Closed Reduction of Irreducible Posterolateral Rotatory Knee Dislocation / 대한정형외과학회잡지

In general, most knee dislocations are reduced easily by simple traction. In rare cases, closed reduction of the knee dislocation is attempted, but ruptured ligaments or muscles are stuck in the joints and cannot be reduced. The cases of this irreducible knee dislocation have sometimes been reported. The authors encountered a case of irreducible knee posterolateral rotational dislocation that was not reduced by simple traction and report it along with a review of the literature. This case provides an opportunity for clinicians to examine the clinical considerations when experiencing an irreducible knee dislocation.

May–Thurner Syndrome with Deep Vein Trombosis after Total Knee Arthroplasty / 대한정형외과학회잡지

May–Thurner syndrome (MTS), also known as iliac vein compression syndrome, is a condition, in which compression of the commonvenous outflow tract of the left lower extremity can cause discomfort, swelling, pain or blood clots in the iliofemoral veins. The problemis due to left common iliac vein compression by the overlying right common iliac artery. This paper describes the case of a 75-year-oldfemale with MTS after performing right total knee replacement arthroplasty. The authors diagnosed MTS through intravenous angiographyand angiographic computed tomography on swelling and pain of the left lower extremities after performing right total knee replacementarthroplasty. The thrombus was removed using a thrombolytic agent and mechanical thrombectomy, and an intravenous stent then insertedafter angioplasty. No case of MTS after performing total knee replacement arthroplasty has been reported in Korea. Therefore, this case isreported along with review of the relevant literature.

A Comparison of the Results between Internal Fixation and External Fixation in AO C Type Distal Radius Fractures

PURPOSE: The purpose of this study was to evaluate the radiological and clinical results of plate fixation and external fixation with additional devices for treating distal radius fracture in AO type C subtypes, and propose a treatment method according to the subtypes. MATERIALS AND METHODS: Two hundred and one AO type C distal radius fracture patients were retrospectively reviewed. Eighty-five patients in group 1 were treated with volar or dorsal plate, and 116 patients in group 2, were treated with external fixation with additional fixation devices. Clinical (range of mtion, Green and O'Brien's score) and radiological outcomes were evaluated. RESULTS: At the 12-month follow-up, group 1 showed flexion of 64.4°, extension of 68.3°, ulnar deviation of 30.6°, radial deviation of 20.8°, supination of 76.1°, and pronation of 79.4° in average; group 2 showed flexion of 60.5°, extension of 66.9°, ulnar deviation of 25.5°, radial deviation of 18.6°, supination of 73.5°, and pronation of 75.0° in average. The mean Green and O'Brien score was 92.2 in group 1 and 88.6 in group 2. The radial height of group 1 and group 2 was 11.6/11.4 mm; radial inclination was 23.2°/22.5°; volar tilt was 11.6°/8.7°; and the ulnar displacement was 1.27/0.93 mm. CONCLUSION: Judicious surgical techniques during device application and tips for postoperative management during external fixation can produce similar clinical results compared with internal fixation patients.

Preliminary Examination for Apoptosis and Cell Proliferation Related to Aging Process in the Anterior Cruciate Ligament Cells of the Human Degenerative Arthritic Knee Joint / 대한정형외과학회잡지

PURPOSE: We investigated the association between aging-induced apoptosis and cell proliferation in the anterior cruciate ligament (ACL) of aged patients. MATERIALS AND METHODS: Twenty patients with osteoarthritis who underwent total knee replacement arthroplasty were enrolled in the study. They were divided into three groups according to age: group A ( or =76 years). The ACL tissue was obtained intraoperatively and subjected to terminal deoxynucleotidyl transferase dUTP nick-end labeling staining and immunohistochemistry to quantify the apoptosis and cell proliferation indices. RESULTS: Apoptosis occurred in all groups, with the highest apoptosis index found in group C, followed by that in groups B and A. A statistically significant positive linear correlation was observed, with a 1-year increase in age resulting in an average increase of 1.49 in the apoptotic index. The lowest cell proliferation index was observed in group C, followed by that in group B and group A, with a 1-year increase in age resulting in an average decrease of 1.0 in the cell proliferation index, which was a statistically significant negative linear correlation. Consequently, a statistically significant negative correlation was confirmed between the apoptosis and cell proliferation indices, whereby an increase of 1.0 in the apoptosis index was concurrent with a decrease of 0.45 in the cell proliferation index. CONCLUSION: Apoptosis occurred in the ACL of human knee joint. With increasing age, apoptosis increased and cell proliferation decreased.

Secondary Aneurysmal Bone Cystic Change of the Chondroblastoma, Mistaken for a Primary Aneurysmal Bone Cyst in the Patella

A 29-year-old woman complained of a 3-month history of left knee pain without trauma history. X-ray showed a well-defined osteolytic lesion with a sclerotic margin in the patella and magnetic resonance imaging showed T1-low and T2-high signal intensity with different fluid level. Our impression was an aneurysmal bone cyst. At surgery, the lesion was a blood-filled cystic cavity, surrounded by a gray or brownish tissue. Hemorrhagic soft tissues with recognizable bone fragments were observed. Curettage and autogenous bone graft was done. Microscopically, sheets of tumor cells were intermingled with some areas of eosinophilic chondroid matrix. The tumor cells showed oval-shaped nuclei with moderate eosinophilic cytoplasm. Several multinucleated giant cells and blood filled cystic cavities were observed. The final diagnosis was a chondroblastoma with a secondary aneurysmal bone cyst. At the post-operative 1.5-year follow-up, grafted bones were well incorporated radiographically and there were no recurrent evidence or any other abnormal symptoms.

Weil Osteotomy for Freiberg's Disease / 대한족부족관절학회지

PURPOSE: The aim of this study was to evaluate the result of combined Weil and dorsal closing wedge osteotomy for Freiberg's disease. MATERIALS AND METHODS: We performed combined Weil and dorsal closing wedge osteotomy of the second metatarsal under the diagnosis of Freiberg's disease in 7 patients, 7 feet (2 male and 5 female). The mean age at the time of operation was 29 years and the mean follow-up period was 31 months. Patients had no trauma history and no combined deformity of the foot. The surgical results were evaluated by VAS and weight bearing radiographs in antero-posterior and oblique projection. RESULTS: According to Smillie staging system, there were 1 of stage II, 2 of stage III and 4 of stage IV patients. The osteotomy site was united at 8 weeks and the second metatarsal was shortened in length of average 2.8 mm. Remodeling of the metatarsal head was observed at 24 months. The mean VAS was decreased from 8.2 points preoperatively to 2.7 points at follow-up. And average range of motion of second metatarso-phalangeal joint was increased from 30o preoperatively to 45o at follow-up. There was no transfer metatarsalgia or arthritis of the metatarsal head during follow-up. CONCLUSION: Combined Weil and dorsal closing wedge osteotomy of the metatarsal appears to be an effective procedure for the treatment of Freiberg's disease with a view to shortening of metatarsal length and elevation of metatarsal head.

Growth Differentiation Factor 5 (GDF5) Core Promoter Polymorphism Is Not Associated with Susceptibility to Osteoarthritis of the Knee in the Korean Population

BACKGROUND: Osteoarthritis (OA) is a common disease characterized by degenerating joint cartilage in the knee, hip, and hand. A functional single nucleotide polymorphism (SNP) +104T/C; rs143383 in the 5' untranslated region of the growth differentiation factor 5 (GDF5) gene was recently associated with susceptibility to OA in the Japanese and Chinese populations. METHODS: To investigate whether this association is present in the Korean population, the frequency of the polymorphism was investigated in 276 patients with knee OA and 298 healthy subjects as controls. Polymorphism analysis was performed by amplifying the core promoter region of the GDF5 gene and digesting it with the BsiEI restriction enzyme. RESULTS: The frequency of the TT, CT, and CC genotypes was 54.3% (150/276), 41.7% (115/276), and 4.0% (11/276), respectively, in patients with OA, and 53.4% (159/298), 37.9% (113/298), and 8.7% (26/298), respectively, in healthy controls. No significant differences in genotypic or allelic frequencies of the +104T/C SNP of the GDF5 gene were observed between patients with OA and controls. Also, no significant differences in allelic and genotypic frequencies were found when the individuals were stratified by age and gender. CONCLUSIONS: The results suggest that the +104T/C; rs143383 GDF5 core promoter polymorphism is not a risk factor for OA in the Korean population.

Effect of early oral intake on postoperative bowel function in patients undergoing lower extremities surgery under epidural anesthesia / 대한마취과학회지

BACKGROUND: Early oral intake (EOI) associated with early recovery of normal bowel function has been shown to be an important determinant for improving patients' satisfaction. We investigated the tolerability of EOI and its effects on the recovery of bowel function after epidural anesthesia. METHODS: A prospective randomized trial of patients undergoing lower extremities surgery under epidural anesthesia was performed. A liquid drink was given to 150 patients in the EOI group 1 hours after surgery, and to 150 patients in the delayed oral intake (DOI) group 8 hours after surgery. We recorded presence of bowel sounds immediately after operation, symptoms of ileus, time to the first flatus, time to the first defecation, degree of appetite before the first meal, and patients' satisfaction. RESULTS: There was no significant difference in the presence of immediate postoperative bowel sounds, the degree of appetite before the first meal, mild ileus, and severe ileus between groups. Time to the first flatus and time to the first defecation in the EOI group were shorter than those of the DOI group. The patients' satisfaction in the EOI group was higher than that of the DOI group. CONCLUSIONS: For uncomplicated patients undergoing lower extremities under epidural anesthesia, beginning oral hydration as early as 1 hour after the operation is safe and well tolerated and resulting in faster recovery of bowel function and higher patients' satisfaction.

Matrix Metalloproteinase-2 Expression of the Injured Anterior Cruciate Ligament in the Knee and Changes in Relation to Signal Transduction Pathways / 대한정형외과연구학회지

PURPOSE: This study was designed to pursue the basic relationship between MMP-2 and ligament injury via ex vivo stretching of the anterior cruciate ligament (ACL) and its changes by signal transduction pathway. MATERIALS AND METHODS: After femur-ACL-tibia complex was harvested from rats, release of MMP-2 in stretch group and non-stretch group was checked using gelatin zymography. Firstly, authors investigated whether MMP-2 was released from the ligament or not and if so, how long it was released. In addition, the complexes were divided into two groups. In group I, 5 and 12N weights were used to stretch the complex for 10, 30, and 60-minute. In group II, after the ligament complexes were stretched by 15N for 30 minutes, various signal pathway inhibitors such as pertusis toxin, SP600125, PD98059, KT5720, curcumin, and Bay11-7082 were added to their supernatants. MMP-2 activity was evaluated. RESULTS: MMP-2 was immediately released after ligament injury and its activity was increased in proportion to stretching duration and magnitude. As for the signal pathways, inhibition of JNK, ERK, AP-1, and NF-k beta pathways caused MMP-2 expression to be decreased. CONCLUSION: It is considered that the release of MMP-2 plays an important role in remodeling process after ACL injury.

Matrix Metalloproteinase(MMP)-2 Expression Related to Stretch Injury of the Anterior Cruciate Ligament in the Knee / 대한정형외과학회잡지

PURPOSE: Tissue remodeling is essential for the natural healing of damaged tissue. The matrix metalloproteinases (MMPs) that degrade the extracellular matrix to play a central role in this process. This study was designed to examine the basic relationship between MMP-2 and anterior cruciate ligament (ACL) injury. MATERIALS AND METHODS: After the femur-ACL-tibia complex was harvested from rats, the continuous release of MMP-2 in the stretch group was evaluated. The complexes were divided into three groups. To stretch the complexes, in group I, 5 and 12 N weights were used for 10, 30, and 60 minutes. In group II, 5 and 15 N weights were used for 5, 10, 30, 60, and 120 minutes. And in group III, 5, 8, 10, 12, and 15 N weights were used for 30 and 60 minutes. MMP-2 activity was evaluated using 0.05% gelatin zymography. RESULTS: MMP-2 was expressed and the signal intensity was increased according to the stretch duration and magnitude. In the tissue analysis, active MMP-2 was markedly present and the expression was increased in response to the stretch in the supernatant samples. CONCLUSION: MMP-2 was released immediately after ligament injury and its activity was increased in proportion to the stretch duration and magnitude. It is believed that MMP-2 expression plays an important role in the remodeling process after an ACL injury.

Effectiveness of Patellar Replacementin Total Knee Arthroplasty : Randomized, Prospective Study using Simultaneous Bilateral Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study evaluated the clinical and radiological results of a randomized clinical trial of patella resurfacing. MATERIALS AND METHODS: A blinded, prospective study was carried out for 20 patients who underwent bilateral TKA with one patellar side being resurfaced from Jan. 2002 to Jun. 2003. The clinical results were assessed using the knee society clinical rating system, patellar score and patient-satisfaction score. Radiologically, patellofemoral congruency was assessed by measuring the patellar displacement in the skyline view. RESULTS: There were no significant differences between the resurfaced and non-resurfaced knees with respect to the overall knee society knee scores or the patellar scores. In the patient-satisfaction scale, 2 out of 4 knees with anterior pain postoperatively were unsatisfactory to the patients. The average patellar congruency in the non-resurfacing/resurfacing group was 98.8%/98%. CONCLUSION: The clinical and radiological results after TKA were not associated with patellar resurfacing. It appears that a variety of factors such as preoperative anterior knee pain, pathological lesion and alignment of patella, and the surgical technique are related to the postoperative results.

The Effect of the Epidermal Growth Factor(EGF) on the Healing of the Injured Anterior Cruciate Ligament of the Knee in Dog: in Vivo Study / 대한정형외과연구학회지

PURPOSE: The purpose of this study is to find out the possibilities of the new treatment via continuous stimulation by photo-immobilization of growth factor in the anterior cruciate ligament(ACL) injury. MATERIALS AND METHODS: Photo-reactive epidermal growth factor(EGF-Az) synthesized by conjugating EGF with N-(4-azidobenzoyloxy)succinimide was immobilized onto biodegradable tissue-regenerative mesh(Bio-Mesh(R)) using UV irradiation. We sutured the BioMesh containing photo-reactive EGF on the artificial defect area of ACL in the left knee of beagle dogs and sutured the BioMesh that was not treated with EGF-Az on the defect area of ACL in the right knee. Four weeks later, we obtained the tissues from the defect area of both ACLs and compared the results of HE stain, immunohistochemistry and RT-PCR in both tissues. RESULTS: In results of HE stain and immunohistochemistry, we observed better cellular proliferation and more definite spindle shape of cells in EGF-immobilized area than in non-EGF defect area. Also cellular density was higher in EGF-immobilized area. On the other hand, cells had shaped more round and cellular density was lower in non-EGF defect area. In results of RT-PCR of GAPDH(Glyceraldehyde-3-phosphate dehydrogenase), COL I(Collagen type I), COL III and EGF, except for TGF-beta1(Transforming growth factor-beta 1), we also observed more definite expressions in EGF-immobilized area than in non-EGF defect area. CONCLUSION: We were able to confirm rapid cellular proliferation via artificial stimulation effect induced by photo-immobilized EGF. If EGF is immobilized onto biodegradable materials for clinical application, it will contribute to the treatment of ACL injury.

Parosteal Lipoma of the Tibia: A Case Report / 대한정형외과학회잡지

We experienced a very rare case of parosteal lipoma, which was situated on the adjacent periosteum of the tibia with hyperostosis, as a bony reaction without due causes and mimicking parosteal osteosarcoma or osteochondroma in a 30 year old Korean housewife. The hyperostosis was limited on the cortex with no connection to the medullary canal. We reported the case because of it's rarity, and its specific magnetic resonance image findings. No local recurrence was observed in 14 months after marginal excision.

The Effect of the Photo-immobilized Epidermal Growth Factor on the Proliferation of the Anterior Cruciate Ligament Cell of the Knee / 대한정형외과연구학회지

PURPOSE: The purpose of this study is to find out the possibilities of the early treatment via artificial juxtacrine stimulation by photo-immobilization of growth factor in the anterior cruciate ligament (ACL) injury. MATERIALS AND METHODS: Photo-reactive Epidermal Growth Factor (EGF-Az) was synthesized by conjugating EGF with N-(4-azidobenzoyloxy)succinimide and was immobilized onto the polystyrene culture plates by UV irradiation. Human ACL cells (1 x 10 5 cells/ml , 100 m l /well) were cultured with serum free media in each group (group 1 : no EGF, group 2 : native EGF 2 m g /ml , group 3 : 50 m l EGF-Az immobilization, group 4 : 100 m l EGF-Az immobilization). We observed the changes of cells with long-term culture and compared the difference of cellular response of EGF-treated and non-treated groups. To examine the cellular migration, in vitro wound closure assay was performed. RESULTS: Cells were proliferated for 3 days. It was not changed significantly after that time. Cellular growth was more remarkable in the photo-immobilized EGF group. In cell migration test, the defect site in the photo-immobilized group was indistinguishable from the non-scratched area after culture for 72 hours, while cellfree area was still clearly visible in the no EGF group. CONCLUSION: Photo-immobilized EGF induce rapid proliferation of fibroblasts via artificial juxtacrine stimulation. If EGF is immobilized onto bioabsorbable materials such as polyglycolic acid or polylactic acid for clinical application, it will contribute to the treatment of ACL.

Intraosseous Ganglion of Both Patellae: A Case Report

An intraosseous ganglion cyst, of which pathogenesis is unclear, is grossly and histologically identical to soft tissue ganglion. It predominates in the subchondral regions of tubular bones and is an osteolytic lesion that is well demarcated, radiographically. Pathologically, it is composed of a multilocular, thick, fibrous walled cyst-like structure filled with a slimy, mucin rich fluid. Curettage or curettage with bone graft is usually curative. Authors experienced a case diagnosed as intraosseous ganglia of both patellae. A 37-year-old man complained of both knee joint pains for about 4 month. About 1 year ago prior to this visit, he was treated one time because of the anterior knee pain. In the following X-rays, a well-defined osteolytic lesion involving the subchondral area of both patellae was showed. After CT and bone scan-ning, excision biopsy with curettage was performed. The thick, jelly-like mucinous fluid oozed out. His-tological findings were consistent with an intraosseous ganglion cyst. At 8 months follow-up, pain was completely resolved and other abnormal findings were not observed clinically.

Localized Pigmented Villonodular Synovitis of the Knee: A Case Report

Pigmented villonodular synovitis (PVNS) is a benign proliferative disorder of the synovium of joints. It occurs most commonly in the knee joint. The disease presents in two forms: diffuse or localized. The diffuse form of PVNS involves virtually the entire synovial lining of the affected joint. The localized form of PVNS is a rare pathologic entity characterized by a limited involvement of the synovium and generally presented as a nodular, pedunculated lesion protruding into the articular cavity. The lesion of localized form of PVNS is usually easily identified with arthroscopy and can be removed arthroscopically, We expreienced a patient who was diagnosed as localized PVNS, whose main symptoms were pain and mass on the medial side of the knee joint. On physical examination, there were no abnormal evidences. So, diagnostic arthroscopy was performed, and typical findings of localized PVNS were identified. Complete removal of the lesion was done arthroscopically. Postoperatively, the patient was completely symptom free.

Cementless Total Knee Arthroplasty and Effects of Disease Modifying Anti-Rheumatic Drugs in Rheumatoid Arthritis / 대한정형외과학회잡지

PURPOSE: We reviewed patients with rheumatoid arthritis to evaluate the results of cementless total knee replacement and the effects of Disease Modifying Anti-Rheumatoid Drugs. MATERIALS AND METHODS: The results of 59 cementless total knee arthroplasty in 35 patients were retrospectively analyzed. Cases were divided into two groups: one was treated with Disease Modifying Anti-Rheumatic Drugs and the other without them. Clinical and radiological outcomes were evaluated using the Knee Society clinical rating system and Knee Society roentgenographic evaluation and scoring system, respectively. RESULTS: At the most recent follow-up, femoral flexion angle, tibial angle and total valgus angle in anteroposterior view were 97.1, 89.1 and was 7.6. Femoral flexion angle and tibial angle in lateral view were 3.0 and 91.0. There were no statistical differences as compared with the postoperative values. There were also no statistical differences between the two groups. Knee score and function score of all cases were 85.5 and 67.6. Those of the group treated with Disease Modifying Anti-Rheumatic Drugs were 90.9 and 78.1. Those of the group without them were 74.0 and 45.5. CONCLUSIONS: Results of the cementless total knee arthroplasty in rheumatoid arthritis are very promising and Disease Modifying Anti-Rheumatic Drugs have an effect on the postoperative clinical results.

Ganglion of the Cruciate Ligament of the Knee / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical characteristics of ganglia of the cruciate ligament of the knee. MATERIALS AND METHODS: We retrospectively analyzed the clinical symptoms and signs, magnetic resonance findings, arthroscopic findings and operative results of 14 patients. RESULTS: The most common complaint was pain. McMurrays test was negative and instability was not identified. Limitation of motion was observed in 7 cases. In the remaining 7 patients who had no limitation, pain was caused by hyper-flexion or hyper-extension. Most ganglia (11 of 14) arose from the femoral insertion side of the cruciate ligament. Treatment methods were arthroscopic drainage in 11 of the cases and open excision in the remaining cases. Irrespective of treatment methods, all patients gained full range of motion without pain and returned to their preoperative jobs within 3-4 weeks. CONCLUSIONS: When patients complain of limitation of motion or pain on hyper-flexion and/or hyper-extension without trauma, a ganglion of the cruciate ligament should be considered if there is no instability nor negative findings on McMurray's test. Magnetic resonance imaging is diagnostic in confirming the lesion. Arthroscopic drainage of the ganglia is useful in treating the symptomatic patient with ganglia of the knee.

Sparganosis in Subcutaneous Tissue of Thigh: A Case Report / 대한정형외과학회잡지

A case of rare subcutaneous sparganosis in thigh treated by surgical excision is reported. In this 49year-old male with a palpable mass on the anteromedial aspect of mid-thigh (5x7x5cm sized) which was misdiagnosed with a soft tissue tumor initially, a sparganosis was suspected by a plain x-rays, bone scan and his past history which he frequently had raw snakes, frogs and raw fishes before but confirmed by MRI and surgical excision. This represents tor warning to some Koreans who have frequently comsumed raw fishes, snakes or frogs etc., and to some doctors because it is easily confused with a soft tissue tumor.

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.