How Difficult Is It to Surgically Treat AO-C Type Distal Humerus Fractures for Inexperienced Orthopedic Surgeons?

PURPOSE: Twenty early surgical management cases of distal humerus type-C fractures were analyzed. MATERIALS AND METHODS: This study analyzed 20 early patients, who received surgical management of distal humerus type-C fractures, and could be followed-ups for more than one year between March of 2013 and May of 2015. The operative time, bone union time, and elbow range of motion were analyzed. The Mayo's functional score was used to evaluate their postoperative function. The primary and secondary complications of each patient immediately after each of their surgery were also reviewed. RESULTS: All patient groups achieved bone union within an average period of 16.4 weeks. Based on the Mayo functional score, 6, 10, and 4 patients scored excellent, good, and fair, respectively. The average range of motion was a flexion contracture of 14.5° with a follow-up improvement averaging 120.7°. Six patients received nine revision operations due to major and minor complications. Two patients received revision fixation from an inadequate fixating power, and another patient received an ulnar nerve transposition. Other complications included olecranon osteotomy site displacement, superficial operational site infection, and pin loosening. CONCLUSION: Distal humerus fractures of the AO-C type can cause a range of complications and has a very high rate of revision due to its difficult nature of surgical manageability. Therefore, it is imperative for a surgeon to expect various complications beforehand and a careful approach to their postoperative rehabilitation is essential.

Mid-Term Results of Oxford Medial Unicompartmental Knee Arthroplasty in Young Asian Patients Less than 60 Years of Age: A Minimum 5-Year Follow-up

PURPOSE: The purpose of this study was to evaluate the efficacy of unicompartmental knee arthroplasty (UKA) in young active Asian patients by analyzing clinical outcomes, complications and survival rates. MATERIALS AND METHODS: Eighty-two knees were evaluated with a minimum follow-up of 5 years after Oxford phase 3 UKA in patients less than 60 years of age at the time of surgery. Their mean age was 54.7 years (range, 44 to 59 years). The mean follow-up period was 8.9 years (range, 5.3 to 12 years). Kaplan–Meier survivorship analysis was used to estimate implant survival. RESULTS: Including 3 bearing dislocations, 1 medial tibial collapse and 1 lateral osteoarthritis, the total complication rate was 6.1% (5/82). Of the 3 cases of bearing dislocation, 2 cases were resolved by replacing with a thicker bearing and 1 case was converted to total knee arthroplasty (TKA) due to repeated dislocation. The two knees with a medial tibial collapse and a lateral osteoarthritis were converted to TKA. The 10-year cumulative survival rate using Kaplan-Meier survival method was 94.7% (95% confidence interval: 88.7%–100%). CONCLUSIONS: Oxford medial UKA was reliable and effective in young active Asian patients providing good clinical results and survival rate in the mid-term follow-up.

A Comparison between Minimally Invasive Percutaneous Plate Osteosynthesis and Plate Fixation in the Treatment of Clavicle Midshaft Fracture / 대한정형외과학회잡지

PURPOSE: To retrospectively compare minimally invasive percutaneous plate osteosynthesis (MIPPO) with open plate fixation for the treatment of clavicle midshaft fracture. MATERIALS AND METHODS: Between November 2011 to May 2014, 40 cases that were followed for more than 1 year–among all cases of MIPPO and open plate fixation–were analyzed. The study population was divided into two groups: group A included 20 cases of MIPPO and group B included 20 open plate fixation cases. The comparative analysis between the two groups was based on the operative time, bone union, functional evaluation (American Shoulder and Elbow Society score), incision length, pain relief (visual analogue scale, VAS), and complication. RESULTS: The bone union was successful for all the cases, and the functional evaluation scores of the shoulder joint were satisfactory for both groups (p>0.05). The operative time was 47.5 minutes and 58.7 minutes for group A and B, respectively (p<0.05). The incision length for group A was 6.2 cm and that for group B was 10.7 cm with statistical significance (p<0.05). Pain relief (VAS) after surgery for group A showed a quick recuperation in the early stages. For complications, there were 2 cases of dysesthesia and 1 case of malunion due to metal fixation failure in group A. There were 6 cases of dysesthesia and 2 cases of cosmetic problem due to hypertrophic scar in group B. CONCLUSION: Surgical results of clavicle shaft fracture were satisfactory for both groups, but group A had advantages of shorter operative time, minimal incision length, and better pain relief in the early stages compared with group B. However, we need further evaluations with long-term follow-up results and complications, such as malunion and exposure on radiation.

The Effect of Second Toe Valgus on Correction Loss of Hallux Valgus Angle in Surgical Treatment / 대한족부족관절학회지

PURPOSE: The purpose of this study is to determine the correlation between the correction loss of hallux valgus angle and the severity of valgus angle of the second toe. MATERIALS AND METHODS: We selected 312 cases from 268 surgical patients with hallux valgus deformity receiving distal chevron osteotomy. For a radiological evaluation, we analyzed the changes in the hallux valgus angles, first to second intermetatarsal angles, and valgus angle of the second toe post index operations. All patients were women; the mean age was 46 years. The mean follow-up period was 17 months. RESULTS: The mean hallux valgus angle was 33.6° preoperatively (range, 25.7°~44.8°), 13.1° (range, 8.4°~16.4°) after 4 weeks of postoperative period, and 17.1° (range, 9.4°~28.5°) at their final follow-up. The mean valgus angle of the second toe was 8.4° preoperatively (range, 2.0°~25.8°) and 8.3° (range, 1.7°~24.9°) at the final follow-up. Preoperatively, there was a positive correlation between the valgus angle of the second toe and hallux valgus angle (r=0.747, p=0.001). The correction loss of hallux valgus angle had a significant correlation with the severity of valgus angle of the second toe (r=0.802, p=0.001). CONCLUSION: The existence of the second toe valgus deformity may present itself as a cause of correction loss of hallux valgus angle. The preoperative measurement of the second toe valgus angle may be a good predictor of correction loss; therefore, thorough preoperative warning on the possibility of correction loss should be conducted to maximize patient satisfaction after the procedure.

Errata to "Coronal Alignment of the Lower Limb and the Incidence of Constitutional Varus Knee in Korean Females"

The Editorial Office apologizes for any inconvenience this may have caused.

Coronal Alignment of the Lower Limb and the Incidence of Constitutional Varus Knee in Korean Females

PURPOSE: In total knee arthroplasty (TKA), it is important to restore neutral mechanical alignment. The purpose of this study was to assess whether the lower limb alignment is neutral in healthy Korean females and investigate the incidence of constitutional varus knees among them. MATERIALS AND METHODS: Weight-bearing full-leg standing radiographs were obtained from 118 healthy females between the ages of 20 to 39 years. One radiologist and two orthopaedic surgeons measured the hip-knee-ankle angle (HKAA), medial proximal tibial angle (MPTA), and femoral anatomic mechanical angle (FAMA) on the radiographs and compared with the traditional gold standard HKAA of 0degrees, MPTA of 3degrees varus, and FAMA of 6degrees. RESULTS: The interobserver reliability of the three independent observers was high (p<0.001). The HKAA of the study subjects (1.35degrees+/-2.04degrees) was significantly different from the standard HKAA of 0degrees (p<0.001), but no statistically significant difference was observed in the MPTA (-3.18degrees+/-1.61degrees) and FAMA (5.99degrees+/-0.70degrees) from the standard values (p=0.083 and p=0.887, respectively). The incidence of constitutional varus alignment was 20.34%. CONCLUSIONS: In Korean females, the mechanical axis of the lower limb was not neutral and the incidence of constitutional varus alignment was slightly higher than that in Western females. We believe that these findings should be taken into consideration in planning reconstructive surgery of the knee, such as TKA, unicompartmental knee arthroplasty, and high tibial osteotomy.

Nicolau Syndrome Following Intramuscular Diclofenac Injection / 대한정형외과학회잡지

Nicolau syndrome is a rare complication causing severe pain and tissue necrosis after intramuscular injection. In Korea, the Korea Dermatological Association has reported 12 cases, and some severe cases required surgical treatment. Most cases have been related to the administration of a variety of drugs, including nonsteroidal anti-inflammatory drugs, corticosteroids, and antibiotics. We present two patients who developed this complication, 1 case of typical Nicolau syndrome and 1 case of atypical Nicolau syndrome.

Tibiotalocalcaneal Arthrodesis Using Retrograde Compressive Intramedullary Nail / 대한족부족관절학회지

PURPOSE: The purpose of this study was to evaluate the radiological and clinical outcomes of tibiotalocalcaneal arthrodesis using retrograde compressive intramedullary nail for patients with complex hindfoot problems, including Charcot arthropathy, osteonecrosis of talus, combined arthritis of the ankle and subtalar joint, failure of previous ankle arthrodesis, and failed total ankle arthroplasty. MATERIALS AND METHODS: Eighteen consecutive patients (10 men and 8 women) with an average age of 54 years (range, 42~72 years) underwent tibiotalocalcaneal arthrodesis using retrograde compressive intramedullary nail fixation. The mean duration of follow-up was 16 months (range, 12~23 months). Radiological evaluation included assessment of the union status of ankle and subtalar joints. Clinical evaluations included visual analogue scale (VAS) for pain and patient satisfaction, and postoperative complications were analyzed. RESULTS: Radiological union was achieved in 14 ankle joints (77%) and 16 subtalar joints (88%) at an average of 16 weeks (range, 14~40 weeks) and 14 weeks (range, 12~24 weeks), respectively. The preoperative VAS were 4.6 (range, 4~8) at rest and 8.2 (range, 7~10) during walking, and the postoperative VAS were 2.2 (range, 0~3) and 4.6 (range, 4~6), respectively (p<0.05). There were 6 nonunions (4 ankle joints and 2 subtalar joints), 3 tibia fractures, 2 delayed union of ankle joints, and 2 breakage of the implant. CONCLUSION: Tibiotalocalcaneal arthrodesis using retrograde compressive intramedullary nail may be considered as a viable option in patients with complex hindfoot problems.

Transarticular Fixation of Akin Osteotomy on Patients with Hallux Valgus after Resection of Medial Protrusion of Base of Proximal Phalanx / 대한족부족관절학회지

PURPOSE: When medial protrusion in the base of proximal phalanx is severe from removing metatarsal bunion during the hallux valgus surgery, it could lead to skin irritation and medial pain after the surgery. The purpose of this paper was to report our clinical and radiographic results with transarticular fixation of Akin osteotomy for the treatment of patients with hallux valgus after resection of the medial protrusion of base of the proximal phalanx. MATERIALS AND METHODS: Our study is subject to 34 cases of 30 patients who went through proximal phalanx medial corticectomy among patients undergone both hallux valgus surgery and Akin osteotomy at our institution from March 2006 to March 2012. In all cases, we used absorbable suture material through the articular surface for Akin osteotomy after resection of the medial protrusion in proximal phalanx. Radiographs were reviewed to assess the union and displacement of osteotomy site at the time of postoperative 6 months. The clinical results were assessed by using AOFAS score and complication such as skin irritation and pain. RESULTS: AOFAS score was improved from average 44 points(36-58), before operation and average 87 points(74-96), 12 months after operation. In two cases, partial union was suspected in radiological perspective, however, complete union on the osteotomy site was observed in all cases, 12 months after the operation. No patients was dissatisfied with pain, joint discomfort, skin irritation and inflammation from the knot. CONCLUSION: When medial protrusion in the base of proximal phalanx is severe from removing metatarsal bunion during the hallux valgus surgery, We have good results by transarticular fixation of Akin osteotomy using absorbable suture material.

The Comparison of Minimally Invasive Percutaneous Plate Osteosynthesis versus Open Plate Fixation in the Treatment of in the Distal Femur Fracture

PURPOSE: To evaluate the efficacy of surgical treatment through retrospective comparison of minimally invasive percutaneous plate osteosynthesis (MIPPO) vs open plate fixation in the treatment of the distal femur fractures. MATERIALS AND METHODS: Thirty-one patients with distal femur fractures from January 2002 to December 2010 were divided into two groups depending on the surgical method. Minimum follow up was 12 months. Group A consisted of 17 patients treated with MIPPO, and group B was comprised of 14 patients treated with open plate fixation. Clinical outcomes including operation time, transfusion rate, rehabilitation, range of motion, and interval change of postoperative C-reactive protein (CRP) were evaluated to assess postoperative inflammatory reaction, postoperative complications and clinical results with the use of Sanders criteria. RESULTS: The operative time was 86/135 min and transfusion volume was 0.8/1.9 unit respectively. The postoperative 3-day and 7-day CRP were 7.4/1.5 mg% in group A and 10.3/2.4 mg% in group B, showing more minimal tissue injury and early recovery in group A. There were no significant differences in clinical results by Sanders criteria in both groups. CONCLUSION: Both MIPPO and open plate fixation for the treatment of distal femur fractures showed comparably good results. However, the MIPPO technique is superior to group B in view of minimal tissue injury and operation time and was proven to lessen the transfusion rate.

The Diagnosis of Osteoporotic Occult Vertebral Fracture and Vertebroplasty

PURPOSE: To evaluate the effectiveness of magnetic resonance imaging (MRI) for the diagnosis and usefulness of vertebroplasty in osteoporotic occult vertebral fractures. MATERIALS AND METHODS: Of 472 osteoporotic vertebral fractures treated from May 2003 to July 2009, 45 patients were diagnosed with occult osteoporotic vertebral fracture. Their medical charts and radiographs were reviewed. The degree of vertebral body collapse was graded by a semiquantitative method. In order to increase the reliability, interpretation was based on radiographic diagnoses from 3 orthopedic surgeons. Vertebroplasty was performed at 31 of the 45 patients, for whom conservative treatment failed. Pre-operatively and post-operatively, pain was evaluated using a visual analog scale (VAS). RESULTS: We observed 55 occult fractures in 45 patients. Forty vertebrae (72.7%) among the 55 vertebrae were just adjacent to an old vertebral fracture with deformation of the vertebral body. The rediagnosis rate of occult fracture attempted without MRI was only 21.8%. The average pre-operative VAS score of 8.07 (6~9) was improved to 2.43 after surgery and showed no delayed vertebral body collapse. CONCLUSION: Gadolinium enhancement of MRI is critical to the diagnosis of occult vertebral fractures, which are 9% of whole osteoporotic vertebral fractures. Seventy-two point seven percent of occult vertebral fractures were just adjacent to an old vertebral fracture with collapse of the vertebral body. This means that if vertebroplasty is performed without thorough MRI examination, it may fail.

Comparison of Hematologic Changes between Rivaroxaban and Aspirin for Venous Thromboembolism Prophylaxis after Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To compare the hematologic changes and the rates of transfusion of patients using rivaroxaban or aspirin for venous thromboembolism prophylaxis after a total knee arthroplasty. MATERIALS AND METHODS: Among patients with total knee arthroplasty from July 2010 to March 2011, two groups of 100 consecutive cases were enrolled in this study, 50 patients with Rivaroxaban group and 50 patients with Aspirin group for venous thromboembolism prophylaxis after a total knee arthoplasty. Hematologic changes and transfusion rates were calculated in each group. RESULTS: The mean of decreased hemoglobin was 4.7 (3.1-6.6) in the Rivaroxaban group and 3.6 (2.0-5.1) in the Aspirin group (p<0.05). The number of patients with decreased hemoglobin of less than 8 g/dl was observed in 23 cases (46%) in the Rivaroxaban group, and 9 cases (18%) in the Aspirin group. The numbers of patients who needed transfusion were 12 in the Rivaroxaban group, and 2 in the Aspirin group (p<0.05). CONCLUSION: Rivaroxaban group revealed more significant decrease of hemoglobin and needed more transfusion than the Aspirin group did. For the prevention of venous thromboembolism after total knee arthroplasty, we should be careful using Rivaroxaban for the standard risk patients of venous thromboembolism.

The Usefulness and Technique of Unilateral Extrapedicular Approach in Vertebroplasty

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the effectiveness of unilateral extrapedicular approach in the treatment of osteoporotic compression fracture, as compared to transbipedicular approach. SUMMARY OF LITERATURE REVIEW: There has been no comparative study assessing this topic. MATERIALS AND METHODS: 115 patients presenting with percutaneous vertebroplasty between Mar. 2002 and Feb. 2009, were divided into three groups: Group A (43 vertebrae; 29 patients) who were treated with bipedicular approach, Group B (66 vertebrae; 47 patients) treated with early cases of unilateral extrapedicular approach, and Group C (43 vertebrae; 39 patients) treated with late cases of unilateral extrapedicular approach. We analyzed radiological test results including the volume of injected cement and the distribution of intravertebral body, cement leakage, height restoration and kyphosis correction. Statistical analysis was done using SPSS. Clinical results were analyzed using VAS scores. RESULTS: The mean follow-up period varied from one year at minimum to seven years and six months at maximum. The mean volume of injected cement was 3.39cc/5.39cc/3.79cc for groups A, B and C respectively. Cement leakage was at 13.4/34.8/12.8% in each group. Cement leakage was higher in group B, but most leakage took place in early cases that we tried to inject more and more cement in early inexperienced period. Bilaterally well distributed cement in the vertebral body was at 85.7/76.9% in groups B and C respectively. VAS scores improved from 8.4/8.3/8.5 preoperatively to 2.0/2.0/1.6 postoperatively. CONCLUSIONS: Percutaneous vertebroplasty treated with unilateral extrapedicular approach can lessen perioperative operating time. This treatment led to clinical and radiologic results that were comparable to those with a bilateral transpedicular approach.

Fixation with Absorbable Suture Material in Akin Osteotomy / 대한족부족관절학회지

PURPOSE: The Akin osteotomy which is a closing wedge osteotomy of the proximal phalanx widely used for the correction of hallux valgus has several methods of fixation. we tried to report the effects of the fixation using an absorbable suture material during the Akin osteotomy for the hallux valgus. MATERIALS AND METHODS: This study was based on 448 cases of 346 patients who were able for follow-up more than 12 months among the patients who had an Akin osteotomy together with the surgery of hallux valgus between March of 2006 and May of 2010. Absorbable suture material had been used in all cases. Radiologically displacement and union of osteotomy site were observed after the surgery, and clinically postoperative complication such as skin irritation, pain and satisfaction were investigated. RESULTS: Radiologically all cases had showed complete union and no case had the loss of an correction due to loss of fixation. Also, any case had no skin irritation due to a knot. Three cases had a medial cortical breakage due to a strong knot, and the initial one case among them had additionally fixed the osteotomy site for four weeks using K-wire, and the remaining two cases had fixed a suture on an articular surface without any fixation of an additional wire. If a medial cortical bone was lost by carrying out an ostectomy due to proximal protrusion of proximal phalanx, three cases could show union through the fixation of suture on an articular surface. CONCLUSION: This study considers that the fixation of the osteotomy site using an absorbable suture material in an Akin osteotomy was effective method and the advantage of this procedure was unnecessity of the material removal and no skin irritation.

Preventing Lateral Skin Numbness after Medial Unicompartmental Knee Arthroplasty

BACKGROUND: The authors report the results of preserving the infrapatellar branch of the saphenous nerve during unicompartmental knee arthroplasty to prevent lateral skin numbness. METHODS: All 100 cases had medial compartmental osteoarthritis and a minimally invasive technique had been used. The mean follow-up duration was two years and eight months (range, 24 to 42 months). RESULTS: The classification according to the location of this nerve was observed as either Mochida Type I with 76 cases (76%), Type II with 16 cases (16%), and unclassified type with 8 cases (8%). In Type I, the nerve was saved in 62 cases (82%), but could not be preserved in Type II because of the surgical procedure. These results showed that the mean distance from the joint line to the nerve of Type I was 9.13 mm (range, 4 to 15 mm) and the nerve passed inferiorly. CONCLUSIONS: This study showed the location of this nerve can be predicted ahead of the procedure, which will help preserve it during the surgery.

Solitary Intradural Metastatic Tumor From Renal Cell Carcinoma: A Case Report / 대한척추외과학회지

Most of intradural tumors are primary tumors and few of them are metastatic tumors. Especially, spinal intradural metastatic tumors which are derived from renal cell carcinoma are rarer. Even though such tumors occur, it accompany with brain metastasis in many cases. And there was no report regarding isolated intradural metastasis, without metastasizing on brain or other central nervous system organs, in domestic.

Spinal Arachnoid Cyst: Treated with Pars Osteotomy and Recapping Laminoplasty: Report of 5 Cases / 대한척추외과학회지

Spinal arachnoid cysts are a rare disease with an unknown origin. Because of their broad base, a total laminectomy with or without fusion has been the treatment of the choice. We encountered 5 patients with a spinal arachnoid cyst who were treated by recapping laminoplasty after pars osteotomy. This procedure has not been reported in Korea. All patients showed neurological recovery with no recurrence of the cyst. The findings on the stressed plain film confirmed bony union and stability of the posterior element.

The Intraneural Ganglion of the Posterior Tibial Nerve and Medial Plantar Nerve / 대한정형외과학회잡지

Intraneural ganglion of the tibial nerve is very rare. We have experienced a case of the intraneural ganglion cyst in the tibial nerve and medial plantar nerve, which was located at the level of the ankle and foot. A 29-year-old male suffered from lumps causing numbness around the medial aspect of the sole and great toe. But there was no weakness and change of the motor function. We excised the cystic mass successfully and the neurologic symptoms disappeared.

Results of the First Fifty Minimally Invasive OxfordUnicompartmental Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To report the advantages and the defects through an analysis of the early results of minimally invasive unicompartmental knee arthroplasty (UKA). MATERIALS AND METHODS: The first fifty consecutive minimally invasive UKA for medial osteoarthritis that were followed up for at least 2 years (2 years-2 years 10 months) were included. The surgical parameters, clinical parameters, radiological parameters and complications were examined. RESULTS: The average preoperative knee score was 47.7, which improved to 82.7, 86.7, 87.9 and 89.4 at 6 weeks, 6 months, 1 year and 2 years after surgery, respectively. The average function score was 42.2, which improved to 71.5, 77.4, 81.3 and 84.7 at the 6 weeks, 6 months, 1 year and 2 years follow up, respectively. The average range of knee motion was 124.6 degrees preoperatively, which changed to 128.4 degrees, 134.2 degrees, 136.8 degrees and 138.5 degrees at 6 weeks, 6 months, 1 year and 2 years, respectively. The preoperative tibiofemoral angle was 2.5 degrees of varus, which changed to 3.4 degrees of valgus postoperatively. Three revisions to total knee arthroplasty were performed due to two fractures of the medial tibial condyle and one dislocation of the femoral component. CONCLUSION: The early postoperative results of minimally invasive UKA showed satisfactory improvement in the knee score, function score and recovery of the range of motion. However, surgeons must be aware of the severe complications that require a revision procedure.

The Operative Treatment of Displaced Intra-articular Calcaneal Fracture with Injectable Calcium Sulfate (MIIG(TM)) / 대한족부족관절학회지

PURPOSE: To evaluate the clinical results of operative treatment of the intra-articular calcaneal fracture with injectable calcium sulfate (MIIG(TM)). MATERIALS AND METHODS: Between March 2004 and October 2006, a total 19 intra-articular calcaneal fracture (16 patients) with a large bony defect that underwent operative treatment with plate fixation and injectable calcium sulfate (MIIG(TM)) with minimum follow-up of one year following. The mean age at time of surgery was 44.7 years (23 to 54). All of the cases were type 2 and 3 on the basis of Sanders classification. The lateral L shaped approach was used in all cases. Full weight bearing on the affected extremity was regained at an average 10 weeks postoperatively. RESULTS: The mean B?hler angle was improved from 2 degrees (-18.5~12.5 degrees) preoperatively to 23.8 degrees (12~37.5 degrees) and the angle at last follow-up was 22.5 degrees (11.5~37.5 degrees), showing about 0.3 degree decline compared to postoperative B?hler angle. Only two case of whitish leakage of graft material but other complication were none. CONCLUSION: MIIG(TM) augumentation of displaced intra-articular calcaneal fracture with large bone defect seems to bo useful method for initial stabilized and plate fixation.