Femoral Periprosthetic Fractures after Total Knee Arthroplasty: New Surgically Oriented Classification with a Review of Current Treatments

PURPOSE: As the number of total knee arthroplasties (TKAs) increases, the incidence of femoral periprosthetic fractures after TKA is also increasing. This review aimed to suggest a new surgically oriented classification system for femoral periprosthetic fractures. METHODS: We investigated the classifications, and current treatment trends for femoral periprosthetic fractures after TKA by means of a thorough review of the relevant literature. RESULTS: Numerous studies reported good results of surgical treatment with modern fixatives including locking compression plates and retrograde intramedullary nails. However, few classifications of femoral periprosthetic fractures reflect the recent developments in surgical treatment. CONCLUSIONS: We recommend that surgical management be considered the first-line treatment for femoral periprosthetic fractures after TKA. Our new classification will help in deciding the surgical treatment option for femoral periprosthetic fractures after TKA.

Combined Rotational Alignment Change after Total Knee Arthroplasty in Different Tibial Component Designs: Implications for Optimal Tibial Component Rotational Alignment

PURPOSE: The rotational alignment of the femoral and tibial components is closely related to the results after total knee arthroplasty (TKA). In this study, we measured the combined rotational alignment change (ΔCR) after TKA and compared the different influence of symmetric and asymmetric tibial component designs on the combined rotational alignment. MATERIALS AND METHODS: Eighty-four patients (mean age, 67.9 years) were included. A symmetric tibial component was used in 51 knees (group I), whereas an asymmetric tibial component was used in 50 knees (group II). We measured the angles of four anatomical landmarks by using preoperative and postoperative computed tomography images. The combined rotational alignment and the amount of change were calculated. The correlation between the isolated tibial component rotation (ITR) and ΔCR was analyzed by using the Spearman correlation coefficient. RESULTS: The mean ΔCR was −0.1°±6.3° in group I and −4.8°±5.7° in group II after TKA. Excluding the intercomponent rotation, the change was −1.0°±7.3° and −6.7°±6.7° in group I and group II, respectively. A correlation analysis between the ITR and tibial component rotation relative to the tibial tuberosity showed a statistically significant correlation. CONCLUSIONS: The combined lower limb rotational alignment was internally rotated in both symmetric and asymmetric tibial component designs after TKA. The asymmetric tibial component was better than the symmetric tibial component in achieving internally rotated combined lower limb rotational alignment. The internal rotation of the symmetric tibial component relative to the tibial tuberosity tip should fall within 20° to correct the externally deformed lower limb.

Eight to Ten Year Follow-Up Results of Total Knee Arthroplasty Using Electromagnetic Navigation System / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the clinical and radiological results between patients who underwent total knee arthroplasty using the conventional method and the navigation-assisted method. MATERIALS AND METHODS: A retrospective review of was performed on 32 patients (40 knees) who underwent total knee arthroplasty between February 2004 and December 2006 and were followed-up for 8 to 10 years. Mechanical axis deviation, range of motion, radiologic position of the implants, and subjective clinical scores were measured and compared between 20 navigation-assisted total knee arthroplasties and 20 conventional total knee arthoplasties. Change in the values (α, β, γ, and δ angles) from the immediate postoperative period to the last follow-up were also calculated and compared between the two groups. RESULTS: The mean range of motion in the navigation group was improved to 121.8°±16.3° (92°–140°) at the last follow-up, and the Western Ontario McMaster Universities osteoarthritis Index (WOMAC) score was 89.8±5.4 and the Knee Society score (KSS) was 91.5±7.5. The mean range of motion in the conventional group was 112.6°±25.6° (60°–140°) at the last follow-up. The WOMAC score was 84.2±10.6, and the KSS was 81.1±14.3. The α, β, γ, and δ angles of the implants were not significantly changed until the last follow-up. In the comparison between the two groups, only the mean range of motion (p=0.018) and the KSS (p=0.038) showed statistically better results in the navigation group than the conventional group. CONCLUSION: Navigation-assisted total knee arthroplasty showed better KSS and range of motion compared with the conventional group in a cross-sectional study with 8 to 10 years of follow-up results. However, only the KSS showed a significant difference between the two groups by the amount of changes in the clinical and radiological results.

Differences between the Upper Extremity and the Lower Extremity in Reconstruction Using an Anterolateral Thigh Perforator Flap

BACKGROUND: While reconstruction of soft tissue defects is the common purpose, surgical reconstructions of upper extremities and lower extremities have different goals in terms of functional and aesthetic outcomes. The purpose of the current study was to compare and analyze differences between reconstructions of upper extremities and lower extremities using an anterolateral thigh (ALT) flap. METHODS: We analyzed 74 patients who underwent reconstructions of upper extremities and lower extremities using an ALT flap from October 2006 to August 2012 (upper extremities, 45 cases; lower extremities, 29 cases). The study focused on the statistical analysis of patient satisfaction according to the donor site of the ALT flap and the timing of a debulking procedure. RESULTS: On the choice of donor site, in the upper extremity reconstruction, flap elevation from the opposite side of the recipient limb was preferred (p = 0.019) because it causes less inconvenience while walking. In the lower extremity reconstruction, flap elevation from the same side of the recipient limb (p = 0.002) was preferred. The debulking procedure performed on the upper extremities at 4 weeks after reconstruction led to better functional results and enhanced patient satisfaction (p = 0.022). In the case of lower extremities, enhanced satisfaction was noted in patients who underwent the procedure at 6 months after reconstruction (p < 0.001). CONCLUSIONS: Elevation of the flap in reconstruction reduced inconvenience when performed on the same side of the recipient limb for lower extremities and on the opposite side for upper extremities. In addition, debulking resulted in better satisfaction when performed 4 weeks postoperatively in the upper extremities and 6 months postoperatively in the lower extremities.

High-Flexion Total Knee Arthroplasty Using NexGen LPS-Flex System: Minimum 5-year Follow-up Results

PURPOSE: This study is to report clinical and radiological results of high-flexion total knee arthroplasty (TKA) using NexGen LPS-flex system at a minimum 5-year follow-up, and to analyze the implant survivorship based on the results. MATERIALS AND METHODS: A total of 80 patients (118 knees) who underwent patellar preserving TKA using NexGen LPS-flex implant between February 2007 and February 2008 and could be followed for minimum 5 years were reviewed. The range of motion (ROM), hip-knee-ankle angle, Knee Society Knee score (KSKS), and Knee Society Function score (KSFS) were assessed preoperatively and at the last follow-up and analyzed. Implant position of the femoral and tibial components on the immediate postoperative and last follow-up X-rays were compared. RESULTS: The mean ROM was 110.2degrees+/-14.5degrees (range, 60degrees to 140degrees) preoperatively and 132.4degrees+/-5.2degrees (range, 90degrees to 145degrees) at the last follow-up. KSKS was 36.9degrees+/-6.4degrees preoperatively and 94.2degrees+/-3.2degrees at the last follow-up. KSFS was 30.5degrees+/-5.7degrees preoperatively and 93.7degrees+/-4.1degrees at the last follow-up. There was no statistically significant change in the implant position measured as alpha, beta, gamma, and delta angles at the last follow-up compared to the immediate postoperative values. Radiolucent lines were observed in 13 knees (11%) on the last follow-up X-rays. Revision TKA was performed due to aseptic implant loosening in 1 knee (0.84%), and the survival rate at the 5th postoperative year was 99.2%. CONCLUSIONS: The clinical and radiological outcomes of high-flexion TKA using NexGen LPS-Flex implant design were satisfactory with 99.2% implant survival rate after 5 years of protected activities of daily living.

Acute Patellar Tendon Rupture after Total Knee Arthroplasty Revision

Patellar tendon rupture is a catastrophic complication following total knee arthroplasty (TKA). Though revision TKA has been suspected of being a predisposing factor for the occurrence of patellar tendon rupture, there are few reports on patellar tendon rupture after revision TKA. Here, we present a case of acute patellar tendon rupture that occurred after TKA revision. In the patient, the patellar tendon was so thin and could not be repaired, and accordingly was sutured end to end. We used the anterior tibialis tendon allograft to augment the poor quality patellar tendon tissue. Fixation of the allograft was done by using the bone tunnel created through tibial tuberosity and suturing the allograft to the patellar tendon and quadriceps tendon. The patient was instructed to wear a full extension knee splint and was kept non-weight bearing for 6 weeks after operation. Full knee extension could be achieved 6 weeks postoperatively.

Comparison of Precision between Optical and Electromagnetic Navigation Systems in Total Knee Arthroplasty

PURPOSE: The purpose of this study is to compare and analyze the precision of optical and electromagnetic navigation systems in total knee arthroplasty (TKA). MATERIALS AND METHODS: We retrospectively reviewed 60 patients who underwent TKA using an optical navigation system and 60 patients who underwent TKA using an electromagnetic navigation system from June 2010 to March 2012. The mechanical axis that was measured on preoperative radiographs and by the intraoperative navigation systems were compared between the groups. The postoperative positions of the femoral and tibial components in the sagittal and coronal plane were assessed. RESULTS: The difference of the mechanical axis measured on the preoperative radiograph and by the intraoperative navigation systems was 0.6 degrees more varus in the electromagnetic navigation system group than in the optical navigation system group, but showed no statistically significant difference between the two groups (p>0.05). The positions of the femoral and tibial components in the sagittal and coronal planes on the postoperative radiographs also showed no statistically significant difference between the two groups (p>0.05). CONCLUSIONS: In TKA, both optical and electromagnetic navigation systems showed high accuracy and reproducibility, and the measurements from the postoperative radiographs showed no significant difference between the two groups.

Total Knee Arthroplasty in a Patient with an Ankylosing Knee after Previous Patellectomy

Patellectomized patients may have less satisfactory clinical outcomes following total knee arthroplasty (TKA) due to a decreased extensor mechanism efficiency and potential instability. Furthermore, the existing literature does not provide concrete guidance on the expected results of TKA or the type of implant that should be used in patellectomized patients. We present a case of a patient with an ankylosing knee who had undergone patellectomy due to gunshot injury 45 years ago and was treated with primary TKA using a posterior stabilized prosthesis at our institution. TKA using this prosthesis in the ankylosed knee with a previous history of patellectomy yielded good results in terms of postoperative clinical scores, range of motion and joint stability.

Navigation-Assisted Total Knee Arthroplasty for Patients with Extra-Articular Deformity

PURPOSE: Since the existence of an extra-articular deformity seriously alters the normal geometry and kinetics around the knee joint, difficulties are often encountered in total knee arthroplasty (TKA) using a standard surgical technique. The purpose of this study was to evaluate the usefulness of surgical navigation system as a treatment option for osteoarthritic knees with extra-articular deformity. MATERIALS AND METHODS: The authors retrospectively reviewed medical records of the patients who underwent primary TKA between 2007 and 2012. Knees with preoperative radiography showing an angular deformity within the region from the middle third of the femur to the middle third of the tibia in the ipsilateral limb of the arthritic knees were considered as cases having extra-articular deformity. Thirteen knees of the 13 patients were found to have undergone TKA using a navigation system for osteoarthritis with ipsilateral extra-articular deformity. The hip-knee-ankle angle, Knee Society score (KSS), and range of motion were measured before and after the operation to evaluate the improvement. RESULTS: The mean hip-knee-ankle angle in the coronal plane was improved to 0.2degrees+/-4.5degrees in valgus alignment postoperatively. The KSS was improved to 89.6+/-4.6 points postoperatively at the last follow-up, with over 90% of good and excellent results. The range of motion was improved to 118.5degrees+/-10.5degrees postoperatively. CONCLUSIONS: Navigation-assisted TKA is a good treatment option of osteoarthritic knees with extra-articular deformity.

Anatomy, Classification and Radiology of the Pelvic Fracture

No abstract available.

Baker's Cyst with Intramuscular Extension into Vastus Medialis Muscle

Baker's cysts are one of the most common cystic lesions around the knee joint and mainly caused by fluid distension of the gastrocnemius-semimembranous bursa that is situated along the medial side of the popliteal fossa. Typically, a Baker's cyst extends along the intermuscular planes around the knee joint and may enlarge any direction. However, it is mostly located in the inferomedial or superficial layers of the knee joint and less commonly extends laterally or proximally. Expansion of the cyst tends to respect the intermuscular planes, and Baker's cysts along the intramuscular route have been rarely reported. Thus, we report a case of Baker's cyst with intramuscular extension into the vastus medialis muscle.

Comparison of Mobile-Bearing and Fixed-Bearing Designs in High Flexion Total Knee Arthroplasty: Using a Navigation System

PURPOSE: We compared and analyzed the short term results of high flexion total knee arthroplasty (TKA) with mobile-bearing and fixed bearing designs. MATERIALS AND METHODS: We studied 32 patients that had undergone TKA with LPS-Flex Mobile and 34 patients with LPS-Flex Fixed using an electromagnetic navigation system between January 2010 and June 2010, and were followed up for at least 1 year. RESULTS: Knee Society Functional Score (KSFS) and Knee Society Knee Score (KSKS) of the mobile-bearing group were 94.5 and 93.8 points, respectively, and were 48.2 and 45.3 points preoperatively, whereas those of the fixed-bearing group were 95.1 and 94.2 points, respectively, and were 49.5 and 46.9 points preoperatively. Postoperative mechanical axis deviation and implant position of the femoral and tibial component both on the coronal and sigittal planes showed no significant differences between the two groups. Range of motion (ROM) and maximal flexion angle (MFA) of the knee joint also showed no significant differences between the two groups. The possibility of crossed-legged sitting and kneeling position also showed no significant differences between the two groups. CONCLUSIONS: Clinical and radiologic parameters, ROM and MFA of knee joints showed no significant differences in both the groups, but long term follow-up results may be necessary, including survival rate.

Arthroscopically Assisted Reduction and Internal Fixation of Intra-Articular Fractures of Tibial Plateau / 대한정형외과학회잡지

PURPOSE: To evaluate clinical and radiological results of arthroscopically assisted reduction and internal fixation of intra-articular fractures of the tibial plateau. MATERIALS AND METHODS: Between July 2003 and June 2009, we performed arthroscopy and fluoroscopy-assisted reduction and internal fixation for tibia plateau fracture. Our study included 21 patients who had been followed-up for more than 18 months. We used the Knee Society Knee Score (KSS) and Knee Society Functional Score (KSFS) for the clinical evaluation. We used the Rasmussen Radiological Score for the radiological evaluation. RESULTS: At the last follow-up, all 21 cases showed bone union, and the mean range of movement was 115.5+/-8.5degrees. According to the KSS and KSFS, we obtained excellent or good results in 18 cases (85%). We obtained excellent or good results in 19 cases (90%) each by the Rasmussen Clinical Score and Rasmussen Radiological Score, respectively. CONCLUSION: The 2 year follow-up of arthroscopy assisted surgery showed relatively satisfactory results.

Editorial

No abstract available.

The Integrity after Arthroscopically Repairing the Rotator Cuff Tendon Using the Suture Bridge Technique / 대한정형외과학회잡지

PURPOSE: We evaluated the integrity after repairing the arthroscopic rotator cuff tendon using the suture-bridge technique in patients with full thickness rotator cuff tendon tears. MATERIALS AND METHODS: Forty two (males: 14, females: 28) consecutive shoulders that were treated with this index procedure and that had magnetic resonance imaging (MRI) taken at a mean of 9 months postoperatively were enrolled to estimate the postoperative intregrity of the repair. The mean age was 57 years (range: 44-75 years) and the mean follow-up period was 14 months (range: 12-16 months). The follow up MRI was evaluated using the Sugaya classification for postoperative cuff integrity. The clinical outcomes were evaluated by using the University of California Los Angeles (UCLA) score, the Korean Shoulder Scoring System (KSS) and Visual Analogue Scale (VAS). Significance was set at p values < 0.05 RESULTS: In the 42 cases with follow up MRI, the cuff integrity was graded as type I in 10 cases, type II in 28, type III in 2, type IV in 1 and type V in 1 case. Out of the 39 cases having a medium to large tear, the type I and II cuff integrity was 92.3% and two patients had type III cuff integrity postoperatively, while the rate of retear was 33.3% (1 of 3) in the cases with massive tear. The overall rate of retear was 4.8%. For the intact postoperative repair rate, the precent of cases with fatty degeneration of grade 3 or less seen on preoperative MRI was 92.7%. For 41 patients, except for 1 case of type V retear, the UCLA score and the KSS score were significantly improved (p < 0.05) from 17.2 to 31.4 and from 58.2 to 90.8 on average, respectively, which showed satisfactory clinical outcomes regardless of the type of repair integrity. CONCLUSION: The arthroscopic suture-bridge technique resulted in intact repair integrity in 90.4% of the cases and improved clinical outcomes, so we think this technique is one of the reliable procedures for treating full-thickness rotator cuff tear.

A Comparative Study of Three Different Fixation Techniques for Displaced Two- and Three-Part Proximal Humeral Fractures / 대한정형외과학회잡지

PURPOSE: To analyze and compare the results of three different surgical methods - closed reduction and percutaneous pinning (Group I), bifurcated plate and tension band wiring (Group II), locking compression plate (Group III), - for displaced two- and three-part proximal humeral fractures. MATERIALS AND METHODS: Sixteen patients were treated with a closed reduction and percutaneous pinning, 19 with bifurcated plate and tension band wiring and 18 with locking compression plate. All patients were followed up for more than 1 year, and were reviewed and evaluated with respect to radiological and clinical results. The radiological results were evaluated by bony union and humerus neck shaft angle using the Paavolainen method. The clinical results were evaluated by Neer's evaluation criteria. RESULTS: Bony union rate, time period to achieve bony union, neck shaft angle and clinical results in Groups II and III were better than those in Group I (p<0.05). There were no significant differences between Groups II and III. We observed trends for worse clinical outcomes in patients older than 65 years compared with those in patients younger than 65 years. Clinical outcome for patients older than 65 years in Group III (average 87.5 points) was better than that for the same age group in Groups I (average 77.2 points) and II (average 79.3 points), but the cohorts were too small to obtain statistical significance. Complication rate in Groups II, III was lower than that in Group I (p=0.005). CONCLUSION: The radiological and clinical results in Groups II and III were significantly better than those in Group I, and there were no significant differences between Groups II and III. We thought that bifurcated plate and tension band wiring and locking compression plate were useful surgical methods for displaced two- and three-part proximal humeral fractures.

Comparison of the Mobile-bearing and Fixed-bearing Designs for High Flexion Total Knee Arthroplasty

PURPOSE: We compared and analyzed the follow-up results of high flexion total knee arthroplasty (TKA) with using the mobile-bearing and fixed-bearing designs. MATERIALS AND METHODS: We studied 130 patients who had undergone high-flexion TKA from December 2003 to December 2007 and who were followed up for at least 2 years. Of all the 130 patients, 65 patients had undergone TKA using a mobile-bearing design, and the other 65 patients had undergone TKA using the fixed-bearing design. RESULTS: The post-operative Knee Society Knee Score (KSKS) and Knee Society Functional Score (KSFS) of the mobile-bearing group were 95.6 and 96.1 points, which were 53.2 and 49.7 points, respectively, preoperatively, and the post-operative KSKS and KSFS of the fixed-bearing group were 94.5 and 95.1 points, which were 54.1 and 50.9 points, respectively, preoperatively. The range of motion (ROM) and maximal flexion angle (MFA) of the knee joints of the mobile-bearing group were 129.1degrees and 131.4degrees, which were 122.3degrees and 125.8degrees, respectively, preoperatively, and those of the fixed-bearing group were 128.3degrees and 129.3degrees, which were 122.2degrees and 123.9degrees, respectively, preoperatively. There were no significant differences between the two groups. Crossed-legged sitting and attaining a kneeling position also showed no significant differences between the two groups, but the mobile-bearing group could easily take a crossed-legged sitting position. CONCLUSION: The clinical parameters and the ROM and MFA of the knee joint showed no significant differences between both groups, but the mobile-bearing group felt more comfortable in the crossed-legged sitting position.

Deep Vein Thrombosis after Total Knee Arthroplasty: Correlation between the Incidence and Clinical Risk Factors

PURPOSE: We compared and analyzed the correlation between the incidence and clinical risk factors of deep vein thrombosis (DVT) after total knee arthroplasty (TKA). MATERIALS AND METHODS: One hundred eight patients underwent TKA between January 2008 and January 2009. Thirty four cases were in the high-risk group (having at least one risk factor) and 74 cases were in the low-risk group (not having any risk factors). RESULTS: Six (17.6%) of 34 high-risk cases and 11 (14.9%) of 74 low-risk cases experienced DVT, and there were no statistically significant differences between the two groups. But among the risk factors, age and obesity had positive correlation with the incidence of DVT (p<0.05). Among the 17 cases of DVT, 4 patients showed symptoms of DVT and they were treated with anticoagulants. CONCLUSION: The incidence of DVT after TKA showed no significant differences between the high and low risk groups, and among the 17 cases of DVT, 4 patients showed symptoms of DVT. Therefore, it is desirable to perform definitive diagnostic modalities like CT venography and then to treat with anticoagulants only the patients with DVT symptoms after TKA.

Treatment of Femur Supracondylar Fracture with Locking Compression Plate

PURPOSE: To evaluate the effectiveness of locking compression plate by analyzing the clinical outcomes of open reduction and internal fixation with locking compression plate in the treatment of femur supracondylar fracture. MATERIALS AND METHODS: We reviewed 21 cases of distal femur fractures which were treated with locking compression plate in our hospital from February 2005 to March 2009 and followed up for minimal 1 year. The types of fractures were seven A1, four A2, two A3, six C2, and two C3 according to AO classification. 2 cases were open fractures. The cases were evaluated by the criteria of Schatzker-Lambert. RESULTS: The mean time to union was 14.3 weeks. One delayed union, one refracture were observed, but no nonunion and postoperative infection was observed. The outcomes were excellent in 6 cases, good in 11, fair in 3, and failure in 1 by the criteria of Schatzker-Lambert. The overall results were excellent or good in 17 cases (81.0%). CONCLUSION: In the treatment of femur supracondylar fracture, open reduction and internal fixation with locking compression plate yields good result and locking compression plate is useful choice of fixation option.

Treatment of Kienbock's Disease Using the 4+5 Extensor Compartmental Vascularized Bone Grafting Procedure: Early Experience / 대한정형외과학회잡지

PURPOSE: Kienbock's disease can be treated with a vascularized bone graft to provide relief of wrist joint symptoms and prevent collapse of the lunate. We evaluated the functional outcome and subjective satisfaction in patients with Kienbock's disease treated with the 4+5 extensor compartmental vascularized bone graft. MATERIALS AND METHODS: We included 6 patients in the study. 3 males and 3 females with an average age of 37.5 years (range 21-49). Kienbock's disease was staged by Lichtman classifi cation based on plain radiography. Three patients were in stage II and three in stage IIIA. Cooney's wrist function score was used to evaluate changes in severity of pain, functional status, range of motion, and grip strength. We also assessed subjective patient satisfaction, carpal height ratio and bone union on the radiographs, and the occurence of complications. The mean follow-up period was 30 months. RESULTS: Four patients had excellent and two had good outcomes of wrist function. Three patients showed excellent subjective satisfaction, and three were good. All patients showed radiographic bone union and no further progression of lunate necrosis. The presurgical carpal height ratio was similar to the value at last follow-up, and there was no radiographic carpal bone collapse. For two cases of Lichtman stage IIIA, the slight degenerative arthritis at the lunocapitate joint observed preoperatively did not change. Skin necrosis and pin track infection were not observed. CONCLUSION: The 4+5 extensor compartmental vascularized bone graft is a reliable procedure for Lichtman stage II and IIIA patients with Kienbock's disease, as it achieved not only pain relief and improvement of range of motion but also maintenance of the intercarpal bone relationship on radiographs, with relatively few complications.