Aims. To determine whether there is any benefit using a minimally invasive trans-sartorial approach as described by Professor Søballe compared to the ilio-femoral for peri-acetabular osteotomy. Methods. 30 consecutive patients were operated on by a single surgeon. The first 15 underwent an ilio-femoral (I-F) approach whilst the following 15 had a trans-sartorial (T-S) approach. Fixation was achieved with 3 or 4 screws. All other aspects of surgery and rehabilitation were the same. Data was collected prospectively and included operation time, intra-operative blood loss and length of stay. Acetabular correction was measured using the sourcil and centre edge angle (CEA) on pre and post-operative radiographs. Results. Both groups had acceptable radiographic corrections with CEA improving from mean 14.5 to 38.7 degrees (T-S) and 14 to 39 degrees (I-F). The sourcil angle improved from mean 17.8 to 2 degrees (T-S) and 19.5 to −1.5 (I-F). Minimally invasive surgery reduced anaesthetic time by 62 minutes. Haemoglobin loss was reduced by 1 gram/L and there was no requirement for transfusion. Hospital stay reduced by 0.8 days. There were no major adverse complications although two partial femoral neurapraxias were noted early in the series. These fully resolved. Conclusion. We have found significant benefit from changing to minimally invasive PAO. Our patients have smaller wounds, a shorter operative time, reduced bleeding and a shorter length of stay. We found no adverse effects. The time savings have also corresponded to a cost saving for our institution. We recommend this technique although recognise that it has a learning curve and should be initiated by surgeons with previous PAO experience

Introduction

Minimally invasive plate osteosynthesis (MIPO) is a relatively new surgical technique for the management of distal tibial fractures. Conventional open technique is unfavourable to the fracture biology because of excessive soft tissue stripping and can be associated with significant devastating complications.

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures.

This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20⁰, using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years.

All patients in both operatively treated groups were corrected to under 10⁰ of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture.

The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%.

Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%.

MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible.

There was no loss of correction in either operatively treated groups.

The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction.

MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity.

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

Introduction. Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

Purpose. Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. Methods. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications. Results. Ten patients (3.2%) had intraoperative femoral fractures (greater trochanter: 2 cases, calcar: 8 cases). Five fractures required additional wiring. Difficult access to proximal femur was reported in the operative records for 10 other patients (3.2%). There was no difference in diagnosis, age, sex, BMI between the patients with or without intraoperative complications. No significant group differences were found for surgical time, and blood loss. Patients with intraoperative complication, presented a significantly lower pelvic incidence than patients without intraoperative complications (mean PI: 39.4° vs 56.9°, p<0.001). The relative risk of intraoperative complications in patients with low PI (PI<45°) was more than thirteen times (relative risk; 13.3, 95% CI= 8.2 to 21.5. p<0.001) the risk for patients with normal and high PI (PI>45°). Conclusions. Anterolateral approach for THA implantation in lateral decubitus is reported to have anatomical and functional advantages. Nevertheless, the exposure of the femur remains a limitation. This study highlights a significant increased risk in case of low PI less than 45°. This specific anatomical pattern reduces the local working space as the possibility for posterior translation and elevation of the proximal femur is less on a narrow pelvis. This limitation is due to the length and the orientation of the hip abductor and short external rotator muscles related to the relative positions of iliac wing and greater trochanter (Fig. 2). This study points out the importance of pelvic incidence for the detection of anatomically less favourable patients for THA implantation using ALA. For any figures or tables, please contact the authors directly

Purpose. To update current surgical management of knee osteoarthritis. Methods. A literature review was done using standard keyword search. Articles were scrutinized by the investigators to ensure relevancy to the purpose of this review. Summary of the review. Arthroscopy, osteotomy and arthroplasty are three major techniques for knee osteoarthritis. Arthroscopy is more and more common as it is diagnostically and therapeutically useful, especially for patients with painful osteoarthritis with mechanical symptoms. Recently, arthroscopic techniques to treat subchondral bone marrow lesions associated with knee osteoarthritis have been developed. Osteotomy is a technique that preserves the natural biomechanics of the joint and reestablishes joint alignment. Its accuracy has been improved with the advancement of computer-assisted surgery. Arthroplasty includes Unicompartmental knee arthroplasty (UKA) and Total knee arthroplasty (TKA). In UKA, patient selection is a key factor for good outcomes, which can be enhanced with newer implant designs and robotic technology. TKA is the mainstay technique for end-stage osteoarthritis. Minimally invasive TKA was developed to overcome major limitations of conventional technique. Considerable number of new technologies have been introduced for patients requiring TKA, such as gender-specific knee implants, computer-assisted navigation, robotic-assisted surgery and patient-specific cutting guides. Conclusion. As advances in surgical techniques and tools continue and numerous options are available, appropriate patient selection and understanding indications to each options are critical to success

Introduction. Most Japanese patients who receive total hip arthroplasty (THA) are osteoarthritic and 70% have development dysplasia of the hip. Their stature is shorter than average and their sizes (acetabular cup and femoral stem) are smaller. The Taperloc Microplasty (BIOMET) is a short femoral stem. It was launched on July 2012 in Japan (extended on January 2013). It is essentially a shortened version of the Taperloc stem (35mm shorter than the standard stem). Objectives. We aimed to evaluate the outcomes of minimally invasive anterolateral THA using a short stem. Methods. We retrospectively reviewed all 56 patients who underwent THA at our hospitals between July 2013 and April 2015. Of these 28 (50%) were performed with short stems. The surgical approach was antero-lateral in the lateral position. The patients (4 men and 24 women) had a mean age at surgery of 66.5 years (range, 46–85 years). The original diseases were osteoarthritis (25 patients) and osteonecrosis (3 patients). We investigated the system type, size (cup, femoral head, and stem), radiological findings and complications (fracture, infection, deep vein thrombosis, and dislocation). Results. There were no severe complications, such as, infection, deep vein thrombosis, or dislocation. One patient had a femur fracture during operation and was switched to a standard stem. The mean surgery duration was 102 minutes (range, 80–142 minutes) and the mean amount of bleeding during surgery was 254 g (range, 95–720 g). Mean cup size was 51.0 mm (range, 48–60 mm) and stem size is 6 (range, 4–13). Radiological findings showed 2 patients had stem subsidence (within 5mm). One of them had severe osteoporosis and the other patient had leg length discrepancy. Conclusions. Minimally invasive anterolateral THA using a short femoral stem has good clinical and radiological results in Japanese patients. Long-term results should be further observed prospectively

Background:. Morbidity of any surgical procedure is undefined. Major surgeries and minor surgeries have different morbidities but the morbidity after any surgical procedure is neither quantified nor defined in literature. Minimally invasive surgeries have evolved in all surgical branches and are known to have less morbidity after the surgery. There is no score or index to assess early recovery after any surgical procedure. Aim:. The objective of the study was to develop a scoring method to assess early post operative recovery of TKR patients. Materials and methods:. 50 consecutive total knee replacement patients were evaluated and scored at day 0, day 1, day2 and day3 post operatively. All the patients were operated upon by a single senior surgeon using minimally invasive approach. The scoring of the index consist of a questionnaire with 10 different questions regarding the general well being of the patient, wound condition, physical abilities and few other important parameters. The scores were judged from 0 to 3. Total score ranges from 0 to 30. The higher the score, the higher is the morbidity of the patient. Results:. The patients showed that the general morbidity decreases in great values from postoperative period to 24 h and 48 h after the surgery. Conclusion:. The morbidity index is a very reliable and precious way of assessing post operative condition of the patient in both surgeon's aspect and patient's aspect of view. Since there is no scoring method for early post operative assessment, this morbidity index may be important to measure the early surgical outcome of different surgeries

Minimally invasive (MIS) screw fixation for Hangman's fracture can decrease iatrogenic soft-tissue injury compared with conventional open approach, but increase the risk of instrumentation-related complications due to lack of anatomical landmarks. With the advantages, the intra-operative three-dimensional fluoroscopy-based navigation (ITFN) system seems to be an inherent partner for MIS techniques. The purpose of this study was to evaluate the accuracy and feasibility of MIS techniques incorporating with ITFN for treating Hangman's fracture. 20 patients with Hangman's fracture underwent C2-C3 pedicle screw fixation using ITFN. 6 patients used MIS technique, with the other 14 patients using conventional open technique. Preoperative visual analogue score (VAS) was 5.7±1.4 in CAOS-MIS group and 5.5±0.9 in CAOS-open group. Operative time, blood loss and postoperative neurovascular complications were recorded. The accuracy of screw positions was studied by postoperative CT scan. All patients were followed up for at least 6 months and the fusion status was ascertained by dynamic radiographs. The average operative time was 134.2±8.0 min in CAOS-MIS group and 139.3±25.8 min in CAOS-open group, and there was no significant difference between the two (p&gt;0.01). The blood loss was 66.7±25.8 ml in CAOS-MIS group and 250.0±141.4 ml in CAOS-open group. Statistical difference existed with CAOS-MIS group significant less than CAOS-open group (p&lt;0.01). A total of 80 screws were inserted. No screw-related neurovascular injury was observed. Post-operative CT scan revealed 83.3% (20/24) screws of grade 1 and 16.7% screws of grade 2 (4/24) in CAOS-MIS group, meanwhile 89.3% screws of grade 1 (50/56) and 10.7% screws of grade 2 (6/56) in CAOS-open group. There was no grade 3 screw detected. Fisher's exact test showed there was no statistical difference between these two groups (p&gt;0.01). There was no statistical difference in pre-operative VAS between these two groups (p&gt;0.01). Compared with the CAOS-open group (1.7±0.6), neck pain VAS at 6-month follow-up in CAOS-MIS group (0.3±0.5) was significantly lower (p&lt;0.01). Solid fusion was demonstrated in all the cases by dynamic radiographs. So it is feasible and safe for percutaneous minimally invasive C2-C3 pedicle screw fixation for Hangman's fracture using intra-operative three-dimensional fluoroscopy-based navigation, which can also decrease the incidence of post-operative neck pain

Introduction. Minimally invasive Computer Assisted Total Knee Arthroplasty (MICATKA) has benefits of reduced blood loss, shorter hospital stay, improved post-operative quadriceps function and enhanced post-operative recovery. Our study looked into these factors to compare if there was a significant difference when compared to conventional Computer Assisted Total Knee Arthroplasty (CATKA). Objective. Compare radiological and clinical outcomes of MICATKA and CATKA at a minimum of 5 years. Methods. 40 patients who underwent MICATKA were compared with 40 patients having conventional CATKA. Component positioning was assessed radiographically with AP long leg standing views. Knee Society Scores, length of stay and recovery of straight leg raise was also recorded pre-operatively and at 6-monthes and then yearly until 5 year follow up. Results. Pre-operative Knee Society Scores showed no significant difference between the two groups. Post operatively the mean femoral component alignment was 89.7 degrees for MICATKA and 90.2 for CATKA. The mean tibial component alignment was 89.7 degrees for both. Knees Society Scores in the short term (6, 12, 18 and 24 months) were statistically better in the MICATKA (p<000.1) group. Straight leg raise was achieved by day one in 93% of the MICATKA compared to only 30% of the CATKA. Length of stay for MICATKA was a mean of 3.25 days with CATKA a mean of 6 days. At five years there was no significant difference in the MICATKA and CATKA in Knee Society Scores and there were two revisions in the MICATKA group and one in the CATKA group. Conclusions. MICATKA have significantly better outcomes in the immediate short-term compared to CATKA. In the medium term these differences are not significant and similar outcomes can be achieved when performing CATKA in both clinical and radiographic assessments

Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care. Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme

Recent emphasis in total knee arthroplasty has been on accelerated rehabilitation and recovery. Minimally invasive and quadriceps sparing techniques have been developed to expediate return to normal function. The aim of this study was to evaluate the effect of the tourniquet on post-operative pain and quadriceps function in total knee arthroplasty. This study involved a randomised, blinded, prospective trial of 20 patients undergoing total knee arthroplasty by a single surgeon. All patients received a general anaesthetic, identical prosthesis and post-operative protocol. Patients were randomly allocated to one of two group: (a) tourniquet group or (b) no tourniquet group. A standard surgical tourniquet was applied to all patients but only inflated in the tourniquet group. Outcomes included Oxford knee scores, post-operative pain scores, post-operative drainage and transfusion requirements, thigh and knee circumference measurements, range of motion, and surface EMG measurements at intervals of two weeks, six weeks, six months and twelve months. The study included 16 male and four female patients with 11 right and nine left knees. There was no significant difference pre-operatively between groups in age, degree of deformity or range of motion. There was no significant difference detected between Oxford knee scores up to twelve months, days to discharge, post-operative drainage and range of motion. However, the pain scores were significantly higher in the tourniquet group. Surface EMG as a measurement of quadriceps activation showed a significant difference between the groups and between time points. The no tourniquet group can support more energy in their quads muscle than the tourniquet group. The use of a tourniquet in total knee arthroplasty has no effect on overall knee function at twelve months as measured by the Oxford knee score and range of motion; however tourniquet use results in higher initial pain scores and reduction in quadriceps function as measured by surface EMG

Introduction. A new surgical approach for minimally invasive hip resurfacing is described with early results. Method. A posterior gluteus maximus splitting approach is used. The incision is in line with the fibres of gluteus maximus and is placed 5 cm. distal to the tip of the greater trochanter. Special instruments were necessary to carry out surgery: MIS targeting device for placement of centring pin, MIS retractor system, Chana curved acetabular reamer handle, and curved acetabular impactor. Results. 136 operations were carried out from December 2001 to February 2006. The average age of the patient was 56 years (range 30-78 years). The average body mass index was 32 (range 17.5 to 41.7). The average incision range was 7 cm. (range 6-10 cm.). The average blood loss was 245 ml (range 100-800 ml). All these patients were sent a postal questionnaire and 91 were returned (70%). Of these 38 were left sided and 53 right sided, 12 bilateral, 47 males and 32 females. The average review period was 26 months (range 6-56 months). There were 62 conserve implants and 29 ICON implants used. The median Oxford score was 9.38% and the mean COOP score was 29.8%. There were 2 fracture neck of femurs, one at 6 weeks and the other at 4 weeks post-surgery. Both of these were revised using the same approach with modular head hip replacement system giving a success rate of 97.8% in situ at 26 months (average). There were no cases of infection, nerve palsy, dislocation and hypertrophic bone formation. Conclusion. Minimally invasive hip replacement can be done safely through a minimally invasive approach using special instruments and the early results are very good

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

Excessive under correction of varus deformity may lead to early failure and overcorrection may cause progressive degeneration of the lateral compartment following medial unicompartmental knee arthroplasty (UKA). However, what influences the postoperative limb alignment in UKA is still not clear. This study aimed to evaluate postoperative limb alignment in minimally-invasive Oxford medial UKAs and the influence of factors such as preoperative limb alignment, insert thickness, age, BMI, gender and surgeon's experience on postoperative limb alignment. Clinical and radiographic data of 122 consecutive minimally-invasive Oxford phase 3 medial unicompartmental knee arthroplasties (UKAs) performed in 109 patients by a single surgeon was analysed. Ninety-four limbs had a preoperative hip-knee-ankle (HKA) angle between 170°-180° and 28 limbs (23%) had a preoperative hip-knee-ankle (HKA) angle <170°. The mean preoperative HKA angle of 172.6±3.1° changed to 177.1±2.8° postoperatively. For a surgical goal of achieving 3° varus limb alignment (HKA angle=177°) postoperatively, 25% of limbs had an HKA angle >3° of 177° and 11% of limbs were left overcorrected (>180°). Preoperative HKA angle had a strong correlation (r=0.53) with postoperative HKA angle whereas insert thickness, age, BMI, gender and surgeon's experience had no influence on the postoperative limb alignment. Minimally invasive Oxford phase 3 UKA can restore the limb alignment within acceptable limits in majority of cases. Preoperative limb alignment may be the only factor which influences postoperative alignment in minimally-invasive Oxford medial UKAs. Although the degree of correction achieved postoperatively from the preoperative deformity was greater in limbs with more severe preoperative varus deformity, these knees tend to remain in more varus or under corrected postoperatively. Overcorrection was more in knees with lesser preoperative deformity. Hence enough bone may need to be resected from the tibia in knees with lesser preoperative deformity to avoid overcorrection whereas limbs with large preoperative varus deformities may remain under corrected

Minimally invasive total knee arthroplasty is growing in popularity. It appears to reduce blood loss, reduce hospital stay, improve post-operative quadriceps function and shorten post-operative recovery. We show our experience of minimally invasive TKA with a computer navigation system. The first series compared forty MICA TKA and forty conventional computer assisted total knee arthroplasties (CATKA). Component positioning was assessed radiographically with long leg Maquet views. Knee Society Scores (KSS) were recorded pre-operatively and at 6, 12, 18 months. Length of stay and recovery of straight leg raise was also recorded. A second series of fifty MICATKA patients were assessed post-operatively for component alignment using long leg Maquet views. Twenty-two of these patients had assessment of femoral rotation using CT. In the first series pre-operative KSS showed no significant difference between the two groups. Post-operatively the mean femoral component alignment was 89.7 degrees for MICATKA and 90.2 for CATKA. The mean tibial component alignment was 89.7 degrees for both. KSS at 6, 12, 18 months were statistically better in the MICATKA (p<000.1). Straight leg raise was achieved by day one in 93% of the MICATKA compared to 30% of the CATKA. Length of stay for MICATKA was a mean of 3.25 days with CATKA a mean of 6 days. In the second series the mean femoral component varus/valgus angle was 89.98 degrees, the mean tibial component varus/valgus angle was 89.91 degrees and the mean femoral component rotation was 0.6 degrees of external rotation. MICATKA is a safe procedure with reproducible results. Alignment is equivalent to CATKA. It gives statistically significant improvement in KSS compared to the open procedure. The length of stay and time to straight leg raise are also reduced. At 2 years follow-up we have seen no revisions and no evidence of loosening radiographically

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

Dupuytrens disease is a fibrosing condition of the palmar aponeurosis and its extensions within the digits. Normal fascial fibres running longitudinally in the subcutaneous tissues of the palm become thickened and form the characteristic nodules and cords pathognomonic of Dupuytrens disease. A wide variety of surgical interventions exist, of these the partial fasciectomy remains the most conventional and widely used technique. Minimally invasive surgical treatments such as needle fasciotomy are, however, becoming increasingly popular. Dupuytrens disease remains a challenging condition to treat as recurrence is universally found with all surgical interventions. Although recurrence may be related to the severity of the disease, there are currently no research tools other than clinical examination to examine changes in the diseased tissue postoperatively and predict likelihood of long-term success. Magnetic Resonance Imaging (MRI) may be of value for the study of Dupuytren disease, at present its use has been greatly underexplored. We wished to carry out a pilot study in order to examine the possibility of using 3.0 Tesla MRI to study Dupuytren tissue and then furthermore to examine the potential changes post-operatively following percutaneous fasciotomy. Five patients set to undergo percutaneous needle fasciotomy were recruited and consented for the study. All patients underwent MRI scanning of the affected hand pre-operatively and at two weeks post-operatively. Scanning was carried out in the 3.0 Tesla research MRI scanner at Aberdeen Royal Infirmary. Patients were placed prone in the MRI scanner with the hand outstretched above the head in the so-called “Superman” position. A specially designed wrist and hand coil was used. Under the expertise of radiographers and physicists, image capture encompassed four novel scanning sequences in order to make a volumetric three-dimensional image sample of the affected hand. MIPAV software (Bethesda, Maryland) was used for image analysis. Scanning revealed well defined anatomy. The Dupuytren cord arose from the palmar aponeurosis tissue which is deep to the palmar skin and subcutaneous tissue. It was distinctly different to deep structures such as the flexor tendons and intrinsic hand muscles which appeared with a uniform low and high signal respectively. The Dupuytren tissue had a heterogeneous signal on both T1 and T2 images. On T1 the tissue signal appeared high to intermediate, similar to that of bone and muscle, but low areas of signal were observed diffusely in an irregular fashion throughout. On T2 the tissue had a low signal throughout with some focal areas of high signal. Dupuytren tissue was mapped using MIPAV software for pre- and post-operative comparisons. Signal intensity, surface area and volume of the cords and fasciotomy sites were explored. Our initial results suggest MRI can be used to study Dupuytren tissue. Such a research tool may be of use to study the natural history of Dupuytren disease and furthermore, the response to medical and surgical interventions

Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure