Open-wedge high tibial osteotomy in patients with discoid lateral meniscus.

BACKGROUND: There are concerns about the progression of the lateral osteoarthritis (OA) should be taken into account when high tibial osteotomy (HTO) is performed in patients with discoid lateral meniscus (LM). This study evaluated the clinical results of HTO in patients with discoid LM and elucidated factors affecting the results. METHODS: This study evaluated 32 female patients with varus deformity and medial OA. Patients with discoid LM (8 patients) or without discoid LM (24 patients) underwent open-wedge HTO. The mean age was 53.5 years and the mean follow-up period was 35 months. Clinical results, including the Hospital for Special Surgery (HSS) score, Knee Society knee score (KS) and function score (FS), were evaluated. The progression of OA in the lateral compartment was also evaluated. Finally, we evaluated the factors affecting the clinical results and OA progression in the lateral compartment. RESULTS: Between two groups, all clinical scores were not different (p = 0.964, 0.963, and 0.559, respectively). Three of eight patients (37.5%) in the discoid group developed OA in the lateral compartment, whereas 2 of 24 patients (8.3%) in the control group developed such; however, this was not significantly different (p = 0.085). In discoid group, patients with undercorrection has higher KS relative to patients with acceptable correction (p = 0.044). Other clinical results and OA change in the lateral compartment were not affected by evaluated factors. CONCLUSIONS: Patients who underwent open-wedge HTO showed the satisfactory clinical results and lateral OA progression regardless of the presence or absence discoid LM. However, when discoid LM was present, patients with undercorrection showed higher KS in comparison with patients with acceptable correction.

The patellofemoral joint does not deteriorate clinically after open-wedge high tibial osteotomy.

BACKGROUND: After high tibial osteotomy (HTO), the loading of the lateral compartment can be increased. Moreover, the change of patellar height may adversely affect the patellofemoral joint and functional outcomes. HYPOTHESIS: We hypothesized that the cartilage of the lateral compartment and patellofemoral joint would worsen after open-wedge HTO and the overcorrection of HTO could worsen the cartilage state of the patellofemoral joint. We evaluated the cartilage status and clinical results after medial open-wedge HTO and the factors affecting the outcomes. MATERIALS AND METHODS: From 2011 to 2018, 49 patients who had a mean age of 54.9 years and who underwent medial open-wedge HTO were selected. Plate removal was performed at a mean of 37.0 (range, 13-89) months after HTO, whereas diagnostic arthroscopy was performed during medial open-wedge HTO and plate removal. The cartilage status of each joint and the clinical results, including the Hospital for Special Surgery (HSS) score, Knee Society knee score (KS) and function score (FS), and patellar score, were compared. We evaluated the postoperative changes in the cartilage status and clinical scores. Additionally, we evaluated whether the postoperative correction degree could affect the clinical results. RESULT: After medial open-wedge HTO, the patellar height decreased. There was no change in the cartilage at the patellar and femoral trochlear groove. The HSS score, KS, and FS improved, but the patellar score remained unchanged. In the overcorrection group, the cartilage status significantly deteriorated at the lateral tibia condyle as compared with that in the undercorrection group. Higher preoperative clinical scores were associated with less postoperative improvement. DISCUSSION AND CONCLUSION: The outcomes in the patellofemoral joint, including the cartilage condition and clinical scores, did not change after open-wedge HTO, despite patellar infera. Additionally, they were not influenced by the correction degree. Higher preoperative clinical scores were associated with less postoperative improvement. LEVEL OF EVIDENCE: IV; retrospective study.

Does proximal femoral nail antirotation achieve better outcome than previous-generation proximal femoral nail?

BACKGROUND: There are few studies in the literature comparing the clinical outcomes and radiographic results of proximal femoral nail (PFN) and proximal femoral nail antirotation (PFNA) for pertrochanteric femoral fracture (PFF) in elderly patients. AIM: To evaluate both clinical and radiographic outcomes after fixation with PFN and PFNA in an elderly patient population. METHODS: One hundred fifty-eight patients older than 65 years with PFF who underwent fixation with either PFN or PFNA were included. Seventy-three patients underwent fixation with PFN, whereas 85 were fixed with PFNA. The mean follow-up was 2.4 years (range, 1-7 years). Clinical outcome was measured in terms of operation time, postoperative function at each follow-up visit, and mortality within one year. Radiographic evaluation included reduction quality after surgery, Cleveland Index, tip-apex distance (TAD), union rate, time to union, and sliding distance of the screw or blade. Complications including nonunion, screw cutout, infection, osteonecrosis of the femoral head, and implant breakage were also investigated. RESULTS: Postoperative function was more satisfactory in patients who underwent PFNA than in those who underwent PFN (P = 0.033). Radiologically, the sliding difference was greater in PFN than in PFNA patients (6.1 and 3.2 mm, respectively, P = 0.036). The rate of screw cutout was higher in the PFN group; eight for PFN (11.0%) and two for PFNA patients (2.4%, P = 0.027). There were no differences between the two groups in terms of operation time, mortality rate at one year after the operation, adequacy of reduction, Cleveland Index, TAD, union rate, time to union, nonunion, infection, osteonecrosis, or implant breakage. CONCLUSION: Elderly patients with PFF who underwent PFNA using a helical blade demonstrated better clinical and radiographic outcomes as measured by clinical score and sliding distance compared with patients who underwent PFN.

Can medial stability be preserved after open wedge high tibial osteotomy?

PURPOSE: This study evaluated the medial joint stability after high tibial osteotomy (HTO) releasing the superficial medial collateral ligament (sMCL) without cutting and repairing. METHODS: Twenty-one patients who performed HTO were enrolled. After an L-shaped incision was made in the pes anserinus, the sMCL was released from the distal portion during surgery. After plate fixation, the sMCL was reattached and the pes anserinus was repaired underneath the plate. Plate removal was performed after 31.1 ± 14.2 months. Before HTO, a valgus force of 40 N was exerted at extension for reference values. Before and after plate removal, a valgus force of 40 N was exerted at extension and at a flexion position of 20°. Medial stability was evaluated by measuring the joint line convergence angle (JLCA). RESULTS: The JLCAs in the extension state before HTO and plate removal were 1.64° ± 1.15° and 1.83° ± 1.36°, respectively; there was no significant difference (p = 0.198). There was also no significant difference in JLCA before HTO and after plate removal (p = 0.835). There was also no significant difference in JLCA before and after plate removal both at a knee extension and flexion position of 20° (p = 0.348 and p = 0.456, respectively). CONCLUSIONS: Releasing the sMCL without cutting and repairing the pes anserinus underneath the plate during medial open wedge HTO could facilitate the maintenance of medial joint stability.

A comparative study between thoracoscopic surgery and posterior surgery using all-pedicle-screw constructs in the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To present the results of thoracoscopic surgery in the treatment of adolescent idiopathic scoliosis (AIS) and to compare the results of thoracoscopic surgery with those of posterior surgery. SUMMARY OF BACKGROUND DATA: Although racoscopic scoliosis correction has attracted attention since the early 2000s, its use has declined gradually, whereas posterior surgery using pedicle screws has become popular. Few studies have compared thoracoscopic surgery with posterior pedicle screw fixation for single thoracic AIS correction. METHODS: Sixty-five patients with Lenke type-1 AIS were included and followed up for a minimum of 24 months. Forty-two patients underwent thoracoscopic surgery (thoracoscopic group) and 23 patients underwent posterior surgery (posterior group). Radiographic outcomes, including the correction rate and loss of correction, perioperative morbidities, and complications, were compared. RESULTS: Both groups were similar in terms of the preoperative baseline data. Although the correction rate of major thoracic curve was similar, the posterior group had a tendency to have a greater correction rate (72% vs. 66%). A loss of correction was significantly greater in the thoracoscopic group. The thoracoscopic group had a longer operation time and less intraoperative blood loss, with a lower transfusion rate than the posterior group. There was no difference at the last follow-up in terms of pain score and satisfaction. Five implant failures (12%) occurred in the thoracoscopic group and none in the posterior group. There were 3 patients with significant pulmonary complications necessitating active treatments in the thoracoscopic group. CONCLUSIONS: Despite its advantages, thoracoscopic surgery is losing its place in the surgical correction of AIS because of the frequent perioperative pulmonary complications and fixation problems compared with posterior pedicle screw fixation. Nevertheless, it can be utilized in selected cases particularly in cases of patient's strong demand for minimally invasive surgery.

Metastatic spinal tumor.

In accordance with extending survival periods of cancer patients, number of consecutively developing metastatic spinal tumor is also increasing. There have been improvements in the treatment results of metastatic spine tumor by virtue of the developments in diagnostic radiology, chemotherapy, adjuvant treatment, operative device and technique, discrete preoperative plan, and standardized operation. Accordingly, surgical indication has also increased. Clinically, in case of metastatic spine tumor, treatment of tumor itself should be focused on pain relief, preservation of neurologic function, prevention of pathologic fracture, prevention of pathologic fracture, and correction of spinal instability for improving quality of life, rather than for extension of survival. Additionally, etiology of spinal tumor, correct diagnosis and subsequent treatment principles should be thoroughly understood before establishing treatment plans for effective treatments.

Long-term results of anterior cruciate ligament reconstruction using bone-patellar tendon-bone: an analysis of the factors affecting the development of osteoarthritis.

PURPOSE: To evaluate the clinical outcomes and incidence of knee osteoarthritis (OA) and the factors associated with the onset of OA in the 3 compartments of the knee joint separately after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft. METHODS: Clinical and radiologic assessments were obtained from 117 patients (80.1%). At follow-up, knee function was evaluated with the Lysholm score, Hospital for Special Surgery (HSS) score, Tegner score, and International Knee Documentation Committee (IKDC) 2000 forms. We also evaluated stability and donor-site morbidity. On the follow-up radiographs, OA was assessed by IKDC grading. The factors affecting the onset of OA in the 3 compartments of the knee joint were evaluated. RESULTS: The mean follow-up period was 10.3 ± 1.0 years. The mean Lysholm and HSS scores significantly increased at final follow-up (P < .001). The mean IKDC subjective score was 90.6, and 93.9% of patients had grade A or grade B knees on the objective evaluation. The mean side-to-side difference measured by KT-2000 arthrometer (MEDmetric, San Diego, CA) was 1.6 ± 1.7 mm, with 82.0% of patients showing a difference of less than 3 mm. Discomfort from knee walking on hard ground and skin numbness were reported by 38.4% and 37.6% of patients, respectively. OA developed in the medial, lateral, and patellofemoral compartments in 30.7%, 9.3%, and 7.6% of patients, respectively. The onset of OA was associated with partial meniscectomy (odds ratio [OR], 20.73; P = .005) or sagittal tibial tunnel position (OR, 1.18; P = .02) in the medial compartment and body mass index (BMI) (OR, 1.56; P = .02) in the lateral compartment. CONCLUSIONS: ACL reconstruction with bone-patellar tendon-bone autograft showed satisfactory clinical results after a mean of 10.3 years. However, pain when walking on hard ground (38.4%) and numbness of the skin (37.6%) were reported. Moreover, the onset of OA appeared in over 40% of the patients. The onset of OA in the medial compartment was correlated with partial meniscectomy and sagittal tibial tunnel position, and the onset of OA in the lateral compartment was correlated with higher BMI. LEVEL OF EVIDENCE: Level IV, therapeutic case series.