The Usefulness of a Simplified Navigation-Based Instrumentation for a Novice Surgeon in Primary Total Knee Arthroplasty: A Retrospective Analysis of a Randomized Controlled Trial

Background@#A novel simplified navigation-based instrumentation system has been developed. It simplifies the existing navigation system and facilitates convenient bone cutting by positioning the tracker on an existing cutting block without additional pin fixation. This study aimed to compare the outcomes of this newly developed simplified navigation-based instrumentation system in primary total knee arthroplasty (TKA) performed by a novice surgeon with those of conventional surgical techniques. @*Methods@#From January 2020 to July 2020, 67 knees that underwent primary TKA using the ExactechGPS TKA Plus (group A) were compared to 68 knees that underwent primary TKA using a conventional technique (group B). All patients had a minimum follow-up of 24 months. The operative details such as tourniquet time were investigated. Postoperative hip-knee-ankle (HKA) angle and component position angles in the coronal and sagittal planes (α, β, γ, and δ angles) were evaluated. The outlier rates were compared between the groups as those lying outside ± 3°. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, the Western Ontario and McMaster Universities Osteoarthritis Index for pain and function, and range of motion were compared. @*Results@#There was no statistically significant difference in average tourniquet time between the groups (74.3 vs. 70.3 minutes, p = 0.061). Outlier rates for HKA angle (7.5% vs. 23.5%, p = 0.010) and β angle (1.5% vs. 22.1%, p < 0.001) in group A were significantly lower than those in group B. There were no significant differences in clinical outcomes between the groups. @*Conclusions@#Primary TKA performed by a novice surgeon using a simplified navigation-based instrumentation system did not significantly increase the operation time, and more accurate lower extremity mechanical alignment and tibial component alignment in the coronal plane could be obtained.

Factors Associated with Mechanical Complications in Intertrochanteric Fracture Treated with Proximal Femoral Nail Antirotation / 대한고관절학회지

Purpose@#Although proximal femoral nail antirotation (PFNA; Synthes, Switzerland) has demonstrated satisfactory results when used for the treatment of intertrochanteric fractures, mechanical complications may occur. To better quantify the risk of mechanical complications when proximal femoral nail antirotation is used to treat intertrochanteric fractures, this study aimed to: (1) characterize the frequency of mechanical complications and extent of blade sliding and their correlation with reduction quality and (2) identify factors associated with mechanical complications. @*Materials and Methods@#A review of medical records from 93 patients treated for intertrochanteric fractures with a minimum of 6-months of follow-up between February 2014 and February 2019 was conducted. Blade position was evaluated using Tip-apex distance (TAD) and Cleveland index. The extent of blade sliding was evaluated using the adjusted Doppelt’s method for intramedullary nailing. Individuals were classified as having or not having mechanical complications, and reduction quality and radiologic outcomes were compared between the two groups. @*Results@#Mechanical complications occurred in 12 of 94 hips (12.8%), with 11 out of 12 being from the intramedullary reduction group. There was no significant difference in TAD between groups; however, there were significant differences were noted in Cleveland index, AO/OTA classification, reduction quality and extent of blade sliding. The mean blade sliding distance was 1.17 mm (anatomical group), 3.28 mm (extramedullary group), and 6.11 mm (intramedullary group), respectively (P<0.001). Data revealed that blade sliding was an associated factor for mechanical complications (odds ratio 1.25, 95% confidence interval 1.03-1.51). @*Conclusion@#The extent of blade sliding determined using the adjusted Doppelt’s method was significantly associated with mechanical complications suggesting that prevention of excessive sliding through proper intraoperative reduction is important to help achieve satisfactory treatment outcomes.

Current perspectives in stem cell therapies for osteoarthritis of the knee / 영남의대학술지

Mesenchymal stem cells (MSCs) are emerging as an attractive option for osteoarthritis (OA) of the knee joint, due to their marked disease-modifying ability and chondrogenic potential. MSCs can be isolated from various organ tissues, such as bone marrow, adipose tissue, synovium, umbilical cord blood, and articular cartilage with similar phenotypic characteristics but different proliferation and differentiation potentials. They can be differentiated into a variety of connective tissues such as bone, adipose tissue, cartilage, intervertebral discs, ligaments, and muscles. Although several studies have reported on the clinical efficacy of MSCs in knee OA, the results lack consistency. Furthermore, there is no consensus regarding the proper cell dosage and application method to achieve the optimal effect of stem cells. Therefore, the purpose of this study is to review the characteristics of various type of stem cells in knee OA, especially MSCs. Moreover, we summarize the clinical issues faced during the application of MSCs.

Osteotomy around the Knee: Indication and Preoperative Planning / 대한정형외과학회잡지

Osteotomy around the knee is a widely considered surgical procedure for osteoarthritis with lower extremity malalignment. High tibial osteotomy (HTO) is performed for varus deformity, while distal femur osteotomy (DFO) is performed for valgus deformity. However, if the correction is insufficient, double osteotomy can also be considered. This report included the basic principles and current concepts of patient selection and preoperative planning in osteotomy around the knee.

Staged Treatment of Bicondylar Tibial Plateau Fracture (Schatzker Type V or VI) Using Temporary External Fixator: Correlation between Clinical and Radiological Outcomes

PURPOSE: This study is to investigate clinical and radiological results of staged treatment using a temporary external fixator in bicondylar tibial plateau fractures (TPFs) and to evaluate correlation between prognostic factors and postoperative clinical outcomes. MATERIALS AND METHODS: Twenty-four bicondylar TPF patients were selected. All patients were operated by a temporary external fixator first and then open reduction and internal fixation with dual plating. Clinical and radiological outcomes were evaluated. RESULTS: The mean American Knee Society score (AKSS) was 85.3. The mean Western Ontario and McMaster Universities Osteoarthritis index was 11.2. The mean range of motion (ROM) was 123.4°. The mean medial tibial plateau angle (mTPA) was 88.3°, and the mean proximal posterior tibial angle (PPTA) was 8.4°. Compared with the uninjured limb, the mean difference of mTPA was 1.5° and that of PPTA was 4.0°. The difference of PPTA and the AKSS demonstrated negative correlation (p=0.007). Patients with normal mTPA showed better ROM than those with abnormal mTPA (p=0.041). CONCLUSIONS: Staged treatment using a temporary external fixator in bicondylar TPFs showed good clinical and radiological outcomes. Surgeons should evaluate the reduction status intraoperatively by fluoroscopy and also refer to the uninjured limb radiologically.

Diagnostic Tools for Acute Anterior Cruciate Ligament Injury: GNRB, Lachman Test, and Telos

PURPOSE: The purpose of this study is to compare the accuracy of the GNRB arthrometer (Genourob), Lachman test, and Telos device (GmbH) in acute anterior cruciate ligament (ACL) injuries and to evaluate the accuracy of each diagnostic tool according to the length of time from injury to examination. MATERIALS AND METHODS: From September 2015 to September 2016, 40 cases of complete ACL rupture were reviewed. We divided the time from injury to examination into three periods of 10 days each and analyzed the diagnostic tools according to the time frame. RESULTS: An analysis of the area under the curve (AUC) of a receiver operating characteristic curve showed that all diagnostic tools were fairly informative. The GNRB showed a higher AUC than other diagnostic tools. In 10 cases assessed within 10 days after injury, the GNRB showed statistically significant side-to-side difference in laxity (p<0.001), whereas the Telos test and Lachman test did not show significantly different laxity (p=0.541 and p=0.413, respectively). CONCLUSIONS: All diagnostic values of the GNRB were better than other diagnostic tools in acute ACL injuries. The GNRB was more effective in acute ACL injuries examined within 10 days of injury. The GNRB arthrometer can be a useful diagnostic tool for acute ACL injuries.

High Tibial Osteotomy versus Unicompartmental Knee Arthroplasty for Medial Compartment Arthrosis with Kissing Lesions in Relatively Young Patients

PURPOSE: The purpose of this study is to compare the clinical and radiographic outcomes of high tibial osteotomy (HTO) and unicompartmental arthroplasty (UKA) in advanced medial compartment arthritis accompanied by kissing lesions in relatively young patients. MATERIALS AND METHODS: Forty-five patients were divided into the HTO (n=23) and UKA (n=22) groups. Clinically, we evaluated the Lysholm knee scoring scale, visual analogue scale, Hospital for Special Surgery, and Western Ontario and McMaster Universities Osteoarthritis index scores preoperatively, 6 and 12 months postoperatively, and at the final follow-up. Radiographically, we measured the femoral-tibial angle and mechanical axis deviation preoperatively and at the final follow-up. RESULTS: All clinical outcomes gradually improved in both groups from the postoperative period to the final follow-up. At the final follow-up, all clinical outcomes were slightly better in the UKA group than in the HTO group; however, differences were not statistically significant. CONCLUSIONS: HTO is comparable to UKA in terms of clinical outcomes. Thus, the results of this study suggest that HTO might be a good alternative treatment to UKA for medial unicompartmental arthritis accompanied by kissing lesions in relatively young patients.

Current Concepts of Posterolateral Corner Injuries of the Knee

The number of posterolateral corner (PLC) injury patients has risen owing to the increased motor vehicle accidents and sports activities. Careful examination is required because this injury is easy to overlook and may lead to chronic instability. The purpose of this article is to review the anatomy, biomechanics, diagnosis, classification and, treatment of PLC injuries and summarize the recent literatures regarding the treatment outcomes.

Comparative Study of Clinical and Radiographic Outcomes of High Tibial Osteotomy in Patients with Kissing Lesions and Non-Kissing Lesions

PURPOSE: High Outerbridge grade lesions of the articular cartilage have been associated with poor outcomes of high tibial osteotomy (HTO). However, there has been no report on the efficacy of HTO in the presence of kissing lesions. The purpose of this study was to compare clinical and radiographic outcomes of HTO between kissing lesion and non-kissing lesion groups. MATERIALS AND METHODS: Of the patients with medial compartment osteoarthritis and varus deformity treated with HTO between 2007 and 2012, 21 cases with kissing lesions and 22 cases without kissing lesions were selected. Clinical outcomes were assessed using the Lysholm knee scoring scale score, visual analogue scale score, Hospital for Special Surgery score, Western Ontario and McMaster Universities score, and Tegner activity score. Radiographic outcomes were assessed using the femoral-tibial angle, mechanical axis deviation, medial proximal tibial angle, posterior tibial slope angle, and joint space width. RESULTS: Clinical outcomes were improved in both groups from the postoperative assessment to the final follow-up, which showed no statistically significant difference between groups at the final follow-up. No statistically significant differences were observed with regard to radiographic assessment. CONCLUSIONS: Since both groups showed favorable short-term clinical and radiographic outcomes, HTO might be an alternative treatment option for degenerative osteoarthritis with kissing lesions in relatively young patients.

Efficacy of Open Debridement and Polyethylene Exchange in Strictly Selected Patients with Infection after Total Knee Arthroplasty

PURPOSE: To assess the efficacy of open debridement and polyethylene exchange (ODPE) combined with proper antibiotic therapy in strictly selected patients with infection after total knee arthroplasty (TKA) and analyze factors associated with treatment failure. MATERIALS AND METHODS: From January 2010 to January 2014, 25 cases that underwent ODPE under the diagnosis of infection within four weeks after TKA or acute hematogenous infection within five days of symptom onset were reviewed in this study. RESULTS: Treatment was successful in 22 out of 25 cases (88.0%). Factors associated with failure were accompanying infection (periprosthetic infection in the ipsilateral foot, cervical parotid abscess, and masticator space abscess) and diagnosis of rheumatoid arthritis (RA) before TKA. Resistant bacteria did not entail a risk. On clinical results, the mean postoperative Lysholm score and Korean Knee score were 81.4 and 79.4, respectively, the knee range of motion was 115.4°±12.9°, and duration of hospitalization was 32.3±8.4 days. On radiographic results, 3.47±1.56 mm joint line elevation and a valgus change of 0.61°±2.35° in knee alignment were observed. CONCLUSIONS: ODPE combined with appropriate antibiotics therapy could be a useful treatment method for infection after TKA if the procedure is performed within a symptom duration of five days or less in the absence of accompanying infection in patients whose indication for TKA was not RA.

Comparison of the Treatment Results between Reduction with Percutaneous Wiring and Reduction without Percutaneous Wiring in Reverse Oblique Trochanteric Fractures (AO Classification 31-A3.3)

PURPOSE: The aim of this study was to investigate the utility of percutaneous wiring in the reduction of reverse oblique trochanteric fractures (AO classification 31-A3.3) by analyzing the treatment results with or without the use of percutaneous wiring. MATERIALS AND METHODS: Thirty-five cases from January 2008 to August 2014 that could be followed-up for at least one year were selected among patients with unstable trochanteric fractures who underwent either internal fixation or open reduction. Seventeen patients underwent surgery with percutaneous wire fixation but another 18 patients underwent surgery without it. All patients received a closed reduction and internal fixation with an intramedullary nail. The factors evaluated were as follows: the length of operation, loss of blood, length of in-hospital stay, lower limb function scale, return to preinjury daily life, change in femur neck shaft angle, postoperative gap of the fracture site, time taken for bone attachment, quality of post-operative reduction, and complications. RESULTS: No significant difference in the mean operative time, loss of blood, length of in hospital stay, lower limb function scale, return to pre-injury daily life, change in femur neck shaft angle, postoperative gap of the fracture site, and quality of postoperative reduction was observed between the two groups. A significant difference was noted in the time taken for bone attachment (p=0.032). Bone attachment took 13.3 weeks (9–17 weeks) on average when fixed with percutaneous wiring and no patient was found to have any complications. When treated without percutaneous wiring, however, bone attachment took 17.8 weeks (12.5–28.0 weeks) on average and three cases resulted in delayed union. CONCLUSION: Percutaneous wiring is a recommended treatment option for patients with an unstable trochanteric fracture.

Impaired Bone Healing Metabolic and Mechanical Causes

Non-union is one of the most devastating complications after fracture fixation. It usually results in prolonged treatment duration and unpredictable results. We reviewed the literature to identify recent information regarding the following: risk factors of nonunion; mechanical risk factors, including fracture gap width and stability, osteonecrosis and healing mechanism, osteoporotic fracture and fixation method, the characteristics of fracture, soft tissue injury, local infection, and multiple fractures; as well as the metabolic risk factors, including age, comorbidities, smoking, alcoholism, and medications. The technique and devices for fracture treatment have been developed, and treatments of nonunion are evolving according to the enhancement of our understanding of nonunion. Clinicians should refer to the risk factors and advancements while developing a treatment plan.

Impaired Bone Healing Metabolic and Mechanical Causes

Non-union is one of the most devastating complications after fracture fixation. It usually results in prolonged treatment duration and unpredictable results. We reviewed the literature to identify recent information regarding the following: risk factors of nonunion; mechanical risk factors, including fracture gap width and stability, osteonecrosis and healing mechanism, osteoporotic fracture and fixation method, the characteristics of fracture, soft tissue injury, local infection, and multiple fractures; as well as the metabolic risk factors, including age, comorbidities, smoking, alcoholism, and medications. The technique and devices for fracture treatment have been developed, and treatments of nonunion are evolving according to the enhancement of our understanding of nonunion. Clinicians should refer to the risk factors and advancements while developing a treatment plan.

Comparison of Difference in Hematologic and Hemodynamic Outcomes between Primary Total Knee Arthroplasty and Revision of Infected Total Knee Arthroplasty

PURPOSE: This study is to identify preoperative cautions for revision of infected total knee arthroplasty (TKA) by understanding the differences in hematologic and hemodynamic changes between primary TKA and revision of infected TKA. MATERIALS AND METHODS: The study included 40 patients in each of the two groups: one group with patients who underwent TKA and the other group with patients who underwent revision of infected TKA. All patients matched for age and body mass index. The following data were compared between the groups: changes in blood pressure, variations in hemoglobin level, amount of postoperative blood loss and transfused blood, incidence of blood transfusion, white blood cell (WBC) count, albumin level, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver enzyme level. RESULTS: The hemoglobin levels, transfusion rate, and the amount of blood loss were significantly higher in the revision group (p=0.012). In both groups, CRP reached the highest level on the 3rd postoperative day but it was normalized 2 weeks postoperatively; however, the revision TKA group showed a greater tendency to normalization (p=0.029). There were significant differences between the groups in ESR, WBC, blood pressure, and changes in liver enzyme levels. CONCLUSIONS: Revision of infected TKA results in greater hemodynamic variations than primary TKA. Therefore, more efforts should be made to identify pre- and postoperative hemodynamic changes and hematologic status.

Effects of Teriparatide Administration on Fracture Healing after Intramedullary Nailing in Atypical Femoral Fractures / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the effects of teriparatide administration on fracture healing after intramedullary nailing in atypical femoral fractures. MATERIALS AND METHODS: We retrospectively reviewed 26 patients (26 cases) with atypical femoral fracture who were treated using intramedullary nailing between January 2009 and December 2013. Teriparatide was not administered to 15 patients (non-injection group) and was administered to 11 patients after surgery (injection group). Clinical results were assessed using the Nakajima score and the visual analogue scale (VAS). Radiographic results were compared for the time of callus formation, callus bridge formation, and bone union between the groups. RESULTS: Time to recover walking ability and to decrease pain in the surgery region (VAS≤2) were significantly shorter in the injection group than in the non-injection group. The time of callus formation, callus bridge formation, and bone union was significantly shorter in the injection group than in the non-injection group. There were 5 cases of delayed bone union (33.3%) and 1 case of none union (6.7%) in the non-injection group and all cases obtained bone union in injection group. CONCLUSION: The injection group showed better clinical and radiographic results than the non-injection group after intramedullary nailing in atypical femoral fracture. Therefore, we think that teriparatide administration after intramedullary nailing could be a useful treatment option to promote bone union.

Treatment of Fused Knee Flexion and Valgus Deformity Using Gradual Correction with Ilizarov Frame / 대한정형외과학회잡지

Various surgical methods including soft tissue procedures and bone procedures are commonly used to treat knee flexion and contracture deformity. However, several complications such as, neurovascular injury and skin necrosis were reported because of rapid correction. We aim to report good results from gradual correction using Ilizarov following supracondylar osteotomy in a 24-year-old man suffering from fused knee flexion and valgus deformity, a complication developed by septic arthritis.

Surgical Treatment for Displaced Intra-Articular Calcaneal Fractures

Calcaneal fractures are the most common type of tarsal fracture, and comminuted and bursting fractures are common due to the anatomic characteristics of the calcaneus. Assessment and treatment of calcaneal fractures has improved significantly over time. Despite advancements in surgical techniques and equipment, these fractures remain difficult to treat. In this review article, the physiopathology, classification, and surgical treatments of displaced intra-articular calcaneal fractures are updated.

The Mid-Term Result after Osteosynthesis of Intra-Articular Fractures of Distal Femur

PURPOSE: This study was to evaluate the radiological and clinical mid-term results and the presence of post-traumatic osteoarthritis after osteosynthesis in patients under the age of 50 years undergoing osteosynthesis for distal femur intra-articular fractures (AO/OTA 33-B & C) from high-energy trauma. MATERIALS AND METHODS: Between January 2008 and January 2013, a total of twenty-one patients with more than three years of follow-up were enrolled. Recovery of the alignment of the lower extremity, union period, and the presence of post-traumatic osteoarthritis were confirmed by follow-up radiographs. Clinically, the range of motion, pain on fracture lesion, and Knee Society score (KSS) were evaluated. RESULTS: The average duration of union was 18.2 weeks (10-28 weeks), and the alignment of the lower extremity was within normal range in all patients. Seven patients showed post-traumatic osteoarthritis at the final follow-up after more than three years. The presence of post-traumatic osteoarthritis was associated with the classification of fractures, coronal plane fracture, and age. The average range of motion, knee score among KSS, and function score at the last follow-up were 128.7°, 86.1, and 85.1, all showing a greater improvement when compared with the one-year follow-up scores. CONCLUSION: The mid-term result was radiologically and clinically satisfactory. Furthermore, only 33.3% of patients showed a slight progress of post-traumatic osteoarthritis, which critically effects the prognosis.

Steinmann Pin Assisted Reduction of Subtrochanteric Femoral Fracture

PURPOSE: Nail insertion is the treatment of choice for subtrochanteric femoral fracture, but displacement of proximal bone fragment makes it difficult to find an ideal entry point. Therefore, in this study we aimed to determine the usefulness of treatment of subtrochanteric femoral fracture using Steinmann pin assisted reduction, internal fixation, and insertion of intramedullary nails. MATERIALS AND METHODS: We evaluated 33 patients who were followed-up more than a year with a displaced subtrochanteric femoral fracture treated with closed reduction and intramedullary nail fixation between January 2008 and March 2013. In addition, we studied postoperative bone union time, postoperative reduction status, change of the femur neck shaft angle, evaluation of hip joint function, return to daily life, and complications. RESULTS: All fractures with Steinmann pin assisted reduction were united but they included three cases of delayed union. In Fogagnolo classification, all cases were up to acceptable states and the varus change of femur neck shaft angle was 0.94degrees+/-3.1degrees; no significant difference in Harris hip score was observed between preoperative and last follow-up (p>0.05). CONCLUSION: There were satisfactory results in bone union and reduction state with Steinmann pin assisted reduction. Therefore, Steinmann pin assisted reduction is a useful surgical technique for subtrochanteric femoral fracture.

Age-related NADPH Oxidase (arNOX) Activity Correlated with Cartilage Degradation and Bony Changes in Age-related Osteoarthritis

The purpose of this study was to investigate the age-related NADPH oxidase (arNOX) activity in patients with age-related knee osteoarthritis (OA). Serum and cartilage arNOX activities were determined using an oxidized ferricytochrome C reduction assay. Full-thickness knee joint cartilages obtained through total knee replacement surgery were graded according to the Outerbridge (OB) classification. Radiographic severity of OA was determined on Knee X-rays according to the Kellgren-Lawrence (K/L) grading system. Cartilage beta-galactosidase, HIF-1alpha, and GLUT-1 expression levels were evaluated as markers for tissue senescence, hypoxia, and glycolysis. Higher arNOX activities occurred with higher levels of cartilage beta-galactosidase, HIF-1alpha, and GLUT-1 (P = 0.002). arNOX activity in cartilages with surface defects (OB grade II, III) was higher than in those without the defects (OB grade 0, I) (P = 0.012). Cartilage arNOX activity showed a positive correlation with serum arNOX activity (r = -0.577, P = 0.023). Serum arNOX activity was significantly higher in the OA subgroup with bilateral ROA than in the OA with no or unilateral ROA (2.449 +/- 0.81, 2.022 +/- 0.251 nM/mL, respectively, P = 0.019). The results of this study demonstrate that OA itself is not a cause to increase arNOX activities, however, arNOX hyperactivity is related to a high degree of cartilage degradation, and a high grade and extent of ROA in age-related OA.