Surgical management of severe planovalgus foot deformity in children with generalised joint hypermobility.

BACKGROUND: This study aimed to evaluate the outcomes of calcaneal lengthening osteotomy (CLO) and double arthrodesis of the talonavicular and calcaneocuboid joints (DA) for correcting planovalgus foot deformity exclusively in patients with generalised joint hypermobility. METHODS: We retrospectively reviewed 29 feet in 17 consecutive patients who underwent either CLO or DA. The mean age at surgery was 11.3 ± 2.3 years, and the mean follow-up duration was 7.7 ± 3.2 years. Preoperative and final follow-up radiographs and dynamic foot-pressure measurements were analysed. RESULTS: Both operations significantly improved the radiographic parameters, except for the lateral talocalcaneal angle in the CLO group. Pedobarographic study demonstrated an elevation of the medial longitudinal arch and an improved foot-pressure distribution after both surgeries. The plantar pressure in the lateral forefoot significantly increased only in the DA group, while the pressures exerted on the medial forefoot and hindfoot and the arch index improved only in the CLO group. CONCLUSIONS: Both CLO and DA effectively improve the foot alignments of the deformity in patients with generalised joint hypermobility. However, differences were observed in the changes in the lateral talocalcaneal angle and plantar pressure distribution between the two procedures. LEVEL OF EVIDENCE: Therapeutic Level III.

Effect of Solitary Osteochondroma on Alignment and Length in the Lower Extremities.

BACKGROUND: There is a lack of information about the effects of untreated solitary osteochondroma (SO) on longitudinal growth of the lower extremities in children and adolescents. This study aimed to assess the coronal alignment and length of the lower extremity in patients with SO around the knee and to identify the factors related to the development of deformities. METHODS: We retrospectively reviewed 111 patients diagnosed with SO around the knee. The patients were classified into 2 groups depending on the location of the SO: 51 in the distal femur and 60 in the proximal tibia. Characteristics of the lesions, such as type, location, size, and distance from the joint line, were determined. Radiographic analysis of the lower limbs included mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, whole-leg length, femoral length, and tibial length. RESULTS: The mean age at the time of diagnosis was 12.3±3.4 years. No statistically significant differences were found between the affected and contralateral sides for mechanical lateral distal femoral angle and mechanical medial proximal tibial angle in either the distal femur or the proximal tibia groups. In patients with femoral lesions, the femoral and whole-leg lengths were significantly shorter on the affected side than on the unaffected side ( P <0.001 and 0.002, respectively), and the mean differences were 2.1±3.6 and 2.1±4.4 mm, respectively. Univariate logistic regression analysis did not reveal any factors associated with limb length discrepancy (LLD). In patients with tibial lesions, no statistically significant differences were found in LLD. CONCLUSIONS: SOs around the knee did not cause clinically significant deformity of the lower extremity. However, in contrast to proximal tibia lesions, SO in the distal femur was associated with the shortening of the affected limb. Consideration should be given to the development of LLD in skeletally immature children with SO in the distal femur. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Overgrowth of long bone in rabbits by growth stimulation through metaphyseal hole creation.

Overgrowth of long bones was noted in pediatric patients who underwent anterior cruciate ligament reconstruction. Hyperaemia during creating a metaphyseal hole and the microinstability made by the drill hole may induce overgrowth. This study aimed to determine whether metaphyseal hole creation accelerates growth and increases bone length and compare the effects of growth stimulation between metaphyseal hole creation and periosteal resection. We selected 7- to 8-week-old male New Zealand white rabbits. Periosteal resection (N = 7) and metaphyseal hole creation (N = 7) were performed on the tibiae of skeletally immature rabbits. Seven additional sham controls were included as age-matched controls. In the metaphyseal hole group, the hole was made using a Steinman pin at the same level of periosteal resection, and the cancellous bone beneath the physis was removed by curettage. The vacant space in the metaphysis below the physis was filled with bone wax. Tibiae were collected 6 weeks after surgery. The operated tibia was longer in the metaphyseal hole group (10.43 ± 0.29 cm vs. 10.65 ± 0.35 cm, P = 0.002). Overgrowth was higher in the metaphyseal hole group (3.17 ± 1.16 mm) than in the sham group (- 0.17 ± 0.39 mm, P < 0.001). The overgrowth in the metaphyseal hole group was comparable to that in the periosteal resection group (2.23 ± 1.52 mm, P = 0.287). In rabbits, metaphyseal hole creation and interposition with bone wax can stimulate long bone overgrowth, and the amount of overgrowth is similar to that seen in periosteal resection.

Natural behaviours after guided growth for idiopathic genu valgum correction: comparison between percutaneous transphyseal screw and tension-band plate.

BACKGROUND: Percutaneous epiphysiodesis using a transphyseal screw (PETS) or tension-band plating (TBP) has shown favourable correction results; however, the physeal behaviours in terms of rebound, stable correction, or overcorrection after guided growth have not been completely understood. In patients with idiopathic genu valgum, we therefore asked: (1) How is the correction maintained after implant removal of guided growth? (2) Is there any difference in the natural behaviours after PETS or TBP removal at the femur and tibia? METHODS: We retrospectively reviewed 73 skeletally immature limbs with idiopathic genu valgum treated with PETS or TBP. PETS was performed in 23 distal femurs and 13 proximal tibias, and TBP was performed in 27 distal femurs and ten proximal tibias. Mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle were measured at pre-correction, implant removal, and final follow-up. Changes of ≤ 3° in mechanical angles after implant removal were considered stable. Comparisons between the implant, anatomical site, and existence of rebound were performed. RESULTS: The mean MAD improved from - 18.8 mm to 11.3 mm at implant removal and decreased to -0.2 mm at the final follow-up. At the final follow-up, 39 limbs (53.4%) remained stable and only 12 (16.4%) were overcorrected. However, 22 limbs (30.1%) showed rebound. TBP was more common, and the correction period was longer in the rebound group (p < 0.001 and 0.013, respectively). In femurs treated with PETS, the mean mLDFA increased from 86.9° at implant removal to 88.4° at the final follow-up (p = 0.031), demonstrating overcorrection. However, a significant rebound from 89.7° to 87.1° was noted at the femur in the TBP group (p < 0.001). The correction of the proximal tibia did not change after implant removal. CONCLUSION: The rebound was more common than overcorrection after guided growth; however, approximately half the cases demonstrated stable correction. The overcorrection occurred after PETS in the distal femur, while cases with TBP had a higher probability of rebound. The proximal tibia was stable after implant removal. The subsequent physeal behaviours after each implant removal should be considered in the guided growth.

Fate of hips complicated by avascular necrosis of the femoral head following reconstructive surgery in nonambulatory patients with cerebral palsy.

The purpose of this study was to evaluate the influence of avascular necrosis of the femoral head (AVN) following hip reconstructions on the future hip development of cerebral palsy (CP) patients. A retrospective study of 394 hips in 205 nonambulatory patients with spastic CP who underwent reconstructive hip surgery was performed. The mean age at surgery was 7.3 ± 2.4 years. The mean follow-up duration was 5.6 ± 2.7 years, and the mean age at the latest follow-up was 12.8 ± 3.4 years. AVN was classified in terms of its severity and location. Femoral head remodelling was assessed by the spherical index and the Mose circle. An unsatisfactory radiological outcome was defined as having a migration percentage of more than 30% at the final follow-up. AVN was observed in 169 (42.9%) hips. Older age at the time of surgery, higher preoperative migration percentage, and open reduction procedures were predictors for the development of AVN. Hips with AVN confined to the lateral epiphysis, and AVN involving the entire epiphysis with preserved height experienced successful remodelling. 27 (65.9%) of the 41 hips with unsatisfactory outcomes experienced AVN. Younger age, higher postoperative migration percentage, and occurrence of AVN were related to unsatisfactory outcomes. The highest incidence of failed remodelling and unsatisfactory outcomes were observed in hips with entire epiphyseal involvement and more than 50% loss of its height. AVN following hip reconstructions is not necessarily associated with poor hip development, however, depending on the severity and location, it is a prognostic factor for unsatisfactory radiological outcomes.

Hip-Spine Syndrome in Patients With Spinal Cord Injuries: Hyperlordosis Associated With Severe Hip Flexion Contracture.

Aim: Spinal cord injury (SCI)-related flaccid paralysis may result in a debilitating hyperlordosis associated with a progressive hip flexion contracture. The aim of this study was to evaluate the correction of hip flexion contractures and lumbar hyperlordosis in paraplegic patients that had a history of spinal cord injuries. Methods: A retrospective review was performed on 29 hips of 15 consecutive patients who underwent corrective surgeries for severe hip flexion deformity from 2006 to 2018. The mean age at surgery was 10.1 years (2.7 to 15.8), and the mean follow-up was 68 months (7 to 143). Relevant medical, surgical, and postoperative information was collected from the medical records and radiographs. Results: Improvements were seen in the mean hip flexion contracture (p < 0.001) with 100% hip correction at surgery and 92.1% at the latest follow-up. Mean lumbar lordosis decreased (p = 0.029) while the mean Cobb angle increased (p = 0.001) at the latest follow up. Functional score subdomains of the Spinal Cord Independence Measure, Functional Independence Measure, and modified Barthel activities of daily living (ADL) scores remained the same at the final follow-up. Conclusion: For paraplegic SCI patients, we found an association between treating the hip flexion contracture and indirect correction of their lumbar hyperlordosis. We recommend the surgeon carefully examine the hip pathology when managing SCI-related spinal deformities, especially increased lumbar lordosis.

Anatomic Differences in the Sagittal Knee Joint Are Associated With ACL Injury: Results From a Skeletally Immature Korean Population.

BACKGROUND: Differences in tibiofemoral articular morphology are associated with risks of anterior cruciate ligament (ACL) injury. PURPOSE: To determine whether bony and cartilaginous morphological characteristics are related to ACL injury in pediatric patients and to investigate any differences according to sex. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 200 skeletally immature Korean patients from a single institution were included in this study; 100 patients had an ACL injury, and 100 had an intact ACL. Condylar morphology and tibial slopes were evaluated and compared between the groups, and differences between sexes were evaluated in the ACL-injured group. RESULTS: The lateral femoral curvature was significantly greater and the lateral and medial tibial curvatures were significantly smaller in the ACL-injured group than in the intact group (P < .01 for all). In addition, the lateral and medial femoral curvatures as well as the lateral tibial curvature were significantly smaller in female than in male patients (P < .01 for all). Both the medial and lateral tibial slopes were greater in the ACL-injured versus intact group (medial slope, 5.5° vs 5.0°; lateral slope, 3.0° vs 1.3°, respectively); this difference was statistically significant for lateral tibial slope (P = .026). No sex-based differences were found for medial or lateral tibial slope. CONCLUSION: Femoral and tibial curvatures as well as lateral tibial slope were significantly different between the ACL-injured and ACL-intact patients, and the lateral tibial curvature was significantly smaller in female than in male patients. Medial and lateral tibial slopes were not associated with a significant difference in ACL injury between male and female patients.

One-Stage Extension Shortening Osteotomy for Syndromic Camptodactyly.

Syndromic camptodactyly often affects multiple fingers, and severe deformities are common compared to idiopathic camptodactyly. This study aimed to evaluate the use of a one-stage extension shortening osteotomy of the proximal phalanx for patients with syndromic camptodactyly without tendon surgery. Forty-nine cases of syndromic camptodactyly were included. Forty fingers (81.6%) were associated with arthrogryposis multiplex congenita, and nine (18.4%) with other syndromes. Six fingers presented with a moderate form (30° to 60°) of camptodactyly, whereas 43 fingers manifested the severe form (>60°). The mean age at the time of surgery was 8.5 years, and the patients were followed for a mean of 3.9 years. The mean length of the shortening of the proximal phalanx was 4.9 mm, which averaged 17.8% of the proximal phalanx's original preoperative length. The mean operative time was 25.8 min, and the PIP joint was fixed using Kirschner wires with an average flexion position of 7.6°. The mean flexion contracture improved from 76° preoperatively to 41° postoperatively. The mean preoperative active arc of motion was 23°, which improved to 49° postoperatively. A one-stage extension shortening osteotomy is a straightforward and effective technique for the improvement of finger function through the indirect lengthening of volar structures without the flexor tendon lengthening. The osteotomy could simultaneously correct bony abnormalities. This simple procedure is especially suitable for surgery on multiple fingers in patients with syndromic camptodactyly.

Femoral trochlear morphology is associated with anterior cruciate ligament injury in skeletally immature patients.

PURPOSE: Knee joint morphology is a known contributor to anterior cruciate ligament (ACL) injury, and the shape of the distal femur condyle is one of the associated factors. However, the relationship between femoral trochlear morphology and ACL injury is unclear, especially in pediatric patients. Therefore, the present study aimed to evaluate the effect of femoral trochlear morphology on ACL injury in pediatric patients and investigate the possibility of gender differences. METHODS: In total, 116 skeletally immature children aged 3-18 years with primary ACL injuries were matched with a control group of 116 skeletally immature children. Lateral trochlear inclination, trochlear facet asymmetry, trochlear depth, and sulcus angle were evaluated using magnetic resonance imaging (MRI). Differences between patient groups and gender were investigated. Receiver-operating characteristic (ROC) curves were constructed to obtain the sensitivity and specificity of all parameters. RESULTS: A significant difference was observed in the sulcus angle and trochlear inclination between the ACL injury and control groups (p < 0.05). No significant difference was observed between the ACL injury and control groups with respect to the anatomic patellar instability risk factors. All parameters showed an area under the curve of 0.6 in the ROC analysis, indicative of failure of the diagnostic test. CONCLUSIONS: There was a significant association between femoral trochlear morphology and increased risk of ACL injury in pediatric patients. No gender difference was found except in the trochlear depth. It was showed that the difference in trochlear morphology should be considered between normal children and pediatric patients with ACL injury to increase the awareness regarding ACL injuries. LEVEL OF EVIDENCE: III.

Outcome of Femoral Varus Derotational Osteotomy for the Spastic Hip Displacement: Implication for the Indication of Concomitant Pelvic Osteotomy.

No previous studies have suggested a reliable criterion for determining the addition of a concomitant pelvic osteotomy by using a large patient cohort with quadriplegic cerebral palsy and a homogenous treatment entity of femoral varus derotational osteotomies (VDRO). In this retrospective study, we examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement. We wished to investigate potential predictors for re-subluxation or re-dislocation after the index operation, and to suggest the indications for a simultaneous pelvic osteotomy. We reviewed the results of 144 VDROs, with or without open reduction, in 72 patients, at a mean follow-up of 7.0 (2.0 to 16.0) years. Various radiographic parameters were measured, and surgical outcomes were assessed based on the final migration percentage (MP) and the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grades. The effects of potential predictive factors on the surgical outcome was assessed by multivariate regression analysis. A receiver operating characteristic (ROC) curve analysis was also performed to determine whether a threshold of each risk factor existed above which the rate of unsatisfactory outcomes was significantly increased. In total, 113 hips (78.5%) showed satisfactory results, classified as MCPHCS grades I, II, and III. Thirty-one hips (21.5%) showed unsatisfactory results, including six hip dislocations. Age at surgery and preoperative acetabular index had no effects on the results. Lower pre- and postoperative MP were found to be the influential predictors of successful outcomes. The inflection point of the ROC curve for unsatisfactory outcomes corresponded to the preoperative MP of 61.8% and the postoperative MP of 5.1%, respectively; these thresholds of the pre- and postoperative MP may serve as a guideline in the indication for a concomitant pelvic osteotomy. Our results also indicate that the severely subluxated or dislocated hip, as well as the hip in which the femoral head is successfully reduced by VDRO but is still contained within the dysplastic acetabulum, may benefit from concomitant pelvic osteotomy.

Overgrowth of the Femur After Internal Fixation in Children With Femoral Shaft Fracture-A Multicenter Study.

OBJECTIVES: To evaluate overgrowth after internal fixation for pediatric femur fracture and to identify any factors related with overgrowth in terms of fracture type and fixation method. DESIGN: Retrospective comparative study. SETTING: Multicenter, children's hospital and general hospital. PATIENTS/PARTICIPANTS: Eighty-seven children between 4 and 10 years of age were included. Length-stable fracture was noted in 49 children, and length-unstable fracture was found in 38 children. INTERVENTION: Thirty-six children were treated by minimal invasive plate osteosynthesis (MIPO), and elastic stable intramedullary nail fixation (ESIN) was used in 51 children. MAIN OUTCOME MEASUREMENTS: The degree of overgrowth after internal fixation compared to fracture type, fracture site, and surgical method. Multivariable logistic regression analysis was conducted to identify factors related with overgrowth. RESULTS: The average overgrowth of the femur was 10.5 ± 7.3 mm. There was no patient who required correction for final leg length discrepancy (>2 cm). There was no significant difference in overgrowth between ESIN (9.9 ± 7.2 mm) and MIPO (11.2 ± 7.6 mm) (P = 0.417). Overgrowth was similar among length-unstable fractures (12.3 ± 7.4 mm) and length-stable fractures (9.2 ± 7.0 mm), although it was statistically greater in length-unstable fractures (P = 0.048). In the MIPO group, length-unstable fractures were associated with an increased log odds of 6.873 for overgrowth of the femur (P = 0.042). CONCLUSIONS: Femur overgrowth after internal fixation seems to not be a clinically significant problem, regardless of whether that be for length-stable or length-unstable fractures and whether they were treated by MIPO or ESIN. Length-unstable fracture may be a risk factor for overgrowth in children. However, the difference is very small, and the postoperative overgrowth would likely not be a significant factor in deciding the surgical plan. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for authors for a complete description of levels of evidence.

Distal Femoral Shortening Osteotomy for Severe Knee Flexion Contracture and Crouch Gait in Cerebral Palsy.

Although there have been advancements of surgical techniques to correct gait abnormalities seen in patients with cerebral palsy, the crouch gait remains one of the most difficult problems to treat. The purpose of this retrospective study was to examine our results of distal femoral shortening osteotomy (DFSO) and patellar tendon advancement (PTA), performed in patients with crouch gait associated with severe knee flexion contracture. A total of 33 patients with a mean fixed knee contracture of 38° were included in the study. The mean age at the time of surgery was 12.2 years and the mean follow-up was 26.9 months. The measurements of clinical, radiological, and gait parameters were performed before and after surgery. The mean degrees of knee flexion contracture, Koshino index of patella height, and Gait Deviation Index were found to be significantly improved at the time of final follow-up. The maximum knee extension during the stance phase improved by an average of 25°, and the range of knee motion during gait increased postoperatively. On the other hand, the mean anterior pelvic tilt increased by 9.9°. Also, the maximum knee flexion during the swing phase decreased and the timing of peak knee flexion was observed to be delayed. We conclude that combined procedure of DFSO and PTA is an effective and safe surgical method for treating severe knee flexion contracture and crouch gait. However, the surgeons should be aware of the development of increased anterior pelvic tilt and stiff knee gait after the index operation.

Clinical and Gait Parameters Related to Pelvic Retraction in Patients with Spastic Hemiplegia.

Pelvic retraction during walking is a common finding seen in patients with spastic hemiplegia. However, potential factors related to this condition have not been comprehensively examined in a systemic manner in previous studies. The purpose of this study was to elucidate any clinical and gait parameters related to pelvic retraction in patients with hemiplegic cerebral palsy. A total of 212 independent ambulatory patients were enrolled in the study. Group I consisted of 113 patients who had persistent pelvic retraction, and Group II of 99 with a normal range of pelvic rotation throughout the gait cycle as evidenced by kinematic analysis. A multivariate logistic regression analysis using a clustering technique was performed, with use of eight gait factors and five clinical factors. Decreased ankle dorsiflexion, increased hip internal rotation, increased anterior pelvic tilt, the Winters classification type II, and asymmetrical posturing of the upper extremity during gait were found to be related to pelvic retraction. This is the only study including a broader array of assessment domains of both clinical and gait parameters with a considerably large and homogenous population with hemiplegia. Further studies will be needed to see whether the rectification of those parameters may improve abnormal gait and pelvic retraction in hemiplegia.

A comparative evaluation of tibial metaphyseal-diaphyseal angle changes between physiologic bowing and Blount disease.

The purpose of this study was to estimate the rate of spontaneous improvement in tibial metaphyseal-diaphyseal angle (TMDA) in physiologic bowing in comparison to that in Blount disease and to provide reference values of TMDA for monitoring patients with highly suspected to have Blount disease.We retrospectively reviewed patients with physiologic bowing meeting the following criteria:(1) TMDA greater than 9° before 36 months of age at initial evaluation;(2) two or more standing long bone radiographs available; and(3) follow-up conducted up to resolution of deformity.Patients with Blount disease had(1) more than 2 standing long bone radiographs obtained before 36 months of age and(2) underwent no treatment during the period in which these images were obtained.TMDA measurements were obtained from 174 patients with physiologic bowing and 32 patients with Blount disease. Rates of TMDA improvement were adjusted by multiple factors using a linear mixed model, with sex and laterality as fixed effects and age and individual patients as the random effects.In the physiologic bowing group, TMDA improved significantly, by 3° per 6 months and by 6° per year. Changes in TMDA were not significant in the Blount disease group.Knowing the rate of TMDA change can be helpful for physicians seeking to monitor infants with suspected as having Blount disease with a high TMDA and to avoid unnecessary repeat radiographic evaluations.

Functional recovery of daily living and sports activities after cosmetic bilateral tibia lengthening.

PURPOSE: The aims of this study were to evaluate the recovery of physical function and to investigate whether there are factors that adversely affect functional recovery after cosmetic bilateral lengthening of the tibia. METHODS: One hundred twenty-five healthy individuals who had undergone bilateral cosmetic tibia lengthening by the lengthening and then nail (LATN) method, lengthening over intramedullary nail (LON) method or intramedullary skeletal kinetic distractor (ISKD) were included in the study. Functional outcomes were evaluated using the Sports Activity Rating Scale (SARS), International Knee Documentation Committee (IKDC) Subjective Knee Form and patient self-reported ability scores. RESULTS: SARS and IKDC scores decreased at post-operative one year and improved significantly at post-operative two years. SARS and IKDC scores recovered similarly to pre-operative levels. Average patient self-reported ability scores at post-operative two years were 94.6 and 89.9 for daily living and light sports, respectively. However, the average score for moderate-to-strenuous sports was 68.1 and 39 patients (31.2%) recorded below average score for the moderate-to-strenuous sports. CONCLUSIONS: Patients who had undergone bilateral cosmetic tibial lengthening may expect almost full recovery of daily and light sports activities at post-operativetwo years. However, several patients may feel some limitation in moderate-to-strenuous sports activities.

A new relative tumor sizing method in epi-metaphyseal osteosarcoma.

BACKGROUND: The goal of this study was to develop a new method for determining tumor size to predict prognosis with high performance in osteosarcoma. METHODS: This study was approved by the institutional review board. We retrospectively reviewed 41 magnetic resonance (MR) images at diagnosis and 57 MR images after neoadjuvant chemotherapy from 59 patients with non-metastatic, high-grade extremity osteosarcoma, who had undergone surgery between October 1994 and October 2009. RESULTS: A new parameter of tumor axial ratio (TAR) was designed to normalize tumor size by dividing the absolute tumor axial size by the reference bone axial size (RBS) of the affected bone. RBS was defined using anatomical landmarks for each type of bone. Absolute tumor length (ATL), absolute tumor volume (ATV), and relative tumor volume (RTV) were comparatively analyzed. TAR was only significantly decreased after chemotherapy in the survival (P = 0.009) and metastasis-free (P = 0.018) group in the paired t-test. With the Kaplan-Meier method, significant differences in overall survival (log rank P = 0.004) and disease-free survival (Log Rank P = 0.009) were noted between decreased TAR after chemotherapy and increased TAR. After Cox regression analysis, TAR showed an odds ratios of 5.931 for survival (95% Confidence Interval [CI], 1.153-30.513) and 14.144 for metastasis (95% CI, 2.826-70.784), whereas ATL, ATV, and RTV showed no associations with these clinical variables. The AUC value of TAR was 0.713 (95% CI, 0.548 to 0.878) for survival and 0.759 (95% CI, 0.608 to 0.909) for metastasis. CONCLUSIONS: TAR is a novel sizing method with potential as a prognostic tool in osteosarcoma.

Minimum 5-year Follow-up Results of Minimally Invasive Total Knee Arthroplasty Using Mini-Keel Modular Tibial Implant.

PURPOSE: To evaluate the minimum 5-year mid-term clinical and radiological results of minimally invasive surgery total knee arthroplasty (MIS-TKA) using a mini-keel modular tibia component. MATERIALS AND METHODS: We retrospectively evaluated 254 patients (361 cases) who underwent MIS-TKA between 2005 and 2006. The latest clinical and radiological assessments were done in 168 cases that had been followed on an outpatient basis for more than 5 postoperative years. Clinical results were assessed using the Hospital for Special Surgery (HSS) score and Knee Society score. Radiological evaluation included measurements of knee alignment. RESULTS: The average postoperative knee range of motion and HSS score were 134.3°±12.4° and 92.7°±7.0°, respectively. The average postoperative femorotibial angle and tibial component alignment angle were 5.2°±1.7° valgus and 90.2°±1.6°, respectively. The average tibial component posterior inclination was 4.8°±2.1°. The percentage of cases with tibial component alignment angle of 90°±3° was 96.1%, and that with the femorotibial angle of 6°±3° valgus was 94.0%. Radiolucent lines were observed in 20 cases (12.0%): around the femur, tibia, and patella in 14 cases, 10 cases, and 1 case, respectively. However, they were less than 2 mm and non-progressive in all cases. The survival rate was 99.4% and there was no implant-related revision. CONCLUSIONS: MIS-TKA using a mini-keel modular tibial plate showed satisfactory results, a high survival rate, and excellent clinical and radiological results in the mid-term follow-up.

Arthroscopic stabilization for recurrent shoulder instability with moderate glenoid bone defect in patients with moderate to low functional demand.

PURPOSE: The purpose of this study was to investigate the functional outcomes of arthroscopic Bankart repair for recurrent shoulder instability in the setting of moderate glenoid bone defect ranging from 20% to 30% in patients with moderate to low functional demand. METHODS: This study included 36 patients with unilateral recurrent instability and glenoid bone defects of 20% to 30% treated with arthroscopic stabilization. Glenoid bone loss was estimated on the en-face view of preoperative 3-dimensional computed tomography. Joint laxity was assessed clinically by use of the Beighton and Horan criteria, and patients were divided into 2 groups based on the presence of excessive joint laxity, group L (n = 13), or absence of excessive joint laxity, group N (n = 23). Functional assessments were performed with the patient-reported activity level; subjective shoulder value; Rowe score; and University of California, Los Angeles shoulder score. RESULTS: The mean glenoid defect size was 25.1% (range, 20% to 29%), and the overall functional outcomes improved significantly after surgery. A return to greater than 90% of the premorbid activity level was reported by 72% of patients (26 of 36 patients), and patient satisfaction was 83% (30 of 36 patients). There was no significant difference in functional outcomes between groups L and N (subjective shoulder value, 85.0% for group L v 88.9% for group N, P = .397; Rowe score, 83.5 for group L v 92.8 for group N, P = .537; and University of California, Los Angeles shoulder score, 32.2 for group L v 31.9 for group N, P = .697). Recurrent instability occurred in 4 patients (11%), 3 patients in group L (3 of 13, 23%) and 1 patient in group N (1 of 23, 4%), but this difference was not statistically significant (P = .125). CONCLUSIONS: Arthroscopic stabilization for recurrent shoulder instability in patients with moderate to low functional demand produced satisfactory outcomes despite the presence of moderate glenoid bone defects of 20% to 30%. For patients with excessive joint laxity, however, arthroscopic stabilization may not be reliable, with a recurrence rate of 23%. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Effects of Ginkgetin from Ginkgo biloba Leaves on cyclooxygenases and in vivo skin inflammation.

Ginkgetin, a biflavone from Ginkgo biloba leaves, was previously reported to be a phospholipase A2 inhibitor and this compound showed the potent antiarthritic activity in rat adjuvant-induced arthritis as well as analgesic activity. This investigation was carried out to find effects on cyclooxygenase (COX)-1 and -2 including an in vivo effect. Ginkgetin (1 - 10 microM) and the biflavonoid mixture (10 - 50 microg/ml), mainly a 1 : 1 mixture of ginkgetin and isoginkgetin, from G. biloba leaves, inhibited production of prostaglandin E2 from lipopolysaccharide-induced RAW 264.7 cells. This inhibition was mediated, at least in part, by down-regulation of COX-2 expression, but not by direct inhibition of COX-1 or COX-2 activity. Down-regulation of COX-2 by ginkgetin was also proved in the dorsal skin of ICR mouse treated by 12-O-tetradecanoylphorbol 13-acetate (TPA). At total doses of 1,000 microg/site on the dorsal skin (15 mm x 15 mm), ginkgetin inhibited prostaglandin E2 production by 65.6 % along with a marked suppression of COX-2 induction. In addition, ginkgetin and the biflavonoid mixture (100 - 1,000 microg/ear) dose-dependently inhibited skin inflammation of croton oil induced ear edema in mice by topical application. The present study suggests that ginkgetin from G. biloba leaves down-regulates COX-2 induction in vivo and this down-regulating potential is associated with an anti-inflammatory activity against skin inflammatory responses.