Component Asymmetry in Bilateral Cementless Total Hip Arthroplasty

Background@#This study investigated the results of component asymmetry (CA) in bilateral cementless total hip arthroplasty (THA). @*Methods@#This study included 300 patients, who underwent bilateral cementless THA between April 2000 and December 2017. They were divided into the component symmetry (CS) and CA groups; CA group was sub-classified into acetabular component asymmetry (ACA) and femoral component asymmetry (FCA). Radiologic and clinical outcomes of the CA group were compared with those of the CS group. @*Results@#The incidence of CA was 25.7% (77/300 patients), including 55 patients with ACA, 34 patients with FCA, and 12 with both components asymmetric. The mean time interval between operations in the CA group was significantly longer than that in the CS group (p < 0.001). The mean differences in horizontal and vertical distances from teardrop to the center of rotation of the acetabular component between both hips in the ACA group were significantly larger than those in the CS group (p = 0.033 and p < 0.001, respectively). The mean femoral component alignment angle difference between both hips was significantly larger in the FCA group than in the CS group (p < 0.001). The mean Harris Hip Score at last follow-up of the CA group was similar to that of the CS group. @*Conclusions@#CA in patients undergoing bilateral cementless THA was not rare, especially with a longer time interval between operations. Regardless of CA, when stable fixation of the components was achieved, satisfactory radiologic and clinical outcomes were obtained.

Symptomatic Os Paracuneiforme: A Case Report / 대한족부족관절학회지

An extremely rare accessory bone of the foot located in the distal portion of the navicular that articulates with the medial cuneiform was observed. Os paracuneiforme is usually located medial to the medial cuneiform or the naviculocuneiform joint. Although os paracuneiforme is often referred to as an accessory bone around the foot, few cases of this type of accessory bone have been reported. This paper reports a patient with a painful Os paracuneiform who underwent surgical excision of the accessory bone.

Development of a Diabetic Foot Ulceration Prediction Model and Nomogram

Purpose@#This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM). @*Methods@#This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients’ electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow–Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples. @*Results@#The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ2 = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years. @*Conclusion@#The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.

Symptomatic Os Paracuneiforme: A Case Report / 대한족부족관절학회지

An extremely rare accessory bone of the foot located in the distal portion of the navicular that articulates with the medial cuneiform was observed. Os paracuneiforme is usually located medial to the medial cuneiform or the naviculocuneiform joint. Although os paracuneiforme is often referred to as an accessory bone around the foot, few cases of this type of accessory bone have been reported. This paper reports a patient with a painful Os paracuneiform who underwent surgical excision of the accessory bone.

Development of a Diabetic Foot Ulceration Prediction Model and Nomogram

Purpose@#This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM). @*Methods@#This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients’ electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow–Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples. @*Results@#The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ2 = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years. @*Conclusion@#The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.

What Happens without Treating Chronic Lateral Ankle Instability / 대한족부족관절학회지

The term chronic lateral ankle instability (CLAI) embraces a spectrum of conditions that involve functional and mechanical instability, both in athletes and lower-demand patients. The hallmarks of CLAI are recurrent sprains, persistent pain, and repeated episodes of the ankle giving way. CLAI is the main complication of acute ankle sprains, which can cause discomfort in daily and sports activity. Approximately 10% to 30% of patients with acute ligament ruptures will develop chronic instability over the course of a year from the index injury. An accurate diagnostic approach and successful treatment plan should be established based on a comprehensive understanding of the concept of functional and mechanical instability. Unfortunately, the optimal modality for the management of CLAI is unclear. Even after conservative treatment or surgical intervention, it could result in degenerative changes to the ankle joint in the long term. Thus far, the incidence of ligamentous posttraumatic ankle osteoarthritis was reported to be 13% to 78%. The mean latency time between injury and osteoarthritis was at least 10 to 34.3 years. CLAI is an important pathological condition that can cause discomfort or dysfunction in daily activity in the short term, resulting in joint destruction in the long term. Therefore, it is important to understand the various complications that can occur when CLAI is not treated properly.

Iatrogenic Sacral Root Entrapment after Iliosacral Screw Fixation in a Patient with Pelvic Ring Fracture - A Case Report -

Objectives@#Despite precise iliosacral (IS) screw placement, we encountered a case of a neurological deficit due to a bony fragment that remained around the nerve root after reduction of the fracture gap in a patient with a pelvic ring injury.Summary of Literature Review: Percutaneous IS screw fixation is a commonly used procedure because it enables an adequate fixation force to be secured through a minimally invasive method in patients with pelvic ring fractures. Percutaneous IS screw fixation using C-arm fluoroscopy has been well described. In addition, several studies have investigated methods to prevent neurological damage. @*Materials and Methods@#A 48-year-old man was diagnosed with a lateral compression type 1 pelvic ring fracture. Bilateral IS screw fixation was performed in the patient, who had no preoperative neurological abnormalities. He complained of pain around the sacroiliac joint that radiated to the lower leg after percutaneous IS screw fixation, and he was diagnosed with S1 radiculopathy on electromyography. @*Results@#While reviewing the patient’s preoperative computed tomography images, a bony fragment in the fracture gap on the left S1 root was noted. After confirming S1 root entrapment, decompressive laminectomy was performed. @*Conclusions@#Surgeons should be aware that postoperative neurological symptoms may be caused by a bony fragment resulting from the fracture, regardless of screw malposition in percutaneous IS screw fixation. Preoperative planning with meticulous image review and intraoperative neurological monitoring, as well as using full-threaded screws, may help to prevent this problem.

Triamcinolone Acetonide Injections for Lateral Malleolar Bursitis of the Ankle / 대한족부족관절학회지

PURPOSE: This study examined the clinical outcomes and usefulness of triamcinolone acetonide (TA) injections as an option in the conservative treatment of patients with lateral malleolar bursitis of the ankle. MATERIALS AND METHODS: A total of 27 patients (27 ankles), in whom TA injection had been performed between March 2016 and June 2017, were reviewed retrospectively. After the aspiration of fluid in the lateral malleolar bursal sac, 1 mL (40 mg) of TA was injected into the malleolar bursal sac. After the injection, the ankle was compressed with an elastic cohesive bandage for 2 to 4 weeks. The clinical outcomes and side effects were evaluated at the following time points: 2 weeks, 4 weeks, 3 months, 6 months, and 1 year after TA injection therapy. The responses to treatment were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling. RESULTS: The mean age was 62.1 years (range, 41~81 years); there were 19 males and 8 females. Complete resolution was observed in 26 patients (96.3%) after the first or second application of a TA injection, and a partial response was observed in 1 patient (3.7%) after the first TA injection. The physical component scores of Medical Outcomes Study 36-item Short-Form Health Survey improved from 71.1 to 76.0 at the last follow-up (p=0.001). Associated complications were 1 patient (3.7%) with skin atrophy and 3 patients (11.1%) with transient hyperglycemia in diabetes mellitus. CONCLUSION: TA injection is a useful and safe procedure for patients not responding to the usual conservative treatment of lateral malleolar bursitis of the ankle.

Congenital Insensitivity to Pain with Anhidrosis: Five-Year-Old Girl with a Neglected Distal Femur Fracture / 대한정형외과학회잡지

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare disease that affects the sensory and autonomic nervous system. The patients do not have the ability to sense different sensations, such as pain, which tends to lead to different injuries. In addition, the patients suffer from fluctuations in body temperature due to autonomic involvement. The present case was a five-year-old girl with a neglected distal femur fracture. X-rays taken during the follow-up showed marked callus formation and pseudarthrosis of the distal femur. She had biting injuries of the tongue, auto-amputation of the fingers, some developmental delay and a history of recurrent fever with an unknown origin. The electrodiagnostic study was normal. The quantitative sudomotor axon reflex test revealed markedly reduced postganglionic sudomotor axonal responses at all sites recorded on the left. She was diagnosed with CIPA. As the initial presentation of CIPA involves the musculoskeletal system, orthopedic surgeons should have a high index of suspicion.

Comparative Study of Open Reduction and Internal Fixation and Primary Subtalar Arthrodesis for Sanders Type 4 Intra-Articular Calcaneal Fractures / 대한정형외과학회잡지

PURPOSE: To compare clinical outcome of Sanders type IV intra-articular calcaneal fracture treated with open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis (PSTA). MATERIALS AND METHODS: Between March 2003 and November 2013, 22 patients with 22 Sanders type 4 intra-articular calcaneal fractures were included in this study. Of these, 11 were treated with ORIF (ORIF group), and 11 were treated with ORIF and PSTA (PSTA group). The mean follow-up period was 34.6 months (range, 18–72 months). Clinical outcomes were assessed along with the American Orthopedic Foot and Ankle Society's ankle-hindfoot scale (AOFAS score), and the visual analogue scale pain score (VAS score) at 6-month, 12-month, and last follow-up. Patient satisfaction, return to previous occupation and postoperative complications were also investigated. RESULTS: The results for ORIF did not differ from those for PSTA based on the last follow-up AOFAS scores or the VAS scores (p>0.05). However, patient satisfaction was significantly higher in the PSTA group (p=0.008). Secondary subtalar arthrodesis was conducted in five patients (45.5%) of the ORIF group within 2 years postoperatively. CONCLUSION: We were unable to demonstrate a significant difference in clinical outcomes between ORIF and PSTA; however, the patient satisfaction was higher in the PSTA group. PSTA may be a suitable choice for patients who need fast recovery to daily activity and to prevent the need for secondary subtalar arthrodesis.

Tricortical-allobone Grafting in Screw Fixation for Intra-articular Calcaneal Fracture via Ollier Approach / 대한족부족관절학회지

PURPOSE: Bone grafting is often necessary to maintain a reduction and prevent delayed collapse of reduced fracture in a treatment of severely displaced comminuted intra-articular calcaneal fractures. Herein, we analyzed the usefulness and necessary conditions to perform tricortical-allobone grafting in open reduction of calcaneal fracture via the Ollier approach. MATERIALS AND METHODS: We performed a retrospective review of 57 intra-articular calcaneal fractures that underwent an operation via the Ollier approach between April 2009 and April 2015. They were divided into two groups: Group 1 (n=17) included those with tricortical-allobone grafts underneath the posterior facet fragment, and group 2 (n=40) included cases without a bone graft. We measured the Böhler angle, Gissane angle, height, and width of the calcaneus at preoperative, postoperative, and final follow-up radiograph. We measured the sagittal rotational angle of the posterior facet fragment of preoperative computed tomography to analyze the effect and necessary conditions for bone grafting. We also reviewed the clinical results by the American Orthopaedic Foot and Ankle Society (AOFAS) scale, visual analogue scale (VAS), and any complications. RESULTS: According to the Sanders classification, there were 3 type-II fractures, 12 type-III fractures, and 2 type-IV fractures in Group 1; whereas in Group 2, there were 26 type-II fractures, 13 type-III fractures, and 1 type-IV fracture (p=0.002). Regarding the preoperative radiologic parameters, there were significant differences in the Böhler angle (p=0.006), Gissane angle (p=0.043), and rotational angle of the posterior facet fragment (p=0.001). No significant difference was observed in the preoperative calcaneal height and width, as well as postoperative radiologic parameters. There was no significant clinical difference between the two groups (p=0.546). CONCLUSION: We suggest that a tricortical-allobone graft may be useful in open reduction and screw fixation via the Ollier approach for displaced intra-articular calcaneal fracture with a bony defect after reduction of collapsed posterior facet fragment. This graft can contribute to the stable reduction via a small approach, even without a plate.

Unusual Presentation of Traumatic Neuroma of the Medial Plantar Nerve after Deep Laceration Mimicking a Foreign Body Granuloma: A Case Report / 대한족부족관절학회지

Traumatic neuromas are rare benign tumors that are common after trauma or surgery and are usually accompanied by obvious symptoms of pain. Most reports show neuromas in the face, neck, and limbs, and the traumatic neuroma of the medial plantar nerve has rarely been reported. We encountered a traumatic neuroma of the medial plantar nerve after a deep laceration mimicking a foreign body granuloma. A small mass lesion was found around plantar aponeurosis with heterogeneous high signal intensity in the T2 fat suppression view and slightly enhanced intensity in the magnetic resonance imaging that suggested a foreign body granuloma. The lesion was diagnosed pathologically as a traumatic neuroma. A satisfactory clinical result was obtained after excision of the traumatic neuroma and burial of the proximal and distal stumps to the adjacent muscle at the secondary operation.

Results of Patients with Unstable Femoral Intertrochanteric Fractures Treated with Proximal Femoral Nail Antirotation II / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate radiologic and functional outcomes of patients with unstable femoral intertrochanteric fractures treated with proximal femoral nail antirotation II (PFNA II). MATERIALS AND METHODS: Between August 2009 and December 2013, 108 hips (108 patients) with unstable femoral intertrochanteric fractures were treated with PFNA II and followed for at least 1 year. The mean follow-up period was 15.2 months. The radiographic outcomes, reduction state, sliding distance of the helical blade, bone union, and complications were assessed. The functional outcomes were assessed according to the Charnley hip pain scoring system, walking ability, and the Activities of Daily Living index. RESULTS: The postoperative radiograph showed a good or acceptable reduction in all cases. The mean sliding length of the blade was 4.1 mm. The mean duration of radiologic bone union was 4.8 months. There were 2 postoperative complications including nail breakage and nonunion. The mean Charnley hip pain score was 5.1 points. Preoperative walking ability was restored for 74.1% of patients. Preoperative activities of daily life were restored for 60.2% of patients. CONCLUSION: PFNA II used for treatment of unstable intertrochanteric fracture showed favorable outcomes. However, due to decreasing walking ability and delayed return to the activities of daily living, further studies are needed, focusing on functional recovery and rehabilitation to improve postoperative clinical outcomes.

Usefulness of Computed Tomography in Patients with Acute Malleolar Fracture / 대한족부족관절학회지

PURPOSE: We compared plain radiographs with computed tomography (CT) images to evaluate the usefulness of preoperative CT in acute ankle malleolar fracture in terms of accuracy of diagnosis and planning of operative strategy. MATERIALS AND METHODS: A retrospective analysis was conducted on 210 cases of malleolar fracture treated at our institute for which plain radiograph and CT were obtained preoperatively. Observers had reviewed plain radiographs and recorded fracture classification, anatomical diagnosis, extent and configuration of fractures and then subsequently reviewed CT images. Records from each image were compared and information regarding the differences in fractures was assessed. RESULTS: Fractures were notably changed in appearance in 88 cases (41.9%) and diagnosis changed in 30 cases (14.3%). According to the change of diagnosis and fracture appearances, the operative strategy was changed in 15 cases (7.1%) including incision, order of reduction, and target of fixation. CONCLUSION: CT could be a useful adjunctive imaging tool in addition to the plain radiograph in planning of operative treatment for acute malleolar fracture in terms of estimating exact configuration, extent of fractures and even newly revealed hidden fractures.

What Is the Usefulness of the Fragmentation Pattern of the Femoral Head in Managing Legg-Calve-Perthes Disease?

BACKGROUND: Within the lateral pillar classification of the Legg-Calve-Perthes (LCP) disease, hips seem quite variable in the pattern of fragmentation as seen in radiographs. The purpose of this study was to determine: if it is possible to reliably subdivide the lateral pillar groups into femoral head fragmentation patterns, and if such a subdivision of the lateral pillar groupings is clinically useful in managing LCP disease. METHODS: Two hundred and ninety-three anteroposterior radiographs taken at the maximal fragmentation stage (189 lateral pillar B, 57 B/C border, and 47 C hips; mean bone/chronologic age at the time of first visit, 6.2/7.9 years) and at skeletal maturity (mean age, 16.6 years) were analyzed. We distinguished 3 fragmentation patterns in each pillar group based on the region of major involvement. We tested the inter- and intraobserver reliability of our classification system and analyzed the relationships between the fragmentation patterns and the Stulberg outcomes as well as other factors such as surgical treatment and age. RESULTS: Inter- and intraobserver consistency in fragmentation pattern assignments was found to be substantial to excellent. A statistically significant trend (p = 0.001) in the proportion of Stulberg III or IV outcomes in comparison with Stulberg I and II was only found for the different fragmentation patterns in our lateral pillar B patients: fragmentation patterns having mainly lateral-central necrosis led to poor outcomes. No significant association was found between fragmentation patterns and Stulberg outcomes in pillar groups B/C border and C. CONCLUSIONS: Our results are consistent with the lateral pillar classification itself. Therefore, fragmentation patterns in each lateral pillar classification did not provide clinical usefulness in the management of LCP disease.

Early Results after Treatment of Femoral Neck Fractures with Total Hip Arthroplasty Using Cementless Fiber Metal Taper(R) Stem in Elderly Patients / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the early results of clinicoradiological outcomes after cementless total hip arthroplasty (THA) for displaced femoral neck fracture in elderly patients. MATERIALS AND METHODS: A total of 44 cementless THA procedures performed between January 2008 and January 2012 for displaced femoral neck fracture in patients older than 65 years of age were enrolled in this study and all patients presented normal cognitive ability preoperatively and were followed for more than two years after surgery. We evaluate the clinical and radiological results. The mean age was 72 years (range 65-81 years), 34 patients were female, and 10 patients were male. The mean follow-up period was 30.7 months. RESULTS: Clinically, at the last follow-up, the mean Harris hip score was 96.5 points. Walking ability was recovered postoperatively in 79.5% of cases (35 cases), and activities of daily living were achieved in 66% of cases (29 cases). Radiographically, none of the acetabular cups showed evidence of migration, loosening, or osteolysis. All cases showed excellent or good fixation postoperatively and stable bony fixation of the femoral stem, with the exception of one case, who presented with a periprosthetic fracture during follow-up. There were no cases of osteolysis, significant alignment change or progressive subsidence. Postoperative dislocation occurred in two cases (4.5%), but no re-dislocations were observed after closed reduction. CONCLUSION: Short-term outcomes proved to be satisfactory in elderly patients older than 65 years of age, who presented with normal cognitive ability preoperatively, undergoing cementless THA for displaced femoral neck fractures.

Alterations in Serum Levels of Receptor Activator of Nuclear Factor-kappa B Ligand and Osteoprotegerin in Patients with Head Injury and Fracture

PURPOSE: Receptor activator of nuclear factor-kappa B ligand (RANKL), osteoprotegerin (OPG) have been shown to be important regulators of osteoclastogenesis during bone remodeling, and their expressions were examined during fracture healing in a mouse model of tibial fracture. However, studies linking RANKL and OPG in patients with head injury and fracture are lacking. We evaluated the changes in serum levels of RANKL and OPG in patients with head injury and fracture (head injury group) and in patients with fracture (fracture group) and compared these with levels found in healthy control subjects. MATERIALS AND METHODS: 18 male patients of head injury and fracture and 20 male patients of fracture alone were enrolled. 20 healthy men were recruited to serve as controls. Within the first few hours of admission to hospital, at 4, 8 and 12 weeks after injury 20 ml of blood were obtained from 18 patients with head injury and fracture and 20 patients with fracture only. RESULTS: RANKL levels were significantly lower in the head injury group than in the fracture group at 8 and 12 weeks after injury. OPG levels were significantly higher in the head injury group than in the fracture group at 4, 8 and 12 weeks after injury. RANKL/OPG ratios were significantly lower in the head injury group than in the controls immediately after and 4, 8 and 12 weeks after injury, and were significantly lower in the head injury group than in the fracture group at 8 and 12 weeks after injury. CONCLUSION: We have shown changes in the profiles of RANKL, OPG and RANKL to OPG ratio. The altered RANKL, OPG and RANKL/OPG ratio in the head injury group lasted longer than in those of the fracture group.