Surgical Treatment of Piriformis Syndrome

BACKGROUND: Piriformis syndrome (PS) is an uncommon disease characterized by symptoms resulting from compression/irritation of the sciatic nerve by the piriformis muscle. Uncertainty and controversy remain regarding the proper diagnosis and most effective form of treatment for PS. This study analyzes the diagnostic methods and efficacy of conservative and surgical treatments for PS. METHODS: From March 2006 to February 2013, we retrospectively reviewed 239 patients who were diagnosed with PS and screened them for eligibility according to our inclusion/exclusion criteria. All patients underwent various conservative treatments initially including activity modification, medications, physical therapy, local steroid injections into the piriformis muscle, and extracorporeal shock wave therapy for at least 3 months. We resected the piriformis muscle with/without neurolysis of the sciatic nerve in 12 patients who had intractable sciatica despite conservative treatment at least for 3 months. The average age of the patients (4 males and 8 females) was 61 years (range, 45 to 71 years). The average duration of symptoms before surgery was 22.1 months (range, 4 to 72 months), and the mean follow-up period was 22.7 months (range, 12 to 43 months). We evaluated the degree of pain and recorded the responses using a visual analog scale (VAS) preoperatively and 3 days and 12 months postoperatively. RESULTS: Buttock pain was more improved than sciatica with various conservative treatments. Compared with preoperatively, the VAS score was significantly decreased after the operation. Overall, satisfactory results were obtained in 10 patients (83%) after surgery. CONCLUSIONS: PS is thought to be an exclusively clinical diagnosis, and if the diagnosis is performed correctly, surgery can be a good treatment option in patients with refractory sciatica despite appropriate conservative treatments.

Surgical Treatment for Stable 2-Part Intertrochanteric Femur Fracture Using Dynamic Hip Screw with 2-Hole Side Plate in Elderly Patients

PURPOSE: The purpose of this study is to evaluate the postoperative outcomes of elderly patients with stable 2-part intertrochanteric femur fractures surgically treated using dynamic hip screw with 2-hole side plate. MATERIALS AND METHODS: From February 2008 to January 2014, 50 patients older than the age of 65 years, who had been followed-up for more than 6 months after the operation at The Catholic University of Korea, Bucheon St. Mary's Hospital were enrolled. A clinical evaluation of the skin incision length, operating time, and ambulatory status, using Clawson's Ambulation Capacity Classification, was performed, and a radiologic evaluation of Fogagnolo reduction quality, tip-apex distance (TAD), Cleveland index, sliding extent of lag screws, time duration till bony union, and complications was also done. RESULTS: The mean skin incision length was 9.8 cm (range, 8-13 cm), the mean operating time was 41.4 minutes (range, 30-60 minutes), and 32 patients recovered their ambulatory function. Forty-eight patients gained bony union, and the time lapsed till union was average 10.6 weeks (range, 8-16 weeks). The evaluation of postoperative radiologic images showed the following reduction statuses by the Fogagnolo classification: 46 cases of "Good", 3 cases of "Acceptable," and 1 case of "Poor." Moreover, the mean TAD was 18.9 mm (range, 9.0-24.9 mm). While 45 cases fit into the zone 5 of the Cleveland index, other 3 were within zone 8 and the other 2 were within zone 6. The mean sliding length of the lag screws were 4.9 mm (range, 0.1-19.4 mm). There were a case of nonunion and a case of periprosthetic infection with nonunion as complications. CONCLUSION: Using dynamic hip screws with 2-hole side plate for stable 2-part intertrochanteric femur fractures in elderly patients showed satisfactory results with respect to the recovery of ambulatory functions and bony union.

Comparison of Perioperative Blood Loss in Primary Non-cemented Total Hip Arthroplasty for Rapidly Destructive Coxarthrosis and Osteonecrosis of the Femoral Head / 대한고관절학회지

PURPOSE: The purpose of this study is to compare the perioperative blood loss in primary non-cemented total hip arthroplasty (THA) performed for rapidly destructive coxarthrosis (RDC) with the perioperative blood loss in primary non-cemented THA for typical osteonecrosis of the femoral head (ONFH). MATERIALS AND METHODS: From January 2000 to December 2013, 19 patients were diagnosed with RDC (group 1) and 40 patients were diagnosed typical Ficat stage IV ONFH (group 2), comparison of perioperative blood loss between group 1 and group 2 in primary noncemented THA was done. Patients with preoperative usage of steroid or anticoagulants medication and with hemodynamic abnormal blood test results were excluded. The blood loss was measured up to the fifth post operation day and calculated with formula proposed by Mercuriali, Inghilleri and Nadler. RESULTS: Non-compensated blood loss calculated in milliliters of red blood cells was 362 mL (standard deviation [SD], 187; range, 77-675) in group 1 and 180 mL (SD, 145; range, 53-519) in group 2. Compensated blood loss was 630 mL (SD, 180; range, 380-760) in group 1 and 503 mL (SD, 260; range, 190-1, 505) in group 2. The total blood loss after primary non-cemented THA is greater when surgery is performed for RDC than for ONFH, with the volume of 992 mL (SD, 300; range, 457-1, 434) in group 1 and 683 mL (SD, 360; range, 226-1, 975) in group 2 respectively. CONCLUSION: Total perioperative blood loss was significantly greater in RDC than in ONFH in primary non-cemented THA.

Metal-on-metal Articulation of Total Hip Replacement / 대한고관절학회지

Metal-on-metal (MoM) total hip replacement (THR) and hip resurfacing have an advantage of low wear rate and greater stability by larger head size and different characteristics of wear mechanism, tribology, lubrication or generating wear debris compared to conventional metal-on-polyethylene THR. Although the mid- or long term clinical reports of second generation MoM THR were excellent, concerns about local and systemic effect by metal particles or metal ions were remained. Recently, reports have emerged of abnormal soft-tissue reactions to metal particles or metal ions and some hip resurfacing implants were expelled from the market due to high revision rate. This article includes the history of MoM THR, tribology, the biologic effect of metal particles and ions, the clinical results of MoM THR and the issues regarding the problems associated with hip resurfacing.

Treatment of Intertrochanteric Fracture of the Femur Using a Dyna Locking Trochanteric (DLT) Nail

PURPOSE: We analyzed the clinical and radiological results after treatment of intertrochanteric fracture of the femur using a Dyna locking trochanteric (DLT) nail. MATERIALS AND METHODS: From March 2008 to February 2009, 36 patients (10 males and 26 females) who had at least 6 months follow-up among 43 patients were included in our study. The average age of the patients was 76.4 years (range: 65~90 years) and the average follow-up period was 13.4 months (range: 9~21 months). We evaluated the radiological results such as the neck-shaft angle and the sliding length of the lag screw at last follow-up and the clinical results such as intraoperative complications, the operation time, the postoperative blood loss and the incidence of fixation failure. RESULTS: The average neck-shaft angle at last follow-up was 131.1 degrees and the average sliding length of lag screw was 3.6 mm. Two cases (5.6%) of femoral shaft fracture during the insertion of a lag screw or nail happened and one case of stress fracture of the femoral neck occurred. Two cases of fixation failure developed due to deep infection or varus angulation. CONCLUSION: Fixation using a DLT nail can be a good option for the treatment of intertrochanteric fractures of the femur.

Treatment of Intertrochanteric Fractures in Patients with Severe Osteoporosis with Dynamic Compression Hip Screws

PURPOSE: The purpose of this study was to compare the clinical results in the treatment of femoral intertrochanteric fractures with dynamic compression hip screws (DHS) in patients with or without osteoporosis. MATERIALS AND METHODS: Between March 2003 and February 2006, the clinical results in the treatment of intertrochanteric fractures of the femur with DHS in patients with severe osteoporosis (T score-2.5; 46 patients [group 2]) were reviewed. We retrospectively compared the mortality rate, the incidence of postoperative complications or fixation failures, and the patterns between the two groups. RESULTS: The mortality rate in group 1 was 30.4% at postoperative 1 year and 21.4% at 6 months. The mortality rate at 1 year was 21.8% in group 2 (p<0.05). There were no differences in fracture patterns according to the AO/OTA classification between the two groups. However, the incidence of fixation failures were 19.6% in group 1 vs. 13.0% in group 2 (p<0.05). CONCLUSION: There was a higher postoperative mortality rate at 1 year (30.4% vs. 21.4%), and the incidence of fixation failures (19.6% vs. 13.0%) in the treatment of osteoporotic intertrochanteric fractures by DHS in osteoporotic compared to non-osteoporotic fractures.

Anatomy and Biomechanics of the Hip

The ball and socket structure of the hip joint allows a wide range of motion that is exceeded in no other joint of the body except the shoulder. At the same time, a remarkable degree of stability is provided by the close fit of the femoral head into the acetabulum and its deepening lip, the glenoid labrum, and by the support of the strongest capsular ligaments and the thickest musculature of the body. Of all the joints, the hip is most deeply situated. This relative inaccessibility increases the difficulty of diagnosing hip lesions, rendering thorough operative exposure of the joint arduous. Precise knowledge about the anatomy of the hip joint and its surrounding structures help orthopaedic surgeons diagnose and treat various diseases and trauma around the hip joint. An understanding of the biomechanics of the hip is vital to advancing the diagnosis and treatment of many pathologic conditions. Benefits from advances in hip biomechanics include the evaluation of joint function, the development of therapeutic programs for treatment of joint problems, procedures for planning reconstructive surgeries, and the design and development of total hip prostheses. Biomechanical principles also provide a valuable perspective to our understanding of the mechanism of injury to the hip, to femoroacetabular impingement, and to the etiology of degenerative hip disease.

Short Term Results of Cementation of a Polyethylene Liner into a Well-Fixed Metal Shell

PURPOSE: To evaluate the radiological and clinical results of cementation of a polyethylene liner into a well-fixed metal shell in revision total hip arthroplasty. MATERIALS AND METHODS: From November 2001 to April 2006, 11 cases (10 patients) were included in this study. There were 5 males (6 cases) and 5 females with a mean age of 54.3 years. The mean follow-up period was 35.2 months. The acetabular shells were stable and their position was acceptable in all cases. Pre-existing screws were removed and screw holes were filled with allogenic bone. The inner surface of the metal shells and convex backside of the liners were roughened with a burr. The clinical results were evaluated using the Harris hip score (HHS) and the radiological results with evidence of a positional change in the acetabular cup and liner, and the progression of osteolysis around the cup. RESULTS: The mean HHS was 69.5 points preoperatively and 89.2 at the last follow up. There was no change in the cup and liner position or progression of the osteolytic lesion around the femoral or acetabular components. CONCLUSION: Cementation of a polyethylene liner into a well-fixed metal shell showed satisfactory results in revisional total hip arthroplasty with a short term follow-up period.

The Comparision of Mitigative Effect of Alendronate and Risedronate on Particle-Induced Osteolysis: in Mouse Calvarian Model / 대한정형외과연구학회지

PURPOSE: The purpose of this study was to compare the mitigative effect of alendronate and risedronate on osteolysis in the mouse calvarian model by using titanium (Ti) and polymethylmethacrylate (PMMA) particles. MATERIALS AND METHODS: Experimental mice (male C57/BL6) are divided into three groups; control, Ti particle-treated and PMMA particle-treated group. Each Ti and PMMA particle-treated group was divided into three subgroups which received no bisphosphonates, which received alendronate, and which received risedronate. We measured number of osteoclast, area of osteolysis, bone and soft tissue thickness, ratio of bone and total tissue on mid-sagittal suture area (MSSA) and compared between two groups. RESULTS: Both alendronate and risedronate had significant inhibitory effect on Ti or PMMA particle-induced osteolysis in mouse calvarian model (p<0.05). Furthermore, bisphosphonates prevented formation of particleinduced osteolysis as RANK/Fc. Risedronate had better capability for preserving bone thickness in PMMA treated mice and also showed decreased soft tissue thickness in Ti treated mice than alendronate (p<0.05). CONCLUSION: Both alendronate and risedronate may be an effective agents on mitigation of Ti and PMMA particle-induced osteolysis. However, risedronate showed better structual bone preserving capacity than alendronate in particle-treated mouse calvariae.

Factors affecting Fixation Failure in Treatment of Intertrochanteric Fracture of the Femur by Dynamic Compression Hip Screw

PURPOSE: The purpose of this study was to analyze the factors affecting fixation failures of intertrochanteric fractures of the femur treated by dynamic compression hip screw in elderly patients. MATERIALS AND METHODS: Between March 1999 and February 2005, we evaluated 164 cases of intertrochanteric fractures of the femur treated by dynamic compression hip screw. The failure group (group 1) contained 14 cases, and the control group (group 2) contained 150 cases. We compared the fracture pattern, type of reduction, method of fixation, tip-apex distance, location of screw within head, and presence of lateral trochanteric wall fracture between the two groups. The average patient age was 76.1 years (range 63-92) in group 1 and 75.0 years (range 63-93) in group 2. RESULTS: The mode of fixation failure in group 1 included 6 cases of nonunion, 5 cases of varus and cutting-out, 2 cases of excessive sliding of lag screw, and 1 case of plate debonding. There was a significant relationship between the fracture pattern, tip-apex distance, position of lag screw (especially the posterior location), and presence of lateral wall fracture when compared against postoperative fixation failure (P<0.05). The use of bone cement augmentation and the central location of lag screw within the head correlated with the avoidance of cutting-out of lag screw through the head. However, there was no relationship between the type of reduction, the use of additional fixation with a screw, or greater trochanter stabilizing plate when compared against fixation failure. CONCLUSION: The structural integrity of lateral wall support is thought to be an essential factor in successful treatment of unstable intertrochanteric fractures of the femur. Furthermore, methods such as concentric screw placement in the head, minimal tip-apex distance, and cement augmentation may be useful for preventing cutting-out through obtaining secure purchase of the lag screw in the head.

Activation of Transcription Factor NF-kappaB and c-Jun/AP-1 by Various Compositions of Particles in Osteoclast Precursor Cells

PURPOSE: This study was performed in order to investigate the effects of various particle preparations on NF-kappaB and c-Jun/AP-1 activity in osteoclast precursor cells. MATERIALS AND METHODS: Osteoclast precursor cells isolated from C57BL mice were treated with PMMA (polymethylmethacrylate) spheres, polystyrene, titanium particles, and retrieved metal particles from failed cementless total hip replacements. NF-kappaB and c-Jun/AP-1 DNA binding activities were analyzed using electrophoretic mobility shift assays (EMSA). RESULTS: Commercially available PMMA and polystyrene spheres routinely showed negativity on endotoxin assays, but titanium particles and retrieved metal particles consistently showed positivity. PMMA spheres, with a maximal response noted at 30 minutes with an optimal concentration of 0.6 mg/ml, were potent stimulator of NF-kappaB and c-Jun/AP-1 activity in osteoclast precursor cells. Other particles (polystyrene, titanium, metal retrievals) also activated transcription factor NF-kappaB and c-Jun/AP-1 compared to controls. Endotoxin removal from retrieved metal particles diminished the biologic effect by approximately 40%. CONCLUSION: Particles of various compositions and sizes (PMMA, polystyrene, titanium, and retrieved metal particles) activated the NF-kappaB and c-Jun/AP-1 signaling pathways. This suggests that NF-kappaB and c-Jun/AP-1 may have important roles in the pathogenesis of periprosthetic osteolysis.

Simultaneous Dorsal Dislocation of Interphalangeal Joints in the Same Finger: Two Case Report

We treated 2 cases of simultaneous dorsal dislocation of interphalangeal joints in the 5th finger. One case was injured by herperextension during basketball, and treated by open reduction and K-wire fixation. Another case was injured by industrial accident, and treated by splint for 1 week.

Arthroscopic Treatment of Pigmented Villonodular Synovitis of the Knee / 대한정형외과학회잡지

PURPOSE: To evaluate the efficacy of arthroscopic synovectomy through the direct posterior-posterior approach in pigmented villonodular synovitis (PVNS) of the knee. MATERIALS AND METHODS: Between January 1997 and May 2004, twenty-one patients underwent an arthroscopic synovectomy for PVNS of knee. The mean follow-up period was 35 months. The arthroscopic and MRI findings revealed the localized form of PVNS in six patients and the diffuse form in fifteen patients. All patients underwent an arthroscopic examination and synovectomy through the direct posterior-posterior approach. The clinical results were evaluated by the range of motion, Lysholm knee score, and the knee pain score using the visual analogue scale (minimum 0-maximum 10). RESULTS: Among the fifteen cases with the diffuse form, three cases (14%) recurred and had secondary arthroscopic total synovectomy. One cases recurred again. Therefore, radiation therapy was performed. The Lysholm knee score improved from 62.5 to 87.3, and the VAS score improved from 5.9 to 1.8. Three patients had a mild limitation in knee motion. However, the others had full range of motion of the knee at the last follow-up. CONCLUSION: Arthroscopic synovectomy through the direct posterior-posterior approach could be a useful method for the treatment of PVNS of the knee, and can be used as an effective therapeutic tool particularly in posteromedial or posterolateral lesions.

Complete Rupture of Sciatic Nerve by Protruded Kuncher Nail in Pelvic Bone Fracture: A Case Report

Rupture of sciatic nerve is a rare injury in minimally displaced pelvic bone fracture. We report one case of complete rupture of sciatic nerve that were resulted from the extremely protruded Kuncher nail inserted before accident and the preexisting heterotopic ossification with a review of the relevant literature.

Treatment of Femoral Neck Fractures in Patients with Ischemic Heart Disease by Cemented Hemiarthroplasty

PURPOSE: There is a controversy about whether the use of polymethylmethacrylate (PMMA) in orthopedic reconstructive surgery can increase the possibility of cardiovascular dysfunction. This study was undertaken to determine if cemented hemiarthroplasty is safe for treating femoral neck fracture in patients with ischemic heart disease. MATERIAL AND METHODS: Between March 1999 and February 2004, we performed cemented hemiarthroplasties for displaced femoral neck fractures in 158 consecutive patients. This retrospective study consisted of 44 patients with ischemic heart disease (group 1) and 58 age matched control patients (group 2). We compared the mortality rate, the incidence of deep vein thrombosis (DVT), pulmonary embolism, cerebrovascular disease, dislocation and deep infection, the amount of postoperative blood loss and the grade of cementation according to the schema of Barrack on the radiograph between the two groups. RESULTS: No difference was found in the perioperative mortality rate, the deep infection rate, the incidence of DVT or pulmonary embolism, the newly developed heart ischemic events or brain hemorrhagic lesions between the two groups. But there was a greater incidence of dislocation related to weakness from past brain ischemic lesion and the newly developed brain ischemia in group 1 than in group 2 (p<0.05). More importantly, six patients in group 1 had transient symptoms of dyspnea, signs of hypotension and bradycardia within two days postoperatively, which raises suspicions of embolic phenomenon, even though this was not confirmed. CONCLUSION: Close and careful observations should be done for the occurrence of dislocation related to previous brain ischemia, or newly developed brain ischemic lesion or embolic phenomenon. Appropriate thromboprophylaxis is necessary in patients with ischemic heart disease after cemented hemiarthroplasty for the treatment of femoral neck fracture.

Preoperative Use of 3D Computed Tomography for Prediction of Fracture Stability in Treatment of Jensen Type 4 Intertrochanteric Fractures of the Femur

PURPOSE: We wanted to evaluate the efficacy of performing preoperative 3D computed tomography scanning in treatment of Jensen's type 4 intertrochanteric fractures of the femur for predicting the stability of fractures. MATERIALS AND METHODS: From March 2001 to February 2005, 56 patients, who were at least 65 years old, with Jensen's type 4 intertrochanteric fractures were included in our study. We divided them into two groups; group 1 (the control group, 34 cases) and group 2 (the experimental group, 22 cases). The average age of the patient was 78.7 years (range: 65~95) in group 1 and 77.8 years (range: 65~89) in group 2. We measured the volume of each fragments in the 3-part fractures by performing preoperative 3D computed tomography scanning. The criteria of unstable fracture were that the ratio of the volume of the greater trochanter to the the volume of the proximal femur was less than 25% and the ratio of the volume of the lesser trochanteric fragment to the volume of the greater trochanter was above 0.5. Dynamic compression screws alone were used in 30 cases (group 1) and 19 cases (group 2). Additional fixation by employing a greater trochanter stabilizing plate was done in 4 cases (group 1) and in 3 cases (group 2). We compared the radiological results and the rates of the fixation failure at the last follow-up between the two groups. RESULTS: There were four cases of fixation failure in group 1: varus &cut-out (2 cases), nonunion (1 case) and excessive backout of the screw (1 case). But there was no case of fixation failure in group 2. The neck shaft angle was 131.6+/-5.2 in group 1 and 134.7+/-4.3 in group 2. The sliding length of the lag screw was 8.4+/-3.2 mm in group 1 and 5.5+/-2.7 mm in group 2 (p<0.05). CONCLUSION: The volumetric measurement of each of the fragments in Jensen's type 4 intertrochanteric fracture by preoperative 3D computed tomography scanning for predicting the stability of fracture is useful in preventing fixation failures. Yet the radiation hazard or cost effectiveness should be considered for the risk vs benefit.

OPG Inhibits PMMA Induced Osteoclastogenesis and NF-kappaB Activation in Osteoclast Precursor Cells / 대한정형외과연구학회지

PURPOSE: We investigate the effect of osteoprotegerin (OPG) on activation of osteoclastogenesis and NF-kappaB activation by PMMA (Polymethyl methacrylate) particles in osteoclast precursor cells. MATERIALS AND METHODS: Osteoclast precursor cells (CSF-1 dependent) were obtained from whole bone marrow of C57BL mouse. Four experiments included 1) different dose of RANKL (Receptor Activator of NF-kappaB ligand) treatment (0, 1, 10, 40 ng/ml) 2) PMMA treatment +/- RANKL 3) PMMA treatment with different dose of RANKL 4) PMMA treatment +/- OPG. After treatments, cultured cells were stained with TRAP (Tartrate resistant alkaline phosphatase). The activity of NF-kappaB DNA nuclear translocation was detected by EMSA (electrophoretic mobility shift assay). RESULTS: The experiments with RANKL on osteoclast precursors differentiation demonstrated a dose-dependent stimulation of osteoclastogenesis (p<0.05). Control cultures without RANKL had no osteoclasts, while maintenance in 1 ng/ml of RANKL results in low level osteoclast formation. PMMA particles activated osteoclastogenesis in RANKL-primed osteoclast precursor cells. And the effect of particles on osteoclastogenesis were dependent on RANKL concentration (p<0.03). OPG treatment significantly decreased osteoclast formation and NF-kappaB DNA binding activity by PMMA particles in osteoclast precursor cells. CONCLUSION: OPG inhibits activation of osteoclast formation and NF-kappaB DNA binding activity by PMMA particles through RANK-RANKL pathway.

The Role of Lateral Buttress in Treatment of Jensen type 4 Intertrochanteric Fractures of the Femur using Dynamic Compression Hip Screw in the Elderly / 대한정형외과학회잡지

PURPOSE: To investigate the effect of lateral buttress on the fracture healing of Jensen type 4 intertrochanteric fracture of the femur treated by dynamic compression hip screw (DCS) in elderly patients, retrospectively. MATERIALS AND METHODS: From March 1999 to February 2003, 54 patients, older than 65 years, of Jensen type 4 intertrochanteric fractures of the femur treated by DCS were included. The relationship between the structual integrity of lateral buttress measured by proximal-medial fragment angle (PMFA) and postoperative neck-shaft angle, penetrating length of lag screw, the sliding length and incidence of fixation loss were evaluated. RESULTS: Among 38 patients of group II (PMFA above 50 degree), 6 cases (15.8%) including 4 cases of cutting out of lag screw from femoral head, 1 case of nonunion and 1 case of excessive extrusion of lag screw failed radiologically. But there was no fixation loss case in 16 cases of group I (PMFA 50 and below 50). The neck-shaft angle in last follow-up was 138.1 degree in group I and 132.1 in group II. The sliding length of lag screw was 7.0 mm in group I and 12. 5 mm in group II (p<0.05). CONCLUSION: Preoperative evaluation of intactness of lateral buttress measured by proximal-medial fragmentary angle is an useful method in treatment of Jensen type 4 intertrochanteric fractures treated by DCS in elderly patients.

Expression of RANKL/OPG in Joint Fluids of Periprosthetic Osteolysis / 대한정형외과학회잡지

PURPOSE: This study evaluated the expression level of Receptor Activator of NF-kappaB Ligand (RANKL), Osteoprotegerin (OPG)and other pro-inflammatory cytokines in the osteoarthritic and periprosthetic joint fluid in order to characterize the role of these regulatory proteins in periprosthetic osteolysis. MATERIALS AND METHODS: Joint fluid specimens taken from 47 patients undergoing hip or knee reconstructive surgery were analyzed by enzyme-linked immunoassay (ELISA)in order to determine the relative protein expression level of RANKL, OPG, IL-1beta, IL-6 and TNF-alpha. The fluid from joints with osteoarthritis (15 cases, Group I), implants revised without associated osteolysis (15 cases, Group II)and failed implants with radiographically moderate to severe osteolysis (17 cases, Group III) were compared. The fluids from all cases with implants (Group II and III) was combined (Group IV)and compared with the osteoarthritic joint fluids. RESULTS: RANKL was present in all the fluids at similar concentrations. The OPG levels were significantly lower (2.2-3.9 fold)in Groups II and III than in Group I (p<0.0001). The IL-1beta concentration was significantly higher in Groups II, III and IV and with Group III being the highest (12.1 fold)(p<0.0001). The IL-6 expression level was significantly higher in Group III (2.0 fold)than in Groups I and II (p<0.0001). The TNF-alpha levels were 2.0 times higher in Group III and significantly higher in all implant cases (Group IV)are analyzed (p=0.03). CONCLUSION: Permissive RANKL protein expression coupled with suppressed OPG levels and enhanced osteoclastogenic cytokine expression results in periprosthetic osteolysis.

Snapping Metacarpo-Phalangeal Joint after Depressed Fracture of Metacarpal Neck: Case Report

We report one case of snapping metacarpo-phalangeal joint after depressed fracture of metacarpal neck which could be diagnosed by exploration for the snapping during extension in spite of conservative treatments.