Vaccination for Athletes: Evidence and Recommendations / 대한스포츠의학회지

As interest in sports rapidly grows in Korea, fostering of elite athletes and preservation of the athletic ability no longer became the task of advanced countries only. In that aspect, health of athletes and their associated coaches, athlete trainers, team members such as team doctors, and even their families is certainly a matter of concern. Especially when it comes to the inoculation of infectious disease prevention, it needs to be considered as one of the most economical and effective ways to promote health in sports people as well as elite athletes. The purpose of this article is to go over the specific circumstances of the athletes and related literatures on vaccination. In addition, we provide recommendations on the vaccination of athletes regarding the actual situation of sports in Korea.

Treatment of Infected Total Knee Arthroplasty

No abstract available.

The Effects of Adherence to Non-Steroidal Anti-Inflammatory Drugs and Factors Influencing Drug Adherence in Patients with Knee Osteoarthritis

We aimed to compare the clinical outcomes of knee osteoarthritis patients according to drug adherence; and to find out the factors the affecting those outcomes. We analyzed the drug adherence and clinical outcomes in 1,334 primary knee osteoarthritis patients who took non-steroidal anti-inflammatory drugs (NSAIDs) for 3 weeks. Clinical outcomes of Pain Numeric Rating Scale (NRS), Knee injury and Osteoarthritis Outcome Score (KOOS) and EQ-5D were compared at baseline and 3 weeks' follow-up between the two groups of adherent group and non-adherent group (1,167 vs. 167 patients). Logistic regression analysis was performed to examine the factors affecting the adherence, and the reasons for the non-adherence were asked. The follow-up clinical outcomes of NRS and KOOS symptom, pain and activity of daily life were significantly higher in the adherence group (P = 0.003, P = 0.048, P = 0.005, and P = 0.003, respectively). The adherence was better in the elderly and in the male group (P = 0.042 and P = 0.034, respectively) and the top reason for no strict adherence was "symptom improved" (21.5%) followed by side effects. In this study, the patients with better adherence to NSAIDs showed better outcomes compared to those with poor adherence. This study can contribute to the patient education for the pharmacological treatment in knee OA patients.

Platelet-Rich Plasma Therapy for Knee Joint Problems - Review of the Literature, Current Practice and Legal Perspectives in Korea - : Secondary Pulblication / 대한정형외과학회잡지

Platelet-rich plasma (PRP) is a concentrate extract of platelets from autologous blood, and represents a possible treatment option for the stimulation and acceleration of soft-tissue healing and regeneration in orthopedics. Currently, the availability of devices for outpatient preparation and delivery contributes to the increase in the clinical use of PRP therapy in practical setting of orthopedic fields. However, there is still paucity of scientific evidence in the literature to prove efficacy of PRP therapy for the treatment of ligament or tendon problems around the knee joint. Moreover, strong evidence from well-designed clinical trials to support the PRP therapy for osteoarthritis of the knee joint is yet scanty in the literature. Scientific studies need to be performed to assess clinical indications, efficacy, and safety of PRP, and this will require high powered randomized controlled trials. Nonetheless, some hospitals exaggeratedly advertise PRP procedures, as the ultimate treatment and a novel technology with abundant scientific evidence for the treatment of knee problems. As a matter of fact, PRP protocols are currently approved only for the use in clinical trials and research, and are not allowed for treatment purpose by any institutions in Korea. At present, clinical use of PRP therapy for ligament or tendon problems or osteoarthritis of knee joint is defined as an illegal medical practice, regardless of whether it is performed as a sole procedure or as a part of prolotherapy, because the safety and validity are not yet approved by the Ministry of Health and Welfare, and Health Insurance Review and Assessment Service. Practicing physicians should remember that injection of PRP to patients by imposing medical charge is still illegal, as per the current medical laws in Korea.

Do the Fibroblasts Contained in Early Passage MSC Population Adversely Affect the Characteristics of Stem Cell Population Obtained from Human Placenta?

BACKGROUND AND OBJECTIVES: Mesenchymal stem cells (MSCs) have been obtained from various human tissues by harvesting plastic adherent fibroblast-like cell population. For potential use in regeneration medicine, early passage MSC population is preferred to avoid cell senescence. The early passage adherent cell population contains MSCs as well as fibroblasts, however, the significance of the contained fibroblasts has not been well investigated. Thus, we investigated the stem cell characteristics of the early passage MSC population with and without fibroblasts depletion. METHODS AND RESULTS: We obtained adherent cell populations from full term placenta at passage 2~3 and divided them into two subpopulations: fibroblasts depleted (popFD) and non-depleted population (popFND) using magnetic cell sorting method. The two subpopulations were compared in terms of cell morphology, potential for long term culture, colony forming ability, and tri-lineage differentiation for adipogenic, chondrogenic, and osteogenic differentiation. The percentage of fibroblasts contained in the early passage MSC population was 5.3% (2.9~8.4). Both the popFD and popFND was spindle shaped from early passages and maintained long term culture up to 20~22 passages. CFU-F assay showed no difference between the subpopulations. Overall, tri-lineage differentiation showed a tendency of better differentiation potential of popFND than popFD. CONCLUSIONS: We confirmed that fibroblasts are contained in early population of placenta-derived MSCs obtained by current method. This study revealed that the contained fibroblasts in early passage MSC population do not adversely affect the properties of MSCs in terms of cell morphology, potential for long term culture, colony forming ability, and tri-lineage differentiation.

Platelet-Rich Plasma Therapy for Knee Joint Problems: Review of the Literature, Current Practice and Legal Perspectives in Korea

Platelet-rich plasma (PRP) is a concentrate extract of platelets from autologous blood, and represents a possible treatment option for the stimulation and acceleration of soft-tissue healing and regeneration in orthopedics. Currently, the availability of devices for outpatient preparation and delivery contributes to the increase in the clinical use of PRP therapy in practical setting of orthopedic fields. However, there is still paucity of scientific evidence in the literature to prove efficacy of PRP therapy for the treatment of ligament or tendon problems around the knee joint. Moreover, strong evidence from well-designed clinical trials to support the PRP therapy for osteoarthritis of the knee joint is yet scanty in the literature. Scientific studies need to be performed to assess clinical indications, efficacy, and safety of PRP, and this will require high powered randomized controlled trials. Nonetheless, some hospitals exaggeratedly advertise PRP procedures as the ultimate treatment and a novel technology with abundant scientific evidence for the treatment of knee problems. As a matter of fact, PRP protocols are currently approved only for use in clinical trials and research, and are not allowed for treatment purpose by any institutions in Korea. At present, clinical use of PRP therapy for ligament or tendon problems or osteoarthritis of knee joint is defined as illegal medical practice, regardless of whether it is performed as a sole procedure or as a part of prolotherapy, because the safety and validity are not yet approved by the Ministry of Health and Welfare and Health Insurance Review and Assessment Service. Practicing physicians should remember that injection of PRP to patients by imposing medical charge is still illegal as per the current medical law in Korea.

Prescription Pattern of NSAIDs and the Prevalence of NSAID-induced Gastrointestinal Risk Factors of Orthopaedic Patients in Clinical Practice in Korea

This is a cross-sectional observational study undertaken to explore the current prescription pattern of non-steroidal anti-inflammatory drugs (NSAIDs) and the prevalence of NSAID-induced gastrointestinal (GI) risk factors of orthopaedic patients in real clinical practice in Korea. Study cohort included 3,140 orthopaedic outpatients at 131 hospitals and clinics between January 2008 and August 2008. A self-administered questionnaire was completed by each patient and physician. A simplified risk scoring scale (the Standardized Calculator of Risk for Events; SCORE) was used to measure patients' risk for GI complications. The pattern of NSAIDs prescription was identified from medical recordings. Forty-five percents of the patients belonged to high risk or very high risk groups for GI complications. The cyclooxygenase-2 enzyme (COX-2) selective NSAID showed a propensity to be prescribed more commonly for high/very high GI risk groups, but the rate was still as low as 51%. In conclusion, physician's considerate prescription of NSAIDs with well-understanding of each patient's GI risk factors is strongly encouraged in order to maximize cost effectiveness and to prevent serious GI complications in Korea. Other strategic efforts such as medical association-led education programs and application of Korean electronic SCORE system to hospital order communication system (OCS) should also be accompanied in a way to promote physician's attention.

Rapid Chondrolysis of Knee Joint after Arthroscopy Using Radiofrequency Device / 대한정형외과학회잡지

We report the cases of 3 young individuals, each of whom presented to our hospital for the evaluation and treatment of sudden onset chondrolysis. Previously, all 3 individuals had undergone arthroscopic knee procedures over a similar time at another hospital. In this paper, we review the possible problems that cause chondrolysis during or after arthroscopic procedures, such as the followings: use of thermal treatment, occult infection with Propionibacterium acnes, idiopathic or iatrogenic osteochondral injury, high temperature of fluid during arthroscopic irrigation, improperly placed implants, and the use of an intra-articular pain pump. We can exclude other causes of chondrolysis through the clinical course of the patients and surgical records and progress records. We conclude that the possible cause of chondrolysis in all cases was due to thermal injury caused by high temperatures, which decreased or blocked the irrigation fluid flow generated during arthroscopy.

Treatment of Infected Total Knee Arthroplasty

Deep infection after total knee arthroplasty (TKA) represents a significant treatment challenge with the possibility of disastrous consequences. The rate of deep infection rate after TKA was reported to be 1.3~2.9% in the past. With the improvements of the operation environment and operative technique and the use of prophylactic antibiotics and antibiotic-mixed bone cement, the rate of deep infection was recently reported to be 0.5~1%. The goal of treatment of a periprosthetic TKA infection is the restoration of a painless, well-functioning joint, with eradication of the infection. Yet the outcome is not always favorable, and the end result could be an arthrodesis, amputation or a pseudoarthrodesis. In some instance, the only realistic option is to suppress the infection with continued oral antibiotics while simultaneously retaining the prosthesis. Two-stage resection arthroplasty remains the standard treatment for chronic periprosthetic infection. Early deep infection may be treated with aggressive debridement and intravenous antibiotics without removal of the implant. Two-stage reimplantation after removal of the implant is most important for the treatment of chronic infection.

Two Cases of Septic Arthritis by Mycoplasma hominis after Total Knee Replacement Arthroplasty / 대한진단검사의학회지

Mycoplasma hominis has been related with pelvic inflammatory illnesses and postpartum and neonatal infections. Extragenital M. hominis infections are rare, but septicemia, septic arthritis, wound infection, meningitis, and other infections in Immunocompromised patients have also been described. Here we report two cases of septic arthritis caused by M. hominis in patients following total knee replacement arthroplasty. After the surgery, the patients presented with knee pain and clinical signs of infection, such as fever, erythema and swelling on the surgical site. Arthroscopic debridement operations were performed on the surgical site. M. hominis was isolated from the joint fluid and identified by the microscopic visualization of the typical "fried-egg-type" colonies on Mycoplasma specific agar (pleuropneumonia-like organism agar). It was also confirmed by 16S rRNA sequencing. To the best of our knowledge, this is the first report of prosthetic joint infections with M. hominis in Korea.

Clinical Results of the Accelerated Rehabilitation Program after Meniscal Repair using the RapidLoc Device / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the clinical results of the accelerated rehabilitation program after performing meniscal repair using the RapidLoc device, and we wanted to investigate the incidence of complications related to using the RapidLoc device together with the accelerated rehabilitation program. MATERIALS AND METHODS: We performed a retrospective review of a consecutive series of meniscal repairs that were done by single surgeon with using the RapidLoc meniscal repair device. An accelerated postoperative rehabilitation program followed, and this was independent of whether anterior cruciate ligament (ACL) surgery was also performed. The Lysholm and IKDC (International Knee Documentation Committee) activity scores, the clinical examination findings and the adverse events were recorded for all the patients. In addition, using Barrett's criteria, a repaired meniscus was considered healed if there was no joint line tenderness, effusion or a negative McMurray's test at the latest follow-up. RESULTS: At follow-up, the mean IKDC activity score was 3.38 (1.75 preoperatively), the Lysholm score was 91.8 (48.7 preoperatively). Clinical success occurred for 30 repairs (93.7%) at the time of the last follow-up. Two patient had tenderness on joint line palpation and intermittent effusion, so theses repair were considered failure according to our criteria. There was no specific complication related to the RapidLoc device. CONCLUSION: Our results show that accelerated rehabilitation program after arthroscopic meniscal repair with using the RapidLoc device provided a high rate of clinical meniscus healing and this appeared to be safe and effective.

A Comparison of the Functional Results of High-Flex Total Knee Arthroplasty: LPS-Flex vs. Scorpio-Flex TKA / 대한정형외과학회잡지

PURPOSE: This study compared the clinical and functional results of LPS-Flex with those of Scorpio-Flex TKA. MATERIALS AND METHODS: Fifty cases of High-Flex TKA (24 LPS-Flex and 26 Scorpio-Flex) were analyzed retrospectively. All the procedures were performed during the same period by the senior author and the patients were followed-up for more than 5 years. A functional evaluation was performed by a questionnaire on the high flexion-related activities, including cross-leg sitting, squatting, standing from the floor, standing from a chair and ascending and descending stairs. Each function was classified by the patients into five grades. The clinical evaluation included the range of motion, the Knee Society Knee Score and Function Score (KSKS & KSFS), the WOMAC score and the patient's satisfaction score. RESULTS: The functional evaluation showed a better result in the LPS-Flex group for the cross-leg sitting function (p=0.039) but there was no difference in the other functions. The clinical evaluation showed more flexion in the LPS-Flex group than that in the Scorpio-Flex group (p=0.044) but there were no difference in the KSKS, KSFS, WOMAC score and the patient's satisfaction score. CONCLUSION: LPS-Flex TKA showed better functional results for cross-leg sitting than did Scorpio-Flex TKA. This difference was attributed to the LPS-Flex group having more flexion than that of in the Scorpio-Flex group.

The Use of COX-2 Selective Nonsteroidal Anti-inflammatory Drugs for the Treatment of Osteoarthritis

Nonsteroidal anti-inflammatory drugs (NSAIDs), are characterized by their anti-inflammatory, analgesic, and antipyretic activities; they have been widely used for the management of acute pain and chronic inflammation. The mechanism of action of NSAIDs is inhibition of prostaglandin biosynthesis. Inflammatory prostaglandins are primarily derived from COX-2, while the prostaglandins formed by COX-1 have in general a more homeostatic role. Based on their selectivity for COX-1 or COX-2, NSAIDs are classified into non-selective NSAIDs and COX-2 selective NSAIDs. Non-selective NSAIDs and COX-2 selective NSAIDs have similar effects on pain relief and inflammation. One major problem associated with the use of non-selective NSAIDs is their adverse effects on the gastrointestinal tract, caused by inhibition of COX-1. Compared with non-selective NSAIDS, the main advantage of COX-2 selective NSAIDs is reduced gastrointestinal complications. Reviews have suggested that COX-2 selective NSAIDs increase the risk of cardiovascular events; however, cardiovascular risk may vary among the selective NSAIDs. Because of their anti-inflammatory properties, the use of NSAIDs is essential for the relief of pain and the symptoms associated with inflammatory conditions such as active osteoarthritis. When NSAIDs are prescribed, age, additional medication such as aspirin, gastrointestinal and cardiovascular status, and co-morbidity must be taken into account. COX-2 selective NSAIDs have minimal effects on platelet function and thus, can also be used for pre and postoperative pain control in patients with osteoarthritis waiting for the surgery.

Functional Evaluation of High-Flex Total Knee Arthroplasty

PURPOSE: This study analyzed the functional result of High-Flex (HF) total knee arthroplasty (TKA) with focusing on the activities related to the Korean life style, and we identified the suitability of the presently used tools for performing functional evaluation. MATERIALS AND METHODS: We retrospectively analyzed 266 knees that underwent HF-TKAs with using a Scorpio-flex and the follow up period for all the knees was over 1 year. Functional evaluation was performed by questionnaire on activities, including cross-leg sitting, squatting, kneeling, standing from the floor, standing from a chair and ascending and descending stairs. The clinical evaluation included the Knee Society Knee Score (KSKS) & Function Score (KSFS), the WOMAC score and the patient's satisfaction score. The identification of suitable tools for the functional evaluation of high flexion activities was performed by statistical analysis. RESULTS: Deep flexion of the knees averaged 132.6degrees. Cross-leg sitting was possible for 90.6%, squatting for 32.3%, kneeling for 28.0%, standing from the floor for 66.9%, standing from a chair for 99.6%, ascending stairs for 96.2% and descending stairs for 90.6%. The WOMAC score and KSKS well differentiated the groups for the possibility of their activities, but the KSFS and patient's satisfaction did not differentiate between the groups for some activities. CONCLUSION: The functional evaluation after total knee arthroplasty with HF-TKA revealed good results on cross-leg sitting, standing from chair, ascending & descending stairs, but still poor results on squatting and kneeling. For the functional evaluation of HF-TKA, we believe that the WOMAC and KSKS are good evaluation tools. The KSFS and the patient's satisfaction need careful interpretation when using these for high flexion-related functional evaluation due to their lack of ability to differentiate between good and poor results by some activities.

Clinical Outcome after Septic versus Aseptic Revision Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the clinical outcomes of septic and aseptic revision total knee arthroplasty. MATERIALS AND METHODS: This study compared the clinical and radiographic results of 12 septic and 10 aseptic revisions. All septic revisions were treated with two-stage reimplantation using an articulating cement spacer. The range of motion, Knee Society score, WOMAC score, and radiographic results of the American Knee Society were assessed. RESULTS: The preoperative data, which included the average range of motion, Knee Society score, WOMAC score and femoro-tibial angle, were similar in both groups. At the final follow-up, the average range of motion was similar in the two groups: 102.5degrees in the septic revisions, and 114.5degrees in the aseptic revisions (p=0.070). In addition, the Knee Society score, WOMAC score and femoro-tibial angle were similar in both groups. There was no loosening or failure of either component observed in any case. A patellar tendon rupture was observed in one septic revision after surgery. CONCLUSION: Two-stage reimplantation using an articulating cement spacer in septic revisions could achieve functional results that are compatible to aseptic revisions.

Reconstruction of the Medial Collateral Ligament for the Medial Instability after Primary Total Knee Arthroplasty: A Case Report / 대한정형외과학회잡지

An absence or compromise of the medial collateral ligament that occurs after primary total knee arthroplasty is a challenging reconstructive problem. Treatment usually requires unlinked-constrained total knee arthroplasty. Revision with unlinked-constrained prostheses often causes more bone loss and transmits increased stress to the bone-cement and prosthesis-cement interfaces, which can increase the risk of aseptic loosening. However, there are no treatment options other than constrained prostheses. We present a 47-year-old female who suffered from medial instability that occurred after total knee arthroplasty, which was treated successfully by a medial collateral ligament reconstruction.

A Comparative Study between High-Flex and Non High-Flex TotalKnee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the clinical results of a high-flex design (Scorpioflex(R), Stryker) in total knee arthroplasty with those of a non-high-flex design (Scorpio(R) PS type, Stryker). MATERIALS AND METHODS: Fifty-two knees with at least 120 degrees of further flexion preoperatively underwent total knee arthroplasty. Of the 52 knees, there were 35 knees in the high-flex design (HF group) and 17 knees in the non high-flex design (non-HF group). The clinical results were evaluated by postoperative further flexion at 3 months, 6 months, 1 year, 2 years and 3 years, as well as by Delta flexion, which means postoperative flexion improvement. The Knee Society Score and X-rays were evaluated preoperatively and at the 3-year follow-up. RESULTS: The HF group showed significantly greater flexion than the non-HF group at 3 months postoperatively (p=0.000). The delta flexion was also greater in the HF group at 3 months postoperatively (p=0.000). The Knee Society Score and X-rays were similar in the two groups at the final follow-up (p>0.05). CONCLUSION: High-flex total knee arthroplasty appears to facilitate greater flexion in the first 3 months postoperatively, but there is no significant difference between both groups with regard to the range of motion, clinical and radiographic variables after 3 months.

Arthroscopic Treatment of Acutely Infected Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study is to evaluate the results of arthroscopic treatment for an acutely infected total knee arthroplasty (TKA) and to determine the protocol for a successful arthroscopic treatment. MATERIALS AND METHODS: Of 16 cases of acutely infected TKA treated at this institution, 7 cases treated with arthroscopic debridement were retrospectively reviewed. The indication for arthroscopic debridement was patients with a radiographically stable prosthesis and within 72 hours of the onset of symptoms. The necessity and method of the secondary procedures were determined using a follow up of the C-reactve protein (CRP) test and physical examination after the primary arthroscopic debridment. Successful treatment was defined as no recurrence or no re-operation by the final follow-up. RESULTS: All 7 cases were treated with a retention of the prosthesis. 3 cases were treated successfully with primary arthroscopic debridement only. Three cases were treated with open debridement after primary arthroscopic debridement. One case was treated with repeated arthroscopic debridement after primary arthroscopic debridement. CONCLUSION: Arthroscopic debridement is an effective treatment option for an acutely infected TKA within 72 hours of the onset of symptoms. A careful CRP follow up is suggested as the critical index to determine the secondary procedure for successful treatment of an acutely infected TKA by arthroscopic debridement.

Delayed Repair with Augmentation using Achilles Allograft of Old Ruptured Patellar Tendon after Revison Total Knee Arthroplasty: A Case Report / 대한정형외과학회잡지

The rupture of the patellar tendon after total knee arthroplasty (TKA) is rare but serious complication resulting in a severe dysfunction in the extension mechanism. There are a few reports on the treatment of this condition. However, there is still some controversy regarding the choice of proper management. There is no report of the patellar tendon augmentation or reconstruction in this condition in the Korean literature. We report a case of an old patellar tendon rupture in 70-year old patient that occurred at 5 months after a two stage revision for an infected TKA and was treated satisfactorily by delayed repair with augmentation using an Achilles allograft.

The Availability of Total Knee Prostheses in Korean Knees

PURPOSE: This study is to compare the size distribution of current total knee prostheses with a measurements of Korean knees. MATERIALS AND METHODS: 566 consecutive osteoarthritic knees were measured, intraoperatively, for anteroposterior(AP) dimension of medial and lateral condyle, and mediolateral(ML) dimension of distal femur and proximal tibia. The size distribution of 5 total knee arthroplasty(TKA) systems were compared with these measurements. RESULTS: Regarding femoral component, the numbers of available lateral AP sizes within +/-1SD of Korean knees were two in Genesis II, PFC-RPF, Scorpio and one in Advance MPK, LPS-Flex. Those of available ML sizes for +/-1SD range were two in all systems. Regarding tibial component, the numbers of available lateral AP sizes for +/-1SD range were four in Scorpio, three in LPS-Flex, PFC-RPF and two in Advance MPK, Genesis II. Those of available ML sizes for +/-1SD range were two in Advance MPK, Scorpio and one in the others. CONCLUSION: Korean-friendly total knee prostheses should incorporate the size distribution as well as the dimension of the Korean knees.