Position Statement: Atypical Femoral Fracture from the Korean Society for Bone and Mineral Research in 2023

As the aging population increases, the number of patients with osteoporosis is gradually rising. Osteoporosis is a metabolic bone disease characterized by low bone mass and the microarchitectural deterioration of bone tissue, resulting in reduced bone strength and an increased risk of low-energy or fragility fractures. Thus, the use of anti-resorptive agents, such as bisphosphonates (BPs), to prevent osteoporotic fractures is growing annually. BPs are effective in reducing hip and other fractures. However, the longer a patient takes BPs, the higher the risk of an atypical femoral fracture (AFF). The exact mechanism by which long-term BP use affects the development of AFFs has not yet been clarified. However, several theories have been suggested to explain the pathogenesis of AFFs, such as suppressed bone remodeling, impaired bone healing, altered bone quality, and femoral morphology. The management of AFFs requires both medical and surgical approaches. BPs therapy should be discontinued immediately, and calcium and vitamin D levels should be evaluated and supplemented if insufficient. Teriparatide can be used for AFFs. Intramedullary nailing is the primary treatment for complete AFFs, and prophylactic femoral nailing is recommended if signs of an impending fracture are detected.

A Systematic Review and Meta-Analysis of Arthroscopic Meniscus Repair in Young Patients: Comparison of All-Inside and Inside-Out Suture Techniques

PURPOSE: The purposes of the present study were to review published studies that investigated arthroscopic meniscus repair to treat meniscus injury in young patients and to compare all-inside and inside-out suture techniques. METHODS: Various electronic databases were queried for published articles, and this search was updated in August 2017 for evaluating the outcomes of arthroscopic meniscus surgery in young patients. Data search, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines, and the clinical outcomes were evaluated using various outcome values in young patients according to suture techniques. RESULTS: Three randomized controlled trials and three prospective comparative studies were included in this systematic review and meta-analysis. There were no significant differences in clinical outcomes such as meniscus healing rate (risk ratio [RR], 1.11; 95% confidence interval [CI], 0.90 to 1.37; I²=39%) and perioperative complications (RR, 0.62; 95% CI, 0.23 to 1.72; I²=43%) between all-inside and inside-out techniques for meniscus repair. CONCLUSIONS: The present study shows favorable results for clinical outcomes such as meniscus healing rate and perioperative complications in young patients. Furthermore, based on our results, both all-inside and inside-out meniscal suture techniques are equally effective in these patients.

Medial patellofemoral ligament reconstruction using an autograft or allograft for patellar dislocation: a systematic review

PURPOSE@#The purpose of this study is to review the use of an allograft or autograft in medial patellofemoral ligament (MPFL) reconstruction.@*MATERIALS AND METHODS@#Various electronic databases were searched for relevant articles published from January 2000 to September 2017 that evaluated clinical outcomes of MPFL reconstruction using an autograft or allograft. Data search, extraction, analysis, and quality assessments were performed based on Cochrane Collaboration guidelines.@*RESULTS@#The study of 21 autografts and one allograft was included in this review. Although direct comparative studies were unavailable, the Kujala score and subjective results were reported in the majority of these studies. While the use of an autograft for MPFL reconstruction yielded satisfactory clinical outcomes with few perioperative complications, no new outcome has been drawn from the use of allografts.@*CONCLUSIONS@#Although many studies have shown favorable clinical results for MPFL reconstruction using an autograft, the clinical results of MPFL reconstruction using an allograft have not yet been sufficient to achieve meaningful clinical results due to low levels of evidence. Direct comparisons were not conducted because there were very few studies on allografts; thus, further research in this area should be performed in the future.

Inhibition of the Expression of Matrix Metalloproteinases in Articular Chondrocytes by Resveratrol through Affecting Nuclear Factor-Kappa B Signaling Pathway

In the present study, we tried to examine whether resveratrol regulates the expression of matrix metalloproteinases (MMPs) through affecting nuclear factor-kappa B (NF-κB) in articular chondrocytes. Rabbit articular chondrocytes were cultured in a monolayer, and reverse transcription-polymerase chain reaction (RT-PCR) was used to measure interleukin-1β (IL-1β)-induced gene expression of MMP-3, MMP-1, MMP-13, a disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS-4), ADAMTS-5 and type II collagen. Effect of resveratrol on IL-1β-induced secretion of MMP-3 was investigated in rabbit articular chondrocytes using western blot analysis. To elucidate the action mechanism of resveratrol, effect of resveratrol on IL-1β-induced NF-κB signaling pathway was investigated in SW1353, a human chondrosarcoma cell line, by western blot analysis. The results were as follows: (1) resveratrol inhibited the gene expression of MMP-3, MMP-1, MMP-13, ADAMTS-4, and ADAMTS-5, but increased the gene expression of type II collagen; (2) resveratrol reduced the secretion of MMP-3; (3) resveratrol inhibited IL-1β-induced activation (phosphorylation) of inhibitory kappa B kinase (IKK), and thus phosphorylation and degradation of inhibitory kappa Bα (IκBα); (4) resveratrol inhibited IL-1β-induced phosphorylation and nuclear translocation of NF-κB p65. This, in turn, led to the down-regulation of gene expression of MMPs in SW1353 cells. These results suggest that resveratrol can regulate the expression of MMPs through affecting NF-κB by directly acting on articular chondrocytes.

A Comparison of Results after Anterior Cruciate Ligament Reconstruction in over 40 and under 40 Years of Age: A Meta-Analysis

PURPOSE: Anterior cruciate ligament (ACL) injury is one of the most common injuries that occur in the knee, and ACL reconstruction (ACLR) is commonly performed for preventing aggravation of degenerative changes and restoring of knee stability in young, athletic patients. This metaanalysis has a purpose of evaluating the clinical and arthrometrical outcomes of ACLR in a group of middle age patients (40 years and older) and comparing with patients under 40 years of age. METHODS: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and SCOPUS electronic databases were searched for relevant articles comparing the outcomes of ACLR between younger and older than 40 years of age until December 2016. Data searching, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated and compared between groups. The results were presented as mean difference for continuous outcomes with 95% confidence intervals whereas risk ratio for binary outcomes. RESULTS: Seven studies were included in the meta-analysis. Based on International Knee Documentation Committee classification, side-to-side difference, Tegner activity score, Lysholm knee score, there were no significant clinical and mechanical differences between the groups. CONCLUSIONS: This meta-analysis confirmed that after ACLR, middle age (>40 years) and young age (<40 years) patients did not present with significant difference in clinical and arthrometric results.

Conservative Treatment of Pyogenic Spondylitis in the Elderly

STUDY DESIGN: Retrospective study. OBJECTIVES: To analyze the outcomes of conservative management in elderly patients over 65 years of age who were diagnosed with pyogenic spondylitis. SUMMARY OF LITERATURE REVIEW: The surgical treatment of pyogenic spondylitis can lead to complications in elderly patients in a poor general condition or with underlying diseases. MATERIALS AND METHODS: We performed a retrospective review of 32 patients who were diagnosed with pyogenic spondylitis and had a minimum of 12 months of follow-up. Age, sex, comorbidities, clinical symptoms, and the involved segments were analyzed retrospectively. The diagnosis was assessed using clinical, laboratory, and radiologic findings. Antibiotic therapy was either specific (if positive culture results were found) or broad-spectrum cephalosporin (when the pathogenic agent was not isolated). Outcomes were assessed using residual pain and neurologic deficits. RESULTS: The mean onset time was 23.5 days (range, 3-90 days). The mean period of intravenous antibiotic therapy was 36.3 days (range, 10-90 days). All cases underwent conservative management, and 4 patients with progressive neurologic deficits due to epidural abscess underwent posterior laminectomy and abscess drainage. In all cases, the infection was successfully treated, although 12 cases reported residual lower back pain and 2 continued to exhibit minor neurologic deficits. CONCLUSIONS: In elderly patients with pyogenic spondylitis, satisfactory results were obtained with conservative management using antibiotics and orthosis after an early diagnosis, unless progressive neurologic symptom instability or spine deformities were noted.

Effect of oleanolic acid on the activity, secretion and gene expression of matrix metalloproteinase-3 in articular chondrocytes in vitro and the production of matrix metalloproteinase-3 in vivo

In the present study, we tried to examine whether oleanolic acid regulates the activity, secretion and gene expression of matrix metalloproteinase-3 (MMP-3) in primary cultured rabbit articular chondrocytes, as well as the production of MMP-3 in the knee joint of rat to evaluate the potential chondroprotective effect of oleanolic acid. Rabbit articular chondrocytes were cultured in a monolayer, and reverse transcription-polymerase chain reaction (RT-PCR) was used to measure interleukin-1β (IL-1β)-induced gene expression of MMP-3, MMP-1, MMP-13, a disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS-4), ADAMTS-5 and type II collagen. In rabbit articular chondrocytes, the effects of oleanolic acid on IL-1β-induced secretion and proteolytic activity of MMP-3 were investigated using western blot analysis and casein zymography, respectively. The effect of oleanolic acid on in vivo MMP-3 protein production was also examined, after intra-articular injection to the knee joint of rat. The results were as follows: (1) oleanolic acid inhibited the gene expression of MMP-3, MMP-1, MMP-13, ADAMTS-4, and ADAMTS-5, but increased the gene expression of type II collagen; (2) oleanolic acid reduced the secretion and proteolytic activity of MMP-3; (3) oleanolic acid suppressed the production of MMP-3 protein in vivo. These results suggest that oleanolic acid can regulate the activity, secretion and gene expression of MMP-3, by directly acting on articular chondrocytes.

Compartment Syndrome Following Total Knee Arthroplasty: Clinical Results of Late Fasciotomy

Compartment syndrome after total knee arthroplasty (TKA) is a rare complication. Because of its rarity, it may be overlooked and misdiagnosed as peroneal nerve palsy or deep vein thrombosis. This misdiagnosis could have a profound impact on the patient's outcome. We report a case of a 77-year-old female who developed unilateral compartment syndrome in the calf after staged bilateral TKA at an outside clinic. The patient presented with medical complications related to compartment syndrome: rhabdomyolysis and myoglobinuria, which caused acute renal failure. Thus, we performed late fasciotomy one week after symptom onset to debride necrotic tissue and salvage the compartment. In the discussion section, we will discuss risk factors for compartment syndrome after TKA, results of late fasciotomy and other indications for surgical treatment of compartment syndrome.

Thromboprophylaxis for Deep Vein Thrombosis and Pulmonary Embolism after Total Joint Arthroplasty in a Low Incidence Population

Postoperative venous thromboembolism is one of the most serious complications following total joint arthroplasty. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep vein thrombosis and pulmonary embolism. Use of pharmacological prophylaxis requires a fine balance between the efficacy of the drug in preventing deep vein thrombosis and the adverse effects associated with the use of these drugs. In regions with a low prevalence of deep vein thrombosis such as Korea, there might be a question whether the benefits of using pharmacological prophylaxis outweigh the risks involved. The current article reviews the need for thromboprophylaxis, guidelines, problems with the guidelines, pharmacological prophylaxis use, and the current scenario of deep vein thrombosis, and discusses whether the use of pharmacological prophylaxis should be mandatory in low incidence populations.

Isolated Polyethylene Liner Exchange in a Revision Total Hip Arthroplasty

PURPOSE: To analyze the results of isolated exchange of polyethylene (PE) liners for treatment of wear and osteolysis around a well-fixed Harris-Galante (HG) cementless acetabular cup. MATERIALS AND METHODS: Thirty-three PE liner changes were performed without the removal of stably ingrown implants (33 hips of 32 patients). They were able to be followed for a mean period of 92 months. Clinically, the Harris hip score (HHS), pain evaluation, and complications were evaluated. Radiologically, the annual wear rate and the size of the osteolytic lesions were measured before the operation and the latest follow-up. The bone graft incorporation scale and the development of new osleolytic lesions were checked during the final follow-up. RESULTS: HHS improved to 89.3 at last follow-up. The size of the osteolysis was significantly reduced postoperatively. Bone graft incorporation scales were Grade I in 9 and Grade II in 14 cases. New osteolytic lesions have not developed at latest follow-up. As a complication, one case of dissociation of a liner and a periprosthetic fracture were noted. Annual wear rates during the same period were significantly reduced. There was no sign of alteration in stability of the PE liner. CONCLUSION: Exchange of a PE liner without removal of stable implants can be a good option for the treatment of wear and osteolysis around a stable cementless THA implant, even if the system has a weak locking mechanism, such as the HG cup. In these cases, under certain states with a higher risk of early failure in the locking mechanism, it would be better to select other revision procedures such as cup revision or cemented polyethylene liner fixation.

Treatement of Osteomyelitis and Soft Tissue Infection of Fingers Using Mini External Fixator

PURPOSE: Finger is the one of the common site of open fracture, and it causes osteomyelitis of the phalanges. The purpose is to analyze the efficacy of management of chronic osteomyelitis in hand phalanges with mini external fixatior. METHODS: From March 2002 to December 2008, we experienced 8 cases of chronic osteomyelitis in hand phalanges. One case was a phalangeal infection after toe transfer, and three cases were the epiphyseal injury of phalanx in children. All cases used mini external fixator. Soft tissue coverage was performed using rotational flap in 4 cases, pedicled flap in 3, and cross finger flap in 1. Additional operation was required a mean of 2.2 times per patients. RESULTS: All cases achieved soft tissue coverage, eradication of osteomyelitis and bony union. However, five cases had bone shortening due to severe infection, and two cases showed mild growth disturbance. CONCLUSIONS: Mini external fixator is effective in management of osteomyelitis occurred in hand phalanges.

Multiple Pinning in Base Fracture of Distal Phalanx

PURPOSE: The purpose of this study was to evaluate the use of multiple pinning in base fracture of distal phalanx. MATERIALS AND METHODS: We reviewed the results of 8 patients treated with a multiple pinning in fracture of distal phalanx base. There were 7 men and 1 woman, and the mean age was 52.6 years(45~66 years). The type of injury was a crushing injury in 6 patients and, in direct trauma in 2. The injured finger was thumb in 4 patients, index finger in 1, long finger in 1, and ring finger in 2. We used three K-wires for fixative devices in all fractured phalanx. The average removal period of K-wire was 6.5 weeks(5~8 weeks). RESULTS: Postoperatively, immobilization was applied for 6.5 weeks (5~8 weeks). The mean fragment size was 33.8%(10~50%) of long axis of distal phalanx. The range of motion was 1.3degrees (0~5degrees ) in extension lag and 88.1degrees (85~90degrees ) of flexion of the distal interphalangeal joint. CONCLUSION: The multiple pinning of base fracture of distal phalanx was one of the useful method to stabilizing of distal phalanx fracture.

Linear Sebaceous Hyperplasia

We report an unusual case of sebaceous hyperplasia in an 18-year-old male manifestated clinically as yellowish, grouped papules with a linear distribution, present on the right side of forehead since birth. Histopathologically, a large sebaceous gland composed of numerous lobules grouped around a centrally dilated duct was seen. The sebaceous lobules distributed in the upper dermis showed direct connection to the skin surface, which suggested a transepidermal elimination of sebaceous lobules.

A study of peripheral blood eosinophil and serum IgE level in patients with atopic dermatitis / 대한피부과학회지

The peripheral blood eosinophil and serum IgE level in 53 patients with atopic dermatitis (AD) were measured. The patients were divided into 2 groups by severity(mild and severe grous) and into 3 groups by the associated respiratory atopic deseases and/or their family history : respiratory group(patient, with both AD and respiratory atopy), family history group (patient with both AD and family history of respiratory atopy), and atopic group(patient with neither respiratory atopy nor family history of respiratorv atopy). We designed to study which factors are important in the elevation of serum IgE and peripheral blood eosinophil level in AD, and to know possible relationships between the serum eosinophil and IgE level and the several groups of AD. The results are as follows : 1. Peripheral eosinophil counts were higher in severe group(224.8/mm) than in mild group (180.0/mm)(p<0.05). 2. Peripheral eosinophil counts were 220.0/mm in atopic group, l65.0/mm in family history group, and 332.4/mm in respiratory group, but there was no stitistically significant difference among 3 groups. This suggests that concomitant respiatitiry atopy or a family history of respiratory atopy is not an important factor in the elvation of peripheral blood eosinophil counts in AD. 3. Serum IgE was higher in severe group(443.2IU/ml) than in mild group(231.5IU/ml)(p<0.05). 4. Serum IgE level in respiratory group(754.6IU/ml) were signifiiantlly higher than in atopic (286.6IU/ml) or family history group(342.0IU/ml)(p<0,01). But there was no significant. difference between family and atopic group. This result suggests that concomittent respiratory atopy is a potential factor in elevation of serurn Igi in AD. 5. Slightly high correlation between peripheral blood and IgE level appeared in all 53 patients (r=0.434) and severe group(r=0.480). But, respiratory group(r=0.060), family history group(r=0.111) and atopic group(r=0.202) showed poor relationships.

A Case of Contact Dermatitis due to Herb Ointment / 대한피부과학회지

A case of contact dermatitis due to herb onintment is described in a 24 year-old female patient. After topical application of herb ointment, she developed erythematous papules and plaques on the face and neck. Patch test revealed positive reactions to ammoniated mercury, thimerosal, and the herb ointment. Energy-dispersive X-ray microanalysis of the herb ointment showed a striking peak for mercury.