supply to the distal fracture fragments, thereby increasing the risk for non-union. The findings of our study showed that MIPO caused less damage to the accessory nutrient arteries and their blood flow, unlike the case with ORIF, where they were frequently damaged and often necessi- tated ligation. And it has been confirmed that these accessory arteries is crucial to fracture healing and ligation of them will lead to adverse outcome . Put together, these findings indicate that MIPO might be superior to ORIF in preserving the blood supply of the mid-distal portion of the humeral shaft. And because the fracture pattern is unpredictable, it is preferable to use a min- imal invasive approach to preserve the remaining blood supply and minimize the iatrogenic disruption of the perfusion .
Background: Traditional open instrumentation may cause surgical complica- tions due to fragile bones and induce medical comorbidities in senile patients. Vertebroplasty and kyphoplasty are palliative augmentation procedures that have been associated with increased risks of cement leakage, adjacent frac- tures and non-union. Objective: The aim of this study was to describe a nov- el approach for the union of osteoporotic vertebral compression fractures with minimallyinvasive open reduction and internalfixation. Patients and Methods: Seven consecutive patients with intractable back pain without neurological deficits due to osteoporotic vertebral compression fractures were treated using minimallyinvasivefixation with intra-vertebral expandable pil- lars and artificial bone substitute. The clinical symptoms and image findings were recorded. Results: All of the patients reported relief of back pain, and the height of the vertebral bodies was well restored. X-ray findings obtained 2 to 4 years after the procedures showed fracture healing and favorable forma- tion of the callus confirmed in the anterior longitudinal ligament. Conclu- sion: This mini-open procedure with intravertebral devices is an effective and reliable technique for osteoporotic vertebral compression fractures and may avoid complications related to traditional open spinal instrumentation pro- cedures and augmentation with bone cement.
All operations were performed in the supine position with the use of a pneumatic tourniquet. For group A (MIS), a medial and/or lateral skin incision of approximately 4 - 6 cm was made. Fracture reduction and bone grafting, if nec- essary, were performed. Then, the anatomic plate was ad- vanced to the tibial shaft and mini-incisions were made to insert the distal screws. In group B (ORIF), a medial and/or lateral skin incision of approximately 10 - 12 cm was made. Fracture reduction, bone grafting (if necessary), anatomic plate application, and insertion of distal screws were car- ried out in the same manner. In both groups, reduction and fixation were examined using plane radiographs. Fol- lowing drain placement in the wound, the soft tissue and skin were closed layer by layer.
There is an increasing trend of shaft of humerus fractures being treated operatively . Denies  in his study compared conventional plating with intramedullary interlocking nail in 91 patients. He reported high complica- tion rate with intramedullary nail and suggested plating as primary treatment for humeral shaft fractures. In most instances dynamic compression plating is preferred   . The most commonly used approach are the post- erior and anterolateral approaches  . Oh  in his study compared open reduction with internalfixation and minimallyinvasive plate osteosynthesis in humeral shaft fractures he reported no difference in fracture un- ion however radiation hazard was high with mippo technique. Boschi  in his study concluded subbrachial ap- proach as practical and effective and the loss of muscle strength was significantly less with subbrachial approach. In our study medial plating was done through anterolateral approach without splitting the brachialis, the brachia- lis was elevated and retracted laterally
include open reduction and internalfixation (ORIF), mini- mally invasive reduction with percutaneous fixation (MIRPF) or primary arthrodesis. Controversies and variable opinion exist among foot and ankle surgeons regarding the choice of operative or non-operative treatment. The results of a prospective randomized controlled trial (RCT) from Canada comparing operative and non-operative treatment of DIACFs suggested that without stratification of the groups, the functional results were equivalent in both groups. However, after unmasking the data by
screw–rod instrumentation has been widely used for most thoracolumbar fractures nowadays [6, 8] since it can achieve favorable outcomes in terms of spine stabilization, kyphosis correction, postoperative neuro- logic improvement [9, 10, 26]. However, traditional open posterior operation requires massive paraspinal muscles stripping to expose the spinous process, lamina and facet, followed by short-segment (1 level above and below the injured level) or long-segment (2 levels above and below the injured level) internalfixation. The lamin- ectomy is also performed at the injured level for canal decompression in patients with neurologic deficit. In this approach, massive paraspinal muscles stripping would cause ischemia, necrosis and denervation of the paraspinal muscle, resulting in atrophy and contractile properties loss of paraspinal muscles postoperatively. Denervation and dysfunction of the paraspinal muscles, as well as destruction of the posterior column stability, are believed to be associated with refractory postopera- tive back pain and disability . Recently, Li et al.  measured the cross-sectional area of the paraspinal muscle using MRI to compare the paraspinal muscle be- tween the minimallyinvasive transforaminal lumbar interbody fusion (miTLIF) group and the traditional open TLIF group after the treatment of 1-segment lum- bar disease. After 48 months follow up, patients in the traditional open TLIF group had significantly smaller cross-sectional area of the paraspinal muscle, compli- cated with worse back pain VAS scores and ODI scores, indicating the advantages of miTLIF in preventing para- spinal muscle atrophy, reducing postoperative back pain and improving postoperative life quality . Another disadvantage of the traditional posterior approach is that the canal decompression might be limited, espe- cially when the canal encroachment is caused by re- pulsed bone fragments from injured vertebral bodies  and the posterior longitudinal ligament is likely to be injured, or the intra-canal fracture fragments are lo- cated in apterium of the posterior longitudinal ligament . Although some authors have reported no signifi- cant association between the extent of canal encroach- ment and neurological function [28, 29], a complete canal decompression theoretically offers a better chance for neurologic improvement and a more complete canal decompression with low risk of complications is worth trying for patients with neurologic deficit.
Distal tibia fractures are rare fractures of lower limb. They account for less than 1 percent of all fractures of lower extremity. They involve weight bearing articular surface and These fractures are aused by high energy axial forces which account for et al., 2008) The management of complex distal tibial fractures is challenging and triggers debate among trauma surgeons regarding optimal The most important variables that affected the final clinical result are the type of fracture, associated soft tissue injury, the method of treatment Ranjeesh and Renu, 2013; Reilmann, 2008) Distal tibia fractures classified by AO as extra articular, partial and Murphy, 2000) In literatures the treatment options for distal tibia fractures are RIF), interlock nailing, external fixators and minimallyinvasive bridge plating. However these treatment modalities are not without complications. Open reduction and internalfixation (ORIF) can result in wound infection and dehiscence. External fixators and
Bicondylar tibial plateau fractures (AO/OTA type C) rep- resent 20.4% of all proximal tibial fractures [1, 2]. Because of articular comminution and the frequent occurrence soft-tissue injuries, clinical management still remains challenging for traumatic surgeons [3–5]. Traditional open reduction and internalfixation (ORIF) requires ex- tensive soft tissue dissection, which may lead to numerous soft-tissue complications [6–8]. The Ilizarov technique al- lows a better choice of closed reduction and fixation which does not necessitate excessive soft-tissue stripping . Today, this technique is being widely used in open and comminuted tibial plateau fractures. However, the external fixation method has its theoretical risks, including pins infection, neurovascular injury, deep venous thrombosis, scar problems, and limitation of joint move- ment [9, 10]. Besides, frequent management of the circular frame was inconvenient for both patients and doctors.
by Bano  in 2009, based on prying reduc- tion. In the treatment of calcaneal fractures, the guide needle is inserted into the calcaneal body and the balloon dilator is then inserted into the guide needle. The fracture is then re- duced through balloon dilatation. At the time of expansion, the two sides of the calcaneus are compressed by both hands to restore the height and width of the calcaneus. Jacquot  used balloon dilatation to treat 11 patients wi- th calcaneal fractures, of which 5 were San- ders II and 6 were Sanders III. After 3-5 years of follow-ups, the rate of excellent and good AO- FAS scores was 81.8%. There were no compli- cations or wound-related infections, except for 1 case of subtalar arthritis and arthrodesis and one case of retirement. The remaining patients recovered to preinjury working statuses. The authors concluded that it is better to restore first, then inject bone cement. Chen  et al. suggested that prying reduction should be per- formed first, followed by balloon dilatation re- duction. Comparisons between balloon dilata- tion combined with cannulated screw fixation (38 cases) and open reduction and internal fix- ation (40 cases) showed that there were no sig- nificant differences in postoperative complica- tions, Bohler angles, or calcaneal shape reduc- tion. There were no significant differences in operative times, blood loss, postoperative joint mobility, AFOAS scores, or Maryland foot sc- ores. The average score was superior to that of open reduction and internalfixation. The sam-
Common methods for treating anterior pelvic ring fractures consist of external and internalfixation. The advantages of external fixation are little trauma and simple operation, but compli- cations, such as pin tract infection, aseptic loosening, and local ulceration, can affect hip joint mobility and require inconvenient nursing care . Internalfixation has become the pre- ferred method for treating unstable pelvic frac- tures. However, the complex anatomical struc-
conservatively with a sling or figure-of-eight bandage (Neer, 1960; Rowe, 1968; Jeray, 2007). Functional outcome of midshaft clavicle fractures is not only related to its union, but also to its length (Lazarides, 2006). Clavicle acts as a "strut", that keeps the upper limb away from the torso for efficient shoulder and upper limb function, while also transmitting forces from upper limb to the trunk. Thus, displaced or comminuted fractures carry a risk of symptomatic malunion, non-union and poor functional outcome with cosmetic deformity (Canadian Orthopaedic Trauma Society, 2007; Hill et al., 1997; Wild et al., 2006). The recent trend is shifting towards internalfixation of these displaced midshaft clavicle fractures (DMCF) (Lazarides, 2006; Hill et al., 1997; Wild et al., 2006; Smekal et al., 2009; McKee et al., 2003; Zlowodzki et al., 2005). Displaced midshaft fractures have traditionally been treated non-operatively because of early reports suggesting that clavicular non-union were very rare and clavicular mal-union, being of radiographic interest only, was without clinical importance (Neer, 1960; Canadian Orthopaedic Trauma Society, 2007). However, recent studies
In December 2016, a search was conducted on the PubMed and MEDLINE databases using the keywords displaced intra-articular calcaneal fracture, open reduc- tion and internalfixation, sinus tarsi approach, extensile lateral approach, minimallyinvasive and percutaneous. The references of the articles found were also reviewed to identify additional studies for inclusion. Studies were included in the meta-analysis if they met the following criteria: (1) sample population at skeletal maturity, (2) sample size > 1 (i.e. not a case study) and (3) investigated outcome measures (both quantitative and qualitative) between ORIF and minimallyinvasivefixation. Studies that included patients with bilateral or concurrent injur- ies secondary to trauma were not excluded from the meta-analysis due to the high rate of associated injuries
The goal in treating pelvic fractures is to reduce the pelvis, restore the stability of the pelvic ring, and reduce the inci- dence of complications [1, 2]. Open reduction and internalfixation of pelvic fractures are associated with several prob- lems, such as great damage, increased bleeding, and nerve and vascular injury, as well as a high incidence of complica- tions, such as wound disunion and infection. In contrast, the minimallyinvasive closed reduction cannulated screw treatment of pelvic fractures has advantages such as small incision, reliable fixation, and low cost. In addition, it can effectively shorten the length of surgery and reduce damage to the nerves and blood vessels in the surgical region [3–5]. Currently, several difficulties in the treatment of pelvic fractures are still remaining. For example, how to fully re- store the anatomical structure of the fractured pelvis through closed reduction and how to insert the cannulated screw safely and effectively to achieve a reliable fixation, thereby reducing the damage to the blood vessels and nerves, as well as pelvic organs, owing to screw malposition. In recent years, along with the development of digital medicine in clinical treatment, 3D printing technology has achieved a quantum leap from virtual simulation to the real-world clinical application [6, 7]. At the same time, the technology has been utilized as an important component of personalized treatment plans in fracture treatment, especially the treatment of unstable pelvic fractures, which has complex requirements with respect to the diagnosis of the overall fracture pattern and surgi- cal procedures . Most importantly, the positioning of the cannulated screw in the process of minimally inva- sive treatment of unstable pelvic fractures is very critical. Therefore, accurate diagnosis and perfect preoperative planning are essential to the whole treatment. The emer- gence of 3D printing technology undoubtedly aids in solving this orthopedic problem.
Abstract: Objective: Unstable pelvic fractures are relatively rare injuries usually requiring reduction and internalfixation. Selecting appropriate methods for unstable pelvic fractures remains a challenging problem for orthopaedic surgeons. The aim of this study was to present the techniques and outcomes of MIAP for unstable pelvic fractures. Methods: We performed a retrospective analysis of patients with unstable pelvic ring fractures treated with mini- mally invasive adjustable plate at a level I trauma centre. Outcome evaluation was assessed using Majeed score standard, duration of surgery, blood loss, radiation exposure and size of incision. Results: Twenty-one patients were available for follow-up after at least 12 months. The main findings were as follows: the average duration of surgery was 67.5 min, the intraoperative blood loss was 204 ml on average, the average radiation exposure was 8 s, and the size of incision was 8.8 cm on average. The mean Majeed functional evaluation score was 85.3 points. Conclusion: Minimallyinvasive adjustable plate may be a good alternative for treating unstable pelvic fractures. It has the ad- vantages of technically safe, minimallyinvasive, less radiation exposure and time saving.
asymmetric expansion of the abdomen when coughing . Zobrist et al.  addressed these problems with the help of an endoscope. Their endoscopic technique facili- tated reliable internalfixation of anterior ring fractures with minimal soft tissue trauma. This technique, however, is technically demanding, time-consuming and needs a special instrument. Vaidya et al. , in a recent study that included 24 patients, presented a novel internalfixation device for stabilising unstable pelvic fractures using supra- acetabular spinal pedicle screws and a subcutaneous con- necting rod. There were no infections, delayed unions, or nonunions, and all fractures healed without significant loss of reduction. The authors did, however, report neuropraxia in two patients, and one patient required repositioning of the pedicle screw and readjustment of the screw rod, which had caused discomfort. Their incisions were directly over the anteroinferior iliac spine for pedicle screw placement, which is a high-risk zone in regard to injuring the lateral femoral cutaneous nerve. A similar study by Heisterman et al.  was a randomized controlled trial that compared anterior pelvic external fixation versus anterior pelvic in- ternal fixation for unstable pelvic ring injuries. They pre- sented the idea of an anterior pelvic bridge, which is a percutaneous method for fixing the anterior pelvis through limited incisions over the iliac crest and pubic symphysis. In addition to the inherent limits of minimallyinvasive pel- vic fixation (e.g., the lack of direct visualisation), their method required adequate posterior ring stability. Thus, it could be used only in patients who have residual instability anteriorly after the posterior pelvis has been verified to be stable. Yu  et al. introduced a similar minimally inva- sive plate osteosynthesis (MIPO) technique for the treat- ment of pubic ramus fractures in 15 patients. For exposure of the medial window, the ligaments
With the aim of improving patient comfort and min- imizing the complications associated with traditional treatment techniques, minimallyinvasive techniques have been widely used for anterior pelvic ring fixation. The potential benefits include minimal soft tissue dissec- tion, diminished surgical site infections, and faster pa- tient rehabilitation with better pain control. These procedures comprise subcutaneous implants fixed into the ilium with or without fixation into the parasymphy- seal region (reported as the pelvic bridge) , the occipi- tocervical spinal plate-rod technique , and an anterior subcutaneous pedicle screw-rod internal fixator (INFIX) [10–12]. However, iatrogenic lateral femoral cutaneous nerve (LFCN) palsy is a common complication of these procedures and is reported in 30 to 48.3% of patients [13, 14]. The placement of pedicle screws in the supra-acetabular region, as in external fixation, and of INFIX, requires incisions directly over the anterior infer- ior iliac spine (AIIS) with pedicle screws placed in a high-risk zone for LFCN .
The aim of treatment in fractures of the distal femur prox- imal to total knee arthroplasties is to achieve a painless and stable knee without any residual malalignment. Conservative treatment has been reported with successful results in these fractures . However, this may be asso- ciated with difficulty in maintaining reduction, prolonged period of immobilisation, reduced knee functions, malu- nion and nonunion. Merkell and Johnson recommended conservative treatment, although nine of 26 patients (35%) in their study required revision arthroplasty because of nonunion, malunion, loosening of components and extensor lag . Culp et al.  recommended opera- tive treatment for displaced fractures, as conservative treatment resulted in nonunion in 20% and malunion in 23% of patients. Several authors have recommended open reduction and internalfixation using lateral plates for these fractures [4, 5]. Healy et al.  treated 20 fractures with open reduction and internalfixation using a variety of different implants including blade plate, condylar screw and condylar buttress plates. They performed bone grafting in 15 patients and achieved union in 18 patients. Two patients, who did not undergo bone grafting at the time of index surgery, needed reoperation and bone graft- ing to achieve union. The authors recommended primary bone grafting with internalfixation to increase the chances for union of these difficult fractures . However, internalfixation using plates could be techni- cally demanding in osteopenic bone in elderly patients. Figgie et al.  reported union in only five of 10 cases; the remaining five cases needed further surgical proce- dures. They also noted that eight of 10 cases developed varus alignment despite satisfactory intraoperative align- ment due to metaphyseal comminution . To address the problem of poor fixation in osteopenic bone, locking plates have been developed which can be inserted with a minimallyinvasive approach. Clinical studies have reported good results using locking plates for the treat- ment of periprosthetic supracondylar femur fractures Fig. 2 Radiographs of the knee showing complete fracture union
The minimallyinvasive, balloon-assisted reduction and cement-augmented internalfixation of the tibial plateau, also termed balloon tibioplasty, is an innovative, possibly superior surgical procedure [7, 10]. Originally designed as a kyphoplasty for vertebral compression fractures, it uses a trocar to enter the bone, a balloon to dilate and reduce, and cement for augmentation . Its elegance lies in the indirect elevation of the impressed defect in- stead of mechanical elevation with regular instruments, which may even enlarge the void created by the impre- cise reducing action . It has been shown to have similar reduction capabilities as conventional mechanical tamps and can be used successfully to elevate tibial im- pressions . Another advantage of this technique con- sists of the percutaneous approach without periosteal stripping/fenestration, which means a reduction in post- operative complications such as infections, delayed wound healing and pseudarthrosis . Although the cement is rather expensive, it is still cheaper than other synthetic bone substitutes. The procedure with poly- methyl methacrylate (PMMA) may be followed by im- mediate full weight-bearing with shorter hospitalization times as well as faster rehabilitation, less postoperative infections, and, therefore, reduced overall costs . In the beginning, the indication for balloon tibioplasties were elderly, multimorbid patients at risk of postoperative wound complications and in need of prompt rehabilitation . Recently, due to the increasing popularity of calcium phosphate (CaP) cements, these procedures have also been expanded to younger patients and hardly accessible posterolateral impression fractures, which can be com- puted tomography (CT)-navigated in difficult cases. In this
Previous studies have shown that the traditional deltopectoral approach to the proximal humerus provides limited access to the posterolateral aspect of the shoulder and that the visualization and reduction of a large retracted greater tuberosity fragment may be difficult [11,14-18]. The deltopectoral approach requires extensive soft tissue dissection and muscle retraction to gain adequate exposure to the lateral aspect of the humerus [10,11,14,16,18-20]. This can cause further devasculariza- tion of fracture fragments during dissection and plating, leading to the disruption of critical blood supplies to the humeral head [10,18-20]. The deltoid splitting approach, which is an alternative method, provides good visualization of the posterolateral aspect of the shoulder without extensive soft tissue dissection or forcible retraction; however, there is an increased risk of injuring the axillar nerve as compared to the conventional deltopectoral approach [16,21,22]. Recently, many studies have demonstrated the superiority of MIPO techniques via anterolateral deltoid splitting combined with skin inci- sions for the management of proximal humerus fractures [15,17,19,21-28]. This method is a minimallyinvasive technique, leading to less soft tissue injury, decreased postoperative pain, and decreased functional loss. In addition, MIPO allows for the visualization of the axillary nerve [12,14,16,22]. Thus, MIPO is a safe and effective method for the treatment of proximal humerus fractures [14,19,20,22].