Functional Outcomes After Critical Pathway for Inpatient Rehabilitation of Total Knee Arthroplasty

OBJECTIVE: To investigate functional outcomes after the application of a critical pathway for inpatient rehabilitation of total knee arthroplasty (TKA).METHODS: A total of 184 patients (57 males and 127 females; average age, 71.5±5.9 years) who underwent unilateral or bilateral TKA were included. The critical pathway included early, intensive individualized rehabilitation exercises. Patients completed the following performance-based physical function tests: the stair climbing test (SCT), 6-minute walk test (6MWT), and Timed Up and Go test (TUG) as well as measurement of isometric knee flexor and extensor strength of the operated knee, gait speed, and range of knee flexion and extension. Self-reported physical function and pain were measured using the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and visual analog scale (VAS), respectively, and self-reported quality of life was measured using the EuroQoL 5 dimension (EQ-5D) questionnaire. These evaluations were performed preoperatively and at 1 month and 3 months postoperatively.RESULTS: Performance-based and self-reported physical function and quality of life measures improved nonlinearly over time. Specifically, the 6WMT, TUG, gait speed, WOMAC-pain, WOMAC-function, VAS, and EQ-5D scores showed a significant improvement at 1-month post-TKA, whereas SCT, peak torque of the knee extensors and flexors, and WOMAC-stiffness scores showed gradual, but substantial, improvements over 3 months. There were between-group differences (unilateral and bilateral TKA groups) in the time course of the SCT, 6MWT, TUG, VAS, WOAMC-stiffness, and WOMAC-function results.CONCLUSION: Patients who underwent critical pathway rehabilitation after TKA showed significant improvements in functional measurements during the first 3 months post-surgery.

Low concentration continuous femoral nerve block improves analgesia and functional outcomes after total knee arthroplasty in spinal anesthesia

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe pain postoperatively. Femoral nerve block is commonly used for pain control after TKA. This study investigated whether continuous femoral nerve block (CFNB) can improve postoperative analgesia and functional outcome as compared to intravenous patient controlled analgesia (PCA) in patients with TKA. METHODS: We reviewed the electronic medical records of patients who underwent TKA with spinal anesthesia between March 2014 and February 2015. In Group IV, postoperative pain was managed by IV-PCA. Group CFNB received CFNB-PCA via a device. Thirty patients were enrolled per group. Patient outcomes were assessed by analgesia, functional outcomes, and health-related quality of life factors. RESULTS: Additional analgesics and additional nerve block for adequate pain control were significantly more frequent in the IV than CFNB group (P = 0.015 and P = 0.012, respectively). Range of motion up to 105 degrees was prolonged in the IV group than CFNB group (P = 0.013). EuroQol five dimensions score was improved in the CFNB group than IV group postoperative 3 weeks (P = 0.003). The incidence of transfusion due to postoperative bleeding was significantly frequent in the IV group than CFNB group (P = 0.042). CONCLUSIONS: Postoperative low concentration continuous femoral nerve block for analgesia after TKA improves analgesia, functional outcomes, and incidence of transfusion without falling risk.

Improvement of Osteoporosis Medication after Multimodal Intervention in Patients with Hip Fracture: Prospective Multicenter Study

BACKGROUND: The authors had earlier conducted a retrospective cohort study from 2008 to 2011 in Jeju Island, among 945 hip fracture patients above 50 years of age. Of these 945 patients, 344 patients (36.4%) underwent a bone mineral density test and 218 patients (23.1%) received treatment for osteoporosis. The purpose of this study was to determine whether a patient education program could improve osteoporosis management after hip fracture. The data of the previous study was used for comparison. METHODS: From November 1, 2014 to September 30, 2015, 190 patients above 50 years of age who were admitted for hip fractures at six different hospitals, were enrolled in the present study. During the hospitalization period, patients underwent education sessions and were provided brochures. Patients were evaluated for diagnosis and treatment of osteoporosis at six months after discharge and were followed-up for at least a year. RESULTS: Of the 222 patients with hip fractures, 190 patients (37 men, 153 women) were enrolled at six hospitals in 2015. Dual energy X-ray absorptiometry was performed on 115 patients (60.5%) and 92 patients (48.4%) were prescribed medication for osteoporosis at the time of discharge. A total of 43.7% and 40.2% of the patients were found to be compliant with osteoporosis medication at 6 months and 12 months follow-up respectively. CONCLUSIONS: This interventional multicenter study demonstrated that a patient education program in patients with hip fractures can improve compliance to osteoporosis medication up to 12 months of follow-up.

Effects of Early Combined Eccentric-Concentric Versus Concentric Resistance Training Following Total Knee Arthroplasty

OBJECTIVE: To investigate the effects of early combined eccentric-concentric (ECC-CON) or concentric (CON) resistance training following total knee arthroplasty (TKA). METHODS: Patients who underwent a primary TKA were randomly assigned to an ECC-CON group (n=16) or a CON group (n=18). All patients received early, progressive resistance training with five sessions per week for 2 weeks starting 2 weeks after TKA. Isometric knee flexor and extensor strength of the surgical and non-surgical knees, instrumental gait analysis for spatiotemporal parameters, 6-Minute Walk Test (6MWT), Timed Up and Go Test (TUG), Timed Stair Climbing Test (SCT) were used to evaluate performance-based physical function. The Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and EuroQOL five dimensions (EQ-5D) questionnaire were used to evaluate self-reported physical function and self-reported quality of life. All patients underwent these evaluations before and 1 month after TKA. RESULTS: The ECC-CON group showed clinically meaningful improvements in extensor peak torque (PT) of the non-surgical knee, gait speed, and 6MWT from preoperative values. The CON group had an increase in H/Q ratio of the surgical knee and improvement in SCT-ascent postoperatively. Both groups showed significant improvements in WOMAC-Pain, function, and EQ-5D scores. Although extensor PT of the surgical knee did not reach the preoperative level in either group, the postoperative change was significantly less in the ECC-CON group than the CON group. CONCLUSION: Early combined ECC-CON resistance training minimizes the loss in quadriceps strength of the surgical knee and improves endurance and gait speed after TKA.

Rotational Alignment of the Distal Femur in Korean Female Patients with Osteoarthritis Using a Computer Image Program / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to propose a method to measurement of the exact anatomical alignment from the femur using a reference axis on computed tomography (CT) images and compare the difference of alignment axis between healthy young females and female patients with osteoarthritis of knee. MATERIALS AND METHODS: A total of 218 female patients with osteoarthritis of the knee joint (OA group), who underwent total knee arthroplasty, between January 2013 and December 2014, were enrolled in this study. The control group included 50 female patients with healthy knee joint. Each study subjects took a CT scan of their knee, and a series of axial CT images of the distal femur were overlapped using the image program. Angles were measured among the anteroposterior (AP) axis, posterior condylar axis (PCA), anatomical transepicondylar axis (aTEA), and surgical transepicondylar axis (sTEA). The differences of rotation angle between the normal and osteoarthritic knee were evaluated. RESULTS: The mean AP-PCA angle in the OA group was 92.9°±1.70°, whereas that in the control group was 96.3°±1.87° (p<0.01). The mean AP-aTEA angle was 84.5°±2.59°, and 90.8°±1.12° respectively (p<0.01). The mean AP-sTEA angle in the OA group was 88.7°±1.98°, whereas that in the control group was 95.1°±1.27° (p<0.01). The mean aTEA-PCA angle in the OA group was 8.4°±2.84°, while control group was 5.5°±2.00° (p<0.01). The mean sTEA-PCA angle in the OA group was 4.3°±1.17°, whereas that in the control group was 1.2°±2.10° (p=0.917). CONCLUSION: We measured the exact relationship between the rotational axes of the distal femur by overlapping the axial images of a CT scan. The OA group revealed a more internally rotated AP axis compared with aTEA and an increased angle of aTEA-PCA than control group.

Trend in Hip Fracture Incidence and Mortality in Korea: A Prospective Cohort Study from 2002 to 2011

This prospective longitudinal cohort study was to assess the 10-yr hip fracture incidence and mortality trend of person > or = 50 yr of age between 2002 and 2011 of eight hospitals in Jeju Island. Sex-specific incidence rate (per 100,000 person-years) were calculated based on that estimated for the population in the United States in 2008. Poisson and logistic regressions were used to examine trends in incidence and mortality. There was a 101% increase in the number of hip fractures from 151 in 2002 to 304 in 2011. The crude incidence of hip fractures in the Jeju population > or = 50 yr of age increased from 126.6/100,000 to 183.7/100,000. The fracture incidence in the population standardized to the 2008 population in the United States increased from 100.6/100,000 for men and 194.4/100,000 for women in 2002 to 114.2/100,000 for men and 278.4/100,000 for women in 2011. The annual increasing incidence rate of hip fracture was 4.3% (5.3% in women and 2.2% in men). Poisson regression did not show significant trends in the mortality rates for all age groups or for both genders. The total number of hip fractures increased two-fold and the incidence rate of hip fractures increased markedly during the 10-yr study period.

Undertreatment of Osteoporosis Following Hip Fractures in Jeju Cohort Study

BACKGROUND: Osteoporosis treatment following hip fracture is well known to not enough. We previously performed intervention study for orthopaedic surgeon's education and reported twofold increase in osteoporosis detection and treatment rate observed between 2005 and 2007. This follow-up observational study was conducted to find out the rate in which a diagnostic workup and treatment for osteoporosis were done in patients with hip fracture. METHODS: Medical records and radiographs in patients who were older than 50 years and diagnosed as having femoral neck or intertrochanteric fractures at 8 hospitals in Jeju island, South Korea from 2008 to 2011 were reviewed. The numbers of patients who were studied with bone densitometry and who were treated for osteoporosis after the diagnosis of hip fracture were analyzed. RESULTS: Nine hundred forty five hip fractures (201 in 2008, 257 in 2009, 265 in 2010, and 304 in 2011) occurred in 191 men and 754 women during the study periods. The mean age of the patients was 79.7 years. The mean rate of osteoporosis detection using dual energy X-ray absorptiometry was 36.4% (344/945 hips) (ranged from 24.2% in 2009 to 40.5% in 2011). The mean initiation rate of osteoporosis treatment was 23.1% (218/945 hips) (ranged from 20% in 2009 to 29% in 2008). CONCLUSIONS: Detection and treatment rate of osteoporosis following hip fracture during follow-up periods was still not enough. Additional intervention studies are required to further improvement of osteoporosis treatment rates after hip fracture.

Morbidity and Mortality in Jeju Residents over 50-Years of Age with Hip Fracture with Mean 6-Year Follow-Up: A Prospective Cohort Study

This prospective cohort study was performed to estimate the morbidity and mortality with 790 patients over 50-yr of age that sustained a femoral neck or intertrochanteric fracture from 2002 to 2006, followed-up for a mean of 6 yr (range, 4 to 9 yr). Crude and annual standardized mortality ratios (SMRs) were calculated; and mortalities in the cohort and the age and sex matched general population were compared. The risk factors on mortality and activities pre- and post-injury were assessed. Accumulated mortality was 16.7% (132 patients) at 1 yr, 45.8% (337 patients) at 5 yr, and 60% (372 patients) at 8 yr. SMR at 5 yr post-injury was 1.3 times that of the general population. Multivariate analysis demonstrated that age (OR, 1.074; 95% CI, 1.050-1.097; P<0.001), woman (OR, 1.893; 95% CI, 1.207-2.968; P=0.005), and medical comorbidity (OR, 1.334; 95% CI, 1.167-1.524 P<0.001) were independently associated with mortality after hip fracture. Only 59 of the 150 patients (39.3%) who were able to ambulate normally outdoors at preinjury retained this ability at final follow-up. Patients with a hip fracture exhibits higher mortality at up to 5 yr than general population. Age and a preinjury comorbidity are associated with mortality.

Intramuscular Schwannoma Arising from the Gluteus Maximus Muscle: A Case Report

Intramuscular schwannomma is unusual and rare cases were reported in the literature in the gluteus maximus muscle. We present a case of an intramuscular schwannoma arising from the gluteus maximus muscle in a sixty-five-year-old woman. An oval in shape and well encapsulated tumor was found embedded with the gluteus maximus muscle, and then the lesion was excised surgically. Two years following excision of the lesion, the patient remained asymptomatic, with no evidence of local recurrence.

Lisfranc's Joint Injuries / 대한족부족관절학회지

Lisfranc joint injuries are rare and account for 0.2% of all injuries. The pattern of Lisfranc injuries varies from low-energy ligamentous sprain to high-energy fractures or crushing injuries. Early diagnosis and appropriate treatment of Lisfranc injuries are important to prevent chronic foot pain and dysfunction.

Orthopedic Surgeon's Awareness Can Improve Osteoporosis Treatment Following Hip Fracture: A Prospective Cohort Study

Through retrospective Jeju-cohort study at 2005, we found low rates of detection of osteoporosis (20.1%) and medication for osteoporosis (15.5%) in those who experienced hip fracture. This study was to determine the orthopedic surgeons' awareness could increase the osteoporosis treatment rate after a hip fracture and the patient barriers to osteoporosis management. We prospectively followed 208 patients older than 50 yr who were enrolled for hip fractures during 2007 in Jeju-cohort. Thirty four fractures in men and 174 in women were treated at the eight hospitals. During the study period, orthopedic surgeons who worked at these hospitals attended two education sessions and were provided with posters and brochures. Patients were interviewed 6 months after discharge using an evaluation questionnaire regarding their perceptions of barriers to osteoporosis treatment. The patients were followed for a minimum of one year. Ninety-four patients (45.2%) underwent detection of osteoporosis by dual energy x-ray absorptiometry and 67 (32.2%) were prescribed medication for osteoporosis at the time of discharge. According to the questionnaire, the most common barrier to treatment for osteoporosis after a hip fracture was patients reluctance. The detection and medication rate for osteoporosis after hip fracture increased twofold after orthopedic surgeons had attended the intervention program. Nevertheless, the osteoporosis treatment rate remains inadequate.

Bilateral Open Transcalcaneal Fracture with Talonavicular Dislocation: A Case Report

Although calcaneal fracture is relatively common in ankle injury, open intraarticular calcaneal fracture with dorsal dislocation of the navicular from talus is extremely rare and severe injury. There are few data which are available concerning the injury mechanism and treatment options. The purpose of this report is to describe a case with bilateral open transcalcaneal fracture with talonavicular dislocation and to discuss the prevalence, mechanism of this injury, and treatment options.

Osteonecrosis of the Jaw in a Patient with Osteoporosis Treated with Oral Bisphosphonates / 대한정형외과학회잡지

Bisphosphonates are widely used in the management of metastatic bone disease and in the prevention of osteomalacia and osteoporosis. In particular, oral preparations are more commonly used for the prevension and treatment of osteoporosis. Bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been well documented recently in relation to intravenous preparations of the drug. But, a few cases have been reported of oral bisphosphonate-associated osteonecrosis. We could not find any risedronate cases in the Korean medical literature. Here we report a case of BRONJ in a 91-year-old woman patient receiving an oral bisphosphonate (risedronate) for the treatment of osteoporosis.

Pathologic Fracture in a Subchondral Cystic Lesion at the Superior Acetabulum / 대한정형외과학회잡지

Subchondral cyst is a benign cystic lesion, and it is often found in patients with rheumatoid arthritis or osteoarthritis. However, its occurrence in those joints without preexisted disease is rare. Furthermore, there has been no report in the medical literature regarding pathologic fracture in the bony plate of a subchondral cyst at the superior acetabulum. We report here on a case of the 44-year-old woman for whom a pathologic fracture was found in the bony plate of a subchondral cyst at the superior acetabulum.

Incidence of Hip Fractures in Jeju Island, South Korea: A Prospective Study (2002-2006)

BACKGROUND: This study was perfomed to estimate the incidence of hip fractures of people older than 50 years in South Korea. METHODS: Information of patients over 50 years of age who had sustained a hip fracture were obtained from the records of eight hospitals in Jeju Island between 2002 and 2006 to calculate the incidence of hip fractures in this age group. RESULTS: There were 820 hip fractures during the study period. The mean age of the patients at the time of fracture was 77.8 years (71.3 years in 181 men, 79.7 years in 639 women). The crude incidence was 128/100,000 (66.1/100,000 in men, 174.4/100,000 in women). The age-specific incidence according to the 10-year age groups increased from 19.3/100,000 for those 50 to 59 years of age to 1,095.4/100,000 for those over 90 years of age (18.9/100,000-960.4/100,000 in men and 19.7/100,000-1112.1/100,000 in women). The standardized incidence of hip fracture to the Caucasian population in the United States in 1990 was 100/100,000 for men and 207/100,000 for women. CONCLUSIONS: Hip fractures will become an important socioeconomic problem in South Korea due to the rapid aging of the population.

Spontaneous and Simultaneous Rupture of Bilateral Quadriceps Tendons in a Patient with Chronic Renal Failure: A Case Report / 대한스포츠의학회지

Spontaneous bilateral rupture of the quadriceps tendons without a significant history of trauma is an uncommon disease. It is generally associated with mechanical factors and coexisting systemic and local factors are taken into consideration in the pathogenesis of these ruptures. In patients with some chronic systemic diseases, simultaneous rupture can occur spontaneously or with minor trauma. We present a case of patient with chronic renal failure on hemodialysis for the past 9 years, who sustained this injury, and subsequently had surgical repair of both tendons. We performed a preoperative magnetic resonance imaging to confirm the diagnosis, then we repaired the ruptured quadriceps tendons and performing MRI postoperatively 1 yr later. He regained his normal knee joint functions 1 yr after the operation.

The Comparison of Minimally Invasive Plate Osteosynthesis and Intramedullary Nailing in the Treatment of the Proximal and Distal Tibia Fracture

PURPOSE: To compare the efficacy of the surgical treatment through the comparison of Minimally Invasive Plate Osteosynthesis (MIPO) and Intramedullary (IM) nailing in the treatment of the tibial shaft fractures expended to metaphysis retrospectively. MATERIALS AND METHODS: Patients with proximal or distal third fracture of tibial shaft from May 2003 to Aug. 2006 were divided into two groups depending on the surgical method. Group A consisted of 30 patients treated with IM nailing, Group B was 29 patients treated with MIPO. The clinical outcomes were evaluated retrospectively from the time for bone union and callus formation confirmed by X-ray, functional score of knee or ankle joint, and complications including nonunion, malalignment and infection. RESULTS: Bone union was seen radiologically at a mean of 17.4 weeks in group A, and 17.0 weeks in group B. In postoperative complications, group A showed two nonunion, two delayed-union, six malalignment, and two wound infection while group B showed only one delayed-union and one wound infection. CONCLUSION: There were no significant differences in the time for bony union and functional score between IM nailing and MIPO. Conventional IM nailing with only interlocking technique showed higher incidence of malalignment and deformity than MIPO for the treatment of the proximal or distal third fracture of the tibial shaft.

Analysis of the Deformities of the Foot after Tibial Fracture and Outcome of the Surgical Treatment / 대한족부족관절학회지

PURPOSE: We wanted to evaluate the relating factors for deformities of the foot after tibial fracture and the outcome of respective surgical treatment. MATERIALS AND METHODS: We studied thirty-two patients (thirty-five feet) who had foot deformities after tibia fracture. The age, gender, shape, location, concurrent soft tissue injury and operative treatment of tibial fracture were analysed and outcome of the surgical treatment was investigated. RESULTS: Deformities of the foot mostly occurred in open fractures of Gustilo type 3 or closed fracture with severe soft tissue injury. Variable surgical treatments such as simple release, lengthening, Z-plasty and osteotomy were performed. The AOFAS ankle-hind foot scale was improved from average of 37.3 points preoperatively to an average of 77.2 points at the last follow up. The Maryland foot score was from 42.9 to 90.2 and AOFAS Lesser Toe Metatarso-phalangeal interphalangeal scale was from 42.9 to 90.5. Radiological correction was also improved from 21.9 degrees to 7.9 degrees (Meary angle), from 112.2 to 138.5 (Hibb's angle) and from 33.8 to 25.9 (Calcaneal pitch). CONCLUSION: We proposed that great care should be taken of treatment for the tibial fracture and early detection and proper management of the foot deformities are crucial.

Cemented Bipolar Hemiarthroplasty for the Femoal Neckor Intertrochanteric Fracture in Elderly Patients: Multicenter Study / 대한정형외과학회잡지

Purpose: This multicenter study was carried out to estimate the clinical and radiological results of cemented bipolar endoprosthesis replacement arthroplasty of a hip fracture in patients aged over 50 years in Jeju Island. Materials and Methods: Eighty-eight hips underwent bipolar endoprosthesis in 2002. Thirty-two patients died during the follow-up period and 7 patients refused a radiological evaluation or an interview. Two patients who underwent cementless bipolar endoprosthesis were excluded. Forty- nine hips (48 patients) completed the average 27 months follow-up. A neck fracture was involved in 40 hips (39 patient) and an intertrochanteric fracture was involved in 9 hips (9 patients). The average age was 77.7 years. The results were evaluated using clinical and radiological methods. Results: At the last follow-up, the average Harris hip score was 70.1 and 22 hips (45%), which indicated excellent and good results, respectively. Among the 42 patients with normal activity at the preoperative period, 28 patients were still active at the final follow-up. The number of medical illnesses and the severity of mental deterioration were also associated with the poor Harris hip scores. The pressurization cementing technique was found to be excellent at the radiological evaluation. One femoral stem appeared to have loosened and subsided but there was no revision surgery. Conclusion: The clinical result of the cemented bipolar endoprosthesis in multicenter study showed that the only 45% of patients showed results >good. The major factors influencing the results were the postoperative activity, the number of medical illnesses, and the severity of the mental changes.

Spinal Cord Regeneration in Rat using Neural Stem Cell Differentiated from Human Telencephalon / 대한정형외과학회잡지

PURPOSE: To evaluate the effect of neural stem cells differentiated from a human telencephalon on the neural regeneration in the severed spinal cord. MATERIALS AND METHODS: The 1st surgery involving the insertion of plastic membrane in the transected cord was performed to prevent spontaneous healing of adult female rats (n=20, 171-237 g) with a complete spinal cord transection. The media was inserted only after removing the previously inserted plastic membrane in the control group (n=6). In the experimental group (n=14), media and neural stem cell (1x) were transplanted after removing the membrane, and immunohistochemical staining was performed. The experimental group was perfused transcardially 5 weeks after the 2nd surgery, and the level of neural cell regeneration determined by immunohistochemical staining. In behavioral analysis, the Basso-Beatie-Bresnahan (BBB) scores of the control and experimental group were compared weekly from immediately after the injury until 5 weeks post-injury after the 2nd surgery. RESULTS: Immunohistochemical stain revealed no neural regeneration in the control group. On the other hand, the survival of transplanted human neural stem cells and remarkable neural regeneration (differentiate to neuron and astrocyte) were observed in the experimental group. In the BBB locomotor scale, the experimental group showed significant recovery in terms of control; and the score increased from postoperative 2 weeks to 3 weeks, and reached a plateau from 3 weeks to 5 weeks. CONCLUSION: The effect of neural stem cells differentiated from human telencephalon on cord regeneration does not produce functional recovery in the BBB locomotor scale, but there is slight recovery of the muscle function. The survival of transplanted human neural stem cells and the possibility of differentiation to neurons or astrocytes were observed.