technology is a new tool which can help surgeons to a more accurate hip component implantation and a better reproducibility of the procedure. The purpose of this study was to compare conventional and navigated technique and a new developed straight hip stem for uncemented primary total hip replacement. The results of two consecutive implantation series of 42 patients (non navigated) and 42 patients (navigated) were analysed for implant positioning and short term complications. Non navigated components were implanted through conventional incision (15 cm), navigated component by minimal invasive surgery (5 cm). All surgeries were performed through Hardinge approach and by a single senior surgeon. Radiographic analysis of cup position showed a significant improvement with reduced radiological inclination (53° non navigated/44° navigated, p< 0.001) and higher anteversion (7° non navigated/12° navigated, p< 0.001). The mean postoperative limb length difference was 6.2 mm (SD 9.0, non navigated) and 4.4 mm (SD 6.4, navigated). Intraoperative and early postoperative complications were not different. No dislocation occurred in both groups. There was one intraoperative trochanter fracture which was not revised (non navigated) and one revision because of a periprosthetic fracture caused by fall down during rehabilitation (navigated). We conclude that acetabular implant positioning can be significantly improved by the use of navigated surgery technique even in minimal invasive surgery condition. The data for postoperative limb length difference was still similar but within the expected range in both groups. Navigation technology seems essential for minimal invasive surgical procedure yielding help and security to the surgeon. The effect of improved cup positioning on mid and long term results for both groups have to be further investigated

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

Today minimally invasive surgery inspires orthopaedic surgeons to consider techniques that minimize morbidity and produce equal or better outcomes. Minimally invasive surgery–total knee arthroplasty (MIS-TKA) approach involves a medial para-patellar incision which leads to a smaller skin incision, limited soft tissue dissection and sparing of the Quadriceps muscle. This prospective and retrospective study was carried out at Dayanand Medical College and Hospital, Ludhiana (India) from January 2007 to June 2010 to evaluate forty nine patients with unilateral and six patients of Bilateral MIS-TKA. Patients with osteoarthritis and rheumatoid arthritis undergoing primary TKA using cemented modular posteriorly stabilized prosthesis were included in the study. All the procedures were performed through anterior midline incision measuring 8.5–10 cms (mean 9.2 cms). Extent of the incision into the quadriceps tendon was limited to the level of superior pole of patella and vastus medialis muscle was not split. Patella was not everted but retracted laterally. Four in One Nexgen legacy, minimal invasive surgery instrumentation was used. Aggressive physiotherapy was started on the first postoperative day with knee bending and walking on day two. The patients were evaluated according to knee society knee score and function score at one, three and six months and again at one year postoperatively. Mean final knee score improved from 30 to 91 (p-value = .00001). Mean functional score improved from 25 to 78 (p-value = .00001). Mean stability score improved from 19.46 to 22.98 points postoperatively. Patients with lesser preoperative flexion contracture had better outcomes and preoperative range of motion predicted final range of motion. Mean ROM improved from preoperative value of 85 to 101 at discharge, 114 at 12 weeks and 120 at 6 months (p-value = .0007, .0006, .0009 respectively). 79.1% patients were completely pain-free on the final follow-up. Mean tourniquet time was 65 minutes (55–75). 91.4% patients suffered <300 ml blood loss in drains. One patient each of patellar maltracking and deep infection was seen in our study. We concluded that MIS-TKA with quadriceps sparing approach in our patients lead to a limited arthrotomy, decreased blood loss, less blood transfusion requirements, less postoperative pain, faster recovery of motion and return of function. This study proposes that MIS-TKR has many advantages over the conventional procedure and these are mainly attributed to the sparing of quadriceps muscle

Introduction. Injectable hydrogels via minimally invasive surgery reduce the risk of infection, scar formation and the cost of treatment. Degradation of the intervertebral disc (IVD) currently has no preventative treatment. An injectable hydrogel material could restore disc height, reinforce local mechanical properties, and promote tissue regeneration. We present a hydrogel material Laponite. ®. associated poly(N-isopropylacrylamide)-co-poly(dimethylacrylamide) (NPGel). Understanding how the components of this hydrogel system influence material properties, is crucial for tailoring treatment strategies for the IVD and other tissues. Methods & Results. The effect of hydrogel wt./wt., clay and co-monomer percentages were assessed using a box-Behnken design. Rheometry, SEM, FTIR and swelling was used to measure changes in material properties in simulated physiological conditions. Rheometry revealed gelation temperature of hydrogel materials could be modified with dimethyl-acrylamide co-monomer; however, final maximum mechanical properties remained unaffected. Increasing the weight % and clay % increased resultant mechanical properties from ∼500–2500 G' (Pa), increased viscosity, but retained the ability to flow through a 26G needle at 39°C. Discussion & Conclusions. By increasing the weight and clay percentage of the material we can attain greater mechanical properties, this could be beneficial for orthopaedic or even dental applications. By modifying the co-monomer percentage, we can control gelation temperature important for ensuring the material is fully set at 37°C, this could also be utilised to locally deliver drugs from the implanted material. Our current work is focused on comparing our NPGel material formulation with human IVD tissue. Acknowledgements. We would like to thank Arthritis Research UK grant number 21497 for supporting this research. No conflicts of interest. Sources of Funding: Funded by Arthritis Research UK grant number 21497

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

There is no question that at some point many TKAs will be cementless-the question is when. The advantages of cementless TKA include a shorter operative time, no need for a tourniquet, more suitability for MIS, no concern for cement extrusion, and the history of THA. The concerns for cementless TKA include the history to date with cementless TKA (tibia and metal-backed patella), variable bony substrate, surgical cut precision, cost, revision concerns, and the patella (for patella component resurfacers). Cemented total knee arthroplasty remains the gold standard and has proven to provide durable results in most patients. The early experience with cementless tibial fixation was problematic due to tibial micromotion leading to pain and loosening. Screw fixed tibial components had additional problems as portals for polyethylene debris leading to tibial osteolysis. Moreover, metal-backed patellar components were associated with a high failure rate and most surgeons began to cement all three components. Renewed interest in cementless tibial fixation is driven in part by newer materials felt to be more suitable for ingrowth and by the perceived benefit of minimally invasive surgery. One of the concerns in limited exposure total knee arthroplasty is the difficulty in preventing the extravasation of cement posteriorly. If there is evidence-based data that quad sparing non-patella everting and limited incision length facilitates rehabilitation and does not jeopardise outcome, cementless tibial fixation will be a more attractive option in some patients. An additional concern is that the tibial surface is frequently quite variable in terms of the strength of the cancellous bone. Bone cement stabilises those differences and provides a homogeneous platform for load bearing through the tibial component

The October 2012 Foot & Ankle Roundup. 360. looks at: ankle arthrodesis in young active patients; the Bologna-Oxford total ankle replacements; significant failure and revision rates for total ankle arthroplasty; surgical treatment of Achilles tendon rupture; selective plantar fascia release; whether removal of metalwork can resolve foot pain; allografting of osteochondral lesions; distracting from osteoarthritis; and ultrasound-guided minimally invasive surgery

Introduction Unicompartmental knee arthroplasty (UKA) is well established in the treatment of OA of the knee, but has not been performed in large numbers compared with total knee arthroplasty. However, with the development of minimally invasive surgery, numbers of procedures are increasing rapidly. This study examines the results of minimally invasive UKA performed by one surgeon since august 1998. Methods A consecutive series of 388 knees in 360 patients operated between August 1988 and February 2003 were evaluated using a prospective database. All surgeries were performed by the senior author using a minimally invasive technique in a day surgery unit. General anaesthesia was used in all cases with local anaesthesia intra-operatively, combined with an anaesthetic infusion pump. No patient received parenteral narcotics. Ninety-seven percent were medial and three percent were lateral arthroplasties. Results Post-operatively no patients were lost to follow-up which ranged from two months to 4.5 years. Average age was 66 years. The average IKS score improved from 75 to 158 post-operatively. Most patients retained their pre-operative range of motion which averaged 120°. Average length of stay was 1.57 days with 41% of patients discharged the same day. There were five failures, due in part to osteoporosis and overcorretion. These were revised successfully to a ‘primary’ type knee prosthesis. Satisfaction rate subjectively was 98%. Conclusions Mid term results of UKA using the Repicci technique of minimally invasive surgery with rapid mobilisation and early discharge has ahcieved excellent results for unicompartmental OA of the knee. The procedure is better tolerated with a low complication rate and higher patient satisfaction than total knee replacement in this gourp of patients

Introduction: The aim of the study is to evaluate different operation techniques after total knee arthroplasty (TKA). Functional outcome as well as objective results in activity (activity monitor) after minimal invasive TKA was compared with functional outcomes after a standard midvastus approach. Purpose: The primary purpose of the present study was to determine the difference between two approaches in surgery of total knee arthroplasty. Is there a difference in outcome between a standard and a minimal invasive surgery because of less muscle damage and soft tissue stress?. Material and methods: The study includes two groups with 20 patients each (MIS group versus standard group) The patients are investigated at six different times: 1 day preoperatively as well as on 1., 3., 7. day postoperatively as well as 6 and 12 weeks after surgery. We used the AMP 331 (Dynastream Innovations, Inc., Cochrane, AB) a new ankle-mounted activity monitor. Step count, distance travelled, walking speed, step length, cadence and energy expenditure were measured. 1, 6 and 12 weeks postoperatively patients got the device for 5 days. Results: The average age in the standard group was 66.4 years and for the MIS group, 66,8. The MIS group has been shown a sig. higher KSS Score versus standard group in all follow up visits. Standard group has shown a slight higher blood loss and higher values of muscle specific lab parameter (Creatininkinase and Myoglobin). The Activity Score was better in the MIS group in comparison to the standard group. These results also mirrored the data from the activity monitor (AMP 331, Dynastream Innovations, Inc., Cochrane, AB). The average walking speed at 1, 6 and 12 weeks was sig. (p< 0.05) better than in the standard group. Same trend we have seen in cadence, step length and steps per day. Conclusion: This study shows that patient who underwent minimal invasive surgery in knee arthroplasty have an better early outcome after surgery in activity and function because of saving muscle structure and minimise soft tissue stress

The treatment of fractures has evolved from extensive open reduction and internal fixation to minimally invasive surgery and biological fixation. High energy bicondylar tibial plateau fractures pose a treatment challenge to most orthopaedic Surgeons. This study evaluates the results of biologic plating of bicondylar tibial plateau fractures. Between January 2005 and January 2006 we treated 25 closed bicondylar tibial plateau fractures with minimally invasive surgery using locking plates and screws. Routine tomograms and CT scans were performed after a detailed history and physical examination were performed. Pre-operative planning and templating was performed in all cases. Surgery was carried out by the same surgical team using a tourniquet and an anterolateral or medial surgical approach. Bone grafting was also performed in some cases. The implants used were pre-contoured locking plates (Synthes, Smith & Nephew). The rehabilitative programme was commenced on day 2 by the same Physiotherapist and non weight bearing for 12 weeks. Four patients refused to be part of the study and two were lost to follow up. Nineteen patients were available for follow up with a mean follow up of 10 months. There were 10 males with mean age of 35 years. Two patients were treated for early superficial wound sepsis which healed. Eight patients needed a bone graft at the time of surgery. The average range of movement was 5–110 degrees of flexion. There were no implant failures or non unions. At six months all patients walked unaided with no deformity and were satisfied with the operation. As an alternative to external fixation of these difficult fractures we recommend a less invasive precontoured plate with locking screws. The advantages include sub-muscular, extraperiostal plate application through a relatively small incision, percutaneous screw placement through a guide, the fixed angle of the plate obviating the necessity of medial plate fixation, and plate lengths are available to span the metadiaphysis. The results suggest that biologic plating with a precontoured locking plate of bicondylar tibial plateau fractures may give better short term results with excellent function

Introduction: The surgical management for carpal tunnel syndrome is the release of pressure on the median nerve by dividing the transverse carpal ligament. There are different ways to release median nerve viz.extensive lazy ‘S’ incision from palm to forearm and the advanced arthroscopic release at wrist. We describe a simple, effective and minimally invasive surgery for C.T.S. to divide transverse carpal ligament. Material & method: We present 38cases of C.T.S. after clinical and Electro diagnosis confirmation underwent the minimal invasive surgery. A 1” transverse incision over the center of distal wrist crease placed exposing the palmeris longus (retracted/divided) and exposing transverse carpal ligament. These transverse fibers are cut in the line of skin incision and exposing the median nerve. With blunt curved scissors the transverse ligament is cut distally in the palm and proximally in the wrist separating from the median nerve thus relieving the compression. The wound is closed in layers over the drain and compression bandage applied. Post operatively hand elevated for 24hours, drain removed after 48hours and suture removed at 7th day. Results: In all the 38cases there was pain relief immediately after the surgery. There was progressive neurological recovery (sensory/motor) took place from 6months to 1year. One case developed a pulsatile swelling at the wrist (false A-V aneurysm). The false aneurysm was due to accidental nicking of superficial palmar branch of radial artery, which was ligated on second day. There was superficial marginal necrosis was observed in 6 cases, which healed in 12–16 days. Discussion: The technique is simple, short, safe, economic, effective and easily reproducible. The transverse incision gives better visualization of transverse carpal ligament; easy resection of the ligament and better exposion of median nerve at the wrist makes this procedure to have good results. This tiny incision is in the langhans line at wrist has early wound healing, a cosmetic scar and least morbidity

Introduction. The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery. Methods. The study examines the plantar anatomy of the lesser toes in ten cadaver feet. The tendons, nerves and bony anatomy are recorded. Results. The anatomy of the flexor tendons reveals the short flexor tendon bifurcates to allow the long flexor tendon to pass through it reliably at the level of the metatarsophalangeal joint (MTPJ) in the lesser rays. The division of the intermetatarsal nerves to digital nerves relative to the MTPJ is more variable. This nerve division is more consistently related to the skin of the web between the toes. In the first webspace the division is on average 3cm proximal to the skin at the deepest part of the cleft. In the second, third and fourth webspaces this distance is reduced to 1cm. The level of the deepest part of the webspace to the MTPJ is also variable. Discussion. Surgical release of the flexor tendons is recommended just proximal to the MTPJ for releasing both tendons and distal to the proximal interphalangeal joint for the long flexor tendon. The webspace skin and MTPJ's are easily identifiable landmarks clinically and radiologically. Awareness of the intermetatarsal nerve division will help to reduce nerve injuries with minimally invasive surgery to the plantar forefoot

Purpose of the study: Navigation systems have proven efficacy for the implantation of unicompartmental knee prostheses. Minimally invasive methods, which limit access to non-operated compartments, might compromise system accuracy. Material and methods: A standard navigation software was used for kinematic acquisition of the lower limb and to acquire anatomic landmarks for both femorotibial compartments. A modified version of the navigation software designed for minimally invasive surgery replaed palpation of the anatomic landmarks of the non-operated compartment by a computation method based on other data. Three groups of patients were analyzed. Group 1 included 64 patients who underwent minimally invasive surgery for implantation of a medial unicompartmental prosthesis. Group B included 60 patients selected randomly among 140 cases of medial unicompartmental prosthesis patients treated with the standard navigation technique. Group C included 30 patients selected randomly among 180 patients who underwent total knee arthroplasty with the standard navigation system. The quality of the implantation was assessed on the postoperative ap and lateral views by comparing five criteria describing the desired prosthetic alignment. The number of criteria describing correct alignment was noted for each patient, thus yielding a quality score from 0 to 5. ANOVA was used to compare the mean scores of the three groups using Boneffini-Dunn correction at the 5% risk level. Results: The mean quality score was 3.5±1.2 for group A, 4.5±0.8 for group B and 4.2±1.0 for grup C (p< 0.001). Ther was no significant difference between groups B and C (p=0.24). The quality score was significantly lower in group A (A versus B: p=0.015; A versus C: p< 0.001). Discussion: The minimally invasive approach is proposed to enable more rapid functional recovery after implantation of a unicompartmental knee prosthesis. The long-term outcome however depends on the quality of the implantation. The quality of the implantation with a minimally invasive method should thus be equivalent to that achieved with the standard method. Conventional minimally invasive methods are more difficult. Navigation could be expected to overcome this difficulty without sacrificing implantation quality. However, the version used here did no enable an implantation equal to the quality achieved with the standard navigation system. Conclusion: The standard navigation system for the conventional access remains the gold standard for implantation quality. Changes resulting from a less invasive approach should be validated before routine use

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

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy

Background: There has been much interest recently in reducing the length of inpatient stay after hip and knee arthroplasty and much of the relevant literature has linked this to minimally invasive surgery. Orthopaedic departments are often under great pressure to reduce inpatient stay in order to increase throughput of patients. However it is incumbent on those of us responsible for patient care to ensure that systems are in place to maintain safety. Patients and Methods:We looked at a 6 month period of early discharge with a dedicated ‘Accelerated Discharge Team’ (A.T.T.) at our institution. The team consisted of three nurses, two physiotherapists and two ‘technical instructors’. All patients undergoing hip or knee arthroplasty were assessed pre-operatively and post-operatively for admission to the care of the A.T.T. against fixed criteria. Patients were visited at home on the day of discharge and every day until released from the care of the team. 333 patients underwent lower limb arthroplasty during the study period of which 305 (91.6%) were admitted to the care of the A.T.T. Results: The mean lengths of stay for primary hip and knee replacements were 3.43 and 3.30 days respectively. The mean for revision hip and knee were 5.75 and 3.29 days respectively. 66% (95% C.I. 57%–74%) of patients undergoing primary hip arthroplasty went home by 3 days and 91% (95% C.I. 85%–95%) by 4 days. 73% (95% C.I. 64%–81%) of patients undergoing total knee arthroplasty went home by 3 days and 93% (95% C.I. 87%–97%) by 4 days. The most common reasons for delay were: social reasons or living alone; low blood pressure or haemoglobin level; difficulty walking. Of the 305 patients, 12 (4%) were readmitted to hospital within 6 weeks of discharge, 2 of these patients (1%) were still under the care of the A.T.T. Almost 90% of patients responded to a satisfaction survey. 94.2% of those responding indicated that they would use the A.T.T. scheme again. Discussion: Other authors have linked early discharge to minimally invasive surgery or to special anaesthetic/ analgesic techniques. It has also been shown that both carepathways and patient education protocols can reduce length of stay. In the year before implementing the A.T.T. the mean stay for primary hip and knee replacements was over 9 days. We were able to reduce this to less than 3.5 days for over 90% of our patients during the study period. This was achieved safely and without any special surgical or anaesthetic techniques. The total cost of the scheme was just under £100 000 for the 6 month period. We estimate that 2000 bed days were saved during the same period. This is cost effective on these terms alone. As well as transferring 12 elective orthopaedic beds to a different department we were able to perform an estimated 75 extra lower limb arthroplasties in the 6 month period

Fractures of distal femur and tibia treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation of closed fractures of the lower limb using MIPO in comparison with conventional O.R.I.F. procedure. From January 1998 to May 1999 we collected 32 cases of lower limb fractures (10 distal femur, 15 pilon, 7 distal tibia) treated with O.R.I.F procedure (Group I). The mean age was 47.6 years (range 23–76). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional devices (36 cases). From March 2001 we performed part of our minimal invasive surgery (54 cases) with new devices with angular stability (Less Invasive Stabilization System, Synthes) that offer more tools for subcutaneous osteosynthesis and more mechanical stability of the implants. Our 90 cases formed Group II. The mean age was 53.2 years (range 21–80). The mean follow up was 18 months. We used bone grafts in only 1 case of severe pilon fracture. In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had no infection, no delayed or non-union (a mean consolidation time of 8–10 weeks for pilon fractures, 6 weeks for distal tibia fractures, 10–12 for distal femoral and proximal tibia ones). 2 cases of varus deformity in 1 pilon fractures (1 MIPO); 1 DVT in distal tibial fracture; 2 cases of varus deformity of distal femoral fracture (1 DCS). Conventional O.R.I.F. surgery showed some limits: wide exposure, damage to vascular supply of soft tissues and bone, blood loss, high risk of infections, not indicated in polytrauma patient: international literature reported high rate of postoperative complications. The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability and facilitated this technique In conclusion, minimal invasive surgery is a demanding technique with undoubted advantages: it reduces surgical exposures and risk of infection; it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients

Fluoronavigation is an image-guided technology which uses intra-operative fluoroscopic images taken under a real-time tracking system and registration to guide surgical procedures. With the skeleton and the instrument registered, guidance under an optical tracking system is possible, allowing fixation of the fracture and insertion of an implant. This technology helps to minimise exposure to x-rays, providing multiplanar views for monitoring and accurate positioning of implants. It allows real-time interactive quantitative data for decision-making and expands the application of minimally invasive surgery. In orthopaedic trauma its use can be further enhanced by combining newer imaging technologies such as intra-operative three-dimensional fluoroscopy and optical image guidance, new advances in software for fracture reduction, and new tracking mechanisms using electromagnetic technology. The major obstacles for general and wider applications are the inability to track individual fracture fragments, no navigated real-time fracture reduction, and the lack of an objective assessment method for cost-effectiveness. We believe that its application will go beyond the operating theatre and cover all aspects of patient management, from pre-operative planning to intra-operative guidance and postoperative rehabilitation

Over the past fifteen years, the average length of stay for total hip (THA) and total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and peri-operative protocols. Rapid recovery techniques and peri-operative protocols have been refined to allow for same-day discharge with improved outcomes. In addition to Rapid Recovery techniques for the clinical care of the outpatient, one critical component to same-day total knee arthroplasty is the efficient performance and simplicity of the procedure itself. Simplified instrumentation and elimination of modularity can provide that efficiency and simplicity. All polyethylene tibial components have been mostly supplanted by modular metal-backed designs in recent years. However, mounting evidence suggests that survivorship of TKA with an all-poly tibia is superior to TKA with metal-backed, modular designs in all age groups except younger than 55, in which survival is equal to a modular design. Furthermore, this survival advantage was unaffected by obesity. Combining these excellent clinical results with the efficiency of a non-modular component can add to the efficiency and simplicity of the surgical technique. Therefore, in outpatient total knee arthroplasty, the all-poly tibia truly represents the less is more mentality

Minimally invasive total hip replacement surgery not only decreases the number of visual cues necessary for proper acetabular component position, the small incision makes it technically more difficult to use traditional mechanical alignment guides. Furthermore, traditional mechanical guides have been shown to be unable to accurately predict component position as determined by intraoperative computer measurements.[ 1,2 ] Computer assisted intraoperative navigation can enable minimally invasive surgery by giving the surgeon immediate intra-operative feedback of actual component position. We wished to compare the intraoperative computer determined measurement of acetabular inclination with the postoperative radiographic measurement of inclination in order to validate the results of the computer assisted measurements in the clinical setting. To determine whether computer assisted navigation of the acetabular component allows the surgeon to accurately place the prosthesis in minimally invasive hip replacement and to compare the results of intraoperative navigation with the postoperative radiograph. 42 consecutive patients underwent a minimally invasive posterior approach for total hip arthroplasty with the assistance of CT based intraoperative navigation with the BrainLAB VectorVision software. Preoperative surgical planning was performed after acquisition of a CT scan. All components were templated to be placed in 45 degrees of inclination and 25 degrees of anteversion. Intraoperatively, cementless acetabular components were aligned with the computer navigation at these values prior to implant impaction. Because of the press fit nature and limited soft tissue exposure, many components would shift during impaction. Final component position was then verified and values recorded by detecting points on the acetabular surface. If the prosthesis was felt to be in an acceptable position, no attempt was made to modify component position to the predetermined values in order to avoid potentially compromising component fixation. Postoperative supine AP pelvis radiography was then used to determine final inclination. Measurements were made by drawing a line perpendicular to the acetabular teardrop and parallel to the acetabular component and measured with a standard goniometer. These data were then placed in an SPSS database and analyzed by an independent statistician. Assessing acetabular component position in routine total hip arthroplasty has been shown to be unreliable even with experienced surgeons with mechanical alignment guides. [1,3] In minimally invasive total hip arthroplasty, routine visual cues are limited and mechanical instruments are difficult to place in the small operative wounds making an already difficult task even more difficult. CT based image guided surgery can has been shown to improve the acetabular component position intraoperatively 2. However, postoperative validation studies comparing the intraoperative computer assessment with the postoperative radiographic measurement are scarce. [ 2 ] In this consecutive series, which represents the author’s first experience with this technology, several conclusions can be made. First, the act of impacting a solid, porous coated, hemispherical cementless acetabular component in minimally invasive hip surgery often leads to a final component position different from the intended position. Second, computer generated determination of implant position is reliable but care must be taken to make sure the reference arrays do not lose fixation during the procedure or spurious results can occur. Third, routine AP pelvis radiographic measurements are not accurate enough to determine whether the computer determined values are accurate. In spite of these measurement inaccuracies, the computer determined results and the radiographic results were within 10 degress 95 % of the time which is far more accurate than results obtained with mechanical alignment tools 3. Finally, further validation studies need to be done with postoperative CT scanning to determine the accuracy of the intraoperative computerized measurements and determine the measurement errors inherent in the clinical setting. Given these limitations, computer assisted navigation improves the accuracy and reliability of acetabular component position over traditional mechanical instruments and can be utilized in minimally invasive hip surgery to assist in the appropriate placement of the acetabular prosthesis

Aims: Minimal invasive surgery is now possible for hip replacement. We present our system (called the SE Hip SystemTM). It is a universal system and is here used with the LINKTM C.F.P stem and T.O.P cup. Methods: We have used this system on forty patients. It involves five steps. One (incision) – a single 5cm. postero-lateral incision; two (neck cut) – application of a cutting block to the femoral neck and removal of the head; three (broaching the femur) – preparation of the femur; four (reaming the acetabulum) – ream using the modified reamers and precisely place the cup with the lollipop device; five- place the stem and soft tissue balance with the spacers. The hip is then reduced and the wound closed. Results: The average pre-operative Harris hip score was 28.64; the average post-operative score was 82.65. Complications included one transient sciatic nerve palsy. Average blood loss was 250 mls, the average time in hospital was 3 days and the average number of physiotherapy sessions required was 4. Conclusions: Minimal invasive hip surgery is now possible. There is a markedly reduced cone of dissection. Navigation systems and intra-operative imaging are not required. This technique should minimize maltracking (and wear) and shorten the recovery period allowing the possibility of day or outpatient hip surgery

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. Methods. A systematic review and meta-analysis of randomised and prospective studies were conducted to compare the MIS and open surgery in acute Achilles tendon ruptures. Results. 13 studies were included in the meta-analysis in 4 languages involving total of 854 patients, 426 in the MIS group and 428 in the open group. Although the re-rupture rates were not significantly different between the groups (10 events in 410 patients in MIS group and 9 events in 341 patients in the open one, P=0.41), there were significantly more complications in the open surgery group (29 in 426 MIS patients versus 105 in 428 patients in open surgery group, P<0.00001). Conclusions. MIS in acute Achilles tendon ruptures results in similar re-rupture rates, in comparison with open surgical method with significantly less post-operative complications

The August 2013 Spine Roundup. 360 . looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis

Background. Both minimally invasive surgery(MIS) and computer-assisted surgery(CAS) in total knee arthroplasty have been scientifically linked with surgical benefits. However, the long-term results of these techniques are still controversial. Most surgeons assessed the surgical outcomes with regard to knee alignment and range of motion, but these factors may not reflect subjective variables, namely patient satisfaction. Purpose. To compare satisfaction and functional outcomes between two technical procedures in MIS total knee arthroplasty, namely computer-assisted MIS and conventional MIS procedure, operated on a sample group of patients after 10 years. Methods. Seventy cases of posterior-stabilized total knee prostheses were implanted using a computer-assisted system and were compared to seventy-four cases of matched total knee prostheses of the same implant using conventional technique. Both groups underwent arthrotomy by 2 centimeter limited quadriceps exposure minimally invasive surgery (2 cm Quad MIS). At an average of ten years after surgery, self-administered patient satisfaction and WOMAC scales were administered and analyzed. Results. Demographic data of both groups including sex, age, preoperative WOMAC and post-operative duration were not statistically different. Post-operative WOMAC for the computer-assisted group was 38.94±5.68, while the conventional one stood at 37.89±6.22. The median of self-administered patient satisfaction scales of the computer-assisted group was 100 (min37.5-max100), while the conventional one was 100 (min25-max100). P-value was 0.889. There was 1 re-operative case in the conventional MIS group due to peri-prosthetic infection which was treated with debridement, polyethylene exchanged and intravenous antibiotics. Conclusion. The long-term outcomes of computer-assisted MIS total knee arthroplasty are not superior to that of the conventional MIS technique. Computer assisted MIS total knee arthroplasty is one of the treatment options for osteoarthritis of the knee that has comparable levels of satisfaction to the conventional MIS technique

Objectives. Few reports were shown about the position of the cup in total hip arthroplasty (THA) with CT-based navigation system. We use minimally invasive surgery (MIS) technique when we perform cementless THA and the correct settings of cups are sometimes difficult in MIS. So we use CT-based navigation system for put implants with correct angles and positions. We evaluated the depth of cup which was shown on intra-operative navigation system. Materials and Methods. We treated 30 hips in 29 patients (1 male and 28 females) by navigated THA. 21 osteoarthritis hips, 6 rheumatoid arthritis hips and 3 idiopathic osteonecrosis hips were performed THA with VectorVision Hip navigation system (BrainLAB). Implants were AMS HA cups and PerFix stems (Japan Medical Materials, Osaka). Appropriate angles and positions of cups were decided on the 3D model of pelvis before operation. According to the preoperative planning, we put the implants with navigation system. We correct the pelvic inclination angle and measured the depth of cups with 3D template software. Results. The average distance from the surface of the cup to the edge of medial wall of pelvis was 3.4mm (0.0–8.0mm) on the axial plane which include the center of femoral head on postoperative CT. The average distance from the surface of the cup to the edge of medial wall of pelvis was 6.4mm (1.5–15.0mm) on intraoperative navigation. The average error was 2.9mm (0.0–9.0mm). The cup positions of post operative CT were deeper than that of intraoperative navigation in twenty six hips (86%). Conclusions. The shallow setting of cups caused the instability of cups. Deep setting caused damage of acetabular fossa. The positions of cups on the navigation system tend to be shown shallower than actual positions, so we should take care of deeper setting

Robotic technology in adult reconstruction – initially the placement of the stem during THR – was introduced in the early nineties of last century, starting in the US. The underlying technology dated back to the year 1986. Because of regulatory restrictions the technology could not spread in the US, but was exported to Europe in 1994. There the technology – primarily distributed in Germany – had a great success and by the year 2000 roughly 50 centers were using Robodoc – the first robot on the market – and a very similar German competitor’s product, CASPAR. The initial robot was a crude machine, basically the unchanged beta version. Cumbersome fixation, a registration process using three fiducials, the requirement for second surgery to place the fiducials, and last but not least raw and hardly elaborated cutting files made surgery with Robodoc a demanding undertaking. Yet feedback from the surgeons, sometimes vigorously expressed during regular user meetings, let to continuous evolution of the system and resulted in an advanced and stable technology. Also training – with important input from the already experienced sites – improved significantly, which can best be demonstrated by procedure time for first surgery: in Frankfurt 1994 roughly four hours, while today first surgeries at new sites rarely exceed two hours. Further applications – revision surgery, total knee replacement – helped to justify the significant investment into the system. While robotic technology underwent evolution, other related technologies were developed and entered the market. Main products were the navigation systems, which initially were developed for neurosurgery and spine surgery and which, due to easier handling and lower costs, found more acceptance on behalf of the surgeons. Although the navigation technology in some regards is a step back from the robotic technology, it appealed for just that reason: the surgeon stays in the loop. The surgeon uses the traditional instruments, and the navigator helps him to achieve precision in reaming or placement of implants. In orthopaedic surgery navigators became very popular in TKR, but also in THR. Another development, completely unrelated to the mentioned technology, presented a new challenge: minimal invasive surgery. While in knee surgery the introduction of arthroscopy in the late seventies already proved the feasibility of minimal invasive techniques, adult reconstruction remained the domain of sometimes aggressive and robust surgery. Only recently minimal invasive procedures were introduced and standardized for a couple of applications. It is important to stress the fact that the term ‘minimal invasive’ did not relate to the size of skin incision only, but to the overall degree of soft tissue damage necessary to prepare for and place the implants. Some companies now offer new instruments allowing for very minimal incisions and reduced soft tissue compromise. In contrast to this development robot assisted surgery remained – in spite of numerous improvements – a rather invasive piece of surgery. These separate developments – navigators and minimal invasive surgery – made robot assisted joint surgery in the eyes of many potential users a rather outdated, superfluous and expensive type of technology. It is therefore time to revisit the original intentions that let to the development of robot assisted surgery. The original ideas were sponsored by veterinary surgeons specializing in cementless THR for dogs. They experimented with custom implants, but they identified two fields of concerns: fractures and poor placement. Both problems are – still – common in human THR. Robot-assisted surgery was supposed to mainly address these problems. Another asset of robot-assisted surgery is seen in machine milling, which was invented as part of the robotic procedure and which turned out to be superior to conventional reaming. The published results of robot-assisted THR (i.e. Nishihara et al, 2006) prove that these requirements were met. In our own series in Spain we had no fracture and every single implant was seated according to the preoperative plan. Animal experiments allowing for histological examination of the bone-implant interface showed the uncompromised cancellous scaffolding supporting the implant, while hand-reamed interfaces showed signs of destruction and atrophy. On the other hands there are concerns that current minimal invasive approaches do cause problems in these regards: control of position is mainly feasible by use of intraoperative x-ray, and fractures do occur. Therefore robot-assisted surgery seems to be the ideal complement for the minimal invasive approach. The deficits of MIS regarding orientation and visualization of the surgical object can be compensated by the robots proven ability to execute preoperative established plans. The challenge is the current invasiveness of robotic surgery, which – as primary tests and studies show – can be easily accounted for. In conclusion there is an ever increasing role for robot-assisted surgery in adult reconstruction. It is up to the surgeons to define the requirements and ask for specifications that will meet their and the patient’s expectations regarding the degree of invasiveness involved

Spinal infections are rare diseases, whose management highlights the importance of a multidisciplinary approach. Although treatment is based on antibiotics, always selected on coltural and antibiogram tests, surgery is required in case of development of spinal instability or deformity, progressive neurological deficits, drainage of abscesses, or failure of medical treatment. The first step of the algorithm is diagnosis, that is established on MRI with contrast, PET/CT scan, blood tests (CRP and ESR) and CT-guided needle biopsy. Evaluation of response to the specific antibiotic therapy is based on variations in Maximum Standardized Uptake Value (SUVmax) after 2 to 4 weeks of treatment. In selected cases, early minimally invasive surgery was proposed to provide immediate stability and avoid bed-rest. From 1997 to 2014, 182 patients affected by spinal infections have been treated at the same Institution (Istituto Ortopedico Rizzoli – Bologna, Italy) according to the proposed algorithm. Mean age was 56 years (range 1 – 88). Male to female ratio was 1.46. Minimum follow-up was 1 year. Infections were mostly located in the lumbar spine (57%) followed by thoracic (37%) and cervical spine (6%). Conservative treatment based on antibiotics needed surgery (open and/or percuteneous minimally invasive) as an adjuvant in 83 patients out of 182 (46%). Management of spinal infections still remains a challenge in spinal surgery and a multisciplinary approach is mandatory. This algorithm represents the shared decision- making process from diagnosis to the most appropriate treatment and it led to successful outcomes with a low-complication rate. We present this algorithm developed to organize the various professionals involved (orthopaedic surgeons, nuclear medicine and infective disease specialists, interventional radiologists and anaestesiologists) and set a shared pathway of decision making in order to uniform the management of this complex disease

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Introduction. With the introduction of minimally invasive surgery techniques and improved polyethylene wear properties, there has been a renewed interest in Unicondylar Knee Replacements (UKR). Customized, Individually Made (CIM) UKR have been in the market for some time, and have shown to provide improved coverage and fit. The purpose of this study was to assess clinical and patient-reported outcomes utilizing CIM-UKR prostheses. Methods. A prospectively recruited cohort of 118 patients was implanted with 120 CIM-UKR (110 medial/10 lateral) at multiple centers across the US. Patients were diagnosed with uni-compartmental osteoarthritis of the medial or lateral compartment. Patients with compromised cruciate or collateral ligaments or having a varus/valgus deformity <15. °. were excluded. Patients were assessed for Knee Society Knee and Function Scores, WOMAC & ROM pre-operatively (120 patients), at 6-weeks post-op (119), 6-months post-op (71 optional visit), 1 year post-op (113) and 2 years post-operatively (96). For the 3 and 4 year post-operative time points, patients were contacted to report on any possible adverse events. Results. Range-of-motion was improved from 120. °. pre-operatively to 131. °. at 2 years post-op. Patients demonstrated marked improvements from baseline scores across all domains. All patients have passed their 2-year follow up visit to date. Average KSS Knee Scores significantly improved from their preoperative levels to 95 at the 2-years follow-up visit. KSS Function domain scores significantly improved from pre-operative levels to 91 at the 2 year time-point. Similar improvements were noted in the WOMAC score, which was reported to be 89 at the 2 year time point. Average VAS Pain scores at the 2 year visit was 1.3. To date, at an average follow-up of 3.1 years there have been 2 patients revised for tibial loosening and an additional 2 patients have been revised for disease progression in the other compartments of the knee. Discussion. There are a multitude of studies of off-the-shelf mobile and fixed-bearing UKR. The 2-year follow up data collected on CIM-UKR compares favorably to both published scores as well as revision rates for off-the-shelf implants

Total joint arthroplasty (TJA) has historically been considered primarily an inpatient operation. However, the actual length of stay (LOS) has diminished over time. At our institution the LOS from 1987 to 1990 averaged five to seven days. This decreased to three days from 1993 to 2002 and down to one to two days from 2005 to 2011. With the adaptation of improved anesthesia and pain management protocols, minimally invasive surgery techniques, rapid recovery protocols, and proper patient selection, outpatient (OP) TJA appears to be the next step in maximizing peri-operative efficiency; especially as younger patients are undergoing TJA. Other potential benefits of OP TJR include improved patient care and control, better patient and surgeon satisfaction and a lower overall cost. Over a twenty-four month period (July 2012 to June 2014) we performed 250 primary TJAs (139 hips and 111 knees) and twelve revision TJAs (six hips and six knees). All patients received 400 mg of celecoxib pre-operation and 200 mg/day for ten days. In addition to general anesthesia, hips received a short-acting spinal and knees received an adductor canal block. Tranexamic acid (IV or topical) and a pericapsular injectable cocktail of liposomal bupivacaine was routinely used. There was one deep infection (0.4%) and one readmission for pain control (0.4%). Two cases of deep vein thrombosis were diagnosed (0.8%). Patient education, home health care utilization, and proper patient selection are key factors to keep hospitalization rates, emergency room visits, and re-admission rates to a minimum

Purpose of study:. The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures. Methods:. A retrospective review of clinical and radiological records was performed on patients with intramedullary nailing of isolated gunshot radius fractures between 2009 and 2013. Results:. Twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19–40). Follow-up was for an average period of 11 weeks (range 6–24). One patient had a median nerve palsy and 2 a posterior interosseous nerve palsy pre-operatively. All operations were performed within 3 to 12 days of the injury. No primary bone grafting was performed. All fractures united with the index procedure. Average time to union was 10 weeks (range 8–24). Fourteen patients (64%) had their radial bow restored and maintained; these patients had minimal comminution in the middle to distal third of the radius. The bow could not be satisfactorily restored in severely comminuted fractures in the proximal third of the radius. Using the Anderson classification outcome was excellent in 14 patients (64%), satisfactory in 6 (27%) and unsatisfactory in 2 (9%). There were no complications associated with the surgery and one patient required nail removal for implant migration. Conclusion:. Intramedullary nail fixation of gunshot radius fractures has shown promising results in our hands with no significant complications. The fracture site and zone of comminution directly influenced our ability to restore radial bow

Total knee replacements (TKR) have been the main choice of treatment for alleviating pain and restoring physical function in advanced degenerative osteoarthritis of the knee. Recently, there has been a rising interest in minimally invasive surgery TKR (MIS-TKR). However, accurate restoration of the knee axis presents a great challenge. Patient-specific-instrumented TKR (PSI-TKR) was thus developed to address the issue. However, the efficacy of this new approach has yet to be determined. The purpose of the current study was thus to measure and compare the 3D kinematics of the MIS-TKR and PSI-TKR in vivo during sit-to-stand using a 3D fluoroscopy technology. Five patients each with MIS-TKR and PSI-TKR participated in the current study with informed written consent. Each subject performed quiet standing to define their own neutral positions and then sit-to-stand while under the surveillance of a bi-planar fluoroscopy system (ALLURA XPER FD, Philips). For the determination of the 3D TKR kinematics, the computer-aided design (CAD) model of the TKR for each subject was obtained from the manufacturer including femoral and tibial components and the plastic insert. At each image frame, the CAD model was registered to the fluoroscopy image via a validated 2D-to-3D registration method. The CAD model of each prosthesis component was embedded with a coordinate system with the origin at the mid-point of the femoral epicondyles, the z-axis directed to the right, the y-axis directed superiorly, and the x-axis directed anteriorly. From the accurately registered poses of the femoral and tibial components, the angles of the TKR were obtained following a z-x-y cardanic rotation sequence, corresponding to flexion/extension, adduction/abduction and internal/external rotation. During sit-to-stand the patterns and magnitudes of the translations were similar between the MIS-TKR and PSI-TKR groups, with posterior translations ranging from 10–20 mm and proximal translations from 29–31mm. Differences in mediolateral translations existed between the groups but the magnitudes were too small to be clinically significant. For angular kinematics, both groups showed close-to-zero abduction/adduction, but the PSI-TKR group rotated externally from an internally rotated position (10° of internal rotation) to the neutral position, while the MIS-TKR group maintained at an externally rotated position of less than 5° during the movement. During sit-to-stand both groups showed similar patterns and magnitudes in the translations but significant differences in the angular kinematics existed between the groups. While the MIS-TKR group maintained at an externally rotated position during the movement, the PSI-TKR group showed external rotations during knee extension, a pattern similar to the screw home mechanism in a normal knee, which may be related to more accurate restoration of the knee axis in the PSI-TKR group. A close-to-normal angular motion may be beneficial for maintaining a normal articular contact pattern, which is helpful for the endurance of the TKR. The current study was the first attempt to quantify the kinematic differences between PSI and non-PSI MIS. Further studies to include more subjects will be needed to confirm the current findings. More detailed analysis of the contact patterns is also needed

Introduction:. The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. Material and methods:. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months. Results:. The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months. Discussion:. The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases

INTRODUCTION. Percutaneous surgery is an increasingly accepted technic for the treatment of Hallux valgus but it has some limitations when the intermetatarsal angle ismoderate to severe, having high risk of recurrence. The mini tight-rope used as a complement for precutaneous surgery avoids complications of open surgery osteotomies (delays consolidation, pain, screws protusion, infection) and it allows us continue with the recurrent trend towards minimal invasive surgery. MATERIAL AND METHOD. Between 2007 and 2009, 60 patients with severe Hallux valgus were treated in our Hospital using the percutaneous mini tight-rope. The mean age of patients was 62, 5 patients were man and 55 were woman. The mean follow-up was 18 months. RESULTS. Patients had clinical assessment using AOFAS score, radiological assessment and a subjective satisfaction degree assessment at 2,6 weeks and 4-6-12 months postoperative. As complications we found four technical failures due to learning curve, one infection and one second metatarsal fracture. CONCLUSION. mini tight-rope is a good option as a supplement in the treatment of severe hallux valgus by percutaneous technique because it avoids complications of open surgery, obtaining satisfactory results in 76% of cases according to the AOFAS scale

Purpose of Study. To assess the results of Revision Hip Surgery in which a less invasive technique was utilized in situations where a number of different options was available. Method. The authors rely on an experience of 3,445 hip arthroplasties by a single surgeon over a period of 20 years, of which approximately 20% were revision cases. Of these 617 cases, we report on 175 in which a minimally invasive option was taken. This does not apply to the skin incision, as all cases were adequately exposed. We have adopted this term to describe cases in which a surgical options was taken that resulted in the least morbidity and the shortest surgical time. We postulated that would lead to the best outcomes with the least complications. Acetabular revisions: 1) Isolated polyethylene exchange. 2) Liner revision with cement technique in cases of cup malposition or poor locking mechanism. 3) Revision of cup with a primary prosthesis with significant medial bone loss. Stem revisions: 1) Cement on cement technique. 2) Strut graft and primary stem. Results. We found a very low complication rate utilizing these methods: Fatal pulmonary emboli: 0 Sepsis: 2 Dislocations 3 Repeat revisions 3. Conclusion. Revision surgery offers many challenges that tend to be compounded with successive operations. We believe that good results can be achieved when a philosophy of minimally invasive surgery is adopted. NO DISCLOSURES

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. The direct anterior approach (DAA) for THA was first performed in Paris, by Robert Judet in 1947. This procedure has since been performed consistently by a small group of surgeons and has recently gained great popularity. Access to the hip can be safely performed with one or two assistants. The advantages of the anterior approach for hip arthroplasty are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. Care must be taken to avoid cutting the lateral femoral cutaneous nerve which runs over the fascia of the sartorius. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to hip arthroplasty and by abandoning the posterior approach and adopting the anterior approach his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation while the posterior rotators and capsule provides active and passive stability and accounts for immediate stability of the hip and a low risk of dislocation. Using the anterior approach, patients are allowed to mobilise their hip freely. The gluteus maximus and tensor fascia latae muscles insert on the iliotibial band which joins them and form a ´hip deltoid´. Lack of disturbance of these abductors and pelvic stabilisers is another benefit of the anterior approach and accelerates gait recovery. The lateral femoral cutaneous nerve is at risk when the fascia is incised between the tensor fascia latae and the sartorius muscle. Damaging it may lead to a diminished sensation on the lateral aspect of the thigh and formation of a neuroma. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intra-operative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. In obese or muscular patients, where visibility is in doubt, an increase of the incision length will give the surgeon the required view. The choice of approach used to perform a primary THA remains controversial. The primary goal of a hip replacement is pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach. The proposed benefits of with the DAA are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the DAA in THA

Introduction. Early rehabilitation of hip and knee replacement patients has been advocated with the recent minimally invasive approaches to lower limb replacement allowing earlier mobilization and earlier discharge. Rehabilitation has been progressively shortened from the time of Charnley in such a way that patients are now expected to stay in hospital for only a couple of days before going home. New rehabilitation protocols recommend mobilization on day 0, the day of surgery, with earlier discharge possible. Methods. All primary hip and knee replacement patients were enrolled in a rapid rehabilitation protocol. All patients had standard incisions performed: a posterior approach for THR and a standard Insall para-patellar approach for TKR. The protocol included pre-emptive analgesia, post-op oral analgesia with high dose NSAIDs, pregabolin, neuro-axial anaesthesia, avoidance of opiates and colloid fluid replacement prior to mobilization. Morning patients were mobilized the day of surgery and afternoon patient the following morning. Duration of hospitalisation was compared to patients treated the previous year where the only difference in protocol was femoral blocks for TKR, no colloid replacement prior to mobilization, and routine day 1 mobilization. Results. 125 patients were enrolled (78 TKR and 47 THR). All patients could be mobilized according to this protocol, irrespective of age. The day of discharge was on average 4,2 days post-op. (Range 3 – 6 days). This was compared to the previous year of joint replacements where the average discharge day was 6,3 days (range 4 – 8 days). Conclusion. This protocol has seen an average 2,1 day earlier discharge from hospital with the same end point at discharge. This has shown us that safe day 0 mobilization of patients is possible, with dramatically improved patient morale, which resulted in much earlier discharge from hospital. These results can thus be achieved not only by minimal invasive surgery but also with standard arthroplasty approaches. NO DISCLOSURES

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. Methods. Medial UKA on 180 cases in 142 patients was performed over a period of 1 year after the first introduction of minimally invasive UKA from January 2002 to December 2002. Among these, 166 cases in 128 patients who underwent Oxford phase 3 medial UKA using the minimally invasive surgery, with the exclusion of 14 cases including 10 cases of follow-up loss and 4 cases of death, were selected as the subject. The mean age of the patients at the time of surgery was 61 years, and the duration of the follow-up was minimum 10 years. All the preoperative diagnosis was osteoarthritis of the knee joint. Clinical and radiographic assessments were measured by the Knee Society clinical rating system, and the survival analysis was confirmed by the Kaplan–Meier method with 95% confidence interval (CI). Results. The mean Knee Society knee and function scores improved significantly from 53.8 points (25 to 70) and 56.1 points (35 to 80) preoperatively to 85.4 points (58 to100) and 80.5 points (50 to 100) at 10-year follow-up, respectively(P<0.001). The mean range of the motion of the knee joint recovered from 128.6° (110° to 135°) to 132.5o (105o to 135o) (P<0.001), and the tibiofemoral angle changed from the mean 0.2° of varus (7o of varus to 7o of valgus) to 4.6° of valgus (2° of varus to 11° of valgus) under the weight-bearing X-ray (P<0.001). Failures following the UKA occurred in 16 cases in 14 patients out of a total of 166 cases (9.6%), and the mean time of the occurrence of the failure was 6.2 years after the surgery. The causes of the failure included 7 cases of simple dislocation of mobile bearing, 4 cases of loosening of implant, 1 case of dislocation of mobile bearing accompanied by loosening of implant, and 1 case of dislocation of mobile bearing accompanied by the rupture of the medial collateral ligament (MCL). Moreover, there was 1 case of fracture of polyethylene bearing, 1 case of deep infection and 1 case of failure because of medial tibial condylar fracture. Of the total of 16 cases of failures, 11 cases (69%) were treated with revision total knee arthroplasty (TKA), whereas 5 cases (31%) were treated with a simple change of mobile bearing. The 10-year survival rate was 90.5% (95% CI, 85.9 to 95.0) when failure was defined as all the reoperations, whereas the 10-year survival rate was 93.4% (95% CI, 89.6 to 97.1) when the cases in which only revision TKA was defined as failure. Conclusions. The results of this study show outstanding functions of the knee joint and satisfactory 10-year survival rate after minimally invasive UKA. Therefore, minimally invasive UKA could be a useful method in the treatment of osteoarthritis in one compartment of knee joint

Introduction & Discussion: From an experience of over 250 Salter osteotomies, 148 of which have been reviewed at skeletal maturity, certain technical tips merit discussion:-. Preoperative positioning and the incision. Psoas tenotomy, capsular exposure and the capsulotomy. Facilitation of the Gigli saw osteotomy. Sizing and procurement of the graft. Displacement and fixation of the osteotomy. Application of the hip spica. Some questions are worthy of debate:-. Can the osteotomy be safely combined with open reduction of the high dislocation?. Should the osteotomy be fixed before reducing the femoral head?. Are there alternatives to autogenous bone graft and K-wire fixation?. Is minimally invasive surgery an option?. Are the contraindications and alternatives to the Salter osteotomy fully appreciated?

The advent of the Australian National Joint Replacement Registry has been an outstanding success in identifying prosthesis with higher than average failure rates, but it is principally a measure of revision rates for specific prostheses. In order to consider the causes of failure it is necessary to start at the point where prostheses are able to enter the Australian market through the Therapeutic Goods administration, Australian Registered Therapeutic Goods list (ARTG) and consider each of the steps of the joint replacement procedure from that point to well beyond the operation date. This ARTG listing process as it now exists is described and an explanation of how this process may need to be reformed if the occasionally very inadequate prosthesis is to be eliminated from the Australian market. Other matters that may be predictors of variable outcomes include hospital case volume, surgeon experience, patient selection and pre-operative planning. Intra-operative factors that lead to failure, including from infection, will include surgical approaches, operative technique, instrumentation, wound care and theatre discipline. Post operatively patient factors, particularly falls and osteoporosis, will influence long-term outcomes as will prosthesis performance. Further concern has been the advocacy by some by what might be considered, fashionable orthopaedics, but the literature to date has demonstrated little benefit from endeavours such as minimal invasive surgery and two-incision hip replacement. Gender specific prostheses and navigation have yet to make their mark as a universally accepted method of performing joint replacement surgery and there may be some negative issues with these matters

Osteocondritis dissecans (OCD) is a relatively common cause of knee pain. Ideal treatment is still controversial. Aim of this exhibit is to describe the outcomes of 5 different surgical techniques in a series of 63 patients. 63patients (age 22.5±7.4 years) affected by OCD of the femoral condyle (45 medial and 17 lateral) were treated by either osteochondral autologous transplantation, autologous chondrocyte implantation with bone graft, biomimetic nanostructured osteochondral scaffold (Maioregen) implantation, bone-cartilage paste graft or bone marrow derived cells transplantation “one-step” technique. Patient evaluation included IKDC score, eq-vas score, X-Rays and MRI preoperatively and at follow-up. Global mean IKDC improved from pre-operative 40.1±14.6 to 77.2±21.3 (p<0.0005) at mean 5.3±4.7 years follow-up, while eq-vas improved from 51.7±17.0 to 83.5±18.3(p<0.0005). No influence of age, size of the lesion, length of follow-up and associated surgeries on the result was found. No differences were found between the results obtained with different surgeries except a slight tendency of better improvement in the result following autologous chondrocyte implantation (p<0.01). Control MRI evidenced a satisfactory repair of cartilaginous layer and subchondral bone. The techniques described were effective in providing good clinical and radiographic results in the treatment of OCD and confirmed the validity of autologous chondrocyte implantation over time. Newer techniques such as Maioregen implantation and “one-step” base on different rationales, the first relying on the characteristics of the scaffold and the second on the regenerative potential of mesenchymal cells. Both of them have the advantages to be minimally invasive surgeries and to require a single operation

Over the past 10 years, the orthopedic community has witnessed an increased interest in more conservative surgical techniques for hip arthroplasty. During this time, second-generation hip resurfacing and minimally invasive surgery enjoyed extensive marketing attention. After a decade of this renewed interest, both of these methods have met with serious concerns. As hip resurfacing numbers decline, both patients and surgeons are looking for other potentially successful conservative treatments to THA. This search has focused surgeon interest toward short-stem designs. Today, a variety of short-stem implants are available with very little clarification of design rationale, fixation features, surgical technique, and clinical outcomes. Virtually every major implant company now offers a “short stem,” and now there are a plethora of different designs. It is important to note, however, that not all short stems achieve initial fixation at the same bone interface region. Furthermore, surgical techniques vary greatly, and postoperative radiographic interpretation of short-stem position and fixation need to be carefully scrutinized. The purpose of this paper is to review past, present, and potential future developments of short femoral stems and to present a classification system that can offer guidance when reporting on the many different stem variations. Short Curved neck-sparing stem (JISRF classification 2a). Recently, new designs are following Pipino's Biodynamic stem style of saving the femoral neck. These designs feature a short curved stem that finds its stabilization contact region in the femoral neck and saves considerable bone in the medial calcar region. In addition, the curvature of the stem prevents violation of the lateral trochanteric region. The shorter stem also reduces blood loss by not reaming the femoral canal distally. These style stems generally have a variable stem length between 90 and 135 mm. This might not appear much shorter than conventional cementless stems (110 to 150 mm). However, the shorter curved neck sparing stems penetrate on average 1 to 2 cm less distally in the femoral canal. Short stems have a definite role in modern THA, as greater emphasis is being placed on soft tissue and bone sparing techniques and as refinements continue in the understanding of proximal femoral fixation. Metaphyseal short stems have significantly less surface contact area compared with conventional length stems and as a result, they might have less torsional and axial resistance. Neck-retaining short stems provide additional axial and torsional stability and reduced stress at the implant– bone interface and may be a consideration in the more active patient profile. Bone quality and the patient's physical activity should be considered prior to the selection of short-stem devices. Many short-stem designs have considerably different style features that may alter bone remodeling. Knowing the design and the required technique is vital to fit the device properly to the patient. The variations of short stems available call for caution in their overall use until there is better understanding of how dependent these stems are on individual stem features, bone quality, and surgical techniques. Overall, the authors are cautiously optimistic and continue advocating their selective use

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

Method: This study reports upon 216 patients (97 Minimally invasive and 119 Standard) enrolled into a randomised control trial comparing a standard posterior approach to the hip with a single incision minimally invasive surgery (MIS) posterior approach at 6 weeks and 1 year post-operatively. Primary outcome measures included operative time, blood loss, length of stay and functional hip scores. Results: The demographics and pre-operative hip scores for both cohorts were statistically similar. Intra-operative blood loss was significantly reduced in the MIS cohort (p=< 0.01). There was no difference in surgical time (p=0.37), time to discharge (p=0.24) or complication rate between the two groups. Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach. Conclusion: This study demonstrates that MIS THA is a safe, reproducible technique in a DGH. We recommend the use of MIS techniques in primary THA and adhere to the principle that an incision need be no longer than necessary to perform the procedure safely

Introduction. Scar sensitivity is a recognised complication of foot surgery. However there is very little published about it. This study looks at the incidence and natural history of scar sensitivity following hallux valgus surgery. Materials and Methods. Patients who had open hallux valgus surgery from December 2008 to December 2009, with a minimum follow up of 12 months, were contacted. Data regarding scar symptoms, their duration, severity at their worst and interventions undertaken were collected. Patients also completed a Roles and Maudsley patient satisfaction score. Results. 125 patients were contacted with response rate of 84%. 30% of patients had experienced scar symptoms following surgery. Of these, 20% had undertaken some form of nonsurgical intervention. The mean duration of symptoms was 16 weeks, and 95% of patients experienced resolution of symptoms. 99% of patients would opt to have the surgery again. Roles and Maudsley score ranged from 1 to 2. Discussion. Nearly one third of patients experienced scar symptoms, however nearly all resolved completely with or without simple treatments. Symptoms were not severe and did not affect satisfaction, function or the decision to have the surgery again. Educating patients preoperatively about scar sensitivity can relieve anxiety and improve the patient experience and they can be advised on simple and effective strategies should this common side effect occur. The results of this study provide the surgeon with valuable information in the consent and education of patients. Also, the fact that nearly all symptom settled within 16 weeks brings into question one of the purported advantages of minimally invasive surgery. Conclusion. Scar symptoms following hallux valgus surgery are common, but mild and almost all resolve in time

Aim: Preliminary results and complications of AGC Total knee Arthroplasty with early results are presented. Materials and Methods: 51 AGC Total Knee Arthroplasties were undertaken between October 2005 and September 2006. There were 22 males and 28 females. Indication for Total Knee Arthroplasty was Primary and Traumatic Osteoarthris. Brain Lab Implant dedicated Navigation was used. Results: Outliers were significantly reduced. Complications including superficial infection, late rehabilitation, and stiffness are reported. No revision was undertaken. Tips and pearls regarding navigated Arthroplasty with reference to learning curve are discussed. Discussion: Each navigation system type has its advantages and disadvantages and can be used with minimally invasive surgery (MIS) total knee arthroplasty (TKA). In addition, concerns for computer glitches, training of personnel, extra time requirements, cost and ability to demonstrate improvements in technique and results are discussed. Conclusions: Navigated Knee Arthroplasty using AGC-Biomet implant is recommended. Early experience is reported. Salient features of early learning curve are discussed. The current paper shows how the anatomic approach can influence soft tissue tension and support the surgeon during release of soft tissues in leg axis deformities

Introduction/Aims. An increased mortality associated with hip fractures has been recognized, but the impact of vertebral osteoporotic compression fractures (VCF) is still underestimated. The aim of this study was to report on the difference in survival for VCF patients following non-operative and operative [Balloon Kyphoplasty (BKP) or Vertebroplasty (VP)] treatments. Methods. Operated and non-operated VCF patients were identified from the US Medicare database in 2006 and 2007 and followed for a minimum of 24 months. Patients diagnosed with pathological and traumatic VCFs in the prior year were excluded. Overall survival was estimated by the Kaplan-Meier method, and the differences in mortality rates (operated vs non-operated; balloon kyphoplasty vs vertebroplasty) were assessed by Cox regression, with adjustments for patient demographics, general and specific co-morbidities, that have been previously identified as possible causes of death associated with osteoporotic VCFs. Results. A total of 81,662 operated (vertebroplasty or kyphoplasty) patients had a survival rate of 74.8% at 24 months following VCF diagnosis compared to 67.4% for the 329,303 non-operated patients. In operated (Vertebroplasty or kyphoplasty) patients there was 44% less mortality than in non-operated VCF patients (p<0.0001). The survival rates for VCF patients following vertebroplasty or kyphoplasty were 72.3% and 76.2% at 24 months, respectively. In kyphoplasty patients there was 12.5% more survival than in vertebroplasty patients (p<0.0001) after 2 years. Conclusions. This retrospective analysis, in 410,965 patients diagnosed with a VCF confirmed the statistical significant decrease (43%, p<0.0001) in mortality between patients receiving minimally invasive surgery compared to non-operated patients. Additionally the present study confirmed a statistical significant decrease (12.5%, p<0.0001) in mortality in BKP patients compared to VP patients

Minimal invasive surgery (MIS) is accepted when the scar is 10 cm or less. The anterior and the antero-lateral approaches had gained recently interest in the total hip arthroplasty because they allow complete muscle sparing. The postero-lateral and lateral approaches were propsed to be less satisfactory from this point of view. The goal of this paper was to report an objective and carfull assessment of the advantages of the minimal invasive posterior approach in short stem (Nanos) total hip arthroplasty. Material and methods. From juli 2005 to march 2009 a total of 113 (70 males,53 female) uncemented Nanos-short-stem prothesis were implanted in 111 patients. The patiens average age was 53 years (33-73). The indication for this procedure was predominantly coxarthrosis. In all cases a minimal invasive posterior approach was used. The mean follow up period was 2,5 years (range 6 months- 4,5 years). The patients were assessed using Harris Hip Score and radiologically to detect any bone changes, the stand of the prothesis and peri-articular ossifications. Results. The perioperative Harris Hip Score was 53 (28-77), postoperative was 94 (86-100). Untill now we have not discovered any prothesis specific complications. Radiological follow up examinations showed the development of increasing trabecular reinforciment of the femoral neck and pertrachanteric regions. There is no evidence of any loosing or migration of the prothesis. No luxation. Calcification was noted in 8 cases (Grad 1), 4 cases(Grad 2), 1 case (Grad 3). In 3 cases we have to change the cup because of malposition. Conclusion. the stem design of Nanos-short-stem prothesis allowed a metaphyseal intertrochanteric multipoint primary fixation. The surgical technique using posterior approach give a good access to the femur and acetabulum. It allows intraoperative ROM as well as extention in the event of intraopertive complications. Long term studies still be needed

Introduction: During the design of minimally invasive surgeries (MIS) carried out on the third toe of the foot, it is important to know the position of the nutrient foramen in the third metatarsal shaft and/or proximal phalanx to prevent complications such as avascular necrosis or delays in consolidation further to corrective osteotomies carried out to treat certain conditions that affect the third toe in toe-to-hand surgical transposition. Our aim was to determine the location of the main nutrient foramen of the third metatarsal and/or proximal phalange providing a mathematical method to accurately locate it prior to surgery. Materials and methods: We studied 70 third metatarsals and proximal phalanges of the third toe from surgically amputated lower limbs. We established the position of the nutrient foramen in both normal feet and those with forefoot pathological conditions by means of the nutrient index and the distance from the nutrient foramen to the base and the distal cartilage border and, for the third metatarsal, also to the dorsal aspect. Results: The most frequent location of the nutrient foramen was the middle third of the shaft on the plantar aspect of both bones, and in the majority it was the only location. The distance from the nutrient foramina to each base was significantly correlated with their total length and physiology; we provide the corresponding predictive equations with regression lines. Conclusions: We propose predictive equations of the distance of the NF from the base of both bones based on their total lengths. This distance can be determined by somatic measurement or by means of conventional dorso-plantar x-rays without contrast medium

Purpose: Objective, prospective study of professional athletes with chronic forearm compartment syndrome and treatment. Materials and methods: We studied 18 cases of chronic compartment syndrome in 12 patients. The sample consisted of 12 men in an age range of 17 to 33. Both forearms were involved in six cases. Sixteen patients were motorcyclists and two were windsurfers. The clinical picture was compatible with chronic compartment syndrome. For confirmation the compartment pressure was measured after simulating each person’s activity. The test was considered positive when the pressure measured 15′ after exercise was > 15 mmHg. Results: The 12 patients presented clinical pictures and compartment pressure test results compatible with severe chronic compartment syndrome of the forearm with loss of sensitivity and proprioception. We found compartment pressures of 15–20 mmHg 15′ after exercise in two cases, 20–30 mmHg in six cases and > 30 mmHg in ten. The flexor and extensor compartments of the forearm were released by minimally invasive surgery. Conclusions: We can conclude that fasciotomy was followed by clinical improvement with no evidence of loss of strength, and the athlete was able to play again within a short time

Purpose: The interest in minimally invasive surgery (MIS) for total hip arthroplasty has not waned in anyway (THA). Different surgical approaches have been used to do MIS-THA. The purpose of this study was to compare the outcome of the THA using the minimally invasive postero-lateral approach (MIS-PL) and minimally invasive antero-lateral approach (MIS-AL). Patients and Methods: Fifty randomly assigned patients with MIS-PL and 32 patients with MIS-AL were included in the study. There were no significant differences in age, sex, diagnosis, JOA score or body mass index in each group. The operation time, length of incision, blood loss, implant position, muscle recovery and complication were observed. Results: Total blood loss and pain was significantly less in patients undergoing THA via MIS postero-lateral approach. In addition, the MIS-PL had improved recovery of muscle strength (hip flexion and abduction) which was statistically significant. Median cup inclination was 42.3 degrees (MIS-AL) and 41.7 degrees (MIS-PL). Median cup anteversion was 18.3 degrees (MIS-AL) and 15.9 degrees (MIS-PL), respectively. Roentgenographic evaluation of femoral component positioning showed no significant difference. Other postoperative data (length of hospital stay, operation time, complication) were comparable. Conclusion: The MIS antero-lateral approach have often been selected to decrease the risk of dislocation, but this approach needs to release the one third of the gluteus medius from the greater trochanter. MIS postero-lateral approach caused less pain and improve recovery time, postero-lateral approach is more suitable for minimally invasive total hip arthroplasty

Introduction: In most areas of surgery there has been a move in recent years towards less invasive operative techniques. However, minimally invasive surgery (MIS) is not automatically ‘better’ surgery. Several MIS techniques for correcting hallux valgus have been described. We present our experience with an MIS chevron type osteotomy, Akin osteotomy and distal soft tissue release. This technique utilises rigid internal screw fixation (without the need for k wire fixation). This is the first such series to be reported in the United Kingdom. Patients & Methods: A consecutive series of twenty three patients (30 feet) with mild to moderate HV deformity were included in the study and were independently assessed clinically and radiographically and scored using the AOFAS scoring system, visual analogue score for pain and a subjective outcome score. All surgery was performed by a single surgeon (DR) using a high-speed burr to create the osteotomies. The osteotomy was fixed with a rigid screw. The mean age was 59 (24–75), and 90% were female. All patients had minimum follow-up of three months (mean 7.5, range 5–12). Results: The mean AOFAS score improved from 39.3 (median 44, range 25–57) preoperatively to 89.9 (median 92, range 77–100) postoperatively. The mean visual analogue score improved from 7 to 1. 82% of patients were very satisfied / satisfied with the procedure. There were no cases of infection, two cases of type 1 complex regional pain syndrome and two screws required removal. Conclusion: This small series represents the senior author’s learning curve with this new technique and as such, these early MIS results compare well with outcomes reported with modern open techniques for mild to moderate hallux valgus deformities. A randomised study to compare open and closed techniques is now being undertaken

Unicompartmental knee arthroplasty (UKA) is a logic procedure when osteoarthritis or avascular necrosis is limitad to one femorotibial compartment. The indications for the procedure includes osteoarthrosis or osteonecrosis with full-thickness loss of articular cartilage limited to one of the tibiofemoral knee compartments. Physical examination should ensure full range of knee motion. Frontal and sagittal knee stability has to be tested. A particular attention should be given to the state of the anterior cruciate ligament. The status of the patellofemoral joint should be analysed by physical examination and patellofemoral view at 30, 60 and 90° of flexion. Preoperative anteroposterior varus and valgus stress radiographs should be done to confirm the complete loss of articular cartilage in the involved compartment, the full thickness cartilage in the opposite compartment and the possibility of full correction of the deformity to neutral. The so-called minimally invasive surgery (MIS) procedure using a specific instrumentation is able to provide quicker recovery since the extensor mechanism disruption is eliminated. More importantly the radiological evaluation has shown that precise implantation of the components is possible with an MIS approach which is important for the long term results of the arthroplasty. The clinical results at ten years of follow-up of cemented metal-backed UKA performed through a conventional approach have shown results comparable to those obtained with total knee arthroplasty. The in vivo kinematic evaluation of patients implanted with UKA has shown that kinematics similar to the normal knee can be obtained, enhancing the importance of a functional anterior cruciate ligament. Recent design improvements have increased the femorotibial area of contact to accommodate high flexion angles. Additionally our experience has demonstrated that modern UKA is a valid alternative for young and active patients with unicompartmental tibiofemoral noninflammatory disease, including both osteoarthritis and avascular necrosis. Compared to medial UKA lateral UKA represents in our experience only 5% of all UKA implantations. However the long term results of lateral UKA compares at least equally with those reported for medial UKA

Objectives. Few reports were shown about the position of the cup in total hip arthroplasty (THA) with CT-based navigation system. We use minimally invasive surgery (MIS) technique when we perform cementless THA and the correct settings of cups are sometimes difficult in MIS. So we use CT-based navigation system for put implants with correct angles and positions. We evaluated the depth of cup which was shown on intra-operative navigation system. Materials and Methods. We treated 30 hips in 29 patients (1 male and 28 females) by navigated THA. 21 osteoarthritis hips, 6 rheumatoid arthritis hips and 3 idiopathic osteonecrosis hips were performed THA with VectorVision Hip 2.5.1 navigation system (BrainLAB). Implants were AMS HA cups and PerFix stems (Japan Medical Materials, Osaka). Appropriate angles and positions of cups were decided on the 3D model of pelvis before operation. According to the preoperative planning, we put the implants with navigation system. We correct the pelvic inclination angle and measured the depth of cups with 3D template software. Results. The average distance from the surface of the cup to the edge of medial wall of pelvis was 3.4mm (0.0-8.0mm) on the axial plane which include the center of femoral head on postoperative CT. The average distance from the surface of the cup to the edge of medial wall of pelvis was 6.4mm (1.5-15.0mm) on intraoperative navigation. The average error was 2.9mm (0.0-9.0mm). The cup positions of post operative CT were deeper than that of intraoperative navigation in twenty six hips (86%). Conclusions. The shallow setting of cups caused the instability of cups. Deep setting caused damage of acetabular fossa. The positions of cups on the navigation system tend to be shown shallower than actual positions, so we should take care of deeper setting

The short stem titanium prothesis preserves the femoral neck. No reamer and no rasp is used for the implantation. Two times compression of the bone with a compressor and with the prothesis it self continues the principle of bone retention. Preserving the femoral neck and compression of the bone lead to an high anchorage and the best primary stability. This is mandatory for safe osseo integration. Except metal on metal all combinations are suitable. Deltaceramic-Deltaceramic is the most modern possibility. The high anchored short-stemp leaves enough virgin-bone for any standard prothesis in case of later revision. In 1999 implantation of CFP Prothesis was started in the Endoklinik-Hamburg. Until 2005 2500 prothesis were implanted. A five year follow up of the first hundert cases does not show system corellated failures. An overview of 2400 implants shows a revision rate of 1%. Total exchange procedure was necessary in 8 cases because of deep infection (0,33%). Only very few none fixed stems and cups had to be reviced. Minimal invasive surgery is well suitable. In our clinic we prefer the posterior aproach. With six sizes left and right nearly all tipe of bone shape is covered. Extreme varus or valgus hips are not indicated as well as severe deformaties. The CFP Prothesis is an good alternative to the CUP Prothesis especially for the young patients with femoral head necrosis which we see in about 10%. A five year follow up is only really interessting if it has bad results, with goog results it gives us confidence to wait for the ten year results

Purpose. To determine if minimally invasive surgery (MIS) for primary hip replacement surgery increases the risk of long term aseptic loosening as predicted by implant micromotion measured with radiostereometric analysis (RSA). Method. Ninety patients undergoing primary THA for osteoarthritis (exclusion criteria: post-traumatic arthritis, rheumatoid arthritis, hip dysplasia, previous hip infection) were randomized to undergo THR surgery utilizing the standard direct lateral approach (n=45; 24 male; age=58 yrs; BMI=27) or MIS via a one-incision direct lateral approach using specific instrumentation (n=45; 23 male; age=55; BMI=29). Uncemented acetabular and femoral (ProfemurZ) components were used with ceramic on ceramic bearings. The femur was marked with 9 tantalum beads placed in the greater trochanter, lesser trochanter, and femoral shaft distal to the tip of the prosthesis. Post-operative care was be standardized according to the care maps at our institution. Primary outcome measure was femoral stem MTPM (maximum total point motion) measured using Model-based RSA. Stereo supine X-rays were taken before weight bearing and 3, 6, and 12 months postoperatively. At the same time intervals Harris Hip Score, Oxford-12, WOMAC, and SF36 questionnaires were administered. Rates of infection, dislocation and revision were recorded. Results. Nine patients were lost to follow-up (4 due to missing post-op exams; 5 did not have enough beads placed during surgery). Ten patients were revised (2 due to failure of the ceramic femoral head; 8 due to long (38.5 mm) neck fractures at 17–30 months postop). There were no differences between groups for all outcome measures. Mean MTPM at 24 months was 3.0mm (SD=2.0mm) for the MIS group and 2.9mm (SD=2.1mm) for the standard group. Conclusion. No difference between groups at one year indicates MIS for uncemented primary THR through a direct lateral approach does not appear to negatively affect stability of the femoral stem. However, there was a high rate of femoral neck fracture in the study cohort that was not related to micromotion or treatment group that indicates a problem with the design of the titanium alloy modular femoral neck

Direct anterior approach (DAA) in supine position is one of the successful minimally invasive surgery (MIS) approaches, but it may need special traction table and stem selection is limited. DAA in lateral position is easier, and full porous cylindrical stem is easily inserted in this approach. The purpose of this presentation is to report this technique and result. 55 patients with osteoarthrosis (Crowe group1 to 3) were undergone THA with DAA in lateral position and followed for a minimum of 7months. Approach and cup settlement is the same as usual DAA in supine position. After liner placement, proximal femur is pushed up anterolaterally with the hip hyperextension, external rotation and adduction, which make excellent view of femoral neck cut surface. Because the leg is shortened, neurovascular relaxation is achieved. PCL retractor of TKA instrument is used to keep tensor fascia femoris muscle laterally over greater trochanter. No other special instrument is needed in stem insertion. Hip scores improved from 37.8 preoperatively to 87.8 postoperatively. Mean incision length was 9cm and mean operation time was 85minutes including routine intra-operative X-ray check. Neither auto blood donation nor cell saver was used. Blood transfusion was not needed. Stem position with over 2 degree varus were in 5 cases (9%) and over 2 degree valgus were in 3 cases (5%). There were no dislocation, loosening, infection, or femoral nerve injury. In supine position, hip motion in sagittal plane has limitation. DAA in lateral position afford more extension with easily controlled external rotation and adduction which is the key to insert stem easily. DAA in lateral position is easy and tolerable MIS

On the basis of observations made in recent years, it can be inferred that the incidence of venous thromboembolism (VTE) in Japan is as high as that in Western countries. Since 2007, the use of fondaparinux for the prophylaxis of VTE following lower-limb orthopedic surgery has been approved for Japanese patients. This study was performed with an aim to investigate the safety and efficacy of fondaparinux for the prevention of VTE following hip surgery in Japanese patients. From June 2007 to August 2008, we evaluated 141 consecutive patients (148 hips; average age, 65.6) undergoing total hip replacement (THR), consisted of cementless minimally invasive surgery, and hip fracture surgery (HFS), consisted of open reduction and internal fixation or bipolar hemiarthroplasty. We mainly used 2.5 mg of fondaparinux for a period extending up to 14 days. We estimated the symptomatic VTE and asymptomatic deep-vein thrombosis (DVT) rates in patients by ultrasonography performed on preoperative and postoperative day 3. In addition, we evaluated the pre-operative and postoperative plasma D-dimer levels on days 3, 7, and 14. We determined that both the preoperative and postoperative incidence of symptomatic VTE was 0%. A D-dimer value of 20 ug/ml or higher was not observed on preoperative days 3 and 7; however, this value was observed in 2 hips on postoperative day 14. The incidence of asymptomatic DVT was observed to be 0.8% preoperatively and 4% postoperatively. In particular, the corresponding value following HFS was observed to be 7.7% preoperatively. The incidence of the hemorrhagic event was observed to be 14.9%. Bleeding was mostly observed in the surgical and drainage areas. An overall major bleeding incidence of 0.7% (1 patient) was observed. The corresponding value in patients in whom the administration of fondaparinux was discontinued by day 14 was 18.9%. The study results indicate that fondaparinux is useful in Japanese patients for the prevention of VTE following hip surgery. However, the administration of this drug should be accompanied by additional measures to prevent the associated side effect of bleeding

Introduction:. Proponents of quadriceps-sparing (QS) subvastus approach for total knee arthroplasty (TKA) suggest short-term advantages including better early functional results, less pain and shorter hospital stay. However, because of potentially reduced visibility and exposure, the QS approach may compromise component alignment – an important surgeon-controlled outcome affecting implant longevity. The purpose of this study was to determine if a QS approach resulted in compromised component alignment compared to a medial parapatellar arthrotomy (MPPA), when both were performed with contemporary minimally invasive surgery (MIS) principles including small incision (≤ 15 cm), MIS instrumentation, patellar subluxation without eversion, and in situ bone cuts. Methods:. This prospective, randomized, double-blinded study enrolled 128 patients with knee osteoarthritis undergoing primary TKA using the same cemented, posterior-stabilized prosthesis. After skin incision, patients were randomized to MPPA (n = 66) or QS technique (n = 62), with all surgeries performed by two fellowship-trained arthroplasty surgeons. Using the Knee Society roentgenographic evaluation system, two reviewers blinded to the surgical approach evaluated post-operative radiographs to measure coronal and sagittal plane alignment using the standing femoral and tibial angles as well as the lateral femoral flexion and tibial angles. Inter-observer agreement was ensured by a secondary review of all x-rays where the two observers differed by more than 1 degree in their measurements of a specific radiograph. Differences in mean angles were evaluated using the general linear model and differences in proportions were evaluated using binary regression. All analyses were conducted with SAS 9.3 on the Windows Ultimate 64-bit operating system. Results:. Standing and lateral radiographs were available for 63 of 66 patients in the MPPA group and 61 of 62 patients in the QS group. No significant differences were noted in either coronal or sagittal plane component alignment between the two groups and the proportion of patients whose implants were in the normally acceptable range of alignment was not significantly different between the QS and MPPA groups (Table 1). The inter-rater reliability for each of the four radiographic measures was above .90. Conclusions:. In this prospective, randomized, blinded study, a QS surgical approach did not result in radiographic alignment differences or an increase in TKA component malalignment relative to a MPPA approach, when MIS principles were adhered to in both groups. Of all measurements, the standing tibial angle showed the most outliers in terms of acceptable alignment, with coronal plane tibial component position outside the desired range in 17.5% of patients in the MPPA group and 16.4% of patients in the QS group

Although modern operative intervention for calcaneal fractures has improved the outcome in many patients, there still is no real consensus on treatment, operative technique, or postoperative management. Vira® is a system for reconstruction-arthrodesis of severe calcaneal fractures, consisting in minimally invasive surgery using cannulation technique. The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with severe calcaneal fractures. The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it. CPG include three phases determined from the physiopathology and biomechanical reasoning of surgical system (weeks after the surgery: 2. a. –5. a. , 5. a. –14. a. , 14. a. –+/−24. a. ). Unfortunately, evidence related to the treatment of severe calcaneal fracture was sparse and often of poor methodologic quality. The recommendations that were included: early onset (2. a. week after the surgery) with early mobility and loading, program of home exercises, manual therapy (articular and miofascial techniques), walking in swimming pool, continuous electromagnetic fields of 99Hz with an intensity of 99 Gaussian during 30 min/day; electrotherapy of the intrinsic muscles of the feet (80Hz; 8:12, 20 mi), a program of active exercises of the feet (dorsiflexion and plantarflexion, not supination and pronation) and resistive exercises of triceps surae muscle (7. a. week), criotherapy and anti-inflammatory positions

Introduction and Aims: With interest in minimally invasive surgery, and smaller incisions for total hip arthroplasty (THA), ways to ensure appropriate alignment are critical. Femoral stem varus has been associated with poorer results. We report the incidence of varus placement of a tapered, proximally plasma-sprayed, titanium femoral component and describe the outcomes of varus at minimum five-year follow-up. Method: Between 1986 and 1997, 1080 tapered, proximally plasma-sprayed femoral components were implanted in primary cementless THA at one institution. Twenty-six components in 25 patients were placed in five degrees or more of varus. Two patients were lost to follow-up. The need for further surgery was assessed and Harris hip scores evaluated. Results: Harris hip scores improved an average of 44 points. All femoral components were judged to be osteo-integrated. There was no displacement or progression into further varus, or impending failures. One well-fixed stem was revised at an outside institution for unexplained pain at 2.5 years. Survival with aseptic loosening as an end-point is 100 percent. Overall survival of the femoral component is 96 percent at 10 years average follow-up. Conclusion: As visualisation decreases with decreasing incision length, a component that is reliably placed into appropriate position is required. Implant position with this component is forgiving. It may be an excellent choice for less-invasive techniques with compromised visualisation. In varus, the stem performs well, with no revisions for aseptic loosening and a 96 percent survival at up to 16 years

Introduction. Prospective study based on professional sportsmen who affected from Chronicle Compartmental Syndrome in forearm and its treatment. Material and methods. 32 Chronicle Compartmental Syndrome in forearm were studied in 24 patients. Our selection was composed by 16 men and 8 women. In 8 of our cases both forearms were operated. The age range was from 17 to 33 years of age. Their sportive activity included: 20 professional motorcyclists, 2 wind-surfers and 2 mountainbikers. To demonstrate evidence of Chronicle Compartmental Syndrome we performed a diagnostic test based on the measure of the intracompartmental pressure after stimulating their usual sportive activity. We considered a positive test when the measured an IMP> 15 mmHg after effort. We also performed a dynamometric of their grip and strength of the thumb-index forceps before and after surgery. Results. All 24 patients presented clinical and tests compatible with Chronicle Compartmental Syndrome in forearm during effort activities which reached severe range due to loss of sensibility and propioception. - From 15 to 20 mmHg of IMP after effort, 8 cases. - From 20 to 30 mmHg of IMP after effort, 11 cases. - Over 30 mmHg of IMP after effort, 13 cases. Minimal invasive surgery based on fasciotomy was performed to release compartmental pressure in flexor and extensor compartments of the forearm. Conclusions. We can conclude that after fasciotomy most of our patients improve either clinically and diagnostic tests results, without strength loss, and are able to return to their usual activity completely recovered in a short period of time

Aim. The purpose of this study was to assess the outcome of arthroscopic shoulder surgery by evaluating the pre- and postoperative shoulder function using a simple self-assessment questionnaire filled in by the patient. Patients and Methods. In this study 89 patients were studied who underwent arthroscopic subacromial decompression. Shoulder function was assessed preoperatively and at 3 to 6 months following surgery according to a self-assessment questionnaire, which was developed in our Shoulder Unit. It allows for a maximum score of hundred, with 30 points for pain, 20 for power and 50 points for work, recreation and 8 activities of daily living. Results. All patients reported improvement in shoulder function with an average total shoulder score increase from 33.4% preoperatively to 87.8% post-surgery. The pain score increased from 21% to 83%, power from 30% to 89% and activities of daily living from 42% to 90%. Detailed analysis of ADL’s showed substantial improvement in all functions. Conclusion. This study has shown that minimal invasive surgery to the shoulder in the form of arthroscopic procedure, results in satisfactory improvement of all outcome measures in the majority of the patients. Together with low morbidity and early functional recovery, shoulder arthroscopy appears to be the procedure of choice in current surgical practice. We believe that the self-assessment questionnaire represents a useful outcome measure and reflects the improvement in shoulder function as perceived by the patient

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: 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

Background. Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery. Methods. Over a twenty-two month period all patients undergoing interventional hip arthroscopy were recorded on a prospective database. Patient demographics, diagnosis, operative intervention and complications were noted. Patients were scored pre-operatively and postoperatively at 6 months and 1 year using the McCarthy score. Results. 94 patients met the criteria for inclusion in this study. Median age was 39 (15–66) years with 57.4% female, 16 patients were over the age of 50 years. At operation, 50 patients had a labral tear, 70 had cam impingement and 62 had chondral damage, with 21 of these deemed severe (grade 3 or 4). For all patients a mean increase in the McCarthy score of 14.6 (p=<0.0001) was seen at 6 months and 19.1 (p=0.0002) at 1 year postoperatively. For those over 50 years, at 6 months an increase of 11.9 (p=0.08) was seen, improving to 33.8 (p=<0.0001) at 1 year. Eight patients underwent THR, of these, 2 were over 50 years of age. All of this group of patients had chondral damage (50% judged as severe at arthroscopy). At 6 months postoperatively these patients had severe pain and their mean score worsened by −16.3 (p=0.2). Few complications were seen, 7 patients had tight access (5 males), 3 of which received chondral scuffing and 1 had the procedure abandoned, 1 patient had groin labral bruising and 2 patients had transient parasthesia. Conclusions. Patients see a gradual and significant improvement post hip arthroscopy, with symptoms continuing to improve until 1 year. This is a well-tolerated procedure with a low complication rate and the opportunity for treatment of a range of hip pathology. Patients over the age of 50 gain a significant improvement from this procedure. Two groups of patients who gain no improvement are those with inflammatory arthropathy and those with dysplastic acetabulae

Aims: The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability. Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before. NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time. Methods: We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute 56 fractures were uni-condylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3). The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen. X-rays. Results: The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%). Conclusions: We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cut-down the functional recovery time. Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness

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

Introduction: Introduction of the minimal invasive surgery as a new concept in spinal surgery necessitated the need for implants that can be applied through minimal invasive approaches. One of the great challenges was the development of anterior minimal invasive vertebral replacement implants that are mechanically fit and easily applicable. Many studies were concerned with the early results of such implants but not yet the long-term or late ones. Methods: Between January 2003 and December 2003 we have operated 23 patients (13 males and 10 females) with traumatic thoracic or thoracolumbar fractures that were indicated for corpectomy. In addition to posterior transpedicular instrumentation, anterior thoracoscopically assisted corpectomy and reconstruction using a telescopic vertebral body replacement cage was done in all patients. Patients were operated either in one or two sittings. Preoperative complete clinical, neurological and radiological evaluation was done. Postoperatively, clinical and radiological outcomes were evaluated, including postoperative neurological improvement, ODI (Oswestry Disability Index) and fusion rate. The average follow up period was 4 years. Results: Fusion rate was 100% at the final follow up. The mean age was 52.5 years. 6 patients had preoperative neurological deficits varying from Frankel B to Frankel A that were improved postoperatively in 5 cases and not improved in one case. The average corpectomy time was 148 minutes (range 75–240 min.). The average ODI was 8.6 (range 0 – 31). Postoperative complications included wound healing problems in one patient, psoas abscess in one patient and pulmonary embolism in one patient. The average preoperative kyphosis (Cobb angle) was 22.43 that were improved to 7.28 degrees postoperatively, and it was 11.8 degrees at the final follow up. Considerable cage sinking (more than 5 mm) was detected in two cases. Conclusion: Vertebral body replacement cage that can be thoracoscopically applied is a good solution for ventral implants in cases of thoracolumbar fractures that required corpectomy. It showed good early as well as 4 years follow up results. Study Type: Prospective observational study

The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability. Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before. NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time. We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute Norian:. 56 fractures were unicondylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3). The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen. X-rays. The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%). We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cutdown the functional recovery time. Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness

The purpose of this study was to evaluate early results of a new, as yet undescribed, minimally invasive, gluteus maximus splitting posterior approach for metal on metal (MOM) hip resurfacing. Surgical approach is described, backed with a video of the procedure. Results of the first 100 cases are presented. A new, minimally invasive, gluteus maximus splitting approach is described. The single incision approach allowed MOM hip resurfacing to be carried out through an incision ranging 8.25 ± 2.25cm. Release of gluteus maximus insertion to femur is not necessary. Intra-operative fluoroscopy is not necessary. Special acetabular reamer handle and acetabular impactor had to be used for accurate acetabular component placement. Femoral neck targeting device, suitable for minimally invasive surgery was used for accurate placement of femoral neck centring pin. This allowed for accurate placement of femoral component. Results of 100 patients who had undergone MOM hip resurfacing are presented: Average review was 2 years, range 22–46 months. Average age of patient was 57 years; range 55 ± 22 years. Average BMI was 27; range 29.95 ± 11.85. Average blood loss was 270ml; range 450 ± 350ml. Average incision was 8cm; range 8.25 ± 2.25cm. Operation time was no longer than conventional open posterior approach. Early discharge at day 3, post-op was possible and patients were able to walk without aids at 3 weeks, post-op. There were no cases of infection, nerve damage, dislocation or malposition of implant. There was no case of hypertrophic bone formation. There was one fracture neck of femur at 6 weeks post-op. Minimally invasive hip resurfacing can be carried out successfully using a new gluteus maximus splitting approach with excellent early results and no complications apart from 1% risk of fracture neck of femur

Introduction. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy. In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards. Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August 2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to co-existing medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure. Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In addition, any adverse outcomes were recorded. Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1) midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction (1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days. Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed

Introduction. Recently used hip resurfacing systems remove bone, ream away the subchondral bone stock and reduce biomechanical properties of the femoral neck. Since much bone was removed from the head, the biomechanical properties decrease. The Onlay Resurfacing technique preserves complete bone stock and individual anatomy without any change in offset or leg length. To quantify the clinical outcome and adverse events a group receiving standard total hip arthroplasty was designed as control. Methods. 104 patients with primary osteoarthritis underwent hip onlay resurfacing. Mean aged 51 years, BMI 27,2. An onlay resurfacing system with a cemented femoral cup and a modular cementless acetabular component was used for resurfacing. The control group (n:104) got a standard cementless THA with a standard head size of 32 mm in diameter. All procedures were performed by one surgeon and the same minimal invasive antero lateral approach was used. An identical post-operation procedure with regards to rehabilitation, physiotherapy and medication was performed in both groups. The Harris Hip Score was designed as the primary criteria. Results. In the Onlay Resurfacing group the HHS improved six weeks, six months and three years after surgery from 46 to 89, to 95 and 97 after three years. Compared to resurfacing the THA improved from 42 to 85, to 92 and 93 after three years. At six months and three years, the SF12 score (mental and physical) improved to normal in both groups. One neck fracture and one aseptic loosening occurred in the onlay resurfacing group, one DVT and 1 dislocation were found in the control group. No implant failure in both groups and no difference in blood loss. The mean leg length after standard THA shows 0.4 mm lengthening in contrast to resurfacing without statistic significant difference. Conclusion. Hip onlay resurfacing preserves maximal bone stock and provides excellent functional outcome. The outcome was better in the onlay resurfacing group compared to standard THA. Combined with minimal invasive surgery patients will be able to shorten the rehab phase significantly. Side effects such as luxation, instability and length differences were expected to appear less frequently but adverse events typically related to resurfacing such as neck fracture occur. Because of the modularity of the onlay resurfacing system, revisions of the femoral component could be done as a primary hip arthroplasty

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 attempt to achieve and institude the potential less minimal invasive hip hemiarthroplasty by using common instruments is the aim of our study. We report on a randomly selected group of 80 patients, 40 of which were operated by a small incision 5–10 cm (group A) and 40 by a standard incision 15–20 cm (group B). The approach was through the gluteus medius muscle (lateral-Hartinge) in all of the cases. In group A an additional small transverse incision of the fascia was needed without any other inside extension. There were no statistical differences in gender, age (mean age 80 and 79 years old respectively), weight of the patients (average BMI 27,5 kg/m2 and 27 kg/m2 respectively) and implant type. The operations were supervised by the same surgeon. PMMA was used in 18 of the cases in each group. Blood loss was less in group A (mean 200cc less) and 21 patients were not transfused at all intraoperatively. A second assistant was necessary in educational operations. Four of the patients had postoperatively bruises and skin scratches. Early postoperative pain was less in the first group, but was the same two months postoperatively. Thirteen patients slept on the operated leg on the 2nd and 3rd postoperative day. Discharge from the hospital was available two days earlier in the first group. We had one hip dislocation in the first group in a psychiatric patient who had also DVT. In conclusion , minimal invasive surgery in hip hemi-arthroplasty is possible to be performed with the use of common instruments and it is worth once while. Experience of the surgical team is necessary for reducing operative time and further research is needed for establishing possible contraindications

Purpose: To determine the level of promotion of minimally invasive surgery (MIS) & computer assisted orthopaedic surgery (CAOS) in total knee replacement (TKR) through internet sites by BASK members. Methods: We obtained an updated list of active members of BASK in March 2007 and permission from the executive committee to undertake this study. Standard search engines commonly used in our daily lives (viz. Google, Yahoo and Ask.com) were used to search for websites related to each surgeon during Sep–Nov 2007 period. The surgeon’s name, initials and job title thereof were used as keywords in conducting the search. Thus for each surgeon, all websites found were browsed and evaluated for MIS/CAOS and TKR/UKR information. Both direct (surgeon’s personal website/private practice) and indirect (group practice/hospital/university affiliation) information from these websites were reviewed and a standard pre-formed questionnaire proforma was filled in against that particular surgeon. Results: A total of 178 websites were found for 405 members (392 inland + 13 overseas). 2.8% and 4.5% made direct and indirect reference to MIS TKR respectively. The most commonly listed benefits of MIS were quicker recovery, smaller incision and hence lesser pain. Very few specific risks of MIS were outlined by these websites. None of the websites quoted any peer-reviewed publication to support their claims. CAOS was discussed in 1.7% and 2.8% of these sites respectively. Conclusion: Our study suggests that many active members do not have personal websites and these procedures are not commonly promoted by them via the internet. Many of these are often associated indirectly with group practice/institutional affiliation websites which may not necessarily be endorsed the surgeon. Our plan in near future is to monitor the changes in internet dissemination of information and close the audit loop by next year

The knee is one of the most commonly affected joints in osteoarthritis. Unicompartmental knee replacement (UKA) was developed to address patients with this disease in only one compartment. The conventional knee arthroplasty jigs, while usually being accurate, may result in the prosthesis being inserted in an undesired alignment which may lead to poor post-operative outcomes. Common modes of failure in UKA include edge loading due to incorrect sizing or positioning, development of disease in the other compartment due to over-stuffing or over-correction and early loosening or stress fractures due to inaccurate bone cuts. Computer navigation and robotically assisted unicompartmental knee replacement were introduced in order to improve the surgical accuracy of both the femoral and tibial bone cuts. The aim of this study was to assess accuracy and reliability of robotic assisted, unicondylar knee surgery in producing reported bony alignment. Two hundred and twenty consecutive patients with a mean age of 64 + 11 years who underwent successful medial robotic assisted unicondylar knee surgery performed by two senior total joint arthroplasty surgeons were identified retrospectively. The mean body mass index of the cohort was 33.5 + 8 kg/m. 2. with a minimum follow-up of 6 months (range: 6–18 months). Femoral and tibial sagittal and coronal alignments as well as the posterior slope of the tibial component were measured in the post-operative radiographs. These measurements were compared with the equivalent measurements collected during intra-operative period by the navigation to study the reliability and accuracy of femoral and tibial cuts. Radiographic evaluation was independently conducted by two observers. There was an average difference of 2.2 to 3.6 degrees between the intra-operatively planned and post-operative radiological equivalent measurements. For the femur, mean varus/valgus angulation was 2.8 + 2.5 degrees with 83% of those measured within 5% of planned. For the tibia mean varus/valgus angulation was 2.4 + 1.9 degrees with 93% within 5% of planned resection. There was minimal inter-observer variability between radiographic measurements. There were no infections in the evaluated group at the time of radiographic examination. Alignment for unicondylar knee arthroplasty is important for implant survival and is a more difficult procedure to instrument as it is a minimally invasive surgery. Assuming appropriate planning, robotically assisted surgery in unicondylar knee replacement will result in reliably accurate positioning of component and reduce early component failures caused by malpositioning. A mismatch between pre-planning and post-operative radiography is often caused by poor cementing technique of the prosthesis rather than incorrect bony cuts. Addressing these factors can lead to greater success and improved outcomes for patients

Introduction. Total hip arthroplasty (THA) using the direct anterior approach (DAA) in a supine position is a minimally invasive surgery that reduces postoperative dislocation. Excellent exposure of both the acetabulum and proximal femoral part is important to reduce intraoperative complications. Generally, two surgical assistants need to hold four retractors to maintain excellent exposure of the acetabulum. We examined intra- and postoperative complications as indicators of the efficiency of using the “Magic Tower” (MT) device compared with a non-MT group. Material and Method. Twenty consecutive DAA THAs using MT were analyzed, and 20 DAA THAs not using MT were also analyzed. MT is a retractor-holding device, and has an arm structure that can be moved in a wide variety of directions. This device holds a retractor stably, and each movement of the arm can be locked by one click. Operating time, blood loss, length of skin incision, intraoperative complications, and number of assistants were recorded. Postoperative radiographs were obtained to evaluate implant position. Results. Mean operating time was 105 min in the MT group and 118 min in the non-MT group. Mean blood loss was 232 g in the MT group and 233 g in the non-MT group. Mean length of skin incision was 80 mm in the MT group and 85 mm in the non-MT group. Mean cup inclination was 45.8° in the MT group and 47.3° in the non-MT group. Postoperative implant position was also excellent in both groups. In all comparisons, no significant differences were seen between groups. No intraoperative complications were encountered. Two assistants were required in the non-MT group, and one in the MT group. Discussion. A majority of the complications reported with THA can be attributed to access issues, i.e., difficulties in exposure and accurate component implantation. To achieve excellent exposure at the acetabulum, four retractors (anterior, posterior, cranial, and caudal) are desirable. In such procedures, two surgical assistants are needed to hold retractors. One of these assistants needs to hold the anterior retractor and cranial/caudal retractor from the opposite side of the surgery beyond the abdomen of the patient. However, the assistant on the opposite side cannot achieve good exposure, as strong retraction of the anterior part of the acetabulum may cause complications of femoral nerve palsy. The MT is able to hold a retractor firmly by applying pressure toward the acetabulum instead of traction, and also reduces the number of surgical assistants required. While preparing the femur, exposure of the femoral canal was also better than in the non-MT group. Conclusion. In primary DAA THA, no significant differences between groups were identified. However, the MT is clearly a useful device that allows maintenance of excellent exposure, reducing the number of surgical assistants required

Introduction. Unicompartmental knee arthroplasty (UKA) has seen renewed interest in recent years due to improved surgical techniques and prosthetic design, and the desire for minimally invasive surgery. For patients with limited degenerative disease, UKA offers a viable alternative to total knee arthroplasty. Historically, the outcomes of lateral compartment UKA have been inferior to medial compartment UKA, with suboptimal patient satisfaction and increased revision rates. Robotic-assisted UKA has been shown to improve precision and accuracy of component placement, which may improve outcomes of lateral UKA. The purpose of this study was to compare the outcome of robotic-assisted UKA to conventional UKA for degenerative disease of the lateral compartment. The hypothesis of the study was that robotic-assisted lateral UKA results in superior outcomes compared to conventional UKA. Materials and methods. A search of the institution's joint registry was conducted to identify patients who underwent UKA for limited degenerative disease of the lateral knee compartment. A total of 130 lateral UKAs were identified that were performed between 2004 and 2012. The mean age of the patients was 63.1 years (range, 20 to 88); patients had a mean BMI of 29.9 (range, 18 to 48). The medical records of all patients were reviewed and assessed for the type of surgical procedure used (robotic-assisted versus conventional), length of hospital stay, Oxford knee score, and occurrence of revision surgery. Results. A total of 93 robotic-assisted and 37 conventional UKA were analysed. At a mean follow-up 35 months (range, 1 to 107 months), the mean Oxford scores in the robotic-assisted and conventional group were similar (39.6 versus 35.9, p=0.135). The length of stay was significantly shorter after robotic-assisted UKA (1.7 days) compared to conventional UKA (2.3 days, p<0.001). There were significantly more revisions in the conventional UKA group [6 conversions to total knee arthroplasty (TKA), 2 tibial component exchanges] compared to robotic-assisted UKA (2 conversions to TKA, p<0.001). Conclusions. The findings of this study revealed a decreased revision rate in robotic-assisted lateral UKAs compared to conventional lateral UKA. Furthermore, patients who received robotic-assisted UKAs had a shorter postoperative hospital stay compared to patients who received conventional UKA. However, overall surgical outcomes were similar in both patient cohorts based on similar postoperative Oxford scores. UKA is a technically challenging procedure with limited joint visualisation and less tolerance for acceptable component position; a two-degree error may lead to UKA failure. Malaligned components may lead to impaired joint biomechanics causing pain and disease progression to other knee compartments. Robotic-assisted UKA systems offer increased accuracy of component placement with objective soft-tissue balancing. Improved component positioning with robotic-assisted UKA systems may improve the long-term survival of UKA in patients with limited lateral degenerative disease, which is performed less often than medial UKA

In the recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that innovative technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied. This study is a prospective clinical randomized trial which primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for hemiarthroplasty in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. To date, 45 patients have been randomized between the two surgery groups has follows: 22 patients in the mini-incision surgery group (MIS) and 23 patients in the standard incision group (STD). Data were collected preoperatively as well as 4 days, 3 and 6 weeks, 3, 6, 12, and 24 months postoperatively. The following validated disease-specific outcome instruments where used: the Jaglal Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life where assessed by the components of the Harris hip Score and SF-36. Radiograghic outcomes where also evaluated as well as the rates of all reported complications and adverse events during the two years follow-up. The demographic data where similar between the 2 groups for age, gender, weight, type of anaesthesia used, pre-operative haemoglobin and preoperative comorbidities. There was no significant difference for operative time, blood losses, 72h postoperative haemoglobin and the need for transfusion therapy between the 2 groups. Also, there was no difference between the groups for post-operative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using the LEM, TUG, Harris Hip score and SF-36 scores did not demonstrate any statistically significant difference between mini and standard incision. This study demonstrates that the clinical and functional outcomes measured are similar between the two groups, thus limiting the potential benefits of MIS in hip fracture patients

Surgical instrumentation for total knee arthroplasty has improved the accuracy, reproducibility and reliability of the procedure. In recent years, minimally invasive surgery introduced instrumentation that was reduced in size to fit within the smaller operative field; with this move the impact and influence of technology became proportionately larger. The introduction of computer navigation is an attempt to improve the surgeon’s visibility in a limited operative field, improve the position of the resection guides, and ultimately the position of the final components. While it may be appealing to rely on computer navigation to perform a TKA, it is not artificial intelligence and does not make any of the surgical decisions. The procedure still is surgeon directed with navigation serving as a tool of confirmation with the potential for improvements in surgical accuracy and reproducibility. The accuracy of TKA has always been dependent upon the surgeon’s judgment, experience, ability to integrate images, utilize pre-operative radiographs, knowledge of anatomic landmarks, knowledge of knee kinematics, and hand eye co-ordination. Recent advances in medical imaging, computer vision and patient specific instrumentation have provided enabling technologies, which in a synergistic manner optimize the accurate performance of the surgery. The successful use of this technology requires that it not replace the surgeon, but support the surgeon with enhanced intra-operative feedback, integration of pre-operative and intra-operative information, and visual dexterity during the procedure. In developing smart tools or robotic systems, the technology must be: safe; accurate; compatible with the operative field in size and shape, as well be able to be sterilized; and must show measurable benefits such as reduced operative time, reduced surgical trauma and improved clinical outcomes. Advocates believe this is attainable and robotic assisted TKA can achieve levels of accuracy, precision and safety not accomplished by computer assisted surgery. Smart instruments and robotic surgery are helping us take the next step into the operating room of the future. The role of robots in the operating room has the potential to increase as technology improves and appropriate applications are defined. Joint replacement arthroplasty may benefit the most due to the need for high precision in placing instruments, aligning the limb and implanting components. In addition, this technology will reduce the number of instruments needed for the procedure potentially further improving efficiency in the operating room. As technology advances, robots may be commonplace in the surgical theater and potentially transform the way total knee arthroplasty is done in the future. Robotic surgery and smart tools are new innovative technologies and it will remain to be seen if history will look on its development as a profound improvement in surgical technique or a bump on the road to something more important

Introduction: Recently frameless stereotaxy has been introduced to assist with the spinal instrumentation. The mobility of individual vertebra however limits its accuracy and ease of use. The authors have developed a novel method of spinal stereotaxy using exact plastic copies of the spine manufactured using biomodelling technology. Methods: Fifteen patients with complex spinal disorders requiring instrumentation were recruited. A 3D CT scan of their spine was performed and the data were transferred via DICOM network to a computer workstation. ANATOMICS BIOBUILD software was used to generate the code required to manufacture exact acrylate biomodels of each spine using rapid prototyping. The biomodels were used to obtain informed consent from patients and simulate surgery. Simulation was performed using a standard power drill to place trajectory pins in the appropriate pedicles. Acrylate drill guides were manufactured using the biomodels as templates. The biomodels and templates were sterilised and used intra-operatively to assist with the placement of the instrumentation. Results: The biomodels were found to be highly accurate and of great assistance in the planning and execution of the surgery. The ability to drill optimum screw trajectories in the biomodel and then accurately replicate the trajectory was judged especially helpful. Accurate screw placement was confirmed with post-operative CT scanning. The design of the first two templates was suboptimal as the contact surface area was too great and complex. Approximately 20 minutes was spent pre-operatively preparing each biomodel and template. Operating time was reduced, as less reliance on intra-operative X-ray was necessary. Minimal invasive surgery was greatly facilitated in planning and execution. Patients stated that the biomodels improved informed consent. Conclusion: Biomodel spinal stereotaxy is a simple and accurate technique which may have advantages over frameless stereotaxy

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