Invasive Fixation Technique Research Articles

A novel technology integrating robotics and 3D printing for closed reduction of tibia shaft fracture with MIPPO:A proof-of-concept study

Less invasive fixation techniques, such as intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO), are now the preferred choices for treating tibia shaft fractures (TSFs). However, malreduction and radiation exposure are the main deficiencies associated with less invasive fixation techniques, especially when assessing rotation around the shaft axis intra-operatively. The purpose of this study was to investigate the feasibility and reduction accuracy of an innovative technology that integrates robotics and 3D printing for achieving anatomical reduction of TSFs with MIPPO. The surgical workflow from a standardized CT protocol, via 3D reconstruction, 3D printing tibia model, pre-contouring plate, 3D scanning plate, 3D planning of the trajectories of the robot, and use of a commercial surgical robot, robot-assisted screw hole drilling, to automatic fracture reduction through precise installation of the plate was described. The reduction accuracy was evaluated by an optical tracking system. The mean variations of 1.95 ± 1.36mm in length, 1.63 ± 0.92 mm in apposition, 2.78 ± 1.69° in alignment, and 1.99 ± 1.81° in rotation. The interoperator reliabilities were almost perfect, with values of 0.91, 0.93, 0.92, and 0.90, respectively. The proposed technology achieved anatomic reduction on phantom bones.

A monocenter, patient-blinded, randomized, parallel-group, non-inferiority study to compare cochlear implant receiver/stimulator device fixation techniques (COMFIT) with and without drilling in adults eligible for primary cochlear implantation

BackgroundDuring the cochlear implantation procedure, the receiver/stimulator (R/S) part of the implant is fixated to prevent postoperative device migration, which could have an adverse effect on the position of the electrode array in the cochlea. We aim to compare the migration rates of two fixation techniques, the bony recess versus the subperiosteal tight pocket without bony sutures.Methods and analysisThis single-blind randomized controlled trial will recruit a total of 112 primary cochlear implantation adult patients, eligible for implantation according to the current standard of practice. Randomization will be performed by an electronic data capture system Castor EDC, with participants block randomized to either bony recess or standard subperiosteal tight pocket in a 1:1 ratio, stratified by age. The primary outcome of this study is the R/S device migration rate; secondary outcomes include patient-experienced burden using the validated COMPASS questionnaire, electrode migration rate, electrode impedance values, speech perception scores, correlation between R/S migration, electrode array migration and patient complaints, assessment of complication rates, and validation of an implant position measurement method. Data will be collected at baseline, 1 week, 4 weeks, 8 weeks, 3 months, and 12 months after surgery. All data analyses will be conducted according to the intention-to-treat principle.DiscussionCochlear implantation by means of creating a tight subperiosteal pocket without drilling a bony seat is a minimally invasive fixation technique with many advantages. However, the safety of this technique has not yet been proven with certainty. This is the first randomized controlled trial that directly compares the minimally invasive technique with the conventional method of drilling a bony seat.Trial registrationNetherlands Trial Register NL9698. Registered on 31 August 2021.

Minimally Invasive Fixation in Osteoporotic Vertebral Fractures: A Review Article

here are several surgical strategies which have been proposed to treat the osteoporotic patient with vertebral fracture, ranging from vertebral body cement augmentation, percutaneous/mini-open short segment pedicle screw fixation, and cortical bone trajectory screw to kyphotic deformity correction surgery. Minimally invasive spine surgery has the potential benefits of faster recovery, reduced blood loss, less postoperative wound pain, lower infection risk, and shorter length of hospital stay. Novel surgical techniques such as percutaneous instrumentation fixation, cortical bone trajectory technique, screw cement augmentation, and vertebral body augmentation are developed. However, various complications have been reported, including pedicle fracture, instrumentation loosening, adjacent-level disc degeneration with herniation, and progressive junctional kyphosis. The purpose of this review was to outline various advancements in minimally invasive spinal surgery for patients with osteoporosis. Minimally invasive surgical techniques for fixation including percutaneous instrumentation, cortical bone trajectory technique, screw cement augmentation, and vertebral body augmentation have benefited patient with osteoporosis. Studies and discussions about short-segment pedicle screw fixation (one level above and below the fracture level) have shown that it provides enough stability for thoracolumbar burst fractures. There are also complications, including cement embolism, adjacent vertebral fracture, neuraxial anesthesia, and infection, which have been observed with the above technique. With the advancement of instrument and technique, the complication rate decreased in recent studies. Minimally invasive fixation still has many advantages for patients with osteoporosis. Many of these studies and strategies only have evidence from biomechanical and cadaveric studies and require further clinical trials to establish their clinical efficacy.

The Bridging Infix: a modified, minimally invasive subcutaneous anterior pelvic fixation technique

Various methods for anterior pelvic ring fixation have been described in the literature, each with specific advantages and disadvantages. We describe a modified minimally invasive subcutaneous technique for anterior fixation: the Bridging Infix. It combines the benefits of internal plate fixation with external fixator principles. We merged and modified features of the existing INFIX and Pelvic Bridge techniques during the design. Similar to these techniques, we use plate-rods typically used during occipitocervical fusions. The design changes allow for less discomfort due to prominent hardware in thin patients and eliminate the need for an intact medial pubic rami for fixation. There is also no risk of bladder injury due to accidental screw perforation through the pubic rami. The Bridging Infix is ideal for patients who are physiologically too frail for extensive open reduction and plate osteosynthesis, such as elderly patients with pelvic fragility fractures who are failing to mobilise due to pain. It can also be used for patients in whom external fixators may be impractical or poorly tolerated, such as obese patients or those with increased nursing demands. This technique does not provide adequate posterior pelvic ring stability, thus it requires an intact posterior tension band or the addition of separate posterior fixation. Patients can commence in-bed mobilisation the same day as the procedure, with weight-bearing as tolerated allowed for most cases, and toe-touching reserved for highly unstable injury patterns only. The implants are not routinely removed unless requested by the patient, especially in the elderly to avoid additional anaesthetic exposure. Potential complaints include lateral thigh pain, due to lateral femoral nerve compression, and mechanical discomfort during exercise activities. Level of evidence: Level 5

Double Barrel Screw Fixation for Proximal Phalanx Fracture.

A variety of fixation options exist for treatment of unstable proximal phalanx fractures. Variables which require consideration include the strength of fixation, the invasiveness of the technique and the postoperative rehabilitation protocol. Here we present a minimally invasive technique for dual headless compression screw fixation of proximal phalanx fractures which reduces extensor tendon violation and allows early motion in the immediate postoperative period.

Intrascleral anchoring knot on the double suture without peritomy for fixation of intraocular lens.

A new minimally invasive technique for universal fixation of any posterior chamber intraocular lens (IOL), iris prosthesis or capsular tension device (CTD), both for rescuing in case of dislocation and for secondary implantation, is described. It uses intrascleral anchoring knot on the reinforced double 9-0 polypropylene suture without conjunctival opening or scleral dissection. The technique was applied for scleral fixation of the S-shaped monoblock acrylic IOL dislocated into the vitreous cavity in 1 eye, and decentered IOL-CTD-capsular bag complexes in 3 eyes. In none of the cases, complications including knot slippage, suture exposure or hypotony were observed. All patients were followed up for 6 months. The uncorrected distance visual acuity was significantly improved and the IOLs positions remained stable. The described technique might be a simple, effective and safe alternative to flanged scleral fixation approaches.

Minimally Invasive Fixation with Dorsal Suspension Button and Volar Plate in Distal Radius Fractures with Dorsal Die Punch Fragments: A Preliminary Study.

Objective The objective of the study is to analyze the clinical and radiological results obtained using a minimally invasive fixation technique with a volar locking plate and a suspension system with a dorsal button in distal articular radius fractures with dorsal comminution. Materials and Methods Six patients with distal radius fractures, between 19 and 68 years of age, were included in the study. Mean follow-up was of 15 weeks. Range of motion (ROM) in flexion, extension, radial deviation, ulnar deviation, pronation, supination, the strength in kilograms, and values on the Visual Analog Scale (VAS), Disabilities of Arm, Shoulder and Hand (DASH), and Mayo Wrist Score (MWS) scales were evaluated at 4, 8, and 12 weeks postoperative. Correction of anteroposterior diameter of the radius and concordance between postoperative anteroposterior diameter and the contralateral wrist diameter were evaluated radiologically. Results The following mean values were obtained at 12 weeks postoperative: ROM in flexion: 40.5°, ROM in extension: 49.5°, ROM in radial deviation: 24.5°, ROM in ulnar deviation: 15°, ROM in pronation: 87°, ROM in supination: 89°, strength: 37.5 kg, pain in VAS scale: 2 points, DASH: 54.5 points, and MWS: 67.5 points. At 12 weeks postoperative, the mean correction of anteroposterior diameter was 0.49 mm. The anteroposterior diameter and that of the contralateral wrist were strongly correlated. Conclusion Fixation with the volar locking plate and dorsal suspension button could be considered an alternative to dorsal plate fixation for treatment of distal radius fractures with comminution or associated dorsal die punch fragments.

A New Technique for Anterior Pelvic Ring Fixation Using a Minimally Invasive Approach

Introduction: Percutaneous screw fixation have been introduced as a minimally invasive method in anterior pelvic ring fractures. The aim of the study is to present the outcomes of a new minimally invasive technique for fixation of anterior pelvic ring fractures medial to the pubic tubercle. Materials and Methods: Sixty-two patients were referred to our center during 5 years for the fixation of the anterior pelvic ring fracture under the new procedure. The fracture site was bridged using a 3-hole 3.5 mm reconstruction plate when 1 or 2 long retrograde screw was passed through the plate in the superior ramus. Results: A case of device failure was observed in the patient treated with the new method, which did not lead to loss of reduction and did not limit the patient’s activity. Apart from this, we did not have any abnormalities in the follow-up radiographs of the patients and no complications were reported. Conclusion: The results of this study showed the potential of our new method for fixation of various types of anterior pelvic ring injuries. Level of Evidence: Level IV.

Concept for Minimally Invasive Hook Plate Stabilisation of the Acromioclavicular Joint.

Despite the availability of various operative procedures, hook plates are still one of the main implants used for the treatment of acromioclavicular (AC) joint dislocation. The aim of this report is to present a novel minimally invasive operation technique for AC hook plate fixation. The functional outcomes of patients operated upon with this technique are presented. A retrospective analysis was performed for 5 patients who were operated upon with minimally invasive hook plate fixation. The QuickDASH score (QDS) and subjective shoulder value (SSV) were used to express functional outcomes, and the numeric rating scale (NRS) was used to evaluate pain. The mean (SD) follow-up was 30±7 months. Patients were hospitalized for a mean of 3±1 days and operated upon for a mean of 54±7 minutes. Functional outcomes measured with the QDS showed a median (IQR) of 2.3 (0 - 6.8) and a median SSV relative to the healthy side of 95% (89 - 100). The median NRS was 0 (0 - 0). Minimally invasive hook plate fixation for acromioclavicular joint dislocation led to excellent functional outcome scores without complications in a small case series of 5 patients.

Outcomes of Treating Tibial Shaft Fractures Using Intramedullary Nailing (IMN) versus Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO).

Background:Tibia shaft fractures are one of the most common long-bone fractures, second most common open sport-related injuries and they are estimated to occur in 4 percent of the senior population.Objective:Management of tibial fractures has been updating to achieve the best outcomes and avoid complications especially when talking about most common long bone fractures. Less invasive fixation techniques are the preferred ones to reduce surrounding soft tissue injury, improve healing process and decrease complications. Minimally invasive percutaneous plate osteosynthesis (MIPPO) and Intramedullary nailing (IMN) are the least invasive and most popular modalities used nowadays. This study compares outcomes and complications of both modalities.Methods:This is a retrospective cohort study conducted in orthopedics department at KAUH-Jordan. Patients were followed up for a mean of 15.3 months. Only MIPPO and IMN were used, and exclusively tibial shaft fractures were included. Open fractures were classified according to the Gustilo-Anderson classification. Results:Ninety patients with a mean age of 36.9 years (range, 9-79) were observed. Fifty nine of them were treated with IMN; nine of them had complications. Thirty one patients were treated with MIPPO and only three developed complications. Three patients treated with IMN had non-union, whereas none of MIPPO patients developed non-union. Only perioperative blood loss was more when MIPPO was used taking into consideration the amount in the suction tube, amount of fluid irrigation and soaked gauze.Conclusion:In treating tibial shaft fractures, MIPPO appears to cause fewer complications and provides better healing environment therefore attributes to lower non-union rates than IMN. Larger sample size might be needed to provide better results.

Technical note: A modified wiltse technique for minimally invasive surgery transforaminal lumbar interbody fusion

Background: Conventional midline dorsal approach to spine leads to excessive muscle retraction and hence muscular injury, denervation, atrophy, or ischemic necrosis. Wiltse paraspinal approach prevents these complications. We present a modified Wiltse approach using minimally invasive surgery techniques for fixation of lumbar spinal instability patients.Methods: Here, we provide a step wise description of the modified Wiltse approach. We then put together, a step wise analysis of the preparation, patient positioning, skin incision, fascial opening, dissection, bone identification, retractors, deprioritization, decompression, discectomy, instrumentation, arthrodesis, and closure for the Wiltse technique.Conclusion: The classical approach described by Wiltse is essentially minimally invasive, sparing both the muscle planes and soft tissues. Adding a modification with tubular retractor system gives an additional advantage of muscle-sparing discectomy and fusion with a very low complication rate.

Outcome of minimally invasive technique for fixation of Sacroiliac injury

Outcome of minimally invasive technique for fixation of Sacroiliac injury

Video-Assisted Thoracoscopic Internal Rib Fixation.

Rib fractures result in serious morbidity and mortality after trauma. Although there is ongoing debate about surgical rib fixation, it is increasingly important for some patients. Minimally invasive techniques for rib fixation are gaining traction within the trauma community. We present an observational experience at our level 1 trauma center with our first 10 cases of video-assisted thoracoscopic surgery (VATS) internal rib fixation. Video-assisted thoracoscopic surgery internal plates are especially helpful for rib fractures under the scapula, which are difficult to access traditionally. This technique is also excellent at reducing complex segmental fractures as the bridge can span across multiple fractures with a single post on either side. They also work well for posterior fractures where multiple screws cannot be placed. Video-assisted thoracoscopic surgery internal rib fixation is a viable and exciting option for surgical fixation. The plates work particularly well for certain fracture patterns.

The SWISS IOL Technique (Small-Width Incision Scleral Suture): A Mini-Invasive Technique.

Purpose To evaluate the outcomes and safety of a minimally invasive technique for sutured IOL scleral fixation in case of compromised capsular and iris support. Materials and Methods In this retrospective study, we explain our mini-invasive technique and assess the outcomes in terms of visual acuity, pre- or postoperative complications, and IOL position (Sensar AR40e, AMO) in a case series of three patients. Results The expected best corrected visual acuity could be achieved after one month. Surgeries were uneventful with a stable eye. No postoperative complications occurred except for one patient who had a conjunctival disinsertion. Neither postoperative hypotony nor raised IOP was found. Additionally, no patient experienced corneal edema at one week control, IOL dislocation, vitreous hemorrhage, or new pupil's irregularity. Conclusions In conclusion, each scleral technique has its own advantages and its inherent postoperative complications. To date, there is no evidence of superiority of any single technique. By improving our scleral sutured lens techniques, we could improve peroperative ocular stability, potentially decrease postoperative complication rate, and offer a rapid recovery with a stable visual acuity within a month.

Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year.

The treatment of unstable (Neer type IIB and V) extra-articular distal clavicle fractures remains challenging, especially when encountering a small lateral fragment which does not allow for sufficient screw purchase. It was the purpose of this study to present the clinical and radiologic outcome of a consecutive series of patients treated by a stand-alone coracoclavicular stabilization using a so-called cow-hitch technique with a suture anchor. Nineteen patients were treated with a specific surgical technique for distal clavicle fractures (11 left, 8 right) with either rupture or bony avulsion of the coracoclavicular ligaments. Fourteen patients were examined in our outpatient clinic for the purpose of this study after a mean follow-up of 5 years (1-12.2 years). The examination included scoring according to Constant Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Subjective Shoulder Value (SSV), and follow-up radiographs. Two additional patients were amenable to a telephone interview. All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of +1.8 mm. Sports activities were fully resumed after an average of 4.7 months. The coracoclavicular stand-alone cow-hitch suture repair for unstable distal clavicle fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication and high bony union rate. Both radiographic and clinical long-term results are very satisfactory.

Minimally invasive subcutaneous anterior fixation of pelvic fractures in the elderly: case report and literature review

ABSTRACT BACKGROUND: As our population ages, the incidence of pelvic fragility fractures will rise accordingly. Despite these fractures having similar mortality rates to proximal femur fractures, there exist discrepancies between the management of these injuries. Although a number of pelvic fragility fractures can be treated successfully with conservative means, early treatment with appropriate surgical means should be considered in those failing conservative treatment or with unstable fracture patterns. CASE REPORT: We present an 84-year-old female who sustained a pelvic fragility fracture after a low-energy fall. Despite adequate conservative treatment, she was unable to mobilise. She was taken for anterior and posterior fixation, using our modified minimally invasive subcutaneous technique (the Bridging Infix) for anterior fixation. At the six-week follow-up she had regained full independent mobility. She had three syncope-related falls during this period, but radiographs revealed no sign of implant displacement. One year after her surgery she had complete union of her fracture, good function and no desire to have the implant removed. DISCUSSION: With the expected increase in pelvic fragility fractures due to the growing elderly population, our understanding of these injuries has begun to change. Occult posterior ring injuries have been described in up to 80% of cases, while fracture progression to unstable patterns can occur in up to 15% of stable patterns. Despite conservative management being the primary treatment of choice, these patients suffer morbidity and mortality rates comparable to proximal femur fractures. Early appropriate surgical management should be considered in patients failing to mobilise. Various surgical techniques have been described, each with their own advantages and disadvantages. Newer minimally invasive techniques are gaining favour, especially for use in elderly patients. These constructs combine the low profile benefits of internal plate fixation with ex-fix principles. CONCLUSION: The Bridging Infix is a modified technique for minimally invasive subcutaneous anterior pelvic fixation. Its use can strongly be considered by even the general orthopaedic surgeon in cases where patients are too frail for extensive or invasive surgeries, such as open reduction and internal fixation with plate and screws. Level of evidence: Level 5 Keywords: pelvic fracture, anterior pelvic fixation, elderly, minimally invasive

Minimally invasive technique for suprasyndesmotic ankle fracture fixation

Objective: To evaluate the clinical and radiographic results of suprasyndesmotic ankle fracture fixation with a minimally invasive technique. Methods: Retrospective study of 11 patients with suprasyndesmotic fractures of the lateral malleolus who underwent surgery between 2016 and 2018. Retrospective analysis of medical records considered the following: radiographic assessments (preoperative, immediate postoperative, six weeks postoperative), clinical evaluation, and strength scale and movement test results. Results: Of the 18 patients qualified for inclusion, 7 failed to appear at the follow-up appointment and were excluded. The patients’ age varied from 20 to 53 years, and 72.7% were male. The trauma mechanisms included torsion (46% of the cases), automobile accidents (36.4%) and direct trauma (17.6%). The mean time between trauma and definitive surgery was 3.27 days. The mean talocrural angle in the preoperative period was 83.13º, ranging from 80.63º in the immediate postoperative period to 81.27º at 6 months postoperatively. Approximately 90% of the patients did not lose strength. Regarding the range of motion, the mean dorsiflexion and plantar flexion 6 months postoperatively were 10.72º and 34.4º, respectively. Conclusion: The minimally invasive technique had excellent technical results in patients treated surgically for ankle fractures and required smaller incisions than conventional surgery. Osteolysis or fatigue of the osteosynthesis material is a possibility with this technique, which generally occurred between three and four months postoperatively. Level of Evidence IV; Therapeutic Studies; Case series.

Intrascleral Suture Anchoring: A Flapless/Grooveless Four-Point Intraocular Lens Fixation Technique.

Purpose We describe a minimally invasive suture fixation technique for four-point fixation of intraocular lenses (IOLs) in the treatment of aphakic eyes, namely, the intrascleral suture anchoring technique. Neither scleral flaps nor large conjunctival dissections are required. Methods This study included 11 eyes (11 patients). After looping the eyelets on the IOL haptics and externalizing the threads, the curved needle attached to the externalized thread was started with two sequential intrascleral passes from the first fixation point to reach the second fixation point. The same procedure was performed for the other side of the IOL. A fixation knot was created in the sclerotomy by the two ends of the thread to close the suture loop for IOL fixation. Another knot was created about 2 to 3 mm from the exiting point and was intrasclerally anchored by the aid of the attached curved needle. Results The mean postoperative follow-up period was 9.7 ± 5.8 months (range 5–15 months). The IOLs of all eyes remained well positioned and stable postoperatively. The postoperative visual acuities were improved. No suture erosion, suture loosening, hypotony, scleral atrophy, chronic inflammation, retinal tear, and/or detachment were observed within the follow-up period. Conclusion The present technique is an alternative, flapless method for the four-point suture fixation of IOLs. It provides both minimal surgical trauma and reliable stability.

C-arm Guided Minimally Invasive Percutaneous Fixation Technique of Mandibular Angle and Ramus Fractures - a Prospective Clinical Study at a Tertiary Care Center of Odisha, India.

Background: Rigid internal fixation of displaced mandibular angle and ramus fractures often poses a unique challenge to oral and maxillofacial surgeons. Various methods have been published to provide a safe and secure gateway for these circumstances. Intra-oral approach supplemented by a limited percutaneous method of fixation offers a distinct advantage of rigid fixation, reducing the known morbidity of using the sole internal as well as external techniques. The objective was to describe a minimally invasive technique for the mandibular angle and ramus fractures using the combined intraoral and extra-oral approach.Methods: This study was conducted on ten patients with mandibular angle or ramus fractures. All patients underwent open reduction and internal fixation. The intra-oral incision was used for visualization and reduction of fractures, and supplemental percutaneous stab incision was utilized to create a path for insertion of the handheld battery-operated microdrill shaft and screwdriver to permit screws fixation perpendicular to the plates.Results: This combined technique depicted minimal or no soft tissue infections, wound dehiscence, occlusal disturbances, or seventh cranial nerve paralysis. The mean surgical duration was 41.5 minutes. No patient had an visible scar marks, which would require further intervention.Conclusion: The described minimally invasive combined percutaneous and intraoral approach for mandibular angle, and ramus fracture provides a satisfactory alternative which could be safely applied to provide rigid fixation of these fractures with minimal damage to vital structures.

Flapless Intrascleral Knotting Technique for Suture Fixation of Intraocular Implants.

We will describe a flapless/grooveless/pocketless and minimally invasive technique for scleral suture fixation of intraocular implants. After introducing the suture into the eye, the two ends of the suture were left exterior to the globe, the free end and the end connected to a curved needle (the needle side). A back-and-forth intrascleral suture passage was performed with the aid of a curved needle. The suture was thus supported by adequate scleral tissue. The suture was fixated to the sclera by knotting it into the sclerotomy. The ends of the suture were finally anchored intrasclerally with the aid of a 30-gauge needle. The technique was used in 15 eyes of 15 patients. The mean postoperative follow-up period was 9.1 ± 4.6 months. Postoperatively, the intraoperative lenses of all the eyes remained well-positioned and stable. The postoperative visual acuities for all of the eyes were also improved. No suture erosion, suture loosening, hypotony, scleral atrophy, chronic inflammation, retinal tears, and/or detachments were observed within the follow-up period. The present technique provides minimal surgical invasion for the scleral suture fixation of intraocular implants.