The analgesic efficacy of the continuous adductor canal block compared to continuous intravenous fentanyl infusion with a single-shot adductor canal block in total knee arthroplasty: a randomized controlled trial

BACKGROUND: The adductor canal block (ACB) is an effective intervention for postoperative analgesia following total knee arthroplasty (TKA). However, the ideal ACB regimen has not yet been established. We compared the analgesic effects between a continuous ACB group and fentanyl-based intravenous patient-controlled analgesia (IV-PCA) with a single-shot ACB group. METHODS: Patients who underwent TKA were randomly allocated to either a continuous ACB group (Group CACB) or IV-PCA with a single-shot ACB group (Group IVACB). Before the surgery, ultrasound guided ACB with 0.5% ropivacaine 20 cc was provided to all patients. Before skin incision, the infusion system (0.2% ropivacaine through an adductor canal catheter in group CACB vs. intravenous fentanyl in group IVACB) was connected. The postoperative pain severity; the side effects of local anesthetics and opioids; administration of rescue analgesics and anti-emetics; and sensorimotor deficits were measured. RESULTS: Postoperative pain severity was significantly higher in the IVACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The averages and standard deviations (SD) of the NRS score of postoperative pain were 0.14 ± 0.37, 4.57 ± 2.37, 6.00 ± 1.63, and 4.28 ± 1.49, respectively in the IVACB group. Rescue analgesic requirements and quadriceps muscle strength were not statistically different between the groups throughout the postoperative period. Moreover, rescue antiemetic requirements were higher in group IVACB than group CACB. CONCLUSIONS: In this study, the continuous ACB provided superior analgesia and fewer side effects without any significant motor deficit than the IV-PCA with a single-shot ACB.

Computer-Assisted Navigation in Total Knee Arthroplasty / 대한정형외과학회잡지

Total knee arthroplasty has become a standard procedure for advanced knee arthritis to relieve pain and improve function. Computer-assisted navigation systems have been used in total knee arthroplasty to improve the mechanical axis of the limb as well as the alignment and position of the components. A computer-assisted navigation system has the advantage of real-time feedback during surgery, such as mediolateral balance in extension and flexion gap, alignment of the lower limb, and components. On the other hand, the computer-assisted navigation system requires an additional stab wound for tracker fixation, which can increase the likelihood of superficial wound infection and stress fractures and increase the operation time and cost of surgery. The clinical efficacy of computer-assisted navigation in total knee arthroplasty is also controversial. Compared to the conventional technique, computer navigation improves the accuracy of the postoperative mechanical axis within outliers of 3° varus or 3° valgus. This paper reviews the surgical technique, pitfalls, clinical and radiological outcomes, useful clinical cases, and future perspectives in computer-assisted navigation total knee arthroplasty.

Reliability and Validity of the Femorotibial Mechanical Axis Angle in Primary Total Knee Arthroplasty: Navigation versus Weight Bearing or Supine Whole Leg Radiographs

PURPOSE: To evaluate the reliability and validity of the femorotibial mechanical axis angle from radiographs in the weight bearing (WB) and supine positions compared with navigation-measured values. MATERIALS AND METHODS: Sixty-eight cases of navigation-assisted total knee arthroplasty (TKA) were included. The pre- and postoperative whole leg radiographs (WLRs) in WB and supine positions were compared with the initial and final navigation values. RESULTS: The mean mechanical axis angle from the preoperative WBWLR and navigation were not statistically different (p=0.079) and were correlated strongly with each other (intraclass correlation [ICC], 0.818). However, on postoperative measurements, although the WBWLR and navigation values were not different (p=0.098), they were not correlated with each other (ICC, 0.093). The standard error of measurement was 1.8°±3.6° for the preoperative WBWLR and 2.5°±4.8° for the postoperative WBWLR. The validity that was determined by the Bland-Altman plot was not acceptable for both pre- and postoperative measurements. CONCLUSIONS: The preoperative WBWLR could provide accurate but not precise measurement value of the femorotibial mechanical axis angle for navigation-assisted TKA, and postoperative measurements in navigation were not comparable with radiographic measurements. The lack of agreement was found between the radiographic and navigation measurements of the coronal alignment regardless of pre- or postoperative evaluation although the accuracy was found acceptable. LEVEL OF EVIDENCE: Level 4

Time-Dependent Clinical Results of Rotating-Platform Total Knee Arthroplasty According to Mechanical Axis Deviation

PURPOSE: We hypothesized that the low contact stress (LCS) posterior stabilization system in knees with 3degrees deviation). The clinical assessments were performed using the Knee Society score and Hospital for Special Surgery systems and Western Ontario and McMaster Universities index. RESULTS: The survival rate was 97.4% in Group 1 and 96.8% in Group 2. No statistically significant intergroup difference was observed in the clinical scores before surgery and since 1 year after surgery (p>0.05). However, a significant intergroup difference was noted between 6 months to 1 year after surgery (p<0.001). Less than 2 mm radiolucent lines were found more frequently in Group 2. Time-dependent improvement was noted within one year after TKA in both groups. CONCLUSIONS: Most of the expected improvements were achieved at 6 months after surgery in Group 1 and at 1 year after surgery in Group 2. The present study suggests that the LCS system yields time-dependent improvement regardless of coronal alignment deviation.

Arthroscopic Treatment of Septic Arthritis of the Hip in a Child: A Case Report / 대한고관절학회지

Recommended treatment options for acute septic arthritis in children include repeated aspiration, open arthrotomy, and arthroscopic drainage. However, reports of arthroscopic treatment of septic arthritis of the hip in a child are rare. We experienced a case of arthroscopic management of acute septic arthritis of the right hip joint in a three-year-old child using a 30degrees, 2.7 mm arthroscope for the ankle joint through manual traction without use of a traction table. The patient had complete range of motion in the right hip joint two weeks after surgery and recurrent infection was not observed at the final follow-up two years postoperatively.

Modified Tension Band Wiring Combined with Anti-Gliding Loop Augmentation Technique for the Treatment of Comminuted Patellar Fracture: Technical Note and Report of Early Results: Technical Note

In order to investigate the feasibility of a modified tension band combined with anti-gliding loop augmentation technique for the treatment of comminuted patellar fracture, 21 patients with comminuted patellar fracture were enrolled in this study. After the modified tension band wiring of patellar fracture, a cerclage wire was passed around the patella. Anti-gliding loops were made on the bending sites of Kirshner-wires. A knot was tied using both ends of the anti-gliding loops, and the cerclage wire was tightened using proximal knots. Bone union was achieved at 4.5+/-1.5 months postoperatively without nonunion. The Lysholm score was 87.1+/-2.8, and the range of motion of the knee was 2.1degrees+/-3.4degrees to 132.2degrees+/-6.5degrees at the last follow-up. The modified tension band combined with anti-gliding loop augmentation technique might be considered an alternative modification of modified tension band wiring for the treatment of comminuted patellar fracture.

Remnant Preservation is Helpful to Obtain Good Clinical Results in Posterior Cruciate Ligament Reconstruction: Comparison of Clinical Results of Three Techniques

BACKGROUND: The purpose of the present study was to compare the clinical results of 3 posterior cruciate ligament reconstruction techniques according to the time from injury to surgery and remnant PCL status and to evaluate the efficiency of each technique. METHODS: The records of 89 patients who underwent primary PCL reconstructions with a posterolateral corner sling were analyzed retrospectively. Thirty-four patients were treated by anterolateral bundle (ALB) reconstruction with preservation of the remnant PCL using a transtibial tunnel technique in the acute and subacute stages of injury (group 1). Forty patients were treated with remnant PCL tensioning and an ALB reconstruction using the modified inlay technique in the chronic stage (group 2), and fifteen patients were treated with double-bundle reconstruction using the modified inlay technique (group 3). The double-bundle reconstruction was performed if there was a very weak or no PCL remnant. RESULTS: The mean side-to-side differences in posterior tibial translation on the stress radiographs were reduced from 10.1 +/- 2.5 mm in group 1, 10.6 +/- 2.4 mm in group 2, and 12.8 +/- 3.2 mm in group 3 preoperatively to 2.3 +/- 1.4 mm in group 1, 2.3 +/- 1.5 mm in group 2, and 4.0 +/- 2.5 mm in group 3 at the last follow-up (p < 0.001, p < 0.001, and p < 0.001, respectively). Statistical analyses revealed that group 1 and group 2 were similar in terms of side-to-side difference changes in posterior tibial translation on the stress radiographs; however, group 3 was inferior to group 1 and group 2 at the last follow-up (p = 0.022). The clinical results were not significantly different among the three groups. CONCLUSIONS: Excellent posterior stability and good clinical results were achieved with ALB reconstruction preserving the injured remnant PCL in the acute and subacute stages and remnant PCL tensioning with ALB reconstruction in the chronic stage. The PCL injuries could be surgically corrected with different techniques depending on both the remnant PCL status and the interval between the knee trauma and operation.

Is It a Simple Stress Fracture or Bisphosphonate-related Atypical Fracture?

A number of reports regarding atypical fractures of the femur have raised questions concerning the possible correlation between long-term bisphosphonate treatment and the occurrence of insufficiency fractures in the proximal femur. However, clinically, it is often confused whether is it a fatigue fracture because of implant induced stress concentration or a bisphosphonate-related atypical fracture, especially in a patient with a subtrochanteric fracture who receive bisphosphonate therapy after open reduction and internal fixation, such as dynamic hip screw (DHS) fixation for previous ipsilateral femoral neck or intertrochanteric fracture. The authors experienced a case of a progressive femoral insufficiency fracture in a woman who had been on Fosamax (Alendronic acid with Vitamin D; Merck & Co. Inc, NJ, USA) therapy for four years after ipsilateral femoral neck fracture treated with a two hole DHS system. Despite a high suspicion of an insufficiency femoral subtrochanteric fracture by bone scan, the occult fracture progressed to a displaced femoral subtrochanteric fracture one year after. The fracture site was fixed with a 6 hole DHS plate, and six months after reoperation the patient had no symptoms and the fracture site had united without any complication.

Antibiotic-impregnated Cement Plate for the Treatment of Infected Periprosthetic Femoral Fracture after Cementless Total Hip Arthroplasty: A Case Report / 대한고관절학회지

A 62-year-old man with an infected periprosthetic femoral fracture, which occurred after a cementless total hip arthroplasty (THA) procedure, was treated utilizing an antibiotic-impregnated cement plate for internal fixation. Open reduction and internal fixation using a cable plate were initially attempted in his case, but a deep infection with methicillin-resistant staphylococcus epidermidis at the fracture site occurred 2 months after the initial cable plate procedure. Using an antibiotic-impregnated cement plate for internal fixation, one month later, the fracture had stabilized. Successful fusion occurred at 12 months after deploying the antibiotic-impregnated cement plate. This technique was useful in this complicated case because it facilitated the goals of eradicating infection, alleviating pain, and improving function.

Rehabilitation after Anterior Cruciate Ligament Reconstruction

The purpose of postoperative rehabilitation after anterior cruciate ligament (ACL) reconstruction is to restore the knee joint function by recovering the joint stability and preventing postoperative complications, such as stiffness and patello-femoral problem. Many accelerated rehabilitation programs have been introduced in order to restore the knee joint function, and performed pre-and post-operatively. Pre-operative rehabilitation programs consistof preparing the operation mentally and physically, especially the patient education is the most important point of this step. Post-operative rehabilitations and methods of the ligament reconstruction should be explained and expectation of the patients also should be fully understood by the surgeon. The main purpose of rehabilitation is to acquire contentable range of motion by regulating painand swelling of the knee joint, and to prevent atrophy of quadriceps muscles. The fundamental concepts of the post-operative rehabilitation are early knee joint extension, early weight bearing and early recover of quadriceps muscle power of the knee joint. Passive knee extension should be achieved completely within 1 week post-operatively to prevent contracture of the posterior capsule and scaring of the femoral condylar notch, but if not attained at least 2 weeks, that could bring a poor outcomes. Partial weight bearing should be started immediately if not painful, and full weight bearing could be allowed after 4 weeks. Quadriceps muscle exercise including isometric contracture should begin to start at the first day after surgery because restoration of quadriceps muscle power is important for return to activity of daily living. Electrical muscle stimulation and biofeedback would be helpful to recover quadriceps muscle power by decreasing pain and swelling of the joint effectively. Two weeks after surgery, patients could begin closed kinetic chain exercise, after that, patients could exercise the quadriceps muscle more effectively adding open kinetic chain exercise. Recently, trainings for proprioception and neuromuscular control have been emphasized in orderto improve dynamic stability of the knee joint. Nowadays, variable post-operative rehabilitation programs are introduced for regain the knee joint function, and can be differed by types of graft, concomitant injuries, and especially methods of surgery, so should be performed individually, not by standardized program.

Calcifying Aponeurotic Fibroma: An Atypical Case

Calcifying aponeurotic fibroma is a very rare benign soft tissue tumor with predilection for the fingers and palms of children and adolescents. We describe an unusual case of a calcifying aponeurotic fibroma in old age that circumferentially involved the dorsal and palmar side of the third metacarpal head.We performed a wide excision using two incisions, resulting in satisfactory clinical result. A calcifying aponeurotic fibroma must be considered in the differential diagnosis of a calcifying soft tissue lesion occuring in the hand of old age.

A Case of Isolated, Localized Form, Pigmented Villonodular Synovitis of the Proximal Tibiofibular Joint

To the best of our knowledge, there have been no documented cases of isolated pigmented villonodular synovitis in the proximal tibiofibular joint in Korea. We have experienced satisfactory outcome by performing excision in a patient who has isolated, localized form, pigmented villonodular synovitis in the proximal tibiofibular joint. We report on this case along with briefly reviewing the related literature.

Cementless Bipolar Hemiarthroplasty for Treating Intertrochanteric Fracture in Elderly Patients

PURPOSE: To evaluate clinicoradiological outcomes after cementless bipoloar hemiarthroplasty in elderly patients with femoral intertrochanteric fractures. MATERIALS AND METHODS: From March 2006 to February 2008, 28 patients-all in patients greater than 80 years of age, classified unstable intertrochanteric fractures in Evans classification-were followed for more than 1 year. 24 patients were women and 4 patients were men. The mean age of the patients was 84.6 years, the mean follow-up period was 16.3 months. Harris hip score, postoperative inguinal and thigh pain, Parker and Palmer mobility score were analyzed clinically. The radiological results were assessed using various radiological indicies including bone-union, fit and alignment change of femoral stem and vertical subsidence. RESULTS: The average Harris hip score was 82.9, Parker and Palmer mobility score preoperative 8.0 changed to 5.2 postoperatively. More than moderate pain was presented in 1 case. There were no cases of varus deformity or osteolysis. All stems were stable without significant alignment change or subsidence except 1 case of periprosthetic fracture. There were no dislocation, thromboembolism, death during operation or hospital days. CONCLUSION: In elderly patients, cementless bipolar hemiarthroplasty is good treatment method of unstable intertrochanteric fracture and short-term clinicoradiological outcomes proved to be satisfactory.

Radiologic Analysis and Treatment of Posterior Malleolar Fractures of the Ankle

PURPOSE: The purpose of this study was to classify posterior malleolar fractures according to the position of fragments and to analyze radiologic features of each type. MATERIALS AND METHODS: We analyzed forty-six patients of ankle fractures involving a posterior malleolus who were treated between January 2004 and December 2007. The posterior malleolar fractures were categorized into three types (posterolateral, posteromedial, shell) based on the major fracture line. In each type, we analyzed amount of displacement, involvement of articular surface, existence of subluxation and osteochondral impacted fragments. RESULTS: The forty-six patients were categorized into three types: Posterolateral (PL) type (33 cases, 72%), Posteromedial (PM) type (8 cases, 17%), shell type (5 cases, 11%). Of the 8 cases with PM type, 7 cases showed displacement more than Grade II, 4 cases showed subluxation of ankle joint, and 3 cases showed osteochondral impacted fragment. Average involvement of articular surface of PM type is 35% (15~65%). CONCLUSION: Posterior malleolar fractures with medial extension tended to have adverse effect on ankle stability and Preoperative CT scan is essential for evaluation of fracture type and determination of appropriate surgical approach.

Long Term Follow up Results of the Operative Treatment of the Acromioclavicular Joint Dislocation with a Wolter Plate

PURPOSE: To evaluate the long-term clinical and radiological results of the operative treatment of the acromioclavicular dislocation with a Wolter plate. MATERIALS AND METHODS: We reviewed clinical and radiological data of twenty patients (mean age: 37 years) who underwent the operative treatment of acromioclavicular joint dislocation using a Wolter plate from September, 1999 to December, 2002 with minimum of five years follow-up (average 6 years 7 months). The clinical outcomes of twenty patients were evaluated by UCLA scoring and radiological results of fifteen patients with available radiograph were evaluated by Zanca view and stress view. RESULTS: The mean UCLA score was mean 33 points (range, 27~35) at final follow up. By clinical evaluation, twelve cases (60%) were excellent, six cases (30%) were good and two cases were poor (10%). By radiological evaluation, eight cases (54%) were excellent (without displacement), five cases (33%) were good (displacement 5 mm). Erosive change in acromioclavicular joint was seen in poor case. CONCLUSION: Wolter plate fixation may be a useful modality for treating acromioclavicular joint dislocation. Great care should be taken to make the hook hole at the appropriate position during operation for long-term prognosis.

The Treatment of Posterolateral Malleolar Fractures using Percutaneous Reduction Technique

PURPOSE: To evaluate the usefullness of the percutaneous reduction technique with K-wire that could reduce the displaced posterolateral fracture fragment which persisted even after an anatomical reduction of the lateral malleolar fracture. MATERIALS AND METHODS: From January 2004 to December 2006, we reviewed 72 patients who underwent surgical treatment for their trimalleolar fractures. We estimated the clinical and radiological results of 5 cases treated by percutaneous reduction technique with K-wire when more than the distal tibial articular step-off was left after reduction of the lateral malleolar fracture. The method of reduction starts with temporary fixation of lateral malleolar fracture followed by checking ankle radiographic image to confirm the accuracy of reduction. In case of incomplete reduction of the posterior fragment, a K-wire is inserted into the posterior fragment and pushed downward to the ankle joint level, and then lag screws were inserted. RESULTS: The average articular involvement by the posterolateral fracture fragment was 30.2%. The average step-off after reduction of the lateral malleolar fracture was 3.7 mm. At the final follow up, step-off was less than 2 mm in all cases. In clinical results by Baird and Jackson score, 3 out of 5 cases were excellent, other 2 were good. CONCLUSION: Percutaneous reduction technique for posterolateral fragment using the K-wire is relatively easy. This technique may be useful when the posterolateral fragment is large (more the 25% of articular surface) and not severely comminuted.

The Effect of COX-2 Inhibitor on the Expression of MMP-13 during Early Fracture Healing Phase in Rats

PURPOSE: This study investigated the effect of COX-2 inhibitor on the expression of MMP-13 in the healing process of fracture. MATERIAL AND METHODS: Adult Sprague-Dawley rats were divided into two groups of twenty five rats each. Unilateral femoral shaft fractures were created artificially under displacement in all two groups. COX-2 inhibitor was only given to the experimental group from the postoperative day 1. At 2 weeks after fracture the rats were sacrificed and the callus from each group was used for histologic examination and real time RT-PCR for MMP-13 expression. RESULTS: Histologically, proliferation of osteoblasts and formation of osteoid was less abundant in the experimental group. In real time RT-PCR, the mean expression of MMP-13 is 2.84+/-2.50 in the control group compared with 1.16+/-1.05 in the experimental group. CONCLUSION: In the early stage of fracture healing, COX-2 inhibitor suppress the expression of MMP-13.

Dual Plate Fixation Compared with Hybrid External Fixator Application for Complex Tibial Plateau Fractures

PURPOSE: To cmpare the clinical results of complex tibial plateau fractures treated by hybrid external fixation and dual plate fixation. MATERIALS AND METHODS: We studied forty patients with Schatzker type V and VI fractures respectively and selected twenty seven patients who were followed at least one year between January 2000 and December 2005. We evaluated the clinical results in which fourteen fractures with hybrid external fixation were compared with thirteen fractures with dual plate fixation. The clinical results were evaluated according to Knee Society Clinical Rating System and the statistical analysis was performed by Student t-test. RESULTS: There were no significant differences in terms of bone union time (average union time: dual plate fixation 13.8 weeks, hybrid external fixation 14.2 weeks). The quality of osseous reduction was superior in the fractures with dual plate fixation than those with hybrid external fixation. There were significant differences in functional score (average functional score: dual plate fixation 73, hybrid external fixation 62), but not in average knee score. CONCLUSION: The hybrid external fixation can be a useful modality for treatment of complex proximal tibial plateau fractures. But the good quality of the fracture reduction by dual plate fixation may be a indicator for favorable prognosis for satisfactory knee function.

Bipolar Clavicular Dislocation: A Case Report

Bipolar clavicular dislocation is simultaneous dislocation of both poles of the clavicle (mainly an anterior dislocation of the sternoclavicular joint and a posterior dislocation of acromioclavicular joint) and rarely reported. We report a case of bipolar claviclular dislocation after a seat belt injury and describe its presumed mechanism and treatment with a review of literature.

The Effect of Hyaluronic Acid on the Expression of MMP-13 in Healing Process of Bone Defect in Rats / 대한정형외과학회잡지

PURPOSE: Matrix metalloproteinase (MMP)-13 has a degradation effect on type II collagen and is expressed in osteoblastic cells and hypertrophic chondrocytes. However, the role of MMP-13 is not completely understood. This study investigated the effect of exogenous Hyaluronic acid (HA) on the expression of MMP-13 in the healing process of bone defects. MATERIALS AND METHODS: After making a bone defect in the metaphysis of the distal femur in rats, HA was instilled into the defect in the experimental group. In the control group, a bone defect was made but HA was not instilled. Two weeks after the experiment, the rats were sacrificed and the callus that filled the bone defects was obtained. A histological examination and real time reverse transcription polymeric chain reaction (RT-PCR) were performed to investigate the healing response and expression of MMP-13. RESULTS: Histologically, the proliferation of osteoblasts and the formation of osteoid were more active in the experimental group. Nevertheless, the level of MMP-13 expression was significantly lower in the experimental group than in the control group. CONCLUSION: From the results of this study, it appears that exogenous HA inhibits the expression of MMP-13 at the early stage of bone healing.