The Learning Curve for Biplane Medial Open Wedge High Tibial Osteotomy in 100 Consecutive Cases Assessed Using the Cumulative Summation Method

PURPOSE: The purpose of this study was to investigate whether surgical experience could improve surgical competency in medial open wedge high tibial osteotomy (MOWHTO). MATERIALS AND METHODS: One hundred consecutive cases of MOWHTO were performed with preoperative planning using the Miniaci method. Surgical errors were defined as under- or overcorrection, excessive posterior slope change, or the presence of a lateral hinge fracture. Each of these treatment failures was separately evaluated using the cumulative summation test for learning curve (LC-CUSUM). RESULTS: The LC-CUSUM showed competency in prevention of undercorrection, excessive posterior slope change, and lateral hinge fracture after 27, 47, and 42 procedures, respectively. However, the LC-CUSUM did not signal achievement of competency in prevention of overcorrection after 100 procedures. Furthermore, the failure rate for overcorrection showed an increasing tendency as surgical experience increased. CONCLUSIONS: Surgical experience may improve the surgeon’s competency in prevention of undercorrection, excessive posterior slope change, and lateral hinge fracture. However, it may not help reduce the incidence of overcorrection even after performance of 100 cases of MOWHTO over a period of 6 years.

Surgical treatment of severe osteoporosis including new concept of advanced severe osteoporosis

Severe osteoporosis is classified as those with a bone mineral density (BMD) T-score of −2.5 or lower, and demonstrate one or more of osteoporotic, low-trauma, fragility fractures. According to the general principle of surgical approach, patients with severe osteoporosis require not only more thorough pre- and postoperative treatment plans, but improvements in surgical fixtures and techniques such as the concept of a locking plate to prevent bone deformity and maximizing the blood flow to the fracture site by using a minimally invasive plate osteosynthesis. Arthroplasty is often performed in cases of displaced femoral neck fracture. Otherwise internal fixation for the goal of bone union is the generally accepted option for intertrochanteric, subtrochanteric, and femoral shaft fractures. Most of osteoporotic spine fracture is stable compression fracture, but vertebroplasty or kyphoplasty may be performed some selective patients. If neurological paralysis, severe spinal instability, or kyphotic deformity occurs, open decompression or fusion surgery may be considered. In order to overcome shortcomings of the World Health Organization definition of osteoporosis, we proposed a concept of ‘advanced severe osteoporosis,’ which is defined by the presence of proximal femur fragility fracture or two or more fragility fractures in addition to BMD T-score of −2.5 or less. In conclusion, we need more meticulous approach for surgical treatment of severe osteoporosis who had fragility fracture. In cases of advanced severe osteoporosis, we recommend more aggressive managements using parathyroid hormone and receptor activator of nuclear factor kappa-B ligand monoclonal antibody.

Perception of severe osteoporosis amongst medical doctors in South Korea: Awareness, impact, and treatment

OBJECTIVES: Little is currently known about the issues surrounding management and treatment of severe osteoporosis in South Korea. Our objective was to assess doctors' views on the perception, diagnosis, and treatment of severe osteoporosis. METHODS: Face-to-face interviews were conducted (16 February-13 March 2015) with 100 doctors (specialists in orthopedic surgery, endocrinology, neurosurgery, family medicine, or rheumatology) who treated ≥5 severe osteoporosis (T-score ≤ -2.5, plus fracture) patients per month. Respondent demographic characteristics, their perception of severe osteoporosis, its impact and treatment, and their views on current practice and unmet needs were assessed. RESULTS: Of 416 doctors approached, 100 completed the survey (24% response rate). Most doctors (90%) specialized in orthopedic surgery, endocrinology, or neurosurgery. When diagnosing severe osteoporosis, most doctors (79%) considered both bone mineral density and fracture. Almost all doctors (≥91%) ranked disease impact and seriousness highly, but much fewer (≤25%) doctors thought society agreed. Most doctors (89%) had concerns with current treatments, switching treatments because of the efficacy and safety of bisphosphonates (>89%), the efficacy of selective estrogen receptor modulators (>71%), and the high cost of parathyroid hormone (>73%). Parathyroid hormone was ranked highest for efficacy and was preferentially prescribed to severe osteoporosis patients (mean 32.2% of prescriptions) compared with osteoporosis patients overall (3.7%). "Limitations with reimbursement" was the most commonly cited (76%) unmet need. CONCLUSIONS: There are concerns with the safety, efficacy, and affordability of current treatments for severe osteoporosis in South Korea, as well as a perceived lack of disease awareness amongst patients and doctors.

Outcome of Unicompartmental Knee Arthroplasty: A Systematic Review of Comparative Studies between Fixed and Mobile Bearings Focusing on Complications

The purpose of this systematic review is to collate results of studies comparing fixed and mobile bearing unicompartmental knee arthroplasty (UKA), focusing on complications and timing for reoperations. Out of 723 results derived from PubMed, EMBASE and Cochrane database search engines on bearings in arthroplasty, 10 studies comparing clinical results of fixed bearings to mobile bearings in UKA were found eligible for analysis. The reoperation rate was calculated using a novel method such as reoperations per hundred component years, and the causes of specific reoperations were investigated. The overall reoperation rate per hundred component years was similar between the mobile bearings (1.392) and fixed bearings (1.377); however, mobile bearings were more susceptible to reoperations in cases with aseptic loosening (0.393>0.255), progression of arthritis (0.428>0.357) and implant dislocation (0.286>0). The overall incidence of complications is similar for fixed and mobile bearing designs in UKA. The discussion on complications presented above may assist surgeons in their choice of bearing design.

Arthroscopic Treatment of Delayed Patella Infera / 대한정형외과학회잡지

Patella infera (baja) is a rare condition that can result from several etiologies including trauma around the knee. Risk factors include scar tissue formation in the retropatella fat pad, extensor mechanism dysfunction, immobilization in extension position of the knee joint, etc. Unawareness and delayed recognition are known to be associated with long-term disability. In this condition, arthroscopic treatment is generally recommended only for early cases. In this report, we present a case with reasonable outcome of delayed patella infera treated by arthroscopic treatment. Prudent arthroscopic debridement of the responsible scar tissue and accelerated rehabilitation therapy is necessary for achievement of a successful outcome.

Measurement of Capsular Thickness in Magnetic Resonance Arthrography in Idiopathic Adhesive Capsulitis of Hip / 대한고관절학회지

PURPOSE: The clinical suspicion of idiopathic adhesive capsulitis of the hip (IACH) involves restricted range of motion and normal hip radiographs. The purpose of this study was to delineate the characteristic findings observed on magnetic resonance arthrography (MRA) by identifying the anatomical structures involved and their significance on clinical presentation of restricted range of motion. MATERIALS AND METHODS: We retrospectively evaluated MRA's of 46 hips (44 patients) who suffered hip pain from September 2006 to August 2012 in our hospital. Of those, 10 cases (8 patients) with clinical suspicion of IACH were compared to 20 normal hip cases (control group). To identify anatomical evidence of adhesive capsulitis in the MRA's of the IACH group, capsular thickness was measured superiorly, inferiorly, anteriorly and posteriorly, and compared to that of the randomly selected control group. RESULTS: Comparison of the MRA findings of the control group to that of the IACH group showed that there was a statistically significant increase in the mean thickness of the joint capsule superiorly and posteriorly (P<0.01), while comparison of examination findings revealed a statistically significant decrease in the mean range of motion (flexion 122.5degrees+/-5.5degrees/abduction 28.0degrees+/-2.8degrees/adduction 26.5degrees+/-2.4degrees/external rotation 30.5degrees+/-3.8degrees/internal rotation 25.5degrees+/-2.4degrees) in the IACH group. CONCLUSION: A change in the capsular thickness on MRA is a common finding in IACH patients with the increase more evident in the posterior and superior capsules than the anterior and inferior capsules.

Osteonecrosis of the Femoral Head in the Setting of a Complex Acetabulum Fracture without Hip Dislocation Treated Surgically Using Ilio-inguinal Approach: A Case Report / 대한고관절학회지

Osteonecrosis in isolated fractures of the acetabulum without dislocation of hip seems to be a known complication, but to our knowledge it has not been reported adequately. The causative nature of post-traumatic femoral head osteonecrosis has not been studied critically. The pathophysiology of osteonecrosis in this case also eludes us. Striking evidence points towards the intra-operative blood loss and low mean arterial pressure possibly leading to hypo-perfusion of femoral head leading to osteonecrosis. Fractures of the acetabulum pose a difficult problem for the patient and the surgeon because of possible complications. Thus any surgeon involved in surgery for fractures of the acetabulum should be aware of the possibility of this potential complication. Here is a 61-year male, who sustained a complex fracture of the acetabulum without hip dislocation, subsequently was treated surgically with internal fixation using an anterior approach, 10 months after surgery patient developed osteonecrosis of the femoral head.

Fracture of the Greater Trochanter during Closed Reduction of Obturator Type Hip Dislocation / 대한고관절학회지

Obturator (Inferior) type dislocation of the hip joint is a rare and the fracture of greater trochanter during closed reduction for it has never been reported in literature. In this report, we present a case of a fracture of greater trochanter during difficult closed reduction which required operative fixation. Surgeons need to be aware of this complication and excessive force for reduction should be avoided when treating of this type dislocation.

Discrepancies of Patellofemoral Indices between Supine and Standing Merchant Views

PURPOSE: This research was conducted to compare supine and standing Merchant views, to observe radiographic changes of the patellofemoral joint according to weight-bearing conditions, and to evaluate correlation factors affecting patellofemoral joint indices. MATERIALS AND METHODS: Forty-four patients without skeletal problems were selected for this study. Patellar tilt angle, lateral patellofemoral angle, congruence angle, lateral subluxation distance and lateral patellar displacement were measured on each radiograph and evaluated for statistical significance. Possible correlation factors that can affect the radiographic discrepancy were analyzed using the univariate and multivariate regression analysis. RESULTS: In the standing Merchant view, the patellar tilt angle, congruence angle and lateral patellar displacement were significantly decreased (p<0.001), whereas the lateral patellofemoral angle was significantly increased (p<0.001) compared to that in the supine Merchant view. Thigh width (p<0.001, r2=0.22) and radiographic Q-angle (p<0.001, r2=0.34) were found correlated with the radiographic discrepancy of congruence angle. Discrepancy of the lateral patella displacement increased as radiographic Q-angle increased (p=0.027, r2=0.112). CONCLUSIONS: Compared with the supine Merchant view, standing (weight-bearing) Merchant view showed decreased patella tilt angle, congruence angle, and lateral patella displacement. The results indicate that both supine and standing Merchant views should be considered in the radiographic evaluation of the patellofemoral joint.

Intrapelvic Anterior Plate Fixation for Crescent Fracture-Dislocation of Sacroiliac Joint

PURPOSE: To evaluate the radiological and clinical outcomes of intrapelvic anterior plate fixations for Day Classification Type II crescent fracture-dislocations of sacroiliac joints. MATERIALS AND METHODS: Ten patients who had undertaken the surgical treatment for the sacroiliac joint from 2006 to 2012 were enrolled in this study. All cases fell into Type II by Day Classification for sacroiliac joint injuries. For surgical treatments, the plate fixation through the intra-pelvic anterior approach was first performed for all cases and anterior ring fixation was performed in 4 cases with more severely displaced anterior pelvic ring injuries. Then, radiological and clinical evaluation was implemented. RESULTS: The bone union was observed from all patients whom performed the surgical fixation. In the radiological results, 9 cases with the anatomic and nearly-anatomic reductions were observed. Out of the 10 cases which performed the rotational displacement analysis, there were 3 excellent cases, 6 good cases and 1 fair case. The 10 cases that performed the deformity index and vertical displacement analysis, less variations were observed in the anterior ring fixations after intra-pelvic anterior plate fixation group. According to the clinical results, 4 excellent cases, 3 good cases, and 3 moderate cases were observed. CONCLUSION: In the Type II crescent fracture-dislocation of sacroiliac joint, the intrapelvic anterior plate fixation achieved satisfactory anatomical reductions, radiological stabilities and clinical results.

Usefulness of a Modular Hip System for Combined Anteversion in Cementless Total Hip Arthroplasty / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the usefulness of a modular total hip system for combined anteversion in cementless modular total hip arthroplasty. MATERIALS AND METHODS: We performed twenty cementless modular total hip arthroplasty procedures. The patients lay in lateral position and 15degreesinternal rotation of the thigh. The surgeon inserted an acetabular cup component first, followed by a femoral component. He selected an appropriate modular neck component using an intra-operative manual combined anteversion test. All patients underwent post-operative computed tomography. RESULTS: The average measurement of anteversion of the acetabular cup was 15.9+/-2.9degrees and anteversion of the femoral stem was 15.2+/-11.9degrees. Then, the combined anteversion was calculated to 24.0+/-8.2degrees. Significant difference was observed between combined anteversion and theoretical combined anteversion. CONCLUSION: The method using an intra-operative manual combined anteversion test cannot realize the theoretical combined anteversion in cementless modular hip arthroplasty.

Isolated Semitendinosus Tendon Rupture in Non Athlete / 대한스포츠의학회지

Isolated rupture of distal semitendinosus is reported rarely. Here, we report a case of 51-year-old previous healthy working man diagnosed with isolated semitendinosus tendon rupture treated successfully by conservative management.

Surgical Fixation of Sacroiliac Joint Complex in Unstable Pelvic Ring Injuries / 대한고관절학회지

PURPOSE: To evaluate the effectiveness and clinical outcomes of surgical fixation of a sacroiliac joint complex in unstable pelvic ring injuries. MATERIALS AND METHODS: We selected sixteen cases in our hospital from 2006 to 2010 that underwent surgical fixation of the sacroiliac joint complex and had unstable pelvis ring injuries corresponding to B and C of Tile classification. Plate fixation through an intra-pelvic anterior approach was performed for 9 cases, tension band plate fixation for 2 cases, iliosacral screw fixation for 4 cases, and spino-pelvic fixation through extra-pelvic posterior approach for 1 case. Radiological and clinical evaluations were implemented to determine the results of treatment. RESULTS: Bone union was observed in all patients. For radiological evaluation using the Matta and Saucedo criteria, 15 cases were above the nearly-anatomic reduction. Out of 10 cases that performed rotational displacement analysis, 9 cases were above fair. All cases had above moderate clinical results as well. CONCLUSION: For unstable pelvic ring injuries, the satisfactory radiological and clinical results have been obtained through the anatomical reduction of the sacroiliac joint complex and firm internal fixation. And from the evaluation of fracture types, the Type C fracture and vertical shear type fractures showed relatively poor results.

Surgical Fixation of Sacroiliac Joint Complex in Unstable Pelvic Ring Injuries / 대한고관절학회지

PURPOSE: To evaluate the effectiveness and clinical outcomes of surgical fixation of a sacroiliac joint complex in unstable pelvic ring injuries. MATERIALS AND METHODS: We selected sixteen cases in our hospital from 2006 to 2010 that underwent surgical fixation of the sacroiliac joint complex and had unstable pelvis ring injuries corresponding to B and C of Tile classification. Plate fixation through an intra-pelvic anterior approach was performed for 9 cases, tension band plate fixation for 2 cases, iliosacral screw fixation for 4 cases, and spino-pelvic fixation through extra-pelvic posterior approach for 1 case. Radiological and clinical evaluations were implemented to determine the results of treatment. RESULTS: Bone union was observed in all patients. For radiological evaluation using the Matta and Saucedo criteria, 15 cases were above the nearly-anatomic reduction. Out of 10 cases that performed rotational displacement analysis, 9 cases were above fair. All cases had above moderate clinical results as well. CONCLUSION: For unstable pelvic ring injuries, the satisfactory radiological and clinical results have been obtained through the anatomical reduction of the sacroiliac joint complex and firm internal fixation. And from the evaluation of fracture types, the Type C fracture and vertical shear type fractures showed relatively poor results.

Effect of Combined Sex Hormone Replacement on Bone/Cartilage Turnover in a Murine Model of Osteoarthritis

BACKGROUND: Estrogens act on estrogen receptors distributed in articular cartilages, synovial membrane, and ligaments, which are thought to be related with degenerative changes. Meanwhile, progesterone is known to have a weak anabolic action on bone formation This study evaluates the effects of estrogen and progesterone hormone on bone/cartilage turnover in ovariectomized (OVX) rats. METHODS: Thirty-five 7-month-old female Sprague-Dawley rats were randomly divided into 5 groups and then ovariectomized bilaterally except the sham control group. The first and the second group acting as controls did not receive hormonal therapy, the third group received estrogen, the fourth group received progesterone, and the fifth group received combination of both hormones 10 weeks after surgery. Evaluations were done using the serum levels of cartilage oligomeric matrix protein (COMP) for cartilage turnover, collagen type I C-telopeptide (CTX-1) and osteocalcin (OC) for bone turnover at 11, 15, 19 weeks after OVX and histology using the Osteoarthritis Research Society International (OARSI) osteoarthritis (OA) cartilage histopathology assessment system. RESULTS: Significantly less cartilage degradation (decreased levels of COMP) was found in the combined hormone treated group in comparison with OVX group. Similarly, both hormonal treatment resulted in increased bone formation and decreased bone resorption i.e., a low overall bone turnover status (decrease in the serum OC and CTX-1 levels). CONCLUSIONS: Combined estrogen and progesterone therapy was found to be convincing in terms of reducing the severity of OA in this experimental model.

Measurement of the Weight-bearing Standing Coronal and Sagittal Axial Alignment of Lower Extremity in Young Korean Adults / 대한정형외과학회잡지

PURPOSE: The aim of this study was to establish a measurement standard for the weight-bearing axial alignment of the lower extremities when performing a lower extremity reconstruction. MATERIALS AND METHODS: Among 274 patients (147 males and 127 females) in their 20s to 30s without any physical disabilities, and who had undergone weight-bearing full leg standing radiographs, 188 patients (100 males and 88 females) were examined this study. The data was analyzed further according to their age and gender using the radiographic value on the coronal and sagittal alignment of the lower extremities. RESULTS: The weight bearing ratio was 38.47+/-10.52% on the coronal plane and 36.11+/-7.88% on the sagittal plane. Both the mechanical axis and the the weight bearing axis were not identical due to their 0.68+/-0.89degrees difference on average. The most adjacent point of the femoral condyles to the tibial plateau on the sagittal plane was assigned to the center of the knee joint. The difference between the mechanical axis and weight bearing axis was 0.04degrees, which was not significant. CONCLUSION: There is a difference between the mechanical axis, which consists of both a line from the center of the femoral head to the center of knee joint and a line from the center of the knee joint to the center of ankle joint, and the weight bearing axis, which is linked directly from the center of the femoral head to the center of the ankle joint. Furthermore, the weight bearing axis passes through the anteromedial part in the knee joint. The center of the knee joint is defined as the most adjacent point of both femoral condyle to the tibial plateau on the sagittal plane.

Short-term Results of Posterior Cruciate Sacrificing and Substitution Total Knee Arthroplasty

PURPOSE: To compare clinical and radiologic results after total knee arthroplasty (TKA) with posterior cruciate sacrificing (PCS) and posterior cruciate substitution (PS). MATERIALS AND METHODS: Of 66 knees in 53 patients with degenerative arthritis, we completed both practical and radiological evaluations for 27 patients with PCS TKA (30 knees) and 31 patients with PS TKA (36 knees). RESULTS: The knee score improved from 33 to 81.9 for PCS TKA and from 35 to 86.6 for PS TKA. Preoperative flexion was 104.5degrees in the PCS TKA group and 104.7degrees in the PS TKA group.These scores significantly improved to 113.9degrees and 104.7degrees respectively (p0.05). On radiological evaluation, the alpha angle was found to be 98.9degrees, the beta angle 89.9degrees , the gamma angle 5.0degrees, and the delta angle 39.2degrees for PCS TKA. Also, the alpha angle was 95.6degrees, beta angle 89.0degrees, gamma angle 9.0degrees, and delta angle 88.4degrees for PS TKA (p>0.05). Loosening was not encountered in either type. Postoperative complications were few; there was 1 knee (1.5%) with a polyethylene insert spin-out for the PCS TKA group and 1 knee (1.5%) with a periprosthetic fracture for the PS TKA group. CONCLUSION: On both clinical and radiological evaluations, PCS TKA and PS TKA demonstrated satisfactory results out to 4.5 years of follow up, which also indicated a lack of any significant difference between these two types.

Helical Blade versus Lag Screw for Treatment of Intertrochanteric Fracture

PURPOSE: To evaluate the radiographic and functional outcomes between who had unstable intertrochanteric fracture, treated with the ITST (lag screw design) and the PFNA (helical blade design). MATERIALS AND METHODS: We selected each 17 and 13 patients of unstable intertrochanteric fracture which were treated with ITST or PFNA from April 2005 to December 2008. We evaluated the radiographic results by follow-up radiography and the clinical outcomes with the mobility score of Parker and Palmer, Social function scoring system. RESULTS: The mean sliding distance of cervical screw with ITST nails was not shown significant differences than with using PFNA nails. The other factors were not statistically different. Decrease of mobility score of Parker and Palmer, Social function score were similar. 2 cases of cutting out was noted with ITST nails and 1 case of cutting out was noted with PFNA nails. CONCLUSION: Unlike the existed biomechanical reposts, there are no differences that are clinical and radiological results in treatment of unstable intertrochanteric fracture using the ITST nails and PFNA nails.

Triceps-Sparing Posterior Approach for Intra-articular Fracture of Distal Humerus

PURPOSE: To evaluate the therapeutic results of intra-articular fracture of distal humerus treated through triceps sparing posterior approach. MATERIALS AND METHODS: From February 2001 to December 2003, we reviewed total 9 cases of intra-articular fracture of distal humerus, which were treated by surgical treatment and were followed more than for 12 months. According to the OTA classification, nine cases were classified as type A; two, as type C1; five, as type C2; two. Triceps sparing posterior approach was used in all nine patients. An extensile posterior incision was used over the olecranon without triceps muscle injury. Exposure of the fracture site was done by obtaining medial-lateral mobility through dissection of medial and lateral edge of triceps muscle. Therapeutic results were assessed by bone union, duration for fracture union, complication. and for functional estimation, Mayo elbow performance score was checked and analysed. RESULTS: The range of the elbow joint motion was flexion contracture 5.2 degree to further flexion 135.5 degree on average. Clinical results using Mayo elbow performance score were as follows; six excellent, three good. Compressive neuropathy of ulnar nerve which has been done anterior transposition was observed in one patient. CONCLUSION: Triceps sparing posterior approach is useful surgical technique that provides sufficient exposure of medial and lateral condyle without injury of triceps muscle in intra-articular fracture of distal humerus to the extent of OTA type C2.

Radiologic Result of Treatment of Intertrochanteric Fracture Using Compression Hip Screw: Involvement of Lateral Cortex

PURPOSE: To assess the meaning of the unstable intertrochanteric fracture of femur with involvement of lateral cortex by analysing the radiologic result of the surgical treatment using a compression hip screw. MATERIALS AND METHODS: Classifing patients (who has taken the surgical treatment for intertrochanteric fracture of femur using compression hip screw from January 1999 to June 2002) in our hospital with 24 patients who had not much difference statistically in the compression screw located within the femur, Tip-Apex distance (TAD) the Singh Numerical Value of osteoporosis. The results were divided into two groups, group A (without fracture extends through lateral cortex of femur: 16 cases) and B (fracture extends through lateral cortex of femur: 8 cases), when analyzing it. And then analyzed the final examination in the evaluation of electrical potential level by radiology, change of the inside and outside of neck-shaft angle, descent level of the screw and the change of the neck-shaft angle. RESULTS: In the latest follow up, the sliding amount of the screw in group B, the average was 14.9+/-9.3 mm, and 6.7+/-3.6 mm in group A. There was no difference statistically (p value>0.05). In the varus change in group B, the average was 8.00+/-8.12degrees and in group A it ws 2.75+/-2.63degrees There was statistical difference(p value<0.05). In displacement after operation, it was 7.60+/-2.61 mm in group B and 0.5+/-1.80 mm in group A. There was statistical difference (p value<0.05). CONCLUSION: The intertrochanteric fracture with involvement of lateral cortex of femur have to be considered as unstable fracture having tendency of displacement.