Treatment of periprosthetic fractures following TKA / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical and radiological results of periprosthetic fracture treatments following total knee arthroplasty (TKA) . MATERIALS AND METHODS: Between Jan. 1991 and Jun. 1998, 16 knees in 15 patients were treated for periprosthetic fractures following TKA. Average age of the patients were 56 years (26-69 years) , and 14 patients were women and one was a man. The average follow-up period after fracture was 2 years 5 months (1 year - 8 years 2 months) . We analyzed clinical results according to the knee rating score of Hospital for Special Surgery (HSS) , bony union time and femorotibial angle. RESULTS: Among 980 knees in 633 patients with primary total knee arthroplasty, 16 knees in 15 patients developed periprosthetic fractures. The incidence was 1.6%. Three knees were treated with closed reduction and cast immobilization, seven knees were treated with Ender nailing, and six knees were treated with open reduction and internal fixation. Range of motion was 113 degrees on an average before fracture and 94 degrees at the last follow up, and HSS knee rating score averaged 88 points before fracture and 83 points at the last follow up. Radiologically, 15 knees had complete union and one knee had nonunion. CONCLUSION: The authors think that conservative management was not effective due to prolonged immobilization and late start of ROM exercise. Open reduction with internal fixations provided a better reduction of the fracture, preserving the alignment of fragment and restoring function. Also, Ender nailing was an alternative option of treatment considering less morbidity and satisfactory functional results.

Microfracture Surgery for Cartilage Regeneration in Degenerative Arthritis of the Knee / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical and histological results after microfracture surgery for degenerative arthritis of the knee. MATERIAL AND METHOD: Thirty-five patients, who had moderate to severe pain with no improvement after conservative treatment, moderate osteoarthritic change in standing AP radiogram, and no severe angular deformity, underwent microfracture surgery. Their mean age at the time of operation was 56 years (range, 33-75 years) and mean follow-up period was 1 year (range, 6-17 months) . In the 14 cases, 'second-look' arthroscopies and biopsies were performed at 6 months following microfracture for full thickness chondral lesions. At the last follow up clinical results were evaluated with Baumgaertner's scale. The specimens were stained with H-E, Safranin-O, and Masson's trichrome. RESULTS: Most of the patients showed significant improvement clinically. 'Second-look' showed that the chondral defect areas were covered with newly grown grayish white tissues. Histologically, the regenerated tissue appears to be a hybrid of hyaline cartilage and fibrocartilage. There are viable chondrocytes in lacunae with a uniform matrix. CONCLUSION: Microfracture surgery can induce chondral resurfacing for full thickness defects of osteoarthritic knee. However, the exact nature and fate of regenerated cartilagenous tissues need further long term follow-up study.

Treatment of Infection after Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To analyze the clinical results of treatment for infected TKA and find a reasonable method of treatment. MATERIALS AND METHODS: Between March 1988 and August 1997, 34 patients with infection after total knee arthroplasty were treated at Kyung Hee University Hospital. The average follow-up period was 4 year 8 months. At-the time of infection management, the average age was 59 years (range, 20 to 79 years); there were 31 women and three men. Infected patients were managed with several methods. Twenty patients were treated with one-stage or two-stage reimplantation, and arthrodesis was done in 12 cases. Two cases were treated conservatively. We assessed knee function before and after revision, according to the knee rating system of The Hospital for Special Surgery. RESULTS: Prior to revision operation, the average knee score in 20 reimplantation cases was 52 points, and the average range of motion was 76. After revision, the average knee score was 84 points, and the average range of motion was 90. All patients had complete union at an average 5.3 months after arthrodesis. There were no recurrences of infection after one-stage or two-stage reimplantation, or fusion. CONCLUSIONS: Thoughtful method of treatment should be decided in managing infected total knee arthroplasty.

TKA in Hemophilic Arthropathy of the Knee / 대한정형외과학회잡지

PURPOSE: To analyze functional gains after TKA in patients with hemophilic arthropathy. MATERIALS AND METHODS: From January 1989 to December 1996, 16 total knee replacements were performed in 11 patients with hemophilia. The average age at operation was 30 years and nine months. The average follow-up period was 3.2 years (range, 1 to 7 years). There were 14 knees of hemophilia A and 2 knees of hemophilia B. Preoperatively, all patients complained of severe pain and had marked knee joint deformity of grade IV or V by Arnold and Hilgartner classification. The knee rating scale of Hospital for Special Surgery was used for clinical assessment. RESULTS: The average preoperative range of motion was 87.9 degrees (range, 25-125 degrees) and 94 degrees (range, 70-125 degrees) postoperatively. The average flexion contracture was 20.7 degrees (range, 0-40 degrees) preoperatively and 4.7 degrees (range, 0-15 degrees) postoperatively. The knee rating scale improved from 44.3 points (range, 40-76) to 88.8 points (range, 81-97). There was one case of superficial necrosis of skin. CONCLUSIONS: The range of motion was not improved significantly after total knee replacements in hemophilic patients. However, knee pain and bleeding episodes have decreased prominently.

Deep Vein Thrombosis and Pulmonary Embolism after Cementless Total Hip Arthroplasty / 대한정형외과학회잡지

Thromboembolism is the most common serious complication following total hip arthroplasty and most common cause of death after total hip arthroplasty. A prospective randomized study in 170 cases of elective cementless total hip arthroplasty was carried out to examine the incidence of deep vein thrombosis and pulmonary embolism after cementless total hip arthroplasty from Aug. 1993 to May 1995. Laboratory study, clinical symptoms and signs, chest roentgenograph and precipitating factors were analysed. Venography and lung perfusion scan using radionuclide scan were used for this study. The weight, height, sex, habitus of alcohol and smoking, hypertension, diabetes mellitus, previous operation history of ipsilateral lower extremity, etiology of hip joint disease, and transfusion of blood were not precipitating factors, but the age over 40 and previous history of pulmonary embolism had a significant effect on the incidence of deep vein thrombosis. There was no significant relationship between the incidence of deep vein thrombosis and the laboratory assay, clinical symptoms and signs. Deep vein thrombosis was detected in 29 cases(17.0%), pulmonary embolism in 22 cases(12.9%), and fatal pulmonary embolism in 1 case(0.6%). The most common location of deep vein thrombosis was the popliteal area.

Reversed Tendon Sheath Wrapping on Indirect Rupture of Tendo Calcaneus / 대한정형외과학회잡지

In the operative treatment of an indirect rupture of tendo calcaneus, we should consider difficult repair and postoperative adhesion with surrounding tissues. In this paper, the new surgical technique for indirectly ruptured tendo calcaneus was introduced and evaluated. From July 1994 to Sep. 1995, we experienced 10 cases of closed rupture of Achilles tendon which was treated with reversed tendon sheath wrapping of juncture site after direct repair. This technique consists of conventional core suture with strong suture material followed by fine tide up sutures around the ragged outer margin of the ruptured end. Then, we made a delicate incision on the synovial sheath of the tendon two inch proximal to the tendon juncture site and elevated it carefully and rolled it back reverse direction to wrap around the juncture site, then hooked it up with the synovial sheath of distal part of ruptured tendon. It was very helpful to prevent adhesion by lowering the endotendon cellular ingrowth between tendon proper and tendon sheath by wrapping the ragged end of rupture site. Their least follow-up period was 12 months. The clinical outcome of the patients was assessed according to the criteria of Hooker, and there were eight cases of excellent (80%), and two cases of satisfactory results. We report good results with the reversed tendon sheath wrapping around juncture site after direct repair of Achilles tendon, as a new technique the treatment of indirectly ruptured tendo calcaneus.

Total Knee Arthroplasty in Ankylosed Knee with Previous Infecton

Generally, exposure and the operative technique are common difficulty encountered in the total knee arthroplasty of ankylosed knee due to old infection sequelae. Also the postoperative range of motion and relief of pain is poor due to deformity and excessive soft tissue contracture around knee. There have heen few reports, however, that address the reconstructive challenge of total knee arthroplasty in a previously infected ankylosed knee. We perfoined TKA in thirty six patients who had ankylosed knee between July l986 and Dec. 199S. After follow up of average five years and one month, we analysed the results. The definition of ankylosis was a knee ROM less than 90 degree. Average age of patients were 36.7 years old. Twelve patients were meii and twenty four patients were women. Sixteen patients of partial ankylosis and twenty patients of complete ankylosis were performed operation. There were nineteen cases of healed tubercuiosis knees and seventeen cases of healed pyogenic knees. For the release of soft tissue contracture in 9 cases, we lengthened quadrceps tendon with the method of modified V-Y advancement technique. Patella tendon was proximally reattached with staples and suture in 6 cases and tibial tubercle was proximally transferred in 3 cases. As results, the postoperative average range of motion was 79.3 (30 - l21') in complete ankylosis, 107 (60 - 135 ) in partial ankylosis. The average Hospital for Speciai Surgery knee rating score improved from 56.3 points preoperatively to 84.8 points postoperatively. Radiolucent line was observed in two Knees with less than 2mm width in three years and four months, and four years postoperatively, hut the patient had no pain. In five patients who had poor gain of range of motion after operation, we perfonned arthroscopic adhesiolysis. In conclusion, regarding patient selection, reasonable hony development, relative]y healthy extensor mechanism and adequate soft tissue condition are important for success of TKA in old intection sequelae. TKA of ankylosed knee in old infection sequelae is a successful procedui which can ohtain the restoration of function of the ankylosed knee.