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

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

There is no question that at some point many TKAs will be cementless-the question is when. The advantages of cementless TKA include a shorter operative time, no need for a tourniquet, more suitability for MIS, no concern for cement extrusion, and the history of THA. The concerns for cementless TKA include the history to date with cementless TKA (tibia and metal-backed patella), variable bony substrate, surgical cut precision, cost, revision concerns, and the patella (for patella component resurfacers). Cemented total knee arthroplasty remains the gold standard and has proven to provide durable results in most patients. The early experience with cementless tibial fixation was problematic due to tibial micromotion leading to pain and loosening. Screw fixed tibial components had additional problems as portals for polyethylene debris leading to tibial osteolysis. Moreover, metal-backed patellar components were associated with a high failure rate and most surgeons began to cement all three components. Renewed interest in cementless tibial fixation is driven in part by newer materials felt to be more suitable for ingrowth and by the perceived benefit of minimally invasive surgery. One of the concerns in limited exposure total knee arthroplasty is the difficulty in preventing the extravasation of cement posteriorly. If there is evidence-based data that quad sparing non-patella everting and limited incision length facilitates rehabilitation and does not jeopardise outcome, cementless tibial fixation will be a more attractive option in some patients. An additional concern is that the tibial surface is frequently quite variable in terms of the strength of the cancellous bone. Bone cement stabilises those differences and provides a homogeneous platform for load bearing through the tibial component

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

Over the past fifteen years, the average length of stay for total hip (THA) and total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and peri-operative protocols. Rapid recovery techniques and peri-operative protocols have been refined to allow for same-day discharge with improved outcomes. In addition to Rapid Recovery techniques for the clinical care of the outpatient, one critical component to same-day total knee arthroplasty is the efficient performance and simplicity of the procedure itself. Simplified instrumentation and elimination of modularity can provide that efficiency and simplicity. All polyethylene tibial components have been mostly supplanted by modular metal-backed designs in recent years. However, mounting evidence suggests that survivorship of TKA with an all-poly tibia is superior to TKA with metal-backed, modular designs in all age groups except younger than 55, in which survival is equal to a modular design. Furthermore, this survival advantage was unaffected by obesity. Combining these excellent clinical results with the efficiency of a non-modular component can add to the efficiency and simplicity of the surgical technique. Therefore, in outpatient total knee arthroplasty, the all-poly tibia truly represents the less is more mentality

Purpose. The minimally invasive surgery (MIS) approach has been popularised as an alternative to the standard open approach in acute Achilles tendon ruptures. Advocates of this technique suggest earlier functional recovery, due to less injury to the surrounding tissues. However, the critics argue that due to the reduced exposure risk and complications of such surgery are higher in comparison to the open technique. Methods. A systematic review and meta-analysis of randomised and prospective studies were conducted to compare the MIS and open surgery in acute Achilles tendon ruptures. Results. 13 studies were included in the meta-analysis in 4 languages involving total of 854 patients, 426 in the MIS group and 428 in the open group. Although the re-rupture rates were not significantly different between the groups (10 events in 410 patients in MIS group and 9 events in 341 patients in the open one, P=0.41), there were significantly more complications in the open surgery group (29 in 426 MIS patients versus 105 in 428 patients in open surgery group, P<0.00001). Conclusions. MIS in acute Achilles tendon ruptures results in similar re-rupture rates, in comparison with open surgical method with significantly less post-operative complications

Background. Both minimally invasive surgery(MIS) and computer-assisted surgery(CAS) in total knee arthroplasty have been scientifically linked with surgical benefits. However, the long-term results of these techniques are still controversial. Most surgeons assessed the surgical outcomes with regard to knee alignment and range of motion, but these factors may not reflect subjective variables, namely patient satisfaction. Purpose. To compare satisfaction and functional outcomes between two technical procedures in MIS total knee arthroplasty, namely computer-assisted MIS and conventional MIS procedure, operated on a sample group of patients after 10 years. Methods. Seventy cases of posterior-stabilized total knee prostheses were implanted using a computer-assisted system and were compared to seventy-four cases of matched total knee prostheses of the same implant using conventional technique. Both groups underwent arthrotomy by 2 centimeter limited quadriceps exposure minimally invasive surgery (2 cm Quad MIS). At an average of ten years after surgery, self-administered patient satisfaction and WOMAC scales were administered and analyzed. Results. Demographic data of both groups including sex, age, preoperative WOMAC and post-operative duration were not statistically different. Post-operative WOMAC for the computer-assisted group was 38.94±5.68, while the conventional one stood at 37.89±6.22. The median of self-administered patient satisfaction scales of the computer-assisted group was 100 (min37.5-max100), while the conventional one was 100 (min25-max100). P-value was 0.889. There was 1 re-operative case in the conventional MIS group due to peri-prosthetic infection which was treated with debridement, polyethylene exchanged and intravenous antibiotics. Conclusion. The long-term outcomes of computer-assisted MIS total knee arthroplasty are not superior to that of the conventional MIS technique. Computer assisted MIS total knee arthroplasty is one of the treatment options for osteoarthritis of the knee that has comparable levels of satisfaction to the conventional MIS technique

Objectives. Few reports were shown about the position of the cup in total hip arthroplasty (THA) with CT-based navigation system. We use minimally invasive surgery (MIS) technique when we perform cementless THA and the correct settings of cups are sometimes difficult in MIS. So we use CT-based navigation system for put implants with correct angles and positions. We evaluated the depth of cup which was shown on intra-operative navigation system. Materials and Methods. We treated 30 hips in 29 patients (1 male and 28 females) by navigated THA. 21 osteoarthritis hips, 6 rheumatoid arthritis hips and 3 idiopathic osteonecrosis hips were performed THA with VectorVision Hip navigation system (BrainLAB). Implants were AMS HA cups and PerFix stems (Japan Medical Materials, Osaka). Appropriate angles and positions of cups were decided on the 3D model of pelvis before operation. According to the preoperative planning, we put the implants with navigation system. We correct the pelvic inclination angle and measured the depth of cups with 3D template software. Results. The average distance from the surface of the cup to the edge of medial wall of pelvis was 3.4mm (0.0–8.0mm) on the axial plane which include the center of femoral head on postoperative CT. The average distance from the surface of the cup to the edge of medial wall of pelvis was 6.4mm (1.5–15.0mm) on intraoperative navigation. The average error was 2.9mm (0.0–9.0mm). The cup positions of post operative CT were deeper than that of intraoperative navigation in twenty six hips (86%). Conclusions. The shallow setting of cups caused the instability of cups. Deep setting caused damage of acetabular fossa. The positions of cups on the navigation system tend to be shown shallower than actual positions, so we should take care of deeper setting

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Introduction. With the introduction of minimally invasive surgery techniques and improved polyethylene wear properties, there has been a renewed interest in Unicondylar Knee Replacements (UKR). Customized, Individually Made (CIM) UKR have been in the market for some time, and have shown to provide improved coverage and fit. The purpose of this study was to assess clinical and patient-reported outcomes utilizing CIM-UKR prostheses. Methods. A prospectively recruited cohort of 118 patients was implanted with 120 CIM-UKR (110 medial/10 lateral) at multiple centers across the US. Patients were diagnosed with uni-compartmental osteoarthritis of the medial or lateral compartment. Patients with compromised cruciate or collateral ligaments or having a varus/valgus deformity <15. °. were excluded. Patients were assessed for Knee Society Knee and Function Scores, WOMAC & ROM pre-operatively (120 patients), at 6-weeks post-op (119), 6-months post-op (71 optional visit), 1 year post-op (113) and 2 years post-operatively (96). For the 3 and 4 year post-operative time points, patients were contacted to report on any possible adverse events. Results. Range-of-motion was improved from 120. °. pre-operatively to 131. °. at 2 years post-op. Patients demonstrated marked improvements from baseline scores across all domains. All patients have passed their 2-year follow up visit to date. Average KSS Knee Scores significantly improved from their preoperative levels to 95 at the 2-years follow-up visit. KSS Function domain scores significantly improved from pre-operative levels to 91 at the 2 year time-point. Similar improvements were noted in the WOMAC score, which was reported to be 89 at the 2 year time point. Average VAS Pain scores at the 2 year visit was 1.3. To date, at an average follow-up of 3.1 years there have been 2 patients revised for tibial loosening and an additional 2 patients have been revised for disease progression in the other compartments of the knee. Discussion. There are a multitude of studies of off-the-shelf mobile and fixed-bearing UKR. The 2-year follow up data collected on CIM-UKR compares favorably to both published scores as well as revision rates for off-the-shelf implants

Total joint arthroplasty (TJA) has historically been considered primarily an inpatient operation. However, the actual length of stay (LOS) has diminished over time. At our institution the LOS from 1987 to 1990 averaged five to seven days. This decreased to three days from 1993 to 2002 and down to one to two days from 2005 to 2011. With the adaptation of improved anesthesia and pain management protocols, minimally invasive surgery techniques, rapid recovery protocols, and proper patient selection, outpatient (OP) TJA appears to be the next step in maximizing peri-operative efficiency; especially as younger patients are undergoing TJA. Other potential benefits of OP TJR include improved patient care and control, better patient and surgeon satisfaction and a lower overall cost. Over a twenty-four month period (July 2012 to June 2014) we performed 250 primary TJAs (139 hips and 111 knees) and twelve revision TJAs (six hips and six knees). All patients received 400 mg of celecoxib pre-operation and 200 mg/day for ten days. In addition to general anesthesia, hips received a short-acting spinal and knees received an adductor canal block. Tranexamic acid (IV or topical) and a pericapsular injectable cocktail of liposomal bupivacaine was routinely used. There was one deep infection (0.4%) and one readmission for pain control (0.4%). Two cases of deep vein thrombosis were diagnosed (0.8%). Patient education, home health care utilization, and proper patient selection are key factors to keep hospitalization rates, emergency room visits, and re-admission rates to a minimum

Purpose of study:. The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures. Methods:. A retrospective review of clinical and radiological records was performed on patients with intramedullary nailing of isolated gunshot radius fractures between 2009 and 2013. Results:. Twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19–40). Follow-up was for an average period of 11 weeks (range 6–24). One patient had a median nerve palsy and 2 a posterior interosseous nerve palsy pre-operatively. All operations were performed within 3 to 12 days of the injury. No primary bone grafting was performed. All fractures united with the index procedure. Average time to union was 10 weeks (range 8–24). Fourteen patients (64%) had their radial bow restored and maintained; these patients had minimal comminution in the middle to distal third of the radius. The bow could not be satisfactorily restored in severely comminuted fractures in the proximal third of the radius. Using the Anderson classification outcome was excellent in 14 patients (64%), satisfactory in 6 (27%) and unsatisfactory in 2 (9%). There were no complications associated with the surgery and one patient required nail removal for implant migration. Conclusion:. Intramedullary nail fixation of gunshot radius fractures has shown promising results in our hands with no significant complications. The fracture site and zone of comminution directly influenced our ability to restore radial bow

Purpose of Study. To assess the results of Revision Hip Surgery in which a less invasive technique was utilized in situations where a number of different options was available. Method. The authors rely on an experience of 3,445 hip arthroplasties by a single surgeon over a period of 20 years, of which approximately 20% were revision cases. Of these 617 cases, we report on 175 in which a minimally invasive option was taken. This does not apply to the skin incision, as all cases were adequately exposed. We have adopted this term to describe cases in which a surgical options was taken that resulted in the least morbidity and the shortest surgical time. We postulated that would lead to the best outcomes with the least complications. Acetabular revisions: 1) Isolated polyethylene exchange. 2) Liner revision with cement technique in cases of cup malposition or poor locking mechanism. 3) Revision of cup with a primary prosthesis with significant medial bone loss. Stem revisions: 1) Cement on cement technique. 2) Strut graft and primary stem. Results. We found a very low complication rate utilizing these methods: Fatal pulmonary emboli: 0 Sepsis: 2 Dislocations 3 Repeat revisions 3. Conclusion. Revision surgery offers many challenges that tend to be compounded with successive operations. We believe that good results can be achieved when a philosophy of minimally invasive surgery is adopted. NO DISCLOSURES

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

Introduction. Early rehabilitation of hip and knee replacement patients has been advocated with the recent minimally invasive approaches to lower limb replacement allowing earlier mobilization and earlier discharge. Rehabilitation has been progressively shortened from the time of Charnley in such a way that patients are now expected to stay in hospital for only a couple of days before going home. New rehabilitation protocols recommend mobilization on day 0, the day of surgery, with earlier discharge possible. Methods. All primary hip and knee replacement patients were enrolled in a rapid rehabilitation protocol. All patients had standard incisions performed: a posterior approach for THR and a standard Insall para-patellar approach for TKR. The protocol included pre-emptive analgesia, post-op oral analgesia with high dose NSAIDs, pregabolin, neuro-axial anaesthesia, avoidance of opiates and colloid fluid replacement prior to mobilization. Morning patients were mobilized the day of surgery and afternoon patient the following morning. Duration of hospitalisation was compared to patients treated the previous year where the only difference in protocol was femoral blocks for TKR, no colloid replacement prior to mobilization, and routine day 1 mobilization. Results. 125 patients were enrolled (78 TKR and 47 THR). All patients could be mobilized according to this protocol, irrespective of age. The day of discharge was on average 4,2 days post-op. (Range 3 – 6 days). This was compared to the previous year of joint replacements where the average discharge day was 6,3 days (range 4 – 8 days). Conclusion. This protocol has seen an average 2,1 day earlier discharge from hospital with the same end point at discharge. This has shown us that safe day 0 mobilization of patients is possible, with dramatically improved patient morale, which resulted in much earlier discharge from hospital. These results can thus be achieved not only by minimal invasive surgery but also with standard arthroplasty approaches. NO DISCLOSURES

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. The direct anterior approach (DAA) for THA was first performed in Paris, by Robert Judet in 1947. This procedure has since been performed consistently by a small group of surgeons and has recently gained great popularity. Access to the hip can be safely performed with one or two assistants. The advantages of the anterior approach for hip arthroplasty are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. Care must be taken to avoid cutting the lateral femoral cutaneous nerve which runs over the fascia of the sartorius. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to hip arthroplasty and by abandoning the posterior approach and adopting the anterior approach his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation while the posterior rotators and capsule provides active and passive stability and accounts for immediate stability of the hip and a low risk of dislocation. Using the anterior approach, patients are allowed to mobilise their hip freely. The gluteus maximus and tensor fascia latae muscles insert on the iliotibial band which joins them and form a ´hip deltoid´. Lack of disturbance of these abductors and pelvic stabilisers is another benefit of the anterior approach and accelerates gait recovery. The lateral femoral cutaneous nerve is at risk when the fascia is incised between the tensor fascia latae and the sartorius muscle. Damaging it may lead to a diminished sensation on the lateral aspect of the thigh and formation of a neuroma. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intra-operative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. In obese or muscular patients, where visibility is in doubt, an increase of the incision length will give the surgeon the required view. The choice of approach used to perform a primary THA remains controversial. The primary goal of a hip replacement is pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach. The proposed benefits of with the DAA are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the DAA in THA

The advent of the Australian National Joint Replacement Registry has been an outstanding success in identifying prosthesis with higher than average failure rates, but it is principally a measure of revision rates for specific prostheses. In order to consider the causes of failure it is necessary to start at the point where prostheses are able to enter the Australian market through the Therapeutic Goods administration, Australian Registered Therapeutic Goods list (ARTG) and consider each of the steps of the joint replacement procedure from that point to well beyond the operation date. This ARTG listing process as it now exists is described and an explanation of how this process may need to be reformed if the occasionally very inadequate prosthesis is to be eliminated from the Australian market. Other matters that may be predictors of variable outcomes include hospital case volume, surgeon experience, patient selection and pre-operative planning. Intra-operative factors that lead to failure, including from infection, will include surgical approaches, operative technique, instrumentation, wound care and theatre discipline. Post operatively patient factors, particularly falls and osteoporosis, will influence long-term outcomes as will prosthesis performance. Further concern has been the advocacy by some by what might be considered, fashionable orthopaedics, but the literature to date has demonstrated little benefit from endeavours such as minimal invasive surgery and two-incision hip replacement. Gender specific prostheses and navigation have yet to make their mark as a universally accepted method of performing joint replacement surgery and there may be some negative issues with these matters

Background. In this study, we investigated the long-term clinical results and survivorship of minimally invasive unicompartmental knee arthroplasty (UKA) by collecting cases that have been implanted for >10 years ago. Methods. Medial UKA on 180 cases in 142 patients was performed over a period of 1 year after the first introduction of minimally invasive UKA from January 2002 to December 2002. Among these, 166 cases in 128 patients who underwent Oxford phase 3 medial UKA using the minimally invasive surgery, with the exclusion of 14 cases including 10 cases of follow-up loss and 4 cases of death, were selected as the subject. The mean age of the patients at the time of surgery was 61 years, and the duration of the follow-up was minimum 10 years. All the preoperative diagnosis was osteoarthritis of the knee joint. Clinical and radiographic assessments were measured by the Knee Society clinical rating system, and the survival analysis was confirmed by the Kaplan–Meier method with 95% confidence interval (CI). Results. The mean Knee Society knee and function scores improved significantly from 53.8 points (25 to 70) and 56.1 points (35 to 80) preoperatively to 85.4 points (58 to100) and 80.5 points (50 to 100) at 10-year follow-up, respectively(P<0.001). The mean range of the motion of the knee joint recovered from 128.6° (110° to 135°) to 132.5o (105o to 135o) (P<0.001), and the tibiofemoral angle changed from the mean 0.2° of varus (7o of varus to 7o of valgus) to 4.6° of valgus (2° of varus to 11° of valgus) under the weight-bearing X-ray (P<0.001). Failures following the UKA occurred in 16 cases in 14 patients out of a total of 166 cases (9.6%), and the mean time of the occurrence of the failure was 6.2 years after the surgery. The causes of the failure included 7 cases of simple dislocation of mobile bearing, 4 cases of loosening of implant, 1 case of dislocation of mobile bearing accompanied by loosening of implant, and 1 case of dislocation of mobile bearing accompanied by the rupture of the medial collateral ligament (MCL). Moreover, there was 1 case of fracture of polyethylene bearing, 1 case of deep infection and 1 case of failure because of medial tibial condylar fracture. Of the total of 16 cases of failures, 11 cases (69%) were treated with revision total knee arthroplasty (TKA), whereas 5 cases (31%) were treated with a simple change of mobile bearing. The 10-year survival rate was 90.5% (95% CI, 85.9 to 95.0) when failure was defined as all the reoperations, whereas the 10-year survival rate was 93.4% (95% CI, 89.6 to 97.1) when the cases in which only revision TKA was defined as failure. Conclusions. The results of this study show outstanding functions of the knee joint and satisfactory 10-year survival rate after minimally invasive UKA. Therefore, minimally invasive UKA could be a useful method in the treatment of osteoarthritis in one compartment of knee joint

Over the past 10 years, the orthopedic community has witnessed an increased interest in more conservative surgical techniques for hip arthroplasty. During this time, second-generation hip resurfacing and minimally invasive surgery enjoyed extensive marketing attention. After a decade of this renewed interest, both of these methods have met with serious concerns. As hip resurfacing numbers decline, both patients and surgeons are looking for other potentially successful conservative treatments to THA. This search has focused surgeon interest toward short-stem designs. Today, a variety of short-stem implants are available with very little clarification of design rationale, fixation features, surgical technique, and clinical outcomes. Virtually every major implant company now offers a “short stem,” and now there are a plethora of different designs. It is important to note, however, that not all short stems achieve initial fixation at the same bone interface region. Furthermore, surgical techniques vary greatly, and postoperative radiographic interpretation of short-stem position and fixation need to be carefully scrutinized. The purpose of this paper is to review past, present, and potential future developments of short femoral stems and to present a classification system that can offer guidance when reporting on the many different stem variations. Short Curved neck-sparing stem (JISRF classification 2a). Recently, new designs are following Pipino's Biodynamic stem style of saving the femoral neck. These designs feature a short curved stem that finds its stabilization contact region in the femoral neck and saves considerable bone in the medial calcar region. In addition, the curvature of the stem prevents violation of the lateral trochanteric region. The shorter stem also reduces blood loss by not reaming the femoral canal distally. These style stems generally have a variable stem length between 90 and 135 mm. This might not appear much shorter than conventional cementless stems (110 to 150 mm). However, the shorter curved neck sparing stems penetrate on average 1 to 2 cm less distally in the femoral canal. Short stems have a definite role in modern THA, as greater emphasis is being placed on soft tissue and bone sparing techniques and as refinements continue in the understanding of proximal femoral fixation. Metaphyseal short stems have significantly less surface contact area compared with conventional length stems and as a result, they might have less torsional and axial resistance. Neck-retaining short stems provide additional axial and torsional stability and reduced stress at the implant– bone interface and may be a consideration in the more active patient profile. Bone quality and the patient's physical activity should be considered prior to the selection of short-stem devices. Many short-stem designs have considerably different style features that may alter bone remodeling. Knowing the design and the required technique is vital to fit the device properly to the patient. The variations of short stems available call for caution in their overall use until there is better understanding of how dependent these stems are on individual stem features, bone quality, and surgical techniques. Overall, the authors are cautiously optimistic and continue advocating their selective use

Minimal invasive surgery (MIS) is accepted when the scar is 10 cm or less. The anterior and the antero-lateral approaches had gained recently interest in the total hip arthroplasty because they allow complete muscle sparing. The postero-lateral and lateral approaches were propsed to be less satisfactory from this point of view. The goal of this paper was to report an objective and carfull assessment of the advantages of the minimal invasive posterior approach in short stem (Nanos) total hip arthroplasty. Material and methods. From juli 2005 to march 2009 a total of 113 (70 males,53 female) uncemented Nanos-short-stem prothesis were implanted in 111 patients. The patiens average age was 53 years (33-73). The indication for this procedure was predominantly coxarthrosis. In all cases a minimal invasive posterior approach was used. The mean follow up period was 2,5 years (range 6 months- 4,5 years). The patients were assessed using Harris Hip Score and radiologically to detect any bone changes, the stand of the prothesis and peri-articular ossifications. Results. The perioperative Harris Hip Score was 53 (28-77), postoperative was 94 (86-100). Untill now we have not discovered any prothesis specific complications. Radiological follow up examinations showed the development of increasing trabecular reinforciment of the femoral neck and pertrachanteric regions. There is no evidence of any loosing or migration of the prothesis. No luxation. Calcification was noted in 8 cases (Grad 1), 4 cases(Grad 2), 1 case (Grad 3). In 3 cases we have to change the cup because of malposition. Conclusion. the stem design of Nanos-short-stem prothesis allowed a metaphyseal intertrochanteric multipoint primary fixation. The surgical technique using posterior approach give a good access to the femur and acetabulum. It allows intraoperative ROM as well as extention in the event of intraopertive complications. Long term studies still be needed