Radiological Evaluation of Quadriceps-Sparing Minimally Invasive Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the radiological results of quadriceps-sparing total knee arthroplasty. MATERIALS AND METHODS: 50 consecutive total knee arthroplasties with a quadriceps-sparing surgical technique and 50 consecutive total knee arthroplasties with conventional surgical techniques were performed. The same surgeon performed all the operations with the same type of prosthesis (Nexgen LPS-flex Total Knee System). We compared the differences between these groups in terms of preoperative and postoperative femorotibial angles, tibial component alignment angles, tibial component inclinations, and ratios of size of the tibia component to tibial cutting size. RESULTS: There were no differences in preoperative femorotibal angles, tibial component alignment angles, tibial component inclinations, ratios of sizes of tibia tray to tibial cutting size, and blood loss between the two groups (p>0.05). The average ranges of motion and HSS scores at 8 weeks postoperatively in the quadriceps-sparing total knee arthroplasty group were greater than those in the conventional surgical technique (p<0.05). The mean postoperative femorotibial angle in the quadriceps-sparing total knee arthroplasty group was a valgus of 6.9+/-1.3 degrees compared with a valgus of 7.7+/-1.4 degrees in the standard arthroplasty group (p<0.05). CONCLUSION: A quadriceps-sparing total knee arthroplasty offers predictable results in terms of radiological comparison with the conventional arthroplasty technique. But this technique has the tendency of producing a decreased valgus angle at the distal femur.

Anatomic Assessment of the Acetabular Fossa for Screw Fixation in Acetabular Fracture / 대한정형외과학회잡지

PURPOSE: To obtain spatial information on the acetabular fossa concerning `transacetabular screw' insertion through the acetabular fossa parallel to the quadrilateral surface for fixing an acetabular fracture. MATERIALS AND METHODS: Each hemipelvis harvested from 25 adult fresh frozen cadavers was sectioned into eight segments. This resulted in seven measuring points located along the outer margin of the acetabular fossa. At these points, we measured and compared the vertical thicknesses of cartilage and bone from the quadrilateral surface. RESULTS: The average thickness of the thinnest portion of the acetabular fossa floor was 3.9+/-1.9 mm. The entire thickness of the bone and cartilage measured vertically from the quadrilateral surface at the 7 points ranged from 12.7+/-2.1 mm to 17.8+/-3.8 mm. The thinnest safe space of exposed threads of the `transacetabular screw' inserted through the acetabular fossa was consistently just below the posterior conus of the lunate surface, measuring 4.8+/-1.6 mm (p<0.05). At the other points, it measured 8.3-10.8 mm. CONCLUSION: We suggest that `transacetabular screws' can be inserted safely if due consideration is paid to the spatial characteristics of on the acetabular fossa. Screw insertion into the postero-inferior portion of the acetbular fossa should be done carefully.

Intramedullary and Extramedullary Combined Alignment System for Tibial Component Placement in Total Knee Arthroplasty

PURPOSE: The purpose of this study is to assess the usefulness of combined intramedullary and extramedullay tibial resection guide system. MATERIALS AND METHODS: 277 consecutive total knee arthroplasties were performed using three different alignment systems.: extramedullary system(group 1 ; 89 cases) , intramedullary system(group 2;134 cases), combined system(group 3;54 cases). We compared the differences of these groups in terms of preoperative femorotibial angle, postoperative femorotibial angle and postoperative tibial component alignment angle, respectively. RESULTS: Preoperatively, the three groups were similar in diagnosis, patient age, and preoperative femorotibial angle(p>0.05). Postoperative tibial component alignment angle and femorotibial angle were similar in each group(p>0.05). The optimal tibial component alignment angle was defined within 2 degree of the 90 degree and it was achieved in 51.7% in group 1, 47.8% in group 2 and 59.3% in group 3(p>0.05). The the optimal femorotibial angle was defined by the range from valgus 5 degrees+/-2 and it was achieved in 54.5% in Group 1, 54.5% in Group 2 and 55.6% in Group 3(p>0.05). CONCLUSION: This study demonstrated that the accuracy of the extramedullary system, intramedullary system, and combination system for tibial resection were similar. So the combination system can be one of the acceptable method for cutting the proximal tibia, because it utilizes the strength of the extramedullary system as well as the intramedullary system.

Spiral Plate Fixation For Treatment of Proximal Humerus Fracture / 대한정형외과학회잡지

PURPOSE: When open reduction and internal fixation with plate and screws are indicated in comminuted proximal shaft of humerus, the ideal plate position at proximal end of the humerus is the lateral surface of the greater tuberosity. At midshaft of the humerus, however, insertion of the deltoid muscle limits the application of the plate on the lateral aspect. To overcome this discordance, open reduction and internal fixation for the treatment of comminuted fracture in the proximal humerus with precontoured spiral plate was performed to preserve deltoid insertion. MATERIAL AND METHOD: We performed open reduction and internal fixation with spiral plate in five patients. Two out of five required tricortical autogenous iliac bone graft due to severe comminution at the surgical neck. All patients were folllowed up for 20.5 months in average. The radiographic study for bony union and shoulder function ( Neer's criteria ) were evaluated. RESULT: All five fractures healed. Comminuted fracture at proximal humerus consolidated at 5 months in average. Comminuted fracture at the surgical neck needed an extra 2 months for healing. Shoulder function was classified as one excellent, two good and two fair. Two fair patients, who had severe comminution at the surgical neck, resulted in moderate loss of abduction and external rotation of the involved shoulder. But, the patients were satisfied with their shoulder function at final follow-up. There was no infection or metal failure. CONCLUSION: We recommend spiral plate as a worthwhile treatment for comminuted fracture of proximal humerus. Preservation of deltoid insertion seems to be helpful in the recovery of shoulder function.

Intramedullary Nailing in Distal Tibial Metaphyseal Fracture / 대한정형외과학회잡지

PURPOSE:. To review the efficiency of the primary closed IM nail in 15 cases of distal tibial metaphyseal fractures. PATIENTS AND METHODS: From January 1997 to August 1998, 15 patients were treated by closed intramedullary nailing for distal metaphyseal tibial fracture. All operations were done on the fracture table in supine position, and any fracture extending into the ankle joint was stabilized by supplementary cannulated screw. RESULT: According to Robinson classification, there were 5 type I fractures (33%) , 6 type IIa fractures (40%) , 2 type IIb fractures (13%) , and 1 type IIc fracture (7%) . The mean distance between the distal end of fracture and tibial plafond was 2.3cm (range 0 to 4.5cm) . Three intraarticular fractures were stabilized by a supplementary cannulated screw. The mean score was 93.7 point ( excellent 7 cases, good 4 cases, fair 4 cases ) by Baird ankle scoring system There were no poor results. Fourteen patients (93%) went on to union at average of 18weeks (range 12-28weeks) . One type IIIa open fracture failed to unite and one patient had a valgus deformity of 7 degrees. Nonunion was succesfully treated by bone graft. There was no soft tissue necrosis or infection. CONCLUSION: In this study, we confirmed that IM nailing is one of the safe and effective methods for treating distal tibial metaphyseal fractures.

Quadricepsplasty for the Stiff Knee / 대한정형외과학회잡지

PURPOSE: To report the technique of modified Thompson quadricepsplasty with postoperative treatment using string tie and the results for stiff knees. MATERIALS AND METHODS: From June 1987 to June 1997, we evaluated the results of 20 knees of 19 patients who were managed with modified Thompson quadricepsplasty for the stiff knee and were followed up for an average of 29 months (range, 18 to 49 months). We performed modified Thompson quadricepsplasty, which included arthrolysis, anterolateral or lateral approach, transverse incision on tensor fascia lata, release of middle and distal third of quadriceps muslce. If the knee flexion was less than 130 degree, Z-plasty on distal tendinous portion of rectus femoris was performed. Postoperatively, the knees were flexed with string tie for 3 hours. And then the knees were extended for 3 hours. This periodic passive exercise was started by the 21st day after the surgery. RESULTS: The average gain in flexion from preoperative to postoperative was 74.7 degree+/-25.1 degree. At the latest follow-up, the average loss of range of motion from that obtained in the operating room was 5.3 degree+/-7.2 degree. According to Judet's assessment of results, there were 17 excellent and 3 good results. There was one wound infection but it resolved after wound care and intravenous antibiotics for 3 weeks. CONCLUSIONS: The modified Thompson quadricepsplasty and postoperative care with string tie provided good results for the stiff knee.

Treatment of Infected Nonunion of the Femur with Marked Shortening by Compression and Gradual Distraction at the Nonunion Site: A Report of 2 cases / 대한정형외과학회잡지

The authors report two cases of successful reconstruction in infected nonunion of the femur involving marked shortening by compression and gradual distraction at the nonunion site using Ilizarov external fixator. At first, infection was controlled by radical excision & the administration of systemic antibiotics for four weeks and we also started compression at the nonunion site 3 days after operation. Autogenous iliac bone graft was added to strengthen the site of new bone formation lastly. In this report, the role of the compression seems to provide a good environment for distraction osteogenesis by focal necrosis and triggering inflammation. Compression and gradual distraction may be one of the treatment mordalities for nonunion of a long bone with massive bone loss or shortening, even infected.

Ruptured Lumbar Disc in Patients Undergoing Manipulation of the Lumbar Spine / 대한정형외과학회잡지

Cauda equina syndrome(CES) and disc rupture have been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1996 received 61 reported cases of cauda equina syndrome or disc rupture in patients undergoing manipulation. This article presents four new cases, where a temporal association was found between the onset of cauda equina symptoms or disc rupture and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. Our patients symptoms suggest that acute herniation was caused, or at least precipitated by spinal manipulation. In each of these cases the chiropractitioner failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patient went untreated for several days. Many chiropractic therapists assumed the incidence of CES caused by manipulation to be approximately one in many millions of treatments. However, we assumed that CES or disc rupture is far more common than the literature would reflect. It is therefore essential that persons practicing or prescribing manipulation would be aware of these complications.

The Role of Matrix Metalloproteinases in Aseptic Loosening of Total Hip Prostheses / 대한정형외과학회잡지

Incidence of aseptic loosening of hip prostheses is increasing in recent years. Previous studies suggested the involvement of proteinases and cytokines in the accelerated bone lysis associated with loosening. To investigate the role of matrix metalloproteinases (MMPs) in the loosening, Gelatin/Type IV collagenases, namely, 72 KDa matrix metalloproteinase (MMP)-2 type and 92 KDa MMP-9 type were analyzed in 14 cases of the loosened endoprostheses of the hip. Zymographic and densitometric analyses revealed production of MMP-2 ancl elevated induction of MMP-9 in tissue extracts from both the interface hetween hone and implants and the capsular tissues when compared with those in synovium obtained from a patient with a t'ractured femoral neck. MMP-9 showed stronger activity than MMP-2. In the sample of a fractured femoral neck, MMP-2 was detected, but MMP-9 was not detected. In matched samples, the activity of MMP-2 and MMP-9 in the interface tissues showed stronger activity than those in the capsular tissues. There was no difference between cemented and uncemented femoral prostheses. The state of prostheses(loosening, osteolysis, and cup wear) did not influence on the activity of MMP-2 and MMP-9. Theses findings suggest a role for MMP-2 and MMP-9 type gelatinase/Type IV collagenases in the degradation of extracellular matrix of periprosthetic tissues, where they may cause weakening of the connective tissue hed and the loosening of total hip replacement endoprostheses. Consequently. we could confirm the role of MMP cascade in aseptic loosening of total hip prostheses. The further study ahout other types of MMP and the inhihitor of MMP will be needed.

The Last Fifty Years of Western Medicine in Korea: Korean Orthopedic Association

No abstract available.

The Gamma Intramedullary Nailing for Peritrochanteric Fractures / 대한정형외과학회잡지

This study consisted of 66 peritrochanteric fractures which were treated by the modified Gamma nail (Asian Pacific nail) from August 1993 to October 1995. Sixty-one intertrochanteric fractures and five subtrochanteric fractures were treated in our institution. Average length of follow-up was 15.0 months. Four patients died during follow-up. The results were as follows; Lag screws were ideally introduced in 55 (83%) cases. The mean length in lag screw sliding was 4.3 mm in stable trochanteric fractures and 5.7 mm in unstable ones. Fifty-one out of 62 patients (82%) were returned to their previous ambulatory status. Intraoperative complications were as follows; distal crack (3 cases); rotation of femoral head (2 cases); entry point crack (I case); medialization of proximal fragment (7 cases); and missing of the interlocking screw (1 case). All of these complications did not affect the outcome. All medial cortical gaps were closed after sliding of lag screws. Three distal cracks did not propagate to the shaft. Postoperative complications were a case of superior cut-out, and two second fractures after falls. Callus formed more early in the stable trochanteric fractures (5+/-2.1 weeks) than unstable fractures (7.3+/-2.1 weeks). It was statistically significant. Union time between stable and unstable trochanteric fractures was not statistically significant. In conclusion, the Asian Pacific (AP) nail could appropriately fix the osteoporotic peritrochanteric fractures in elderly patient. It could offer early rehabilitation to these patients and decrease the mortality and morbidity.

Operative Treatment of Post - traumatic Stiff Elbow / 대한정형외과학회잡지

Twenty-seven consecutive patients who had post-traumatic stiffness of the elbow were treated by operative soft tissue release or by soft tissue release and distraction arthroplasty. The purpose of this study was to describe the method of operation and postoperative management and to evaluate the results in the patients who had operative treatment for the post-traumatic stiffness of the elbow. The type of operative procedure was determined by whether the factors limiting motion were extra-articular (extrinsic) or intra-articular (intrinsic) and by pre-operative radiographic evaluation. The soft tissue release was performed by staged adhesiolysis through lateral or combined lateral and medial approaches. And if the factors limiting motion included a severe intraarticular lesions, distraction arthroplasty using the Judet or Oganesian apparatus was added to soft tissue release. The mean pre-operative arc of active motion was 42 degrees. At follow-up examination, nineteen to sixty-six months postoperatively, the mean post-operative arc of active motion was 103 degrees. There were nine complications (33 percent) in twenty-seven patients. All of them was transient ulnar nerve paresthesia. And we analysed the final results with Mayo elbow performance index for the evaluation of clinical outcome. Twenty-five (93%) of twenty-seven patients had satisfactory result according to Mayo elbow performance index. We conclude arthrolysis with or without distraction arthroplasty is useful for the treatment of posttraumatic elbow stiffness. However, the accurate anatomical knowledge, operative skill, and careful postoperative rehabilitation program were needed in the operative treatment of post-traumatic elbow stiffness.

Treatment of Severely comminuted Tibial condylar Fracture through anterior Approach with Z - tenotomy of the Patella Tendon / 대한정형외과학회잡지

Severely comminuted tibial condylar fracture is a major threat to the structures and function of the knee joint. Recently, anterior approach with Z-tenotomy of the patellar tendon was introduced for these complicated fractures. It provides wide exposure of the tibial articular surface for maximum joint reconstruction. The purpose of this study was to describe the operative technique and to evaluate the clinical results of this method. We had performed operative treatment in 13 cases (12 patients) of severely comminuted Schatzkers type II, V, and VI tibial condylar fractures through anterior approach from December 1993 to April 1996. Twelve cases out of 13 (92%) showed acceptable results according to Blokkers criteria. There was no superficial or deep infection. On the basis of these results, we suggest that the anterior approach is a valuable aid in the operative treatment of severely comminuted tibial condylar fractures.

Change of Femoral Anteversion during Closed Femoral Intramedullary Nailing / 대한정형외과학회잡지

Average anteversion of the femur is 15.3 degree. Ultrasound, computerized tomogram, and three dimensional reconstruction from CT or MRI have been used for more accurate measurement of the anteversion. There are two methods in measuing anteversion angle from CT scan:one is by drawing a mid line through long axis of the femoral neck (conventional method). Another is by drawing a line from the center of the head to that of the neck at the base of the trochanter using several cut slices (Murphy’s method). We compared these methods with fluoroscopic measurement of the Anteversion. We traced the change of the anteversion before and after closed femoral intramedullary (IMO) nailing to evaluate the origin of malrotation of the femur. 1. Normal anteversion angles were measured in 15 cases. Average anteversion angle was 6.9 degrees by conventional method, 12.3 degrees by Murphy’s method, and 12.2 degrees by fluoroscope. 2. Anteversion angles were measured after IM nailing in 18 cases. Average was 17 degrees by Murphy’s method and 15.2 degrees by fluoroscope. Mean of difference between these two methods sea 6.3 degrees. That was 1.7 degrees in normal side. 3. Change of the anteversion angle between before and after IM nailing was measured in 17 cases by fluoroscope. Average anteversion angle before the operation was 11.9 degrees and it was change to 15.8 degrees after operation. Mean of these change was 7.1 degrees. 4. Pereperative traction provides important information on change of anteversion. Reduction excessive flexion of proximal fragment was a origin of change of anteversion during nailing procedure. Conclusion : Malrotation of the femur after IM nailing must be keep in mind and it may be preventable by fluoroscopic control of the rotation in nailing procedure.

Cementless Total Hip Arthroplasty in Long Term Steroid-Induced Avascular Necrosis of the Hip / 대한정형외과학회잡지

We performed twenty three cementless total hip arthroplasties(THA) on seventeen patients, all of whom were diagnosed with steroid-induced avascular necrosis of the hip (AVN). The average age of the patients was 41years, mean follow-up period was 41months (24-74months). The final average Harris hip score was 94 and overall results were excellent. On radiographic evaluation, 17 femoral components met the criteria for bone ingrowth(spot weld) but it was somewhat delayed. There was no evidence of loosening of the femoral and acetabular components. The results of this study suggest that long term steriod treatment does not prevent bone ingrowth. Cementless total hip arthroplasty appears to be a reasonable therapeutic option for steroid-induced avascular necrosis of the hip.

Lengthening of Short Tubular Bone by Gradual Distraction / 대한정형외과학회잡지

Thirteen cases of lengthening of short tubular bone by gradual axial distraction using an unilateral external fixator(Orthofix M-100, Orthofix CP0089) are reported. This study aims to prove effective- ness of gradual distraction for lengthening of short tubular bone and usefulness of the newly designed external fixator. Nine patients had brachymetatarsia and four brachymetacarpia. The etiology was consisted of post-traumatic physeal injury in two and congenital in eleven cases. The average amount of lengthening was 14.5mm(37.0%) in metacarpal bone, and 17.3mm(37.5%) in metatarsal. Complications were angular deformity in 3, pin loosening in 2 cases, and premature consolidation, nonunion and pin site infection in one case, respectively. Cosmetical and functional satisfactory results were obtained in all cases. We believe that callotasis is effective for short tubular bone lengthening. Also we confirmed the newly designed external fixa- tor(Orthofix CP0089) useful.

Treatment of Tibial Pilon Fractures: Ilizarov Method vs Conventional Methods / 대한정형외과학회잡지

The tibial pilon fracture has been described as difficult fracture to manage. We have reviewed 23 cases of tibial pilon fractures from Mar. 1987 to Feb. 1993 at our hospital. 1. The fractures were classified into five types according to the system of Ovadia and Beals and the methods of treatment were divided into two groups; 9 cases were treated with Ilizarov device(Group I). 6 cases out of Group I were type 3, 4 and 5. Other methods were performed in 14 cases(Group II). 8 cases out of Group II were type 3, 4, and 5. 2. In type 3, 4 and 5 fractures, there were 86 per cent good and fair radiographic results in Group I and 63 per cent good and fair results in Group II. 3. Satisfactory results were obtained by the treatment of Ilizarov method especially in type 3, 4 and 5 fractures. The advantages of Ilizarov device were its primary reduction with ligamentotaxis, easy open reduction due to proximal and distal stabilization, minimal soft tissue injury and minimal internal fixation.

Dynamic Closing Method Using Elasticity for Skin Defect / 대한정형외과학회잡지

Skin defects unable to close by primary intention have caused many difficulties. Complex surgical interventions such as repetitive debridements, skin graft, or flap have been performed as therapeutic methods. Recently, new techniques for the skin closure based on the stretching property, elasticity or stress relaxation, have been introduced. This biomechanical property exhibits that the force required to keep the skin at a stretched length decreases over time. As the skin is stretching, the convoluted collagen fibers in dermis are straighten and become a line in the direction of stretching force. Fifteen cases of skin defects associated with fracture were closed by a new dynamic closing method at Department of Orthopaedic Surgery, Yonsei University College of Medicine. Two spinal needles were inserted into dermis along the wound margins on each side in order to distribute the even tension. The wound margins were approximated by suture wires engaged with the needles. We have experienced successful results using new stretch closing method in fracture with skin defect. It is confirmed that this method is rapid, simple, cost-effective, cosmetic, and safe way to close the skin defect and shortens hospital stay.

Autotransfusion in Total Joint Arthroplasty / 대한정형외과학회잡지

We present a review of 131 cases in which blood was retrieved and reinfused using Constavac Blood Conservation blood retrieval and reinfusion device postoperatively. The total number of cases in this study included 84 THA, 19 Rev. THA, 16 unilateral TKA and 12 bilateral TKA. The examinations of hemoglobin, hematocrit, antithrombin III, fibrinogen and D-dimer were initiated prospectively before surgery in each case. These parameters were also examined at postoperative day 1 and at day 7 for the evaluation of safety of Constavace Blood Conservation system. The aerobic and anaerobic bacterial culture tests of draining blood were also taken. The results were as follows: 1. The amount of total blood lost averaged 1264±466cc in THA, 2187±632cc in Rev. THA, 1651±543cc in unilateral TKA and 3445±1532cc in bilateral TKA. 2. The amount of blood retrieved and transfused averaged 499±227cc(39% of total lost blood) in THA, 578±527cc(26%) in Rev. THA. 953±451cc(58%) in unilateral TKA and 2219±1191cc(64%) in bilateral TKA. The amount of reinfusion averaged 71% of blood retrieved in THA, 62% in Rev. THA, 80% in unilateral TKA and 84% in bilateral TKA. 3. Fifty one cases out of 84 cases in THA and 14 case out of 28 cases in TKA underwent operation without homologous blood replacement. In the remaining cases, transfused banked blood averaged 364cc(29% of total lost blood) in THA, 620cc(27%) in Rev. THA, 485cc(29%) in unilateral TKA and 914cc(26%) in bilateral TKA. 4. There were no significant change in hemoglobin and hematocrit at postoperative day 7 compared with the preoperative state. 5. The antithrombin III, fibrinogen and D-dimer were converted to normal range at postoperative day 7. 6. The aerobic and anaerobic bacterial culture tests of reinfusing blood proved to be negative in all cases.

The Cementless Total Knee Arthroplasty in Osteoarthritis & Rheumatoid Arthritis / 대한정형외과학회잡지

The results of cementless total knee arthroplasty(TKA) have improved steadly during the past decade due to development of design, fixation and surgical technique. We analyzed the results of 45 total knee arthroplasties performed with Anatomic Modular Knee(AMK) prosthesis at the department of Orthopedic Surgery, Yonsei University College of Medicine between June 1989 and December 1991 and compared their results of rheumatoid arthritis(RA) and osteoarthritis(OA) patients. The follow up ranged from 2 years to 4 years and 2 months (average 2 years and 8 months). Using the Hospital for Special Surgery(H.S.S.) rating system and Knee Society(K.S.) clinical rating system, we found that the clinical results were similar for RA group(Average; H.S.S. 86.1, K.S. 81.2/74.4) and OA group(Average; H.S.S. 88, K.S. 87.8/77.1) even though the preoperative knee score was lower in RA group(Average;H.S.S.42.8) than OA group(Average;H.S.S. 57.7). The average age of RA patients was 14 years younger than that of OA patients. The improvement of range of motin and preoperative flexion contracture after TKA was remarkable in RA group. The radiologic evaluation based on Knee Society roentgenographic evaluation system revealed proper alignment of all component and no definite radiologic loosening except 1 case in which postoperative deep infection had occurred. On the basis of this prospective clinical and radiologic review, we concluded that uncemented implantation of AMK prosthsis both in RA and OA patients was encouraging.