Assessment and nonsurgical management of low back pain: a narrative review

Low back pain (LBP) is a common condition that affects people of all ages and income levels worldwide. The etiology of LBP may be mechanical, neuropathic, systemic, referred visceral, or secondary to other causes. Despite numerous studies, the diagnosis and management of LBP remain challenging due to the complex biomechanics of the spine and confounding factors, such as trivial degenerative imaging findings irrelevant to symptoms and psychological and emotional factors. However, it is imperative to identify the crucial signs (“red flags”) indicating a serious underlying condition. While many recent guidelines emphasize non-pharmacologic management approaches, such as education, reassurance, and physical and psychological care, as the first option, LBP patients in many countries, including South Korea, are prescribed medications. Multidisciplinary rehabilitation combined with prudent use of medications is required in patients unresponsive to first-line therapy. The development of practical guidelines apposite for South Korea is needed with multidisciplinary discussion.

Comparison of a Cryopneumatic Compression Device and Ice Packs for Cryotherapy Following Anterior Cruciate Ligament Reconstruction

Background@#The purpose of the current study was to evaluate and compare the effectiveness of a cryopneumatic compression device with that of standard ice packs following arthroscopic anterior cruciate ligament (ACL) reconstruction, with a primary focus on early postoperative pain. @*Methods@#Participants were divided into two groups: cryopneumatic compression device group (CC group) and standard ice pack group (IP group). Patients in the CC Group (28 patients) received a cryopneumatic compression device (CTC-7, Daesung Maref) treatment, while patients in the IP group (28 patients) received standard ice pack cryotherapy postoperatively. All cryotherapy was applied three times (every 8 hours) per day for 20 minutes until discharge (postoperative day 7). Pain scores were assessed preoperatively and at 4, 7, and 14 days after surgery, and the primary outcome for analysis was pain at postoperative day 4 assessed using a visual analog scale (VAS). Other variables were opioid and rescue medication use, knee and thigh circumferences, postoperative drainage, and joint effusion quantified by a three-dimensional magnetic resonance imaging (MRI) reconstruction model. @*Results@#The mean pain VAS score and difference in VAS relative to the preoperative measurements for postoperative day 4 were significantly lower in the CC group than in the IP group (p = 0.001 and p = 0.007, respectively). The sum of postoperative drainage and effusion quantified by MRI showed a significant reduction of postoperative effusion in the CC group compared to the IP group (p = 0.015). The average total rescue medication consumption was comparable between the two groups. Circumferential measurements at days 7 and 14 postoperatively relative to those at day 4 (index day) demonstrated no significant differences between the groups. @*Conclusions@#Compared to standard ice packs, application of cryopneumatic compression was associated with a significant reduction in VAS pain scores and joint effusion during the early postoperative period following ACL reconstruction.

Evaluation of Appropriateness of the Reimbursement Criteria of Korean Health Insurance Review and Assessment Service for Total Knee Arthroplasty

Background@#We evaluated and compared South Korea’s total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases. @*Methods@#Two TKA appropriateness criteria and HIRA’s reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee jointspecific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group. @*Results@#Data on 448 cases that underwent TKA were examined. According to the HIRA’s reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA’s reimbursement criteria. @*Conclusions@#In terms of insurance coverage, HIRA’s reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.

Safe Optimal Tear Drop View for Spinopelvic Fixation Using a Three-Dimensional Reconstruction Model of the Pelvis

Background@#Spinopelvic fixation (SPF) has been a challenge for surgeons despite the advancements in instruments and surgical techniques. C-arm fluoroscopy-guided SPF is a widely used safe technique that utilizes the tear drop view. The tear drop view is an image of the corridor from the posterior superior iliac spine to the anterior inferior iliac spine (AIIS) of the pelvis. This study aimed to define the safe optimal tear drop view using three-dimensional reconstruction of computed tomography images. @*Methods@#Three-dimensional reconstructions of the pelvises of 20 individuals were carried out. By rotating the reconstructed model, we simulated SPF with a cylinder representing imaginary screw. The safe optimal tear drop view was defined as the one embracing a corridor with the largest diameter with the inferior tear drop line not below the acetabular line and the lateral tear drop line medial to the AIIS. The distance between the lateral border of the tear drop and AIIS was defined as tear drop index (TDI) to estimate the degree of rotation on the plane image. Tear drop ratio (TDR), the ratio of the distance between the tear drop center and the AIIS to TDI, was also devised for more intuitive application of our simulation in a real operation. @*Results@#All the maximum diameters and lengths were greater than 9 mm and 80 mm, respectively, which are the values of generally used screws for SPF at a TDI of 5 mm and 10 mm in both sexes. The TDRs were 3.40 ± 0.41 and 3.35 ± 0.26 in men and women, respectively, at a TDI of 5 mm. The TDRs were 2.26 ± 0.17 and 2.14 ± 0.12 in men and women, respectively, at a TDI of 10 mm. @*Conclusions@#The safe optimal tear drop view can be obtained with a TDR of 2.5 to 3 by rounding off the measured values for intuitive application in the actual surgical field.

Comparison of Clinical Outcomes after Total Knee Arthroplasty with and without Patellar Resurfacing in the Same Patients

Background@#Patellar resurfacing is performed in total knee arthroplasty (TKA) to improve pain in the anterior compartment of the knee joint and to restore proper coordination and movement of the patellofemoral joint. The purpose of this study was to analyze differences in clinical outcomes according to patellar resurfacing in patients who underwent bilateral TKA. @*Methods@#Forty-three patients who underwent bilateral primary TKA with patellar resurfacing on one side only were included. Patellar resurfacing was performed selectively according to the status of the patella cartilage surface. Knee Society score (knee and function), Feller score, Kujala score, and Samsung Medical Center (SMC) score (pain and function) were evaluated. @*Results@#There were no significant differences in Knee Society pain and function scores, Feller score, Kujala score, and SMC pain and function scores according to patellar resurfacing. On the comparison of SMC scores, there was no difference except for two questions. @*Conclusions@#It is advisable not to perform resurfacing on normal patellae. However, in order to apply this result to damaged patellae, comparative studies between resurfaced patellae and damaged patellae are needed.

Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies

Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

Fixation Method Using Bioabsorbable Pins for Osteochondritis Dissecans in the Knee through Mini-Open Approach / 대한정형외과학회잡지

Osteochondritis dissecans (OCD) is a pathologic condition of the subchondral bone which involves the articular cartilage. Unstable OCD can be fixed with various implants, including bioabsorbable materials. Bioabsorbable materials have several advantages. Removal of the implant is not required, and they have low interference on imaging studies, such as magnetic resonance imaging (MRI). This paper reports a case of surgical treatment using bioabsorbable pins for OCD lesion. MRI showed a displaced osteochondral lesion at medial femoral condyle. Arthroscopic reduction and fixation were attempted initially, but additional mini-open incision was needed to reduce the fibrotic fragment. The fragment was trimmed and fixed with two bioabsorbable pins. Union was achieved at the follow-up without complications.The use of bioabsorbable pins for OCD treatment may be one of successful treatment method.

Versatile Application of Navigation System for Total Knee Arthroplasty / 대한정형외과학회잡지

The navigation system helps to perform an accurate and reproducible operation by real-time continuous feedback during total knee arthroplasty (TKA). Although the incidence of malalignment after conventional TKA had been reported to be up to 20%–30%, navigationassisted TKA has shown excellent radiologic results in terms of accurate implant position and mechanical alignment. In addition, the navigation system provides continuous feedback on the extension and flexion gaps that change depending on the bone resection and soft tissue release. Furthermore, the navigation system can be useful in patients with extra-articular deformity or retaining instruments. Robotassisted TKA is a newly developed surgical method that combines the navigation registration technique with bone resection using a robotic arm. A postoperative change in the kinematic axis can be evaluated by comparing the pre- and postoperative functional flexion axis using navigation data. If the functional flexion axis can be provided in real-time in the navigation system, it is expected to be used as a new surgical parameter for the rotational alignment of the femoral component and help restore the patient’s flexion axis postoperatively.

Diagnosis and conservative treatment of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) has a diagnosis rate of 3% to 5% per year, but the number of cases requiring surgical treatments is very small, accounting for only 0.17% to 1.75% of all AIS patients. Most patients with AIS are diagnosed, treated, and managed in outpatient clinics.Current Concepts: AIS is a disease that occurs more frequently, and progresses faster, in females than in males. Scoliosis deformity can occur due to various causes. To differentially diagnose AIS, it is necessary to perform careful physical examinations, investigate family history, and check for neurological, growth, and developmental abnormalities. Definitive diagnosis of AIS can be performed through radiographic imaging. In the case of atypical curvature and symptoms, examinations such as magnetic resonance imaging could be required in addition to radiographic imaging. Treatment of AIS patients in outpatient clinics can be performed through observation, exercise, and orthosis. The selection and application of treatment methods and the termination period of the treatments are complexly affected by the age at the time of diagnosis; pattern, location and size of the curve; and growth potential.Discussion and Conclusion: AIS is a disease in which good results can be obtained with conservative treatments such as exercise and orthosis, which is generally applied in an outpatient setting. To properly treat AIS, it is necessary to have an in-depth understanding of the characteristics of AIS, timing of treatment, and factors influencing treatment.

Biomechanical function of the anterolateral ligament of the knee: a systematic review

Background@#It has been suggested that the anterolateral ligament (ALL) is an important anterolateral stabilizer of the knee joint which functions to prevent anterolateral subluxation and anterior subluxation at certain flexion angles in the knee. Purpose: To analyze and systematically interpret the biomechanical function of the ALL. @*Methods@#An online search was conducted for human cadaveric biomechanical studies that tested function of the ALL in resisting anterolateral subluxation and anterior subluxation of the knee. Two reviewers independently searched Medline, Embase, and the Cochrane Database of Systematic Reviews for studies up to 25 September 2018. Biomechanical studies not reporting the magnitude of anterior tibial translation or tibial internal rotation in relation to the function of the ALL were excluded. @*Results@#Twelve biomechanical studies using human cadavers evaluating parameters including anterior tibial translation and/or internal tibial rotation in anterior cruciate ligament (ACL)-sectioned and ALL-sectioned knees were included in the review. Five studies reported a minor increase or no significant increase in anterior tibial translation and internal tibial rotation with further sectioning of the ALL in ACL-deficient knees. Five studies reported a significant increase in knee laxity in tibial internal rotation or pivot shift with addition of sectioning the ALL in ACL-deficient knees. Two studies reported a significant increase in both anterior tibial translation and internal tibial rotation during application of the anterior-drawer and pivot-shift tests after ALL sectioning. @*Conclusion@#There was inconsistency in the biomechanical characteristics of the ALL of the knee in resisting anterolateral and anterior subluxation of the tibia.

Tunnel Position for Anatomical Reconstruction of the Anterior Cruciate Ligament / 대한정형외과학회잡지

The review provides updated concepts regard to the anatomy of the anterior cruciate ligament (ACL) footprints. The concept of anatomicalACL reconstruction, in which the graft is placed in the native ACL insertion area, has been introduced. However, there is still no consensuson the anatomical positioning of the femoral and tibial tunnel. In this study, authors review and update the literature regarding the tunnelposition for anatomical ACL reconstruction.

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

Adult spinal deformity (ASD) is characterized by three-dimensional abnormalities of the thoracic or thoracolumbar spine that exerts significant impacts on the health-related quality of life (HRQoL). With the important effects that deformity of the sagittal plane exerts on the HRQoL, there have been paradigm shifts in ASD evaluation and management. Loss of lumbar lordosis is recognized as a key driver of ASD followed by reducing kyphosis, pelvic retroversion, and knee flexion. The Scoliosis Research Society (SRS)– Schwab classification reflects the sagittal spinopelvic parameters that correlate pain and disability in ASD patients. Although the SRS–Schwab classification provides a realignment target framework for surgeons, a structured patient-specific systemic approach is crucial for the process of decision-making. ASD management should be focused on restoring age-specific harmonious alignment and should consider the comorbidities and risk factors of each patient to prevent catastrophic complications and enhance the HRQoL.

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

Adult spinal deformity (ASD) is characterized by three-dimensional abnormalities of the thoracic or thoracolumbar spine that exerts significant impacts on the health-related quality of life (HRQoL). With the important effects that deformity of the sagittal plane exerts on the HRQoL, there have been paradigm shifts in ASD evaluation and management. Loss of lumbar lordosis is recognized as a key driver of ASD followed by reducing kyphosis, pelvic retroversion, and knee flexion. The Scoliosis Research Society (SRS)– Schwab classification reflects the sagittal spinopelvic parameters that correlate pain and disability in ASD patients. Although the SRS–Schwab classification provides a realignment target framework for surgeons, a structured patient-specific systemic approach is crucial for the process of decision-making. ASD management should be focused on restoring age-specific harmonious alignment and should consider the comorbidities and risk factors of each patient to prevent catastrophic complications and enhance the HRQoL.

Distal Femoral Varus Osteotomy for Valgus Arthritis of the Knees: Systematic Review of Open versus Closed Wedge Osteotomy

PURPOSE: The purpose of this review is to compare the clinical and radiological outcomes between open and closed wedge distal femoral varus osteotomy (DFO). METHODS: A literature search of online databases (MEDLINE, EMBASE, and Cochrane Library database) was made in addition to manual search of major orthopedic journals. Data were searched from the time period of January 1990 to October 2016. A modified Coleman Methodology Score system was used to assess the methodologic quality of the included studies. A total of 20 studies were included in the review. All studies were level IV evidence. RESULTS: Comparative analysis of open and closed wedge DFO did not demonstrate clinical and radiological differences. The survival rates were also similar. Five studies (56%) on open wedge DFO mentioned the need for either bone grafting or substitute for osteotomy gap filling and reported higher incidences of reoperation for plate removal than the closed wedge DFO studies. CONCLUSIONS: The present systematic review showed similar performance between open and closed wedge DFO. Outcomes including survival rates were not statistically significantly different. However, additional bone grafting or substitutes were often needed to prevent delayed union or nonunion for open wedge techniques. Additional operations for plate removal were commonly required due to plate irritation in both techniques.

Use of resorbable mesh and fibrin glue for restoration in comminuted fracture of anterior maxillary wall

BACKGROUND: The facial bone has a complex structure compared to other bones, and various types of fractures can occur due to its characteristics. Among them, in comminuted fractures of anterior maxillary wall, multiple depressed and impacted bony segments cannot be reduced easily when performing internal fixation using plates and screws or wires, and inadequate restoration leads to a range of complications. This paper introduces an alternative technique using a resorbable mesh with fibrin glue to restore comminuted fractures of anterior maxillary wall. METHODS: Thirteen patients were diagnosed with comminuted fractures of anterior maxillary wall between March 2017 and February 2018 in the authors’ hospital. All patients with comminuted fractures of anterior maxillary wall underwent restoration using resorbable mesh with fibrin glue. The patients’ demographics, causes of facial trauma, mean operation time, length of hospital stay, follow-up period, and complications were recorded. RESULTS: No major complications and only one hypoesthesia of the skin area was noted. Three months after surgery, the hypoesthesia recovered completely. After surgery (mean, 3.9 months; range, 2–12 months), computed tomography showed that the bone fragments in all patients were fixed successfully in their anatomical places. CONCLUSION: In comminuted fractures of anterior maxillary wall, the use of a resorbable mesh with fibrin glue can be an advantageous and effective method for a successful restoration without complications.

Apophyseal Avulsion Fracture of Ischial Tuberosity during Soccer: A Case Report and Literature Review / 대한스포츠의학회지

The incidence of avulsion fracture of ischial tuberosity is reported to present in 1.4%–4% of hamstring injuries. The injury mechanism is known to be caused by a sudden forceful hip flexion in the extended knee with eccentric load to the hamstrings. Although the majority of hamstring injuries are strains of the muscle, avulsion fracture of ischial tuberosity occurs rarely. In this report, a 13-year-old boy with avulsion fracture of ischial tuberosity is presented. Successful clinical outcome was achieved with careful conservative management. Previous literatures including operative indications are reviewed.

A Novel Medial Soft Tissue Release Method for Varus Deformity during Total Knee Arthroplasty: Femoral Origin Release of the Medial Collateral Ligament

INTRODUCTION: Numerous methods of medial soft tissue release for severe varus deformity during total knee arthroplasty (TKA) have been reported. These include tibial stripping of the superficial medial collateral ligament (MCL), pie-crusting technique, and medial epicondylar osteotomy. However, there are inherent disadvantages in these techniques. Authors hereby present a novel quantitative method: femoral origin release of the medial collateral ligament (FORM). SURGICAL TECHNIQUE: For medial tightness remaining even after the release of the deep MCL and semimembranosus, the FORM is initiated with identification of the femoral insertion area of the MCL with the knee in flexion. Starting from the most posterior part of the femoral insertion, one third of the MCL femoral insertion is released from its attachment. If necessary, further sequential medial release is performed. MATERIALS AND METHODS: Seventeen knees that underwent the FORM were evaluated for radiological and clinical outcomes. RESULTS: Regardless of the extent of the FORM, no knees showed residual valgus instability at 24 weeks after surgery. CONCLUSIONS: As the FORM is performed in a stepwise manner, fine adjustment during medial release might be beneficial to prevent inadvertent over-release of the medial structures of the knee.

Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies

PURPOSE: To summarize and compare radiological and clinical outcomes of open wedge high tibial osteotomy (HTO) using imageless computer-assisted navigation with conventional HTO. METHODS: A literature search of online register databases was conducted. The risk ratio (RR) of radiological outliers and mean differences in clinical outcomes were compared between navigated and conventional HTOs. Radiological results were evaluated by subgroup analyses according to the study period (concurrent/consecutive) and the use of locking fixation device. RESULTS: Seven comparative studies with a total sample size of 406 knees were included in this review. Radiographically, the mechanical axis [MA] was within the acceptable range (0degrees-6degrees) in 83.7% of the navigation HTO group, showing significant difference from 62.1% of the conventional HTO group. Clinically, despite the forest plot demonstrating a general trend of favoring the navigation system, there were not sufficient studies to determine statistical significance in the meta-analysis. None of the subgroup analyses demonstrated significant differences in the RR of MA outliers. CONCLUSIONS: The present meta-analysis indicates that the use of navigation in open wedge HTO improves the precision of mechanical alignment by decreasing the incidence of outliers; however, the clinical benefit is not conclusive. Additionally, none of the subgroup analyses demonstrated significant difference in the RR of MA outliers.

Arthroscopic Medial Meniscus Posterior Root Repair: Techniques and Current Issues / 대한정형외과학회잡지

Posterior root tears of the medial meniscus are radial tears, usually found in patients older than 50 years with degenerative articular cartilage. Partial menisectomy has been the conventional treatment for this condition. However, growing dissatisfaction with partial menisectomy for medial meniscus root tears has led to an increasing interest in meniscal repair. One method for medial meniscus root repairs involves suturing around the region of the tear where the sutures are pulled-out and fixed around the tibia. In another approach, a suture anchor was used for fixation of the medial meniscus root tear. Both methods improved functional outcome scores at least during a short-term follow-up period. However, complete healing of the repaired root seemed to be less predictable. Strict patient selection, good surgical skills and proper postoperative rehabilitation are the key factors for successful repairs of medial meniscus root tears.

Extraction of Misplaced Endcap during Tibia Intramedullary Nailing by 'Fish-Hook' Technique: Technical Note

Endcap placement after intramedullary nailing can be cumbersome. Misplacement of the endcap which may be difficult to extract may occur. In this report, a simple Kirschner wire device with 'fish-hook' technique may ease the procedure without further violating bony or soft tissues.