Analysis of the Factors Involved in Failed Fixation in Elderly Intertrochanteric Femoral Fracture

PURPOSE: To analyze the causes of internal fixation failure in elderly intertrochanteric femoral fractures. MATERIALS AND METHODS: We retrospectively analyzed 93 intertrochanteric femoral fractures that were treated by internal fixation. The follow-up period was at least 24 months. The mean age was 73 years. We analyzed the classification of the fracture, screw position, reduction state of the fracture, and neck-shaft angle. RESULTS: Internal fixation failure occurred in 12 cases (12.9%). The causes of internal fixation failure were one case (1.0%) of head perforation, 7 cases (7.5%) of excessive slippage of a screw, and 4 cases (4.3%) of varus deformity. Significant factors infixation failure were displacement of the posterolateral fragment more than 8 mm in anteroposterior radiograph, anterior displacement of a fragment, or more than 20-degree angulation in lateral radiography. Thirty-three cases had a screw in the middle position and 4 of these cases (12.1%) had fixation failure. Notably, 14 cases had a screw in the posteromedial position and 6 of these cases had fixation failure (42.8%). CONCLUSION: Accurate reduction of the posteromedial fragment is essential in unstable intertrochanteric fracture and anterior displacement or angulation should be avoided to prevent fixation failure. The tip apex distance of the screw and central location of the screw in the femoral head is also an important factor.

Measurement of Necrotic Lesion in Osteonecrosis of Femoral Head

PURPOSE: The size of the necrotic lesion is known to be the most important prognostic factor in osteonecrosis of the femoral head (ONFH). We evaluated the accuracy and relationship of three different measuring methods of necrotic lesions for ONFH. MATERIALS AND METHODS: Sixty hips that had ONFH were measured on an MRI by two orthopaedic surgeons using Steinberg, Kim, and modified Kerboul methods. Based on the lesion size of the necrosis as measured with the computerized Steinberg method, the hips were divided into Group I (small lesion: less than 15%), Group II (medium lesion: 15~30%), and Group III (large lesion: more than 30%). Data of the Kim and modified Kerboul methods were reclassified by statistical analysis according to the groups classified by the Steinberg method. RESULTS: Average lesion size of Group I (16 hips) was 10.92%, the average size of Group II (33 hips) was 21.68%, and the average size of Group III (11 hips) was 36.80%. We established a new criteria of the Kim and modified Kerboul methods based on Steinberg. The Kim method was reclassified into Groups I (less than 18%), II (18~33%), and III (33% or more). And the modified Kerboul method was divided into Groups I (less than 200.6degrees), II (200.6~262.4degrees), and III (more than 262.4degrees) as well. CONCLUSION: New criteria for the Kim and modified Kerboul method would be a useful indicator for the prognosis and treatment plan in ONFH.

Diagnosing Symptomatic Accessory Tarsal Bones Using SPECT/CT / 대한족부족관절학회지

PURPOSE: This study was designed to analyze the usefulness of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in diagnosing symptomatic accessory tarsal bones. MATERIALS AND METHODS: Twenty four feet (16 patients) with symptomatic accessory navicular and/or os trigonum, who agreed to take SPECT/CT, were included in this study. Fifteen feet had accessory navicular, five had os trigonum, and four had both. According to the uptake in the SPECT/CT, 11 feet were classified into high and 13 into low uptake groups. The low uptake group was treated non-operatively, while the high uptake group received operations when initial conservative management failed. A modified Kidner procedure was performed for accessory navicular and arthroscopic excision was done for os trigonum. After a mean follow-up of 6.8 (range, 3~13) months, the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Visual Analogue Scale (VAS) for pain were compared. RESULTS: Patients in the high uptake group had a higher initial mean VAS score (7.0+/-0.8 vs 2.2+/-0.9, p<0.05) and a lower initial mean AOFAS score (45.9+/-9.2 vs 83.9+/-4.2, p<0.05) compared to the low uptake group. All patients in the low uptake group improved after non-operative treatment. Seven patients underwent operations and had a decreased VAS (1.6+/-0.5) and an increased AOFAS score (88.3+/-1.8) at the last follow-up. Four patients in the high uptake group demonstrated erratic symptoms. CONCLUSION: SPECT/CT can be a useful diagnostic tool and helpful in designing treatment plans for symptomatic accessory navicular and os trigonum.

Total Hip Arthroplasty Using S-ROM Prosthesis for Dysplastic Hip

PURPOSE: The purpose of this study was to evaluate the clinical and radiological results of total hip arthroplasty using a proximal modular femoral stem in patients who had secondary coxarthrosis associated with a dysplastic hip. MATERIALS AND METHODS: Forty-two patients (45 hips) with secondary coxarthrosis were evaluated after undergoing primary total hip arthroplasty using an S-ROM proximal modular femoral stem. The average follow-up was 80 months (range: 60 to 96 months). Clinical and radiological assessments were performed based on the Harris hip score and the radiological changes around the prosthesis. RESULTS: The average Harris hip score improved from 52.2 points to 88.5 points. All femoral stems showed stable fixation; there were 37 cases by bony ingrowth and 8 cases by stable fibrous ingrowth. Neither osteolysis nor progressive radiolucent lines around the femoral stem were found at the last follow-up. Forty-one hips (91.9%) revealed excellent or good clinical results at the most recent follow-up. CONCLUSION: For advanced secondary coxarthrosis, total hip arthroplasty with the use of the proximal modular femoral stem yielded good mid-term results with respect to the clinical and radiological criteria.

Metal on Polyethylene in Total Hip Arthroplasty

Conventional gamma sterilization could induce substantial oxidative degradation during subsequent storage of the PE component in air and during their use in vivo. This oxidative degradation may induce high wear rates, delamination and/or gross fracture of the affected PE component. An improved understanding of the effects of cross-linking and oxidation on ultra high molecular weight polyethylene (UHMWPE) has lead to the common use of oxygen-protected packing during radiation sterilization and shelf storage. More recently, methods to deliberately highly cross link UHMWPE while reducing the material's potential to oxidize have been develop in the form of highly cross linked UHMWPE. We reviewed the manufacturing, sterilization, cross linking methods and clinical results of the new polyethylene.

Operative Treatment of Displaced Intercondylar Fracture of the Distal Humerus with Reconstruction Plate

PURPOSE: To evaluate the therapeutic effects of chevron olecranon osteotomy and bilateral reconstruction plate as operative treatment for distal humerus intercondylar fracture. MATERIALS AND METHODS: Among patients operated for distal humerus intercondylar fracture in our hospital from June, 1997 to October, 2005, 26 patients were selected who could be followed-up for more than one year. The average follow-up period was 15 months. All olecranon osteotomies were chevron osteotomy and all fractures were treated with internal fixation using bilateral reconstruction plate. The ulnar nerve was checked in all cases. Three patients in which case the plate might irritate the ulnar nerve, received with ulnar nerve anterior transposition. Cassebaum's classification and Mayo elbow performance score were used to evaluate at three, six and twelve months. RESULTS: Mean bone union period was 11.7 weeks. There were 9 excellent cases, 11 good cases, 4 fair cases and 2 poor cases. Mean flexion contracture was 11° and further flexion was 126° at last follow-up. CONCLUSION: Bilateral reconstruction plate internal fixation using chevron olecranon osteotomy showed strong fixation and good clinical results and it is possible for early rehabilitation treatment.

MR Findings of Synovial Sarcoma with Intraosseous Involvement: Case Report

Synovial sarcoma is rare soft tissue tumor mesenchymal origin. Osseous involvement of synovial sarco-ma is rare. A 24-year-old man presented with pain and swelling of the lower extremity. MRI of the lower extremity demonstrated a large mass encircling tibia with osseous involvement. Surgical excision of the mass was done and the mass was diagnosed as biphasic synovial sarcoma with bone marrow involvement. We also discuss the other imaging findings of synovial sarcoma on MRI.

M. chelonae Soft Tissue Infection Spreading to Osteomyelitis

A previously healthy, 54-year-old woman presented with Mycobacterium chelonae soft tissue infection and osteomyelitis of her left lower leg. The infection had started from soft tissue emerging at the medial aspect of the distal femur and had spread through the bone because of delayed diagnosis. The largely indolent, 8-month course to diagnosis was attributable to unremarkable clinical manifestations combined with a low index of suspicion such as immunocompetent patient and/or inadequate finding of acid-fast bacilli in a lesion smear, characteristic histopathological features, and culture techniques. Soft tissue infection and osteomyelitis were successfully treated without surgical intervention and with a 6-month course of chemotherapy.

A Case of Lipoma Arborescens of Knee Presenting as Hemarthrosis / 대한류마티스학회지

This report describes a patient with lipoma arborescens presenting as hemarthrosis of a knee with intraosseous lesions. A 44-year old woman complained of pain and swelling of left knee. Arthrocentesis resulted in bloody effusion. Magnetic resonance images showed villous projecting frondlike fatty soft tissue proliferation in the suprapatellar pouch and ovoid intraosseous lesions in proximal tibia. The soft tissue mass was removed through arthroscopic synovectomy and the biopsy of the mass confirmed the diagnosis. The intraosseous lesions were not considered as a cause of hemarthrosis. We failed to find the exact cause of hemarthrosis. The patient remained asymptomatic after removal of the mass for 10 months. As far as we know, this is the first report of hemarthrosis associated with lipoma arborescens in korea.

Tuberculous Subdeltoid Bursitis with Rice Bodies

A 41-year-old woman with a 2-month history of diffused swelling and persistent dull pain in her right shoulder was examined. Magnetic resonance imaging (MRI) findings revealed subdeltoid bursitis and rice bodies with normal surrounding tissue and shoulder joint. Arthoscopic debridement and biopsy of the subdeltoid bursa were performed. Histologic examination of the bursal tissue showed granulomatous tissue with typical caseous necrosis. A positive culture of Mycobacterium tuberculosis confirmed the diagnosis of tuberculosis. We report on the clinical, radiological and athological findings in a patient with tuberculous subdeltoid bursitis accompanied by multiple rice body formation without coexisting active bone and joint tuberculosis, and conduct a literature review.

Prognostic Factors Related to Meniscal Healing in Arthroscopic Meniscal Repair / 대한정형외과학회잡지

PURPOSE: This study analyzed the significant prognostic factors in terms of age, rupture side (lateral or medial), existence of associated lesion, length and zone-that affect clinical healing after meniscal repair. MATERIALS AND METHODS: Data were obtained from 55 patients who had been observed at least for 18 months after meniscal repair. Healing was decided based on the patients'clinical symptoms, and analyses were made according to clinical data. RESULTS: The clinical healing rate of meniscal repairs was found to be 82% (45 patients), and was higher in ruptures accompanied by anterior cruciate ligament injury than meniscus rupture alone, when the length of the meniscal rupture was less than 2 cm. Age and rupture side (lateral or medial, peripheral or central) had no significant effect upon clinical healing. CONCLUSION: The length of meniscal rupture and meniscal rupture associated with ACL were found to be infinately correlated with good prognosis, but age, site, and zone of meniscal rupture probably do not affect prognosis.

Change of Periprosthetic Bone Mineral Density after Cementless Total Hip Arthroplasty: Using Extensively Porous Coated Femoral Stem / 대한정형외과학회잡지

PURPOSE: To investigate the annual change of bone mineral density (BMD) around the femoral stem and identified the factors that influence the stress shielding effect in patients who have received extensively porous coated cementless stem. MATERIALS AND METHODS: We reviewed seventy-four patients who were followed up for longer than three years after unilateral primary total hip replacement arthroplasty. The BMD was measured annually using a DEXA QDR 4500(R) on the proximal femur according at the Gruen zone. We analyzed the relationship between the results and the possible variates of periprosthetic bone remodeling. RESULTS: In first year after operation, the BMDs of all Gruen zone decreased significantly. From the second year, the BMDs in Gruen zones 1, 2, and 7 were decreased significantly, but those in Gruen zones 3, 5, and 6 were increased. After three years, the BMD showed no significant change. Among the examined variables including sex, patient's age, stem size, and preoperative Singh's index, stem size and age were found to have strong predictive value. CONCLUSION: Our findings suggest that periprosthetic BMD decreased in all areas over first postsurgical year. From the third year, the BMD stabilized.

Clinical Features of Diffuse Pigmented Villonodular Synovitis in the Knee Joint / 대한정형외과학회잡지

PURPOSE: Diffuse pigmented villonodular synovitis (PVNS) is a rare benign disorder characterized by an exuberant inflammation on synovial membrane. The purpose of this study was to report clinical manifestations and the results of treatment in eight cases of PVNS. MATERIALS AND METHODS: Eight patients presenting with PVNS were analyzed from the patient records and the pathologic records. The seven of the patients had been managed with arthroscopic synovectomy and one patient underwent open synovectomy and total joint replacement. Four of the eight patients had magnetic resonance imagings (MRI). Recurrence after synovectomy was considered to have occurred, if there were noteworthy clinical symptoms and signs. RESULTS: The average age of the eight patients with PVNS was thirty years-old. They complained of nonspecific pain and discomfort. Four knees on MRI scans had irregularity with loss and deformity of the intracapsular fat pad (infrapatellar, the suprapatellar and the quadriceps fat pad). Recurrence occurred in three of the eight patients (one total synovectomy, two partial synovectomy). CONCLUSION: We observed characteristic changes in the intracapsular fat pads on the MR images of patients with PVNS. The recurrence rate was high after arthroscopic synovectomy.

Clinical Characteristics of Isolated Meniscal Tear / 대한정형외과학회잡지

PURPOSE: Of all meniscal tears, isolated meniscal tear accounted for about 20%~30%. Also only a few reports in the literature dealt with isolated meniscal tear, which has a lower repairability and healing rate compared to patients with meniscal tear associated with ACL rupture. This study was undertaken to evaluate the clinical characteristics of isolated meniscal tear. MATERIALS AND METHODS: Between June, 1996 and May, 1999, 170 cases confirmed to have a meniscal tear by arthroscopy, were included in this study. We analysed clinical characteristics, according to the type of injury, medial meniscal tear versus lateral meniscal tear, type and site of meniscal tear, as well as possibility of repair. RESULTS: The frequency of medial meniscus tear is more common than that of lateral meniscus tear. Additionally, the most common cause of meniscal tear was non- contact injury. Of the total isolated meniscal tears, 20.5% were repaired. CONCLUSION: In our case, the incidence of medial meniscus tear is higher than that of the lateral meniscus tear, but this study noted a significantly low incidence of repairablity in isolated meniscal tear. Based on preliminary findings in this study, we consider degenerative change of meniscus as the most important factor explaining the clinical characteristics of meniscus tear in patients, especially, over the age of 30.

The Significance of Postural Reduction for Kyphotic Deformity in the Posterior Instrumentation of Unstable Burst Fracture / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the significance of the intraoperative postural reduction for kyphotic deformity in unstable burst fracture and confirm the relations of postural reduction and the final correction after loss of correction by posterior instrumentation. SUMMARY OF LITERATURE REVIEW: The loss of kyphotic correction after instrumentation in unstable burst fracture is found. Some methods have been developed to reduce the loss of correction. MATERIALS AND METHODS: 24 short-segment pedicle screw instrumentations in the patients with a unstable burst fracture were performed. We measured sagittal index, wedge angle of vertebral body and anterior vertebral height preoperatively, intraoperatively, postoperatively and at final follow-up. RESULTS: Sagittal index was 20.2 degrees preoperatively, 7.5 degrees intraoperatively, 0.9 degrees postoperatively and 7.2 degrees at final follow-up, so the loss of correction was 32.6%. Wedge angle of vertebral body was 20.3 degrees preoperatively, 10.1 degrees intraoperatively, 6.8 degrees postopera-tively and 9.4 degrees at final follow-up, so the loss of correction was 19.3%. Anterior vertebral height was 57.0%, 79.3%, 85.0%, and 78.8% respectively, so the loss of correction was 22.1%. The loss of correction occurred more in the disc space and less in the vertebral body itself. Postural reduction corrected 63% of sagittal index, 50% of wedge angle of vertebral body and 52% of anterior vertebral height. CONCLUSIONS: Postural reduction corrected kyphotic deformity appropriately. The correction by posterior instrumentation in unstable burst fracture was lost in some amount. The final correction was similar to the one by postural reduction. It is important to obtain the maximum postural reduction intraoperatively to prevent kyphotic deformity caused by loss of correction after surgery.

Comparison Between Allograft Mixed with Local Bone and Autograft in Posterolateral Lumbar Fusion / 대한척추외과학회지

STUDY DESIGN: A prospective study. OBJECTIVES: To determine the usefulness of allograft and compare the result of allograft mixed with local bone and autograft in posterolateral lumbar fusion. SUMMARY OF LITERATURE REVIEW: Allograft is used for the purpose of spinal fusion, especially in the scoliosis surgery. In some studies allograft is not recommended in posterior lumbar spinal fusion alone. MATERIALS AND METHODS: Fifteen patients underwent one level posterolateral lumbar fusion using freeze-dried allograft mixed with local bone. We compared them with twenty four patients using autogenous iliac bone graft mixed with local bone about radiographic fusion grading, duration of fusion and clinical outcomes. RESULTS: Radiographic fusion grading of allograft was 7 cases of grade 1, 5 cases of grade 2, 3 cases of grade 3, and grading of autograft was 21 cases of grade 1, 2 cases of grade 2, 1 cases of grade 3. Bone fusion was complete after 11.1 months in allograft and 6.7 months in autograft. Clinically, there were 4 excellent, 9 good, 2 fair cases in allograft and 10 excellent, 11 good, 3 fair cases in autograft. CONCLUSIONS: Allograft was inferior to autograft in posterolateral lumbar fusion because allograft mixed with local bone reduced radiographic fusion grading and prolonged duration of bone fusion.

Application of Comptuted Tomography for Tibial Condylar Fractures / 대한정형외과학회잡지

In planning treatment of tibial condylar fracture, the patient's age and physical condition, associated ligament injury and accurate fracture diagnosis, such as presence and degree of separatiori of split fragment, type of fracture and the severity of comminution must be considered. For accurate diagnosis, many kinds of methods including simple X-ray, arthroscopy, arthrography and tomography can be used. In spite of these procedures, sometimes we cannot know the accurate fracture morphology. The computed tomography(CT) has many advantages over other diagnostic methods. The application of CT in the evaluation of patients with spinal and pelvic fractures has been established, but rarely has its usefulness been noted in tibial condylar fracture. We thought that in assessing tibial condylar fracture, CT is more useful and accurate than conventional radiography. From March 1985 to August 1986, we took 17 patients(18 cases) of tibial condylar CT and were convinced with that it is a good diagnostic method. The results are as follows: l. In 5 cases, we could find a new fracture on CT film, which was impossible to be detected on simple X-ray. 2. In 7 cases, the fracture classification by plain X-rays was changed after CT check-up. 3. We could make the decision of treatment methods easily through more realistic classification and better recognition of split and comminution. 4. Proper approach could be done by understanding the accurate fracture size and localization.