Comparison of Denosumab and Zoledronic Acid in Postmenopausal Women With Osteoporosis: Bone Mineral Density (BMD) and Trabecular Bone Score (TBS)

Background@#Denosumab (DEN) and zoledronic acid (ZOL) currently represent the most potent antiresorptive agents for the treatment of osteoporosis. Despite similar effects on bone resorption, these agents have distinct mechanisms of action. The objective of this study was to compare the effect of DEN and ZOL after two-year administration on bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers, and persistence. @*Methods@#A total of 585 postmenopausal women with osteoporosis who did not use osteoporosis medications were retrospectively reviewed. 290 patients were administered 60 mg DEN subcutaneously every 6 months from 2017 to 2018, and 295 patients were treated with 5 mg ZOL intravenously yearly from 2015 to 2017. BMD, TBS, and C-terminal crosslinking telopeptide of type 1 collagen (CTX) measurements were obtained at baseline and two-year after DEN injection or ZOL infusion. @*Results@#After two-year follow-up, 188 patients in the DEN group and 183 patients in the ZOL group were compared. BMD change from baseline at two years was significantly greater in the DEN group compared with the ZOL group (P < 0.001). The changes of TBS in the DEN group were statistically significant compared with baseline (P < 0.001) and the ZOL group (P < 0.001). The DEN group led to significantly greater reduction of CTX compared with ZOL group (P = 0.041). @*Conclusion@#In postmenopausal women with osteoporosis, DEN was associated with greater BMD increase at all measured skeletal sites, greater increase of TBS, and greater inhibition of bone remodeling compared with ZOL.

Functional Recovery Program after Lumbar Spinal Fusion / 대한정형외과학회잡지

As the elderly population increases, the incidence of lumbar fusion is increasing, and there has been increasing interest in rapid rehabilitation and functional recovery after surgery. Enhanced recovery after surgery program and multimodal pain control methods can reduce the complications and allow rapid recovery. Various methods have been used to increase the fusion.

Biportal Percutaneous Endoscopic Spinal Surgery for Lumbar Spinal Stenosis / 대한정형외과학회잡지

Lumbar decompressive surgery is a standard surgery for lumbar spinal stenosis. Many surgical techniques have been introduced, ranging from open surgery to percutaneous procedures. Minimally invasive techniques are preferred because of the less postoperative pain and shorter hospital stay. Uniportal percutaneous endoscopic decompression has technical difficulties due to the narrow field. Biportal percutaneous endoscopic decompression is a satisfactory technique that can compensate for the shortcomings and provide sufficient decompression.

Hip Screening in Infants Presenting with Asymmetricity of Lower Extremity / 대한정형외과학회잡지

PURPOSE: This study aimed to investigate the clinical features of congenital postural deformities and lower extremity asymmetry with respect to the presence of developmental dysplasia of the hip (DDH) in infants with a discrepancy of the limb length referred for suspected DDH. MATERIALS AND METHODS: We retrospectively reviewed the medical records and radiographs of 150 infants who visited Korea University Anam Hospital Orthopedic Clinic for suspected DDH between March 2013 and March 2015. RESULTS: There were greater numbers of infants with a shorter lower extremity on the left side (n=86, 57.3%) than the right. Plagiocephaly was present in 62 infants and trunk curvature in 124 infants (82.7%). Pelvic tilting—indirectly assessed by a skewed direction of the external genitalia in female infants—was present in 62 infants (63.3%). None of the 139 infants with normal physical examination of the hip were diagnosed with DDH. Of those 11 infants with abnormal findings from the hip physical examination, a total of 6 infants were diagnosed with DDH. CONCLUSION: Regardless of the associated findings of congenital postural deformation, all infants diagnosed with DDH had abnormal findings from the physical examination of the hip joint. Thus, we conclude that the hip examination is important as the primary clinical screening in aiding the diagnosis of DDH.

Disparity between Clinical and Ultrasound Examinations in Neonatal Hip Screening

BACKGROUND: For early detection of developmental dysplasia of the hip (DDH), neonatal hip screening using clinical examination and/or ultrasound has been recommended. Although there have been many studies on the reliability of both screening techniques, there is still controversy in the screening strategies; clinical vs. selective or universal ultrasound screening. To determine the screening strategy, we assessed the agreement among the methods; clinical examination by an experienced pediatric orthopedic surgeon, sonographic morphology, and sonographic stability. METHODS: From January 2004 to June 2009, a single experienced pediatric orthopedic surgeon performed clinical hip screenings for 2,686 infants in the neonatal unit and 43 infants who were referred due to impressions of hip dysplasia before 3 months of age. Among them, 156 clinically unstable or high-risk babies selectively received bilateral hip ultrasound examinations performed by the same surgeon using the modified Graf method. The results were analyzed statistically to detect any correlations between the clinical and sonographic findings. RESULTS: Although a single experienced orthopedic surgeon conducted all examinations, we detected only a limited relationship between the results of clinical and ultrasound examinations. Ninety-three percent of the clinically subluxatable hips were normal or immature based on static ultrasound examination, and 74% of dislocating hips and 67% of limited abduction hips presented with the morphology below Graf IIa. A total of 80% of clinically subluxatable, 42% of dislocating and 67% of limited abduction hips appeared stable or exhibited minor instability on dynamic ultrasound examination. About 7% of clinically normal hips were abnormal upon ultrasound examination; 5% showed major instability and 3% showed dysplasia above Graf IIc. Clinical stability had small coefficients between ultrasound examinations; 0.39 for sonographic stability and 0.37 for sonographic morphology. Between sonographic stability and morphology, although 71% of hips with major instability showed normal or immature morphology according to static ultrasound examination, the coefficient was as high as 0.64. CONCLUSIONS: Discrepancies between clinical and ultrasound examinations were present even if almost all of the exams were performed by a single experienced pediatric orthopedic surgeon. In relation to screening for DDH, it is recommended that both sonographic morphology and stability be checked in addition to clinical examination.

Disparity between Clinical and Ultrasound Examinations in Neonatal Hip Screening

BACKGROUND: For early detection of developmental dysplasia of the hip (DDH), neonatal hip screening using clinical examination and/or ultrasound has been recommended. Although there have been many studies on the reliability of both screening techniques, there is still controversy in the screening strategies; clinical vs. selective or universal ultrasound screening. To determine the screening strategy, we assessed the agreement among the methods; clinical examination by an experienced pediatric orthopedic surgeon, sonographic morphology, and sonographic stability. METHODS: From January 2004 to June 2009, a single experienced pediatric orthopedic surgeon performed clinical hip screenings for 2,686 infants in the neonatal unit and 43 infants who were referred due to impressions of hip dysplasia before 3 months of age. Among them, 156 clinically unstable or high-risk babies selectively received bilateral hip ultrasound examinations performed by the same surgeon using the modified Graf method. The results were analyzed statistically to detect any correlations between the clinical and sonographic findings. RESULTS: Although a single experienced orthopedic surgeon conducted all examinations, we detected only a limited relationship between the results of clinical and ultrasound examinations. Ninety-three percent of the clinically subluxatable hips were normal or immature based on static ultrasound examination, and 74% of dislocating hips and 67% of limited abduction hips presented with the morphology below Graf IIa. A total of 80% of clinically subluxatable, 42% of dislocating and 67% of limited abduction hips appeared stable or exhibited minor instability on dynamic ultrasound examination. About 7% of clinically normal hips were abnormal upon ultrasound examination; 5% showed major instability and 3% showed dysplasia above Graf IIc. Clinical stability had small coefficients between ultrasound examinations; 0.39 for sonographic stability and 0.37 for sonographic morphology. Between sonographic stability and morphology, although 71% of hips with major instability showed normal or immature morphology according to static ultrasound examination, the coefficient was as high as 0.64. CONCLUSIONS: Discrepancies between clinical and ultrasound examinations were present even if almost all of the exams were performed by a single experienced pediatric orthopedic surgeon. In relation to screening for DDH, it is recommended that both sonographic morphology and stability be checked in addition to clinical examination.

Surgical or nonsurgical treatment of osteoporotic fractures

The worldwide population of the elderly is steadily increasing, and even more so in Korea, thus causing an increase in the osteoporotic fracture prevalence. Osteoporotic fracture is a serious injury that can decrease quality of life, and can also produce major social problems when it causes mortality. Preventing such fractures from happening in the first place is of utmost importance but once a fracture does occur, it is important to select appropriate treatment modalities to prevent secondary fractures. Recently, with the increase of life expectancy, it has become favorable to perform surgical fixation for significantly displaced osteoporotic fractures and use early rehabilitation programs to return the patient to normal body performance as soon as possible. To do so, it is important to accurately assess the location and the degree of the fractures in order to select appropriate treatment modalities. Furthermore, it is important to prevent secondary fractures from happening once the previous fractures heal.

The Pattern of Occurrence of Fractures in Children and Adolescents and Its Managements Based on the Database of the Health Insurance Review and Assessment Service

PURPOSE: The purpose of this article is to report on the pattern of medical process and relative frequencies of fractures in children and adolescents. MATERIALS AND METHODS: The authors retrospectively analyzed the database of the health insurance review and assessment service regarding children and adolescents under 20 years old treated from 2008 to 2010. Newly registered numbers of fractures in children and adolescents according to sex, month, institution, and anatomical location were also reviewed. RESULTS: A total of 1,893,416 fractures occurred during three years; approximately 630,000 cases were treated during one year (approximately 562 cases among 10,000 people during one year). During one year, the most fractures occurred in June and the least in February. Senior general hospital consisted of 5.72%, 12.30% in general hospital, 19.28% in hospital, and 62.70% in clinics. Among the fracture sites, 0.05% were cervical fractures, 0.91% in sternum and thoracic vertebra, 1.35% in lumbar vertebra and pelvis, 12.79% in shoulder and upper extremities, 26.87% in lower extremities, 38.10% in wrist and hand, 1.01% in femur, 10.40% in lower extremities including ankle, and 8.52% in foot excluding ankle. The maximal incidence was age 14 years in male and 12 years in female. CONCLUSION: The authors reviewed the pattern of medical process and relative frequencies of fractures in children and adolescents.

Basic Principles and Current Trends of Medial Opening-Wedge High Tibial Osteotomy / 대한정형외과학회잡지

High tibial osteotomy (HTO) is a popular surgical procedure for osteoarthritis of the knee with varus deformity. In general, HTO has shown sufficient clinical outcomes with careful patient selection and correct surgical technique. Among various surgical techniques, medial opening-wedge and lateral closing-wedge HTO are widely used. This report includes basic principles and current trends in patient selection and preoperative evaluations and planning, operative technique, complications, and rehabilitation protocol in medial opening-wedge HTO.

Ultrasonographic Findings of Musculoskeletal Tissues / 대한정형외과학회잡지

In order to accurately diagnose lesions of musculoskeletal tissue, evaluation not only of the abnormality of the bone, but the condition of soft tissue is important. Magnetic resonance imaging has been widely used in evaluation of the state of soft tissue, however, it has the disadvantage that testing is expensive and real-time scanning is not possible. In recent years, ultrasonography has been used for evaluation of musculoskeletal tissue and its usefulness has shown a gradual increase. The ultrasound image is determined by the tissue specific acoustic impedance and other factors. Highly reflective tissues such as bone, calcification, ligament, and tendon are expressed as hyperechoic images, and less reflective tissues such as muscle and nerve are expressed as hypoechoic images.

Differences in Bone Mineral Density between the Right and Left Hips in Postmenopausal Women

Bone mineral density (BMD) using dual energy radiography absorptiometry are commonly used for the diagnosis of osteoporosis. It is usually measured at the spine and also at one hip joint. Controversy still exists regarding the use of bilateral hip scanning. We analyzed the difference of BMD at bilateral hips in 384 postmenopausal women, retrospectively. The concordance and discordance rates of the lowest T-score and BMD between both hips were evaluated. The BMDs of the femoral neck and trochanter were significantly different between both hips (P < 0.05). There were also discrepancies between the lowest T-scores of both hips (P < 0.05). The discordance rates were about 30%. Due to significant differences in BMD between both hips at the femoral neck and trochanter and high discordance rate, bilateral hip measurements using DEXA are recommended to avoid underestimating osteoporosis.

Vitamin D Inadequacy in Patients with Osteoporotic Hip Fractures

OBJECTIVE: To investigate the prevalence of vitamin D inadequacy in an elderly patients with hip fracture. METHODS: A prospective study was carried out for 2 years (January 2008 - December 2009). Patient records were searched for hip fracture admission and cross matched with serum vitamin D levels and bone densitometry carried out within 3 days of the hip fracture admission. RESULTS: There were data for 115 hip fracture patient, 69% of the patients were women (n = 79). The mean age at the time of fracture was 76.1 years. The mean of bone densitometry was -2.8 +/- 0.8. About 40% of the patients had a bone mineral density (BMD) below -3.0. The mean vitamin D (25-OH) level was 20.9 +/- 10 ng/mL. Over 80% of patients had a vitamin D level below 30 ng/mL. Especially, patients (n = 17) admitted from assisted nursing home had less a vitamin D level (16.3 ng/mL) than patients admitted from home (22.9 ng/mL). There were no significant differences by age or sex however, there was seasonal differences in vitamin D. CONCLUSION: This study reveals universal vitamin D inadequacy in hip fracture patients.

Medial Malleolar Stress Fracture in Athlete / 대한스포츠의학회지

The stress fracture is a disease which results from the repeated application of an abnormal stress to the normal bone, typically occurs in metatarsal bone, tibia, fibular and femur, but medial malleolus is rare. We report a case of stress fracture of medial malleolus in 22-year old wrestler.

Vesicocutaneous Fistula Presenting Groin Abscess and Chronic Osteomyelitis in Pubic Bone

The authors report a case of bladder fistula associated with a medial thigh cutaneous fistula and chronic osteomyelitis of the pubic bone 11 years after surgery for a pelvic bone fracture and bladder rupture. In the presenting case, despite the clinical suspicion, none of the diagnostic tools demonstrated the bladder fistula preoperatively. This case suggests that bladder repair should be prepared, even if the bladder fistula cannot be confirmed by imaging studies because the amount of urine leakage can be minimal or the fistula can close spontaneously.

Treatment of Shatzker Type VI Tibia Plateau Fracture Using Lateral and Posteromedial Dual Incision Approach and Dual Plating

PURPOSE: To evaluate the radiologic and clinical results of treatment of the Shatzker type 6 tibia plateau fracture using the lateral and posteromedial dual incision approach and dual plating. MATERIALS AND METHODS: Twelve cases in eleven patients of Shatzker type 6 tibia plateau fracture which has been treated using the lateral and posteromedial dual incision approach and dual plating were analyzed with an average follow-up of 16 months. Times to union, alignment and reduction loss on radiograph and postoperative clinical outcome with checking the range of motion of the knee joint, Knee Society Score and UCLA activity scale were analyzed and evaluated. RESULTS: In all cases, bony union was obtained in an average fifteen weeks after the operation, and there was no reduction loss. The arc of motion of the knee joint at the latest follow-up was 132 degrees on average. Average of Knee Society Score was 85 and UCLA activity scale was decreased from 9.6 points preoperatively to 5.7 points postoperatively. CONCLUSION: The treatment of Shatzker type 6 tibia plateau fracture using the lateral and posteromedial dual approach and dual plating have shown clinically preferable results of excellent recovery of joint motion and good knee society score by early range of motion exercise after firm fixation. However, it was high energy injury, so the sports activity of patients was significantly decreased.

Treatment of Choice in the Surgical Management of the Femoral Shaft Fractures in Children: Elastic Intramedullary Nailing

No abstract available.

Bipolar Hemiarthroplasty for the Femoral Neck Fractures in Elderly Patients

PURPOSE: To evaluate the clinical results of bipolar hemiarthroplasty in elderly patients more than 65 years of age with a femoral neck fracture. MATERIALS AND METHODS: Forty-six bipolar hemiarthroplasties in 43 patients more than 65 years of age which could be followed more than 3 years were included in this study. The clinical outcomes were evaluated using Harris hip score, pain score and support score. The radiological results were analyzed by femoral stem loosening and bipolar cup migration. RESULTS: The average Harris hip score was 88.7 (62~96) points. An excellent score was recorded in 34 cases, good in 7 cases, fair in 3 cases and poor in 2 cases. The average pain score was 39.3 points and there were no pain in 20 cases, slight pain in 17 cases, mild pain in 6 cases and moderate pain in 2 cases. The average support score was 9.6 points and 32 patients could walk without the use of any assistive devices. Two cases were converted to total hip arthroplasty due to femoral stem loosening with or without bipolar cup migration. CONCLUSION: For the early ambulation and functional recovery of elderly patients with femoral neck fracture, bipolar hemiarthroplasty was considered as one of recommendable methods.

Easy and Fast Anastomosis using Microvascular Anastomotic Coupler System / 대한정형외과학회잡지

PURPOSE: We report the results of microvascular anastomosis using a microvascular anastomotic coupler (MAC) system. MATERIALS AND METHODS: Twenty cases (12 patients) of venous anastomoses performed using a coupler system were examined. The patients' age, gender, preoperative diagnosis, donor tissue, vessel diameters, size of coupler, time for anastomosis, patency rate immediately after surgery and the final survival rate of the transferred tissue were evaluated. RESULTS: The mean time for anastomosis using the coupler system was 3 min and 15 sec. The immediate patency rate after anastomosis was 100% without any leakage of blood or thrombus formation. At the final follow up, the transferred tissue survived in all cases. CONCLUSION: Microvascular anastomosis using a coupler system in orthopaedic reconstructive surgery can shorten the vascular anastomosis time and significantly reduce the total ischemic time of the transferred tissue. This system can be easily used after a short training period. This system minimizes the intimal damage of the vessel, easily overcomes the diameter discrepancy and provides secure fixation at the anastomosis site. This system can be a good strategy for substituting the conventional suture anastomosis.

Syndesmosis Injury Associated with the Weber Type B Lateral Malleolar Fracture / 대한정형외과학회잡지

PURPOSE: We evaluated the syndesmosis instability associated with Weber type B lateral malleolar fractures. MATERIALS AND METHODS: Eighty one Weber type B lateral malleolar fractures were evaluated and classified according to the radiologic criteria. Syndesmosis instability was checked with a hook test during operation. The radiological and clinical results were assessed. RESULTS: Twenty two cases were associated with a widening of the distal tibiofibular distance. Sixteen (73%) had syndesmosis instability confirmed with a hook test and were fixed with a syndesmotic screw. Eight (66%) out of 12 Wagstaffe fractures were fixed with a syndesmotic screw due to the instability. The distal tibiofibular distance was 7.4+/-2.4 mm, 4.6+/-1.9 mm and 4.9+/-1.9 mm preoperatively, postoperatively, and at the final follow up, respectively. All cases achieved union and good clinical results with more than 85 on the AOFAS score were obtained. CONCLUSION: Weber type B lateral malleolar fractures can be associated with a syndesmosis injury. An intraoperative hook test should be carried out for accurate diagnosis. Considerable attention needs to be paid to Wagsteffe fractures, because of the high probability of combining syndesmosis instability.

Reconstructive Arthrodesis using a Non-living Fibular Graft with an Attached Periosteal Sleeve for Osteosarcoma of the Distal Tibia: A Case Report / 대한정형외과학회잡지

According to previous reports, ankle arthrodesis is regarded as the best reconstructive procedure after limb salvage surgery for osteosarcoma of the distal tibia. Of the many arthrodesis options, vascularized fibular graft (VFG) is widely accepted as the most successful method. However, reconstruction using VFG is not always possible, because VFG is a complicated surgical procedure and is associated with high rates of morbidity at donor sites. The authors devised a novel reconstructive surgical procedure that exploits the osteogenic potential of the periosteum. A 10-year-old female patient with osteosarcoma of the distal tibia underwent limb salvage surgery and the ipsilateral distal fibula and periosteal sleeve were transported to the defect for ankle arthrodesis. The transported fibula and periosteal new bone formation acted as a dual strut bone graft providing better stronger stability than fibula alone transfer. The authors believe the proposed procedure is an easier alternative to the surgically demanding VFG method.