Meniscal Ossicle / 대한정형외과학회잡지

Meniscal ossicle of the knee, an ossified tissue formed within the meniscus, is rare in humans. We experienced a case of a 48-year-old male with no history of trauma, who presented with intermittent locking symptoms and knee pain upon standing. The patient was diagnosed with meniscal ossicle and cartilage lesion in the medial femoral condyle accompanied by a medial meniscus posterior horn radial tear and treated with arthroscopic resection and microfracture. Therefore, we report on this case with relevant literature.

Risk of Anterior Femoral Notching in Navigated Total Knee Arthroplasty

BACKGROUND: We retrospectively investigated the prevalence of femoral anterior notching and risk factors after total knee arthroplasty (TKA) using an image-free navigation system. METHODS: We retrospectively reviewed 148 consecutive TKAs in 130 patients beginning in July 2005. Seventy knees (62 patients) underwent conventional TKA, and 78 knees (68 patients) received navigated TKA. We investigated the prevalence of femoral anterior notching and measured notching depth by conventional and navigated TKA. Additionally, the navigated TKA group was categorized into two subgroups according to whether anterior femoral notching had occurred. The degree of preoperative varus deformity, femoral bowing, and mediolateral suitability of the size of the femoral component were determined by reviewing preoperative and postoperative radiographs. The resection angle on the sagittal plane and the angle of external rotation that was set by the navigation system were checked when resecting the distal femur. Clinical outcomes were compared using range of motion (ROM) and the Hospital for Special Surgery (HSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAX) scores between the two groups. RESULTS: The prevalence of anterior femoral notching by conventional TKA was 5.7%, and that for navigated TKA was 16.7% (p = 0.037). Mean notching depth by conventional TKA was 2.92 +/- 1.18 mm (range, 1.8 to 4.5 mm) and 3.32 +/- 1.54 mm (range, 1.55 to 6.93 mm) by navigated TKA. Preoperative anterior femoral bowing was observed in 61.5% (p = 0.047) and both anterior and lateral femoral bowing in five cases in notching group during navigated TKA (p = 0.021). Oversized femoral components were inserted in 53.8% of cases (p = 0.035). No differences in clinical outcomes for ROM or the HSS and WOMAX scores were observed between the groups. A periprosthetic fracture, which was considered a notching-related side effect, occurred in one case each in the conventional and navigated TKA groups. CONCLUSIONS: Surgeons should be aware of the risks associated with anterior femoral notching when using a navigation system for TKA. A modification of the femoral cut should be considered when remarkable femoral bowing is observed.

Compartment Syndrome of the Thigh Following Manipulation to Treat Knee Stiffness after Total Knee Arthroplasty / 대한정형외과학회잡지

A 67-year-old man developed compartment syndrome of the thigh following manipulation for treatment of knee stiffness after a total knee arthroplasty. Three months earlier, he had undergone arthroscopic synovectomies twice for treatment of septic arthritis in the same leg. Manipulation for treatment of stiffness concomitant with periarticular inflammation is a possible risk factor of compartment syndrome.

Clinical Results after Medial Opening Wedge High Tibial Osteotomy in Medial Compartment Osteoarthritis of the Knee: TomoFix(R) versus Aescula(R) Plates / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the clinical and radiologic results of medial open wedge high tibial osteotomy (HTO) using either TomoFix(R) plate (group A) or Aescula(R) plate (group B) in patients with medial compartment osteoarthritis. MATERIALS AND METHODS: Sixty-four consecutive patients who underwent HTO for medial compartmental osteoarthritis from 2008 were included. Mean follow-up duration was 37.1 months. Twenty men and 44 women with a mean age of 50 years (range, 41 to 62 years) were divided into group A (locking plate, n=20) and group B (spacer plate, n=44). Clinical results were evaluated using knee society rating system (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiological results were obtained by measuring the mechanical axis, posterior tibial slope, and medial joint space width preoperatively, 3 months postoperatively, and at the final follow-up. RESULTS: In overall patients, the mechanical axis was corrected from 7.8degrees+/-2.4degrees of varus preoperatively to 1.9degrees+/-2.2degrees of valgus 3 months after HTO. At the final follow-up, the mechanical axis was to 2.1degrees+/-3.1degrees of valgus which showed no statistical difference in group A. However, loss of correction was observed at the final follow-up, at 0.1degrees+/-3.1degrees of valgus angulation in group B. The increase of the posterior tibial slope was significantly greater in group A than group B. The joint space width in both groups was improved at last follow-up. All clinical results showed improvement after HTO, with significantly improved KSS and WOMAC scores (p<0.001). CONCLUSION: The overall clinical results after HTO for medial compartment osteoarthritis were satisfactory. A group of spacer plates needed for prolonged protective weight bearing and locking plate was effective in maintenance of correction.

A Tenosynovial Giant Cell Tumor Arising from Femoral Attachment of the Anterior Cruciate Ligament

The localized type of tenosynovial giant cell tumor usually occurs on the palmar side of fingers and toes. Tenosynovial giant cell tumors of the tendon sheath are rarely intra-articular. We report a giant cell tumor of the tendon sheath arising from femoral attachment of the anterior cruciate ligament and its treatment with arthroscopy in a 28-year-old man.

Correlation between Femoral Tunnel Location in Three-Dimensional Computed Tomography and Femoral Tunnel Angle in Plain Radiographs after Single-Bundle Anterior Cruciate Reconstruction / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to determine correlation between femoral tunnel angle in the coronal plane on a simple radiograph and femoral tunnel location in the sagittal plane on three-dimensional computed tomography (3D-CT). MATERIALS AND METHODS: The subjects included 42 patients who underwent 3D-CT after the operation out of 70 cases of anterior cruciate ligament reconstruction using quadriceps tendon-patelllar bone autograft from April, 2009 to June, 2011. Measurement of the femoral tunnel angle was based on the anatomical axis of the femur in antero-posterior (AP) and Rosenberg views; femoral tunnel location was described as a proportional percentage on the medial surface of the lateral femoral condyle in the 3D-CT image; then the correlation between femoral tunnel angle and femoral tunnel location was analyzed retrospectively. RESULTS: Femoral tunnel angle was 41.5degrees+/-6.8degrees (range: 29.7degrees-53.9degrees) on AP radiographs, and 34.9degrees+/-6.9degrees (range: 23.8degrees-46.5degrees) on Rosenberg views. The femoral tunnel was located 36.9%+/-11.3% from posterior, and 38.1%+/-6.5% from proximal on the 3D-CT image. On plain AP radiographs, femoral tunnel angle and femoral tunnel location showed negative correlation (p<0.001, rho=-0.498), and, in comparison with Rosenberg view, they showed negative correlation (p=0.006, rho=-0.416). Twenty three patients (53.5%) had femoral tunnel in the anatomical location. Their femoral tunnel angle on AP radiographs was 43.3degrees+/-6.1degrees, while the femoral tunnel angle of patients who had femoral tunnel in non-anatomical locations was 38.4degrees+/-6.4degrees (p=0.004). In the Rosenberg picture, similar difference was observed between the two groups (p=0.012). CONCLUSION: On AP radiographs and Rosenberg views, femoral tunnel angle showed significant correlation with the femoral tunnel location on the 3D-CT image, and the group who had femoral tunnel location in the anatomical range showed a relatively higher femoral tunnel angle.

Epidural Abscess Following Epidural Catheterization for Painless Mobilization after Total Knee Arthroplasty / 대한정형외과학회잡지

Epidural analgesia is one of the effective methods for pain management after total knee arthroplasty. Although epidural analgesia has been reported to have very low epidural abscess rates, infection could be serious and life-threatening, if there is no early diagnosis and treatment. We report on a patient who developed an epidural abscess following epidural catheterization after total knee arthroplasty.

Correlation of Histological Examination of Meniscus with MR Images: Focused on High Signal Intensity of the Meniscus Not Caused by Definite Meniscal Tear and Impact on MR Diagnosis of Tears

OBJECTIVE: To document the causes of high signal intensity of the meniscus which is not caused by definite meniscal tears on MR imaging, through correlation with histological examination. MATERIALS AND METHODS: For the correlation between the MR image and histology, we obtained prospectively 31 meniscal specimens from 21 patients. Proton density-weighted turbo spin-echo MR images were used. Minimal tear, thinning of the lamellar layer, degeneration of the central layer, and radial tie fibers were detected upon histological examination, and were correlated with the corresponding MR images. RESULTS: Minimal tear of the lamellar layer was seen in 60 zones out of 100 slides. On MR images, 29 (48.3%) of these 60 zones had high signal intensity. Thinning of the lamellar layer was seen in 24 zones, with 7 (29.2%) having high signal intensity. 57 central zones showed degenerative change in the central layer and high signal intensity on all corresponding MR images. Radial tie fibers in the central layer appeared as high signal intensity areas. CONCLUSION: Minimal tear and thinning of the lamellar layer, degeneration and radial tie fibers of the central layer of the meniscus cause high signal intensity on MR images.

Arthroscopic Treatment for Osteoarthritic Knee

Arthroscopic treatment for osteoarthritis of the knee has been widely performed as one of the surgical options, in spite of persisting concerns regarding its efficacy. Arthroscopic debridement is a general term that is used to cover many procedures, including lavage, partial meniscectomy, removal of loose body, synovectomy, chondroplasty, removal of offending osteophytes, and/or microfracture. Recently, the role of arthroscopy in managing the osteoarthritic knee has been challenged by elusive consensus on its usefulness. Therefore, we review the available literatures for the arthroscopic intervention in knee osteoarthritis and summarized evidences for proper patient selection, which is a paramount factor to achieve the surgical goal of the arthroscopic treatment in osteoarthritic knee.

Acute Compartment Syndrome in Association with Spontaneous Muscle Infarction / 대한정형외과학회잡지

Diabetic muscle infarction is a rare complication of diabetes mellitus that is not clearly defined in the orthopedic literature. In addition, acute compartment syndrome in association with diabetic muscle infarction is a rarer disease, which has had only a few cases have been reported up to date. A large and painful swelling was noticed in the thigh of a 55-year-old female, who had not experienced trauma. The patient was diagnosed as having compartment syndrome with diabetic muscle infarction by magnetic resonance imaging. The patient underwent immediate fasciotomy, and recovered without any complications.

The Pattern of Use of Oral NSAIDs with or without Co-prescription of Gastroprotective Agent for Arthritic Knee by Korean Practitioners

PURPOSE: The aim of this study was to describe the patterns of use of non-steroidal anti-inflammatory drugs (NSAIDs) for arthritic knees in clinical practice, particularly focusing on the co-prescription of gastroprotective agents for patients with risk factors for adverse gastrointestinal (GI) events. MATERIALS AND METHODS: Each cross-sectional cohort was a group of outpatients visiting 111 physicians who had prescribed NSAIDs for the patients' arthritic knees for more than three consecutive months. A self-administered questionnaire was completed by each patient and physician. RESULTS: Nine hundred and forty five patients (48%) of the whole 1,960 patients belonged to the group with a high or very high risk for NSAID-induced gastropathy determined by northern California Health Maintenance Organization guidelines. Overall, only less than half of the patients were given co-prescription of gastroprotective agents, regardless of the presence or absence of GI symptoms and irrespective of the level of risk for NSAID-induced gastropathy. CONCLUSIONS: The physician prescribing NSAIDs for arthritic knees should monitor any GI symptoms and the patient monitor anylevel for NSAIDinduced gastropathy, and be willing to add gastroprotective agents as necessary in order to prevent serious adverse GI events.

Open Repair of Acute Tibial Avulsion Injury of Posterior Cruciate Ligament: Clinical Outcomes and Usefulness of Preoperative 3-D CT / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical outcome of open repair of acute tibial posterior cruciate ligament (PCL) tibial avulsion injury using the posteromedial approach, and to examine the usefulness of pre-operative 3D-computed tomography (CT) imaging. MATERIALS AND METHODS: From July 2004 onwards, among the 33 patients with acute tibial avulsion injury of the PCL, 22 patients were available for a 1-year follow-up. Patients underwent internal fixation using screws, pullout sutures or staples through the posteromedial approach. Clinical evaluations were performed using the posterior drawer test, posterior drawer stress x-ray, range of motion and Tegner score. In addition, size of the fragment, visibility, comminution, displacement and presence of extension were studied and were compared to the pre-operative X-ray and 3D-CT imaging. RESULTS: Four cases demonstrated 10-degree restriction in flexion and 1 case demonstrated 10-degree restriction in extension compared to the unaffected side. Except for the 2 cases which had Grade I posterior instability on the posterior drawer test, the results of the post-operative joint stability were negative and the posterior drawer stress X-ray using the Telos device showed an average of 0.57+/-0.4 mm. Like the average pre-operative Tegner score of 6.7+/-0.9, the Tegner score was restored to 6.2+/-0.7 (p>0.05) at the last follow-up. 3D-CT showed an improved accuracy in visibility (55.6%), comminution (50%) and displacement (44.4%) compared to the simple X-ray. CONCLUSION: The acute tibial avulsion injury treated with the appropriate internal fixation through the posteromedial approach based on the fracture size demonstrated exellent outcomes. The pre-operative 3D-CT was useful for identifying the fracture pattern and choosing the appropriate internal fixation.

Comparison of Tunnel Enlargement between Single and Double Bundle Anterior Cruciate Ligament Reconstruction / 대한정형외과학회잡지

PURPOSE: The aim of this study was to compare the tunnel enlargement in patients who had undergone a double-bundle (DB) or single-bundle (SB) anterior cruciate ligament (ACL) reconstruction, and to determine the correlation between the extent of bone tunnel enlargement and the clinical results. MATERIALS AND METHODS: Among 224 primary ACL reconstructions performed from January 2004 to May 2008 we examined in this study 38 patients who underwent a SB-ACL reconstruction and 30 patients underwent a DB-ACL reconstruction. They were followed up over 1 year. The evaluation methods were the Lachman test, pivot-shift test and KT-1000 measurement for knee stability and the Lysholm score and International Knee Documentation Committee (IKDC) ratings for the functional results. Tunnel enlargement was measured at the sclerotic ridge of the most widest area on the anteroposterior and lateral radiographs in longitudinal and vertical axis of the tunnel. RESULTS: The tunnel enlargement on the femoral side was similar in the DB-ACL group and the SB-ACL group. On the other hand, on the tibial side, the tunnel enlargement was less in the DB-ACL group than in the SB-ACL group (p=0.001, ICC: 0.94). The two groups showed different functional results and extent of stability recovery. The KT-1000 arthrometer revealed 1.1 mm and 93% of negative in the pivot-shift test for the DB-ACL group, which induced an improved tendency compared to the SB-ACL group. No correlation was found between the tunnel enlargement and clinical results. CONCLUSION: A DB-ACL reconstruction results in less tunnel enlargement on the tibial side than a SB-ACL reconstruction. There was no correlation between the tunnel enlargement and clinical results.

A Case of Asymmetric Bilateral Discoid Medial Menisci

Discoid medial meniscus is a very rare condition of the knee. Even less frequent is the presence of bilateral medial discoid menisci and in fact only 18 cases have been described in the medical literature. We present here one case of asymmetric bilateral discoid medial meniscus. One knee had an incomplete type of discoid medial meniscus with a horizontal cleavage tear confirmed by both magnetic resonance imaging (MRI) and arthroscopy. The other knee showed a complete type of discoid medial meniscus with posterior cyst formation on MRI.

Comparison of Clinical Results for Repairing Lateral Discoid Meniscus Tear between the Contouring Surgery Group and the Additional Repair Group

PURPOSE: We aimed to compare the clinical results of treating lateral discoid meniscus tear between the contouring surgery group and the additional repair group. MATERIALS AND METHODS: We evaluated 60 cases (58 patients) with lateral discoid meniscus tear and who were arthroscopically treated between September 2003 and February 2007 and we followed them for at least two years. The sixty cases were divided into two groups: thirty-two cases underwent contouring surgery (Group A) and twenty-eight cases underwent contouring surgery and repair (Group B). The duration of symptoms, the tear patterns and clinical results between the two groups were investigated. RESULTS: The most frequent types of tear pattern were longitudinal and central hole tears in group A, while complex tear was most common in group B. The mean duration of the symptoms was 5.6 months (range: 1~24) in group A and 16.6 months (range: 1~84) in group B, which was statistically significant (p=0.025). Based on Ikeuchi's grading, the proportions with good or excellent outcomes were not different between the two groups (p=0.12). However, group A had a larger proportion of excellent outcomes (p=0.031) than group B. CONCLUSION: The contouring surgery and additional repair group had a significant longer duration of symptoms, a more complex tear pattern and less excellent results than did the contouring group.

A Comparison of Outcomes after Acute and Chronic Anterior Cruciate Ligament Reconstruction / 대한정형외과학회잡지

PURPOSE: To compare the clinical outcomes of a reconstruction with an autogenous hamstring tendon for an acute and chronic anterior cruciate ligament (ACL) injury. MATERIALS AND METHODS: We reviewed 71 patients who had undergone an ACL reconstruction with an autogenous hamstring tendon from December 2003 to June 2006. The patients were divided into two groups, reconstruction for an acute injury with 34 knees and reconstruction for a chronic injury with 37 knees. The clinical results were evaluated using the Lysholm score, International Knee Documentation Committee (IKDC) score, Lachman test, Pivot shift test, KT-1000 arthrometer, and a Cybex isokinetic test for the strength of the knee flexor and extensor. The presence of associated intra-articular lesions was also investigated. RESULTS: There were no significant differences between the two groups in terms of the stability evaluated by the Lachman test, pivot shift test and KT-1000 arthrometer at the final follow-up (p=0.732, 0.479, 0.078). However, the acute group scored significantly higher with respect to the clinical outcome measured by the Lysholm scores and IKDC rating system at the final follow-up (P=0.042, 0.012). There was a significantly higher incidence of associated intra-articular lesions in the chronic group than those in the acute group (P=0.003). CONCLUSION: A reconstruction for acute ACL injuries showed more satisfactory clinical results and less associated intraarticular lesions than a reconstruction for chronic ACL injuries.

Double-Bundle Anterior Cruciate Ligament Reconstruction

A recent growing interest in double-bundle anterior cruciate ligament reconstruction (DBACLR) reflect the effort of producing better clinical outcomes in traditional single-bundle reconstruction, which showed considerable rate of dissatisfaction in restoration of stability and function of the anterior cruciate ligament deficient knee. There is plenty of evidence that DBACLR has theoretical advantages in anatomical, biomechanical, biological, kinematical, and possibly clinical standpoint compared with traditional one but still a lack of available clinical outcome studies with sufficient follow-up to demonstrate the real advantages of DBACLR. The aim of this article is to review the evidence to support double-bundle technique and to address controversy exists over the usefulness of this technique.

Surgical Treatment of Thoracic Outlet Syndrome Secondary to Clavicular Malunion

According to the literature, thoracic outlet syndrome (TOS) secondary to the malunion of displaced fractures of the clavicle is rare. Various surgical methods, including simple neurolysis, resection of the first rib or clavicle and corrective osteotomy, have been reported. We report a case of TOS secondary to malunion of the clavicle that was treated by an anterior and middle scalenectomy without a rib resection.

Short-term Results of Two-stage Reimplantation Using Antibiotic-loaded Articulating Cement Spacer in Infected Total Knee Arthroplasty

PURPOSE: We reviewed the short-term clinical results of two-stage reimplantation using antibiotic-loaded articulating cement spacer in infected total knee arthroplasty (TKA). MATERIALS AND METHODS: Nineteen consecutive patients (20 knees) with chronic indolent infection after TKA from July, 2004 were treated by two-stage reimplantation using articulating antibiotic spacer and were followed them with a minimum of 18 months. We assessed infecting organism, response of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level following insertion of antibiotic spacer, elapsed time to reimplantation, and duration of parenteral antibiotics therapy. And we also evaluated clinical results using Hospital for Special Surgery (HSS) score, range of motion (ROM) and reinfection rate. RESULTS: The most common was methicillin-resistant staphylococcus epidermidis (8 patients, 53.3%) among the infecting organisms identified in 15 patients. Average ESR and CRP level were 28.9 mm/hr and 3.0 mg/L, each before reimplantation. The elapsed time to reimplantation was 9.7 weeks and the mean duration of parenteral antibiotics was 5.4 weeks. The ROM before spacer insertion was 72.5degrees, increasing to 103.3degrees and HSS score also improved from 47.8 preoperatively to 88.8 without evidence of reinfection at latest follow-up. CONCLUSION: Two-stage reimplantation using articulating antibiotic spacer in infected TKA is thought to be veryeffective surgical option to achieve excellent clinical results through controlling infection and permitting active joint motion.

The Retrieval Study of the Rough Blasted Surface Finish Cement Stem in Metal on Metal Total Hip Arthroplasty

PURPOSE: This study investigated the possible etiologic role of stem loosening and osteolysis by examining the surface of a rough blast retrieval cement stem and physical activity in second generation metal-on-metal (MOM) total hip arthroplasty (THA) MATERIALS AND METHODS: Forty one patients (43 hips) were analyzed retrospectively from Jan. 1996 to Dec.1998. Of the femoral stem, a rough blasted (Ra=1.6 um) cement stem and a cementless Ti-alloy stem was used in 18 and 25 hips, respectively. The mean follow-up duration was 10.15 years. Each patient was evaluated clinically by the HSS and radiographically by Engh's method. Scanning electron microscopy was used to observe the retrieved femoral stem and histology studies were performed. RESULTS: The mean Harris hip score improved from 56.2 points before surgery to 92.6 points after surgery. All the cementless stems and cups showed excellent results at the last follow-up. Eight of the rough blast cement stems were revised. Seven showed loosening and one was a recurrent dislocation. Cross-validation evaluation revealed osteolysis to be associated with a rough surface cement stem of metal on metal THAs (p=0.001). In addition, patients who underwent strenuous activity had a higher incidence of osteolysis (p=0.031). CONCLUSION: These findings suggest that a rough blast surface cement stem is associated with early osteolysis and loosening in patients with a metal-on-metal hip replacement. A prospective study with a large group of patients and multiple diagnostic methods will be needed to determine if there is a causal relationship between metal hypersensitivity and osteolysis. These results suggest that a cement stem with a rough blasted surface should be considered in metal-on-metal total hip arthroplasty.