Fragility Fractures of the Pelvis and Sacrum

The incidence of fragility fractures of the pelvis (FFP) has increased significantly due to the aging popu-lation and improved diagnostic modalities. The evaluation and treatment of these patients differ from that of high-energy pelvic ring injuries typically seen in younger patients. Therefore, it is important to classify the FFP by patterns of the classification system to standardize optimal treatment criteria and appropriate treatment strategy. However, some cases are not classifiable according to the FFP classifi-cation. A newly proposed classification that can be verified by comparing existing FFP classifications isneeded to overcome the weak points. Non-operative treatment is usually considered first and should focus on early mobilization. Operative fixation should focus on stabilizing the minimally invasive pelvic ring than the reduction of fractures to facilitate early mobilization and avoid complications that can arise from comorbidities associated with immobility.

Association of Body Mass Index and Fracture Risk Varied by Affected Bones in Patients with Diabetes: A Nationwide Cohort Study

Background@#Body mass index (BMI) is a risk factor for the type 2 diabetes (T2DM), and T2DM accompanies various complications, such as fractures. We investigated the effects of BMI and T2DM on fracture risk and analyzed whether the association varied with fracture locations. @*Methods@#This study is a nationwide population-based cohort study that included all people with T2DM (n=2,746,078) who received the National Screening Program during 2009–2012. According to the anatomical location of the fracture, the incidence rate and hazard ratio (HR) were analyzed by dividing it into four categories: vertebra, hip, limbs, and total fracture. @*Results@#The total fracture had higher HR in the underweight group (HR, 1.268; 95% CI, 1.228 to 1.309) and lower HR in the obese group (HR, 0.891; 95% CI, 0.882 to 0.901) and the morbidly obese group (HR, 0.873; 95% CI, 0.857 to 0.89), compared to reference (normal BMI group). Similar trends were observed for HR of vertebra fracture. The risk of hip fracture was most prominent, the risk of hip fracture increased in the underweight group (HR, 1.896; 95% CI, 1.178 to 2.021) and decreased in the obesity (HR, 0.643; 95% CI, 0.624 to 0.663) and morbidly obesity group (HR, 0.627; 95% CI, 0.591 to 0.665). Lastly, fracture risk was least affected by BMI for limbs. @*Conclusion@#In T2DM patients, underweight tends to increase fracture risk, and overweight tends to lower fracture risk, but association between BMI and fracture risk varied depending on the affected bone lesions.

Factors Affecting Periprosthetic Bone Loss after Hip Arthroplasty / 대한고관절학회지

Periprosthetic bone loss may lead to major complications in hip arthroplasty, including aseptic loosening, implant migration, and even periprosthetic fracture. Such a complication leads to revision surgeries, which are expensive, technically demanding, and result in a low satisfaction rate. Therefore, a study was conducted of the factors affecting the periprosthetic bone loss around the stem that caused these complications. Factors influencing periprosthetic bone loss include demographic factors such as age, sex, obesity, smoking, and comorbidity including diabetes and osteoporosis. The implant design and fixation method are also factors that are determined before surgery. In addition, there are surgical factors, such as surgical approach and surgical technique, and we wish to investigate the factors affecting periprosthetic bone loss around the stem by comparing the effects of postoperative rehabilitation protocols and osteoporosis drugs.

Closed Reduction of Irreducible Posterolateral Rotatory Knee Dislocation / 대한정형외과학회잡지

In general, most knee dislocations are reduced easily by simple traction. In rare cases, closed reduction of the knee dislocation is attempted, but ruptured ligaments or muscles are stuck in the joints and cannot be reduced. The cases of this irreducible knee dislocation have sometimes been reported. The authors encountered a case of irreducible knee posterolateral rotational dislocation that was not reduced by simple traction and report it along with a review of the literature. This case provides an opportunity for clinicians to examine the clinical considerations when experiencing an irreducible knee dislocation.

May–Thurner Syndrome with Deep Vein Trombosis after Total Knee Arthroplasty / 대한정형외과학회잡지

May–Thurner syndrome (MTS), also known as iliac vein compression syndrome, is a condition, in which compression of the commonvenous outflow tract of the left lower extremity can cause discomfort, swelling, pain or blood clots in the iliofemoral veins. The problemis due to left common iliac vein compression by the overlying right common iliac artery. This paper describes the case of a 75-year-oldfemale with MTS after performing right total knee replacement arthroplasty. The authors diagnosed MTS through intravenous angiographyand angiographic computed tomography on swelling and pain of the left lower extremities after performing right total knee replacementarthroplasty. The thrombus was removed using a thrombolytic agent and mechanical thrombectomy, and an intravenous stent then insertedafter angioplasty. No case of MTS after performing total knee replacement arthroplasty has been reported in Korea. Therefore, this case isreported along with review of the relevant literature.

Intrapelvic Migration of the Lag Screw with Wedge Wing from Dyna Locking Trochanteric Nail: A Case Report and Literature Review / 대한고관절학회지

The intrapelvic migration of cervicocephalic lag screws is a rare complication after intertrochanteric fracture synthesis with an intramedullary nail. Only 15 cases of intrapelvic penetration by three different instrument systems have been described in the literature. However, to our knowledge, there is no report of intrapelvic migration of the lag screw with wedge wing designed to increase fixation power using the Dyna locking trochanteric (DLT) nail. We present a case of intrapelvic migration of the lag screw with wedge wing from DLT nail. The patient described herein underwent a two-staged operation of implant removal without intrapelvic approach followed by bipolar hemiarthroplasty. With intrapelvic migration conditions, although it is not uncommon to require an additional intrapelvic approach, this modification can lead to lethal consequences. For this reason, it is recommended to coordinate with the vascular surgery department due to the close proximity of the major vessels.

Total Hip Arthroplasty after Acetabular Fracture: Acute Phase and Delayed Phase

The incidence of acetabular fractures in the elderly has increased because of the increasing elderly population. To determine the treatment plan for acetabular fractures, the patient's age, gait ability, presence or absence of osteoporosis and osteoarthritis, underlying disease, and fracture pattern should be considered. The application of total hip arthroplasty for acetabular fractures with the proper indications can be expected to have a good prognosis. In this paper, the application of total hip arthroplasty as a treatment method for acetabular fractures is divided into acute and delayed phases.

Short-term Outcomes of Ceramic Coated Metal-on-Metal Large Head in Total Hip Replacement Arthroplasty / 대한고관절학회지

PURPOSE: This study characterizes the short-term outcomes of ceramic coated metal-on-metal (MoM) large head total hip arthroplasty (THA) in prospectively selected patients aged 70 to 75 years. MATERIALS AND METHODS: Eighteen patients (18 hips) between the ages of 70 and 75-years old with THA using ceramic-coated MoM large heads between June 2014 and December 2014 were evaluated. We prospectively selected patients younger than 70 years for bipolar hemiarthroplasty and older than 75 years for conventional THA. There were one case of osteoarthritis, 8 cases of femur neck fracture, and 9 cases of intertrochanteric fracture. All patients underwent clinical and radiological follow-up at 6 weeks, 6 and 12 months, and every year postoperatively. The mean duration of follow-up was 24.2 months (range, 18–34 months). RESULTS: The average Harris hip score at the final follow-up was 81.0, except one case which was ultimately converted to conventional THA due to acetabular cup loosening. Radiographically, mean acetabular cup inclination was 45.8°(range, 38–56°) and anteversion was 20.1° (range, 11–25°). The average femoral head size was 48.7 mm. All stems were neutral-positioned except 1 varus-positioned stem. There was 1 case of a soft tissue infection, 3 patients complained of persistent groin pain, and no dislocations occurred. CONCLUSION: Ceramic coated large MOM articulation (ACCIS) have many complications: cup loosening, groin pain, which can lead to fatal outcomes in the elderly patients. Especially in patients with communicated intertrochanter fracture (AO 31-A22, 23), careful attention should be paid to the choice of surgical option.

Open Posterior Approach versus Arthroscopic Suture Fixation for Displaced Posterior Cruciate Ligament Avulsion Fractures: Systematic Review

PURPOSE: To compare the clinical outcomes between the open posterior approach and arthroscopic suture fixation for displaced posterior cruciate ligament (PCL) avulsion fractures. METHODS: A literature search was performed on MEDLINE, EMBASE, and the Cochrane Library databases. The inclusion criteria were as follows: papers written in English on displaced PCL avulsion fractures, clinical trial(s) with clear description of surgical technique, adult subjects, a follow-up longer than 12 months and modified Coleman methodology score (CMS) more than 60 points. RESULTS: Twelve studies were included with a mean CMS value of 72.4 (standard deviation, 7.6). Overall, 134 patients underwent the open posterior approach with a minimum 12-month follow-up, and 174 patients underwent arthroscopic suture fixation. At final follow-up, the range of Lysholm score was 85–100 for the open approach and 80–100 for the arthroscopic approach. Patients who were rated as normal or nearly normal in the International Knee Documentation Committee subjective knee assessment were 92%–100% for the open approach and 90%–100% for the arthroscopic approach. The range of side-to-side difference was 0–5 mm for both approaches. CONCLUSIONS: Both arthroscopic and open methods for the treatment of PCL tibial-side avulsion injuries resulted in comparably good clinical outcomes, radiological healing, and stable knees.

Superior Gluteal Artery Pseudoaneurysm Caused by Pelvic C-Clamp Blind Application: A Case Report / 대한고관절학회지

To control such a hemorrhage, a displaced pelvic ring must be rapidly reduced and stabilized with a pelvic binder, an external fixator, or a pelvic clamp. Among them, pelvic clamps can be life-saving but pin malposition may cause vascular complications. We present a case of superior gluteal artery pseudoaneurysm caused by AO pelvic C-clamp pin malposition.

Underestimated Sacroiliac Joint Lesion on Computed Tomography in Pelvic Open-book Injury: A Case Report / 대한고관절학회지

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis <2.5 cm) injuries. Here authors present a case demonstrating a necessity of intraoperative stress test for excluding concealed posterior ring disruption.

Arthroscopic Treatment of Isolated Teres Minor Tendon Tear: A Case Report

Arthroscopic repair of an isolated teres minor tendon tear without associated shoulder joint pathology has not been reported in the literature. We report on a case of isolated teres minor tendon tear after trauma. The patient complained of severe shoulder pain and progressive limited range of motion 4 months after the injury. Magnetic resonance imaging showed a full-thickness tear of the teres minor tendon at its musculotendinous junction and arthroscopic repair was performed. At 2 years follow-up, satisfactory clinical and radiological outcomes were observed with return to pre-injury level. Here, the authors report this case and provide a review of literature.

Arthroscopic Treatment of Isolated Teres Minor Tendon Tear: A Case Report

Arthroscopic repair of an isolated teres minor tendon tear without associated shoulder joint pathology has not been reported in the literature. We report on a case of isolated teres minor tendon tear after trauma. The patient complained of severe shoulder pain and progressive limited range of motion 4 months after the injury. Magnetic resonance imaging showed a full-thickness tear of the teres minor tendon at its musculotendinous junction and arthroscopic repair was performed. At 2 years follow-up, satisfactory clinical and radiological outcomes were observed with return to pre-injury level. Here, the authors report this case and provide a review of literature.

Complications of Reverse Total Shoulder Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to analyze complications after reverse total shoulder arthroplasty and report the clinical outcomes with review of previously reported studies. MATERIALS AND METHODS: Complications after reverse total shoulder arthroplasty were analyzed for 98 patients who underwent reverse total shoulder arthroplasty and were followed-up for at least 6 months. Of 98 patients, 22 were men and 76 were women. The mean age was 75.0+/-6.5 years (range, 59-92 years) with a mean follow-up period of 22+/-19 months (range, 6-74 months). The types and time of occurrence of complications, methods of treatment, and clinical outcomes at the final follow-up were analyzed. RESULTS: Complications occurred in 18 of 98 patients (18.4%). Seven of them received operative treatment and 11 were treated conservatively. Two cases had postoperative dislocations and were addressed with open reduction. In 2 cases, periprosthetic fractures occurred and were treated with open reduction and plate fixation. Two acromial stress fractures and 8 cases of heterotopic ossification were managed conservatively. Infection and humeral component loosening occurred in one case, respectively, and were treated with revision arthroplasty. Glenoid component loosening occurred in 2 cases, one of which was treated with revision arthroplasty and the other was managed conservatively. At the final follow-up, clinical outcomes showed a statistically significant improvement. Compared to groups with no complications, there were no significant differences in final clinical outcomes. Scapular notching occurred in 43.9% (43/98 cases). No statistically significant differences of clinical outcomes were observed between the scapular notching group and the no notching group (p>0.05). CONCLUSION: In our study, 18% of complications occurred after reverse total shoulder arthroplasty and final clinical outcomes of these complications showed significant improvement. Scapular notching developed in 44% and did not provide a significant clinical effect at short term follow-up.

Dyspareunia Caused by Pelvis Malunion / 대한고관절학회지

In unstable pelvic ring injury, if there is damage to both the anterior and posterior, both anterior and posterior fixation will be needed in order to stabilze the pelvic ring. A female patient complained of dyspareunia due to malunion and additional bone bridge at the inferior ramus of the pelvis. She should have undergone both anterior and posterior fixation, but had undergone anterior fixation only. We report on a patient who was treated successfully with resection of additional bone bridge, scar tissue and adhesive band around the vagina.

Atypical Pelvic Crescent Fracture Caused by Vertical Shear Force / 대한고관절학회지

The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the sacroiliac joint. This fracture represents a subset of lateral compression injury. The strong posterior ligaments of sacroiliac joint remain intact and a fracture fragment (crescent shape) involving the posterior superior iliac spines remains firmly attached to the sacrum. We report a patient with atypical pelvic crescent fracture that is mainly influenced by vertical shear injury and is characterized by posterior fracture-dislocations of the sacroiliac joint. In this case report, we review the literature on classification and treatment of atypical type of crescent fracture.

Exertional Heat Stroke in a Young Man with Multi-organ Dysfunction and Fulminant Pneumonia

Heat stroke is defined as a core body temperature that rises above 40 degrees C accompanied by central nervous system abnormalities such delirium, convulsions or coma. Despite treatment with optimal cooling, heat stroke causes deaths by complications including rhabdomyolysis, renal failure, hepatic dysfunction, disseminated intravascular coagulation syndrome, acute respiratory distress syndrome, bowel ischemia, myocardial injury, and multiple organ failure. In some cases of survival, heat stroke it can cause irreversible CNS damage. Therefore, if exertional heat stroke is properly diagnosed in the emergency room, we must initiate early and aggressive treatment in order to prevent the multiorgan failure and high mortality associated with this condition. To our knowledge, case reports in the literature are rare describing that patients with multiple organ dysfunction and fulminant pneumonia following exertional heat stroke. This study reports on a relevant case, as well as findingsfrom the literature. The case history is presented of a 20- year-old man who presented with exertional heat stroke with sustained hyperpyrexia ongoing after the first day of admission despite optimal treatment including intensive fluid resuscitation. On the 3rd day of admission, chest infiltrated lesions were discovered. From the high-resolution computed tomography results, multifocal consolidations were discovered in both lungs. Blood cultures revealed Staphylococcus hominis. Treatment with proper antibiotics was begun after identifying the blood culture. The patient fully recovered and was discharged on the 10th day after admission.

Arthroscopic Removal of the Intraarticular Fracture Fragment after Internal Fixation of Acetabular Fracture: A Case Report

Osteochondral fragements incarcerated in the hip joint during fracture-dislocation have been reported to be the cause of posttraumatic arthritis, and open reduction of the fracture or removal of the fragments during surgery is recommended. Locking symptoms developed during hip joint movement in a patient with a history of hip joint fracture-dislocation (Thompson and Epstein (T-E) type III) after undergoing internal fixation of the acetabular fracture. Computer tomographic (CT) scan revealed a bony fragment impinging on the acetabular weight-bearing portion. This bony fragment was removed using hip arthroscopy. We recommend that CT evaluation be performed after surgery for acetabular fractures. We also recommend arthroscopic removal as a treatment option for posttraumatic loose bodies in the hip joint.

Fixation for Reattachment of Trochanteric Fragment in Pertrochanteric Fracture Treated with Bipolar Hemiarthroplasty

Purpose: To retrospectively compare the fixation methods for reattaching a trochanteric fragment in a pertrochanteric fracture treated with bipolar hemiarthroplasty. Materials and methods: Forty cases of an unstable femur pertrochanteric fracture were analyzed and followed up for average of 19(6~40) months. There were 18 cases fixed with tension band wiring (group 1), 7 cases treated using modified tension band wiring with K-wires (group 2) and 15 cases treated with the GTRD (Greater Trochanteric Reattachment Device) (group 3). Result: Group 1 was treated with simple a surgical procedure and the results were good. The second group had firm fixation postoperatively but required additional surgery in two cases to remove the K-wires because of wire migration after ambulation. Group 3 had relatively good results but required more dissection and a longer operating time. Conclusion: Tension band wiring or GTRD are good fixation methods for reattaching trochanteric fragments in pertrochanteric fractures. Moreover, tension band wiring is recommended for old osteoporotic patients due to a simple procedure and firm fixation. The use of modified tension band wiring using K-wire or a Steinmann-pin should not be used due to the possibility of distant migration.

A Case of Incidental Epidermolytic Hyperkeratosis Occurring Normal Looking Skin Adjacent to Folliculitic Papules: In Veterans Who Participated in Vietnam War

On histological examination, an epidermolytic hyperkeratosis was observed adjacent to follicular papules on the back of a 53-year-old man. It has been reported that incidental epidermolytic hyperkeratosis occur either within various lesion (epidermal neoplasm, melanocytic neoplasm, scars, and inflammatory conditions) or in the normal skin adjacent to the lesion. This patient participated in the Vietnam War for 2 years, and had had contact with defoliants. He was treated for multiple peripheral neuropathies and cerebral infarcts. In keratinocytes, 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD; Agent Orange) contained in defoliating agents is associated with altered patterns of keratinocyte differentiation. So, as a cause of incidental epidermolytic hyperkeratosis, defoliant contact could be suspected.