Recent trends in the management of anterior knee pain

Anterior knee pain (AKP) syndrome is one of the most common conditions that prompt active young individuals to seek evaluation at sports injury clinics. Compared to the general population, patients with AKP appear to be at a higher risk of developing patellofemoral osteoarthritis. AKP can be detrimental to the affected patient’s quality of life and, in the larger context, it could markedly burden the economy with high healthcare costs. This opinion aims to present a comprehensive evaluation of AKP to improve its management in clinical practice.Current Concepts: AKP has a multifactorial etiology. It can be attributed not only to structures within and around the knee but also to external factors, such as limb malalignment, weakness of specific hip muscle groups, and core and ligamentous laxity. Hence, AKP warrants a detailed evaluation of patient’s medical history and a thorough clinical examination complemented by relevant radiological investigations to identify its origin in the knee and the underlying cause. Conservative management yields favorable outcomes in the majority of patients with AKP, whereas surgical management becomes necessary only when well-characterized structural abnormalities of the knee or limb correlate with the clinical presentation of AKP or when conservative measures fail to provide substantial and sustained symptoms relief.Discussion and Conclusion: The treatment strategy for AKP should be individualized based on the patient’s profile and the specific cause identified. Therefore, the management of AKP requires a focused evaluation of the patient’s medical history, clinical examination, and radiological investigations to identify the condition’s origin and underlying cause.

Patellofemoral joint disorders

Patellofemoral joint problems refer to a spectrum of conditions affecting the patellofemoral joint, which is the joint between the patella and femur. These conditions can cause pain and instability in the knee and affect an individual’s ability to perform daily activities. Patellofemoral joint problems commonly cause knee pain, particularly among young athletes and physically active individuals. This review article discusses current patellofemoral joint problems, including their epidemiology, pathophysiology, diagnosis, and management.Current Concepts: Patellofemoral joint problems are presented as clinical symptoms of pain and instability. Dividing the diagnostic criteria into anterior knee pain, patella instability, and patellofemoral arthritis is useful. Anterior knee pain is diagnosed after excluding possible causes. Patellar instability is classified into recurrent dislocation, habitual dislocation (extension and flexion types), and permanent dislocation. Moreover, patellar instability can progress to the final stage of patellofemoral arthritis. Thus, patellar instability should be treated according to the Dejour criterion, and patellofemoral arthritis treatment requires artificial joint replacement surgery.Discussion and Conclusion: The pathological mechanism of patellofemoral joint problems still needs to be properly established, and multifactorial causes make it difficult to treat patellofemoral joint problems. Accurate diagnosis is considered an essential factor for successful treatment.

Versatile Application of Navigation System for Total Knee Arthroplasty / 대한정형외과학회잡지

The navigation system helps to perform an accurate and reproducible operation by real-time continuous feedback during total knee arthroplasty (TKA). Although the incidence of malalignment after conventional TKA had been reported to be up to 20%–30%, navigationassisted TKA has shown excellent radiologic results in terms of accurate implant position and mechanical alignment. In addition, the navigation system provides continuous feedback on the extension and flexion gaps that change depending on the bone resection and soft tissue release. Furthermore, the navigation system can be useful in patients with extra-articular deformity or retaining instruments. Robotassisted TKA is a newly developed surgical method that combines the navigation registration technique with bone resection using a robotic arm. A postoperative change in the kinematic axis can be evaluated by comparing the pre- and postoperative functional flexion axis using navigation data. If the functional flexion axis can be provided in real-time in the navigation system, it is expected to be used as a new surgical parameter for the rotational alignment of the femoral component and help restore the patient’s flexion axis postoperatively.

Spinal Accessory Nerve Injury Induced by Manipulation Therapy: A Case Report

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.

Some Considerations in High Tibial Osteotomy

No abstract available.

Intra-Articular Injection of Bone Marrow-Derived Mesenchymal Stem Cells Leading to Better Clinical Outcomes without Difference in MRI Outcomes from Baseline in Patients with Knee Osteoarthritis

PURPOSE: Bone marrow (BM) is frequently used as a source of mesenchymal stem cells (MSCs) because they have a high potential for differentiation. However, it is unclear whether BM-derived MSCs lead to better clinical and magnetic resonance imaging (MRI) outcomes postoperatively. MATERIALS AND METHODS: This meta-analysis compared the clinical and MRI outcomes in patients with knee osteoarthritis (OA) treated with BM-derived MSCs. Eight studies comparing the clinical and MRI outcomes assessed with various measurement tools in patients with knee OA treated with BM-derived MSCs were included. RESULTS: The range of motion (95% confidence interval [CI], −13.05 to 4.24; p=0.32) and MRI outcomes (95% CI, −0.16 to 1.40; p=0.12) did not differ significantly between the baseline and final follow-up. In contrast, pain (95% CI, 0.89 to 1.87; p < 0.001) and functional outcomes (95% CI, 0.70 to 2.07; p < 0.001) were significantly improved at the final follow-up when compared to the baseline. CONCLUSIONS: This meta-analysis found no significant difference in the tested range of motion and MRI outcomes between the baseline and the final follow-up in patients treated with BM-derived MSCs, whereas significant functional improvement and pain relief were noted when compared with the baseline. Thus, BM-derived MSCs appear to be a viable alternative for patients with knee OA, although long-term and high-quality randomized controlled trials are needed to confirm the clinical benefits.

Phrenic Nerve Clipping in a Stroke Patient with Intractable Hiccup: a Case Report

Hiccup is an intermittent, involuntary and erratic contraction of the diaphragm, immediately followed by a laryngeal closure. Persistent and intractable hiccups are rare but severe, keeping a person from doing daily activities; these can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration. Therefore, proper treatments are necessary. We present a case with intractable hiccup treated with an unusual treatment. A 61-year-old man presented with intractable hiccups, which started 6 years ago after subarachnoid and intraventricular hemorrhage. Conventional pharmacologic treatments including metoclopramide, gabapentin, and baclofen were unsuccessful. Cooperating with cardiothoracic surgeons, phrenic nerve clipping operation was done under intraoperative electrophysiologic monitoring. This method was successful that the symptoms were relieved. Reversible clipping done under intraoperative electrophysiologic monitoring can be a promising therapeutic method for persistent and intractable hiccups in patients with stroke.

Quantitative Measurement of Muscle Atrophy and Fat Infiltration of the Supraspinatus Muscle Using Ultrasonography After Arthroscopic Rotator Cuff Repair

OBJECTIVE: To investigate the utility of ultrasonography to objectively examine morphological changes (i.e., muscle atrophy and fatty infiltration) of the supraspinatus muscle. METHODS: Thirty-four patients were prospectively enrolled in this study. The degrees of muscle atrophy and fat infiltration were measured using ultrasonography 3–4 months after arthroscopic supraspinatus tendon repair. Shoulder function (i.e., shoulder active range of motion, visual analogue scale, and constant score) was examined. Using the symmetricity of the muscles in the human body, the degrees of morphological changes of the supraspinatus muscle were quantitatively measured. The associations between the morphological changes of the supraspinatus muscle and shoulder function were identified. RESULTS: There were statistically significant differences in the cross-sectional area (CSA) and echogenicity between the surgery and non-surgery sides (p < 0.001). The CSA ratio, which represents the degree of muscle atrophy, was associated with shoulder forward flexion, external rotation, and constant score; however, the echogenicity ratio, which represents the degree of fat infiltration, was not associated with shoulder function after surgery. CONCLUSION: This study demonstrated that shoulder function could be predicted by evaluating the morphological changes of the supraspinatus muscle using ultrasonography and that objective evaluation is possible through quantitative measurement using the symmetricity of the human body.

Reference Value for Infrapatellar Branch of Saphenous Nerve Conduction Study: Cadaveric and Clinical Study

OBJECTIVE: To determine the optimal stimulation and recording site for infrapatellar branch of saphenous nerve (IPBSN) conduction studies by a cadaveric study, and to confirm that obtained location is practically applicable to healthy adults. METHODS: Twelve lower limbs from six cadavers were studied. We defined the optimal stimulation site as the point IPBSN exits the sartorius muscle and the distance or ratio were measured on the X- and Y-axis based on the line connecting the medial and lateral poles of the patella. We defined the optimal recording site as the point where the terminal branch met the line connecting inferior pole of patella and tibial tuberosity, and measured the distance from the inferior pole. Also, nerve conduction studies were performed with obtained location in healthy adults. RESULTS: In optimal stimulation site, the mean value of X-coordinate was 55.50±6.10 mm, and the ratio of the Y-coordinate to the thigh length was 25.53%±5.40%. The optimal recording site was located 15.92±1.83 mm below the inferior pole of patella. In our sensory nerve conduction studies through this location, mean peak latency was 4.11±0.30 ms and mean amplitude was 4.16±1.49 µV. CONCLUSION: The optimal stimulation site was located 5.0–6.0 cm medial to medial pole of the patella and 25% of thigh length proximal to the X-axis. The optimal recording site was located 1.5–2.0 cm below inferior pole of patella. We have also confirmed that this location is clinically applicable.

Dysphagia as the Only Manifestation of Myasthenia Gravis: A Case Report / 대한연하장애학회지

Dysphagia is a common manifestation of myasthenia gravis (MG), but it has been rarely reported as the only symptom. We report a 46-year-old man who complained of dysphagia without any other symptoms. Based on a videofluoroscopic swallowing study (VFSS), he showed decreased tongue base retraction, premature bolus loss, and incomplete velopharyngeal closure. He also showed impaired laryngeal elevation that caused incomplete laryngeal closure and aspiration with a small amount of thin fluid. Laryngoscopic evaluations, brain magnetic resonance imaging, and repetitive nerve stimulation tests were unremarkable. Since the acetylcholine receptor antibody level was elevated, he was diagnosed with MG. Treatment with pyridostigmine was initiated and the dysphagia symptoms improved completely. MG is one possible cause of unexplained dysphagia. Therefore, neurological examination is required when abnormal findings are observed in VFSS, and evaluations for MG may be important for the final diagnosis.

A Novel Medial Soft Tissue Release Method for Varus Deformity during Total Knee Arthroplasty: Femoral Origin Release of the Medial Collateral Ligament

INTRODUCTION: Numerous methods of medial soft tissue release for severe varus deformity during total knee arthroplasty (TKA) have been reported. These include tibial stripping of the superficial medial collateral ligament (MCL), pie-crusting technique, and medial epicondylar osteotomy. However, there are inherent disadvantages in these techniques. Authors hereby present a novel quantitative method: femoral origin release of the medial collateral ligament (FORM). SURGICAL TECHNIQUE: For medial tightness remaining even after the release of the deep MCL and semimembranosus, the FORM is initiated with identification of the femoral insertion area of the MCL with the knee in flexion. Starting from the most posterior part of the femoral insertion, one third of the MCL femoral insertion is released from its attachment. If necessary, further sequential medial release is performed. MATERIALS AND METHODS: Seventeen knees that underwent the FORM were evaluated for radiological and clinical outcomes. RESULTS: Regardless of the extent of the FORM, no knees showed residual valgus instability at 24 weeks after surgery. CONCLUSIONS: As the FORM is performed in a stepwise manner, fine adjustment during medial release might be beneficial to prevent inadvertent over-release of the medial structures of the knee.

Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies

PURPOSE: To summarize and compare radiological and clinical outcomes of open wedge high tibial osteotomy (HTO) using imageless computer-assisted navigation with conventional HTO. METHODS: A literature search of online register databases was conducted. The risk ratio (RR) of radiological outliers and mean differences in clinical outcomes were compared between navigated and conventional HTOs. Radiological results were evaluated by subgroup analyses according to the study period (concurrent/consecutive) and the use of locking fixation device. RESULTS: Seven comparative studies with a total sample size of 406 knees were included in this review. Radiographically, the mechanical axis [MA] was within the acceptable range (0degrees-6degrees) in 83.7% of the navigation HTO group, showing significant difference from 62.1% of the conventional HTO group. Clinically, despite the forest plot demonstrating a general trend of favoring the navigation system, there were not sufficient studies to determine statistical significance in the meta-analysis. None of the subgroup analyses demonstrated significant differences in the RR of MA outliers. CONCLUSIONS: The present meta-analysis indicates that the use of navigation in open wedge HTO improves the precision of mechanical alignment by decreasing the incidence of outliers; however, the clinical benefit is not conclusive. Additionally, none of the subgroup analyses demonstrated significant difference in the RR of MA outliers.

Is Distal Locking Constantly Necessary When Intertrochanteric Femur Fracture Is Stably Fixed in the Distal Area with Intramedullary Hip Nail? / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to investigate the constant necessity of distal locking when intertrochanteric fracture was treated with an intramedullary hip nail. MATERIALS AND METHODS: From April 2010 to June 2013, 47 stable intertrochanteric fractures (AO/OTA 31-A1) were treated with second generation intramedullary hip nailing. They were followed-up for more than 12 months. In the first group of 18 cases distal locking was used, and in the second group of 29 cases, distal locking was not used. We compared the radiologic and clinical results of the two groups. RESULTS: Comparison of the two groups of patients showed no difference in terms of radiological and functional results. Postoperative thigh pain developed in eight cases (17%). A statistically difference was observed between isthmic diameter and used nail diameter (Fisher exact test, p=0.01) for postoperative thigh pain. In logistic regression analysis, the difference between isthmic diameter and used nail diameter was the most statistically significant factor in development of postoperative thigh pain (p=0.04, odd ratio=27.75). CONCLUSION: Our results suggested that the second generation intramedullary hip nail may be successfully implanted without distal interlocking in 31-A1 intertrochanteric femur fracture when the reduction status was satisfactory and stable fixation of the distal area was estimated by less than 3 mm difference between isthmic diameter and used nail diameter.

Arthroscopic Medial Meniscus Posterior Root Repair: Techniques and Current Issues / 대한정형외과학회잡지

Posterior root tears of the medial meniscus are radial tears, usually found in patients older than 50 years with degenerative articular cartilage. Partial menisectomy has been the conventional treatment for this condition. However, growing dissatisfaction with partial menisectomy for medial meniscus root tears has led to an increasing interest in meniscal repair. One method for medial meniscus root repairs involves suturing around the region of the tear where the sutures are pulled-out and fixed around the tibia. In another approach, a suture anchor was used for fixation of the medial meniscus root tear. Both methods improved functional outcome scores at least during a short-term follow-up period. However, complete healing of the repaired root seemed to be less predictable. Strict patient selection, good surgical skills and proper postoperative rehabilitation are the key factors for successful repairs of medial meniscus root tears.

A Ganglion Cyst Formed after Anterior Transposition of the Ulnar Nerve: A Case Report

In this report, a case of a 70-year-old man with a large ganglion cyst formed after anterior transposition of the left ulnar nerve is presented. Three months after the index surgery, the patient presented with a painless superficial ovoid, soft mass measuring 5x4x2 cm in size located at the posteromedial aspect of the left elbow, the previously operated site. Magnetic resonance imaging showed a well demarcated cystic mass with a stalk connecting to the elbow joint. Excisional biopsy was performed and pathologic findings showed that the cystic wall had no definite lining cells with myxoid degeneration compatible with findings of ganglion cyst.

A Ganglion Cyst Formed after Anterior Transposition of the Ulnar Nerve: A Case Report

In this report, a case of a 70-year-old man with a large ganglion cyst formed after anterior transposition of the left ulnar nerve is presented. Three months after the index surgery, the patient presented with a painless superficial ovoid, soft mass measuring 5x4x2 cm in size located at the posteromedial aspect of the left elbow, the previously operated site. Magnetic resonance imaging showed a well demarcated cystic mass with a stalk connecting to the elbow joint. Excisional biopsy was performed and pathologic findings showed that the cystic wall had no definite lining cells with myxoid degeneration compatible with findings of ganglion cyst.

Ochronotic Arthropathy: Degenerative and Complex Tear of Black Meniscus / 대한정형외과학회잡지

In this report, a case of a black meniscus with underlying ochronosis is described. Further analysis by laboratory findings showed that the patient had underlying alkaptonuria, which was previously undiagnosed. The patient's symptoms showed improvement after arthroscopic treatment.

Artificial Fusion of Infected Total Knee Arthroplasty Using a Flexible Intramedullary Rod Bundle and an Antibiotic-Loaded Cement Spacer / 대한정형외과학회잡지

Multiple total knee arthroplasty (TKA) failure resulting from a recurrent infection is a challenging problem. Knee arthrodesis is one treatment option that normally involves the application of an external fixator, plate fixation, and intramedullary nailing. However, these approaches are not always successful, and a reinfection is a risk, particularly in older, medically compromised patients. This paper reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer. This technique was used in two cases of multiple TKA failure that resulted from a recurrent infection. The procedure was successful in both cases with no evidence of rod or cement failure. Two advantages of this procedure are infection eradication and mechanical strength. However, this procedure should only be used for medically compromised elderly patients at high risk of rerevision TKA failure resulting from persistent periprosthetic infection because rod fracture or loosening can occur with time.

Arthroscopic Treatment of Delayed Patella Infera / 대한정형외과학회잡지

Patella infera (baja) is a rare condition that can result from several etiologies including trauma around the knee. Risk factors include scar tissue formation in the retropatella fat pad, extensor mechanism dysfunction, immobilization in extension position of the knee joint, etc. Unawareness and delayed recognition are known to be associated with long-term disability. In this condition, arthroscopic treatment is generally recommended only for early cases. In this report, we present a case with reasonable outcome of delayed patella infera treated by arthroscopic treatment. Prudent arthroscopic debridement of the responsible scar tissue and accelerated rehabilitation therapy is necessary for achievement of a successful outcome.

Navigated Acetabular Cup Fixation for Acetabular Deformity or Revision Total Hip Arthroplasty / 대한고관절학회지

PURPOSE: To evaluate the usefulness of navigated acetabular cup fixation for total hip arthroplasty in patients with acetabular deformity or revision total hip arthroplasty. MATERIALS AND METHODS: This study enrolled 28 patients with at least 12 months' follow-up. The safe zone of the acetabular cup was defined as 40degrees+/-10degreesin inclination and 15degrees+/-10degreesin anteversion. The authors used the navigation and radiographic data to determine whether the acetabular cup was located within the safe zone or not. To evaluate the clinical outcomes, preoperative and last follow-up Harris hip scores were checked, and the occurrence of complications was evaluated. RESULTS: According to the navigation data, the mean inclination and anteversion were 38.5degrees+/-4.7degrees(range, 32degrees-50degrees) and 16.6degrees+/-4.0degrees(range, 8degrees-23degrees), respectively. According to the radiographic data the mean inclination and anteversion were 40.5degrees+/-4.6degrees(range, 32degrees-50degrees) and 19.4degrees+/-4.2degrees(range, 8degrees-25degrees), respectively. In both cases, all values were within the safe zone. Harris hip score was improved in all patients from preoperative 52.3+/-14.4 points (range, 29-87 points) to 88.0+/-9.0 points (range, 65-99 points) at the last follow-up. There was no dislocation or loosening of both cases. CONCLUSION: Navigated acetabular cup fixation is a useful technique for total hip arthroplasty in patients with acetabular deformity or revision total hip arthroplasty because it prevents the malposition and related complications.