Distal Femoral Medial Opening Wedge Osteotomy for Post-Traumatic, Distal Femoral Varus Deformity.

Restoration of neutral mechanical alignment of the lower limb is an important factor in the treatment of unicompartmental arthrosis. Traditionally, medial opening wedge high tibial osteotomy has been widely performed to correct varus malalignment with unicompartmental arthrosis. However, an ideal indication for the high tibial osteotomy is the knee with metaphyseal tibial varus malalignment. The basic principle of corrective osteotomy is performing an osteotomy at the center of the deformity to prevent abnormal joint line obliquity. If pathologic distal femoral varus deformity is the cause of genu varum, the osteotomy should be performed in the distal femur. Reports of medial opening wedge distal femoral osteotomy (DFO) to correct varus malalignment are rare. We present a case of this very rare and challenging condition in a 47-year-old male, which was successfully treated by medial opening wedge DFO.

Analysis of impingement-free range of motion of the glenohumeral joint after reverse total shoulder arthroplasty using three different implant models.

BACKGROUND: This study aimed to investigate impingement-free range of motion (ROM) of the glenohumeral joint following reverse total shoulder arthroplasty (RTSA) with three types of implant models using computational motion analysis. METHODS: Three-dimensional (3D) scapulohumeral models were created from preoperative computed tomography (CT) images of seven patients by using visualization and computer-aided design software. Three types of implant designs, namely, typical medialization, in between, and lateralization implants, were used for the reconstruction of 3D model; each design was designated as group I, II, and III, respectively. All possible combinations of virtual surgeries were evaluated for impingement-free ROM in all three groups. Maximal ROMs were compared. The effect of implant positions on ROM of the shoulder joints were investigated in each group. RESULTS: The all lateralization group (group III) showed significantly greatest maximal adduction, abduction and external rotation (ER). Adduction and abduction were significantly increased by the glenoid component inferior translation in all three groups. (In group I, p < 0.001 for adduction, p = 0.002 for abduction, respectively; in group II, p = 0.025, p < 0.001, respectively; in group III, p = 0.038, p = 0.011, respectively). Increasing humerus retroversion might have some effect on increasing abduction. In group II and III, internal rotation (IR) and ER were significantly affected by the humerus retroversion (in group II, p = 0.033 for IR, p = 0.007 for ER, respectively; in group III, p = 0.004, p < 0.001, respectively). In group III, ER was also significantly affected by the glenoid component inferior translation (p = 0.003). CONCLUSIONS: Lateralization design model showed greatest ROM of the shoulder joint. The effects of implant positions on impingement-free ROM exhibited different tendencies between medialization and lateralization implant models. Humerus retroversion affected both IR and ER, especially in lateralization design. Increasing glenoid inferior translation increases both adduction and abduction regardless of implant designs.

Arthroscopic Coracoclavicular Fixation Using Multiple Low-Profile Devices in Acute Acromioclavicular Joint Dislocation.

PURPOSE: To introduce an arthroscopically assisted coracoclavicular (CC) fixation technique using multiple low-profile devices to evaluate the clinical and radiologic outcomes in patients with acute high-grade acromioclavicular (AC) joint dislocation. METHODS: Between July 2014 and September 2015, cases of AC joint dislocation that were treated with arthroscopic CC fixation using multiple low-profile devices with a minimum follow-up of 24 months were included. We measured the vertical coracoclavicular distance (CCD) on the anteroposterior view and the horizontal acromioclavicular distance on 3-dimensional computed tomography images to evaluate the changes in radiologic outcomes before and after surgery. We compared final radiologic outcomes between initial AC reduction groups based on hierarchical clustering. Clinical outcomes were evaluated using the Constant-Murley score. RESULTS: We enrolled 27 patients in total, and the mean follow-up period was 27.2 months. The mean CCD of the injured shoulder was 13.68 ± 3.98 mm preoperatively and decreased to 5.72 ± 1.68 mm immediately postoperatively but increased to 7.32 ± 2.29 mm at last follow-up (P = .07). Horizontal displacement of the distal clavicle was 1.1 ± 1.0 mm immediately postoperatively but decreased to 0.9 ± 0.6 mm at last follow-up (P < .05). In particular, in the 2 groups that were determined using the hierarchical cluster analysis, patients with excellent recovery of the initial CCD (20 patients) showed less of an increase in the CCD at last follow-up than did those in the other group (7 patients) (P < .001). The Constant-Murley score was 93.5 ± 2.7 points on the injured side at last follow-up (P = .074). CONCLUSIONS: Our CC fixation technique with multiple low-profile devices exhibited satisfactory clinical and radiologic outcomes. In particular, ensuring good initial recovery of the CCD and the precise placement and location of the AC joints was important in maintaining the proper AC position at the final follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Collagenous Ultrastructure of the Discoid Meniscus: A Transmission Electron Microscopy Study.

BACKGROUND: The collagen ultrastructure of the discoid lateral meniscus (DLM) has not been precisely defined. PURPOSE: To investigate the ultrastructure of the DLM, focusing on its collagen fibers, and to compare the collagen net architecture between intact and torn DLMs using the Collagen Meniscal Architecture (CMA) scoring system. STUDY DESIGN: Descriptive laboratory study. METHODS: Thirty specimens were taken from 30 patients with a diagnosis of a complete DLM using a 1-piece technique. The collagen ultrastructure of the DLMs was assessed with transmission electron microscopy. To evaluate the meniscal ultrastructure, the degree of collagen disruption, intrafibrillar edema, loss of banding, degree of collagen packing, and fibril size variability were assessed and graded from 1 (normal) to 3 (severe disarray) according to the CMA scoring system. The DLM specimens were divided into 3 groups according to the intrasubstance tear: the intact group (group I) had no tear; the simple tear group (group S) had a radial, longitudinal, or horizontal tear; and the complicated tear group (group C) had a complicated horizontal tear. Intact normal meniscus specimens (group N) were used as the control group. RESULTS: There were 10 specimens in group I, 8 in group S, 12 in group C, and 13 in group N. In group I, there were 5 grade 1 and 5 grade 2 menisci; group S had 2 grade 1, 3 grade 2, and 3 grade 3 menisci; group C had 1 grade 1, 4 grade 2, and 7 grade 3 menisci; and group N had 4 grade 1, 7 grade 2, and 2 grade 3 menisci. A significant difference in the CMA score was observed between the 4 groups ( P = .009). The median CMA score was significantly lower in group I (2; range, 1-4) than in group S (4; range, 2-7) ( P = .041) and group C (4.25; range, 1.5-7) ( P = .018). No significant difference was found between groups S, C, and N. CONCLUSION: Variability existed in the collagen ultrastructure of the DLM, and some DLMs showed a nearly normal ultrastructural pattern. The degree of density and disorganization of the collagen architecture in the DLM was related to the tear. CLINICAL RELEVANCE: The study results might provide a histological background for partial meniscectomy in the treatment of a symptomatic DLM.

Effect of the combinatory mixture of Rubus coreanus Miquel and Astragalus membranaceus Bunge extracts on ovariectomy-induced osteoporosis in mice and anti-RANK signaling effect.

ETHNOPHARMACOLOGICAL RELEVANCE: Postmenopausal osteoporosis is one of the most common disorders in women after menopause, which is linked to an estrogen deficiency and characterized by an excessive loss of trabecular bone. Rubus coreanus and Astragalus membranaceus have been used for their various pharmacological properties in Asia as a traditional medicine. The present study evaluated the anti-osteoporotic effects of the optimal combination of Rubus coreanus and Astragalus membranaceus in 7:3 mixture (RAM) in ovariectomized (OVX) mice by investigating bone biomechanical properties and the serum levels of TNF-α, osteocalcin, RANKL, OPG, and RANK-RANKL signal-related osteoclast differentiation markers. MATERIALS AND METHODS: A total of 36 mature female outbred ICR (Institute of cancer research) strain mice (7 weeks) were divided into 6 groups with 7 mice in each group as follows: (1) Sham-operated control mice (Sham) received daily oral phosphate-buffered-saline (PBS) of equal volumes through gavage. (2) OVX mice received a daily oral gavage of PBS (OVX). (3) OVX mice were treated daily with 50mg/kgb.w./day of RAM (4) with 100mg/kgb.w./day of RAM or (5) with 200mg/kgb.w./day of RAM via oral gavage. (6) OVX mice received i.p. injections of 17ß-estradiol (E2) (0.1mg/kgb.w./day) three times per week for 12 weeks. RESULTS: Micro-CT images showed that oral administration of RAM to OVX mice prevented tibial bone loss, preserved trabecular bone microarchitecture, and improved bone biomechanical properties. RAM administration also showed recovery effects on the levels of TNF-α, OPG and RANKL concentration in OVX-states. Additionally, we found that the mechanism by which RAM elicited anti-osteoporotic effects was by down-regulating the expression of TRAF6 and NFATc1 in RANKL-RANK pathway, a route of osteoclast differentiation, followed by reducing the production of osteoclast differentiation factors, calcitonin receptors and cathepsin K. CONCLUSIONS: Our research strongly suggests that RAM can be clinically used in the prevention and treatment of postmenopausal osteoporosis.