There is a strong drive from industry, patients and the media to offer minimal access hip surgery (MAS) for joint arthroplasty. There is a plethora of definitions, implants, specialist instrumentation and techniques available. Confusion reigns as to the definition, who should offer it, which approach should be used, and what training should be undertaken. Method : All Consultant Orthopaedic Surgeons in the United Kingdom were sent a simple questionnaire asking for MAS training undertaken, evidence of specialisation, volume of minimal access cases performed, availability of specialist instrumentation, approach used and definition of mimimal access surgery. Results : 23% of those performing hip arthroplasty had performed MAS. The majority performed between 1–5 cases last year. 41% had observed MAS. Of those with a specialist interest in hip arthroplasty, 37% had performed MAS. Of those performing MAS, 83% had observed another surgeon and 60% had attended a course. 29% of consultants intend to perform MAS in the future. The mean and mode quoted length of a regular total hip arthroplasty scar was 15.4 and 15cm respectively. The mean and mode quoted length of a MAS scar was 9.7 and 10 cm respectively. 75% used the miniposterior approach. Relationships with specialisation, British Hip Society membership and volume breakdown are discussed. Conclusion: MAS is a popular technique although currently small case numbers are being performed. Given the level of interest in the technique, the definition and training required need to be clarified, and the clinical outcome requires close monitoring to ensure that standards of implantation are not jeopardised

Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure.

Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively.

The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately.

We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral.

Calcaneal fracture fixation over the past decade has been practised via an extensile lateral incision. This can be complicated by infection and wound breakdown.

We have developed a new technique for fixation of the calcaneal fractures – MACO. We utilise a 4 cm sub fibular incision to aid joint visualisation and fracture reduction. Fixation is via percutaneous screws.

We analysed our prospectively collected database. 26 fractures were fixed over an 18 month period at Glasgow Royal Infirmary by three consultant surgeons. 22 patients were male and half were smokers. Mean follow up was 5 months (range 1.5 – 18 months).

The mean age of our patients is 41 (range 25–68). The mean pre operative Bohler's angle was 16.7 degrees. Gissane's angle was similarly abnormal with a mean of 129 degrees.

The average duration of surgery was 73 minutes (range 45–100 minutes). Post operatively, Bohler's angle was improved. The mean was 29 degrees. There was no significant difference with Gissane's angle. The mean was 128 degrees.

There were no superficial wound infections. One patient was troubled by wound breakdown with subsequent deep infection. There was no need for metalwork removal in our series of patients. Two patients developed post traumatic osteoarthritis of the sub talar joint. Only one has required sub talar joint fusion.

We conclude that the novel technique which we describe is successful in restoring calcaneal anatomy with few complications. Further follow up is needed to determine the long term outcomes of such surgery.

Purpose: We analysed the radiographic course of anterior lumbar interbody fusion achieved via a minimal anterior extraperitoneal approach.

Material and methods: From January 1996 to December 2001, we operated 198 patients with this technique. Twenty-one patients were excluded from the analysis (two deaths, three tumours, 16 follow-ups less than 12 months). Mean age of the 177 patients retained for study was 53 years (range 22–78). Mean follow-up was 2.7 years. The 55 post-trauma cases involved essentially thoracolumbar junction. The 122 cases of degenerative lumbar spine included 14 cases of scoliosis, 26 cases of spondylolisthesis, 72 cases of unstable spines after primary posterior surgery, and 10 isolated degenerative discs. Only eight patients did not have posterior fixation. Fusion (globally 360 levels) concerned one disc in 89 patients, two discs in 71, three discs in 17. Cancellous autologous grafts were used with cages. Tricortical grafts were implanted after corporectomy (n=23). Radiological fusion was confirmed by the absence of a mobility chamber around the pedicular screws, the cages or the tricortical grafts, and by searching for loss of sagittal angles (digitalized scans and x-ray, Auto Cad L.T.2000).

Results: 1) Early postoperative status. For the post-trauma cases (65 fused levels, 55 patients), a simple callus was observed in 28. For the others, mean correction was 4° per level. 2) Angle loss. For the trauma cases, mean angle loss was 3.9° in 36 cases (29 grafts on a single level). There were two partial expulsions of the tricortical grafts implanted in osteoporotic patients; revision was not attempted. Mean angle loss for the 65 grafted levels was 2°. For the degenerative cases, mean angle loss was 3.7° for 172 fused levels (112 patients). Cage expulsion on a grade 3 spondylolisthesis did not warrant revision. Two cage impactions did not cause significant loss of angle. 3) Anatomic status of the grafts. Fusion was achieved at all levels without cage or tri-cortical graft rupture. We observed a partial but stable lucent line around the case in five cases.

Discussion: The rate of fusion reported after anterior lumbar interbody fusion has varied from 55 to 100% in the literature. This technique is an original approach for trauma victims avoiding the need for extensive posterior assemblies and/or the damage caused by a wide anterior approach. For the degenerative spine, the mediocre quality of the bone and the frequency of several level fusions is not a particular problem.

Conclusion: Anterior lumbar interbody fusion is an interesting method for reinforcing posterior fixation with a real efficacy in terms of effective fusion.

The piriformis muscle is an important landmark in the surgical anatomy of the hip, particularly the posterior approach for total hip replacement (THR). Standard orthopaedic teaching dictates that the tendon must be cut in to allow adequate access to the superior part of the acetabulum and the femoral medullary canal. However, in our experience a routine THR can be performed through a posterior approach without sacrificing this tendon.

We dissected the proximal femora of 15 cadavers in order to clarify the morphological anatomy of the piriformis tendon. We confirmed that the tendon attaches on the crest of the greater trochanter, in a position superior to the trochanteric fossa, away from the entry point for broaching the intramedullary canal during THR. The tendon attachment site encompassed the summit and medial aspect of the greater trochanter as well as a variable attachment to the fibrous capsule of the hip joint. In addition we dissected seven cadavers resecting all posterior attachments except the piriformis muscle and tendon in order to study their relations to the hip joint, as the joint was flexed. At flexion of 90° the piriformis muscle lay directly posterior to the hip joint.

The piriform fossa is a term used by orthopaedic surgeons to refer the trochanteric fossa and normally has no relation to the attachment site of the piriformis tendon. In hip flexion the piriformis lies directly behind the hip joint and might reasonably be considered to contribute to the stability of the joint.

We conclude that the anatomy of the piriformis muscle is often inaccurately described in the current surgical literature and terms are used and interchanged inappropriately.

Cite this article: Bone Joint J 2013;95-B:764–9.

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery. We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip. Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially. The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller. By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm)

To compare the results of standard open carpal tunnel release against minimal access release using the ‘Stryker Knifelight’ in the same patients. A prospective, randomised trial was carried out recruiting all patients with bilateral carpal tunnel syndrome. There were 26 patients (18 females and 8 males), with a mean age of 48 years. The patients were randomised to having the ‘Knifelight’ on one side and therefore acted as their own controls. They were assessed preoperatively, and at 2 and 6 weeks postop by questionnaire, and grip strength measurements. All sides were improved following release but those done by the open method were more likely to have complete resolution at 6 weeks. In contrast, the ‘Knife-light’ sides had better grip strength and allowed earlier return to work. In terms of preference, the patients were split equally between the 2 techniques. 2 patients had minor complications following minimal access release including one with numbness over the thenar eminence for 6 weeks. This study shows that open carpal tunnel release remains the ‘gold standard’ but the minimal access technique offers some advantages in terms of quicker recovery

Stereotactic navigation in cranial surgery is a well-established technique, in routine clinical use since the turn of the century. The advent of computer guided stereotaxis since the early 1990’s has led to an explosion in applications for the technology in cranial surgery, with the development of new surgical techniques, minimal access and consequent claimed reduction in morbidity and mortality. Computer guidance also allows application of stereotactic techniques in spinal surgery. Early interventions have concentrated on the insertion of pedicle screws with improvement in accuracy and certainty of optimal screw placement. The use of fluoroscopic guidance allows the insertion of percutaneous pedicle screws and truly minimal access fusion techniques for the lumbar spine. More recently the development of improved registration has allowed the application of this technology to thoracic spinal surgery and to the cervical spine. Percutaneous techniques for C1/C2 arthrodesis, image guided vertebrectomy and transoral surgery, have been reported. The technology allows the development of surgical techniques designed not only for individual pathology but adapted to the anatomy of the individual patient. Disadvantages include a significant learning curve, especially for cervical spine surgery, the cost and need for registration which may be time consuming. Advantages include claimed accuracy in decompression, hardware placement, minimal access techniques and a three-dimensional solution to what is essentially a three dimensional problem. More recently non-computer based navigation systems have become available with improved hardware placement without the problems associated with computer based systems. The purpose of this paper is to review computer guided spinal surgery, present new techniques based on its application to the adult spine, discuss advantages and disadvantages of those techniques and present the results of studies on the new non-computer based navigation systems

To evaluate the clinical accuracy of computer-assisted fluoroscopy for the placement of percutaneous lumbosacral (LS) pedicle screws. A prospective computed tomographic (CT) analysis was performed in forty consecutive patients. Three independent observers were utilised. Postoperative CT scans of one hundred and fifty-nine titanium pedicle screws (n = 6(L3); thirty-eight(L4); sixty-five(l5) and fifty(S1)) were reviewed. All screws were percutaneously placed using the two-dimensional FluoroNavTM system. The relative position of the screw to the pedicle was graded as follows: I-completely in; II – < 2mm breach; III - = 2–4mm breach; IV – > 4mm breach. The direction of the breach was further classified as well as its trajectory. Correlation between observers was near perfect. The three observers rated 74.2%, 78.6%, and 78.0% of screws were completely contained within the pedicle. The data from the observer with the most significant pedicle breaches is as follows: thirty-five (22%) pedicle breaches (grade II -n=30; III - n=4; IV - n=1/n= 11 medial; n=19 lateral; 5 superior). Only one clinically significant breach occurred medially (grade III) at L5. This required screw revision (performed with a minimal access technique) with complete resolution of acute post-op L5 radiculopathy. The in-vivo percutaneous pedicle breach rate in this study was higher than that reported for similar open navigational techniques. The majority (85.7%) of breaches were minor (< 2mm) and over half (54.3%) were lateral with no potential for clinical squealae. This high lateral breach rate is due to a modified lateral starting point required for the percutaneous technique. However, there is concern that this technique resulted in one clinically significant medial breach and highlights the increased risk associated with percutatneous pedicle screw placement. The findings of this study suggest that improved screw placement accuracy for minimal access instrumented fusions is required

In tibial plateau fracture, anatomical reduction of articular surface with stable fixation can restore the mechanical axis and allow early mobilization. Concomitant management of ligamentous and meniscal injury is essential for preservation of knee function. Open reduction and internal fixation has a significant complication rate.Percutaneous,fluoroscopically and arthroscopically assisted osteosynthesis with special fracture reduction and fixation technique can achieve the purpose of management of tibial plateau fracture, while limiting the soft tissue damage. 18 cases, including all J. Schatzker’s type of tibial plateau fracture, were operated with minimal access surgical technique. Male patients were predominant. The age ranged from 22 to 61 (mean 33.5). Detail pre-operatives planning with CT scan were performed in 16 patients. Fluoroscopy, arthroscopy and special fracture reduction and fixation technique were applied to all cases. All 18 cases could be reviewed. Follow up period ranged from 1 to 4 years (mean 2.3 yr.). Outcome was assessed by HSS Knee Score, standing radiograph and arthroscopy (2 cases). According to HSS score, 14 patients were rated as excellent (100 to 85), 3 good (84 to 70), 1 fair (69 to 60) and none poor (< 60). Subjectively, 14 patients were satisfied with the treatment. 13 patients were working and participating in sport before injury. 15 took no analgesic, 2 took it once a week and 1 more often. In standing radiograph, only 2 patients showed minimal narrowing of joint space. There was no significant complication directly associated with the procedure. Percutaneous, fluoroscopically and arthroscopically assisted osteosynthesis is a safe and effective minimal access surgical procedure. Precise pre-operative planning and special fracture reduction and fixation technique are all crucial for success. Short-term clinical outcome is encouraging

Introduction and Aims: To evaluate open, minimal invasive spine surgery (MISS) with video-assisted thoracoscopic surgery (VATS) using the SynFrame retractor and expandable cages for the anterior reconstruction of thoracic and lumbar spine injuries. Method: Thirty-three consecutive cases of thoracic and lumbar spine pathology requiring anterior reconstruction were analysed. Most patients (90%) underwent prior posterior stabilisation using the Universal Spine System (USS). The thoracic spine was approached by a right-sided mini-thoracotomy, the thoraco-lumbar junction by a left-sided mini-thoracotomy and the lumbar spine by a left-sided mini-retroperitoneal approach using the table-mounted SynFrame retractor system. Fiberoptic endoscopes facilitated illumination and visualisation. The anterior column was reconstructed using expandable cages (Synex) with autologous bone for interbody fusion. Results: Twenty-two males (67%) and 11 females (33%) underwent the procedures. Median age was 38 years (range 19–57). Pathology was trauma in 31 (94%) and tumor in two (6%) cases. Location was thoracic (34%) and lumbar (66%). Mean operating time was 150 minutes (range 75–195 min). Mean blood loss was 0.78 litres. Only three patients needed blood transfusions. Additional bone graft was generated from resected rib or harvested iliac crest in 70% of all cases. There were no visceral/vascular complications, intercostal neuralgia or post-thoracotomy pain syndromes from the minimal access. No anterior reconstruction infections occurred, but there was one superficial and two deep wound infections from the posterior stabilisation. Two cases were abandoned secondary to intercostal vessel bleeding without sequelae. Isolated spine injury cases had mean length of hospital stay of 10 days and return to work at 12 weeks post-operatively. Conclusion: Open, minimal access to the anterior thoracic and lumbar spine is ‘pathology-independent’ and combines the advantages over ‘standard open’ and ‘pure’ endoscopic procedures. Major advantages are direct three-dimensional view of the spine for the surgeon, no need for double-lumen intubation, significant reduction in access morbidity, shorter hospital stay and earlier return to work

Background:. Closed femoral shortening (CFS) is a recognised procedure for managing leg length discrepancy (LLD). Method:. We report twenty-nine consecutive patients with LLD who underwent CFS using an intramedullary saw and nail. Mean age was 29.2 years (16.1–65.8). The primary outcome was accuracy of correction. Secondary outcomes were complications, union, ASAMI score and re-operation, alongside Patient Reported Outcome Measures (PROMs), using EQ5D-5L and GROC. Results:. Mean pre-operative limb length discrepancy was 3.4 cm (1.5–6.5). Mean planned and achieved shortening was 2.9 cm (1.7–5.0). Mean follow-up was 2.0 years (0.2–8.4). Minimal access surgery was possible in all cases but careful technique is essential. All patients achieved a correction within 5mm of the planned shortening (range 0–5mm). 28 patients (97%) achieved uncomplicated union. One patient had a non-union requiring exchange nailing and subsequent compression plating. 13 patients had nail removal at a mean of 1.7 years and 3 had locking screw removal. Patients had an overall positive experience with 81% reporting high PROM scores. Discussion:. This technique offered accurate limb length correction with few complications. Patients rehabilitated well with good functional outcomes. Conclusion;. CFS with an intramedullary saw is a well-tolerated and effective technique when managing LLD up to 5cm

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured. . The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols. Cite this article: Bone Joint J 2014;96-B:406–13

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral

Aims: The study was undertaken in order to assess the clinical and radiological results of treatment of comminuted diaphyseal fractures of long bones using the principle of biological fixation, standard implants and minimum access surgery. Methods: 20 patients operated with this method are subject of this review. All operations were performend on the orthopedic or ordinary translucent table using image intensifier. Fractures were reduced indirectly and fixed with the plate or DCS passed subcutaneously with-our accessing the fracture site. Results: All fractures united in the average period of 5.9 months.There were no snignificant complications and no infections. Function of adjacent joints was good. Conclusion: In case of comminuted diaphyseal fractures of long bones biological fixation with minimal access surgery principle using standard implants gives excellent clinical and radiological results and is a valuable alternative to other fixation methods

We aimed to test the biomechanically predicted hypothesis that in massive rotator cuff tears irreparable by conventional methods the newly developed Nottingham Augmentation Device (NAD) would provide greater functional improvement than that gained from the gold standard of arthroscopic subacromial decompression. Thirty patients treated between 2001 and 2004 were assessed by pre- and six month post-operative Constant scoring. Fifteen underwent open acromioplasty and cuff reconstruction using the NAD (mean age 67.3), while 15 underwent a standard arthroscopic decompression (mean age 67.4). The two groups were matched retrospectively based on size of cuff tear, age and sex. Data was analysed using the student’s t-test at the 95% confidence interval. Both groups displayed a statistically significant increase in Constant score after surgery. The mean increase for NAD patients was 18.7 points compared with 17.6 points for those undergoing arthroscopic decompression. However there was no significant difference between the two groups’ improvement and this was even so in the power sub-category, where increased benefit was predicted with the NAD. The NAD requires greater surgical access, operating time and peri-operative analgesia, and no active mobilisation for six weeks. The arthroscopic technique is minimal access, rapid, involves no prosthesis or foreign body insertion and allows immediate mobilisation. However, with clear biomechanical benefits of the NAD seen in vitro, our results may simply reflect cuff tears in an older population group with irreversible tissue changes and less rehabilitative potential. A randomised prospective trial in a younger patient group with more acute tears and less tissue atrophy would appear the next step in determining the NAD’s place in the management of massive rotator cuff tears

Introduction: Repetitive undertaking of a physical tasks results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”. Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar micro-endoscopic discectomy (MED), when compared to open microdiscectomy. Methods: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open micro-discectomy immediately predating the current series are used as a cohort for comparison. Results: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred. Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach. The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified. Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”. There was no significant difference in clinical outcome and complications between the two groups. Discussion: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium

INTRODUCTION: Repetitive undertaking of a physical task results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”. Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar microendoscopic discectomy (MED), when compared to open microdiscectomy. METHODS: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open microdiscectomy immediately predating the current series are used as a cohort for comparison. RESULTS: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred. Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach. The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified. Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”. There was no significant difference in clinical outcome and complications between the two groups. DISCUSSION: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium

Introduction: The increasing popularity of minimal access surgery in orthopaedic surgery has resulted in increasing use of intra-operative fluoroscopy. The radiation dose received by the surgeon varies from procedure to procedure depending on several factors such as duration of procedure, direct exposure to radiation beam and distance from the radiation source. In particular hand and wrist injuries often involve direct fluoroscopic exposure to the hands of the surgeon and assistant during the procedure. Aim: We undertook a prospective study to directly evaluate the exposure of the surgeon’s and assistant’s hands and thyroid glands during K-wiring procedures of the hand and wrist. In addition we evaluated the efficacy of a lead thyroid shield in limiting the radiation dose to the thyroid gland. In addition we undertook a questionnaire of orthopaedic surgeons and trainees in Ireland to assess the availability of thyroid shields and current practice in wearing them. Method A total of 30 cases were evaluated. Dosimeter film badges (TLD) were obtained from the Radiological Protection Institute of Ireland (RPI). Two dosimeters were worn by each of the surgical team: one on the dorsum of the dominant hand and a second worn on the neck during the procedure. The number of fluoroscopic exposures, number of times that hands were caught in the image field, the total dosage of radiation for the procedure and the length of time of exposure were recorded. In 20 cases the surgical team undertook standard precautions of a lead jacket. In a random selection of 10 cases the surgical team also wore a thyroid shield. Results. The mean dose to the surgical teams’ hands was 1.8 cGy (95% CI + 0.6). The mean dose to the thyroid gland was 0.6 cGy in unprotected cases. Notably the dose to the assistants’ hands was higher though this did not reach statistical approval. In cases in which a thyroid shield was worn a significant decrease in dose was noted (p< 0.05). 35% of surgeons had completed a radiation protection course with junior trainees being less likely to have completed such a course. Conclusion: Significant cumulative radiation dose to the hands and thyroid gland occurs following K-wiring of extremities. The dose to the thyroid gland can be effectively decreased by the use of a thyroid collar. Junior trainees whose operative times and hence radiation exposure are higher, have limited radiation protection training. The mandatory use of thyroid shields and early introduction of radiation protection training may help minimise further radiation exposure