Critical Review of Minimally Invasive Approaches in Knee Arthroplasty

In the last decades, several surgical techniques, such as medial pivot (MP) philosophy and kinematic alignment (KA), have been introduced in total knee arthroplasty (TKA) to improve patients' outcomes. This retrospective study aims to evaluate the clinical, radiographic, and functional results of PCL preservation or sacrifice in KA MP-TKA. A consecutive series of 147 patients older than 60, with a minimum follow-up of two years, were treated with TKA for severe primary knee osteoarthritis (OA) at the Department of Orthopedics and Traumatology between 1 January 2019, and 1 July 2020. After excluding those not meeting the inclusion criteria, 64 patients were included in the study analysis. Regarding radiographic outcomes, no statistically significant difference was observed between patients with preserved or sacrificed PCL (p > 0.05). A slight improvement in Knee Society Score (KSS), knee and function score, and FJS was observed for the PCL-preserved group, although this superiority tendency was not statistically significant (p > 0.05). PCL-preserved MA MP-TKA reported a statistically significant result in only two questions on the FJS questionnaire (p < 0.05). A slight, non-statistically significant improvement in active ROM was found in the PCL-sacrificed group (p > 0.05). No interventions or revisions were reported in this case series for all treated patients at the final follow-up. No significant differences were described in clinical, radiographic, and functional outcomes in preserved or sacrificed PCL KA MP-TKA. Although not significant, a slight trend toward better clinical outcomes was reported in PCL-preserved KA MP-TKA.

To analyze the radiographic and clinical outcomes of deltoid ligament repair, we studied 34 supination external rotation type IV ankle fracture patients with deltoid ruptures who required syndesmosis fixation. We retrospectively evaluated 34 cases of ruptured deltoid ligaments with associated supination external rotation type IV ankle fractures with a widening of the syndesmosis between 2011 and 2017. All of the ankle fractures were treated with a similar surgical protocol (plate and screw fixation). Syndesmotic fixations were performed on all patients. The deltoid ligaments were surgically repaired in 19 patients and in 15 patients, they were not. The preoperative, immediate postoperative, and final follow-up radiographic outcomes (medial clear space, overlap space, and clear space) and clinical scores (Foot and Ankle Outcome Scores and the Foot Function Index) were compared. Patients were followed for an average of 13.6months. There was no significant difference in radiographic and clinical outcomes between the deltoid repair group and the unrepair group (P > 0.05). In both groups, the mean immediate postoperative radiographic outcomes were satisfactory, showing reduced MCS, reduced CS, and increased OS to within-normal ranges that were maintained at the final follow-up. Clinical outcomes were similar between the two groups (P > 0.05). The rate of complications, such as intra-articular lesions, malunions, nonunions, and arthrosis was comparable between the two groups. In both groups, the postoperative and final follow-up radiographic measures were within normal ranges and the radiographic and clinical outcomes were not significantly different between the two groups. Syndesmotic reduction could be much more important than deltoid repair in regard to mortise restoration and medial stability.

BACKGROUNDMinimally invasive lumbar interbody fusion (LIF) procedures have evolved rapidly in recent years, with robot-assisted (RA) techniques increasingly integrated into clinical practice. However, questions remain regarding the relative advantages of RA over traditional fluoroscopy-guided and navigation-assisted methods in terms of perioperative, radiographic, and clinical outcomes. This systematic review synthesizes current evidence on these comparisons, focusing on the accuracy of screw placement, perioperative efficiency, radiographic and clinical outcomes, and complications.AIMTo investigate the comparative effectiveness of RA vs conventional LIF techniques.METHODSA systematic review and meta-analysis was conducted in accordance with PRISMA 2020 and Cochrane guidelines. Databases searched included PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library (through May 2025). Eligible studies were randomized controlled trials and observational studies comparing RA with fluoroscopy - or navigation-guided LIF (transforaminal lumbar interbody fusion, lateral lumbar interbody fusion, oblique lumbar interbody fusion) in adults. Two reviewers independently extracted data and assessed risk of bias. The Grading of Recommendations Assessment, Development and Evaluation framework was used to evaluate certainty of evidence. Meta-analyses were performed where data were sufficiently homogeneous.RESULTSTwenty-two studies were included, encompassing a total of 2313 patients - 1046 who underwent RA-guided procedures and 1267 who received comparator techniques. Meta-analyses showed that RA significantly improved perfect pedicle screw placement [pooled odds ratio = 2.93; 95% confidence interval (CI): 1.40-6.14; I2 = 78.2%] and reduced intraoperative blood loss (pooled standardized mean difference = -0.28; 95%CI: -0.47 to -0.08; I2 = 0%). Operative time did not significantly differ between groups (pooled standardized mean difference = 0.01; 95%CI: -0.30 to 0.31; I2 = 66%). Radiation dose could not be synthesized quantitatively due to heterogeneous definitions and measurement units. Narratively, RA demonstrated consistent advantages in reducing surgical exposure and adjacent segment degeneration. Clinical and radiographic outcomes, fusion success, and complication rates were generally comparable across groups.CONCLUSIONRA LIF improves pedicle screw placement accuracy and reduces blood loss and surgeon radiation exposure while maintaining similar clinical outcomes and safety profiles to conventional techniques. These findings support the integration of RA into spine surgery but highlight the need for high-quality multicenter randomized controlled trials and cost-effectiveness studies to guide broader implementation.

Staged treatment of high-energy periarticular tibia fractures involves temporization with closed reduction and external fixation, aiming to provide early reduction and stabilization while mitigating soft-tissue complications. Various external fixator configurations exist, including those that use a "multipin" clamp capable of holding multiple pins but limiting pin placement to a single plane. The purpose of this study was to compare clinical and radiographic outcomes and associated costs of standard and multipin outrigger clamp constructs in tibial plateau and pilon fractures treated with temporary external fixation. We hypothesized that use of the multipin clamp may be associated with poorly aligned reductions and increased complication rates. A retrospective review of 100 patients with periarticular tibial plateau (AO/OTA: 41B/C) or pilon (43B/C) fracture at a Level 1 trauma center from 2014 to 2023 was conducted. Patient, injury, and complication characteristics were collected. Patients were categorized based on the external fixator clamp used: multipin (MP) or standard (S). Clinical outcomes and complication rates were assessed. Radiographic alignment was evaluated by the change in anterior and lateral distal tibial angles, and sagittal plane translation for pilon fractures, and medial and posterior proximal tibial angles for plateau fractures. 70 patients underwent standard (25 pilon, 45 plateau) and 30 multipin (10 pilon, 20 plateau) external fixation. MP and S groups showed no notable differences in demographics or injury characteristics. Both groups demonstrated comparable complication rates and radiological alignment outcomes, with no notable differences observed. MP constructs were more costly than standard systems. In this retrospective study of 100 patients, there was no difference in radiographic or clinical outcomes between the standard frame and multipin frame groups. Typical costs for the multipin frame constructs were $635 to $1249 more than the standard frame constructs.

BackgroundLow knee awareness after minimally invasive total knee arthroplasty (TKA) has become the ultimate target of a natural-feeling knee that meets patient expectations. The objective of this research was to compare the clinical outcomes of TKA via the mini-midvastus (MMV) approach or the medial parapatellar (MPP) approach, and to evaluate which approach can lead to a better quality of life after surgery.MethodsFrom January 2015 to December 2016, a retrospective cohort study was conducted in 330 patients who underwent TKA via a mini-midvastus (MMV) approach. During this period, we also selected 330 patients who underwent TKA via a medial parapatellar (MPP) approach (MPP group) for comparison. Clinical results were assessed with the visual analog scale score for pain, range of motion, and the Knee Society Score. The Forgotten Joint Score was used to analyze the ability to forget the joint.ResultsThere were significant differences with regard to visual analog scale score, range of motion, and the Knee Society Score until 6 months after surgery between the MMV and MPP groups (p < 0.05), but the differences were not significant at 12 months, 24 months, and 36 months after surgery. However, there were significant differences in the Forgotten Joint Score between the groups during the follow-up period (p < 0.05).ConclusionWhen forgetting the artificial joint after TKA is the ultimate target, better quality of life can be acquired by performing TKA via the MMV approach. In addition, compared with the MPP approach, the MMV approach can offer less pain and a faster recovery.

What's New in Spine Surgery.

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries. Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed. Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates. Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Comparison of clinical and radiographic outcome in instrumented anterior cervical discectomy and fusion with or without direct uncovertebral joint decompression

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa.

Accurate implant position in total knee arthroplasty (TKA) can potentially lead to better long-term functional outcomes and implant survival. Recent studies on whether better clinical results could be obtained from computer-navigated or conventional TKA were inconclusive. In addition, recent reviews only included short-term follow-up studies without performing quantitative mid- to long-term follow-up analysis. Thus, the purpose of the present study was to perform a meta-analysis comparing mid- to long-term clinical outcomes (such as knee scoring and functional results) and radiological outcomes (such as normal alignment of the limb axis or component) between computer-navigated TKA and conventional TKA to determine which method of TKA could obtain better clinical and radiological results. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and SCOPUS electronic databases were searched for relevant articles published through August 2018 that compared outcomes of computer-navigated TKA and conventional TKA. Data search, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines. Clinical and radiological outcomes of both techniques were evaluated using various outcome measures. Seven randomized controlled trials were included. Based on Knee Society Scores, the Western Ontario and McMaster Universities Osteoarthritis Index, pain, and range of motion, there were no significant differences in clinical outcomes between the two techniques. Based on outliers from the normal axis, outliers of femoral components in the coronal plane, and outliers of tibial components in the coronal plane, radiologic outcomes showed no significant differences between the two techniques either. The present study revealed that there were no significant differences in clinical or radiological outcomes between computer-navigated TKA and conventional TKA. It remains unclear which TKA technique yields better results in terms of mid- to long-term clinical and radiological outcomes. I.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: There has been increasing interest in the use of minimally invasive osteotomy techniques for bunionette (Tailor’s bunion) correction. The aim of this study was to investigate the clinical and radiographic outcomes following an unfixed minimally invasive oblique distal diaphyseal osteotomy for bunionette deformity correction. Methods: 43 patients (mean age 54.2 ± 17.1) underwent minimally invasive oblique osteotomy for bunionette deformity correction by a single surgeon over a course of 4 years. We collected data on radiographic parameters (Inter-metatarsal angle(IMA), metatarso-phalangeal angle(MPA), pre-operative Coughlin classification, whether the osteotomy was completed or the lateral cortex was still intact and post-operative callus formation) and Patient Reported Outcome Measures (PROMs) prospectively pre-operatively and at a mean of 18 months follow up. Results: 16 patients had a Coughlin Type 1 deformity, 8 Type 2, 19 Type 3. The patients showed a significant reduction in IMA from 10.0±2.6 to 5.2±1.9 and MPA from 13.8±5.3 to 4.9±2.8. 30 patients had a complete osteotomy, 13 patients had a hinge osteotomy with the lateral cortex remaining intact. 41% of patients had callus equivalent to 150% of the metatarsal width or over at 6 weeks follow up, this reduced to 15% at 6 months and 0% at 12 month follow up. The Manchester Oxford Foot Score significantly improved in all domains as did the VAS Pain score. Conclusion: Minimally invasive oblique osteotomy for bunionette deformity correction seems a safe and effective procedure significantly improving radiographic and clinical outcomes. Whether or not the osteotomy is completed does influence callus formation but does not significantly affect the radiographic or clinical outcomes.

Pure varus posteromedial rotatory instability of the elbow: Radiographic findings, treatment, and outcomes

Background/Objectives: This study aims to conduct a systematic review to determine the clinical and radiographic outcomes and postoperative complications of reverse total shoulder arthroplasty (RTSA) in patients with os acromiale. Methods: A systematic review was conducted according to PRISMA guidelines. Studies investigating outcomes of RTSA in patients with os acromiale were included. Data regarding prevalence, clinical outcomes, range of motion, complications, and radiographic findings was extracted. Results: Six studies were included involving a total of 161 patients with os acromiale who received an RTSA. Os acromiale was present in approximately 6.4% of the total RTSA cases. Comparative studies reported no significant differences in clinical outcomes, complication rates, or reoperations between patients with and without os acromiale. One study with consecutive follow-up evaluations reported postoperative acromial tenderness in up to 27% of patients, which resolved spontaneously in most cases. Radiographic inferior displacement of the os acromiale occurred in 54% (range: 28-63%) of cases, but did not correlate with worse functional outcomes. Conclusions: Os acromiale does not represent a contraindication to RTSA and does not significantly compromise clinical outcomes. Radiographic acromial tilt often occurs without clinical relevance. Preventive surgical fixation of the os acromiale is not routinely recommended. Nonetheless, acromial tenderness may be present postoperatively, with a high likelihood of spontaneous symptom resolution.

BackgroundKnee arthrodesis with intramedullary (IM) nail or external fixator (EF) is the most reliable therapeutic option to achieve definitive infection control in patients with septic failure of total knee arthroplasty (TKA). The first aim of this study was to compare re-infection rates following knee arthrodesis for periprosthetic joint infection (PJI) with IM nail or EF. The second aim was to compare rates of radiographic union, complication, and re-operation as well as clinical outcomes.MethodsA systematic search was performed in electronic databases for longitudinal studies of PJIs (minimum ten patients; minimum follow-up = 1 year) treated by knee arthrodesis with IM nail or EF. Studies were also required to report the rate of re-infection as an outcome measure. Eligible studies were meta-analyzed using random-effect models.ResultsThe rate (95% confidence intervals) of re-infection was 10.6% (95% CI 7.3 to 14.0) in IM nail arthrodesis studies. The corresponding re-infection rate for EF was 5.4% (95% CI 1.7 to 9.1). This difference was significant (p = 0.009). The use of IM nail resulted in more advantages than EF for frequency of major complications and limb shortening. Other postoperative clinical and radiographic outcomes were similar for both surgical strategies.ConclusionsThe available evidence from the aggregate published data suggests that knee arthrodesis with EF in the specific context of PJI has a reduced risk of re-infection in comparison with the IM nail strategy. The use of IM nail is more effective for the complication rate and shortening of the affected limb.

Long-term Angiographic and Clinical Outcomes in Completely Versus Incompletely Coiled Ruptured Intracranial Aneurysms