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Treating scapular fractures is still a challenging task for surgeons. We aimed to evaluate the feasibility, accuracy, and effectiveness of augmented reality (AR) and three-dimensional (3D) plate library-assisted posterior minimally invasive surgery, named AR-scapular system for scapula fracture. We speculated that using AR-scapular system would improve efficiency and quality for scapular fracture surgery.We retrospectively reviewed the records of 21 patients with scapular fractures treated by posterior minimally invasive surgery with reconstruction plates: nine patients were treated with conventional fixation in group I; whereas 12 patients were treated with pre-operative virtual simulation and intra-operative navigation-assisted fixation using AR-scapular system. We compared operative time, blood loss, complication, and Hardegger function between two groups. Statistical analyses evaluated significant differences between the groups for each of these variables.In group II, the pre-operative virtual simulation time was 44.42 ± 15.54 min. The time required for pre-operative contouring of the plates was 16.08 ± 5.09 minutes. The patients in group II had significantly shorter operation time and less blood loss (- 28.75 min and - 81.94 ml, respectively; P 0.05) than patients in the conventional surgery group. The average numbers of plates used were 1.56 ± 0.53 in group I and 1.25 ± 0.45 in group II. The difference was not statistically significant (P 0.05). The follow-up function outcome results were similar between groups (P 0.05). There were no intra-operative or post-operative complications for all patients.Augmented reality and 3D plate library-assisted posterior minimally invasive surgery is an effective and reliable method for treating scapular fractures which can provide precise pre-operative planning and intraoperative navigation. This time-saving approach can give a more customized treatment plan, allowing for a safer reduction surgery. What is more, the portable projector is cheap and easy to use.

In primary metatarsalgia, Distal Minimally invasive Metatarsal Osteotomy (DMMO) achieves a correct load distribution which is a factor in pain relief, but contrary to the elevation of the metatarsal head, shortening the metatarsal length has no influence on plantar-loading parameters, while the increased metatarsal length is a factor in the development of metatarsalgia. Thus, we hypothesized that metatarsalgia could be partly related to a functional imbalance between bone structure and soft tissues and pain relief after DMMO results from soft tissue relaxation. Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. To test our hypothesis, we measured intra-operatively the MTPJ pressure of 19 patients suffering from primary metatarsalgia, before and after DMMO. This pressure is being analyzed as a reflection of joint decompression and forefoot soft tissue release. Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. Lower metatarsals presenting metatarsalgia show a significantly lower MTPJ pressure compared to asymptomatic rays, and DMMO induces a significant increase of MTPJ pressure. Those variations reflect the functional imbalance between bone structure and soft tissue in primary metatarsalgia. The biomechanical rationale of the shortening effect of DMMO could therefore be explained by the release of forefoot soft tissue, which could take part in the pain relief by restoring this balance.

The purpose of this study was to compare the clinical outcomes of intra-articular calcaneal fractures with medial column displacement treated with different surgical techniques, namely extensile lateral approach (ELA) or sinus tarsi approach (STA), combined with percutaneous medial reduction. Ninety-six patients with intra-articular calcaneal fractures who were subjected to ELA or STA (45 in STA group and 51 in ELA group) were retrospectively assessed. Reduction of the posterior facet, calcaneal body, Bohler’s angle, and Gissane’s angle were evaluated. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale (VAS). The complications, time to surgery, operative time, and blood loss were also assessed. Incidence of wound complications, post-operative blood drainage, and time to the operation were significantly different between the two groups. There was no significant difference in the recovery of calcaneal anatomy and articular surface between the two groups. Similarly, no difference was detected in Bohler’s and Gissane’s angles between ELA and STA groups (P > 0.05). Finally, there was no difference in AOFAS and VAS scores between the two groups at the final follow-up (P > 0.05). STA resulted in favourable radiological and clinical results with fewer wound complications and a shorter waiting time when compared to ELA. The percutaneous medial reduction technique is effective in reducing medial column displacement.

Purpose Obesity is associated with increased risk for surgical complications in total hip arthroplasty (THA). The impact of obesity on short-term complication in minimally invasive (MIS) anterolateral approach is not well known. Therefore, this study was conducted to evaluate the early complications within the first 90 days after THA using a MIS anterolateral approach with a short-curved stem stratified by Body Mass Index (BMI). Patients and methods A single centre consecutive series of 1052 hips in 982 patients (index surgery 2014–2019) with a short-curved stem and press fit cup implanted using a MIS anterolateral approach in supine position were screened for inclusion. Inclusion criteria were defined as end-stage primary osteoarthritis of the hip. Eventually, 878 implantations in 808 patients were included and stratified by body mass index (BMI). Peri-operative complications, within the first 90 days after surgery, were retrospectively evaluated. Results Severely obese patients (BMI ≥ 35 kg/m2) and morbidly obese patients (BMI ≥ 40 kg/m2) demonstrated a significantly increased operation time (p Conclusion The risk for early PJI and overall surgical complications in MIS anterolateral approach is significantly increased in severely and morbidly obese patients. This leads to a significantly higher risk for revision surgery after index surgery within the first 90 days. A BMI above 35 kg/m2 is the clear threshold for increased risk of PJI in MIS anterolateral THA with a short curved stem. As the surgical complications are comparable to other approaches, MIS anterolateral short stem THA is also feasible with increasing BMI.

Background Minimally invasive surgery is becoming increasingly common, but evidence of the advantages of the minimally invasive transpiriformis approach in total hip arthroplasty is limited. Therefore, our single-centre randomized controlled trial evaluated the benefits of this approach versus the posterolateral approach. Methods Forty-nine patients undergoing the minimally invasive transpiriformis approach and 57 patients undergoing the posterolateral approach total hip arthroplasty were analyzed. The operative time, length of hospital stay, incision length, and peri-operative data related to the surgery were recorded. In both groups, serum CRP, IL-6, HGb, Hct, MB, CK-MB, and CK levels, Harris hip scores, and VAS scores were recorded. Results Patients who underwent the minimally invasive transpiriformis approach had a smaller surgical incision (9.10 ± 0.94 vs. 15.56 ± 1.20 cm, P = 0.00) and shorter hospital stay (6.20 ± 1.54 vs. 12.26 ± 2.97 days, P = 0.00) than those who underwent the posterolateral approach. Serum levels of CRP, IL-6, MB, CK-MB, and CK were also lower. According to the Harris hip score, the minimally invasive transpiriformis group showed significant improvement at one week and one month after surgery. Conclusion Compared to the posterolateral approach, the minimally invasive transpiriformis approach for total hip arthroplasty provided rapid functional recovery, elicited a significantly reduced post-operative inflammatory response, and caused less muscle damage.

Purpose Hidden blood loss (HBL) is a growing area of interest for spinal surgeons. Simultaneously, spine surgeons’ pursuit of minimally invasive spine surgery has never ceased, as evidenced by the increasing number of articles comparing percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) and minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF). However, there has been no comparison of HBL between Endo-TLIF and Mis-TLIF. This study aimed to compare HBL, visible blood loss (VBL), and total blood loss (TBL) following Endo-TLIF and Mis-TLIF and evaluate the clinical significance of these procedures. Methods Between October 2017 and October 2019, 370 patients underwent lumbar interbody fusion at our institution and were followed up for at least 24 months. Our study included 41 Endo-TLIF and 43 Mis-TLIF cases. We recorded each patient’s age, height, weight, and haematocrit and calculated the TBL, which was used to indirectly obtain the HBL. Additionally, we compared the clinical outcomes of these two groups, including visual analogue scores for the lumbar spine and leg (VAS-Back; VAS-Leg), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, disease type, operative segment, and intervertebral fusion and complication rates. Results Endo-TLIF had significantly lower HBL, VBL, and TBL values than Mis-TLIF (P Conclusion Endo-TLIF significantly reduced HBL, VBL, and TBL compared to Mis-TLIF and improved short-term clinical outcomes; however, long-term clinical outcomes and fusion rates remained comparable between the two groups, as did the incidence of peri-operative complications.

Hallux valgus is a common disease which causes pain and dysfunction of the foot. Although numerous methods of procedures have been introduced, a single procedure cannot correct all deformities of hallux valgus. The study aims to evaluate the radiographic and clinical effectiveness of a new minimally invasive surgery (MIS) versus open Chevron-Akin procedures.This was a retrospective comparative study. Data were collected from May 2018 to January 2020. A total of 27 patients (31 feet) undergoing MIS for hallux valgus were included in this study. The average age of patients underwent MIS was 59.9 years. The mean follow-up was 25.1 months. Open osteotomies were performed in 30 patients (31 feet) during the same period. The mean age of these patients at the time of surgery was 59.1 years. The mean follow-up was 26.1 months. Pre-operative and post-operative radiographic outcome measures included HVA, IMA, DMAA, the Sgarlato's angle and the length of the first metatarsal, and distance between the dorsal cortex of first and second metatarsal necks. The AOFAS and VAS were used to assess foot function.The preoperative HVA in MIS group and open group were 34.8° and 33.1° respectively. The post-operative HVA were 20.4° and 13.7°. The pre-operative IMA in MIS group and open group were 13.0° and 12.1°. The post-operative IMA were 11.4° and 5.5° respectively. The pre-operative DMAA were 14.8° and 15.1° respectively. The post-operative DMAA were 6.3° and 8.7°. The AOFAS increased from 44.0 to 90.2 in MIS group and from 47.6 to 89.5 in open group. The VAS decreased from 7.3 to 1.3 in MIS group and from 7.1 to 1.2 in open group.Although open osteotomies were superior than MIS in HVA and IMA, MIS showed advantages in correcting DMAA. MIS provided equivalent functional outcomes compared to open surgery.

International audience; Purpose: The purpose of this article is to describe the novel technique of arthroscopic-assisted reduction and internal fixation (ARIF) of talar neck fractures, presenting also the outcomes of this treatment method in a series of four patients. Methods: Between 2011 and 2019, we have treated in our service a number of four patients with talar neck fractures, by the arthroscopic technique. The surgical intervention consists in arthroscopic exploration of tibiotalar and subtalar joints, arthroscopic lavage and debridement, reduction, and osteosynthesis with two cannulated screws under both arthroscopic and fluoroscopic control. Post-operative care consists in non-weightbearing immobilization for 6 weeks, followed by partial loading under the protection of a walking brace for the next six weeks and ROM exercises. The patients were followed up at three months, when a CT scan was performed, and at one year, when X-ray images showed the consolidation of fractures. Results: Normal or slightly reduced ROM of the ankle and hindfoot was noted in three out of four patients, absence of any pain, or disability (3 patients). The AOFAS’ Ankle-Hindfoot scale showed good and excellent results; mean score was 92.75 points (86–98p) at one year after the surgery. Conclusion: Arthroscopic-assisted management of talar fractures offers the advantages of minimally invasive surgery combined with good visualization of the fracture, good control of anatomic reduction, and the possibility to treat associated lesions. Main disadvantages of the method are technical difficulties, requires a prolonged learning curve, and offers limited fixation alternatives.

Options for the treatment of proximal- and middle-thirds of humeral shaft fractures include intramedullary interlocking nail (IMN) and minimally invasive plate osteosynthesis (MIPO). However, whether IMN provides better clinical outcomes than MIPO surgical technique still remains unclear. This study was designed to compare clinical outcomes of the IMN with MIPO technique for the treatment of proximal- and middle-thirds of humeral shaft fractures. A retrospective cohort analysis of 55 proximal- and middle-thirds of humeral shaft fractures surgically treated using IMN (n = 25) or MIPO (n = 30) from January 2012 to January 2016. Peri-operative and follow-up data (a minimum of 1 year) of the patients (aged from 18 to 56 years) were collected. Operative time, union time, VAS scores, surgery-related complications, and implant removal rate were compared between the two groups in this study. Besides, the functional outcomes were evaluated using the Rating Scale of American Shoulder and Elbow Surgeons’ Form (ASES) and Mayo Elbow Performance Score System (MEPS). We found significantly shorter operative time and much less blood loss in IMN group, and lower VAS scores in the IMN group after surgery at first and third months but not at the sixth month. Complication rate was found to be relatively higher in the MIPO group when compared to the IMN group. No significant difference was observed between these two groups regarding ASES and MEPS scores. Three patients in the MIPO group suffered iatrogenic radial nerve injury and recovered after four to five months later. No implant failures occurred in either group. Intramedullary interlocking nail seemed to be superior to minimally invasive plate osteosynthesis in the treatment of proximal- and middle-thirds of humeral shaft fractures due to shorter operative time and union time, less early post-operative pain, and fewer complications. The intramedullary interlocking nail could be considered a better surgical option for the management of proximal middle humeral fractures, though it may also depend on the surgeons’ skills and learning curve. Further in-depth prospective studies are in great need to verify our conclusion.

The objective of this study was to evaluate the feasibility and safety of a minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure for proximal humeral shaft fractures using lateral minimal proximal and distal approaches and lateral bridge plating with primary radial nerve control, and to assess its clinical and radiographic outcomes.A retrospective review was done for the medical records of adult patients admitted for fracture of the proximal humeral shaft without associated injury to the ipsilateral upper limb and who consented to undergo a novel MIPPO technique herein reported. Patients were reviewed at regular follow-up periods and assessed at a final follow-up for evaluation of Constant, normalized Constant, and QuickDASH scores.There were 21 adult patients with mean age of 56 years. Three patients were lost from early follow-up; one of them had post-operative radial nerve paralysis. Eighteen patients were reviewed for the purpose of this study at a mean of 20 months of final follow-up; among them, one patient developed post-operative radial nerve paralysis with complete recovery after three months. Bone healing was achieved without any malalignment in 17 patients at a mean of 15 weeks, and one patient developed nonunion. At final assessment (mean, 20 months), the mean values of Constant, normalized Constant, and QuickDASH scores were 84 (range, 59 to 100), 95 (range, 73 to 100), and 5 (range, 0 to 18.2) respectively.Compared to pre-reported methods of MIPPO, this technique of lateral proximal and distal mini-approaches with lateral bridge plating after primary control of the radial nerve seems safe and feasible for proximal humeral shaft fractures. It gives good clinical and radiographic results with excellent restoration of upper limb function, very low incidence of post-operative radial nerve injury, and high rate of bone union in good alignment.

Percutaneous endoscopic discectomy is an effective minimally invasive spine surgery (MISS) for soft disc herniations. The objective of this review was to describe the current indications, surgical techniques, and clinical outcomes of endoscopic spine surgery. A narrative review was performed with a focus on surgical indication of percutaneous endoscopic discectomy and the clinical outcomes in lumbar and cervical spine. Percutaneous endoscopic or full-endoscopic discectomy using a working channel endoscope was described. The basic principles, surgical techniques, and clinical outcomes in lumbar and cervical disc herniations were demonstrated. For the lumbar disc herniation (LDH), transforaminal and interlaminar approaches were reviewed, whereas for the cervical disc herniation (CDH), anterior and posterior approaches were reviewed. Endoscopic spine surgery for soft disc herniation can be effective with benefits of minimal tissue trauma in properly selected cases. Given the recent technical advancements, the surgical indications for endoscopic spine surgery are still expanding and the clinical results have become more practical and reliable.

To date, various minimally invasive surgeries for lumbar disc herniation (LDH) have been performed in many countries, including microendoscopic discectomy (MED) and percutaneous endoscopic discectomy (PED). We herein report the surgical indications, current concepts, and techniques of minimally invasive discectomy for LDH, including MED and PED. The postoperative outcomes and risks of complications compared with conventional discectomy are also discussed. By reviewing past literatures, the current concepts, surgical techniques, and clinical outcomes were described. Minimally invasive discectomy is generally performed using a transmuscular approach with an endoscopic technique and can reduce muscle and soft tissue damage. The minimal invasiveness can also reduce the severity of postoperative pain and improve patient satisfaction compared with conventional open discectomy. Based on the data of previous systematic reviews and meta-analyses, minimally invasive lumbar discectomy, such as MED and PED, appears to be safe and effective alternatives to open discectomy for patients with symptomatic LDH. These minimally invasive surgeries can provide beneficial effects to shorten the hospital stay and time to return to work. However, minimally invasive discectomy has a demanding learning curve. Only a well-trained surgeon and support team should perform these less invasive procedures. Clinical evidence supporting the superiority of MED and PED is still limited. Well-designed prospective multicentered randomized controlled trials with large samples are therefore needed in order to draw a convincing conclusion.

The sacrum is a mechanical nucleus working as the base for the spinal column, as well as the keystone of the pelvic ring. Thus, injuries of the sacrum can lead to biomechanical instability and nerve conduction abnormality. The common classification is the Denis classification, but these fractures are often part of a lesion of the posterior pelvic ring and therefore the Tile classification is very useful. The goals of operative intervention are to reduce fracture fragments, protect neurological structures, and provide adequate stability for early mobilization. The stabilization of these injuries can be difficult even in a patient with adequate bone stock and concomitant medical comorbidities. The posterior-ring tension-band metallic plate and sacroiliac joint screw are two commonly used methods for posterior internal fixation of the pelvis. In this study, we evaluate the differences, in the treatment of sacral fractures, between the two techniques, revising the literature and our experience.

There exist a relevant number of clinical trials comparing the minimally invasive surgery to the standard-invasive approach in total hip arthroplasty (THA). Up to date, there are still debates concerning the most effective approach in THA. The purpose of this study is to compare the clinical outcomes concerning patients undergoing primary THA performed via the minimally invasive versus standard-invasive surgery incision. The search was performed in the main databases, evaluating both quantitative and qualitative results. All the randomised controlled trials (RCTs) and non-randomised controlled trials (nRCTs) comparing the minimally invasive versus the standard-invasive approach were enrolled in this study. We focused on the clinical and radiological outcomes and on the complication rate. Study methodological quality was assessed performing the PEDro critical appraisal scale. All meta-analyses were performed using the Review Manager software. To analyse the publication’s bias, we performed the Funnel plot. We enrolled in our study 4761 patients, undergoing to 4842 total hip arthroplasties. The mean follow-up was 22.26 months. In favour of the minimally invasive group, we reported less total estimated blood loss, shorter surgical duration, and a shorter length of stay. In favour of the standard-invasive group, we reported a higher value of the Harris hip score. Concerning the radiological outcomes, we did not report substantial differences across the two exposures. No difference was observed regarding the risk of femoral fractures, dislocation, and revision rates. We evidenced an increasing risk occurred in an iatrogenic nerve palsy during the minimally invasive approach. Based on currently available evidences concerning the outcomes following THA and the analysis of our results, we stated no remarkable benefits of the minimally invasive compared to the standard-invasive surgery.

To compare the efficacy and safety of novel percutaneous minimally invasive pedicle screw fixation and traditional open surgery for thoracolumbar fractures without neurological deficit.Sixty adult patients with single thoracolumbar fracture between June 2014 and June 2016 were recruited in this study, randomly divided into open fixation group (group A) or minimally invasive percutaneous fixation group (group B). Clinical and surgical evaluation including surgery time, blood losses, radiation times, hospital stay, and complication were performed. The two groups of patients with pre-operative and last follow-up anterior height ratio of fracture vertebral, Cobb angle of fracture vertebral, and VAS score of back pain were compared.All patients completed valid follow-ups, with an average time period of 15.4 months (12-26 months). Group B achieved much better results in time of operation, intra-operative blood loss, and length of stay than group A (P 0.05). Group A was significantly better than group B in the times of radiation (P 0.05). The VAS score was significantly lower in group B than in group A at three days after the operation (P 0.05). There were no significant differences between the two groups in the anterior height ratio of fracture vertebral, Cobb angle, and VAS score in the last follow-up (P 0.05). No injured nerve or other severe complications occurred in both groups; one of the patients from group A had back and loin pain lasting for about one month, which resolved after analgesia and functional training. There was no significant difference between the two groups in incidence of complications.Novel percutaneous pedicle screws with angle reset function can achieve the same effect as traditional open pedicle screw fixation in the treatment of thoracolumbar fractures without nerve injuries. Percutaneous minimally invasive pedicle screw fixation has the characteristics of shorter operative time, less bleeding, and less pain, but it needs more radiation times.

Purpose The purpose of this study was to compare a minimally invasive chevron osteotomy technique (MIS group) and the well-established open chevron technique (OC group) for correction of hallux valgus deformity. Methods Patients who were scheduled to undergo a hallux valgus surgery by means of a distal chevron osteotomy were randomly assigned to one of the two groups. Pre-operatively, six weeks, 12 weeks, and nine months post-operatively the following outcome parameters were determined: Visual Analog Scores (VAS) of pain, the American Orthopedic Foot and Ankle Society (AOFAS) forefoot score, radiographic outcome measures, range of motion (ROM), and patient satisfaction. Results Forty-seven cases were analyzed (25 MIS group; 22 OC group). Both operative techniques achieved significant correction of the hallux deformity. The intermetatarsal angle (IMA) improved from 15.1° to 5.8° in the OC and from 14° to 6.8°in the MIS group, whereas the hallux valgus angle (HVA) improved from 28.3° to 8.5° in the OC versus 26.4° to 6.9° in the MIS group. No significant differences were observed between the groups by any of the determined outcome parameters. Regarding patient satisfaction, statistically significant differences were found between MIS and open surgery 12 weeks post-operatively in favour of the MIS group (p = 0.022). Conclusion With the minimally invasive chevron osteotomy, radiological and clinical outcome is comparable to the open technique.

The goal was to evaluate the clinical outcomes, quality of reduction and complications of pelvic fractures treated by minimally invasive stabilisation of posterior pelvic ring instabilities with pedicle screws connected to a transverse rod. Retrospective analysis of prospectively collected data in a consecutive patient series with pelvic fractures treated by minimally invasive stabilisation of posterior pelvic ring instabilities with pedicle screws between January 2010 and January 2016. The functional outcomes evaluated by Majeed scores, and fracture reduction results were evaluated using the Tornetta and Matta standard. As well as recording the duration of the surgical procedure, intraoperative blood loss, the times of intra-operative fluoroscopy and complications. A total of 29 patients (15 men and 14 women; age range, 21–72 years; mean, 40.8 years) could be followed-up after an average of 38.2 ± 21.3 months (range, 12-84 months). According to the AO/OTA classification, there were 24 patients with B2 injury and five patients with C1 injury of the pelvic ring. For the sacral fractures, according to Denis classification, four cases were zone I fractures and 25 cases were zone II fractures. The duration of the surgical procedure, intra-operative blood loss and the times of intra-operative fluoroscopic of the posterior-ring surgical procedure was 28.2 ± 4.6 minutes (range, 20–38 minutes), 46.7 ± 4.9 ml (range, 39–56 ml), and 13.1 ± 1.6 seconds (range, 10–17 seconds) respectively. Posterior-ring fracture reduction was excellent in 11 patients and 15 were good, three cases were fair; the excellent and good rate was 89.7% (26/29). At the final follow-up, the function result was rated as excellent in ten cases, good in 16, fair in three, and poor in zero cases; the excellent and good rate was 89.7% (26/29). There was no incision infection, intra-operative neurovascular injury, pedicle screw loose or breakage, and non-union of the posterior arch did not occur. Two patients requested removal of the fixator: one patient with breakage of the anterior pelvic ring internal fixator, and the pedicle screw was also taken out in the same operative session; another one with moderate pain on the posterior pelvic ring. Minimally invasive stabilisation of posterior-pelvic-ring instabilities with pedicle screw connected to a transverse rod may be a good alternative to sacroiliac screw fixation because it is quick, safe and associated with a good functional outcome; thus being a useful option in patients who do not qualify for sacroiliac screw fixation.

Whether minimally invasive total knee arthroplasty (MIS-TKA) could offer better and faster recovery without the deviation of post-operative prosthesis position and limb alignment is still controversial. This prospective and randomized study was conducted to compare the clinical and radiological outcomes between patients who underwent the mini-subvastus approach of MIS-TKA and those who underwent the medial parapatellar approach of traditional TKA.Fifty patients, including 50 knees, who required TKA due to osteoarthritis were randomized to the mini-subvastus group (group I) or the medial parapatellar group (group II). All patients accepted the same method of anaesthesia, equal support therapy and identical rehabilitation exercise after surgery. The evaluation system included operation time, tourniquet time, blood loss, skin incision length in flexion, straight leg raising time, the time of lower limb muscle strength up to grade 4, the time of walking with aid or without aid, the time of walking up and down the stairs, the active flexion angle, range of movement (ROM), the Knee Society Scores (KSS), visual analogue score for pain (VAS), hospital stays and radiographic outcomes.The mini-subvastus approach offered smaller skin incision length in flexion, but at the cost of operation time (P 0.001). No significant difference was found in tourniquet time and blood loss. The patients in group I could achieve straight leg raising, the lower limb muscle strength up to grade 4, walking with or without aid, and walking up and down the stairs earlier (P 0.001). The active flexion angle, ROM, VAS and KSS in group I were superior to those in group II until six months post-operatively (P 0.001), but the differences was not apparent at 12 months post-operatively. More importantly, there was no significant difference between the two groups on radiological outcomes (P 0.05).The mini-subvastus approach could offer faster recovery, less pain and shorter hospital stays without compromising the principles of proper prosthesis position and limb alignment compared with the medial parapatellar approach.

The purpose of the study was to introduce percutaneous reduction and fixation of paediatric talar neck fractures. The study also included a comparison between the technique and the conventional open surgery. From October 2003 to May 2013, 23 children (group A) with closed two-part talar neck fractures were treated with percutaneous reduction. For comparison, another group of 26 children (group B) were treated with the conventional open surgery. A p value < 0.05 was considered statistically significant. In group A, bone healing was achieved in all cases at a mean of eight weeks. At the mean follow-up of 27 months, mean plantar flexion and dorsiflexion reached 96% of the opposite, normal, side. There were 20 excellent and three good results. In group B, bone healing occurred in 21 of 26 cases at a mean of 11 weeks. Nonunion was noted in five patients, among whom three were combined with avascular necrosis of the talar body. Mean follow-up was 29 months; mean plantar flexion and dorsiflexion reached 94% of the opposite normal side. There were 13 excellent, six good, two fair and five unsatisfactorily results. There were significant differences in the time to bone healing and in ankle-joint motion and function (p

Acute distal biceps tendon ruptures are uncommon injuries that often affect young active males, typically resulting from an eccentric load on their dominant extremity. The purpose of this study was to compare pullout strength and tendon gapping in the tension slide technique (TST) versus a knotless fixation technique (KFT). Two sets of experiments were performed using cadaveric elbow specimens. In the first experiment, eight elbows from different cadavers were tested to compare TST with a standard locking whipstitch with KFT, four elbows in each group, using a standard locking whipstitch. In the second experiment, 12 elbows were used to study the differences between TST with a standard locking whipstitch with KFT using suture tape reinforced whipstitch (RKFT), using the TST data from the first and second experiment. Each experiment evaluated gapping after cyclic loading and the second experiment also tested the construct to load to failure. Gapping for KFT with a standard locking whipstitch was 10.64 mm versus 2.69 mm for the TST after 1000 cycles (P = 0.016). A reinforced whipstitch significantly improved the failure to gap on the KFT with no significant difference in gapping when compared to TST after 3000 cycles (P = 0.36). The resultant gapping for TST and KST was 2.08 mm and 2.99 mm (P = 0.91), respectively. Load to failure for TST and KFT were 282 Nm and 328 Nm (P = 0.20), respectively. Bone-tendon gap resistance of a KFT repair of a torn distal biceps tendon is limited by suture technique. Using a tape reinforced locking whipstitch, the repair is as strong as TST repair. Levels of Evidence: Basic Science.

Traditional open reduction and internal fixation (ORIF) of extra-articular distal humerus fractures has a risk of iatrogenic radial nerve injury, extensive soft tissue stripping, and long incision scar. We performed an antero-lateral minimally invasive plate osteosynthesis (MIPO) technique with the radial nerve exploration for distal-third diaphyseal fractures of the humerus and evaluated clinical and radiographic outcomes through this respective study. From April 2010 to June 2016, 28 cases of extra-articular distal-third diaphyseal fractures were treated with an antero-lateral MIPO procedure. Patient demographics, Disabilities of the Arm, Shoulder and Hand (DASH) Score, Mayo Elbow Performance (MEP) Score, elbow range of motion, scars and post-operative complications were recorded and analyzed. All fractures were united with a mean time of 3.5 months. One patient exhibited delayed union (3.6%). The mean DASH Score was 6.6, and all patients had excellent or good MEP Score values. The average scar length was 6.8 cm, and the shortest was 4.5 cm. The MIPO technique via an antero-lateral approach for extra-articular distal-third diaphyseal fractures of the humerus results in satisfactory clinical outcomes. Level IV, case series, treatment study.

The purpose of this study was to clarify the difference in implant alignment between the direct anterior approach (DAA) and the anterolateral approach in the supine position (ALS). A retrospective comparative study consisted of 215 consecutive primary total hip arthroplasties using tapered polished and straight cemented-stems via two different minimally invasive approaches (DAA group in 106 hips and ALS group in 109 hips). The cup radiographic anteversion angle was significantly lower in the ALS group than in the DAA group (12.9° versus 16.9°, p = 0.001). The frequency of the safe zone tended to be more favourable in the ALS group than in the DAA group (95% versus 87%, p = 0.052). Stem alignment in the sagittal plane was significantly better in the ALS group than in the DAA group (84% versus 71%, p = 0.022). Both cup and stem alignments were better in the ALS group than the DAA group.

This study aims to introduce a self-designed clavicle reductor and to test the effectivity of a alternative minimally invasive plate osteosynthesis technique (MIPO) for displaced midshaft clavicular fractures (DMCFs) with the application of our self-designed clavicle reductor. From October 2012 to February 2013, 27 male patients who suffered with unilateral displaced midshaft clavicular fracture (DMCFs) were included into our study. Patients were treated by minimally invasive plate osteosynthesis (MIPO) technique with the application of our self-designed clavicle reductor and followed up regularly. Constant-Murley score was employed to test the functional outcomes at one year’s follow up. The average follow-up time for the 27 patients was 15.8 months (range, 13–18 months). The average age of all patients was 32.6 (range, 21 to 48). According to OTC system, 12 cases were simple fractures (15-B1), ten cases were wedge fractures (15-B2) and five cases were comminuted fractures (15-B3). With the application of the clavicle reductor, minimally invasive plate osteosynthesis technique can be performed without any barrier in all of the 27 cases. Operative duration was 48.1 minutes (range, 35–65 minutes) and average fluoroscopy time was 12.8 seconds (range, from 7 to 22 seconds). All of the 27 cases healed from four to six months post-operatively. The average Constant-Murley-score of the 27 patients was 92.7 ± 5.88 (range, 80 to 100). No complications were noted. The self-designed clavicle reductor can effectively pave the way for the application of MIPO technique in the treatment of DMCFs. MIPO technique with locking reconstruction plate is a feasible and worthwhile alternative for displaced midshaft clavicular fractures (DMCFs).

The aim of this study was to evaluate the outcome of a minimally invasive surgical technique for the treatment of patients with acromioclavicular joint dislocation. Sixteen patients with complete acromioclavicular joint dislocation were enrolled in this study. All patients were asked to follow the less active rehabilitation protocol post-operatively. Computed tomography with 3-D reconstruction of the injured shoulder was performed on each patient post operatively for the assessment of the accuracy of the suture anchor placement in the coracoid process and the reduction of the acromioclavicular joint. Radiographs of Zanca view and axillary view of both shoulders were taken for evaluating the maintenance of the acromioclavicular joint reduction at each follow-up visit. The Constant shoulder score was used for function assessment at the final follow-up. Twenty seven of the 32 anchors implanted in the coracoid process met the criteria of good position. One patient developed complete loss of reduction and another had partial loss of reduction in the anteroposterior plane. For the other 14 patients, the mean Constant score was 90 (range, 82–95). For the patients with partial and complete loss of reduction, the Constant score were 92 and 76 respectively. All of them got nearly normal range of motion of the shoulders and restored to pre-operative life and works. With this minimally invasive approach and limited exposure of the coracoid, a surgeon can place the suture anchors at the anatomical insertions of the coracoclavicular ligament and allow the dislocated joint reduced and maintained well. Level IV, Case series; therapeutic study.

The purpose of this study was to evaluate the efficacy and safety of percutaneous pedicle screw fixation at the fractured vertebra in the treatment of thoracolumbar fractures. Thirty-two consecutive patients were enrolled in the study. All patients received percutaneous pedicle screw fixation, and they were randomly divided into two groups to undergo either the placement of pedicle screws into the fractured vertebra (fractured group) or not (control group). The operation time and intra-operative blood loss were recorded. Oswestry disability index (ODI) questionnaire and visual analogue scale (VAS) as clinical assessments were quantified. Radiographic follow-up was defined by the vertebral body index (VBI), anterior vertebral body height (AVBH), and Cobb angle (CA). No significant difference was observed in the operation time and intra-operative blood loss between the two groups. Clinical results (VAS and ODI scores) showed no significant difference during all the follow-up periods. In the fractured group, there were better correction and less loss of AVBH and VBI compared with the control group. However, post-operative correction of the CA immediately after surgery and the correction loss at the final follow-up showed no significant difference between the two groups. Percutaneous screw fixation combined with intermediate screws at the fractured vertebra could more effectively restore and maintain fractured vertebral height, and is an acceptable, minimally invasive surgical choice for patients with type A thoracolumbar fractures.

The aim of this study is to compare clinical and radiological outcome of intramedullary nailing (IMN) and locked plate (LP) in patients affected by fracture of the distal tibia (DTF). We performed also an analysis to identify predictive factors of unfavourable outcome. Data about patients with DTF treated at our first level trauma centre between 2008 and 2017 were collected. Patients were divided in group 1 (IMN) and group 2 (LP). The inclusion criteria were age at least 18 years at the time of diagnosis and unilateral DTF (closed or Gustilo 1). Demographic variables and data related to surgical procedure and hospitalization were registered. X-ray at follow-up was reviewed to identify malunions and nonunions. Clinical outcome was evaluated using scores and registering any complication. One hundred two patients were included in group 1 and 81 in group 2. In group 2 were documented higher operating time and hospitalization. The mean union time was 20.2 weeks for IMN and 24.8 weeks for LP group (p = 0.271). The rate of infections and wound complications was higher in group 2 while malunion and anterior knee pain were more frequent in group 1. No difference in scores for clinical outcome was documented after six months. The full-weight bearing time was significantly longer in the LP group (p = 0.019). At multivariate analysis, no variables showed a predictive power for unfavourable outcome. Clinical and radiological results of LP and IMN appear similar. No predictive factors of unfavourable outcome were identified.

A traction table is recommended for lower limb fractures, while it is unavailable for amputees to immobilize the ipsilateral foot to remain stationary and reduce the fracture. For these patients, our rapid reductor can be applied to guarantee stable fixation and optimal reduction, allowing satisfactory implant positioning. This study aims to evaluate the prognosis of amputee patients with lower limb fractures treated by minimally invasive techniques that employ a rapid reductor to reduce the fracture. Between 2013 and 2014, 11 cases of amputees suffering from a lower limb fracture were enrolled in the study, including four transtibial amputees with a tibial plateau fracture, three transtibial amputees with a femoral shaft fracture, and four transfemoral amputees with a femoral neck fracture. All fractures involved the amputated ipsilateral lower limbs, which were all reduced in a closed fashion using a rapid reductor. During the operation, the rapid reductor was connected to the injured limb for skeleton traction to reduce the fracture and then used to maintain the reduction for subsequent minimally invasive fixation. The operation time, reduction time, fluoroscopy time, and intra-operative blood loss were recorded. Follow-ups were conducted to evaluate the union of the fractures and the functional recovery. All 11 cases were treated successfully using this minimally invasive technique, with anatomical or nearly anatomical reduction reached in all fractures. The average operative time, reduction time, fluoroscopy time, and intra-operative blood loss were 60 minutes (range, 46–90 minutes), 13.2 minutes (range, 7–20 minutes), 19.8 seconds (range, 6–65 seconds), and 95 mL (range, 80–170 mL), respectively. No incidents of reductor-induced complications occurred during the operation. Patients were followed up for an average of 20.8 months (range, 18–24 months). All fractures healed well on an average of six months. At the latest follow-up, all 11 cases reported satisfactory functional recovery of the fixed limbs, which were similar to that before the fractures. The rapid reductor can be used to efficiently reduce and maintain ipsilateral fractures of the amputated lower extremity in a closed fashion, which can facilitate minimally invasive fixation of the fractures. The patients can achieve excellent outcomes.

To investigate if the stability of minimally invasive screw osteosynthesis of displaced intra-articular calcaneal fractures (DIACF) can be effectively increased by an innovative approach to screw tip augmentation. In eight-paired human cadaver hindfoot specimens, DIACF of Sanders type IIB were treated with either standard screw osteosynthesis or with bone cement augmentation of the screw tips in the main fragments. The instrumented specimens were subjected to a cyclic loading protocol (9000 cycles, with stepwise increasing loads, 100–1000 N). The interfragment motions were quantified as tuber fragment tilt (TFT) and posterior facet inclination angle (PFIA) using a 3-D motion analysis system. Bohler’s angle (BA) was evaluated from X-rays. A load-to-failure test was performed after the cyclic loading protocol. All but one specimen of the augmented group withstood more cycles than the respective specimens of the non-augmented group. Mean cycles to failure for the failure criterion of 5° TFT were 7299 ± 1876 vs. 3864 ± 1810, corresponding to loads of 811 N ± 195 vs. 481 N ± 180, (P = 0.043). There were no significant differences observed in the PFIAs. The failure criterion of 5° BA was reached after a mean of 7929 cycles ± 2004 in the augmented group and 4129 cycles ± 2178 in the non-augmented group, corresponding to loads of 893 N ± 200 vs. 513 N ± 218, (P = 0,090). The mean load-to-failure of the four specimens in the augmented group that completed the cyclic loading was 1969 N over a 1742–2483 N range. Screw tip augmentation significantly improved the mechanical stability of the calcanei after osteosynthesis in terms of decreased tuber fragment tilts and less changes in Bohler’s angle.

To describe the rationale, the surgical technique, and the short-term follow-up results of a new minimally invasive treatment of osteonecrosis of the femoral head (ONFH) with an angioconductive bioceramic rod (ABR) implant. Sixty-two patients (72 hips) with ARCO stage IIA-IIIC ONFH treated with the minimally invasive ABR from January 2012 to December 2016 were reviewed (17 females, 45 males, mean age 44.49). This technique used the angioconductive properties of the porous implant to repair the necrosis by driving vascularization from the trochanter to the necrotic area. Patients had a mean follow-up period of 26.74 months. The outcomes were evaluated by hip joint survival, radiograph, and the Harris Hip Score (HHS). The complications occurred during the treatment period were recorded. No serious post-operative complications occurred during the treatment. The overall joint survival rate was 90.27%, with seven conversions to THA. Improvements were observed in 23 (31.95%) hips, 24 (33.33%) hips remained stable, and 25 (34.72%) hips had worse results according to the radiographic evaluation. The mean HHS at the end follow-up significantly improved compared to the pre-operative mean HHS (82.27 vs 58.14, p

Open reductions and internal fixations are currently being used the most in surgeries of humeral shaft fractures. However, there are some limitations such as invasive techniques and formation of many operation scars. To overcome these limitations, a minimally invasive plate osteosynthesis has been recently introduced. However, this has technical limitations such as deep dissections of the distal portion and narrowness of the fixation space. To address these problems, we designed another introductory technique of a minimally invasive osteosynthesis and we have examined the clinical usefulness of that. The results were retrospectively analyzed with 83 patients who visited INHA hospital due to a humeral shaft fractures and who had undergone the above said surgery from the beginning of 2010 to the end of 2012. The patients were divided into two groups: patients treated by the MIPO technique using the newly designed dual approaches (group A) and patients treated by open reduction and plating internal fixation (group B). There was no significant difference in mean duration of injury, the mean fracture union time, range of motion and MEPI for group A and B. There was no statistical significance between the two groups. However, the occurrence of iatrogenic radial nerve palsy in group B, was significantly higher than in group A. MIPOs using the dual approaches on the adult humerus shaft fracture show an excellent bony union without nerve injury which is clinically useful.

The aim of this study was to compare CT-assisted percutaneous excision, which is a closed, economic method and a more cosmetic approach, and open surgery in the treatment of osteoid osteoma. Fifty-three patients (12 female and 41 male patients) who had percutaneous excision (n = 24) and open surgery (n = 29) were evaluated retrospectively. The mean age was 16.6 years and the mean duration of follow-up was 53.5 months. During percutaneous excision, a trephine was advanced through the labeling wire and the site, including the nidus, was excised en-bloc and the incision walls were curetted. During the open surgery, the localization of the nidus was marked using c-arm X-ray and the nidus was accessed by lifting the cortical bone, layer-by-layer, using burr. The nidus was excised and its cavity curetted. The result was successful in 22 and a failure in three patients who had closed excision. The result was successful in 20 and a failure in nine patients who had open surgery. The mean duration of operation was 44.37 minutes in the percutaneous excision group and 80.6 minutes in the open surgery group. There was no difference in the pre-operative VAS values between the two groups, whereas the post-operative VAS values were statistically significantly different. There was also a statistically significant difference in the duration of the operation and the length of the hospital stay between the groups. Percutaneous excision with trephine is a more successful, effective, minimally invasive, safe and a better cosmetic approach in the treatment of osteoid osteoma. This method is also a cheap method that does not require expensive equipment.

The purpose of this study is to analyze the results using the USS fracture MIS system (DePuy Synthes) to treat instable pelvic ring fractures. As its outstanding feature, it is the only Schanz screw and rod system at present that combines angular stability, perforation/fenestration of the screws for cement-augmentation, a variable screw length, and a large screw diameter. Retrospective investigation of 134 pelvic ring fractures treated in 2012–2013. Twenty-five patients obtained the abovementioned implant. Besides baseline characteristics of the included patients and the surgical procedure, a clinical/radiological follow-up of six months was analyzed. Dividing the collective into two groups, I high-energy trauma and II fragility fracture of the pelvis, the following results were recorded: group I: ten patients, six male, age 48.4 ± 19.7 years. Mean ISS 41 ± 22.5, fracture classification: AO/OTA type 61 B1/C1/C3 = 1/5/4. Operative treatment: three transiliac internal fixator, seven iliolumbar fixation, one implant was cement-augmented. Group II: 15 patients, 14 female, age 77.5 ± 10.1 years. Fracture classification according to Rommens: FFPII/III/IV = 6/1/8. Operative treatment: eight transiliac internal fixator, seven iliolumbar fixation, 14 implants were cement-augmented. Overall surgical side complications: 16%. Radiological examination: correct positioning of all ilium screws. Follow-up after six month (16 patients): all showed fracture consolidation. One ilium screw was broken close to the connecting clamp. The investigated Schanz screw rod system is a suitable implant to broaden the established procedures to stabilize dorsal pelvic ring fractures. The study is registered at the Clinical Trial Registry University of Regensburg (Number Z-2017-0878-3).

The purpose of this study was to compare and evaluate the safety and efficacy of percutaneous vertebroplasty at a hyperextension position (PVPHP) and percutaneous kyphoplasty at a hyperextension position (PKPHP) for the treatment of osteoporotic Kümmell's disease.This study was a retrospective, single-centre study. There were 35 patients with osteoporotic Kümmell's disease who were analyzed. Twenty-two of them underwent PVPHP and the other 13 patients underwent PKPHP from January 2013 to January 2015. The volume of bone cement injection and operation costs were compared. We compared the visual analogue score (VAS) and vertebral Cobb's angle at pre-operation, the second day after operation, and the final follow-up. We compared the Oswestry disability index (ODI) score at the pre-operation and the final follow-up.There were no significant differences in gender, age, course of disease, bone mineral density (BMD), and mean follow-up time between the two groups (P 0.05). Regarding the costs of the operation, the PKPHP group was significantly higher than the PVPHP group (P 0.05). Compared with the pre-operation (P 0.05), the post-operative ODI score, VAS, and Cobb's angle of the two groups were improved significantly. Even though the correction of Cobb's angle in the PKPHP group was slightly better than the PVPHP position group, there were no significant differences between two groups (P 0.05). At the final follow-up, the Cobb's angle was increased in both groups, but there was no significant difference (P 0.05). There was no significant difference in the bone cement leakage rate between the two groups (P 0.05).For the treatment of Kümmell's disease, PVPHP and PKPHP are both safe and effective, but PVPHP is more economical and can be considered a preferred method of treatment.

The purpose of this study was to evaluate the results achieved after the use of lateral minimally invasive plate osteosynthesis (MIPO) in oligotrophic humerus nonunions resulting from failed intramedullary nailing (IM). We evaluated nine patients with humerus nonunion after failed locked intramedullary nailing, all treated using 3.5-mm locked compression plates (LCP) placed through lateral minimally invasive approaches, between 2010 and 2016. Patient’s age averaged 39.7 years. All nonunions were diaphyseal and oligotrophic. All nonunions had previous surgical treatment with static locked nails (seven antegrade and two retrograde). The IM nails were all well inserted in the humerus (none of them protruded or had rotator cuff lesions associated). Pre-operative Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 25.5 points. Pre-operative Constant’s score averaged 80.2. Pre-operative visual analog scale of pain averaged 2.4 points. Follow-up averaged 17.7 months. Time between initial surgery and revision procedure averaged 11.7 months. Union was achieved in all cases, after an average of 4.8 months. DASH score at last follow-up averaged 5.1 points, and final Constant’s score averaged 93.7 points. The analog scale of pain averaged 0.7 points. Time from definitive surgery to work return averaged 3.9 months. Long 3.5-mm LCPs were used (plate length averaged 16.9 screw holes). In two cases, a third 4-cm incision at the nonunion site was performed and cancellous autologous iliac crest bone graft was associated. In our series of nine patients, we achieved union and good objective and subjective results, with high patient satisfaction, using a lateral MIPO technique and placing long 3.5-mm LCPs in selected oligotrophic humerus nonunions after failed IM nailing.

Distal tibia fractures are reported to have a high complication rate pre-operatively as well as post-operatively, which can include open fractures, soft tissue damage, infection, malalignment, pseudarthrosis and ankle arthrosis. The operative treatment for the extra-articular distal tibia fractures is a controversial topic in the orthopaedic literature. Some of these fractures are proximal enough to be treated with an intramedullary nail while others are too distal for that. The aim of our study was to compare the results we have had with intramedullary nail (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal metaphyseal (extra-articular) tibia fractures. The study was designed prospectively between January 2013 and March 2016 and took place on the Orthopaedics and Traumatology ward of a Clinical Emergency County Hospital in western Romania. The follow-up visits were scheduled one month, three months and six months post-operatively. For evaluating the ankle function, we used the Olerud–Molander ankle score (OMAS) and union was evaluated at six months on ankle X-rays. At the six-month follow-up visit the average scores were 75.55 (20-100) for the IMN lot and 74.23 (20-90) for the MIPO lot, without finding any statistical difference between the two groups (p >0.1). At the six-month follow-up, X-ray union was objected in 48 (90.5%) of our patients, the IMN lot having worse results (85.18%) than the MIPO lot (96.15%). The results we encountered showed little to no statistical difference when it comes to the functional score we used (OMAS score), leading us to believe that you can achieve comparable results with both implants.

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done. We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity. The average shift achieved was 8.07 mm. The average improvement in Meary’s angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision. In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery. MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

Despite intense research and innovations in peri-operative management, a high mortality rate and frequent systemic complications in trochanteric femoral fractures persist. The aim of the present study was to identify predictive factors for mortality and cardio-respiratory complications after different treatment methods in a ten year period at a level I trauma centre. Retrospectively, all patients above 60 years of age with trochanteric femoral fracture between January 2000 and May 2011 were analyzed at a level I trauma centre. Demographic variables, comorbidities, and data regarding the surgical procedures, including required transfusions and post-operative complications, were evaluated, and the in-hospital mortality was recorded. The grade of osteoporosis was classified radiographically using the Singh index. The in-hospital mortality rate was 8.2% among 437 patients (male/female ratio = 110/327, mean age = 81 years) with extramedullary open (n = 144), intramedullary (n = 166), and extramedullary minimally invasive (n = 125) procedures. Significant influential factors on in-hospital mortality were identified with binary logistic regression analysis: an age of ≥90 years (P = 0.011), male sex (P = 0.003), a high American Society of Anesthesiologists (ASA) grade (3–5, P = 0.042), and a high osteoporosis grade (Singh index 3–1, P = 0.011). A total of 21.5% of the study population suffered cardio-respiratory complications post-operatively. The specific mortality was 28.7% (P

The minimally invasive (MI) anterolateral approach is a relatively new approach for the treatment of femoral neck fractures with a hemiarthroplasty (HA). There is limited research available presenting clinical outcomes after an HA using the MI approach. Therefore the aim of the present study was to compare clinical outcomes of the MI and traditional anterolateral approaches in patients after HA. Data were extracted from a prospective hip fracture database and completed by retrospective review of the electronic medical records. Patients undergoing HA in a level II trauma teaching hospital between 1 January 2011 and 1 May 2016 were enrolled. A total of 463 patients (67% female), 223 in the MI group (mean age, 82 ± 7) and 240 (mean age, 81 ± 8) in the traditional anterolateral group were enrolled. No significant difference was found in baseline characteristics. The surgeons experience measured by the operations performed per year was in favour of the MI anterolateral group (26 vs 18, p

Navigation assisted minimally invasive percutaneous screw fixation (MIS) for pelvi-acetabular fracture was recently advocated. We report 38 consecutive cases of pelvi-acetabular fractures treated with 3D navigation-guided MIS from 2015 to 2016. Ohe hundred and forty-three screws were inserted (59 sacroiliac, 45 retrograde anterior column, 34 supra-acetabular, three antegrade posterior-column and two subcristal). Navigation planning was mainly performed pre-operatively. The mean operative blood loss and time was 179 ml and 141 mins, respectively. The distance (deviation) between the planned and executed screw entry and tip measured by the navigation computer were 1.91 and 1.94 mm, respectively. There were no immediate or early surgical complications. Patients were followed for at least 6 month; 79% had fracture healing at 4.3 months on average, and 53% walked unaided by the six month follow-up. The average visual analogue scale for pain was 2.69. We believe 3D navigation-guided MIS is a safe and effective surgical alternative in most pelvi-acetabular fractures.

Phalangeal Akin osteotomy of the greater toe is a frequently used surgical procedure for correcting hallux valgus interphalangeus deformity. However, previous research did not investigate percutaneous techniques of the Akin osteotomy. It was the aim of this study to investigate feasibility, corrective potential, and safety of a percutaneous minimally invasive Akin osteotomy. We present a series of 81 feet, in which a percutaneous Akin technique was performed using a high-speed burr but no fixation device. The most important outcome parameters were determined as the proximal to distal phalangeal articular angle (PDPAA) (corrective effect of the osteotomy), the osteotomy healing (full, partly, no visibility of the osteotomy gap), and the integrity of the lateral cortical hinge. With regard to the main hypothesis we found significant changes in the PDPAA over the whole period of time (p

Vertebral compression fractures cause significant pain and some patients are debilitated by the pain due to the fracture. Conventional surgery carries a high risk and has a poor outcome. Vertebroplasty is a minimally invasive surgical procedure, which in vertebral fractures restores stability and diminishes pain. The aim of the study was to analyse the effectiveness and safety of vertebroplasty in multiple vertebral compression fractures with a 24-month follow-up. Vertebroplasty was performed in 160 patients with multiple osteoporotic compression fractures under local anaesthesia, using a unilateral transpedicular approach. The level of pain was assessed according to a 10-cm visual analogue scale. The patients were observed for 24 months after surgery. Vertebroplasty significantly diminished the level of pain in 90 % of patients, and half of them were free of pain within 12 hours after surgery. Only 4 % of the patients did not benefit from this type of treatment. During the 24-month follow-up these results changed only slightly, and after two years almost 80 % still benefited, while the number of unsatisfactory results changed from 6 to 9 %. No serious clinical complications were noted; in three patients new fractures appeared during the two year observation period. Vertebroplasty should be seriously taken into account as a primary method of treatment in patients with multiple osteoporotic vertebral compression fractures.

The objective of this study was to compare combined internal and external fixation (CIEF) with minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of distal third tibial fractures, and explore the benefits and defects of these two techniques.From April 2004 to February 2012, a total of 44 patients were randomised to operative stabilisation either by two closed titanium elastic nails combined with an external fixator (CIEF, 22) or by minimally invasive percutaneous osteosynthesis with a locking plate (MIPPO, 22). Pre-operative variables included the patients' age, sex, fracture side, cause of injury, Tscherne classification of soft tissue injury, fracture pattern, presence of open fracture and interval from injury to surgery. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, bone union time, time of recovery to work, the functional American Orthopaedic Foot and Ankle surgery (AOFAS) score and removal of hardware.There was no significant difference in the time to union, the time of recovery to work, function, alignment and total AOFAS scores between the two groups (P = 0.704, 0.835, 0.551, 0.716 and 0.212, respectively). The mean operating time and radiation time were longer in the MIPPO group than in the CIEF group (85.3 ± 12.5 vs. 73.2 ± 12.0 minutes, P = 0.002, and 3.1 ± 1.5 vs. 2.1 ± 1.2 minutes, P = 0.019, respectively). Wound complications were more common in the MIPPO group (18.2% vs. 0% with CIEF, P = 0.105). There was a trend for patients with MIPPO to have a higher incidence of ankle pain (31.8% vs. 9.1% with CIEF, P = 0.135). Painful implants were removed in 31.8% of patients with MIPPO versus 9.1% with CIEF (P = 0.135). Of the 165 self-tapping locking screws of the locking plates seven (four patients) were removed with some difficulty because of stripping of the hexagonal recess.Our results indicated that both CIEF and MIPPO were all efficient methods for treating distal third tibial fractures. However, CIEF had the advantages of a shorter operating and radiation time, less wound complication and ankle pain, less secondary operations for implant removal and easier removal of the implants.

Autologous iliac crest bone graft (ICBG) is the gold standard material for spinal fusion. Bone graft substitutes, such as recombinant human bone morphogenic protein 2 (rhBMP-2) have been developed to promote spinal fusion and address morbidity issues related to ICBG harvesting. The objective of this study was to compare bone fusion rates after anterior lumbar interbody fusion (ALIF) between ICBG and rhBMP-2 by examining thin-cut computed tomography (CT) images at the one year follow-up.Fifty one patients (62 levels) who underwent single- or two-level ALIF via the video-assisted minimally invasive anterior approach in our institution were assessed. Radiolucent cages were inserted in all cases. Each cage has a middle beam delimiting two chambers. Grafting was performed as follows: one chamber was filled with autologous ICBG, and the other chamber was filled with 6 mg of rhBMP-2. Thin-cut CT-scan multiplanar reconstruction analyses were performed to assess the rate and quality of bone fusion at one year of follow-up.Fusion was observed in 55 levels (88.7 %), with significant differences in fusion rates with rhBMP-2 and ICBG (71 % vs. 88.7 %) (P=0.001). Osteogenesis in the rhBMP-2 chamber had a centripetal pattern in all cases, leaving a central void in 97.7 % of cases representing 38.3 % of the surface of its chamber (range 0-80.3 %). In ICBG chambers, graft resorption was present in 44.4 %, representing 9.8 % of the chamber surface (range 0-52.2 %).RhBMP-2 was inferior to ICBG in terms of rate and quality of bone fusion in one- or two-level ALIF.

A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published, all of which compared two different methods. In this randomized, prospective study, we aimed to compare minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures.From November 2002 to June 2012, 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were randomized to be treated by minimally invasive plate osteosynthesis (group A, n = 46), locking intramedullary nail (group B, n = 46) or external fixation combined with limited open reduction and absorbable internal fixation (group C, n = 45). Age, gender, mechanism of injury, fracture pattern and presence of open fracture were equally distributed among the three groups. Indexes for evaluation included hospital stay, operative time, time to radiographic union, union status, infection and the incidence of re-operation. Mazur ankle score was introduced for functional evaluation. Statistics Analysis System (SAS) 9.2 was used for analysis.A total of 121 patients were included in the final analysis (group A 42, group B 40 and group C 39) and evaluated after a mean of 14.8 months follow-up. There was no significant difference (P 0.05) in hospital stay, time to radiographic union and the incidence of union status among the three groups. Although group C was associated with less secondary procedures versus groups A and B, it was related with more pin tract infections (15.4 %). Anterior knee pain occurred frequently after locking intramedullary nailing (37.5 %) and the irritation symptoms were more frequently encountered in group A (59.5 %). There was no difference in ankle function between the three methods after operation (P 0.05).We consider that the minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures. With its wide indications, external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result and no local soft tissue irritation or implant removal.