Outcomes of Angular Stable Locking System in Femoral Diaphyseal Fractures of Elderly Patients:A Multicenter Comparative Study

Background@#The angular stable locking system (ASLS) was developed to provide additional stability to the distal interlocking screw of the intramedullary (IM) nail. Effects of ASLS on the treatment of femoral diaphyseal fractures in the elderly remain unknown. The aim of this study was to compare radiological outcomes of IM nailing using ASLS screws to IM nails with conventional interlocking screws in elderly patients with femoral shaft fractures. @*Methods@#A multicenter retrospective review of 129 patients (average age, 73.5 years; 98 women and 31 men) aged 65 years or older who underwent IM nail fixation for femoral diaphyseal fractures (AO/Orthopaedic Trauma Association [OTA] classification 32) was conducted. Demographic information of patients, fracture site (subtrochanteric or shaft), fracture type (traumatic or atypical), and AO/OTA fracture classification were investigated. Reduction status was evaluated by postoperative plain radiography. Presence of union and time to union were evaluated through serial plain radiograph follow-up. Reoperation due to nonunion or implant failure was also evaluated. @*Results@#ASLS was used in 65 patients (50.3%). A total of 118 patients (91.5%) achieved union without additional surgery and the mean union time was 31.8 ± 13.0 weeks. In terms of reduction status, angulation was greater in the group using ASLS. There were no statistically significant differences of union rate, time to union, and reoperation rate according to the use of ASLS (p > 0.05). There was no difference in the outcomes according to the use of ASLS even when the analysis was divided in terms of fracture site or fracture type (p > 0.05). In further subgroup analysis, only the traumatic subtrochanteric area group showed statistically significantly shorter time to union when ASLS was used (p = 0.038). @*Conclusions@#In geriatric patients with femoral diaphyseal fractures, the use of ASLS was not considered to have a significant effect on fracture healing. Fracture healing seemed to be more affected by surgical techniques such as minimizing the gap and fracture characteristics such as atypical femoral fractures, rather than implants.

Pseudoaneurysm after Knee Arthroscopic Synovectomy in a Septic Arthritis Patient / 대한정형외과학회잡지

Arthroscopic synovectomy is a widely-used method to treat septic knee arthritis. To date, many authors have reported minimal complications related to arthroscopic treatment, especially vascular injuries. A three-dimensional computed tomography angiography revealed a pseudoaneurysm that arise from the popliteal artery near the arthroscopic site in septic arthritis patients with atherosclerosis and neurofibromatosis. A careful arthroscopic procedure via the posteromedial or posterolateral portal is recommended for the prevention of this complication. We, therefore, recommend close observation after arthroscopic procedure, despite the occurrence of complications; nonetheless, early diagnosis and treatment are important. We report a case of pseudoaneurysm of the popliteal artery with a complicating arthroscopic synovectomy in septic arthritis with literature review.

Treatment of Spinal Infection Following Bilateral Total Knee Replacement Postoperative Infection / 대한정형외과학회잡지

Postoperative infection from total knee arthroplasty (TKA) is an issue drawing great attention, which can manifest as a local or general infection. Its development into sepsis has also occasionally been reported. Such sepsis is a critical complication that can spread to various parts of the body, which can ultimately lead to mortality. However, the cases where infection has spread to the spine do not have clear clinical signs, making diagnosis difficult. These cases are not found in the literature. Therefore, this is a case study on both postoperative infection from TKA that has developed into sepsis and spread to the spine.

Comparison of the Modified Transtibial Technique, Anteromedial Portal Technique and Outside-in Technique in ACL Reconstruction

PURPOSE: To compare clinical and radiographic results of anterior cruciate ligament (ACL) reconstruction using modified transtibial technique (mTT), anteromedial (AM) portal technique and outside-in (OI) technique. MATERIALS AND METHODS: From March 2007 to December 2012, ACL reconstruction was performed using the mTT, AM portal technique and OI technique in 20 patients each. Anteroposterior and rotational stability were assessed using the GNRB arthrometer and pivot-shift test. Femoral tunnel obliquity was measured on the anteroposterior and lateral radiographs. RESULTS: Tegner score, Lysholm score, International Knee Documentation Committee score, pivot-shift test were improved at final follow-up in all three groups. However, statistical difference was not shown. Side-to-side difference in GNRB arthrometer was average of 1.4 mm, 1.0 mm and 0.9 mm in mTT, AM and OI group, showing the signicant difference between mTT and AM/OI groups (p<0.001). The mean femoral tunnel obliquity was 56.4degrees in the mTT group, 39.4degrees in the AM group and 33.6degrees in the OI group, showing significant intergroup difference (p<0.001). It showed the significant difference among three groups (p<0.001). CONCLUSIONS: Clinical results were improved in all three groups. Femoral tunnel obliquity in AM and OI were more horizontal on the coronal plane. They are thought to have more benefits in oblique positioning of the grafted ACL in rotational stability; however, there was no significant difference among three techniques in pivot-shift test to assess the rotational stability in this study.

A Two-Stage Approach to Primary Total Knee Arthroplasty in Recurrent Septic Arthritis / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the usefulness of a two-stage approach to primary knee arthroplasty with recurrent septic arthritis. MATERIALS AND METHODS: We studied 22 patients with recurrent septic arthritis, and we observed them for more than one year of follow-up survey from January 2005 to April 2012 at Yeungnam University Medical Center. The clinical assessment was performed following Knee Society knee score, Knee Society function score, and International Knee Documentation Committee Score (IKDC) subjective assessment. In addition, we analyzed the causative organisms, significant medical comorbidities (diabetes mellitus), period up to primary knee arthroplasty, and radiologic assessment with reference to disease prognosis. RESULTS: The average range of postoperative knee motion showed a good result, with an average of 115degrees. Knee Society knee score improved from 23.5 to 81.0, and Knee Society function score also increased from 22.5 to 73.2. Subjective assessment by IKDC was divided into 15 normal patients and 7 nearly normal patients. No significant difference was observed between patients with causative organisms and those with diabetes mellitus. In the final follow-up survey, recurrence of infection was not reported. CONCLUSION: A two-stage approach to primary knee arthroplasty with recurrent septic arthritis is a useful method, because it showed good clinical and radiologic results and favorable subjective assessment.

Staged Protocol in Treatment of Open Distal Tibia Fracture: Using Lateral MIPO

BACKGROUND: To evaluate the radiological, clinical results in patients with open distal tibia factures, who were treated with a staged treatment protocol using the lateral minimally invasive plate osteosynthesis (MIPO) technique. METHODS: From January 2007 to June 2009, 10 patients with open distal tibia fractures (Gustilo-Anderson classification II, 3; IIIA, 1; IIIB, 6) were treated using a staged treatment protocol. The initial debridement and application of an external fixator were performed within 24 hours and the mean interval from injury to definitive surgical treatment was 15 days (range, 6 to 52 days). Eight weeks later, an additional bone graft was performed in 3 patients. The follow-up duration was more than 1 year. RESULTS: The mean fracture healing time was 21 weeks (range, 17 to 28 weeks), and the average Iowa ankle rating score was 84.5 points. At the last follow-up, there was no non-union, angular deformity > 5degrees, shortening > 10 mm or infection. In 10 patients, 2 patients had a superficial wound infection, and another 2 patients showed limitation of ankle joint motion. CONCLUSIONS: This staged treatment protocol using a lateral MIPO technique is a useful alternative method for achieving high functional recovery with good healing and low complication rates in patients with an open distal tibia fracture.

Ipsilateral Femoral Segmental and Tibial Fractures : A Case Report

The ipsilateral femoral segmental and tibial fractures seldom occur such as traffic accidents needed high energy mechanisms. For these fractures, surgical stabilization and early mobilization of joint produce can be the best clinical outcomes. We have experienced a case of ipsilateral femoral segmental and tibial fracture and gained good clinical results with surgical treatment. We have reported here on this case and included a review of the relevant literature.

Comparision between Mobile Bearing and Fixed Bearing T.K.A. in the Same Patient / 대한정형외과학회잡지

PURPOSE: To evaluate the radiological and clinical results including the patient's satisfaction after total knee arthroplasty (TKA) using two differently designed system for both knees in the same patient. MATERIALS AND METHODS: From January 2002 to January 2003, thirty-two bilateral TKAs were prospectively performed using two differently designed systems. One side TKA was performed using a mobile bearing (PFC RP, Dupey) system, and the other side was performed using a fixed bearing system (PFC, Dupey). All 32 patients were followed up for an average of 51.4 months. The mean age of the study group was 67 years (range 54-75). The clinical results were evaluated from the Knee Score, WOMAC score for the patient's satisfaction and range of motion. Radiological analysis including the tibiofemoral angle was also carried out. An independent T-test was used for statistical analysis. RESULTS: The preoperative average knee score improved to 87.3 from 42.5 in the mobile bearing group and to 86 from 39 in the fixed bearing group respectively. The preoperative average WOMAC score decreased to 11.2 from 84.9 in the mobile bearing group and to 16 from 85.5 in the fixed bearing group. The average preoperative range of knee motion improved to 114.5degrees from 104.5degrees in the mobile bearing group and to 113.8degrees from 104.7degrees in the fixed bearing group. The average preoperative tibiofemoral angle improved to 5.3degrees valgus form 4.5degrees varus in the mobile bearing group and to 6degrees valgus from 3.8degrees varus in the fixed bearing group. The only result statistically significant was the WOMAC score (p<0.05). CONCLUSION: The two differently designed TKA system produce similar outcomes except for the subjective satisfaction in the mid-term clinical and radiological evaluation.

The Comparison of LC-DCP versus LCP Fixation in the Plate Augmentation for the Nonunion of Femur Shaft Fractures after Intramedullary Nail Fixation

PURPOSE: The purpose of this study was to evaluate the efficacy of the surgical treatment through the comparison of LC-DCP (Limited Contact-Dynamic Compression Plate) versus LCP (Locking Compression Plate) fixation in the plate augmentation for the nonunion of femur shaft fractures after intramedullary nail fixation. MATERIALS AND METHODS: Twenty-four patients with the nonunion of femur shaft fractures after intramedullary nail fixation who underwent plate augmentation were evaluated from Mar. 2001 to Sept. 2005. The group with LC-DCP augmentation was done bicortical screw fixation and the group with LCP was done monocortical fixation. RESULTS: There was one case of nail breakage in LC-DCP group, but sound bony union were achieved uneventfully in all the cases of both group. LCP fixation was slightly superior to LC-DCP fixation in view of the bony union time, operating time, postoperative Hb down, amount of postoperative transfusion, but there was no statistical difference (p>0.05). CONCLUSION: We got the satisfactory results after monocortical LCP augmentation as well as bicortical LC-DCP fixation and have concluded that monocortical LCP fixation was an effective treatment option for nonunion of femur shaft fracture occurred after Intrmedullary nail fixation.

Comparison Study of Intertrochanteric Fractures Treated with Intertrochanteric/subtrochanteric Fixation with a Standard vs a Mini-incision

PURPOSE: To evaluate the radiographic, clinical results between who had intertrochnateric fracture, treated with ITST with a standard or a mini-incision. MATERIALS AND METHODS: We selected each 20 patients of intertrochanteric fracture which were treated with ITST with a standard incision or a mini-incision from June 2004 to July 2006. We compared of mean operative time, transfusion doses and postoperative VAS score between two groups. We evaluated the radiographic results by follow-up radiography and the clinical results with the mobility score of Parker and Palmer and Salvati and Wilson hip function scoring system. RESULTS: Mean operative time, transfusion doses and postoperative VAS score were significantly less in the mini-incision there were 87.8 min., 2.0 pints and 4.2 for the standard group versus 40.3 min., 1.1 pints and 3.3 for the mini group. The radiographic results were not significantly different. Decrease of mobility score of Parker and Palmer and Salvati and Wilson hip function scoring system were similar. CONCLUSION: Mini-incision significantly reduces operative time, transfusion doses and postoperative pain for fixation intertrochanteric fracture treated with ITST.

Treatment Result of Preserving Peripheral Rim of Torn Lateral Discoid Meniscus

PURPOSE: To evaluate the clinical results of preserving the peripheral rim of meniscus in the injuries of lateral discoid meniscus. MATERIALS AND METHODS: We analyzed 38 patients, 40 knees. Mean follow-up period was 17.4 months and mean age was 34.9 years old(10~62). We classified the lesion according to Watanabe and Ahn(classifying the type of tear according to arthroscopic finding). Clinical results were analyzed by Ikeuchi's clinical grading system and the Lysholm knee scoring scale. Radiographic evaluations were analyzed with plain radiographs. The common clinical results were pain in 40 cases(100%), locking in 16. Radiological degenerative arthritis changes were 31 persons(33 cases, 82.5 %) by simple initial X-ray. The common radiological changes were hypoplasia of lateral femoral condyle in 29 cases (72.5%), widening of lateral joint space in 26. RESULTS: Partial meniscectomy was undergone in 14 patients(15 cases) and partial meniscectomy with meniscal repair was undergone in 24 patients(25 cases). The patients were categorized using Watanabe's classification: complete, 25 cases(62.5%) and incomplete, 15 cases(37.5%). There were longitudinal tears(type 2) in 15 cases(37.5%), complex tears(type 7) in 12 cases. The mean Lysholm score was improved from 56.7 points to 86 points postoperatively after the partial meniscectomy, and from 62.7 points to 88 points after the partial menisccectomy with meniscal repair, which were not statistically significant(p>0.05). According to Ikeuchi's grading system, 11 cases(73.3%) had either excellent or good ratings in the partial menisectomy and 21 cases(84%) in the partial menisectomy with meniscal repair, which were not statistically significant(p>0.05). CONCLUSION: We believe that preserving peripheral meniscus by using partial menisectomy and partial menisectomy with meniscus repair lead to good function and satisfactory results.

A Comparison of Mobile-bearing and Fixed-bearing Total Knee Arthroplasties in Osteoarthritic Patients

PURPOSE: To compare the early clinical and radiographic results including patient's satisfaction after total knee arth- roplasty(TKA) using a mobile bearing knee prosthesis with fixed-bearing device. MATERIALS AND METHODS: From February 2002 to March 2004, author performed 30 posterior cruciate-retaining mobile bearing TKA and 39 posterior cruciate-retaining fixed bearing TKA. Clinical results were evaluated with knee score, patient's satisfaction by WOMAC score and range of motion. Radiographic analysis including tibio-femoral angle was also done. RESULTS: 1) The average knee score improved from 41.9 to 88.6 in mobile bearing group and from 44.3 to 87.6 in fixed bearing group respectively. The improvement of functional score were similar that 49.7 in mobile bearing group, 50.2 in fixed bearing group. 2) The average WOMAC score improved from 85.2 to 12.5 in mobile bearing group and from 85.3 to 13.9 in fixed bearing group. 3) The average range of motion of knee improved from 106.2 to 120.5 in mobile bearing group and from 105.2 to 118.8 in fixed bearing group. 4) The average tibio-femoral angle improved from 5.0 varus to 5.7 valgus in mobile bearing group and from 5.6 varus to 5.7 valgus in fixed bearing group. 5) Two of mobile and one of fixed bearing group complained persistent knee pain and two of mobile and one of fixed bearing group complained giving way sensation. CONCLUSION: This study shows that no significant difference in ROM, function, subjective evaluation and radiologic analysis for patients between two groups after minimum two-year follow-up.

The Clinical Results After Open Wedge Osteotomy of Proximal Tibia in Degenerative Knee Osteoarthritis

PURPOSE: The purpose of this retrospective study was to analyze the radiological and clinical results following high tibial osteotomy of the degenerative knee osteoarthritis. MATERIALS AND METHODS: This study included 12 patients who had degenerative knee osteoarthritis and had been treated with high tibial osteotomy with TS-OA plate. Mean age was 50.2 years old(43~62) and mean follow up period was 17.7 Months. Clinical evaluation were analysed by HSS score. RESULT: There were 2 cases of grade 2 and 10 cases of grade 3 based upon the radiological Kellgren classifications before surgery. The mean femorotibial angle was corrected from varus 6 degrees before surgery to valgus 8.5 degrees at the last follow up and the mean angle between mechanical axis and tibia long axis was corrected from varus 6.7 degrees to valgus 1.6 degrees. The Insall-Salvati ratio was changed from 1.07 before surgery to 1.04 at the last follow up and tibial posterior inclination was changed from 8.1 degrees to 10.2 degrees. HSS score was improved from 58 before surgery(5 cases fair, 7cases poor) to 86.3 at the last follow up(9 cases excellent, 3 cases good). CONCLUSION: The high tibial osteotomy is an effective treatment option for the management of degenerative knee osteoarthritis on medial compartment patients before total knee arthroplasty.

Evaluation of Posterior Cruciate Ligament Reconstruction Using the Femoral Double Tunnel and Tibial Inlay Techniques / 대한정형외과학회잡지

PURPOSE: This study was performed to evaluate the clinical usefulness of femoral double tunnel PCL reconstruction using the tibial inlay technique. MATERIALS AND METHODS: From January 2001 to August 2002, 21 patients underwent femoral double tunnel PCL reconstruction using the tibial inlay technique and were followed for more than 21 months. The mean age was 37 years old (range 16 to 60 years old). The clinical results were evaluated with the Lysholm score and the Tegner activity score. Radiologic analysis was performed using the posterior stress and Telos stress views. RESULTS: The average preoperative Lysholm and Tegner activity scores were 46.0 and 2.3, respectively, and improved to 94.5 and 5.3, respectively, at the final follow-up. The average preoperative scores of the combined posterolateral ligament injury group was 40.6 and 1.5, which improved to 77.1 and 3.5 at the final follow-up. Preoperatively, two cases were grade II, 13 cases were grade III, 6 cases were grade IV, and posterior translation was an average of 14.6 mm. Postoperatively, 18 cases were grade I, 3 cases were grade II, and posterior translation was an average 2.9 mm. In a push view using the Telos device (15 kg) at 30o and 90o of knee flexion, there were no differences in posterior translation. Complications were limitation of flexion (3 cases), limitation of extension (1 case) and quadriceps atrophy (mean, 2.6 cm). CONCLUSION: It is suggested that femoral double tunnel PCL reconstruction with the tibial inlay technique using anterolateral and posteromedial bundles is an effective technique for the restoration of knee function, stability, and activity. However long-term evaluation of patients and comparisons with femoral single tunnel reconstruction are required to confirm the effectiveness of this procedure.

Carthamus tinctorius L. Increases BMP-2 Gene Expression during Bone Fracture Healing in Rats

Carthamus tinctorius L.is known to improve fracture healing, and bone morphogenetic proteins (BMPs) are associated with the formation and healing process of bone. BMP-2 and BMP-7 are two of the most important BMPs during the bone healing process. Human osteosarcoma MG63 cells and rats were used to determine the effects of Carthamus tinctorius L. extract (CTE) on BMP-2 gene expression. BMP-2 gene expression by CTE treatment in human osteosarcoma MG63 cells was not different from the control group until 8 hours of incubation, but was significantly higher, by 31%, than that of the control group at 16 hr of incubation. Microscopic findings of the 9th rib 3 weeks after fracture showed typical rimming of the osteoblast and immature bone formation in control and CTE groups. BMP-2 gene expression by in situ hybridization was remarkably increased by a CTE-supplemented diet in the fracture group compared to the control group. In conclusion, Carthamus tinctorius L. increased BMP-2 gene expression in human osteosarcoma cells and fractured bone. But further studies would be needed to elucidate the effect of CTE on fracture healing in vivo because our results did not show any evidence of healing improvement histologically 3rd week after fracture.

A Comparative Study of Trochanteric Fractures Treated with the Intertrochanteric/subtrochanteric Fixation or the Proximal Femoral Nail

PURPOSE: To evaluate the radiographic, clinical results and the complications between who had intertrochanteric fracture, treated with the ITST or the PFN. MATERIALS AND METHODS: We selected each 30 patients of intertrochanteric fracture which were treated with ITST or PFN from July 2002 to November 2005. We evaluated the radiographic results by follow-up radiography and the clinical results with the mobility score of Parker and Palmer, Salvati and Wilson hip function scoring system and Jensen index. RESULTS: The mean distance of lag screw sliding was 4.1 mm at the ITST group and 6.6 mm at the PFN group. Decrease of mobility score of Parker and Palmer, Salvati and Wilson hip function score were similar. Patients complaint pain over lateral thigh area in 5 cases (ITST group) and 8 cases (PFN group). CONCLUSION: The ITST nail and PFN were seen good results in treatment of stable and unstable intertrochanteric fracture.