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

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

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

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