ischVascular Calcification in Patients Undergoing Total Knee Arthroplasty: Frequency and Effects on the Surgery

Background@#This study aims to investigate the frequency of distal femoral and popliteal arterial calcification and to evaluate the intraoperative and postoperative effects of arterial calcification in patients undergoing total knee arthroplasty using a tourniquet. @*Methods@#The records of 5,438 patients who had undergone primary total knee arthroplasty between January 2003 and January 2017 were retrospectively reviewed. We examined the preoperative radiographs of the knee from all patients for calcifications of the femoral and popliteal arteries. Vascular calcification was identified on preoperative radiographs in 223 cases. Intraoperative and postoperative complications were investigated among these patients. Postoperative complications were analyzed from the time of surgery to the last follow-up (minimum 1-year follow-up). @*Results@#Vascular calcification of the arteries around the knee was found in 223 cases (4.1%). The mean patient age was 70.6 years in the non-calcification group and 73.8 years in the calcification group (p > 0.05). The calcification group was classified into medial, intimal, or mixed subgroups according to the morphology of calcification on preoperative radiographs. The medial type included 46 cases (20.6%); intimal type, 161 cases (72.2%); and mixed type, 16 cases (2.7%). There was no statistically significant difference in demographic and surgical data among the three groups. There were intraoperative complications in two cases in the medial type group, both of which involved tourniquet failure. There was also a postoperative complication in one case in the medial type group, which involved wound dehiscence at 2 weeks postoperatively. No other postoperative complications were identified during 1-year follow-up. @*Conclusions@#Despite the presence of calcifications in the arteries around the knee, total knee arthroplasty (using a tourniquet) can be performed without serious complications.

Effect of Postoperative Parathyroid Hormone Administration on Osteoporotic Intertrochanteric Fractures of Females / 대한정형외과학회잡지

Purpose@#This study examined the effects of the postoperative administration of parathyroid hormone (PTH) on fracture healing in intertrochanteric fractures accompanied by osteoporosis in elderly females. @*Materials and Methods@#Female patients aged 65 years and more who underwent surgery after a diagnosis of intertrochanteric fractures and osteoporosis during the period from July 2013 to December 2017 were included as subjects. The subjects were divided into two groups: PTH-treated group and non-PTH-treated group. The formation time of the first callus, timing of the bridging callus, and time of bony union for both groups were evaluated. @*Results@#In the PTH-treated group, the mean time of the first callus formation, average time of bridging callus, and the average time of bony union were 32, 58, 83 days, respectively, which were significantly shorter than that of the untreated group. @*Conclusion@#PTH, a treatment for osteoporosis, promotes callus formation and the healing process. Therefore it will be helpful in intertrochanteric fractures accompanied by osteoporosis in elderly females.

Does Obesity Affect Clinical and Radiological Outcomes in Minimally Invasive Total Knee Arthroplasty? Minimum 5-Year Follow-up of Minimally Invasive TKA in Obese Patients

BACKGROUND: The aim of this study was to evaluate the clinical and radiological outcomes of minimally invasive total knee arthroplasty (MIS-TKA) in obese patients. METHODS: We examined the records of 371 cases of MIS-TKA performed using the mini-midvastus approach from January 2006 to December 2006. According to body mass index (BMI), the cases were classified into group A (BMI 0.05). There was no difference in terms of the accuracy of the tibial implant alignment, with 97.6%, 95.2%, and 93.4% of each group showing 90°± 3° varus angulation (p > 0.05). With respect to the accuracy of the femorotibial angle, 93.9%, 94.6%, and 90.2% of each group had 6°± 3° valgus angulation, with group C demonstrating the lowest level of accuracy (p 0.05). CONCLUSIONS: MIS-TKA in obese patients showed satisfactory clinical and radiological results without significant difference in surgical results compared to nonobese patients.

Treatment of Recurrent Hemarthrosis after Total Knee Arthroplasty

PURPOSE: The purpose of this study is to evaluate the incidence and treatment of recurrent hemarthrosis after total knee replacement (TKR). MATERIALS AND METHODS: Among a total of 5,510 patients who underwent TKR from March 2000 to October 2016, patients who had two or more bleeding 2 weeks after surgery were studied. Conservative treatments were performed for all cases with symptoms. In patients who did not respond to conservative treatment several times, embolization was performed. We retrospectively evaluated the postoperative bleeding time, bleeding frequency, treatment method, and outcome. RESULTS: Seventeen (0.3%) of the 5,510 patients developed recurrent hemarthrosis. Bleeding occurred at an average of 2 years 3 months after the operation. Joint aspiration was performed 3.5 times (range, 2 to 10 times) on average, and 14 cases (82.3%) were treated with conservative treatment. In 3 patients with severe bleeding and hemorrhage, embolization was performed. CONCLUSIONS: Recurrent hemarthrosis after TKR is a rare disease with a low incidence of 0.3% and usually could be treated by conservative treatment. If recurrences occur repeatedly, embolization through angiography or surgical treatment may be considered, but the results are not satisfactory and careful selection of treatment modalities is warranted.

Extramedullary Tibial Bone Cutting Using Medial Cortical Line in Total Knee Arthroplasty

PURPOSE: This study aims to identify the effectiveness of the medial cortical line for attaining a more accurate tibial component alignment in proximal tibial resection using an extramedullary alignment rod. MATERIALS AND METHODS: The study examined 100 cases of total knee arthroplasty performed from December 2013 to February 2014 in a retrospective manner. On a preoperative anteroposterior (AP) radiograph of the entire tibia, we identified the medial cortical line that runs parallel to the tibial anatomical axis and passes the medial tibial spine, and measured the point where the medial cortical line crosses between the medial malleolus and the lateral malleolus in the ankle joint. RESULTS: The preoperative AP radiograph of the tibia showed the medial cortical line passing the point 40.4%±0.8% medial to the distance from the medial malleolus to the lateral malleolus including the skin thickness in the ankle joint. When the proximal tibial resection was performed with the extramedullary tibial cutting guide aligned with the medial cortical line, the tibial component angle averaged 0.7°±0.3° varus and the alignment accuracy of the tibial component within 0°±3° varus amounted to 97.0%. CONCLUSIONS: The use of the medial cortical line in proximal tibial resection with an extramedullary tibial cutting guide allowed for relatively accurate alignment of the tibial component.

Atypical Fracture-Like Insufficiency Fracture of the Tibia with Prolonged Bisphosphonate Drug: A Case Report

Atypical femoral fracture related to a long-term bisphosphonate therapy has commonly been reported; however, a fracture at the site other than the femur has rarely been reported to date. Herein, we report a case of a patient on long-term bisphosphonate therapy who presented atypical tibial insufficiency fracture at the anterolateral aspect of diaphysis, without trauma. We, for the first time in Korea, present this case with a literature review.

Fracture Preventing Effects of Maxmarvil® Tablets (Alendronate 5 mg + Calcitriol 0.5 µg) in Patients with Osteoporosis

BACKGROUND: The purpose of this prospective, open-label, observational study was to assess the fracture preventing effect of Maxmarvil® tablets (alendronate 5 mg + calcitriol 0.5 µg) in patients with osteoporosis and to evaluate the change in bone mineral density (BMD) at the minimum 1-year follow-up. METHODS: In this multicenter observational study, 691 patients with osteoporosis (aged 50 years or older) were treated with alendronate 5 mg + calcitriol 0.5 µg/day during their normal course of care. Patients were assessed at baseline and at 6 and 12 months. Baseline characteristics (including age, gender, concomitant disease, and baseline fractures) were evaluated. RESULTS: From among the 848 participants, 149 individuals were lost to follow-up at the time of the study and 8 people had died. The 691 participants (54 men and 637 women) finished the follow-up study and completed the questionnaire. The mean age of the participants was 71.5 years (range, 50–92 years; mean age, 72.3 years for men and 71.4 years for women). Osteoporotic fracture occurred in 19 patients (2.7%). BMD of the lumbar spine and hip was improved by 5% and 1.5% at the latest follow-up. At the latest follow-up, 24 patients (3.5%) complained of drug-related complications such as dyspepsia, constipation, and nausea. CONCLUSIONS: This prospective observational study demonstrated that alendronate 5 mg + calcitriol 0.5 µg/day had a preventive effect on osteoporotic fracture and it increased the BMD of the lumbar spine by 5% at the latest follow-up.

Radiologic Outcomes According to Varus Deformity in Minimally Invasive Surgery Total Knee Arthroplasty

PURPOSE: To identify the accuracy of postoperative implant alignment in minimally invasive surgery total knee arthroplasty (MIS-TKA), based on the degree of varus deformity. MATERIALS AND METHODS: The research examined 627 cases of MIS-TKA from November 2005 to December 2007. The cases were categorized according to the preoperative degree of varus deformity in the knee joint in order to compare the postoperative alignment of the implant: less than 5degrees varus (Group 1, 351 cases), 5degrees to less than 10degrees varus (Group 2, 189 cases), 10degrees to less than 15degrees varus (Group 3, 59 cases), and 15degrees varus or more (Group 4, 28 cases). RESULTS: On average, the alignment of the tibial implant was 0.2+/-1.4degrees, 0.1+/-1.3degrees, 0.1+/-1.6degrees, and 0.3+/-1.7degrees varus, and the tibiofemoral alignment was 5.2+/-1.9degrees, 4.7+/-1.9degrees, 4.9+/-1.9degrees, and 5.1+/-2.0degrees valgus for Groups 1, 2, 3, and 4, respectively, in the preoperative stage, indicating no difference between the groups (p>0.05). With respect to the accuracy of the tibial implant alignment, 98.1%, 97.6%, 87.5%, and 86.7% of Groups 1, 2, 3, and 4, respectively, had 0+/-3degrees varus angulation, demonstrating a reduced level of accuracy in Groups 3 and 4 (p0.05). CONCLUSION: Satisfactory component alignment was achieved in minimally invasive surgery in total knee arthroplasty, regardless of the degree of varus deformity.

Thoracic Epidural Cavernous Hemangioma / 대한정형외과학회잡지

A 31-year-old male presented with severe back pain and paraparesis. Imaging studies demonstrated an extraosseous, extradural mass without bone invasion at the T11-T12 vertebral level, located dorsal to the thecal sac. The spinal cord was compressed ventrally. The lesion was completely excised after a T11-T12 laminectomy. Histopathological examination revealed a cavernous hemangioma. The patient's symptoms improved after excision of the lesion.

Manipulation under Anesthesia for Stiffness after Total Knee Arthroplasty

PURPOSE: This study evaluated the incidence of manipulation under anesthesia (MUA) for stiffness after total knee arthroplasty (TKA) and the degree of joint motion recovery after MUA. MATERIALS AND METHODS: A total of 4,449 TKAs (2,973 patients) were performed between March 2000 and August 2014. Cases that underwent MUA for stiffness after TKA were reviewed. TKAs were performed using the conventional procedure in 329 cases and using the minimally invasive procedure in 4,120 cases. The preoperative range of joint motion, timing of manipulation, diagnosis and the range of joint motion before and after MUA were retrospectively investigated. RESULTS: MUA was carried out in 22 cases (16 patients), resulting in the incidence of 0.5%. The incidence after the conventional procedure was 1.2% and 0.4% after the minimally invasive procedure. In the manipulated knees, the preoperative range of motion (ROM) was 102.5degrees+/-26.7degrees, and the preoperative diagnosis was osteoarthritis in 19 cases, rheumatoid arthritis in two, and infection sequela in one. MUA was performed 4.7+/-3.0 weeks after TKA. The average ROM was 64.5degrees+/-13.5degrees before manipulation. At an average of 64.3+/-41.3 months after manipulation, the ROM was recovered to 113.4degrees+/-31.2degrees, which was an additional 49.9degrees improvement in flexion. CONCLUSIONS: The satisfactory recovery of joint movement was achieved when MUA for stiffness was performed relatively early after TKA.

Minimum 5-year Follow-up Results of Minimally Invasive Total Knee Arthroplasty Using Mini-Keel Modular Tibial Implant

PURPOSE: To evaluate the minimum 5-year mid-term clinical and radiological results of minimally invasive surgery total knee arthroplasty (MIS-TKA) using a mini-keel modular tibia component. MATERIALS AND METHODS: We retrospectively evaluated 254 patients (361 cases) who underwent MIS-TKA between 2005 and 2006. The latest clinical and radiological assessments were done in 168 cases that had been followed on an outpatient basis for more than 5 postoperative years. Clinical results were assessed using the Hospital for Special Surgery (HSS) score and Knee Society score. Radiological evaluation included measurements of knee alignment. RESULTS: The average postoperative knee range of motion and HSS score were 134.3degrees+/-12.4degrees and 92.7degrees+/-7.0degrees, respectively. The average postoperative femorotibial angle and tibial component alignment angle were 5.2degrees+/-1.7degrees valgus and 90.2degrees+/-1.6degrees, respectively. The average tibial component posterior inclination was 4.8degrees+/-2.1degrees. The percentage of cases with tibial component alignment angle of 90degrees+/-3degrees was 96.1%, and that with the femorotibial angle of 6degrees+/-3degrees valgus was 94.0%. Radiolucent lines were observed in 20 cases (12.0%): around the femur, tibia, and patella in 14 cases, 10 cases, and 1 case, respectively. However, they were less than 2 mm and non-progressive in all cases. The survival rate was 99.4% and there was no implant-related revision. CONCLUSIONS: MIS-TKA using a mini-keel modular tibial plate showed satisfactory results, a high survival rate, and excellent clinical and radiological results in the mid-term follow-up.

Congenital Anomaly of the Atlas Misdiagnosed as Posterior Arch Fracture of the Atlas and Atlantoaxial Subluxation

Partial or complete absence of the posterior arch of the atlas is a well-documented anomaly but a relatively rare condition. This condition is usually asymptomatic so most are diagnosed incidentally. There have been a few documented cases of congenital defects of the posterior arch of the atlas combined with atlantoaxial subluxation. We report a very rare case of congenital anomaly of the atlas combined with atlantoaxial subluxation, that can be misdiagnosed as posterior arch fracture.

The Inferior Accessory Ossicle of the Anterior Arch of the Atlas Misdiagnosed as Anterior Arch Fracture: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: We report a very rare case of the inferior accessory ossicle of the anterior arch of the atlas misdiagnosed as anterior arch fracture. SUMMARY OF LITERATURE REVIEW: It is necessary to know the existence of inferior accessory ossicle of the anterior arch of the atlas, even though it is extremely rare. MATERIALS AND METHODS: A 29-year-old woman was referred to our emergency service unit with symptoms of neck pain and scalp laceration, after being involved in a car accident. She was diagnosed as the inferior accessory ossicle of the anterior arch of the atlas, by multiple diagnostic mordalities. RESULTS: The symptom of neck pain was relieved spontaneously, and her symptom has been relieved at her latest visit, as a follow up within 3 months. CONCLUSIONS: It is important to be aware of cervical anatomical variants because we commonly confuse it with other pathologic conditions, such as a fracture and thus, misdiagnose the condition.

A Case of Deep Vein Thrombosis in Common Iliac Vein after Arthroscopic Partial Meniscectomy / 대한스포츠의학회지

Knee arthroscopy is generally considered a very safe operation with very high success rates. Few reported cases of complications arising from only arthroscopic partial meniscectomy include deep vein thrombosis and pulmonary embolism. In this study, we present the case of a 44-year-old female patient with complications of deep vein thrombosis arising after undergoing an arthroscopic partial meniscectomy. Eight days post-operation, the patient presented with pain and swelling of the lower limb and inguinal area of the same side as the operation and was diagnosed by computed tomography scan with deep vein thrombosis. Apart from obesity, the patient presented with no other risk factors for deep vein thrombosis. The patient was given heparin treatment and discharged once her symptoms were relieved.

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Spondylolisthesis and Degenerative Segmental Instability

STUDY DESIGN: This is a retrospective case study. PURPOSE: This study was designed to analyze the surgical outcomes of patients who underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) for the treatment of spondylolisthesis and degenerative segmental instability. OVERVIEW OF LITERATURE: If the surgical outcomes of a procedure are evaluated together with multiple indications, it is not clear how the procedure helped each subgroup of patients. For the reason that some indications achieve better outcomes than the others, we performed a subgroup analysis using validated outcome measures to demonstrate the optimal indications and the treatment results of TLIF. METHODS: We conducted subgroup analyses by comparing the prospectively collecting data from the consecutive patients who underwent single-level minimally invasive TLIF for the treatment of the following 3 subgroups of indications: 23 cases of low-grade spondylolytic spondylolisthesis, 24 cases of degenerative spondylolisthesis, and 19 cases of degenerative segmental instability. RESULTS: The average duration of follow up was 36.1 +/- 9.9 months (range, 24 to 63 months). The preoperative pain and disability scores were significantly improved at final postoperative follow-up in all the subgroups (all measurements: p < 0.0001). The 3 subgroups exhibited an equivalent improvement of the pain and disability scores at the final follow-up. The rates of radiographic solid fusion and complications were also similar among the 3 groups. CONCLUSIONS: Our data suggests that minimally invasive TLIF optimally and equivalently alleviates all of the associated symptoms and disabilities from low-grade spondylolisthesis and degenerative segmental instability. Furthermore, these patients seem to have optimal surgical indications for minimally invasive TLIF, while maintaining favorable surgical outcomes.

Postoperative Safety of Sequential Bilateral Total Knee Arthroplasty in Low Risk Patients / 대한정형외과학회잡지

PURPOSE: To study the safety of sequential bilateral total knee arthroplasty in low risk patients. MATERIALS AND METHODS: Those who had received the surgery all at once were grouped as the first group, those who had received the surgery over two weeks interval were the second group and the last group, third group were those who had received the first surgery on only one knee and they were gotten re-hospitalized for the second surgery on the rest of the knee. These groups were compared on the aspects of complication, postoperative bleeding amount, average transfusion amount, operation time and admission period. RESULTS: There were no major complications found in all groups and the minor complication rate of occurrence was 3%, 4%, 6% in each, which did not constitute a significance difference. Each of the total blood loss was 1442.9 mL, 1567.4 mL, 1616.6 mL and which did not constitute a significance difference, either. Each of the average volume of blood transfused was 1220.3 mL, 680.1 mL, 692.2 mL, and the first group had the largest volume transfused (p<0.05). The operation time was 186, 196, 211 minutes in each and the first group had the shortest duration (p<0.05). The average admission periods were 16.8, 28.6, 29.8 days and the first group had the shortest period (p<0.05). CONCLUSION: We suggest that when there are no medical diseases contracted on patients, the sequential bilateral total knee arthroplasty can be performed safely without definite increase in perioperative complications.

Cementless Total Hip Arthroplasty Using VerSys Fiber Metal Midcoat Stem: a Minimum 3-Years Follow-up

PURPOSE: The purpose of this study was to retrospectively evaluate the results of cementless total hip arthroplasties that used a Versys fiber metal midcoat femoral stem. MATERIALS AND METHODS: From March 2000 to June 2005, 28 cases in 23 patients were followed up for a minimum of three years. The average follow up period was 5.1 years. Clinical results were evaluated by Harris hip scores. Radiographic analysis was done by evaluating fixation stability, osteolysis, stress shielding, and cortical hypertrophy. RESULTS: The mean Harris hip score improved from 43.1 to 93.8 at the last follow up. In radiographic analyses of the stem, there was no evidence of positional changes or vertical subsidence. There was heterotopic ossification in four, distal cortical hypertrophy in two, proximal stress shielding in twenty, and femoral osteolysis in five cases. The femoral stem revealed a stable bony ingrowth in all. The acetabular cup revealed a stable bony ingrowth in all. There was no evidence of horizontal or vertical migration or of a change of inclination angle of the acetabular cup. CONCLUSION: Cementless total hip arthroplasty using a Versys fiber metal midcoat femoral stem showed good clinical and radiologic results, but long term follow up is needed.

Intraoperative Balloon Angioplasty in Diabetic Foot with Peripheral Artery Occlusive Disease During Amputation: Two Case Reports / 대한정형외과학회잡지

Amputation should be considered for the patients with limb necrosis or infection due to major vessel obstruction combined with diabetes. Patients with peripheral artery occlusive disease combined with diabetes have a higher risk of amputation and a higher possibility of reoperation than those patients without diabetes because of complications that include hematoma, infection and necrosis of the stump. We report here on 2 cases for which balloon angioplasty was used to promote wound healing on the stump site during amputation, and the patients had peripheral artery occlusive disease with a diabetic foot. The wounds healed early without complication in both cases.

Short Term Result of Minimally Invasive Total Knee Arthroplasty with Mini-Midvastus Approach / 대한정형외과학회잡지

PURPOSE: To investigate the effectiveness of minimally invasive total knee arthroplasty using the mini-midvastus approach through analyzing the short-term clinical outcomes. MATERIALS AND METHODS: Seventy-seven consecutive total knee arthroplasties were performed with the mini-midvastus surgical technique from August 2005 to February 2006 and were followed for more than 1 year after the procedure. All operations were performed with the Nexgen LPS-flex total knee system using a MIS quad-sparing instrument. The evaluation included preoperative and postoperative clinical data, surgical and radiological outcomes. RESULTS: The length of skin incision was average 8.4+/-0.6 cm and the operation time was average 95.5+/-15.7 minutes. The blood loss was average 727.5+/-315.5 cc. The tibial component alignment angles averaged 0.2+/-1.3degrees varus and the tibiofemoral angles averaged 5.8+/-1.8degrees. The mean ROM and the mean HSS score was 117+/-10degrees and 120+/-11degrees, 88.9+/-7.1 and 96.2+/-4.5 at eight weeks and one year after surgery respectively. CONCLUSION: If proper surgical procedures are performed using the appropriate surgical instruments, minimally invasive total knee arthroplasty with the assistance of the mini-midvastus approach, can result in good clinical outcomes and alignment of the implants.

Delayed Intestinal Injury Caused by Intrapelvic Pin Migration after Open Reduction of an Acetabular Fracture: A Case Report

Intrapelvic pin migration of the Kirschner wires or the Steinman pins that are used for the treatment of hip fracture is rare, but it can be serious when it occurs. We experienced a delayed intestinal injury that was caused by the migration of an intrapelvic pin, and this happened 10 years after performing fixation for an acetabular fracture. For preventing this potential complication, the pins have to be used only as a temporary fixation and the end of the pins should be bent. Further, the patients should be followed up clinically and radiographically for a long time. If pin migration does occur, the pin should be removed.