Mini-open Incision Research Articles

Long-Term Outcomes of a New Minimally Invasive Approach in Chiari Type 1 and 1.5 Malformations: Technical Note and Preliminary Results

The treatment options for patients with Chiari malformation type 1 (CM1) and Chiari malformation type 1.5 (CM1.5) have not yet been standardized. In these malformations, the main factors include obstruction at the level of the foramen magnum and dural and ligamentous thickening. Here we present our outcomes of surgery and decompression using a minimally invasive surgery (MIS) technique. Sixty-one patients admitted to our clinics between 2009 and 2016 due to CM1 or CM1.5 and who had undergone MIS were investigated retrospectively. All patients were followed up for a mean period of 55 months, both clinically and radiologically, and the outcomes were recorded. All 61 patients underwent foramen magnum decompression through a 1.5-cm mini-open incision, C1 laminectomy and C2 medial inner side tour, posterior atlanto-occipital membrane removal, external dural delamination, and widening of the internal dura with longitudinal incisions. Fifty-six patients (91.8%) were satisfied with the outcome, 4 patients (6.5%) remained the same, and 1 patient (1.6%) reported a poor outcome. Forty-five percent of the patients with syringomyelia demonstrated resolution within 2 years, and 92% demonstrated resolution in 5 years. Scoliosis was seen in 5 patients (8.1%). The rate of benefit from the surgical procedure was statistically significant (P= 0.0045), and no patient required additional surgery because of poor decompression. MIS is effective for uncomplicated cases of CM1 and CM1.5 due to its minimal connective and muscular tissue damage, short surgical duration, short recovery time, early mobilization, effective posterior foramen magnum widening, lack of liquor fistula development, and better clinical and radiologic improvement during long-term follow-up.

Mini-Open and Arthroscopic Ankle Arthrodesis

To evaluate and compare the clinical results of arthroscopic and mini-open ankle arthrodesis. Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. The external fixation and internal fixation techniques for ankle arthrodesis were developed. Although the open technique is still widely used for ankle arthrodesis with major deformity, the mini-open and arthroscopic ankle arthrodesis were developed and recommend for ankle arthrodesis with minimal or no deformity. To evaluate and compare the clinical results of arthroscopic and mini-open ankle arthrodesis. 74 cases were divided into two groups, Arthroscopy group: 22 cases of arthroscopic ankle arthrodesis; Mini-open group: 52 cases of mini-open ankles arthrodeses. There were the same criteria of inclusion, exclusion in both groups. The cartilage of tibial-talus joint was completely removed under arthroscopy and mini-open incision. Two guide pins were inserted from posterosuperior to anterionferior and cannulated screws were implanted to fix ankle joint. All patients were physically examined with an extended protocol of questionnaires and the AOFAS Ankle and Hindfoot Scales. Ankle fusion in all patients was evaluated by clinical exam and radiology. In the arthroscopy group, all patients, with mean postoperative follow-up period of 40.5 months (range 12–96 Ms), were proved to be bone union by clinical exam and radiology with mean 13.5 weeks (9∼21Ws). In the mini-open group, 51(98.7%) of 52 cases with mean postoperative follow-up period of 41.0 months (range 12–105 Ms), were proved to be bone union by clinical exam and radiology with mean 14.0 weeks (9∼24Ws). There was no significant difference between the arthroscopy group (75.5±7.6, n=22) and the mini-open group (72.3±4.6, n=52) at the final follow-up in the AOFAS Ankle and Hindfoot Scales. There was no infection, local skin necrosis, screw loosing, and so on in both group. Both arthroscopic and mini-open ankle arthrodesis had a good clinical outcomes, with high union rate, lower rate of complications.

Clinical and Radiographic Outcomes With Assessment of the Learning Curve in Arthroscopically Assisted Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears

To evaluate the clinical results of an arthroscopy-assisted latissimus dorsi tendon transfer (aLD) for irreparable posterosuperior cuff tears as a primary surgery. The secondary aim of this study was to quantify the learning curve using the log-linear model. We hypothesized that aLD significantly improved shoulder function and that there was consistent reduction of the operative time in support of a learning-curve effect. After the arthroscopic partial repair was completed, the latissimus dorsi tendon was harvested via axillary mini-open incision and fixed with a knotless anchor arthroscopically. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) scoring system, active range of motion, and the visual analog scale (VAS) for pain. The operative time was recorded to quantify the learning curve using a log-linear model. Thirty patients with a mean age of 67.4years who underwent aLD were included. At a mean of 34 months after an aLD, the mean UCLA score increased from 15.7 preoperatively to 28.8 postoperatively (P< .001). The mean active forward elevation increased from 105° preoperatively to 149° postoperatively (P< .001). The mean active external rotation increased from 22° preoperatively to 32° postoperatively (P < .001). The VAS improved from 58mm to 18mm(P < .001). In all but 2 cases (93%), the preoperative osteoarthritis grade was maintained. The mean operative time was 145minutes. A significant linear correlation was observed between the operative time and cumulative volume of cases after performing a logarithmic transformation. The learning rate was calculated as 84%. Arthroscopy-assisted latissimus dorsi tendon transfer is a technically demanding procedure; however, it can lead to significant improvements in overall shoulder pain and function. This study also confirmed a learning-curve effect for the aLD. The learning rate was 84%, indicating the existence of a long learning period. Level IV, therapeutic case series.

Mini-open Incision Sports Hernia Repair: A Surgical Technique for Core Muscle Injury

One cause of groin pain in highly active patients may be a core muscle injury, commonly referred to as sports hernia. When patients fail nonoperative management, there are a number of surgical options that may be pursued. Typically, they will involve the direct repair of the rectus abdominis back to the pubis. However, we believe that this repair can be further strengthened by the appropriate lengthening of the adductor longus from the conjoined tendon. Therefore, we present a surgical technique that involves both rectus abdominis repair and adductor longus lengthening in those who show a core muscle injury that is refractory to conservative management. We believe that this technique can be easily replicated by practitioners reading this Technical Note.

Semivertical Incision: An Aesthetically and Electrophysiologically Effective Mini-Incision Technique for Carpal Tunnel Decompression.

BackgroundThe purpose of this study was to present the clinical results of our retrospective series of carpal tunnel release (CTR) operations. For these operations we used a unique type of incision, for the first time, for treatment of carpal tunnel syndrome (CTS) consisting of a 1-cm semi-vertical (SV) incision made into the wrist crease for macroscopic open CTR.Material/MethodsThis retrospective study included 114 patients (101 females and 13 males) with CTR who were operated upon in our neurosurgery clinic between December 2010 and June 2015. Patient ages ranged from 35 to 83 years (mean 55.05±12.04 years). In total, 127 hands (73 right and 54 left) were operated upon using the SV skin incision technique. After an average follow-up of 18 months (ranging from 6 to 30 months), clinical and electrophysiological (EP) evaluations were performed.ResultsA review of the English language literature published since 1957, when Phalen first popularised the diagnosis and treatment of this disease, determined that no previous reports of the mini-open incision technique as described in our study have been published. In our retrospective patient case review, we found that after operations using the SV incision technique, statistically significant differences were detected in electromyography (EMG) improvements (p<0.01). In addition, patients who showed improvement in EMG studies (n=90) were satisfied with the result of their surgery.ConclusionsOur study demonstrated that 1-cm skin SV incision was a cosmetically satisfying, fast, and safe approach to CTR that was not only clinically effective but also electrophysiologically effective.

Weber C ankle fractures with tibiofibular diastasis: syndesmosis-only fixation.

ABSTRACTOBJECTIVES: To evaluate syndesmosis-only fixation in Weber C ankle fractures with tibiofibular diastasis and to assess the need for additional fibular fixation.METHODS: Twenty-one patients with Weber C ankle fractures and tibiofibular diastasis were followed for at least 24 months after treatment. In treatment of the Weber C fractures, only a syndesmosis screw was used through a mini open lateral incision if the syndesmosis could be anatomically reduced and fibular length and rotation could be restored. At follow-up, anteroposterior tibiofibular distance, lateral fibular distance, medial mortise distance and fracture healing were compared and patients were clinically evaluated using the Olerud and Molander ankle scale scoring system.RESULTS: The average duration of follow-up was 49 months and the decreases in anteroposterior tibiofibular distance and lateral fibular distance were statistically significant. At the last follow-up the average clinical score was 86. Ankle mortise was reduced at follow-up in all cases except one, which resulted in a late diastasis.CONCLUSIONS: Syndesmosis-only fixation can be an effective method of treating Weber type-C lateral malleolar fractures with syndesmosis disruption in cases where intraoperative fibular length can be restored and anatomical syndesmosis reduction can be achieved. Level of Evidence IV, Case Series.

Mini-open incision for distal biceps repair by suture anchors: follow-up of eighteen patients.

This clinical trial was done to describe a mini approach for distal biceps repair using two or three suture anchors. Twenty patients have undergone surgical repair over the last 10 years. All patients were males with mean age 46.8 (range 35-72), and dominant arm was involved in 70 %. Eighteen patients were evaluated with subjective and objective criteria including patient's satisfaction, active range of motion (ROM), and maximum isometric strength (in supination and flexion) using Cybex dynamometer. Functional scoring included Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score and Oxford Elbow Score. Eighty percent of patients were highly satisfied, with excellent results as defined by Mayo and Oxford Elbow score. Compared to contralateral, the active ROM was not affected in flexion and extension, but pronation and supination were decreased by 5°-10° in two cases. One of eighteen showed hypoesthesia of first and second fingers, and one of eighteen showed a symptomatic heterotopic ossification. There were no reruptures. Surgical repair of distal biceps tendon with a mini-single-incision as we described provides patient's satisfaction and very good results with respect to ROM and functional scoring, with a low complication rate.

Trends in Carpal Tunnel Surgery: An Online Survey of Members of the American Society for Surgery of the Hand

To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N= 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. Economic and decision analysis V.

Management of comminuted tibial plateau fractures with external fixator using ligamentotaxis principle

Background The treatment of proximal tibial fractures is often challenging, and internal fixation is occasionally associated with problems in wound healing due to frequently coexisting soft tissue injuries. Objective This study evaluated the performance of an external fixator in the treatment of different types of proximal tibial fractures by ligamentotaxis principle. Materials and methods Between March 2002 and June 2007, 50 proximal tibial fractures in 48 patients were treated with Ilizarov external fixator in Benha University and health insurance hospitals. The mean age was 39 years (range 19-57 years), and the mean follow-up period was 36.5 months (range 24-50 months). Fracture categorization was performed according to AO/ASIF; closed reduction was performed most often by closed means in 26% of cases or through miniopen incision in 74% of cases. Clinical and functional evaluation of patients in the tibial plateau group was performed using the Knee Society clinical rating score. Results The overall functional outcome of treatment of comminuted tibial plateau fractures treated by indirect reduction and ring fixator in this study was excellent in 18 cases, good in 22, fair in eight cases, and poor in two cases. All fractures in this series eventually healed. Conclusion Ring frames provide mechanical stability of the comminuted tibial plateau fracture. The excellent stabilization of fracture allows early ambulation of the patient with partial weight bearing; even in comminuted fractures, there is beneficial biologic influence of the early weight bearing on osseous healing.

The Efficacy of Carpal Tunnel Release with Mini-Open Incision

We evaluated the effects of carpal tunnel release with a mini-open incision by analyzing symptom improvement. Methods We retrospectively reviewed 64 carpal tunnel syndrome patients who underwent carpal tunnel release with mini-open incisions between January 2001 and December 2010. The 22 males and 42 females had a mean age of 49 years and a mean follow-up of 12 months. We analyzed postoperative symptoms using The Michigan Hand Outcome Questionnaire. Results Patients reported complete resolution of their symptoms, and some patients who had presented with residual symptoms improved gradually. No complications or scar hypersensitivity were observed. MHQ(Michigan Hand outcomes Questionnaire) scores improved significantly between preoperative and postoperative 6 months and 12 months. Conclusions Carpal tunnel release with mini-open incision provides a clinically effective, reliable and safe procedure. &lt;/sec&gt;

Arthroscopic extraarticular reconstruction of the medial patellofemoral ligament with gracilis tendon autograft - surgical technique

The standard approach to reconstruct the medial patellofemoral ligament (MPFL) is by mini-open incision at its patellar insertion and femoral origin. At the medial patella rim, the MPFL insertion may be visualized in most cases by dissection during surgery. On the femur, it is more difficult to localize the MPFL remnants by a mini-open incision due to soft tissue covering the anatomical origin. Therefore, the femoral MPFL origin is usually identified by intraoperative lateral fluoroscopy. However, the insertion and origin of the MPFL at the patella and femur might be directly visualized using an arthroscopic extraarticular approach from the knee joint through a window of the synovial layer. This is especially helpful on the femoral side but also at the patella to find the individual anatomical MPFL footprints. Arthroscopic extraarticular reconstruction may then be performed using one additional medial mid-parapatellar portal. The major advantages of this technique are an individualized anatomical procedure, which is minimal invasive and cosmetically appealing. The aim of this study was to describe the arthroscopic extraarticular approach to the MPFL insertion at the patella and origin at the femur through synovial windows and to explain the procedure of arthroscopic MPFL reconstruction with a gracilis tendon autograft. Level of evidence Expert opinion, surgical technique, Level V.

Mini-open transpedicular lumbar vertebrectomy reconstructed with double cages and short segment fixation

Background:The purpose of this study was to assess the feasibility of using dual expandable cages plus short segment posterior fixation for reconstruction of vertebral bodies following a mini-open transpedicular approach.Methods:A single posterior incision was used to perform a laminectomy of L2, a partial laminectomy of L1 and bilateral transpedicular approaches for a piecemeal vertebrectomy in a patient with spinal compression secondary to metastatic cancer. Subsequently, bilateral cages were placed through the transpedicular corridors and percutaneous pedicle screws were inserted a single level above and below the level of the vertebral column resection.Results:The bilateral transpedicular approach facilitated the use of a mini-open incision (6.0 cm) compared with the extensive dissection normally employed for a lateral extracavitary type approach in the lumbar region. The bilateral transpedicular approach at L2 allowed for a vertebrectomy and complete decompression of neurological elements. The use of expandable cages allowed the nerve roots to be preserved. Placement of the cages in the lateral position was straightforward despite minimal exposure. The reconstruction with double expandable cages appeared robust.Conclusions:In select patients requiring circumferential decompression of the lumbar spine, dual cage reconstruction decreases the technical difficulty of the operation and facilitates a mini-open approach. The durability of this construct will need biomechanical assessment and long-term clinical follow-up.

Conventional rotator cuff repair complemented by the aid of mononuclear autologous stem cells

PurposeTo investigate the behavior of rotator cuff tears treated with conventional repair technique with the aid of autologous bone marrow mononuclear cells (BMMC).MethodsFourteen consecutive patients (9 women, 5 men, mean age of 59.2 years) with complete rotator cuff tears (mean preoperative UCLA score of 12 ± 3.0) were fixed by transosseous stitches through mini-open incision, with subsequent injection of BMMC into the tendon borders, obtained from the iliac crest just prior to surgery. Magnetic resonance images (MRI) were acquired before and after surgery and evaluated by two musculoskeletal radiologists regarding new postoperative findings of patients treated with BMMC.ResultsAfter a minimum 12-month follow-up period, the UCLA score increased from 12 ± 3.0 to 31 ± 3.2. Clinical findings remained unaltered in the following year in all but one patient (13/14). MRI analysis after a 12-month follow-up period demonstrated tendon integrity in all cases (14/14), presence of low-signal intensity areas along the supraspinatus tendon and distal muscle belly in 8 cases (8/14), and high-intensity blooming small round artifact at the bursal and tendon topography in 11 cases (11/14). Six patients (6/14) showed formation of a high-signal intensity zone at the critical zone. Clinical findings remained unaltered in the following year in all but one patient, who relapsed into loss of strength and pain, being considered a bad result.ConclusionImplantation of BMMC in rotator cuff sutures appears to be a safe and promising alternative to other biological approaches currently used to enhance tissue quality in affected tendons.Level of evidenceIV.

Extensor pollicis longus tendon rupture secondary to elastic intramedullary nailing of paediatric forearm fractures: how to avoid them?

The introduction of elastic stable intramedullary nailing (ESIN) has made operative fixation an important option in treatment of the paediatric forearm bone fractures. ESIN is an excellent treatment option, which is easy to perform. However, a considerable number of complications and problems can arise even with experienced hands. We would like to bring to the attention an important complication namely EPL rupture that has been only sporadically reported in the literature. We present our case study of 12 paediatric forearm fractures that underwent ESIN at our hospital. Mean age of the patient was 8.25 (Range: 5–12 years). Ten of them had fracture of both radius and ulna, while the remaining had isolated displaced fracture of the neck of radius. The radial fracture was stabilized with percutaneous nailing with entry point on dorsum of hand at Lister’s tubercle (9 cases)/lateral entry over anatomical snuff box (3 cases). All fractures united by 8–12 weeks, and the nails were removed at 12 weeks. Three cases had extensor pollicis longus (EPL) tendon rupture during follow-up at 8 weeks after the surgery. All these 3 cases had dorsal approach near Lister’s tubercle, and the length of the protruding nail was more than 10 mm from the dorsal cortex (20.34 mm (age-12 years), 13.88 mm (age-7 years) and 14.12 mm (age-11 years). Two of them subsequently went on to have tendon transfer operation successfully regaining the full function of the thumb, while the third patient refused any operative intervention and was lost to follow-up. We strongly feel that this EPL complication is entirely avoidable by adhering to the principles of mini-open incision rather than stab incision, nail entry under direct vision, cutting the nail close to the bone (leaving only 5 mm of nail length protruding outside) to prevent any undue soft tissue irritation and probable nail migration and bringing the patient earlier (at 2 weeks) for follow-up to identify nail migration.

Complications of open carpal tunnel surgery: avoiding the pitfalls

We present a series of 31 patients treated for complications following open carpal tunnel syndrome surgery over a time period of 10 years. The most frequent complications encountered were major nerve lacerations at the wrist and thenar followed by persistent and recurrent symptoms, neuroma formation and wound infection. All patients had primary treatment by a different approach, by different spectrum of training surgeons; in only one patient, the initial operating surgeon was an orthopedic surgeon in hand fellowship training. In ten patients, the typical approach to the carpal tunnel has been used at the initial operation; an excessive ulnar-directed incision and a long proximal- and radial-directed incision have been observed in ten and eight patients, respectively; a mini-open incision and an incision that crossed the wrist perpendicular to the flexion creases have been observed in one and two patients, each. Most complications of open carpal tunnel surgery can be prevented by specialized training in hand surgery of the operative surgeon and proper operative technique, including a properly placed incision and exposure under magnification and direct vision.

Mini-Open Technique for the Achilles Tenotomy in Correction of Idiopathic Clubfoot

Achilles tenotomy is performed for the residual equinus deformity in the Ponseti method of clubfoot treatment. In the present article, we describe a mini-open Achilles tenotomy technique to prevent complications that could occur during tenotomy. This technique was performed on 15 patients (25 feet) during a 3-year period in our clinic on patients whose equinus deformities could not have been corrected by manipulations. Clear improvement (mean angle, 30 degrees ) was observed in equinus in our patients, and we have not seen any complication in this method. We conclude that direct visualizing of the tendon with mini-open incision may reduce the risk of neurovascular injury, especially for surgeons who are not experienced.

The results of arthroscopic versus mini-open repair for rotator cuff tears at mid-term follow-up

BackgroundTo prospectively evaluate patients who underwent a "mini-open" repair versus a completely arthroscopic technique for small to large size rotator cuff tears.MethodsFifty-two patients underwent "mini-open" or all arthroscopic repair of a full thickness tear of the rotator cuff. Patients who complained of shoulder pain and/or weakness and who had failed a minimum of 6 weeks of physical therapy and had at least one sub-acromial injection were surgical candidates. Pre and post-operative clinical evaluations included the following: 1) demographics; 2) Simple Shoulder Test (SST); 3) University of California, Los Angeles (UCLA) rating scale; 4) visual analog pain assessment (VAS); and 5) pre-op SF12 assessment. Descriptive analysis was performed for patient demographics and for all variables. Pre and post outcome scores, range of motion and pain scale were compared using paired t-tests. Analysis of variance (ANOVA) was used to evaluate any effect between dependent and independent variables. Significance was set at p is less than or equal to 0.05.ResultsThere were 31 females and 21 males. The average follow-up was 50.6 months (27 – 84 months). The average age was similar between the two groups [arthroscopic x = 55 years/mini-open x = 58 years, p = 0.7]. Twenty-seven patients underwent arthroscopic repair and 25 underwent repair with a mini-open incision. The average rotator cuff tear size was 3.1 cm (range: 1–5 centimeters). There was no significant difference in tear size between the two groups (arthroscopic group = 2.9 cm/mini-open group = 3.2 cm, p = 0.3). Overall, there was a significant improvement from pre-operative status in shoulder pain, shoulder function as measured on the Simple Shoulder test and UCLA Shoulder Form. Visual analog pain improved, on average, 4.4 points and the most recent Short Shoulder Form and UCLA scores were 8 and 26 respectively. Both active and passive glenohumeral joint range of motion improved significantly from pre-operatively.ConclusionBased upon the number available, we found no statistical difference in outcome between the two groups, indicating that either procedure is efficacious in the treatment of small and medium size rotator cuff tears.Level of EvidenceType III

측와위에서 견인 기구 없이 시행하는 견관절경하 회전근 개 수술

Object: To evaluate the efficiencies of the arthroscopic rotator cuff surgery which is Performed without the traction system in the lateral decubitus position. Methods: Twenty-nine cases of the arthroscopic rotator cuff surgery performed without the traction system in the lateral decubitus position were studied from February, 2002 to January, 2005. We performed a repair using the arthroscopic debridement and the arthroscopic rotator cuff repair, or using the mini-open incision technique after the confirmation of rotator cuff tear, then, the arthroscopic subacromial decompression was performed after the confirmation of subacromial lesions Results: We could easily find the subscapularis tear which was often overlooked in the arthroscopic rotator cuff surgery performed with the traction surgery by the relaxation of the subscapularis, as the arm position was internally rotate about 45 to 70 degrees from abducted position. We found that the operation time was reduced 14 minutes shorter than the operation time of the controlled group which had the surgery with the traction system on the average. We also found that there were no neurovascular complications from all cases. Conclusions: The arthroscopic rotator cuff surgery without traction system in the lateral decubitus position provided the better visual field, easy manipulation of the joint and reducing operation time.