External Tibial Torsion with Proximal Tibia Vara in Total Knee Arthroplasty of Advanced Osteoarthritis with Severe Varus Deformed Knees / 대한정형외과학회잡지

PURPOSE@#External tibia torsion and proximal tibial vara have been reported in severe varus deformed osteoarthritis, which is a tibio-femoral angle of more than 20°. The radiology measurements were compared with those of control group and the preoperative and follow-up radiology and clinical results were examined.@*MATERIALS AND METHODS@#From January 2007 to March 2016, 43 knees from 37 persons, who underwent total knee arthroplasty for a severe varus deformity of more than 20° on the tibio-femoral angle on the standing radiographs and had a follow-up period more than two years, were examined. The mean follow-up period was 45.7 months. The control group, who underwent conservative treatments, had Kellgren-Lawrence grade three osteoarthritis and a tibio-femoral angle of less than 3° varus. The external tibial torsion of enrolled patients and control group were estimated using the proximal tibio-fibular overlap length and the tibial torsion values on computed tomography. The proximal tibia vara was measured using the proximal tibial tilt angle. The preoperative and postoperative proximal tibio-fibular overlap length, tibial torsion value, proximal tibial tilt angle, and hospital for special surgery (HSS) score were evaluated.@*RESULTS@#The mean proximal tibio-fibular overlap length was 18.6 mm preoperatively and 11.2 mm (p=0.031) at the follow-up. The control group had a mean proximal tibio-fibular overlap length of 8.7 mm (p=0.024). The mean tibial torsion value was 13.8° preoperatively and 14.0° (p=0.489) at the follow-up. The control group had a mean tibial torsion value of 21.9° (p=0.012). The mean proximal tibial tilt angle was 12.2° preoperatively and 0° (p<0.01) at the follow-up. The control group had a mean proximal tilt angle of 1.2° (p<0.01). The preoperative tibiofemoral angle and mechanical axis deviation were corrected from preoperative 28.3° and medial 68.4 mm to postoperative 0.7° and medial 3.5 mm (p<0.01, p<0.01), respectively. The HSS scores increased from 34 points of preoperatively to 87 points at the last follow-up (p=0.028).@*CONCLUSION@#Patients with advanced osteoarthritis with a severe varus deformity of more than 20° had significant increases in the external tibial torsion and varus of the proximal tibia. The tibial torsion value before and after surgery in the enrolled patients was not changed statistically, but good clinical results without complications were obtained.

Results of Revision Surgery and Causes of Unstable Total Knee Arthroplasty

BACKGROUND: The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery. METHODS: We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion. RESULTS: Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8degrees/3.2degrees (p = 0.713) and 22.5degrees/5.6degrees (p = 0.032). Mean postoperative alpha, beta, gamma, delta angle were 5.34degrees, 89.65degrees, 2.74degrees, 6.77degrees. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head (p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123degrees to 122degrees (p = 0.82). CONCLUSIONS: Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.

Comparison of Two Year Follow-Up Results in High Flexion Total Knee Arthroplasty with Lospa and Scorpio NRG / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the clinical and radiologic results after high flexion Lospa (Corentec Inc.) and Scorpio NRG (Stryker Inc.) total knee arthroplasty. MATERIALS AND METHODS: We prospectively compared 205 knees in 128 patients who underwent arthroplasty using Lospa (group A) and 164 knees in 102 patients who underwent arthroplasty using Scorpio NRG (group B) from September 2010 to March 2012 at Department of Orthopaedic Surgery, Sun General Hospital (Daejeon, Korea). Mean follow-up period was 23 months in group A and 24 months in group B. The radiologic analysis included the change of mechanical axis deviation and femoro-tibial angle, implant position (alpha, beta, gamma, delta), and patellar tilt. The clinical results were evaluated according to hospital for special surgery (HSS), knee society score (KSS), and range of motion. RESULTS: Mechanical axis deviations were change in varus from 34.8 mm to 2.6 mm (p=0.02) in group A, and change in varus from 34.3 mm to 3.1 mm (p=0.04) in group B; no statistically significant difference was observed between them (p=0.13). Femoro-tibial angles were varus 4.3degrees to valgus 6.6degrees (p=0.02) in group A, and varus 4.4degrees to valgus 6.5degrees (p=0.03) in group B; no significant difference was observed between them (p=0.25). No significant difference in implant position was observed between the two groups (p=0.25 in alpha, p=0.17 in beta, p=0.12 in gamma, p=0.17 in delta). Mean HSS improved from 48.5 to 93.6 (p=0.02) in group A, and from 41.4 to 94.4 (p=0.01) in group B. CONCLUSION: Lospa total knee arthroplasty showed excellent early radiologic, clinical results and no statistically significant difference in the results was observed between Lospa and Scorpio NRG.

Fixation of Greater Trochanteric Fracture Using Double Strands and Double Loops with Figure of 8 Wiring in Non-cement Total Hip Arthroplasty for Unstable Intertrochanteric Fracture / 대한고관절학회지

PURPOSE: Non-cement total hip arthroplasty for unstable intertrochanteric fracture in elderly patients is regarded as another surgical technique preventing complications such as non-union, long term limitation of weight bearing, pressure sore, pulmonary thromboembolism after open reduction or closed reduction with intramedullary nailing, or plate fixation. We would like to announce the short-term results of primary non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring for unstable intertrochanteric fracture in elderly patients. MATERIALS AND METHODS: All of the 20 patients admitted to the hospital between April 2010 and February 2012 who underwent non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring for unstable intertrochanteric fractures were evaluated. The mean age was 71.1(57-86), there were nine males, and 11 females, with an average follow up period of six months. The post-operative state was evaluated by Harris hip score. RESULTS: The mean operation time was 95 min, and the average blood loss was 800 cc. Mean Harris hip score at the last available follow-up was 92.7, and, among the patients, 15 had all functions of daily life without limitation of walking distance, one had hip dislocation, one had breakage of strands. Pressure sore, deep vein thrombosis, and pulmonary thromboembolism were absent. Radiography at the last available follow-up showed no loosening of the femoral stem in any of the patients, and 13 patients had osteogenesis around the fracture site, and there was no osteolysis. CONCLUSION: Primary non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring in elderly patients with unstable intertrochanteric fractures showed satisfactory results. These results are expected to be useful for further studies with a long-term follow-up and in development of a reduction method.

Modified Posterior Approach to Total Hip Arthroplasty

This paper reviews the posterior approach to total hip arthroplasty and introduces the modified short external rotator muscle saving posterior approach, which enhances hip stability after total hip replacement arthroplasty. In total hip replacement arthroplasty, dislocation is the most common early complication. Especially in the posterior approach, dislocation is more common than in the anterior or lateral approach to the hip. However, preservation or meticulous repair of the short rotator could reduce the incidence of posterior hip dislocation after total hip replacement arthroplasty. With a brief review of the posterior approach to the hip, we introduce the short external rotater muscle saving modified posterior approach to total hip arthroplasty.

Rotational Alignment of Femoral Component for Minimal Medial Collateral Ligament Release in Total Knee Arthroplasty

PURPOSE: We attempted to determine the degree of rotation of the femoral component to achieve an ideal rectangular flexion gap with minimal medial collateral ligament (MCL) release using a modified measured technique. MATERIALS AND METHODS: Group I consisted of 60 osteoarthritis patients (72 cases) who underwent total knee arthroplasty (TKA) with minimal MCL release and Group II consisted of 48 patients without osteoarthritis (61 cases). We performed computed tomography (CT) scanning of the knee with 90 degree flexion in all of the patients and analyzed the angles between the distal femur landmarks and the tibial mechanical axis using a Picture Archiving Communication system. External rotation of the femoral component from the Whiteside line and posterior condylar line was measured in group I who underwent TKA with minimum MCL release. The variance in the mediolateral flexion gap according to the degree of rotation was also measured using an Auto-Computer Aided Design program. RESULTS: The CT scans showed that the Whiteside line, posterior condylar line, and transepicondylar line was more internally rotated on average from the longitudinal axis of tibia by 4.12degrees, 5.54degrees, and 4.64degrees, respectively, in group I compared to group II. In group I, the femoral component was inserted with an average external rotation of 5.6degrees from the posterior condylar line and with an average external rotation of 2.0degrees from the Whiteside line with minimal MCL release. From the measurements of the femoral component size and the variance in the degree of rotation using an Auto-CAD program, it was found that the change in the mediolateral flexion gap was greater when the rotation angle was greater and it was greater when the size of femoral component was larger at the same rotation angle. CONCLUSIONS: The average rotation angle of the femoral component to achieve an ideal rectangular flexion gap with minimal MCL release in TKA was an external rotation of 5.6degrees from the posterior condylar line and an external rotation of 2.0degrees from the Whiteside line. We concluded that when a femoral component is small in size, greater than average external rotation needs to be applied and when a femoral component is large in size, less than average external rotation needs to be applied.

Posterior Approach to Total Hip Joint Replacement Arthroplasty

This paper was written to review the posterior approach for total hip arthroplasty and to introduce the modified short external rotator muscle saving posterior approach for enhancing the hip stability after total hip replacement arthroplasty. After total hip replacement arthroplasty, dislocation is the most commom early complication. Especially with using the posterior approach, dislocation is more common than that for the anterior or lateral approach to the hip. We report here that saving or meticulously repairing the short rotator could reduce the incidence of posterior hip dislocation after total hip replacement arthroplasty. Along with a brief review of the posterior approach to the hip, we introduce the short external rotator muscle saving modified posterior approach to total hip arthroplasty.

Cementless Total Hip Arthroplasty with Use of the COREN Hip System

PURPOSE: To report the results of a minimum three-year follow-up of cementless total hip arthroplasty using the COREN Hip System(R) (Corentec, Seoul, Korea), which is the first total hip prosthesis developed in Korea. MATERIALS & METHODS: A total of 57 patients (68 hips) who had undergone cementless total hip arthroplasty using the COREN Hip System(R) between July 2003 and March 2004 were analyzed clinically and radiographically after a minimum follow-up of three years after the index arthroplasty. RESULTS: The mean Harris hip score improved from 46 points preoperatively to 95 points at the one-year follow-up and to 99 points at the three-year follow-up. All the patients reported a good or excellent satisfaction with the results of surgery. All prostheses showed radiographic evidence of stable bony fixation, and no hips showed evidence of osteolysis or prosthesis loosening. During the follow-up period, there were no complications such as a deep infection, dislocation or ceramic fracture in any hip, and no revision surgery was required. CONCLUSION: The clinical and radiographic evaluations of Cementless total hip arthroplasty using the COREN Hip System(R) showed excellent outcomes after a minimum follow-up duration of three years.

Epidermoid Cyst of the Conus Medullaris and Cauda Equina: A case report / 대한척추외과학회지

The objective of this study is to report on a case of a huge epidermoid cyst in the conus medullaris and cauda equina in a 43 year-old lady with the characteristic MRI and histologic findings. She suffered from low back pain, hypoesthesia around the anus and urinary incontinence for over 20 years. Since 15 years previously, she gradually developed right foot drop and muscle atrophy. She underwent surgery and unfortunately, she developed complete paralysis below T12 after complete tumor excision. At postoperative 4 weeks, evidence of partial neurological recovery down to the L3 roots was observed, but as yet there has been no further neurological recovery. Although total surgical excision is thought to be the only radical treatment, we recommend partial tumor excision to avoid damaging the spinal cord and cauda equina during the surgical procedure, than the radical excision, because this cyst is a very slowly growing benign tumor.

Arthroscopic Treatment of Tibia Intercondylar Eminence Comminuted Fracture Used Number 5-nonabsobable Suture Material

PURPOSE: To evaluate effect of modified arthroscopic pull-out suture technique which used number 5-nonabsorbable suture material for tibia intercondylar eminence comminuted fractures. MATERIALS AND METHODS: There were 21 cases of tibia intercondylar emimence fracture which arthroscopic treated at our hospital between 1999 and 2004. However the study population only included 12 cases in which a number 5-nonabsorbable suture material (Ethibond No. 5) was used for tibia intercondylar eminence comminuted fractures and minimum 1-year follow-up has gone. The average follow-up period was 18.5 months (range, 12 to 42 months). Lachman test and KT-2000 athrometer test were evaluated at the pre-and post-operation. Clinical results of all patients were evaluated with the Meyers and Mckeever 's criteria. RESULTS: In all 12 cases, the normal range of motion and sports activities were recovered at the final follow-up. When tested for anterior instability with KT-2000 arthrometer, there were no different between normal knee and operated knee. Clinical results by Meyers and Mckeever's criteria were excellent in 10 patients and good in 2 patients. CONCLUSION: We obtained early mobilization and stable fixation in modified arthroscopic pullout suture technique for tibia intercondylar eminence comminuted fractures. Patients can early return to his job. This technique seems to be one of the effective operative techniques for treatment of tibia intercondylar eminence comminuted fractures.

Subacute Osteomyelitis of Distal Tibia Traversing the Physis in a Child: A Case Report / 대한정형외과학회잡지

A Brodie's abscess is a localized form of subacute or chronic osteomyelitis that occurs most often in the long bones of the lower extremities of young adults. Before physeal closure, it most commonly occurs in the metaphysis. In adults, the metaphyseal-epiphyseal area is involved. Rarely Brodie's abscess traverses the open growth plate, affecting the epiphysis, although such extension does not commonly result in growth disturbance. We reported a subacute osteomyelitis that traversed the physis of the distal tibia in a child, which was treated by surgical curettage and intravenous antibiotics.

Hip Arthroplasty in Aplastic Anemia / 대한정형외과학회잡지

Twenty-six primary hip prostheses were implanted in nineteen patients with a diagnosis of aplastic anemia between January 1990 and December 1992. The preoperative diagnosis were osteonecrosis of the femoral head in twenty-five hips and femoral neck fracture in one. The duration of follow-up was minimum of fours years. Preoperatively, the average Harris hip score was 56. At four years postoperatively, the average score reached 87. At this time, twelve hips were rated excellent, eleven good, two fair, and one poor. One patient who received a bipolar arthroplasty showed an intrapelvic protrusion of the acetabular component. Another bipolar fixed with Boneloc cement was performed due to femoral neck fracture. There was no migration of component, subsidence, radiolucency or osteolysis in three hips with hybrid fixation. No sign of migration of acetabular component was seen with uncemented prosthesis. Two hips with HA coated acetabular components showed a progressive radiolucent line. Progressive retroacetabular osteolysis was found in one hip at zone I and II. There were neither cases of infection nor hemorrhage complications. Two patients died of pneumonia and sepsis, respectively, at fifty-three and fifty-seven months postoperatively. It appears that fatty marrow conversion of proximal femur and pelvis does not affect the survival of cemented and uncemented fixation, but long-term follow-up is needed to validate our view. We have demonstrated that the hip arthroplasty in most patients with aplastic anemia can be successful despite the fact that hematologic characteristics of aplastic anemia seem to indicated a high risk for hemorrhagic complication and infection. In conclusion, we strongly recommend hip arthro-plasty if the patients has a painful hip joint, regardless of severity of aplastic anemia whose prognosis may be disappointing.

Muscle Power following Arthroscopic Primary Repair of ACL / 대한정형외과학회잡지

The aim of this study was to analyze the process of restoration of muscle power following arthroscopic primary repair of ACL with manual test and Cybex test for one year postoperatively. Arthroscopic primary repair of the ACL was performed in 24 fresh tear. Postoperatively a limited motion brace was applied. Full weight bearing was allowed at 10 weeks postoperatively. In all cases mid-thigh circumference at 7.5 cm proximal to the upper pole of patella was measured. Manual muscle power test and Cybex test were also performed and the differences between the normal and the affected legs were recorded. The manual test and measurement of mid-thigh circumference were performed at 6 weeks, 12 weeks, 6 months and 1 year postoperatively. All cases showed 'normal' muscle power at 6 weeks after surgery in manual test. The mean difference of mid-thigh circumference was 4.5 cm(range 2.0-6.0 cm) at 6 weeks, 3.6 cm(range 1.0-6.5 cm) at 12 weeks, 2.9 cm(range 1.8-4.8 cm) at 6 months and 0.9 cm(0.5-2.5 cm) at 1 year after surgery. The peak torque deficit measured by Cybex test showed 50-82%(average 65.8%) in extensor and 24-96 %(average 60.6 %) in flexor at 12 weeks, 21-60 %(average 41.4 %) in extensor and 2-50 %(average 32.4 %) in flexor at 6 months, 1-23 %(average 13.1 %) in extensor and 1-19 %(average 11.4 %) in flexor at 1 year after surgery. From these results it would be suggested that the peak torque of muscles was not normal by Cybex test although the muscle power was restored clinically by 1 year following surgery.

Passive Release of Pulley with Needle for Trigger Finger / 대한정형외과학회잡지

The purpose of this study was to assess the results of passive release of the pulley with needle under local anesthesia performed at the out patient department. There were 68 fingers of 54 patients. Fifteen patients(27.8 %) were male and 39 patients(72.2 %) were female. Involved fingers were 28 thumbs(41.2 %), 7(10.3 %) index fingers, 14(20.6 %) middle fingers, and 19(27.9 %) ring fingers. Ages were varied-between 41 years and 61 years old. Rheumatoid fingers were 12(17.6 %). The others had no underlying disease. An 18 gauge needle was introduced distal to the palpable nodule. The pulley was released passively when the PIP joint was extended. The follow-up period was 4.5 years on average(range; 1-8 years). At final follow-up local recurrence was noted in 1-2 weeks in 7 cases(10.3 %), which was due to technical fault in early trial cases. The patients complained of pain for a few days and mild tenderness for less than 2 weeks. In three cases adhesion occurred, which was resolved in a week by maniqulation. There was no difference between rheumatoid arthritis and the other underlying diseases as far as rate of recurrence was concerned. From these results it would be suggested that the passive release of pulley with needle is an effective method for the treatment of adult trigger finger.

GCT) in the Femur and Tibia Treated with Curettage and Cementation / 대한정형외과학회잡지

This dealt with the 23 cases of giant cell tumor of femur and tibia who were treated with curettage and cementation of the lesion, over 14 year period. Cement by virtue of it's heat of polymerization may “sterilize” the wall upto 3-5mm in depth. Authors adoped cement treatment as an effective adjuvant after intra-lesional surgery(curettage). Curettage was indicated in all stage I lesions; most stage 2 and some stage 3 lesions, provided the residual bone stock were sufficient to make it oncologically and mechanically effective. The follow-up period ranged from 3 to 14 years(oaverage 8 years and 6 months). The sites of the lesions were proximal tibia in 8, dital femur in 13, proximal femur in one, and distal tibia in one. Among these cases, 3(13.0%) cases(two grade 1 and one grade 2) of stage II(To: active), and 2(8.7%) of stage III(grade 2) (Tl or T2: aggressive). Utmost attention was paid to nulify or to reduce the local seeding of the tumor cell during aggressive curettage, which was followed by electrical cautery of the cavitey wall, and lastly by the cavity obliteration with bone cement. None of the cases had lung metastasis. Only in a stage III GCT case(4.3%) of local recurrence after curettage and bone and artificial bone graft, recurettage and cementation brought the successful outcome. Through this study, it was reconfirmed that with correct indications the use of cement as a local adjuvant in conjuction with curettage was effective method in treating GCT without any side effects.

Surgical Treatment of Malunited Proximal Femoral Transepiphyseal Fracture In a Girl / 대한정형외과학회잡지

Authors experienced an unusual case of malunited trans-epiphyseal fracture of the proximal femur in a 2 year-old girl. She was treated at a private clinic by closed reduction and cast immobilization, which subsequently resulted in malunion and capital subluxation. Because of subsequent failure of remodelling of the subluxated malunited fracture for two years, corrective femoral varisation and internal rotation osteotomy was done to reduce the subluxated femoral head. Postoperatively congrous reduction was obtained and gradual remodelling of the malunited fracture took place during 5 and a half years follow-up period.

Post-Laminectomy Swan Neck Deformity in Adults / 대한정형외과학회잡지

Five adult cases of post-laminectomy swan-neck deformity are reported. The factors causing the deformity, prophylactic measures, and treatment of the deformity are discussed. It is strongly adviced to the neurosurgeons and orthopedic surgeons that they should be aware of this unwanted complication of the multi-level cervical laminectomies, and that they should provide every preventive measures before post-laminectomy swan neck deformity develops. Anterior interbody fusion spanning the entire unstable segments is preferably recommended together with application of pre-fusion traction.

Treatment of Fracture of Shaft of Humerus by Ender Nailing / 대한정형외과학회잡지

Authors presented the experience of Ender nail treatment for the humeral shaft fractures in 24 patients. The results of treatment in all were satisfactory, though there were four cases of delayed union. Bridging callus was formed at 8.2 weeks on an average. The average clinical union time was 14 weeks. No complications developed during nailing procedure. A case of radial nerve palsy after fracture recovered spontaneously. Longer nails which hit the end of medullary canal of distal fragment distracted the fracture gap, and resulted in delayed union in 4 cases. Therefore, it is recommended to use the proper size of nail to avoid the distraction effect of the inserted nail, and to use two nails at minimum for better fixation. However, when intramedullary Ender nailing is properly done, single nailing also can give consistently good anatomic and functional results.

Voluntary Habitual Hip Dislocation in a child / 대한정형외과학회잡지

Voluntary habitual dislocation of the hip is very rarely reported in children, and only 13 cases have been reported in the literature. We add a new case in a 5 year old boy. The boy did not have previous history of trauma, skeletal and/or soft tissue anomalies, nor known connective disease. He was treated by intertrochanteric varusinward rotation osteotomy of the affected hip on February 25, 1985 and was followed until January 11, 1993. Postoperative convalescence was uneventfully successful, and the hip developed well without any obvious dysplasia at the latest follow-up.

Surgical Treatment of Pathological Dislocation of Child Hip After Acute Osteomyelitis of Ilium / 대한정형외과학회잡지

A case of pathological hip dislocation in a child, aged 2 years 6 months, who had surgical treatment, is reported. The boy has history of osteomyelitis of right ilium at age of 10 month, which ended up with the right hip dislocation. Postoperatively cephalocotyloid relation of the right hip was very well reestablished during five years of postoperative observation. Through this case, it is reconfirmed that a child hip has a natural remodelling power even in case of hip joint destruction.