Aims. There is a lack of long-term data for minimally invasive acromioclavicular (AC) joint repair. Furthermore, it is not clear if good early clinical results can be maintained over time. The purpose of this study was to report long-term results of minimally invasive AC joint reconstruction (MINAR) and compare it to corresponding short-term data. Methods. We assessed patients with a follow-up of at least five years after minimally invasive flip-button repair for high-grade AC joint dislocation. The clinical outcome was evaluated using the Constant score and a questionnaire. Ultrasound determined the coracoclavicular (CC) distance. Results of the current follow-up were compared to the short-term results of the same cohort. Results. A total of 50 patients (three females, 47 males) were successfully followed up for a minimum of five years. The mean follow-up was 7.7 years (63 months to 132 months). The overall Constant score was 94.4 points (54 to 100) versus 97.7 points (83 to 100) for the contralateral side showing a significant difference for the operated shoulder (p = 0.013) The mean difference in the CC distance between the operated and the contralateral shoulder was 3.7 mm (0.2 to 7.8; p = 0.010). In total, 16% (n = 8) of patients showed recurrent instability. All these cases were performed within the first 16 months after introduction of this technique. A total of 84% (n = 42) of the patients were able to return to their previous occupations and sport activities. Comparison of short-term and long-term results revealed no significant difference for the Constant Score (p = 0.348) and the CC distance (p = 0.974). Conclusion. The clinical outcome of MINAR is good to excellent after long-term follow-up and no significant differences were found compared to short-term results. We therefore suggest this is a reliable technique for surgical treatment of high-grade AC joint dislocation. Cite this article: Bone Joint J 2020;102-B(7):918–924

Percutaneous stabilisation of tibial fractures by locking plates has become an accepted form of osteosynthesis. A potential disadvantage of this technique is the risk of damage to the neurovascular bundles in the anterior and peroneal compartments. Our aim in this anatomical study was to examine the relationship of the deep peroneal nerve to a percutaneously-inserted Less Invasive Stabilisation System tibial plate in the lower limbs of 18 cadavers. Screws were inserted through stab incisions. The neurovascular bundle was dissected to reveal its relationship to the plate and screws.

In all cases, the deep peroneal nerve was in direct contact with the plate between the 11th and the 13th holes. In ten specimens the nerve crossed superficial to the plate, in six it was interposed between the plate and the bone and in the remaining two specimens it coursed at the edge of the plate.

Percutaneous insertion of plates with more than ten holes is not recommended because of the risk of injury to the neurovascular structures. When longer plates are required we suggest distal exposure so that the neurovascular bundle may be displayed and protected.

Objective. We reviewed clinical results with minimally invasive method and using a new developed plate for unstable pelvic ring fractures, especially vertically unstable sacral fractures. Materials & Methods. Between 2002 and 2010, 35 patients with vertically unstable sacral fractures were treated with minimally invasive method and using an M-Shaped transiliac plate which was developed by the author. This plate is anatomically designed for posterior pelvic ring, and achieved rigid fixation. Patients included 19 male and 16 female, with the mean age of 46.2 (range, 17∼79) years old. According to the AO classification, 23 patients had a C1 injury, 9 had a C2 fracture, and 3 patients sustained a C3 injury of the pelvic ring. Functional outcome was assessed using the Majeed's functional evaluation and radiography. Minimum follow-up was one year. Results. All patients were not fixed anterior of pelvic ring. The average of surgical time was 85 minutes (range: 45∼150), and intraoperative blood loss was 332.8 ml (range: 35∼1055). Postoperative functional results were excellent and good in 30 patients (85.7 %), and fair in four cases due to infection or sciatic nerve paralysis, and one case of poor was nonunion. Three patients complicated wound healing delayed, but there were no residual pain and re-displacement. Conclusion. Using an M-Shaped transiliac plate can be achieved significant outcome and rigid fixation with minimal invasion for vertically unstable sacral fractures

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively). After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score, but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures

Introduction. Depending on patient's age, risk factors and pretraumatic mobility, a total- or hemiarthroplasty of the hip have become the treatment of choice in femoral neck fractures(1–4). Internal fixation has shown to provide minor results. The majority of these patients are therefore treated by a hemiarthroplasty of the hip. Since the primary goal is to regain the pretraumatic level of mobility as soon as possible(3;5), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss(6), postoperative pain(7;8) and thus postoperative mobility(9). Patients and methods. In a randomised controlled trial, 48 patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within 72 hours after trauma(10). Apart from parameters like age, ASA-Score or Body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. All data collected were compared between groups to detect statistical significant differences. Additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. Results. A significant difference between groups was found for postoperative pain within the first 72 hours and for operation time, both to the disadvantage of the minimal invasive approach group. Within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at 48 hours was rated higher in patients with complications in the lateral approach group. These results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. Conclusion. Despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. Still, the operation time was significantly linked to postoperative complications. In this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results

Background. Radiofrequency Kyphoplasty (RFK) provides a new minimally invasive procedure to treat vertebral compression fractures (VCF). Purpose. The purpose of this study was to investigate the functional outcomes, safety and radiographic outcomes after the treatment of painful osteolytic vertebral fractures treated with a novel minimally invasive procedure, RFK. Material and Methods. 88 patients (50 females and 38 males) with 158 osteolytic vertebral fractures were treated with RFK using the StabiliT Vertebral Augmentation System (Dfine Inc, San Jose, CA). The StabiliT System provides a navigational osteotome to create a site and size specific cavity prior to delivering ultrahigh viscosity cement with an extended working time (done by applying radiofrequency energy to the cement immediately prior to entering the patient). 12 months follow up in 60 patients (36 females and 24 males) with 110 treated vertebrae are reported. Pre- and postoperative, 3, 6 and 12 months clinical parameters (Visual Analogue Scale, Oswestry Disability Index score), and radiological parameters (vertebral height and kyphotic angle) were measured. Results. The median pain scores (VAS) (p<0.001) and the Oswestry Disability Score (p<0.001) improved significantly from pre- to post-treatment and maintained at 3, 6 and 12 months follow up. Postoperative, 3,6 and 12 months follow-up RFK restored and stabilized the vertebral height and avoided further kyphotic deformity. No symptomatic cement leaks or serious adverse events were seen in the RFK group during 3-months of follow up. In 7 out of 158 vertebrae (4.4%) a cement leakage into the disc or lateral wall could be determined by radiograph postoperatively. Conclusion. Radiofrequency Kyphoplasty is a very safe and effective minimally invasive procedure for the treatment of osteolytic vertebral fractures. Radiofrequency Kyphoplasty shows excellent clinical and radiological results in the 3 and 6 months follow up. Site specific cavity creation and delivery of ultra-high viscosity cement in RF Kyphoplasty with extended working time resulted in the added benefits of height restoration and lower cement leakages intra-operatively

INTRODUCTION. Computer-aided systems have been developed recently in order to improve the precision of implantation of unicompartmental knee replacement (UKR). Minimal invasive techniques may decrease the surgical trauma related to the prosthesis implantation, but there might be a concern about the potential for a loss of accuracy. Mobile bearing prostheses have been developed to decrease the risk of polyethylene wear, but are technically more demanding. Navigation might help to compensate for these difficulties. We wanted to combine the theoretical advantages of the three different techniques by developing a navigated, minimal invasive, mobile bearing unicompartmental knee prosthesis. MATERIAL AND METHODS. 160 patients have been operated on at our institution with this system. The 81 patients with more than 2 year follow-up have been re-examined. Complications have been recorded. The clinical results have been analyzed according to the Knee Society Scoring System. The subjective results have been analyzed with the Oxford Knee Questionnaire. The accuracy of implantation has been analyzed on post-operative antero-posterior and lateral long leg X-rays. The 2-year survival rate has been calculated. RESULTS. We observed 8 complications related to the implant or the operative technique: 2 cases of meniscus instability (1 revision to TKR, 1 bearing exchange); 2 cases of tibia loosening (revised to TKR), 2 cases of femoral loosening (revised to TKR), 1 case of lateral disease progression (revised to TKR), 1 case of unexplained pain syndrome (revised to TKR). The mean Knee Score was 93 points, 44% had the maximum of 100 points, and only 10% have less than 85 points. The mean pain score was 48 points/50. The mean flexion angle was 128°, and 60% had at least 130° of knee flexion. The mean Function Score was 97 points, 84% have the maximum of 100 points, and only 5% had less than 85 points. The mean Oxford Knee Questionnaire score was 19 points (best result: 12 points, worst result: 60 points). Expected limb axis correction was obtained in 77% of the cases. 62% of the cases had an optimally implanted prosthesis for all studied criteria. The 2-year survival rate was 97%. DISCUSSION. Most of the revision cases were related to technical difficulties during the development phase. Fixation of the implant has been improved, and some imprecise steps of the software have been corrected. Since these changes occurred, no severe early complication related to implant or software has been observed. The current implant is considered reliable, and the current minimal invasive navigated technique is considered reliable as well

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 Context. Different minimally invasive approaches to the lumbar spine have been proposed but they can be associated with increased risk of complications, steep learning curve and longer operative time. Purpose. To report the complications associated with a minimally invasive technique of retroperitoneal anterolateral approach to the lumbar spine. Study design. Retrospective study of 179 patients who underwent anterior oblique lumbar interbody fusion (OLIF). Methods. A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. This muscle-splitting approach consists in anterolateral exposure through a 4 cm incision followed by placement of a PEEK cage filled with bone graft and/or substitute. Results. Patients were aged 54.110.6 years with BMI of 24.84.1 kg/m2. Length of follow-up was (0.90.7 years), including 17 patients with a minimum follow-up of 2 years. A left-sided approach was done in 174 patients. The procedure was performed at L1–2 in 4, L2–3 in 54, L3–4 in 120, L4–5 in 134 and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Operative time and blood loss were respectively 32.513.2 min and 57131 cc per level fused. There were 19 patients with single complication and one with two complications, including two patients with postoperative radiculopathy after L3–5 OLIF. There was no abdominal weakness or herniation. Conclusion. Minimally invasive OLIF can be performed easily and safely from L2 to L5, and at L1–2 and L5-S1 for selected cases. Up to 3 levels can be addressed through a “sliding window”. It is associated with minimal blood loss and short operative time. The risk of complications is similar to that reported for traditional anterior approaches, with the advantage of decreasing the risk of abdominal wall weakness or herniation

Introduction. The usefulness of minimal invasive hip replacement is frequently discussed but there is a lack of data on the effect of the surgical approach on early results. We wanted to study the effect of the surgical approach on the peri- and early postoperative outcome. Material/Methods. In a prospective case control study 315 elective hip replacements were performed between January 2008 and March 2010. Until March 2009 a lateral transgluteal approach (STD) was used, then the approach was changed to a minimal invasive anterior approach (MIS). All operations were performed in the same routine setting not affected by the approach. Duration of operation, complications and bloodloss were assessed. 1 week postoperatively, independent mobility, stairs, central analgetics were analysed and length of stay was recorded. At 6 and 12 weeks, pain and patients satisfaction (VAS) and the Harris Hip Score were assessed. Pre- and postoperative radiographs were compared for component position and orientation (EBRA). Results. 6 patients (hips) refused participation, 4 were excluded for other reasons. 174 (57%) hips belonged to STD and 131 (43%) to MIS. There were no demographic differences between both groups. Operation time was longer for MIS (109 vs. 123 min, p=.001). At 1 week, MIS patients were more mobile (rising up from bed, p=.009; stairs, p=.015) and time of hospitalisation became shorter (p=.001). At 6 weeks, MIS patients had less pain at motion (p=.013), less limb (p=.001), a higher HHS (p=.007) and were more satisfied (p=.046). The differences remained unchanged after 12 weeks. There was no difference in implant positioning between the groups. Inclination was higher in group MIS [39° (SD 6°) vs. 38° (SD 7°), p=.030], anteversion was lower [21° (SD 8°) vs. 24° (SD 8°), p=.010]. Conclusion. The introduction of the MIS anterior approach was safe. Early rehabilitation was facilitated and clinical results were better. Radiographical results were not impaired by the new approach. We see no disadvantage of the MIS anterior approach. Adaptions in the clinical setup might further facilitate rehabilitation

Introduction. Minimally invasive implanted unicompartmental knee arthroplasty (UKA) leads to excellent functional results. Due to the reduced intraoperative visibility it is difficult to remove extruded bone cement particles, as well as bone particles generated through the sawing. These loose third body particles are frequently found in minimally invasive implanted UKA. The aim of this study was to analyse the influence of bone and cement particles on the wear rate of unicompartmental knee prostheses in vitro. Material & Methods. Fixed- bearing unicompartmental knee prostheses (n = 3; Univation F®, Aesculap, Tuttlingen) were tested with a customized four-station servo-hydraulic knee wear simulator (EndoLab GmbH, Thansau, Germany) reproducing exactly the walking cycle as specified in ISO 14243-1:2002. After 5.0 million cycles crushed cortical bone chips were added to the test fluid for 1.5 million cycles to simulate bone particles, followed by 1.5 million cycles blended with PMMA- particles (concentration of the third-body particles: 5g/l; particle diameter: 0.5- 0.7 mm). Every 500 000 cycles the volumetric wear rate was measured (ISO 14243-2) and the knee kinematics were recorded. For the interpretation of the test results we considered four different phases: breaking in- (during the first 2.0 million cycles), the steady state- (from 2.0 million to 5 million cycles), bone particle- and cement particle phase. Finally, a statistical analysis was carried out to verify the normal distribution (Kolmogorov-Smirnov test), followed by direct comparisons to differentiate the volumetric wear amount between the gliding surfaces (paired Student's t-test, p<0.05). Results. The wear rate was 12.5±0.99 mm. 3. /mio. cycles in the breaking-in phase and decreased during the steady state phase to 4.4±0.91 mm. 3. /mio cycles (not significant, p = 0,3). The bone particles did not have any influence on the wear rate (3.0±1.27 mm. 3. /mio cycles; p = 0,83) compared to the steady state phase. The cement particles, however, lead to a significantly higher wear rate compared to the steady state phase (25.0±16.93 mm. 3. /mio cycles; p<0.05). Discussion. To our knowledge this is the first study demonstrating that free cement debris which can be found after minimally invasive implanted UKA increases significantly the wear- rate. Bone particles generated for instance through sawing during implantation, however, had no influence on the prostheses wear rate. Our Data suggests, that it is extremely important to remove all the extruded cement debris accurately during implantation in order to avoid a higher wear rate which could result in an early loosening of the prostheses

Clinical Problem. Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems. We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail. Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,. Material and Methods. the XS nail is a 4.5mm or the XXS a 3.5mm straight nail witch is locked by threaded wires witch are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The Fibula is fixed percutaneusly and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. From july 2000 to july2006 54 pilon fractures where treated. The mean age was 54 years (range 25–92). In all cases except one referred after 4 weeks the fibula and joint dislocations where stabilised primarily. The tibia XS nail osteosynthesis or limited invasive plate fixation was performed after 5–8 days except two fixed primarily. Up to now 43 patients could be re-examined more than 12 months after surgery. The results were classified according to the Ovadia Score. In a second study: from 05/2000 to 03/2002 214 ankle fractures were stabilised with a XS or XXS nail. The mean age was 51 year, 59% were woman. 35% were Weber B and 25% type C fractures. The re-examination after 6 months could be performed in 91 Patients and was evaluated according to the Ovadia score (clinical and radiological). Results. All articular pilon fractures and fibula fractures healed without problems but in 3 metaphyseal fractures delayed union required bone grafting. According to the Ovadia Score after one year the results were very good or good in the subjective criteria in 69% of the patients and 61% in the objective criteria. In the ankle fractures study in 2 patients haematoma revisions and in 2 patients with the primary used oblique insertion of the nail a proximal fibula fracture occured. At re-examination 71% showed an excellent and 25% a good result. Conclusion. the minimal invasive stabilisation of pilon fractures with the XS nail and the absence of plates on the bone surface reduces significantly the healin. The Xs nail is also a new option for ankle stabilisation. It improves the stability and reduces the complication of ankle osteosynthesis due to the lack of implant under the skin on the bone surface and due to the higher biomechanical stability of intramedullary implants

Background. Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Method. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data. Results. There was a negative relationship between age at 1 ° operation and EPFR lengthening (p = 0.03). Mean lengthening for all (including revision) EPFR was 3cm (range 0–13.05). 28 (64%) patients were lengthened a mean 4.8cm at a mean 7 procedures each. 18 were not lengthened, of which 12 were deceased at last followup and 1 had undergone amputation. Lengthening of secondary prostheses contributed a mean 3.7cm to limb length. 2 tertiary implants were lengthened noninvasively by 1.2cm (3 lengthenings) and 1.275cm (5 lengthenings). 16 of 21 failed 1 ° femoral components had been lengthened. The 21 implants underwent a mean 4.2 lengthenings in comparison to mean 1.3 lengthenings in the 28 that did not fail. Number of 1 ° prosthetic lengthenings was positively related to risk of component failure (p = 0.035) and total number of complications (p = 0.049). Complication rate was also related to total lengthening of 1 ° prosthesis (in cm) (p = 0.004). There was a statistically insignificant (p = 0.059) trend towards increased infection rate with higher number of minimally invasive lengthening procedures. Complications were commoner in those undergoing lengthening (mean 3 vs 1.75 in non-lengthened prostheses). Number of lengthenings correlated with number of complications (p = 0.001). Total lengthening of distal EPFR correlated with incidence of knee fixed flexion deformity (FFD)(p = 0.034). Median lengthening was 3cm in those with FFD and 0cm in those without (p = 0.019). Open lengthening procedures caused 6 complications: 2 deep & 3 superficial infections and recurrent subluxation requiring acetabuloplasty in a proximal replacement. Summary/Conclusions. The inverse relationship between age at 1 ° operation and lengthening is expected if the aim of offsetting limb length discrepancy during growth is being achieved. Lengthening is associated with increased complications (particularly infection and FFD) and femoral component failure, suggesting that lengthening procedures are implicated in the cause of some complications. 5 infective complications after lengthening were theoretically avoidable if noninvasive growers were used

Adipose tissue is an attractive source of mesenchymal stem cells (MSCs) as it is largely dispensable and readily accessible through minimally invasive procedures such as lipoaspiration. Until recently MSCs could only be isolated in a process involving ex-vivo culture. Pericytes (CD45−, CD146+, and CD34−) and adventitial cells (CD45−, CD146−, CD34+) represent two populations of MSCs (collectively termed perivascular stem cells or PSCs) that can be prospectively purified using fluorescence activated cell sorting (FACS). We performed FACS on lipoaspirate samples from n=129 donors to determine the frequency and yield of PSCs and to establish patient and processing factors that influence yield. The mean number of stromal vascular fraction (SVF) cells from 100ml of lipoaspirate was 37.8×106. Within the SVF, mean cell viability was 82%, with 31.6% of cells being heamatopoietic (CD45+). Adventitial cells and pericytes represented 31.6% and 7.9% of SVF cells respectively. As such, 200ml of lipoaspirate would theoretically yield 24.5 million MSCs –a sufficient number to enable point-of-care delivery for use in several orthopaedic applications. The yield and prevalence of PSCs were minimally affected by donor age, sex and BMI. Storing lipoaspirate samples for up to 72 hours prior to processing had no significant deleterious effects on MSC yield or viability. Our study confirms that pure populations of MSC-precursors (PSCs) can be prospectively isolated from adipose tissue, in sufficient quantities to negate the necessity for culture expansion while widening possible applications to include trauma, where a time delay between extraction and implantation excludes their use

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Background. Although minimally invasive plate osteosynthesis (MIPO) has become popular option for humeral shaft fractures, indirect reduction and its maintenance are technically challenging. The purpose of this study is to describe a reproducible technique utilizing an external fixator during MIPO and to assess its outcomes. Methods. Twenty-nine cases with a mean age of 37.1 years were included. There were 7 simple (type A) and 22 comminuted (type B or C) fractures. Indirect reduction was achieved and maintained by a monolateral external fixator on the lateral aspect of humeral shaft, and MIPO was performed on the anterior surface. Union, alignment, complications, and functional results of the shoulder and elbow were assessed. Results. Twenty-eight of 29 fractures were united with a mean of 19.1 weeks including 3 delayed unions. The mean follow-up period was 20.8 months. There was one hypertrophic nonunion, which was healed after fixing two additional screws. None had angulation greater than 10 degrees in the coronal and sagittal planes. Mean constant shoulder score and mean Mayo elbow performance score were 89.1 and 95.5, respectively. There was no direct damage to nerves related to the pin of external fixator, while two cases of radial neuropraxia developed, which recovered within 2 months after operation. Conclusion. Assisted by the preliminary external fixation, MIPO may achieve successful outcomes for humeral shaft fractures

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

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented. Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed. 77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points. The XXS nails allow a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low

Distal clavicle fractures have a significant non-union rate, and are often managed operatively. Many of the fixation devices used have a high complication rate or require removal. An arthroscopic technique using the Tightrope device (Arthrex) has been used in our institution. We aimed to describe our initial results. Eighteen cases were identified retrospectively, and the notes and radiographs reviewed. Twelve patients were male, six female, with mean age 33 years. All fractures were displaced, lateral to the coraco-clavicular ligament complex: six showed marked comminution. Mean follow-up was thirteen weeks. Fifteen fractures united, with a mean radiological time to union of 8 weeks (range 6-13 weeks). There were three surgical complications. In one, the clavicular button was not seated correctly on bone, and early failure required revision surgery. In another, there was inadequate reduction, radiographic non-union at five months and subsequent device failure. In the last, there was radiographic non-union, but the patient was asymptomatic. The arthroscopic tightrope device provides minimally invasive stabilisation and reliable union. The complications seen were related to incorrect technique, and anticipate the complication rate to diminish as the technique is developed. We recommend the use of this technique for the stabilisation of distal clavicle fractures