Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing
To date, the literature has not yet revealed superiority of
Background:. Previous attempts at small incision hallux valgus surgery have compromised the principles of bunion correction in order to minimise the incision. The
Purpose: There is great interest recently,among Orthopaedic surgeons about
Introduction: The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on
Background. Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after
A major limiting factor for the accuracy in Computer Assisted Surgery (CAS) is the system’s positional knowledge of the patient’s anatomy, derived through the process of registration. In computer assisted
In all cases a specialized dedicated surgical instrumentation was used. Inclusion criteria to enter the study group (A-B-C Groups) were:BMI<
30, diagnosis of primary osteoarthritis, age<
75 years. Following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional outcomes (HHS, WOMAC) at six weeks.
In control group D (149 patients) the following complications were observed: one proximal femoral fracture, one case of cup malposition and one infection.
Background. Total Shoulder Arthroplasty (TSA) has been shown to improve the function and pain of patients with severe degeneration. Recently, TSA has been of interest for younger patients with higher post-operative expectations; however, they are treated using traditional surgical approaches and techniques, which, although amenable to the elderly population, may not achieve acceptable results with this new demographic. Specifically, to achieve sufficient visualization, traditional TSA uses the highly invasive deltopectoral approach that detaches the subscapularis, which can significantly limit post-operative healing and function. To address these concerns, we have developed a novel surgical approach, and guidance and instrumentation system (for short-stemmed/stemless TSA) that minimize muscle disruption and aim to optimize implantation accuracy. Development. Surgical Approach: A muscle splitting approach with a reduced incision size (∼6–8cm) was developed that markedly reduces muscle disruption, thus potentially improving healing and function. The split was placed between the infraspinatus and teres-minor (Fig.1) as this further reduces damage, provides an obvious dissection plane, and improves access to the retroverted articular surfaces. This approach, however, precludes the use of standard bone preparation methods/instruments that require clear visualization and en-face articular access. Therefore, a novel guidance technique and instrumentation paradigm was developed.
Introduction.
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.
Introduction: The value of arthroscopy, fluoroscopy, and e-learning courses (focusing on minimally invasive surgical techniques) for the treatment of intra-articular distal radius fractures (I-ADRF), remains controversial. This study compares the outcomes after fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures, with or without concomitant arthroscopic evaluation. Materials and Methods: Forty-seven patients with I-ADRF underwent FA external fixation and percutaneous pinning. Among them 23 had additional arthroscopic evaluation of their wrist. For teaching purposes procedures with the use of fluoroscopy and arthroscopy were recorded and adapted as a course for the On-line Performance Support Environment for
Introduction: Recent studies have shown that
Various reports confirm that elevations in serum markers associated with skeletal muscle injury exist and can occur after orthopaedic surgery in the absence of overt clinical manifestations of myocardial injury. The purpose of this study is to measure the influence surgical approach on these serum markers following primary
Increasing incidence of osteoporosis, obesity and an aging population have led to an increase in low energy hip fractures in the elderly. Perceived lower blood loss and lower surgical time, media coverage of minimal invasive surgery and patient expectations unsurprisingly have led to a trend towards intramedullary devices for fixation of extracapsular hip fractures. This is contrary to the Cochrane review of random controlled trials of intramedullary vs extramedullary implants which continues recommends the use of a sliding hip screw (SHS) over other devices. Furthermore, despite published literature of minimally invasive surgery (MIS) of SHS citing benefits such as reduced soft tissue trauma, smaller scar, faster recovery, reduced blood loss, reduced analgesia needs; the uptake of these approaches has been poor. We describe a novel technique one which remains minimally invasive, that not only has a simple learning curve but easily reproducible results. All patients who underwent MIS SHS fixation of extracapsular fractures were included in this study. Technique is shown in Figure 1. We collated data on all intertrochanteric hip fractures that were treated by a single surgeon series during period Jan 2014 to July 2015. Data was collected from electronic patient records and radiographs from Picture Archiving and Communication System (PACS). Surgical time, fluoroscopy time, blood loss, surgical incision length, post-operative transfusion, Tip Apex Distance (TAD) were analyzed. There were 10 patients in this study. All fractures were Orthopaedic Trauma Association (OTA) type A1 or A2. Median surgical time was 36 minutes (25–54). Mean fluoroscopy time was similar to standard incision sliding hip screw fixation. Blood loss estimation with MIS SHS can be undertaken safely and expeditiously for extracapsular hip fractures.
Periacetabular osteotomy (PAO) has been established as an effective technique to treat symptomatic hip dysplasia in young patients. Its role in treating borderline dysplasia and acetabular retroversion is evolving. The aim of this study was to:
Examine the prospectively collected outcomes following a minimally invasive PAO in a large cohort of patients Compare the outcomes of patients with severe dysplasia, borderline dysplasia and acetabular retroversion. This is a single-surgeon review of patients operated in a high-volume centre with prospectively collected data between 2013 and 2020, and minimal followup of six months. PAO was performed using a minimally invasive modified Smith Peterson approach. 387 patients were operated during the study period and 369 eligible patients included in the final analysis. Radiographic parameters were assessed by two authors (GS and KB) with interrater reliability for 25 patients of 84–95% (IntraClass Coefficient). Patient reported outcome measures (i-HOT 12, NAHS, UCLA and EQ-5D) were collected prospectively. Case note review was also performed to collate complication data and blood transfusion rates. Radiological parameters improved significantly after surgery with Lateral centre-edge angle (LCEA) improving by 16.4 degrees and Acetabular index (AI) improved by 15.8 degrees. Patient reported outcome measures showed significant improvement in post-op NAHS, iHOT and EQ5D at 2 years compared to pre-op scores (NAHS=30.45, iHOT=42, EQ5D=0.32, p=0.01). This significance is maintained over 2 years post procedure (p=0.001). There was no significant difference between the three groups (severe dysplasia, borderline dysplasia and acetabular retroversion). Clinical outcomes showed an overall complication rate n=31, 8.3% (Major complication rate: n=3, 0.81%). Non-union rate: n=11, 2.96% of which 3 required fixation (0.81%). Hip arthroscopy post PAO: n=7, 1.9%. Conversion to THR: n=4, 1.1%. Blood transfusion requirement: n=46, 12.5%. No patient developed a major neurovascular injury. In this large single-centre study, patients had radiological and reported outcome improvements following surgery. Overall, there was a low complication rate, providing further evidence of the safety and efficacy of PAO for ameliorating pain and long-lasting results in the management of symptomatic hip dysplasia.
There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures.Background
Objective
The anterolateral MIS-THA approach can be divided into the Modified Watson-Jones approach (MWJ) performed in the lateral position and the Anterolateral Supine method (ALS) performed in the supine position. Femoral preparation is flexible in stem selection in the MWJ method. On the other hand, the ALS method is more stable for placement on the acetabular implant. Now we introduce novel anterolateral MIS approach named AL60, it makes use of the merits of both MWJ and ALS methods. The patient is fixed at 30 degrees on the dorsal side from lateral position. That is 60 degrees on the half side from the horizontal plane, and the platform of the operating table is removed just as in the MWJ method. During surgery, the pelvis is fixed by the posterior support, and the stability of the pelvis is very good. Also, if the inclination is accurate at 30 degrees, by holding the holder parallel to the operating table when inserting the cup, the cup is theoretically inserted at Anatomical anteversion 30 degrees. The intraoperative field of view is also visible to the assistant due to the semi-lateral position. Femoral preparation is easier than the MWJ method because the affected limbs have fallen to the dorsal side already. Since March 2017 to the end of August 2018, the AL60 method was used for 207 primary THA. There were no dislocations or fractures and any other complications. Full weight bearing was possible from the next day. The AL60 method has stability of the ALS method for acetabular preparation and the operability of the MWJ method for femoral preparation. Therefore, it can be said that new AL60 approach method makes use of the merits of both MWJ and ALS methods.Technique
Discussion
First metatarsophalangeal joint (MTPJ) arthrodesis plays a significant role in the management of symptomatic hallux rigidus. Several open and very few percutaneous techniques have been described in the literature. The authors present a new minimally invasive technique along with patient reported outcome, radiological parameters and a discussion on this novel technique. A total of fifteen cases of first MPTJ arthrodesis were included in this prospective continuous series from September 2011 to June 2012. Mean age was 56 years and the indication for surgery was hallux rigidus in 13 of 15 cases. All patients underwent the same minimally invasive procedure by the same primary surgeon (AHS), 13 of 15 as day cases. Clinical outcome and patient satisfaction were assessed by the Manchester-Oxford Foot Questionnaire (MOXFQ) preoperatively and at most recent follow up. Radiographic and clinical evaluation of fusion was also assessed. No patients were lost to follow up and all scores were collected by an independent surgical practitioner to avoid bias. Mean follow up was six months (range 1 to 9 months). The MOXFQ score for cases where fusion was achieved (n=14) improved from a mean 40/64 preoperatively to a mean 15/64 at last follow up ( This minimally invasive technique for first MTPJ arthrodesis is simple and can achieve results similar or better than open techniques in experienced hands. Further cases are needed to expand this series and evaluate for further complications.
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. 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.Background
Methods
Unicompartmental knee arthroplasty has been in use since the 1970s. In spite of early enthusiasm, the procedure soon fell into disfavour, particularly in the USA. Early failures were a result of improper indication, poor technique and in some cases and poor prosthetic design. A new instrument system for use with the MG unicompartmental knee arthroplasty has been designed, with guides for accurate and reproducible alignment, sizing and resection. Potential benefits include early mobilisation, rapid rehabilitation, improved range of motion and shortened hospital stay. This paper briefly reviews the literature and discusses indications and surgical techniques.
A new surgical approach for minimally invasive hip resurfacing is described with early results. A posterior gluteus maximus splitting approach is used. The incision is in line with the fibres of gluteus maximus and is placed 5 cm. distal to the tip of the greater trochanter. Special instruments were necessary to carry out surgery: MIS targeting device for placement of centring pin, MIS retractor system, Chana curved acetabular reamer handle, and curved acetabular impactor.Introduction
Method
The periacetabular osteotomy (PAO) improves hip joint mechanics in patients with symptomatic dysplasia. As a consequence of the multi-planar acetabular re-orientation, the course of the iliopsoas tendon over the hip may be affected, potentially resulting in iliopsoas tendon-related pain. At present, little information regarding the incidence of iliopsoas-related pathology following PAO exists. We aimed to identify the incidence of iliopsoas-related pain following PAO. Secondarily, we aimed to identify any risk factors associated with this pathology. We retrospectively reviewed the PAO's performed from 2014–2017, for symptomatic dysplasia in our unit (single-surgeon, minimum 1-year follow-up). All patients with adequate pelvic radiographs were included. Radiographic parameters of dysplasia were measured from pre- and post-operative AP pelvic radiographs using a validated software (Introduction
Methods
minimally invasive surgery is a concept well known in medicine – In orhotpedic surgery the advent of arthroscopic techniques has given a dramatic change in clinical and surgical approach. Total knee replacement (TKR) is a well established procedure. Good result have been widely documented. Nevertheless wide surgical approach, the post op. pain, the lenght of hospitalization, the rehabilitation program are still long and heavy for the patient. Minimally invasive procedure consist in a new way of approaching the surgical intervention in TKR, riducing the lenght of the incision, minimizing the soft tissue thrauma, sparing as much as possible the extensor mechanism. This new approach has brougt to a change also in instruments design. This is a new technique and we don’t have statistically significative data. We rely upon data from authors like Tria and the clinic results of our cases We can affirm that minimally invasive techniques in TKR permits a lower level of post op. pain and bleeding, shorter lenght of hospital admission time, faster rehabilitation
Mini-incision total hip arthroplasty seeks to eliminate some complications of traditional extensile exposure and also facilitates more rapid post-operative rehabilitation. Posterior approach has been associated with increased risk of posterior dislocation. Thus, a modified mini-incision lateral approach of Hardinge was described not only to overcome this problem by preserving the posterior capsule, but also allows adequate access for orientation of the implant. The author has modified the Hardinge approach by a V-shaped incision where the apex is centered over the tip of the greater trochanter with the one limb extending proximally along the fibers of the gluteus medius muscle and the distal limb extending across the proximal part of vastus lateralis. This innovative surgical approach is described in this article. Larger incisions and surgical approaches have been associated with larger blood loss, greater need for perioperative transfusion, use of more postoperative analgesics, a longer hospital stay, and a slower recovery. In this modified approach, the gluteus medius is left intact. The postoperative strength of the abductors of the operated side was the same as that on the non-operated side and functionally, the direct lateral approach was a safe alternative to other approaches in decreasing the trendelenburg gait and incidence of heterotrophic ossification.Conclusion
Minimally invasive total knee arthroplasty is growing in popularity. It appears to reduce blood loss, reduce hospital stay, improve post-operative quadriceps function and shorten post-operative recovery. We show our experience of minimally invasive TKA with a computer navigation system. The first series compared forty MICA TKA and forty conventional computer assisted total knee arthroplasties (CATKA). Component positioning was assessed radiographically with long leg Maquet views. Knee Society Scores (KSS) were recorded pre-operatively and at 6, 12, 18 months. Length of stay and recovery of straight leg raise was also recorded. A second series of fifty MICATKA patients were assessed post-operatively for component alignment using long leg Maquet views. Twenty-two of these patients had assessment of femoral rotation using CT. In the first series pre-operative KSS showed no significant difference between the two groups. Post-operatively the mean femoral component alignment was 89.7 degrees for MICATKA and 90.2 for CATKA. The mean tibial component alignment was 89.7 degrees for both. KSS at 6, 12, 18 months were statistically better in the MICATKA (p<000.1). Straight leg raise was achieved by day one in 93% of the MICATKA compared to 30% of the CATKA. Length of stay for MICATKA was a mean of 3.25 days with CATKA a mean of 6 days. In the second series the mean femoral component varus/valgus angle was 89.98 degrees, the mean tibial component varus/valgus angle was 89.91 degrees and the mean femoral component rotation was 0.6 degrees of external rotation. MICATKA is a safe procedure with reproducible results. Alignment is equivalent to CATKA. It gives statistically significant improvement in KSS compared to the open procedure. The length of stay and time to straight leg raise are also reduced. At 2 years follow-up we have seen no revisions and no evidence of loosening radiographically.
We performed 82 primary unicompatental, medial knee replacements in patients under the age of 50, using a fixed bearing, metal backed tibial design and a conforming anatomic femoral component. Patients were followed prospectively for a minimum of 2 years (range, 24 to 48 months). All patients were rated both clinically and radiographically using Knee Society Scores, SF-36 and standard radiographic instruments. Patients also completed a validated questionnaire that examined activity level, functional outcomes and ability to return to sports.
Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard of care provides open reduction and internal fixation (ORIF) through differentiated surgical approaches which have been associated with relatively high complications rate such as haematomas, superficial and deep infection, and neuro-vascular lesions. Moreover these procedures need long operative times with significant blood loss. To avoid these general and local complications, that sometimes compromise the functional outcome of the operation and the possibility to perform a future arthroplasty, some authors advocated a minimally invasive percutaneous osteosynthesis (MIPO). This approach can also be considered a valid alternative to ORIF in all those cases in which the standard approaches are contraindicated as in open fractures, comminuted fractures in osteoporotic patients or fractures in high risk patients. Between 2001 and 2006 we performed MIPO techniques for acetabular fractures in 15 patients; the reduction has been evaluated with fluoroscopy during the operation and with CT after the operative procedure. In almost all the cases the reduction has been achieved and maintained using an ileo-femoral external fixator according to the ligamentotaxis technique. The frame is applied in distraction bridging the joint from the contra-lateral iliac wing to the omolateral femoral shaft associating whenever possible percutaneous cannulated 4 mm. screws to optimise the reduction and obtain fragment fixation. The fixator is left in place from a minimum of 20 days to a maximum of 40 days in relation to the comminution of the fracture and/or the quality of the bone. Following this strategy is possible to achieve good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. According to the radiological and clinical results obtained the best reduction can be achieved when the treatment is carried out early and the best stability when we associate to the fixator 1 or 2 cannulated screws. The use of external fixation has never compromised the range of movement of the knee (secondary to quadriceps transfixion) and we have never had deep infection related to pin tract problems in the 3 to 6 weeks treatment period.
Total knee arthroplasty (TKA) has evolved over the past 40 years to a point where it now is a routine treatment with fairly predictable outcomes. However, TKA is an end-stage treatment which frequently is used when only one or two compartments in the knee are damaged. Ideally, treatments for earlier stage and isolated disease would be available to provide the same high level of outcome predictability, but provide for isolated treatment of the affected compartments, greater levels of postoperative physical activity and the shorter convalescence demanded by younger, more active, and often employed patients. One approach to a compartment-by-compartment treatment regime is the utilization of discrete condylar unicompartmental prostheses and a patellofemoral prosthesis in any combination. This approach has been practiced in some European clinics for decades with good reported outcomes. However, it remains a major surgical challenge to optimally place multiple discrete arthroplasty components using conventional tools and small incisions. This lecture will present a detailed overview of a unified approach to minimally invasive, modular knee arthroplasty using haptic robotic instrumentation and implants designed specifically for robotic installation in a customized modular treatment regime. Haptic robotics provide a ‘virtual cutting guide’ capability permitting precise sculpturing of bone surfaces using near-zero-visibility minimally invasive incisions. The use of a single-multifunctional tool eliminates many of the instrument trays commonly needed for these procedures. The surgeon has complete control in manipulating the bone cutting tool within the desired bone-removal area, but the haptic robotics prohibit the cutting tool from removing bone outside the planned bone removal volume. Precise bone sculpturing has the potential to minimize bone removal and optimize the alignment and fixation of the prosthetic components. Haptic robotic cutting tools obviously can be used with off-the-shelf prosthetic components, but this approach would fail to fully take advantage of the precision surfaces that can be achieved using robot assisted bone sculpting. Instead, a purpose built system of modular knee components can be defined that work in any combination (medial or lateral unicompartmental, bi-unicondylar, medial or lateral plus patellofemoral, or tricompartmental), require minimum bone removal, can be placed through very small incisions, give great flexibility to customize implant placement to fit the patient’s anatomy, and take advantage of the types of fixation features which easily are created with a robotically controlled bone cutting device. The current treatment implementation and implant design will be presented. Clinical results for unicompartmental procedures and in vitro results for multiple-compartment procedures will be presented and discussed.
There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach. This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterized as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals. A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years. Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.
Short scarf osteotomy (SSO) retains the versatility of standard scarf in treating moderate and severe hallux valgus deformity with the added benefit of less invasiveness translated into less soft-tissue stripping, reduced exposure, less metalwork, less operative time and reduced cost. We present our medium-term clinical, radiographic and patient satisfaction results. All patients who underwent SSO between January 2015 and December 2017 were eligible (98). Exclusion criteria were: follow up less than a year, additional 1st ray procedures, inflammatory arthropathy, infection, peripheral vascular disease and hallux rigidus. Eighty-four patients (94 feet) were included: 80 females / 4 males with average age of 51-year-old (24–81). Minimum follow up was 12 months (12–28). Weight-bearing x-rays and AOFAS score were compared pre- and postoperatively. Non-parametric Mann-Whitney U test assessed statistical significance of our results. Hallux valgus angle (HVA) improved from preoperative mean of 30.8° (17.4°–46.8°) to 12° (4°–30°) postoperatively (p=0.0001). Intermetatarsal angle (IMA) improved from preoperative mean of 15.1° (10.3°–21.1°) to 7.1° (4°–15.1°) postoperatively (p=0.0001). Average sesamoid coverage according to Reynold's tibial sesamoid position improved from average grade 2.18 (1–3) to 0.57 (0–2) (p=0.0001). Average AOFAS score improved from 51.26 (32–88) to 91.1 (72–100) (p=0.0001). Ninety percent of patients were satisfied and 83% wound recommend the surgery. No troughing phenomenon or fractures. Four overcorrections were found 3 of which did not require surgery. One recurrence at 18 months was treated with standard scarf. We believe that this technique offers a safer, quicker and equally versatile way of dealing with Hallux Valgus.
Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard approach provides open reduction and internal fixation (O.R.I.F.) through a variety of surgical approaches which have been associated with relatively high complications rate such as haematomas, deep infection, and neuro-vascular lesions. These procedures need long operative times with significant blood loss. Many authors have demonstrated the feasibility of closed reduction and percutaneous fixation (C.R.P.F.) for minimally or non displaced acetabular fractures; this technique can be considered a valid alternative to O.RI. F. in order to decrease the morbidity related to surgical approaches. Between 2001 and 2006 we performed C.R.P.F. for acetabular fractures in 15 patients; the reduction has been controlled with fluoroscopy during the operation and with CT scan after the operative procedure. The osteosinthesis has been performed with cannulated screws and In more complex cases the reduction has been achieved and maintained with ileo-femoral external fixation (ligamentotaxis technique). Fractures were classified according to AO classification. Clinical and functional results have been evaluated according to Harris Hip Score on the base of post-operative CT scan and on x-ray films at last follow-up. According to our experience the use of external fixation in the treatment of acetabular fractures must be reserved for very selected cases in which for general or local condition the joint the distraction associated with minimal internal fixation can guarantee good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. The best reduction can be achieved when the treatment is carried out early while the best stability is achieved with the association of percutaneous cannulated screws. The use of external fixation has never compromised the range of movement of the hip.
Rapid recovery protocols after joint replacement have been implemented widely to decrease hospital length of stay (LOS). Minimally-invasive total knee arthroplasty (MIS-TKA) may facilitate rapid recovery for patients. Increased complications and LOS have been documented in morbidly obese TKA patients. The objective of the current study was to retrospectively evaluate the impact of morbid obesity on MIS-TKA patients. We conducted a retrospective chart review on patients that underwent MISTKA at a high volume orthopedic center between August 2012 and September 2015 (N = 4173). All surgeries were performed by one of six fellowship trained surgeons utilizing the same implant. MISTKA was performed utilizing a mid-vastus approach under tourniquet. All patients experienced rapid recovery protocols utilizing multi-modal pain management pathways, same day physical therapy, and absence of CPM machines. We evaluated patient age, gender, operative time, LOS, and 90-day readmission for morbidly obese (BMI≥40; n = 597), and non-morbidly obese (BMI<40; n = 3576) patients. Statistical analysis was conducted using Minitab 16 Statistical Software.Introduction
Methods
MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury. 10 paired normal cadaver feet were used. All procedures were performed using a mini C-arm in a cadaveric lab by 2 surgeons: 1 consultant who has attended a cadaveric MIS course but does not perform MIS in his regular practice (8 feet), and 1 registrar who was supervised by the same consultant (2 feet). In each foot, the surgeon performed a lateral release, a MICA (minimally invasive chevron and Akin) procedure for the correction of The dorsal medial cutaneous and the plantar interdigital nerves were intact in all specimens. There was no obvious damage to the arterial plexus supplying the first metatarsal head. No flexor or extensor tendon injuries were identified. There is a significant learning curve to performing the osteotomy cuts in the desired plane. In the DMO, the dissection also revealed some intact soft tissue at the osteotomy site indicating that the metatarsal heads were not truly floating.Materials and Methods
Results
This paper reports the authors’ experience of over 850 unicompartmental knee replacements beginning in 1985 with the MG2 uni and then the LCS uni in 1995, and more recently with the Allegretto, Oxford and PFC minimally invasive uni. Minimally invasive unicompartmental knee arthroplasty (MIU) offers the knee arthritis patient significant benefits compared with total knee arthroplasty. Some of these are especially important for Asian patients, in particular range of movement and ability to squat. The ideal indications for the MIU are not yet fully established but are becoming clearer. Contraindications are also clearer. These issues will be discussed in detail. The results in 100 cases of unicompartmental arthroplasty will be presented and discussed along with the complications in these patients. Special considerations and recommendations for the commencement of MIU will also be discussed. This recent and popular procedure also presents the knee surgeon with significant challenges. However, there are also disadvantages which will be outlined. The surgical technique of the MIU will be shown in detail. The paper closes on a brief discussion into recent developments by an 8 member international group of knee surgeons of a new MIU offering a choice of fixed or mobile bearing MIU, with precise instrumentation of both the femoral and tibial sides, and the early result of the first 18 procedures in 15 patients (3 bilateral).
In orthopaedic spine surgery pedicle screw systems are used for stabilisation of the spine after injuries or disorders. With an percutaneous operation method surgeons are faced with huge challenges compared to an open surgery, but it's less traumatic and the patient benefits with a faster rehabilitation and less traumatic injuries. The screw positions and the required rod dimensions for the stabilising connection between the screws are hard to define without an open view on the operating field. Because of these facts a new smart device based system for rod shape determination was invented. Therefore, an application was developed, which integrates a localiser module to get the position data of the pedicle screws, with help of rigid bodies placed on top of the pedicle screws down-tubes. An algorithm was developed to choose the best fitting rod to connect the pedicle screws with help of calculating the rod length and the rod radius. The system was tested in a test scenario where four pedicle screws were drilled into a wooden plate. The positions of the screws were adjusted to fit a curved and a straight rod. In the test scenario the application chose always the rod correctly.
Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications.Purpose
Methods
Unicompartment knee arthroplasty (UKA) was proven to be one of the standard treatments of medial compartment osteoarthritis. The key to success was restoration of pre-operative alignment. Overcorrection of coronal (AP) alignment may predispose to early osteoarthritis in the contralateral compartment, change in post-operative tibial slope may predispose to proximal tibial bone collapse and loosening of tibial prosthesis. Minimally invasive surgery (MIS) in UKA was developed quickly in the last ten years. However, MIS has limited access to visualize the surgical field and limb alignment. Computer navigation may help the surgeon to place the component in more accurate position. We aim to study the radiological alignment of computer assisted MIS UKA. Eighteen patients with UKA (PreservationTM, all poly tibia, DePuy Orthopaedics Inc, Warsaw, IN) implanted using MIS technique were studied prospectively. The CiTM system (DePuy International Ltd, Warsaw IN) were used for computer navigation. Five male and 13 female patients were studied. The mean age of the patients was 58.2 (range, 45 to 70). All patients had medial compartment osteoarthritis with varus deformity. The postoperative coronal (AP) alignment and tibial slope of the operated limb were compared with the pre-operative alignment for any significant difference. The mean pre-operative and post-operative radiographic coronal (AP) alignment of the operated limb were 8.4° varus (range, 2° to 12°) and 7.2° varus (range, 1° to 15°) respectively, the difference was not significant (p = 0.537). The mean pre-operative and post-operative tibial slope were 6.8° (range, 3° to 11°) and 5.8° (range, 3° to 10°) respectively, the difference was not significant (p = 0.066). The post-operative tibial slope correlated well with the intra-operative tibial slope recorded by computer after bone cut was made (Cronbach’s Alpha = 0.771). The mean tourniquet time was 124 minutes (range, 94 to 140 minutes). There was no significant difference in pre-operative and post-operative coronal alignment of the operated limb. Computer assisted MIS UKA could reproduce the pre-operative coronal alignment and tibial slope. Restoration of the pre-operative limb alignment in coronal plane and tibial slope was crucial to the survival of UKA. Computer navigation could help the surgeon to position the component during minimally invasive surgery. However, the learning curve of computer assisted MIS UKA was steep.
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. 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).Background
Methods
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. 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.Purpose
Methods
About ten years ago we introduced sophisticated instrumentation and an increased range of component sizes for the Oxford unicompartmental knee replacement (UKR) to facilitate a minimally invasive surgical (MIS) approach. The device is now routinely implanted through an incision from the medial pole of the patella to the tibial tuberosity. This has resulted in a more rapid recovery and an improved functional result. As the access to the knee is limited there is a concern that the long term results may be compromised. The aim of this study was to determine the 10 year survival. A prospective follow up of all Phase 3 minimally invasive Oxford UKR implanted by two senior authors (DWM &
CAFD) has been undertaken. So far 1015 UKRs have been implanted for anteromedial osteoarthritis. All patients received a cemented implant through a MIS approach and were followed up prospectively by an independent observer. The data was collected prospectively regarding pre-operative status, complications and clinical as well as functional outcome at predetermined intervals. The average age of patients was 66.4 years (range: 33 – 88) with mean Oxford Knee Score 41 (SD: 7.9) at the time of last follow up, Knee Society Score (objective) of 84 (SD: 13) and Knee Society Score (functional) of 83 (SD: 21). At ten years the survival of this cohort is 96%. There were 22 revisions including 7 for progression of arthritis, 5 for infection, 5 for bearing dislocation, 4 for unexplained pain and one for rupture of ACL secondary to trauma. We conclude that the Oxford Knee can be implanted reliably through a minimally invasive approach, giving excellent long term results.
To validate the efficacy and accuracy of a novel patient specific guide (PSG) and instrumentation system that enables minimally invasive (MI) short stemmed total shoulder arthroplasty (TSA). Using Amirthanayagam et al.'s (2017) MI posterior approach reduces incision size and eliminates subscapular transection; however, it precludes glenohumeral dislocation and the use of traditional PSGs and instruments. Therefore, we developed a PSG that guides trans-glenohumeral drilling which simultaneously creates a humeral guide tunnel/working channel and glenoid guide hole by locking the bones together in a pre-operatively planned pose and drilling using a c-shaped drill guide (Figure 1). To implant an Affinis Short TSA system (Mathys GmbH), novel MI instruments were developed (Figure 2) for: humeral head resection, glenoid reaming, glenoid peg hole drilling, impaction of cruciform shaped humeral bone compactors, and impaction of a short humeral stem and ceramic head. The full MI procedure and instrument system was evaluated in six cadaveric shoulders with osteoarthritis. Accuracy was assessed throughout the procedure: 1) PSG physical registration accuracy, 2) guide hole accuracy, 3) implant placement accuracy. These conditions were assessed using an Optotrak Certus tracking camera (NDI, Waterloo, CA) with comparisons made to the pre-operative plan using a registration process (Besl and McKay, 1992).PURPOSE
MATERIALS AND METHODS
The two-incision technique uses strategically located incisions to insert the prosthesis components in to specific intermuscular or internervous planes in an effort to minimize damage to these tissues. Even though there are many reports about safety and benefits of bilateral simultaneous total hip arthroplasty (THA), none of them has reported about either one-incision or two-incision bilateral simultaneous minimally invasive (MI) THA. This study aimed to assess the feasibility of bilateral simultaneous MI two-incision THA in terms of clinical, radiological and functional outcomes. Sixty two patients, in the age of 24 to 69 years were operated for bilateral simultaneous THA using modified two-incision technique and followed for average 41 months. In the technique of two-incision THA described by Mears, they used modification of Smith Peterson approach for insertion of acetabular component and femoral component is inserted through a small incision situated between greater trochanter and iliac crest, centered directly in line with the femoral shaft. We modified this technique and used part of Watson Jones approach for insertion of acetabular component with patient in lateral position. The posterior incision for insertion of femoral component is through intermuscular interval between gluteus medius and piriformis. The average Harris Hip score improved from 41.8 (range 10 to 59) preoperatively to 95.3 (range 73 to 100) postoperatively (P <
0.05). WOMAC score improved from median of 66.2 (range 31 to 96) preoperatively to 5.0 (range 0 to 19) postoperatively (P <
0.05). Forty-nine (79.03%) patients were pain-free at the time of first follow up (6 weeks after surgery) and remained pain-free till the last follow up, while remaining 13 (20.97%) had only slight pain. Out of those 13, 3 patients complained of occasional mild pain at last follow up. Fifty (80.64%) patients were walking without limp, while remaining 12 (19.35%) had only slight limp at 6 months. Out of those 12, 2 patients had persistent limp at final follow up. Fifty-eight (93.53%) patients were walking without support, 56 (90.32%) were able to walk unlimited distance and 55 (88.70%) were able to climb stairs without using a railing. Walking with walker was started on average 3.7 days (range 1 to14 days) and walking with crutches was started on average 10.3 days (range 1 to 49 days) postoperatively. Patients were able to walk without support on an average 48 days (range 14 to 120 days) and use stairs without support and without any discomfort on an average of 50 days (range 5 to 150 days). The average lateral opening angle of acetabulum was 40 ° and anteversion was 12 °. All femoral components were implanted in neutral to 5 ° valgus position. None of the femoral component showed subsidence of more than 3 mm. The filling of the femoral canal by the prosthesis was excellent in all cases. Post-operative periprosthetic fracture occurred in 2 patients and delayed infection occurred in 1 patient. In conclusion, bilateral simultaneous two-incision minimally invasive THA gives satisfactory clinical and radiological results in comparison with conventional THA. It is safe in experienced hands, without any additional risk of complications. It provides excellent functional outcome and patient satisfaction.
Fractures of the proximal humerus can offer a difficult surgical challenge particularly if they occur in elderly patients and/or are a complex fracture configuration. Much of the morbidity of the surgery relates to the extensile delto-pectoral approach traditionally used for operative treatment of these fractures. A minimally invasive technique for approaching these fractures has was developed using a proximal deltoid split approach at the anterior edge of the deltoid and sliding a precontoured proximal humeral locking plate submuscularly after provisional fracture reduction. This technique was tested in a cadaver model to identify “safe” and “at risk” holes in the plate for percutaneous fixation in relation to the axillary nerve. A case series of eighteen patients who had surgery using this technique were reviewed. All patients achieved acceptable reductions and went on to unite without any signs of AVN or implant failure. One patient had a transient sensory disturbance in an axillary nerve distribution post op. One patient has asymptomatic fibrous union of the greater tuberosity. Minimally invasive plate fixation using a lateral deltoid split approach is technically possible with excellent results. The danger zone around the axillary nerve has been identified and should be avoided with percutaneous fixation utilising this procedure. A jig to allow accurate MIPO fixation has been developed.