Anterior tibial displacement on preoperative stress radiography of ACL-injured knee depending on knee flexion angle

PURPOSE@#To compare side-to-side difference (SSD) of anterior tibial translation in instrumented stress radiography for each series of anterior cruciate ligament (ACL)-injured subjects according to knee flexion angle.@*METHODS@#Forty subjects who were suspected of having significant ACL injury by manual Lachman test and MRI were recruited for this prospective study. These subjects took stress radiographs for both knees with corresponding knee flexion of 10° (series M1) and 30° (series M2) using Telos stress device. Mean SSDs of M1 and M2 were compared. Sensitivities of M1 and M2 were assessed using the SSD ≥3mm or ≥5mm as a cutoff value.@*RESULTS@#Mean SSDs in series M1 and M2 were 4.22 ± 3.72mm and 3.25 ± 3.30 mm, respectively (p < 0.001). When 3 mm of SSD was used as a cutoff value, sensitivities of series M1 and M2 were 47.5% (19/40) and 32.5% (13/40), respectively (p = 0.171). When 5mm of SSD was used as a cutoff value, sensitivities of series M1 and M2 were 45.0% (18/40) and 22.5% (9/40), respectively (p = 0.033).@*CONCLUSIONS@#Anterior tibial translation on stress radiographs using a Telos device is more prominent when knee flexion angle is 10° compared to that when knee flexion angle is 30°. However, stress radiography using Telos device, either at 10° or 30° of knee flexion, might not be suitable to make decision on surgical treatment due to relatively low sensitivities.

One-Year Serial Follow-up Magnetic Resonance Imaging Study of RigidFix for Femoral Fixation in Anterior Cruciate Ligament Reconstruction

PURPOSE: To assess graft slippage at the site of femoral fixation by follow-up magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) reconstruction with a four-strand autogenous hamstring tendon using RigidFix (DePuy Mitek). MATERIALS AND METHODS: Twenty-one subjects diagnosed with ACL rupture underwent ACL reconstruction using hamstring autograft with the transtibial technique. RigidFix was used for femoral fixation and Intrafix and washer screw were used for tibial fixation. Follow-up MRIs were taken immediately after surgery and at 1, 3, 6, and 12 months after surgery. Slippage of the graft and breakage of the RigidFix cross-pin were assessed. Side-to-side difference (SSD) on stress radiographs was measured to assess residual laxity. RESULTS: Mean slippage of the graft was 0.21±0.31 mm at one year after surgery. Cross-pin breakage was noted in two subjects: in one subject, immediately after surgery and in the other subject, at 6 months after surgery. Mean SSD was 1.32±1.07 mm at the last follow-up. The correlation coefficient between graft slippage and SSD was 0.131 (p=0.571). CONCLUSIONS: RigidFix is a stable fixation device for hamstring autograft with minimally statistically significant but clinically insignificant graft slippage. Cross-pin breakage did not affect the clinical outcomes. Careful preparation of the graft is needed for performing the technique correctly.

Fibrous Dysplasia in the Epiphysis of the Distal Femur

Fibrous dysplasia is a common benign skeletal lesion that may involve a single bone or multiple bones. Although fibrous dysplasia can affect any bone, monostotic fibrous dysplasia of the long bone typically occurs in the diaphysis or metaphysis. We report a very rare case of monostotic fibrous dysplasia involving the epiphysis of the distal femur in a young man.

Is Intraoperative Use of QuikClot Combat Gauze Effective for Hemostasis after Total Knee Arthroplasty?

BACKGROUND: To assess the hemostatic effect of QuikClot Combat Gauze (QCG) compared to that of standard gauze during cruciate-retaining total knee arthroplasty (TKA). METHODS: Sixty knees underwent TKA using a pneumatic tourniquet in this prospective randomized study. After implantation of the femoral and tibial components and hardening of the bone cement, the tourniquet was deflated and QCG (group 1) or standard gauze (group 2) was packed into the joint cavity for 5 minutes for hemostasis. Perioperative bleeding volume and blood transfusion volume were compared between two groups. RESULTS: The mean intraoperative bleeding volume was 64.7 ± 12.7 mL in group 1 and 63.9 ± 9.2 mL in group 2 (p = 0.808). The mean postoperative blood drainage was 349.0 ± 170.6 mL in group 1 and 270.1 ± 136.3 mL in group 2 (p = 0.057). The average postoperative blood transfusion volume was 323.7 ± 325.9 mL in group 1 and 403.6 ± 274.8 mL in group 2 (p = 0.314). CONCLUSIONS: QCG was not significantly effective for reducing perioperative bleeding volume or the blood transfusion rate compared with standard gauze during TKA.

A Case of Adult Onset Still's Disease Misdiagnosed as Septic Arthritis

We present a case of adult onset Still's disease (AOSD) that was misdiagnosed as septic arthritis of the shoulder and knee. A forty-nine-year-old woman was admitted for pain in the left knee. The patient's medical history showed that she had undergone arthroscopic irrigation twice and an open debridement under the diagnosis of septic shoulder at another hospital. The laboratory and joint fluid analysis findings led us to suspect septic knee. Arthroscopic irrigation and antibiotics treatment were performed. At five weeks after discharge, she presented with pain in the same joint, fever, and rash. The symptoms were consistent with Yamaguchi's criteria for AOSD. We started corticosteroid therapy, and clinical remission was achieved. In conclusion, we suggest that AOSD should be considered as a diagnosis of exclusion to avoid misdiagnosis with septic arthritis.

Incomplete Anterior Interosseous Nerve Palsy That Accompanied a Monteggia Fracture / 대한정형외과학회잡지

The anterior interosseous nerve innervates the flexor pollicis longus, the flexor digitorum profundus and the pronator quadratus. There are no sensory fibers from the anterior interosseous nerve leading to the skin. Paralysis of the anterior interosseous nerve that accompanies a Monteggia fracture has rarely been reported, and incomplete paralysis of the anterior interosseous nerve has almost not been reported. We experienced a patient with incomplete anterior interosseous nerve palsy involving the flexor pollicis longus as a complication of a Monteggia fracture. The paralysis of the flexor pollicis longus recovered 4 months after the surgery for the Monteggia fracture.

Total Knee Arthroplasty Using an Intra-Articular Correction Method in Patients with Extra-Articular Deformity of the Femur / 대한정형외과학회잡지

PURPOSE: To investigate the result of total knee arthroplasty (TKA) using an intra-articular correction in patients with extra-articular deformity of the femur. MATERIALS AND METHODS: We performed 23 TKAs in 23 patients with extra-articular deformity of the femur. The mean age was 58.0 years and the follow-up period averaged 54.7 months. The American Knee Society's knee and function score were evaluated, and the mechanical axis (MA) was measured. Sixteen knees with a deformity in the distal third of the femur were assigned to group I and 7 knees with a deformity in the proximal or middle third were assigned to group II. Between groups differences in results were analyzed. RESULTS: The average knee score was 47.8 preoperatively and 91.6 at the last follow-up. The average function score was 46.9 preoperatively and 89.1 at the last follow-up. The MA averaged varus was 7.7degrees preoperatively and 1.0degrees postoperatively. The average knee score at the last follow-up was 90.1 in group I and 95.0 in group II. The average function score at the last follow-up was 87.8 in group I and 92.1 in group II. The MA averaged varus was 2.0degrees in group I and 1.3degrees in group II (p=0.042). CONCLUSION: TKA in conjunction with intra-articular correction produced satisfactory results for patients with an extra-articular deformity of femur. The possibility of incomplete correction of limb alignment should be carefully considered, especially in cases with a severe deformity at the distal third of the femur.

Causes and Clinical Outcomes Associated with Re-revision Total Knee Arthroplasty

PURPOSE: To analyze the causes and clinical outcomes associated with re-revision total knee arthroplasty. MATERIALS AND METHODS: Eighteen cases of re-revision total knee arthroplasty (TKA) were performed between June 1996 and September 2006. The average patient age was 69.8 years, and the average follow-up period was 3.4 years. We evaluated the time interval between revision and re-revision arthroplasty and the causes of re-revision. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) knee rating score and determining the range of motion in the knee. RESULTS: The mean interval between revision and re-revision arthroplasty was 9 years 1 month. Causes of re-revision included 9 cases of polyethylene wear, 6 cases of aseptic loosening, 1 case of infection, and 2 cases of other causes. The average HSS score was 89.1, and the average range of motion was 111.1 degrees. For 5 cases of revision undertaken secondary to infected TKA, the interval between revision and re-revision arthroplasty was 9 years 3 months, and the cause of re-revision surgery was aseptic loosening in all cases. CONCLUSION: The main causes of re-revision surgery were polyethylene wear and aseptic loosening. Reasonable restoration of function was achieved in re-revision arthroplasty using appropriately selected implants, metal augmentation, structural allografts, and stems. When revising an infected TKA, it is important to achieve structural stability in the implant because of the possibility of late aseptic loosening.

Midterm Clinical and Radiological Results after Microfracture in Osteoarthritic Knees / 대한정형외과학회잡지

PURPOSE: To evaluate midterm results after microfracture in osteoarthritic knees. MATERIALS AND METHODS: Between October 1997 and April 2006, 67 osteoarthritic knees, with minimum 4-year follow-up, underwent microfracture. Baumgaertner scores were evaluated to determine clinical results. Radiological results were assessed based on joint space widening and improvement of mechanical axis deviation. Joint space widening was calculated by comparing the preoperative joint space with the final follow-up joint space. Varus deformity was evaluated on orthoroentgenogram and recorded as a percentile of the point at which the mechanical axis intersected a line extending from the center of the knee to medial border of the medial tibial condyle. The figure was expressed as MA%. RESULTS: The average Baumgaertner score at final follow-up was 7.0. The average joint space changed from 2.74 mm to 4.22 mm on AP radiographs and from 1.91 mm to 3.85 mm on lateral radiographs. Average MA% was 57.5% preoperatively and 45.8% at final follow-up. Clinical and radiological improvements were maintained in most cases followed for more than 4 years. Four patients had total knee arthroplasty after an average of 4.1 years. CONCLUSION: We noted pain relief, joint space widening, and improvement of mechanical axis after microfracture for degenerative arthritis of the knee. Maintenance of clinical and radiological improvement was observed at midterm follow-up.

Navigation versus Radiographic Measurements in the Open-Wedge High Tibial Osteotomy using Computer Assisted Surgery (CAS) / 대한정형외과학회잡지

PURPOSE: To compare the measurements using a navigation system and radiographic measurement in an open wedge high tibial osteotomy under navigation control. MATERIALS AND METHODS: From July, 2005 to January, 2007, 32 open wedge high tibial osteotomies were performed using a navigation system for osteoarthritis of the knee. The postoperative mechanical axis % (MA%), which is planned on the navigation system, were 62%. The mechanical axis (MA) and MA% were measured on the navigation system. The preoperative and postoperative MA and MA% were measured on the radiographs. The angles measured with the navigation system and radiographs were compared. RESULTS: On the navigation system, the mean MA before osteotomy was varus 8.8degrees. The mean MA and MA% after fixation were valgus 2.9degrees and 57.7%. On the radiographs, the mean MA was varus 9.7degrees preoperatively and valgus 4.0degrees postoperatively. The mean MA% was 10.2% preoperatively and valgus 64.4% postoperatively. There were positive correlations between the values measured with the navigation system and the radiographs (r>0.5, p<0.001). CONCLUSION: There were significant correlations between the values measured with the navigation system and radiographs in an open wedge high tibial osteotomy using a navigation system. The correction angle from the navigation system is reliable, predictable and controllable during surgery.

The Change of the Posterior Tibial Slope after Cruciate Retaining Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To analyze the pre- and postoperative posterior tibial slope angle (PSA) of performing cruciate-retaining total knee arthroplasty (TKA) and to identify the ideal value of the PSA in relation to the clinical results. MATERIALS AND METHODS: From June 1999 to May 2005, 202 TKA with a NexGen(R) cruciate-retaining knee were performed in 160 patients. The mean follow-up period was 39.8 months. The pre- and postoperative PSA referenced by the proximal tibial medullary canal (PSA-A) and the proximal tibial anterior cortex (PSA-B) were measured by two independent observers. The knee and function scoring system of the American Knee Society and the range of motion of the knee at the last follow-up were evaluated as the clinical results. RESULTS: The mean PSA-A was 11.4+/-4.8degrees preoperatively and 6.0+/-2.8degrees postoperatively, and the mean PSA-B was 13.6+/-4.9degrees preoperatively and 8.1+/-2.9degrees postoperatively. The difference between the pre- and postoperative PSA increased as the preoperative PSA-A changed from 6.0degrees and the PSA-B changed from 8.1degrees; these findings showed statistical significance based on a simple linear regression (PSA-A: r= 0.837, p=0.000; PSA-B: r=0.834, p=0.000). The knee and function score of American Knee Society improved respectively from 62.9 and 55.8, preoperatively, to 97.4 and 89.7 respectively, at the last follow-up. The range of motion of the knee joint was 128.0degrees preoperatively and 129.7degrees at the last follow-up. CONCLUSION: In cruciate retaining total knee arthroplasty, PSA-A is mostly distributed within 3.2-8.8degrees, and a reasonable range of PSA-A is 6.0+/-2.8degrees.

Survivorship Analysis of Closing Wedge Proximal Tibial Osteotomy Using Miniplate Staple

PURPOSE: To evaluate the clinical and radiological results and to analyze the survivorship after closing wedge proximal tibial osteotomy(PTO) using miniplate staple. MATERIALS AND METHODS: From November 1993 to August 2003, sixty closing wedge PTO using miniplate staple were performed in forty patients. The average follow-up period was 7.2 years(range, 2.8~12.5 years). According to the post- operative femorotibial angle(FTA), group I was defined as the cases whose FTA was less than 7 degrees of valgus(25 cases) and group II was defined as the cases whose FTA was more than 7 degrees of valgus(35 cases). The HSS score, FTA and survivorship were compared between group I and II. RESULTS: Average HSS score at the last follow up were 75.3 in group I and 85.9 in group II(p=0.006). Average FTA at the last follow up were 0.8 degrees in group I and 7.7 degrees in group II(p=0.006). The overall 7-year survivorship was 92.6% and 12-year survivorship was 75.5%. The 7-year survivorship and 12-year survivorship of group I were 86.7% and 54.2%, respectively. Group II have no failure at last follow up(p=0.0489). CONCLUSION: Our results suggest that the desirable postoperative FTA was more than 7 degrees of valgus, considering the long term satisfactory result and survivorship of the closing wedge PTO using miniplate staple for the osteoarthritic knees.

Management of Femoral Peritrochanteric Fracture with Proximal Femoral Nail / 대한정형외과학회잡지

PURPOSE: To evaluate the relationship between the bone union and the factors affecting the treatment of a peritrochanteric fracture of the femur with a proximal femoral nail along with the associated complications. MATERIALS AND METHODS: From November 2000 to April 2004, 91 peritrochanteric fractures of the femur were treated with a proximal femoral nail. Three cases were excluded due to sepsis and multiorgan failure. The remaining 88 cases were followed up for mean period of 16.4 months (range, 12-36 months). The mean age was 73 years old (range, 36-94 years old). There were 11 stable fractures and 77 unstable fractures including reverse obliquity fractures and subtrochanteric extension. The relationship between the bone union and the potential associated factors such as reduction status, Singh index, and position of lag screw (tip apex index, TAD) was investigated. RESULTS: The mean operation time was 60 minutes (range, 42-90 minutes), and the average amount of bleeding was 165 ml (range, 70-250 ml). The mean period for union was 18.4 weeks (range, 12-40 weeks) and 3 cases showed nonunion. The mean Harris Hip Score at the final follow up was 85.3 (range, 23-99). The average union period was 17.0 weeks in the cases with an excellent or fair reduction and 26.7 weeks in those cases with a poor reduction. The average bone union period was 19.2 weeks in cases with a Singh index of 3 or less, and 16.7 weeks in the cases with a Singh index of 4 or more. The average bone union period was 16.8 weeks in the cases with a TAD 25 mm or less, and 20.0 weeks in cases with a TAD more than 25 mm. CONCLUSION: The treatment of a peritrochanteric fracture using a proximal femoral nail produced bone union in 96.6% of cases with a 4.5% complication rate. The average bone union period correlated with the reduction status and TAD significantly.

Management of Ipsilateral Femur and Tibia Fractures, with Retrograde and Antegrade Nailings from the Knee

PURPOSE: To review the results in the management of ipsilateral femur and tibia fractures, using femoral and tibial intramedullary nailings with single incision on the knee. MATERIALS AND METHODS: We treated 19 cases of ipsilateral femur and tibia fractures (floating knee), and the retrograde femoral nailing and antegrade tibial nailing were done with single incision on the knee. Except one patient of early death, 18 patients were included in this study. The mean age of index procedure was 34.1 years, and all of them had follow-up study for a mean of 2.4 years. The mean injury severity score was 18.8, and 12 patients had other fractures in the lower extremity. RESULTS: Primary union was achieved in all, but one patient of femur and two of tibia. The average period for union was 27.6 weeks for femur and 24.5 weeks for tibia. One femoral nonunion occurred due to the metal failure after using short nail, and two tibial nonunion were caused by the bone loss with open tibial fractures. Most patients showed no limitation in knee motion. According to Karlstrom-Olerud criteria, functional results showed 14 excellent, 3 good and 1 acceptable. The protrusion of nail tip into the knee joint made the acceptable result with moderate limitation of knee motion, but it improved after the removal of nail. CONCLUSION: CONCLUSION: Simultaneous retrograde femoral and antegrade tibial nailing with single incision on the knee, with an appropriate technique, can achieve the satisfactory result in the management of the ipsilateral femur and tibia fractures.

Reconstruction of the Anterior Cruciate Ligament in over 40-year-old Patients / 대한정형외과학회잡지

PURPOSE: The purpose of the current study was to examine outcome after ACL reconstruction in patients over 40 years old, and to evaluate factors affecting outcome, such as, associated injuries and the preoperative period after injury. MATERIALS AND METHODS: Clinical results were obtained from 36 cases over 40 years old at the time of surgery. The average age was 45 years (40 to 67 years), and the average follow-up period was 27.6 months (12 to 85 months). Group 1 was composed of 13 cases with a less than 3 months preoperative period, and group 2 23 cases of more than 3 months. 31 cases had associated injuries and 5 cases did not. The parameters used were the Lachman test, KT-2000 arthrometry, Lysholm score, IKDC score, and return to sports activity before injury. RESULTS: The Lachman test was positive in 9 cases (25%) and mean side-to-side difference as determined by KT-2000 arthrometry was 3.9mm, however, there was no statistical difference between group 1 and group 2, regardless of associated injuries (p>.05). Lysholm score averaged 89.8 in total, and was 92.2 in group 1 and 88.5 in group 2, and 93.6 in those without associated injury and 89.2 in those with associated injury (p>.05). The IKDC score was normal (A) in 7 cases, nearly normal (B) in 25, abnormal (C) in 4. Twelve cases (92.3%) were graded A or B in group 1, and 20 cases (87%) were graded A or B in group 2 (p>.05). There were 5 cases (100%) of grade A or B in the group without associated injury and there were 27 cases (87.1%) of A or B in group with associated injury (p>.05). Return to sports activity before injury was possible in 19 cases (53%); 7 cases (53.8%) in group 1 and 12 cases (52.2%) in group 2 (p>.05), and 3 cases (60%) in the group without associated injury and 16 cases (51.6%) in the group with associated injury (p>.05). CONCLUSION: In patients over 40 years old with ACL injury, results can be successful after ACL reconstruction.

Comparative Results of Arthroscopic Anterior Cruciate Ligament Reconstruction with Autologous Quadriceps Tendon-bone Versus Bone-patellar Tendon-bone

PURPOSES: We analyzed the comparative results of arthroscopic anterior cruciate ligament reconstruction using the autologous quadriceps tendon-bone versus the bone-patellar tendon-bone. MATERIALS AND METHODS: Thirty-three patients with ACL reconstruction using the autologous quadriceps tendon-patellar bone were evaluated (group 1). Control group were 33 patients underwent ACL reconstruction with autologous bone-patellar tendon-bone in similar period (group 2). The mean age was 29.7 years in group 1 and 23.5 years in group 2. The mean follow-up period was 20.8 months in group 1, and 21.8 months in group 2. We selected the patient with the similar age, conditions and operation methods. But group 1 with bone-to-tendon graft healing at one side was delayed rehabilitation program than group 2 (bone-to-bone healing). The final evaluation were range of motion, anterior knee pain, Lachman test, KT-2000 arthrometer, Lysholm score, IKDC evaluation, one-leg hop muscle function test. Student ttest was used for statistical analysis (p 0.05). According to the International Knee Documentation Committee (IKDC) rating system, normal were 30.3%, nearly normal 57.6%, abnormal 12.1% in group 1, and in group 2 normal was 24.3%, nearly normal was 63.6%, abnormal 12.1%. There were no statistical differences in normal and nearly normal rate between two groups (p> 0.05). Recovery of quadriceps strength by one-leg hop test was 78% of the normal knee in group 1, and 80% in group 2 (p> 0.05). CONCLUSION: There were no significant differences of clinical results in ACL reconstruction using between quadriceps tendon-bone and bone-patellar tendon-bone, but anterior knee pain. We consider that autologous quadriceps tendon-bone is a good alternative substitute in ACL reconstruction together with the bone-patellar tendon-bone.