Superior Patellar Sleeve Fracture after Serial Knee Injuries / 대한정형외과학회잡지

Sleeve fractures of the superior pole of the patella are rare but usually occurs in adolescents with an immature skeletal system. This paper reports a 15-year-old male who complained of knee pain after a bicycle accident. The initial radiographs and magnetic resonance imaging showed a bony bruise of the patella with signal change on the medial meniscus. After conservative treatment with immobilization for four weeks, he slipped down, and eccentric forced flexion of the knee was applied. This second injury caused a sleeve fracture of the superior pole of the patella. After splint immobilization for five weeks, the patient showed adequate function of the quadriceps and range of motion.Among the cases collected, some patients showed a similar history of sleeve fracture of the superior pole of the patella after serial knee injuries.

Concurrent Posterolateral Corner Injury Associated with a Schatzker Type 2 Tibial Plateau Fracture: A Case Report

Isolated posterolateral corner (PLC) injury associated with a Schatzker type 2 fracture is a very rare combination of injuries. A male who was driving a motor vehicle was injured after a collision accident. The plain radiographs and computed tomography scans of the knee showed a Schatzker type 2 fracture of the tibial plateau, mostly in the anterolateral portion of tibial plateau, and an avulsion fragment on the fibular tip. Magnetic resonance imaging showed no injury to cruciate ligaments, medial collateral ligament, or any meniscal injury. We performed an open reduction operation and internal fixation for treating the fracture. Six months later, he complained of instability. At 11 months later after initial operation, we performed the second operation for stabilizing the PLC. We present here a rare case of an isolated PLC injury associated with a Schatzker type 2 fracture. We discuss the mechanism of injury and review similar cases.

Three-Dimensional Morphometric Analysis of Penetrative Depth and Size of Nonarthritic and Degenerative Arthritic Glenoids: Implications for Glenoid Replacement in Shoulder Arthroplasty

Background@#Shoulder arthroplasty is technically demanding and relies heavily on the precision of surgical techniques. Proper glenoid component sizing plays a crucial role in successful shoulder arthroplasty. We measured the size and penetrative depth of the glenoid for peg or screw fixation in nonarthritic and degenerative arthritic shoulders by using three-dimensional computed tomography to determine the reference dimensions of the glenoid in nonarthritic and degenerative arthritic shoulders. @*Methods@#From January 2010 to January 2011, data on two groups of patients were collected and reviewed. Group 1 comprised 38 patients who underwent surgical treatment due to fracture of the proximal humerus and who had no evidence of a pathological glenoid. Group 2 comprised 14 patients who underwent surgical treatment due to osteoarthritis of the glenohumeral joint. The height (maximal superoinferior diameter) of the glenoid was measured, and the width (anteroposterior [AP] diameter) of the glenoid was measured at five different levels (H1–H5). Axial images were taken at H1–H5 levels, the AP glenoid diameter of each was divided into eight areas, and division points were labeled as W1–W7. The penetrative depths between the near cortex and far cortex of the glenoid (thickness) at each point (W1–W7) were measured. @*Results@#The overall mean glenoid height was 37.67 ± 4.09 mm in nonarthritic glenoids and 39.42 ± 3.54 mm in degenerative arthritic glenoids. The nonarthritic glenoid was significantly thicker than the degenerative arthritic glenoid at the H1W3, H1W4, H1W5, H2W7, H3W1, H3W6, H3W7, H4W5, H4W6, H4W7, H5W4, H5W5, H5W6, and H5W7 points. The posteroinferior quadrant had the smallest penetrative depth in both nonarthritic and degenerative arthritic glenoids. Also, the degenerative arthritic glenoids were significantly thinner than the nonarthritic glenoids along the posterior and inferior parts of the glenoid. @*Conclusions@#The posterior and inferior parts of the degenerative arthritic glenoid appears thinner than the nonarthritic glenoid. Thus, caution has to be taken when drilling the screw hole or inserting screws into the posteroinferior parts, where the glenoid is thinner than 15 mm on average, to avoid penetration of the far cortex.

Meniscal Extrusions on a Non-Traumatic and Young Knee: Magnetic Resonance Imaging Study / 대한정형외과학회잡지

PURPOSE: The aim of this study was to assess the size and extrusion of the meniscus in young and non-traumatic knees, especially in Korean males. MATERIALS AND METHODS: The participants (n=91 knees, 77 patients) were consecutive patients observed at an orthopedic outpatient clinic who had another problem unrelated to the knee joint. The patients were excluded from the study if they had a history of trauma and pain on the knee joint. The patients received a magnetic resonance imaging (MRI) scan on the knee joint. The size, extrusion, and extrusion ratio of the meniscus on an MRI scan were evaluated. RESULTS: The mean age of the participants was 21.6±1.1 years (range, 19–24 years). The mean size of the medial meniscus on the coronal plane was 9.0±1.1 mm (range, 7.1–11.9 mm). The extent of extrusion on the coronal plane was 2.0±1.0 mm (range, 0–4.4 mm). The extrusion ratio (extruded size/total size×100) of the medial meniscus on the coronal plane was 22.7%±11.5% (range, 0%–53.7%). The extent of extrusion on the sagittal plane was 1.6±1.1 mm (range, 0–4.0 mm). The extrusion ratio (extruded size/total×100) of the medial meniscus on the sagittal plane was 18.0%±11.9% (range, 0%–40.7%). The incidence of medial meniscal extrusion on the coronal and sagittal plane are 92.3% and 80.2%, respectively. The mean size of lateral meniscus on the coronal plane was 11.1±3.4 mm (range, 7.3–22.9 mm). The extent of extrusion on the sagittal plane was 0.5±0.7 mm (range, 0–2.5 mm). The extrusion ratio of the lateral meniscus on the sagittal plane was 4.0%±6.7% (range, 0%–26.3%). The incidence of lateral meniscal extrusion on the coronal plane was 34.1%. No extrusion of the lateral meniscus was observed on the sagittal plane. CONCLUSION: In young and non-traumatic knees, the extrusion of meniscus was common, especially medial meniscus than lateral meniscus.

The Different Treatment Methods for Segmental Fractures of the Clavicle: Cases Report

Segmental fractures of the clavicle are very rare. Therefore, to date, there has not been a clear, standardized method of management of segmental clavicle fractures. Herein, two patients with a segmental fracture are described: One patient was treated conservatively, while another patient was treated operatively. Both patients showed excellent results. We discuss the various management options with a literature review.

Bilateral Discoid Medial Menisci: Two Different Types in One Patient and Bony Changes on the Medial Tibial Plateau / 대한정형외과학회잡지

A discoid medial meniscus is a relatively rare pathology of the knee joint, and bilateral cases are extremely rare. We present one case of bilateral symptomatic discoid medial menisci. Arthroscopy revealed a complete type of discoid medial meniscus in one knee and an incomplete type in the other knee. Ours is a very rare case of bilateral discoid medial menisci with associated osseous changes in the tibia, and it is perhaps the first such reported case in the world. The patient was successfully treated by partial meniscectomy using routine arthroscopic procedures.

Subdeltoid Bursa Chondromatosis Associated with Osteochondral Lesion of the Proximal Humerus and a Rotator Cuff Tear / 대한정형외과학회잡지

Synovial chondromatosis involving the bursa is uncommon, and those cases synovial chondromatosis within the bursa around the shoulder are especially rare. We report here a case of a 57-year-old male who had subdeltoid bursal subdeltoid bursal chondromatosis associated with osteochondral lesion of the proximal humerus and a rotator cuff tear. We also review the relevant literatures.

Delayed Diagnosed Stage 1, 2 Distractive Flexion Injury of the Cervical Spine

STUDY DESIGN: Retrospective study. PURPOSE: To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments. OVERVIEW OF LITERATURE: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs. METHODS: The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined. RESULTS: The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%). CONCLUSIONS: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.

ACL Reconstruction with Autologous Hamstring Tendon: Comparison of Short Term Clinical Results between Rigid-fix and PINN-ACL Cross Pin

PURPOSE: To compare the short term clinical results of anterior cruciate ligament (ACL) reconstruction with autologous hamstring tendon between Rigid-fix and PINN-ACL Cross Pin for femoral side fixation. MATERIALS AND METHODS: 127 patients who underwent arthroscopic ACL reconstruction using autologous hamstring tendon and had been followedup for over than one year were enrolled for the present study. Rigid-fix was used in 71 cases (group 1), and PINN-ACL Cross Pin was used in 56 cases (group 2). Clinical and radiological results, operation time, and perioperative complications were compared amongst the two groups. RESULTS: The International Knee Documentation Committee subjective score and Lysholm score were 94 and 95 in group 1 and 87 and 91 in group 2, with no statistical difference (p=0.892, p=0.833), respectively. However, significant difference was observed in one-leg hop test between the two groups (p=0.032). Five cases in group 1 and 40 cases in group 2 were found to be associated with perioperative complications with statistical difference (p<0.0001). CONCLUSIONS: There was no resultant difference between the employment of PINN-ACL Cross Pin and Rigid-fix as femoral graft fixation for ACL reconstruction with hamstring tendon. However, PINN-ACL Cross Pin led to complications with extensive operation times. Hence, it needs further improvement of tools for minimization of complications.

Minimum 4 Year Follow-up Results of Metalon Metal Hip Resurfacing Arthroplasty / 대한정형외과학회잡지

PURPOSE: To report the minimum 4 year follow up results of metal on metal hip resurfacing arthroplasty. MATERIALS AND METHODS: 39 hips from 36 patients, who received hip resurfacing from November 1998 to September 2001 and were followed up for at least 4 years, were enrolled in this study. The average age was 45 years (28-69 years) and the average follow up period was 51.9 months (48-82 months). A clinical evaluation was performed with the Harris Hip Score and gait analysis postoperatively. A radiologic evaluation was performed regularly after surgery using anteroposterior and lateral simple radiographs. The post-operative cobalt-chrome serum concentration was measured and compared using 21 cases of ceramic-on-ceramic total hip arthroplasty as a control group. RESULTS: The Harris Hip Score improved from 61 points (31-74) preoperatively to 96 points (85-99) postoperatively. There were no cases of acetabular loosening, and the average angle of femoral insert to the shaft was 136 degrees with 22 hips (61.1%) being within 130-140 degrees. The 4 year follow-up survival rate was 97.4%. The serum cobalt and chrome levels were higher than the control group (p<0.05). CONCLUSION: Hip resurfacing showed excellent survival rate after a short-term follow-up, but still requires a long-term evaluation with more cases and further metal ion release studies.

Nonunion of the Humerus Shaft

PURPOSE: To evaluate the cause and treatment results of nonunion of humerus shaft fractures. MATERIALS AND METHODS: 39 cases were treated for humerus shaft nonunion between February 1990 and May 2002. The presence of open wounds, initial treatment modality after injury, treatment method for the nonunion and time to union were studied using medical records. The fracture type and appropriateness and problems of the initial surgical treatment were reviewed. Also, Pain and functional recovery in daily living were evaluated in the outpatient clinic, after surgery for nonunion. RESULTS: Amongst the 30 cases, transverse fracture was the most common with 19cases. Most of 29 cases, initially surgically treated, revealed incorrect selection of the internal fixator or technical errors. For surgical treatment of nonunion, open reduction and internal fixation with cancellous bone graft was performed, most commonly, in 36 cases (92.3%). All cases showed clinical and radiographic union at an average of 13.3 weeks. More than 90% of the patients replied minimal pain and excellent functional recovery of daily living at final follow-up. CONCLUSION: If treated with surgery by correct selection of internal fixation methods and accurate technical skills, nonunion incidence can be reduced.

Two Stage Surgical Treatment of Acute Traumatic Knee Dislocation / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to determine the effectiveness of a new two stage surgical treatment for acute traumatic knee dislocation. MATERIALS AND METHODS: The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up period was 24 months. In the first surgical stage, medial and/or lateral ligament complexes were repaired or reconstructed within two weeks of the injury. In the second surgical stage, once full range of motion was obtained 3-6 months later, anterior or posterior cruciate ligaments (ACL or PCL) were reconstructed if significant laxity was present. The final outcomes were assessed using stress X-rays, range of motion and Lysholm score. RESULTS: There were ten cases of MCL tear and eight cases of LCL tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. Following the first stage of MCL/LCL surgery, the second stage surgery of ACL or PCL reconstructions was deemed to be necessary in three and seven cases, respectively. Five cases did not require ACL or PCL reconstruction. In stress X-rays at the last follow up examination, MCL, LCL, ACL and PCL instability was graded as 0 or 1 in 15, 14, 15 and 11 cases, respectively. PCL instability was graded as 2 in four cases. The mean postoperative Lysholm score was 87.6 points. CONCLUSION: The two stage surgical approach described here resulted in good outcomes for patients suffering from acute knee dislocation patients in terms of range of motion and stability.

Metal Ion Release after a Metal-on-Metal Hip Arthroplasty: Comparison between Resurfacing Arthroplasty and Total Hip Arthroplasty / 대한정형외과학회잡지

PURPOSE: To verify that the metal-on-metal (MOM) surfaces produce metal ions and to ascertain the differences between large and small femoral head diameters with regard to the release of metal ions. MATERIALS AND METHODS: Forty two cases of MOM hip resurfacing arthroplasty (mean head diameter: 47.1 mm) and 39 cases of conventional total hip replacement arthroplasty (head diameter: 28 mm) were performed at our hospital from June 1998 to April 2003. All the cases were followed-up using the serum cobalt and chromium ion levels. The serum cobalt and chromium ion levels were compared in the 21 cases in each group, which were matched by age, weight and follow-up period. The control group involved 21 patients who had undergone an alumina-alumina total hip arthroplasty. The patient's serum metal ion concentration was measured from the serum, which had been separated from the whole blood and diluted using inductively-coupled plasma mass spectrometry (Agilent 4500, Rhode Island, USA). RESULTS: All MOM bearing implants produced higher serum levels of cobalt and chromium ions than the control. The serum concentration of cobalt with MOM resurfacing was higher than that observed with a 28 mm MOM total hip arthroplasty (p=0.025), but the chromium levels were not significantly different (p=0.501). CONCLUSION: The MOM bearing implants in this study produced elevated serum levels of cobalt and chromium ions. In addition, large diameter heads resulted in greater systemic exposure of cobalt ions than the small diameter heads. However, a long-term follow-up will be needed to determine the clinical significance.

Total Knee Arthroplasty using Intramedullary Tibial Cutting Guide

PURPOSE: To evaluate the tibia osteotome angle and whole leg alignment in total knee replacement arthroplasty using intramedullary tibia guide. MATERIALS AND METHODS: Amongst 343 cases of TKA using an intramedullary tibial cutting guide from November 1998 to August 2001, 160 cases who took a standing whole leg AP simple roentgenography within 1 year were selected. Post-operatively, the angle formed by the tibial anatomical axis and tibial component, along with the angle formed between the femoral anatomical axis and tibial anatomical axis were measured. RESULTS: The average angle between the tibial anatomical axis and tibial component was 89.5 degrees (84 degrees~94 degrees), 133 cases(83.1%) were within the range of 90 degrees +/- 2 degrees and amongst these 66 cases(41.3%) were 90 degrees. The average angle formed between the femoral anatomical axis and tibial anatomical axis was 5.6 degrees(0 degrees~11 degrees). CONCLUSION: When used properly, an intramedullary tibial cutting guide in TKA result in satisfactory tibial osteotome angle and whole leg alignment in TKA.

Factors Affecting Range of Motion after Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: Restoration of range of motion (ROM) after total knee arthroplasty (TKA) greatly affects post-operative results. We analyzed various actors, including implant systems, to identify those factors affecting ROM in TKA. MATERIALS AND METHODS: 645 knees of 418 patients who received TKA from the same operator between June 1990 and May 1999 were analyzed. Knees were sorted according to patient (age, sex, body mass index, symptom duration, pre-operative ROM, and deformity), disease (osteoarthritis, rheumatoid arthritis, and osteonecrosis), implant (implant system, and thickness of spacer), operation (preservation or resection of the posterior cruciate ligament (PCL), and lateral release or not). Post-operative ROM was evaluated with a minimum 3 years of follow-up. RESULTS: Within 1 year after TKA, BMI, symptom duration, pre-opeative deformity, pre-operative ROM, and lateral release were found to significantly (p-value<0.05) affect post-operative ROM. At 2 years after TKA, BMI, pre-operative deformity, and pre-operative ROM were found to significantly affect post-operative ROM. At 3 years after TKA, post-operative ROM was significantly better for a wider pre-op. (p<0.0001), and in patients without lateral release (p<0.018). Underlying disease, the implant system used, and PCL treatment showed no significant difference. CONCLUSION: A better pre-operative ROM and no lateral release of the retinacular ligament showed a better post-operative ROM at 3 years after TKRA.