Long-term Follow-up Results of Femoral Revision Hip Arthroplasty Using Impaction Bone Grafting and Standard Cemented Polished Stem

Background@#To report the long-term clinical and radiologic results of impaction bone grafting and standard cemented polished stem for femoral revision arthroplasty in patients with extensive bone deficiency. @*Methods@#We retrospectively reviewed 47 hips that underwent femoral revision hip arthroplasty using an impaction-morselized allograft with a standard cemented polished stem. The average age at the time of revision hip arthroplasty was 55 years (range, 39–75 years). The modified Harris hip score (HHS) was used for clinical evaluation. The radiologic evaluation focused on stem subsidence, stem position, progressive radiolucent lines, bone remodeling, and the incorporation of allografts. @*Results@#The modified HHS improved from an average of 55.04 (range, 25–79.5) preoperatively to 90.1 (range, 81–93.2) at the last follow-up. The mean follow-up duration was 13.5 years (10.9–17.8 years). The radiographic analysis revealed stable stems.Femoral stems showed an average subsidence of 3.2 mm (range, 2–8 mm) in the cement mantle. However, there was no mechanical failure or subsidence of the cement mantle in the femurs. The stem position was neutral or varus less than 5°. No progressive radiolucent line or osteolysis was observed. Evidence of cortical and trabecular remodeling was observed in all cases. There were four cases of intraoperative cracks and four cases of distal femur splitting. @*Conclusions@#Initial stem stability using impaction bone grafting and a standard cemented polished stem in femoral revision arthroplasty resulted in good outcome. Delicate impaction grafting techniques and intraoperative crack and splitting fixation are the points that need attention for successful long-term results.

Efficacy of Preliminary Magnetic Resonance Imaging Measurement in Ultrasonography-Guided L4 Selective Nerve Root Block / 대한정형외과학회잡지

Purpose@#This study examined the utility of preliminary magnetic resonance imaging (MRI) measurements in the ultrasound-guided L4 selective nerve root block. @*Materials and Methods@#As a retrospective study, 71 patients, who met the criteria for outpatient visits from March 2016 to December 2017, were included. From March 2016 to February 2017, 31 patients who underwent an L4 nerve root block without MRI were classified as group A, and 40 patients who underwent an L4 nerve root block through MRI measurements from March 2017 to December 2017 were classified as group B. Group A was injected under ultrasound-guidance through the pararadicular approach without a pre-interventional MRI evaluation, and group B was injected under ultrasound-guidance according to the preliminary MRI measurements. The results were assessed using the numeric rating scale scores before, three hours, and two, six, and 12 weeks after the procedure. @*Results@#At three hours after the procedure, the proportion of patients better than good results were 51.6% in group A and 67.5% in group B. At two weeks after the procedure, the proportion of patients with better than good results were 48.4% and 70.0% in groups A and B, respectively; 58.1% and 62.5% of patient of groups A and B, respectively, showed better than good results after six weeks. In 12 weeks after the procedure, the results of group A and B were 67.7% and 62.5%, respectively. At three hours and two weeks after the procedure, group B showed significant symptom improvement than group A (p<0.05). The procedures were repeated 2.8 and 1.7 times in groups A and B, respectively, between two and six weeks for satisfactory pain relief (p<0.05). @*Conclusion@#A pre-interventional MRI evaluation might improve pain relief within the initial two weeks after ultrasound-guided L4 selective nerve root block by improving the success rate of the procedure.

Outcomes of Cephalomedullary Nailing in Basicervical Fracture / 대한고관절학회지

PURPOSE: A basicervical femoral fracture is defined as a fracture of base of neck of femur that occurs medially from intertrochanteric line above lesser trochanter. In this study, we intended to evaluate radiological and clinical results of basicervical femoral fractures treated by intramedullary nailing. MATERIALS AND METHODS: Fifteen patients, who underwent intramedullary nailing among 50 patients, out of 50 who were diagnosed with basicervical femoral fractures from July 2012 to May 2015 were studied. All of 15 patients' fracture were two-part basicervical fractures. Using radiography, we characterized the: i) state of reduction, ii) location of the lag screw, iii) tip apex distance (TAD), and iv) sliding distance of lag screw and bone union. Additionally, we performed clinical assessment before injury and at final follow-up. RESULTS: In radiological assessment, we achieved acceptable reduction state in all patients. All lag screws were fixated on appropriate locations. Mean TAD was 17.3 mm (11.0–21.1 mm), which showed insertion point of < 25 mm in all cases. The mean sliding distance of the lag screw was 5.1 mm (0.1–16.0 mm) at the final follow-up. The mean bone union period was 4.8 months (3–10 months) with achieving in all cases. In clinical assessment, Harris hip score, visual analogue scale score and Western Ontario and McMaster Universities Arthritis Index score, all of them significantly improved postoperatively compared with preoperative scores (P < 0.05). CONCLUSION: In elderly patients with basicervical femoral fractures, treatment with intramedullary nailing showed satisfactory results, considered to be a useful method if performed with skilled technique.

Breakage of Cephalomedullary Nail Used in the Treatment of Proximal Femur Fractures: Case Report

Internal fixation using a cephalomedullary nail as treatment for proximal femur fracture has recently been popular for early ambulation and rehabilitation. However metal breakage at the lag screw insertion site was reported due to non-union, delayed-union, and early weight bearing. In our orthopedic department, we experienced 2 cases of nail breakage at the lag screw insertion site, therefore we report on evaluation of the cause of metal failure and prevention of complications with literature review.

Complete Rupture of the Tibialis Anterior Tendon Due to Intratendinous Ganglion Cyst / 대한정형외과학회잡지

Spontaneous rupture of the tibialis anterior tendon is rare among ordinary people. The tendon rupture usually occurs in patients iatrogenically after local steroid injection to the tendon or with pre-existing systemic disease such as diabetes mellitus, gout, and rheumatic disease. However, no case of complete rupture of the tibialis anterior tendon due to an intratendinous ganglion cyst has been reported. We report on a case of a 39-year-old female with spontaneous rupture of the tibialis anterior tendon due to intratendinous ganglion cyst and her clinical results.

Primary Aneurysmal Bone Cyst in the Iliac Bone: A Case Report / 대한고관절학회지

Symptomatic aneurysmal bone cysts with expansible lesions in the pelvis are rare in children. The management of an aggressive vascular lesion in a female child is challenging. The standard treatment for aneurysmal bone cysts is accompanied by a high risk of local recurrence. A 12-year-old female presented with a history of pelvic pain for 5 months. Plain radiographs and magnetic resonance imaging showed a very large expansile lytic lesion arising from the right iliac bone. Intralesional curettage, electric cauterization, chemical sclerotherapy and allogeneic bone graft were performed through the window of the iliac crest. At a follow-up consultation 3.5 years post-surgery, the child had painless full-range movement in the hip joint with no recurrence. Although many treatment options are described, our patient was treated successfully using curettage and allogeneic bone graft without recurrence.

Outcome of Isolated Tibial Polyethylene Insert Exchange after Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: We investigated the short term outcomes of isolated tibial polyethylene insert exchange after revision total knee arthroplasty. MATERIALS AND METHODS: We selected 18 cases from 17 patients among the 20 cases from 19 patients who took isolated tibial polyethylene insert exchange after mean 69 months-follow up of TKA, which was carried out from June 1991 to August 2003. Two cases were excluded on account of loss to follow-up. In all cases, isolated tibial polyethylene insert exchange was carried out from May 1998 to October 2008 in our institute and the mean follow-up period after operation was 48 (22-142) months. We evaluated the following clinical and radiologic aspects: range of motion, HSS score, average labor time, and BMI. Together, these factors were used in clinical evaluation while femorotibial angle and radiolucent line were used in radiologic evaluation. RESULTS: The average range of motion was 110.6 degrees and HSS score was 86.9 in follow up period. The average femorotibial angle was valgus 5.3degrees. The average labor time was 9.7 hours and BMI was 25.9. Although radiolucent line was found in 4 cases, there were all confirmed to be non progressive lesion less than 2 mm. Survival rate was 100% in Kaplan-Meier survival analysis. CONCLUSION: Selective isolated tibial polyethylene insert exchange can be the successful method for revision TKA in limited cases.

Comparison of the Gamma Nail and the Dynamic Hip Screw for Peritrochanteric Fracture

PURPOSE: To retrospectively compare the clincal and radiological results between the gamma nail and dynamic hip screw (DHS) on the operative treatment of unstable peritrochanteric fractures. MATERIALS AND METHODS: From January 1999 to December 2006, we selected 215 patients who could be observed at least 1 year among 246 patients who received surgical treatment for unstable peritrochanteric fractures in our hospital. Eighty-six patients were males and 129 were females; the mean age was 72 years. Evans unstable fracture was included in our study. The gamma nail was applied in 133 cases, and the dynamic hip screw was applied in 82 cases. We evaluated union times, the collapse intensity of fractured sites after union, hospitalization duration, operation time, and post-operative complications. RESULTS: The mean union time was 15.7 weeks with the DHS and 13.7 weeks with the gamma nail. The collapse intensity of fracture sites were 3.5 mm and 1.9 mm, respectively. The mean hospital durations were 19.5 days for DHS surgery and 16.3 days for gamma nail surgery. The mean operation time was 85.5 minutes for DHS and 98.2 minutes for gamma nail. The post-operative complications were loosening of internal fixator (6 cases in DHS, 1 case in gamma nail), perforation of the femoral head (2 cases in DHS, 1 case in gamma nail), and non-union (7 cases in DHS, 2 cases in gamma nail). CONCLUSION: In unstable peritrochanteric fractures, biomechanically stable gamma nailing is thought to be one of the most effective treatments for reducing fracture site collapse and complications.

Acetabular Medial Wall Displacement Osteotomy in Total Hip Arthroplasty for Dysplastic Hips

PURPOSE: This study evaluated the results of acetabular medial wall osteotomy to reconstruct the acetabulum in dysplastic hip during total hip arthroplasty. MATERIALS AND METHODS: We clinically and radiologically evaluated 30 hips of 30 patients with secondary hip osteoarthritis caused by congenital hip dislocation or acetabular dysplasia who underwent total hip arthroplasty (THA) between March 1999 and October 2002. The average age of subjects was 46.5 years(17 to 73 years), and the mean follow-up period was 5 years(5.3 to 8.7 years). In 26 cases, a cementless hemispherical acetabular cup was inserted in the true acetabulum; in 4 cases a reinforced ring was inserted. Only 2 hips needed structural bone grafting. RESULTS: The average Harris hip score improved from 56.3 points preoperatively to 93.2 points at the last follow up. Radiographic analysis revealed no aseptic loosening or radiolucent line, and showed stable bony fixation at the true acetabulum. The mean thickness of the medial acetabular wall postoperative was 20.5 mm(10 to 36 mm). Bone union of the medial wall was observed at a mean of four months postoperatively. CONCLUSION: Acetabular medial wall osteotomy can maintain the integrity of the acetabular medial wall while achieving enhanced acetabular coverage and more normal hip biomechanics.

Complications of Femoral Peritrochanteric Fractures Treated with the Gamma Nail

PURPOSE: We analyzed the complications of femoral peritrochanteric fractures treated with the Gamma nail to reduce its complications. MATERIALS AND METHODS: We evaluated the complications among the 96 patients who were treated with the Gamma nail from January 2000 to May 2005. Mean follow-up period was 17.8 months and mean age was 75.2 years. We analysed the relationship between the complication and the fracture pattern, postoperative reduction status, position of the lag screw, bone density, displacement and tip-apex index (TAD). RESULTS: The complications were presented in 12 cases (12.5%). Cut-out of lag screw were in 5 cases, varus deformity with short lag screw in 2 cases, metal breakage of distal screw in 1 case, breakage of drill bit intraoperatively in 1 case, superficial infection in 2 cases and deep infection in 1 case. 5 cases (4.2%) were required reoperation. All of the cut-out of lag screw showed increased TAD (tip apex distance) above 25 mm. CONCLUSION: To reduce the complications of the Gamma nail, we need exact surgical technique, good positioning of the lag screw and choice of appropriate length for the lag screw.

Revision Total Knee Arthroplasty using NexGen(R) LCCK with Allograft / 대한정형외과학회잡지

PURPOSE: To analyze the clinical and radiographic results after revision total knee arthroplasty (TKA) using Nexgen(R) LCCK (Legacy(R) knee constrained condylar knee, Zimmer, Warsaw, IN) with allograft. MATERIALS AND METHODS: Twenty patients (21 knees) taken revision TKA were analyzed. The average age of the patients was 69.2 years old and the average of follow-up duration was for 2 year to 8 years 2 months (average 3 years 5 months). The clinical result and radiographic measurements were assessed using the Hospital for Special Surgery (HSS) knee rating score and the roentgenographic method of the American Knee Society. RESULTS: The mean interval from TKA to revision surgery was 6 years 4 months. In all cases, allograft was used. The average range of motion was increased from 93degrees to 107degrees, HSS score was increased from an average of 45 to 87 points. Postoperative femorotibial alignment was averaged 5.7degrees valgus. In all cases, radiolucency was below 4 scores and there was no loosening of implant. But, three radiopaque lines around a stem. There were wound dehiscence in 1 case and superficial infection in 2 cases. CONCLUSION: Satisfactory results were obtained in revision TKA using a NexGen(R) LCCK with allograft. But, this study is favorable for the long term follow-up.

Two-staged Delayed Minimally Invasive Percutaneous Plate Osteosynthesis for Distal Tibial Open Fractures

PURPOSE: To evaluate the outcomes of distal tibial open fractures treated by two-staged delayed minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. MATERIALS AND METHODS: 25 cases of distal tibial open fractures were treated with temporary ring fixation and two-staged delayed MIPPO. A mean age was 46 years old, follow-up was 23 months. The type of fracture was evaluated using the AO/OTA classification. The type of open fracture was evaluated using the Gustilo-Anderson classification that revealed 6 cases of type I, 9 cases of type II, 8 cases of type IIIA and 2 cases of type IIIB. We analyzed the radiologic results and postoperative complications. The clinical and functional result were evaluated by using Teeny and Wiss scores. RESULTS: The average time of bone union was 18 weeks in 24 cases. There were three delayed union that achieved union twenty weeks after second operation, and 1 case underwent bone graft with additional plate fixation. 6 cases of skin necrosis were treated with skin graft, 2 cases were treated with flap. The clinical and functional assessment showed that 6 cases were excellent, 16 cases were good, 2 cases were fair, and 1 case were poor results. CONCLUSION: Two-staged MIPPO technique for distal tibia open fractures seems to be a good procedure to obtain bone union.

Synovial Chondromatosis of the Metacarpophalangeal Joint: A Case Report / 대한정형외과학회잡지

Synovial chondromatosis is an uncommon lesion, which is characterized by cartilaginous and osseous metaplasia of the joint synovium. Synovial chondromatosis usually involves a large joint and rarely occurs in the hand. Intra-articular synovial chondromatosis during the hand should be considered in the differential diagnosis of swollen, stiff or painful joints. Other possible diagnoses include osteoarthritis, rheumatoid arthritis, gout, trauma and chronic infection. Moreover, if enchondral ossification of loose bodies is not seen a diagnosis of synovial chondromatosis can not be made preoperatively. Intra-articular synovial chondromatosis is a benign condition and surgical synovectomy remains the most effective treatment. The authors report a case of synovial chondromatosis of the fifth metacarpophalangeal joint.

Femoral Revision Hip Arthroplasty with the Use of Impacted Cancellous Allograft and Cement

PURPOSE: To evaluate the radiographic mid-to long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. MATERIALS AND METHODS: Among 27 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 36 months to 10 years, 3 months (mean, 76.6 months). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. RESULTS: Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 5mm) and 1 stem showed moderate subsidence (about 8 mm) in the cement. But there was no mechanical failure and subsidence at the composit-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. CONCLUSION: The result of cemented stem revision with the use of impacted cancellous allograft was good mid-to long-term. and femoral bone stock deficiency may be reconstructed successfully.

Analysis of Homepages Relating to Lumbar Disc Surgery in Orthopaedic and Neurosurgical Hospitals / 대한정형외과학회잡지

PURPOSE: This study evaluated the operability for disease of lumbar intervertebral disc (LID) of practitioners and pay doctors of orthopedic surgeons and neurosurgeons by examining their websites. MATERIALS AND METHODS: From March 2006 to April 2006, we searched the internet using the key words orthopedic surgery and neurosurgery, with NAVER as the portal site. There were 68 homepages of orthopedic hospitals and physician's offices (OHP) and 27 homepages of neurosurgical hospitals and physician's offices (NHP). Each homepage was visited in order to survey the operability for disease of an intervertebral disc and the number of board of orthopedists and neurosurgeons. Statistical analysis was carried out using a chi-square test. RESULTS: In 45.6% (31/68) of OHP and 85.2% (23/27) of NHP, the operation for LID was performed and there was significant difference (p<0.001). In 16.2% (11/68) of OHP, neurosurgeons employed by OHP performed the operation for spinal disorders. In 29.4% of OHP, the orthopedic surgeon performed the operation for LID. Orthopedists were employed in 51.9% of NHP. NHP were significantly higher than OHP in the cases in whom the orthopedists and neurosurgeons worked together in a single hospital (p<0.001). CONCLUSION: In 70% of OHP, surgery for LID was not performed. A survey about reasons for not performing operation for LID and improvement of that reasons should be carried out by the medical association.

Comparison of Articular Spacer Versus Static Spacer in the Treatment of Infected Total Knee Arthroplasty

PURPOSE: To compare and analyze the surgical procedure and clinical results of two-stage re-implantation using both articulating and static spacers at infected total knee arthroplasties(TKA). MATERIALS & METHODS: A total of 14 cases were selected for subject of this study in which patients had been diagnosed as infected TKA and had undergone two-stage re-implantation(7 using static spacers and remaining 7 using articulating spacers) from March 1999 to March 2006. RESULTS: In the group using static spacers, ROM improved from 70 degrees in average preoperatively to 98 degrees postoperatively. In the group using articulating spacers, ROM improved from 74 degrees to 105 degrees (p=0.532). HSS score showed an increase from 43 scores in average preoperatively to 81 postoperatively for static spacers and from 41 to 83 for articulating spacers(p=0.780). There was no significant difference in the hour spent for the 1st surgery. The 2nd operation time was shortened to 241 minutes in case of static spacers, and 208 minutes in articulating spacers. One case of relapse was reported with static spacers but none with articulating spacers. CONCLUSION: Two-stage re-implantation of infected TKA using both static and articulating spacers has been found to be effective ways of treatment, requiring, however, long term follow-ups.

Comparison of Posterior Cruciate Ligament Retentionversus Substitution in PFCSigma Rotating-Platform Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to assess the results of posterior cruciate ligament-retaining and posterior cruciate ligament-sacrificing total knee arthroplasty using PFC Sigma rotating-platform (RP). MATERIALS AND METHODS: The subjects for this study were 43 patients who had undergone total knee arthroplasties by means of PFC Sigma RPs from February 2002 to July 2002 and, thereafter, had been observed for a period of at least 36 months. Twenty-two of the patients were categorized to group I, which retained the posterior cruciate ligament and 21 to group II, which substituted for the ligament. All the patients were evaluated for pre- and post-operative ranges of motion, the Hospital for Special Surgery (HSS) knee rating system, and radiographic analysis. RESULTS: The average flexion contracture was 6.5degrees (+/-1.0o) in group I and 6.7degrees (+/-0.8degrees) in group II pre-operatively, and 1.1degrees (+/-0.3degrees) in group I and 0.9degrees (+/-0.2degrees) in group II at the last follow-up. The average active range of knee motion improved from 87.6degrees (+/-6.5degrees) in group I and 86.6degrees (+/-6.1degrees) in group II pre-operatively, to 123.0degrees (+/-7.8degrees) and 125.1degrees (+/-7.3degrees), respectively, at the last follow-up. The average HSS score improved from 41.1degrees (+/-7.1degrees) in group I and 40.3degrees (+/-5.3degrees) in group II pre- operatively, to 87.3degrees (+/-6.0degrees) and 88.9degrees (+/-4.9degrees), respectively, at the last follow-up. There was also improvement in the average tibio-femoral angle from 8.0degrees in varus to 5.7degrees in valgus in group I and from 10.9 in varus to 5.4degrees in valgus in group II. Radiolucent lines were observed in 4 cases from group I and in 1 case from the group II. No significant progressive periprosthetic osteolysis was observed in the follow-up radiographs of both groups. CONCLUSION: There were no clinical and radiographic differences between the posterior cruciate ligament-retention and ligament-substitution groups, which indicates the necessity for long-term observation.

Treatment of Upper Thoracic Disc Herniation Using Transthoracic Approach without Division of Latissimus Dorsi: Technical Note / 대한척추외과학회지

Thoracic disc herniation is a rare condition in which a posterior approach, extrapleural approach, posterolateral approach, or transthoracic approach is currently used. The posterior approach is not recommended in thoracic disc herniation surgery because of the risk of spinal cord injury. The transthoracic approach makes it possible to remove the intervertebral disc and is considered a standard method. However, due to an extensive transverse skin incision, division of the latissimus dorsi muscles, and rib resection, the conventional open approaches involve a risk of complications, such as infection and post-thoracotomy pain syndrome; and a long period of rehabilitation and recovery is required. Excision of the intervertebral disc under thoracoscopic guidance can reduce the damage to the skin and muscles, but the equipment and surgical materials are expensive and a long learning curve is required. Therefore, we report a case and a new muscle splitting transthoracic approach that can be performed by incising 10 cm of skin longitudinally and preserving the serratus anterior and latissimus dorsi muscles.

Operation Fee and Insurance Charge of Hallux Valgus Surgery / 대한족부족관절학회지

PURPOSE: The purpose of this study was to figure out the appropriate and systemic insurance charge for the hallux valgus operations. MATERIALS AND METHODS: 5 Hospitals for hallux valgus operations were analyzed how they have been charging the national health insurance corporation for their operation fees and how to use the estimated guide and authoritive interpretation through the guide book of health insurance medical treatment grant expense and the guide book of Health insurance medical treatment. RESULTS: There are nothing for guiding principle of hallux valgus operations in both books but a guide of Mcbride operation which is approved 'JA-93-KA and JA-31' for operation fee. So majority of hospitals have charged operation fee depending on their own interpretations they like. According to the guide books, there was a authoritive interpretation that simultaneous operation of osteotomy and tendon transfer for cerebral palsy and flat foot can be eatimated as 'osteotomy +JA-93-NA'. CONCLUSION: Distal soft tissue procedure should be approved as 'JA-93-NAx100%+JA-31x50%' according to the the estimated guide and authoritive interpretation if transected adductor hllucis is transfered to first metatarsal head. So distal chevron osteotomy could be 'JA-30-1-RAx100%+JA-31x50%', proximal metatarsal osteotomy could be 'JA-93-NAx100%+JA-31-50%+JA-30-1-RAx50%', first metatarsocuneiform joint arthrodesis could be 'JA-93-NAx100%+ JA-31x50%+JA-73-RAx50%'.

Surgical Treatment of Scapular Fracture using by Plate Fixation: 4 Cases Report

Fractures of the scapula are relatively uncommon injuries and most can be treated satisfactorily with non-operative methods. But scapular fractures are being seen with increasing frequency in our mechanized society, specially in patients who have multiple injuries. So most injuries were related high energy, that residual deformities were high and related to the residual symptoms. Authors had done open reduction and internal fixation with plate in the four cases of the scapular fracture and analyzed that results.