Arthroscopic Treatment of Symptomatic Internal Snapping Hip with Combined Pathologies

BACKGROUND: Arthroscopic iliopsoas tendon release was introduced in 2000. The purpose of this study was to evaluate clinical outcomes of arthroscopic iliopsoas tendon release for painful internal snapping hip with concomitant hip pathologies. METHODS: Between January 2009 and December 2011, we performed arthroscopic iliopsoas tendon release and related surgeries in 25 patients (20 men and 5 women; mean age, 32 years; range, 17 to 53 years) with combined intraarticular hip pathologies. The patients were followed for a minimum of 2 years postoperatively. Clinical and radiological evaluations were performed. RESULTS: Snapping sounds had disappeared by the 2-year follow-up in 24 of the 25 patients. All patients who had presented with loss of flexion strength postoperatively showed recovery at postoperative week 6 to 10. Harris hip score improved from 65 points (range, 46 to 86 points) preoperatively to 84 points (range, 67 to 98 points) postoperatively (p < 0.001). Seven hips (28%) had an excellent score, 15 hips (60%) a good score, 2 hips (8%) a fair score, and one hip (4%) a poor score (p < 0.001). The Tonnis grade of osteoarthritis did not change in any of the patients at the last follow-up. CONCLUSIONS: Patients with painful internal snapping hip have combined hip pathologies. Therefore, the surgeon should keep in mind that painful internal snapping hips are frequently combined with concomitant intraarticular pathologies.

Undertreatment of Osteoporosis Following Hip Fractures in Jeju Cohort Study

BACKGROUND: Osteoporosis treatment following hip fracture is well known to not enough. We previously performed intervention study for orthopaedic surgeon's education and reported twofold increase in osteoporosis detection and treatment rate observed between 2005 and 2007. This follow-up observational study was conducted to find out the rate in which a diagnostic workup and treatment for osteoporosis were done in patients with hip fracture. METHODS: Medical records and radiographs in patients who were older than 50 years and diagnosed as having femoral neck or intertrochanteric fractures at 8 hospitals in Jeju island, South Korea from 2008 to 2011 were reviewed. The numbers of patients who were studied with bone densitometry and who were treated for osteoporosis after the diagnosis of hip fracture were analyzed. RESULTS: Nine hundred forty five hip fractures (201 in 2008, 257 in 2009, 265 in 2010, and 304 in 2011) occurred in 191 men and 754 women during the study periods. The mean age of the patients was 79.7 years. The mean rate of osteoporosis detection using dual energy X-ray absorptiometry was 36.4% (344/945 hips) (ranged from 24.2% in 2009 to 40.5% in 2011). The mean initiation rate of osteoporosis treatment was 23.1% (218/945 hips) (ranged from 20% in 2009 to 29% in 2008). CONCLUSIONS: Detection and treatment rate of osteoporosis following hip fracture during follow-up periods was still not enough. Additional intervention studies are required to further improvement of osteoporosis treatment rates after hip fracture.

Anomalous Course of Superficial Peroneal Nerve in Distal Fibular Fracture / 대한정형외과학회잡지

PURPOSE: The purpose of our study was to assess the anomalous location and course of the superficial peroneal nerve (SPN), which were come across during exposure of distal fibula fracture. MATERIALS AND METHODS: We operated on 238 cases of ankle fractures, and examined the anomalous location and course of SPN around the distal part of the fibula. The study was performed prospectively. RESULTS: The mean length of surgical exposure was 9.8 cm. In 10 (4%) of 238 cases, the nerve was anomalous in its course, which was in parallel with the distal fibula and rapidly curved anteriorly at 3.5 cm proximal to the tip of the fibula. We found 3 cases of injury to the SPN; one was completely transected, the second was partially transected, and the third was stretched over the fracture site, at 2.5 cm, 5 cm, and 6 cm proximal to the tip of distal fibula, respectively. CONCLUSION: We emphasize the importance of a detailed neurologic examination, including sensory test for patients with ankle fractures, because of the variation in course of the SPN around the distal fibula.

Is It a Simple Stress Fracture or Bisphosphonate-related Atypical Fracture?

A number of reports regarding atypical fractures of the femur have raised questions concerning the possible correlation between long-term bisphosphonate treatment and the occurrence of insufficiency fractures in the proximal femur. However, clinically, it is often confused whether is it a fatigue fracture because of implant induced stress concentration or a bisphosphonate-related atypical fracture, especially in a patient with a subtrochanteric fracture who receive bisphosphonate therapy after open reduction and internal fixation, such as dynamic hip screw (DHS) fixation for previous ipsilateral femoral neck or intertrochanteric fracture. The authors experienced a case of a progressive femoral insufficiency fracture in a woman who had been on Fosamax (Alendronic acid with Vitamin D; Merck & Co. Inc, NJ, USA) therapy for four years after ipsilateral femoral neck fracture treated with a two hole DHS system. Despite a high suspicion of an insufficiency femoral subtrochanteric fracture by bone scan, the occult fracture progressed to a displaced femoral subtrochanteric fracture one year after. The fracture site was fixed with a 6 hole DHS plate, and six months after reoperation the patient had no symptoms and the fracture site had united without any complication.

Sequential Bilateral Insufficiency Fractures of the Femur Neck in Patients Treated with Prolonged Bisphosphonate Therapy: A Case Report

The relationship between long-term bisphosphonate usage and insufficiency fracture in osteoporotic elderly patients has been increased interest in recent years. Most reported insufficiency fractures are predominantly concentrated on proximal femoral shaft or pelvic bone. However, there was no report about insufficiency femoral neck fracture after long term use of bisphosphonate in domestic. We experienced a rare case of a 70-years-old woman who was diagnosed with bilateral insufficiency femoral neck fracture after 8 years use of alendronate. We performed an internal fixation using 6.5 mm diameter cannulated screws for the both insufficiency femoral neck fracture. Symptoms disappeared immediately after the surgery and there was no radiologic and clinical complication such as nonunion or delayed union up to the latest follow-up at 12 months postoperatively.

A Case of Isolated, Localized Form, Pigmented Villonodular Synovitis of the Proximal Tibiofibular Joint

To the best of our knowledge, there have been no documented cases of isolated pigmented villonodular synovitis in the proximal tibiofibular joint in Korea. We have experienced satisfactory outcome by performing excision in a patient who has isolated, localized form, pigmented villonodular synovitis in the proximal tibiofibular joint. We report on this case along with briefly reviewing the related literature.

Calcifying Aponeurotic Fibroma: An Atypical Case

Calcifying aponeurotic fibroma is a very rare benign soft tissue tumor with predilection for the fingers and palms of children and adolescents. We describe an unusual case of a calcifying aponeurotic fibroma in old age that circumferentially involved the dorsal and palmar side of the third metacarpal head.We performed a wide excision using two incisions, resulting in satisfactory clinical result. A calcifying aponeurotic fibroma must be considered in the differential diagnosis of a calcifying soft tissue lesion occuring in the hand of old age.

Radiologic Analysis and Treatment of Posterior Malleolar Fractures of the Ankle

PURPOSE: The purpose of this study was to classify posterior malleolar fractures according to the position of fragments and to analyze radiologic features of each type. MATERIALS AND METHODS: We analyzed forty-six patients of ankle fractures involving a posterior malleolus who were treated between January 2004 and December 2007. The posterior malleolar fractures were categorized into three types (posterolateral, posteromedial, shell) based on the major fracture line. In each type, we analyzed amount of displacement, involvement of articular surface, existence of subluxation and osteochondral impacted fragments. RESULTS: The forty-six patients were categorized into three types: Posterolateral (PL) type (33 cases, 72%), Posteromedial (PM) type (8 cases, 17%), shell type (5 cases, 11%). Of the 8 cases with PM type, 7 cases showed displacement more than Grade II, 4 cases showed subluxation of ankle joint, and 3 cases showed osteochondral impacted fragment. Average involvement of articular surface of PM type is 35% (15~65%). CONCLUSION: Posterior malleolar fractures with medial extension tended to have adverse effect on ankle stability and Preoperative CT scan is essential for evaluation of fracture type and determination of appropriate surgical approach.

Matrix Metalloproteinase-1 and Transforming Growth Factor-beta1 Expression during Distraction Osteogenesis and Fracture Healing of the Rat / 대한정형외과학회잡지

PURPOSE: To evaluate the temporal and spatial expression of Transforming Growth Factor-beta1 and Matrix Metalloproteinase-1 in distraction osteogenesis and fracture healing models. MATERIALS AND METHODS: Distraction osteogenesis was performed on the tibial diaphyses of Sprague- Dawley rats (latent period for 1 week, distraction for 2 weeks). The rats were euthanized at each week and the level of mRNA expression was assessed by real-time RT PCR and immunohistochemical staining. RESULTS: Although the level of TGF-beta1 mRNA and MMP-1 mRNA expression was increased during distraction osteogenesis and fracture healing, the level of mRNA expression was significantly higher in the distraction phase in the distraction group than in the fracture healing group at the same phase. After the distraction phase, the level of mRNA expression in both groups decreased to the base line. The peak expression of mRNA was followed by that of TGF-beta1 mRNA. Immunohistochemical staining revealed that TGF-beta1 was expressed mainly in the osteoblast and endothelial cells, and MMP-1 was expressed mainly in the endothelial cells of the vessel. CONCLUSION: There is specific time sequence in the expression of TGF-beta1 and MMP-1 during fracture healing and distraction osteogenesis. These results suggest that TGF-beta1 expression might be associated with the angiogenesis induced by MMP-1 expression during new bone formation.

Nonunion with a Bony Defect of the Humerus: Treatment by Shortening

PURPOSE: To evaluate clinical results and advantage of interposition and shortening technique for the treatment of the humeral nonunion with bone defect. MATERIALS AND METHODS: Eight patients with the humeral nonunion with bone defect underwent interposition of fragments and shortening had been followed-up for more than one year (mean 70 months, 16~156). There were 4 men and 4 women with a mean age of 60.5 years (range, 48 to 75 years). There included 3 proximal, 3 diaphysis and 2 distal metaphysis according to the site, mean size of the bone defect was 3.3 cm (2~5). The time to union, discrepancy of upper extremity, functional results, cosmetic satisfaction and postoperative complications were assessed. RESULTS: All patients achieved to bone union, average union time was 10.2 weeks (range 8~14). Average limb discrepancy was 2.3 cm. All had improvement in shoulder and elbow motion after operation. Seven patients were satisfied with the cosmetic result and none had functional deficit due to limb discrepancy. CONCLUSION: Treatment by Interposition of fragments and shortening in the intractable nonunion of humerus with a bony defect can achieve not only good functional result, shortened bone union time and improved in shoulder and elbow motion.

Mode of Fixation Failures of Dynamic Hip Screw with TSP in the Treatment of Unstable Proximal Femur Fracture: Biomechanical Analysis and a Report of 3 Cases / 대한정형외과학회잡지

There are few reports of the failure mode of a dynamic hip screw with a trochanteric stabilizing plate (TSP) in the treatment of unstable proximal femur fractures. We present 3 cases of fixation failure of a TSP used to treat unstable intertrochanteric fractures. All cases had the same type of failure mode, which represented a fatigue fracture of the distal screw at the junction of a plate and screw. Non-union occurred in 2 cases, and one case was an incidental finding 4 years after union. Biomechanical analysis and SEM (scanning electron micrograph) examination was also performed. Adding TSP to the plate might increase the level of shear stress and slip motion in the distal screw followed by a fatigue fracture. SEM of the surface of the broken screw revealed a multiple cycle and low stress fatigue fracture. Recommendations are made regarding the implant design and surgical technique.

Effect of Carboxy Methyl Chitosan on Experimental Osteoarthritis in a Rabbit Knee: Carboxy methyl chitosan vs. Hyaluronan / 대한정형외과학회잡지

PURPOSE: This study evaluates the effect on carboxy methyl chitosan on the articular cartilage of an osteoarthritic knee. MATERIALS AND METHODS: The biological effect of chitosan on the osteoarthritic articular cartilage was compared with hyaluronan, which is one of the treatment modalities for an osteoarthritic knee. Chitosan or hyaluronan were injected into the intraarticular space of the experimental osteoarthritic knee of a rabbit with a transected anterior cruciate ligament at weekly intervals for 5 weeks, and the articular cartilage and synovium were obtained. Nine weeks later, the specimens were analyzed by their gross findings, histological examinations, and histo-morphometric studies. RESULTS: The hyaluronan and chitosan group showed less severe osteoarthritic changes than the control group. Although the hyaluronan group showed less severe osteoarthiricic changes than the chitosan group, there was no statistical significance. CONCLUSION: Carboxy methyl chitosan, which has an excellent affinity to the body, appeared to have an positive effect on delaying the progress of cartilage degeneration.

Analysis of the Orientation of Lumbar Isthmic Defect / 대한정형외과학회잡지

PURPOSE: We analyzed angles of defect planes of spondylolysis from coronal plane using axial computed tomography to identify the problem of 45degrees oblique plain radiograph by which we routinely has used and to suggest an appropriate radiological diagnostic tool for spondylolysis. MATERIALS AND METHODS: From January 2001 to July 2002, 84 cases of spondylolysis from 44 patients were studied. The diagnosis of spondylolysis was confirmed with axial computed tomography in all cases and angles of isthmic defect from coronal plane were measured. We intended to assess the distribution of angles of isthmic defect and analyzed the result of plain radiographs which were obtained in the direction parallel to the angle of the mean value. RESULTS: Although angles of lumbar isthmic defects have a wide distribution, the mean value was 20.9+/- 9.5degrees which was nearer to coronal plane than 45degrees oblique plane. Fifty eight cases were distributed within 23degrees from coronal plane. A diagnostic sensitivities were 88.1% in lateral view, 78.6% in 45degrees oblique view and 100% in 20degrees oblique view, so a 20degrees oblique view seemed to be more sensitive in diagnosis of lumbar isthmic defect. CONCLUSION: Because the mean angle of lumbar isthmic defects from coronal plane was about 21degrees, obliqueview with 20degrees was more appropriate and sensitive diagnostic tool for spondylolysis than oblique view with 45degrees which have been used routinely.

Intramuscular Ganglion of the Peroneus Muscle Mimicking Peroneal Compartment Syndrome: A Case Report / 대한정형외과학회잡지

Ganglia around the proximal tibiofibular joint usually occur within the synovial membrane, tendon sheath, or peroneal nerve, but rarely within muscle. A 30 year old male had a painless lump over the lateral aspect of a leg, weakness of dorsiflexion of the ankle and diminution of sensation on the dorsum of the foot, which was suspected to be peroneal compartment syndrome. We experienced a case of an intramuscular ganglion that developed in the peroneus longus and brevis muscle mimicking peroneal compartment syndrome which was satisfactorily treated by excision.

Anatomical Assessment of the Proper Insertion Site for a Tibial Nailing

PURPOSE: To investigate the proper insertion site for a tibial intramedullary nail in the Korean. MATERIALS AND METHODS: Forty volunteers without trauma below knee joint were studied to determine relationship between central axis of medullary canal and lateral tibial spine, patellar tendon and the proper insertion site, and to evaluation changes of proper insertion site during rotation of knee and effective diameter. RESULTS: The proper insertion site located average 4.3+/-0.9 mm medial to the lateral tibial spine. The proper insertion site was in the medial 1/3 of patellar tendon in 6 knees, middle 1/3 of patellar tendon in 20 knees, and lateral 1/3 of patellar tendon in 14 knees. The proper insertion site might be changed two times in internal rotation more than in external rotation. The effective diameter was more narrow in medial slope than in lateral slope at proximal tibia. CONCLUSION: The study indicates the ideal insertion site of tibial nail is the medial aspect of the lateral tibial spine in Korean. To reduce the mal-reduction from a improper insertion site, lateral insertion site might be safer than medial one. However, individual variations in the relationship between the patellar tendon and tibial medullary canal should be considered.

Expression of MMP-2 in the Healing Process of Acute Tear of the Rotator Cuff Tendon in Rats / 대한정형외과학회잡지

PURPOSE: Rotator cuff diseases combined with cuff tear are the most common causes of pain and disability of the upper extremity. Most rotator cuff tears are of partial thickness and respond well to conservative treatment. Many authors have addressed the capacity of cuff tendon healing, but little is known of the precise healing process. The MMPs (matrix metalloproteinases) are synthesized and secreted from connective tissue cells and are known to participate in the degradation and remodeling of organs in both normal and pathologic states. Using a rat model, we studied the healing process of rotator cuff tendon tear with reference to the expression of MMP-2. MATERIALS AND METHODS: Forty Mature Sprague-Dawley rats were used in this anima study. Twenty rats were assigned to the experimental group, the other twenty to the control group. In the experimental group, a partial thickness tear of the rotator cufft tendon was made and rats were examined 4 weeks after surgery. RESULTS: On gross inspection, the defects were covered with granulation tissue, and on microscopic evaluation, proliferation of fibrob-lasts and vessels at the defect demonstrated the healing capacity of rotator cuff tendon. The expression of MMP-2 was determined by immunohistochemistry and RT-PCR. Immunohistochemistry demonstrated MMP-2 positively stained cells at the defect site. Also, RT-PCR demonstrated MMP-2 expression. CONCLUSION: These results suggest that the remodeling and healing processes of injured rotator cuff tendon are associated with the expression of MMP-2.

Surgical Treatment of Intercondylar Fracture of the distal Humerus through the Modified Triceps Sparing Approach / 대한정형외과학회잡지

PURPOSE: We evaluated the therapeutic results of intercondylar fractures of the distal humerus that were treated through the modified tricepssparing approach. MATERIALS AND METHODS: From February, 1997 to september, 2001, we reviewed sixteen cases of intercondylar fracture of the distal humerus, which were treated by surgical treatment. The follow up period ranged from one year to three years, averaging 1 year 8 months. The articularsurface of the distal humerus was exposed through elevation of the triceps from the medial and the lateral intermuscular septum. Theulna nerve was identified and protected, and then, the fracture sites were fixed with double plates. The functional results were evaluated using Broberg and Morrey's functional scale. RESULTS: All united at 14.5 weeks in an average. The functional results were as follows; three excellent, ten good, two fair and one poor. The range of the elbow joint motion was flexion contracture 11 degree to further flexion 130 degree in average. The one patient presented poor result had coronal shear fracture of the capitulum combined with severe comminution. The incomplete ulnar nerve palsy developed in one case. CONCLUSION: The modified triceps sparing approach provided sufficient exposure for rigid fixation of intercondylar fracture of the humerus. But in cases with severe comminution or coronal shear fracture, additional anterior approach or olecranon osteotomy should be considered.

Operative Treatment of Complete Dislocation of the Acromioclaviclar Joint with a Wolter Plate / 대한정형외과학회잡지

PURPOSE: We studied to analyse the results of Wolter plate fixation for the treatment of complete acromioclavicular joint dislocation. MATERIALS AND METHODS: From September 1999 to August 2000, 20 patients with complete dislocation of the acromioclavicular joint were treated by Wolter plate fixation. The radiologic and clinical outcomes were evaluated by UCLA scoring. The mean duration of follow up was fifteen months. RESULTS: Functional outcomes at the last follow up were excellent in eleven (55%), good in seven (35%) and poor in two cases (10%). The mean preoperative coracoclavicular interval on the injured side was 200% versus the normal side, and after operation this was 15%. In one case of an elderly patient, the plate was removed at 6 weeks due to loss of fixation. CONCLUSION: The Wolter plate fixation for complete acromioclavicular joint dislocation was considered as one of the effective method. But careful attention should be taken to prevent possible acromial fracture in the elderly.

Surgical Treatment of Malleolar Fracture with or without Use of a Tourniquet / 대한정형외과학회잡지

PURPOSE: To determine the advantage and disadvantage of using tourniquet in the malleolar fracture treated with open reduction and internal fixation. MATERIAL AND METHOD: Randomized 12 patients were operated on with use of a tourniquet (Group T), and 12 patients without use of a tourniquet (Group NT). The operation time, the technical difficulty during operation, the incidence of postoperative complication and the intensity of postoperative pain were compared between the two groups. RESULT: The demographic of the two groups, including age, sex, fractire type, and delay after injury were similar. The average duration of the operation and the technical difficulty during operation were similar between the both group (76min. in Group T, 81min in Group NT, p=0.28) There were no severe complications, however, Four patients had local redness and oozing (3 in group T, 1 in group NT). The patients in group T had higher VAS (Visual Analogue Scale, p=0.014) and more frequencies of analgesic injection (p=0.03) than within 24 hours after operation than those in Group NT, which difference was more significant in male patients and the patient of more than 40-year old. CONCLUSION: Open reduction and internal fixation of the malleolar fracture without use of a tourniquet can be performed with little difficulty and the severity of postoperative pain and the incidence of postoperative complication can be reduced.

Tardy Ulnar Nerve Palsy after Olecranon Fracture: 3 Cases Report / 대한정형외과학회잡지

There has not been reported that the tardy ulnar nerve palsy could be developed as a sequelae of the olecranon fracture. The purpose of this paper is to report our experience of diagnosis and treatment of tardy ulnar nerve palsy, developed in three patients who had managed for non-union and malunion of olecranon fractutre, with a review of the literature.