Short knee radiographs can be inadequate for estimating TKA alignment in knees with bowing

Purpose@#The aim of this study was to compare the discrepancy of alignment categorization in total knee arthroplasty (TKA) between the anatomical femorotibial angle (aFTA) measured on short knee radiographs and the mechanical hip– knee–ankle axis angle (mHKA) measured on full-length radiographs in knees with and without bowing. @*Methods@#From January 2014 to June 2017, 107 of 526 osteoarthritic knees at our hospital were found to have femoral or tibial bowing. Bowing was defined as a femoral bowing angle (FBA) > 3° or 2° or 7° , mHKA> 3°) alignments. We compared the categorization of alignments between knees with and without bowing using the McNemar test and used logistic regression to find factors for the alignment discordance. @*Results@#Coronal alignment was discordant in 26.2% of the knees with bowing and 13.1% of the knees without bowing (p < 0.001). FBAs were a significant factor affecting the discordance of alignment categorization (OR = 1.152, 95%CI 1.038– 1.279, p = 0.008). @*Conclusion@#Short knee radiographs are insufficient for estimating coronal alignment after TKA, particularly in knees with femoral bowing.Level of evidence: III: Retrospective comparative study.

Evolving Indication of Meniscal Allograft Transplantation / 대한정형외과학회잡지

The first human meniscal allograft transplantations (MATs) were performed 30 years ago. In the early era, candidates were limited to patients who have favorable joint conditions. MAT is currently indicated for patients with post-meniscectomy symptoms, such as compartmental pain or effusion after a subtotal or total meniscectomy. The current indication for MAT is being expanded to other patients who were not indicated previously. The present article reviews how the indications of MAT have changed over the years.

Have Evolving Surgical Methods Improved Clinical Outcomes after Anterior Cruciate Ligament Reconstruction?

No abstract available.

A Randomized, Multicenter, Phase III Trial to Evaluate the Efficacy and Safety of Polmacoxib Compared with Celecoxib and Placebo for Patients with Osteoarthritis

BACKGROUND: The aim of this study was to evaluate the safety and analgesic efficacy of polmacoxib 2 mg versus placebo in a superiority comparison or versus celecoxib 200 mg in a noninferiority comparison in patients with osteoarthritis (OA). METHODS: This study was a 6-week, phase III, randomized, double-blind, and parallel-group trial followed by an 18-week, single arm, open-label extension. Of the 441 patients with knee or hip OA screened, 362 were randomized; 324 completed 6 weeks of treatment and 220 completed the extension. Patients were randomized to receive oral polmacoxib 2 mg (n = 146), celecoxib 200 mg (n = 145), or placebo (n = 71) once daily for 6 weeks. During the extension, all participants received open-label polmacoxib 2 mg. The primary endpoint was the change in Western Ontario and McMaster Universities (WOMAC)-pain subscale score from baseline to week 6. Secondary endpoints included WOMAC-OA Index, OA subscales (pain, stiffness, and physical function) and Physician's and Subject's Global Assessments at weeks 3 and 6. Other outcome measures included adverse events (AEs), laboratory tests, vital signs, electrocardiograms, and physical examinations. RESULTS: After 6 weeks, the polmacoxib-placebo treatment difference was −2.5 (95% confidence interval [CI], −4.4 to −0.6; p = 0.011) and the polmacoxib-celecoxib treatment difference was 0.6 (CI, −0.9 to 2.2; p = 0.425). According to Physician's Global Assessments, more subjects were “much improved” at week 3 with polmacoxib than with celecoxib or placebo. Gastrointestinal and general disorder AEs occurred with a greater frequency with polmacoxib or celecoxib than with placebo. CONCLUSIONS: Polmacoxib 2 mg was relatively well tolerated and demonstrated efficacy superior to placebo and noninferior to celecoxib after 6 weeks of treatment in patients with OA. The results obtained during the 18-week trial extension with polmacoxib 2 mg were consistent with those observed during the 6-week treatment period, indicating that polmacoxib can be considered safe for long-term use based on this relatively small scale of study in a Korean population. More importantly, the results of this study showed that polmacoxib has the potential to be used as a pain relief drug with reduced gastrointestinal side effects compared to traditional nonsteroidal anti-inflammatory drugs for OA.

Clinical Results of Contralateral Arthroscopic Meniscectomy Performed with Unilateral Total Knee Arthroplasty: Minimum 3-year Follow-up

PURPOSE: We assessed the clinical outcome of contralateral arthroscopic meniscectomy performed with unilateral total knee arthroplasty (TKA). MATERIALS AND METHODS: From May 1999 to June 2006, 23 patients underwent unilateral total knee arthroplasty and contralateral arthroscopic meniscectomy at the same time. All patients were women and followed for at least 36 months, except 2 patients who died. For clinical assessment, range of motion of the knee joint, Hospital for Special Surgery (HSS) knee score and the Lysholm knee score were evaluated preoperatively and at the last follow-up. At arthroscopy, meniscal pathology and cartilage changes were recorded and classified according to the Outerbridge scale. Progression of osteoarthritis in the contralateral knee to subsequent TKA was also assessed. RESULTS: The mean age of the 21 patients was 67.1 years and the mean follow-up period was 5.7 years. All of the patients were diagnosed with osteoarthritis and had Outerbridge grade 3 or 4 cartilage changes. Eight of the 21 patients had subsequent TKA at an average of 3.1 years after the index operation. The other 13 patients had no further surgery and clinical results including the HSS knee score and the Lysholm score were improved from 74.5 and 60.6 preoperatively to 90.8 and 82.4 postoperatively, respectively (p<0.001). CONCLUSIONS: Contralateral arthroscopic meniscectomy performed simultaneously with unilateral TKA produces relatively good results regardless of the presence of cartilage degeneration.

Results of Gender-Specific Total Knee Arthroplasty: Comparative Study with Traditional Implant in Female Patients

PURPOSE: To compare the incidence of overhang between two distinct femoral components and whether there is clinical and radiological benefit of gender-specific implants in short-term follow-up. MATERIALS AND METHODS: One hundred and four knees in consecutive 66 female patients who underwent primary total knee arthroplasty due to primary osteoarthritis were included in this study. Overhang was measured and recorded in every cut surface of femur with both gender-specific and traditional trial femoral components respectively in every patient. Then, the knees were divided into two groups according to the type of the permanent femoral component they received. Clinical and radiological outcomes were compared between 2 groups at minimum 3 years after operation. RESULTS: Mean follow-up duration was 41.3 months (range, 36 to 50 months). Sixty two knees (59.6%) showed femoral overhang at least in one area with a traditional trial component, while 26 knees (25.0%) did with a gender-specific trial component (p<0.001). In terms of range of motion, Hospital for Special Surgery knee score, radiographic result, patella tilt angle and displacement, no significant difference was observed between two groups. CONCLUSIONS: The use of gender-specific implants substantially reduced the incidence of femoral overhang but did not demonstrate any clinical, functional or radiologic benefit in short-term follow-up.

Review of Meniscal Allograft Transplantation Focusing on Long-term Results and Evaluation Methods

With recognition of the biomechanical role of the meniscus, such as load distribution and joint stability in the knee joint, there has been a shift in the treatment of meniscal tears from open total meniscectomy to preservation of the meniscal functions as much as possible with symptomatic relief. Recently, technical development of meniscal surgery, with advanced arthroscopic equipment and instruments, enables biological reconstruction of load bearing functions in the meniscus deficient knee through allograft tissue transplantation as well as repair of torn menisci. Meniscal allograft transplantation (MAT) has been considered as one of the few viable treatment options for the young meniscectomized knees based on various animal experiments and clinical studies. Still, there is insufficient evidence for the long-term chondroprotective effect of human MAT. Some long-term follow-up studies showed that the technique resulted in graft degeneration, deformation, and tear, and structural changes in the remodeling process in early MAT cases, disrupting functional restoration of the original meniscus. Nevertheless, advanced outcomes are documented in some recent studies. The purpose of this article is to review the mid- and long-term follow-up results of MAT and to improve understanding of MAT with evaluation methods of meniscal transplants using magnetic resonance imaging or second-look arthroscopy.

The Correlation between Posterior Tibial Slope and Maximal Angle of Flexion after Total Knee Arthroplasty

PURPOSE: The purpose of this study was to evaluate the correlation between the posterior tibial slope and the maximal angle of flexion after total knee arthroplasty.

Clinical Results and Prognostic Factors of Arthroscopic Surgeries for Discoid Lateral Menisci Tear: Analysis of 179 Cases with Minimum 2 Years Follow-up

PURPOSE: The purpose of this study was to evaluate the clinical results and prognostic factors of arthroscopic surgeries for tears of the discoid lateral menisci. MATERIALS AND METHODS: From March 1997 to September 2005, 260 patients received arthroscopic surgeries due to discoid lateral menisci tears. Among these patients, 179 knees in 168 patients were followed up for at least 2 years and were enrolled into this study. The following prognostic factors were evaluated: sex, age, symptom duration, and type of meniscal tear. Visual analogue score (VAS), Lysholm score, and Ikeuchi grade were assessed as clinical results of arthroscopic surgeries. RESULTS: The mean VAS and Lysholm score improved at the last follow-up. According to the Ikeuchi grade, 104 cases were rated as excellent, 51 cases as good, and 23 cases as fair. Male sex (p<0.033), age younger than 20 years (p=0.0474), and symptom duration less than 12 months (p<0.044) were good prognostic factors. However, there was no correlation between tear types of discoid lateral menisci and clinical results. CONCLUSIONS: Sex, age, and symptom duration could be significant prognostic factors of arthroscopic surgeries for tears of discoid lateral menisci.

Meniscus Allograft Transplantation

The biomechanical function of the meniscus is well known and its chondroprotective effect is very important. The meniscus should be preserved whenever possible, but subtotal or total meniscectomy is sometimes inevitable, and especially if considerable tissue damage already exists. Although meniscal allograft transplantation (MAT) is performed for the meniscus-deficient knees to restore the biomechanical function of the meniscus, its current indication has been limited to the symptomatic young patients who do not have advanced osteoarthritis. However, the osteoarthritic process is usually progressive over the time even if there are minimal symptoms. When evident clinical symptoms are present, it is usually associated with advanced cartilage damage. In this status, MAT cannot be indicated or the result of surgery would be very poor. Thus, the status of the articular cartilage should be carefully assessed in subtotal or total meniscectomized knees by performing radiographic and high-resolution magnetic resonance imaging and a meticulous physical examination. MAT could be considered if there is an objective evidence of cartilage damage even without evident clinical symptoms.

Results of ACL Reconstruction with Autologous Hamstrings Fixed by Two Bioabsorbable Cross Pins on the Femoral Side and a Bioabsorbable Interference Screw with Additional Fixation on the Tibial Side / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical outcomes of an anterior cruciate ligament reconstruction using autologous hamstring tendons with stable fixation. MATERIALS AND METHODS: Seventy-six ACL reconstructions using autologous hamstring tendons were reviewed for an average of 16.5 months (Range, 12-35.6 months) postoperatively. All the patients were examined using standard clinical techniques and evaluated by stress radiography, Cybex(TM), Lysholm score, and International Knee Documentation Committee (IKDC) ratings. RESULTS: In all cases, there were no limitations in the range of motion. The mean Lysholm score was 72.9 preoperatively, which later improved to 91.1 postoperatively. According to the IKDC grade, 74 cases were categorized as 'normal' or 'nearly normal' postoperatively. In addition, the CybexTM study showed that at an angular velocity of 60degrees/sec, the strength deficit of the hamstrings decreased to 16% from 24% while the strength deficit of the quadriceps decreased to 27% from 31%. The mean side-to-side difference in stress radiography was 2.4 mm postoperatively. There was a single case of graft failure resulting from a deep infection. CONCLUSION: ACL reconstructions using autologous hamstrings using stable fixation techniques showed satisfactory results at the 16.5 months follow-up. However, further studies will be needed to confirm these findings over a longer follow-up period.

Two Stage Surgical Treatment of Acute Traumatic Knee Dislocation / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to determine the effectiveness of a new two stage surgical treatment for acute traumatic knee dislocation. MATERIALS AND METHODS: The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up period was 24 months. In the first surgical stage, medial and/or lateral ligament complexes were repaired or reconstructed within two weeks of the injury. In the second surgical stage, once full range of motion was obtained 3-6 months later, anterior or posterior cruciate ligaments (ACL or PCL) were reconstructed if significant laxity was present. The final outcomes were assessed using stress X-rays, range of motion and Lysholm score. RESULTS: There were ten cases of MCL tear and eight cases of LCL tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. Following the first stage of MCL/LCL surgery, the second stage surgery of ACL or PCL reconstructions was deemed to be necessary in three and seven cases, respectively. Five cases did not require ACL or PCL reconstruction. In stress X-rays at the last follow up examination, MCL, LCL, ACL and PCL instability was graded as 0 or 1 in 15, 14, 15 and 11 cases, respectively. PCL instability was graded as 2 in four cases. The mean postoperative Lysholm score was 87.6 points. CONCLUSION: The two stage surgical approach described here resulted in good outcomes for patients suffering from acute knee dislocation patients in terms of range of motion and stability.

Scedosporium prolificansInfection by Laceration with a Broken Piece of Flowerpot: A Case Report / 대한정형외과학회잡지

Scedosporium prolificans is a fungus that can be found in soil or polluted water. It is mandatory to evaluate Scedosporium prolificans infection in case of injury by soil- contaminated materials. Musculoskeletal infections by Scedosporium prolificans are extremely rare and the clinical manifestations are similar to other bacterial infections. So it is difficult to detect Scedosporium prolificans infection. We report a neglected case with bone and joint infection by Scedosporium prolificans after joint laceration with a broken piece of flowerpot in a 10-year-old boy.

Validity and Reliability of the Korean Version of the Arthritis Impact Measurement Scales 2 (Korean-AIMS2) in Patients with Osteoarthritis

BACKGROUND: The second version of the Arthritis Impact Measurement Scales (AIMS2) is an improvement on an evaluation instrument that was developed to measure patient outcome in the rheumatic diseases. The goal of this study was to validate a translated version of the revised and expanded Arthritis Impact Measurement Scales (AIMS2) to be used by Korean patients with osteoarthritis (OA) of the knee. METHODS: The AIMS2 was translated into Korean according to a recommended translation guideline. The Korean version of AIMS2 (K-AIMS2) was administered to a cohort of 239 outpatients with symptomatic OA of the knee who attended 7 participating University Hospitals in Seoul, Ilsan and Taejon. Forty eight patients readministered the K-AIMS2, 7 days after the first visit, to evaluate the instrument's test-retest reliability. After 6 weeks of NS AIDs therapy, 79 subjects were asked to complete a second survey of the questionnaire. RESULTS: The internal consistency reliability of each scale score, as estimated by Cronbach's alpha coefficient, was high and indicated that the components of the scale measured the same construct. The items were all correlated with each other, but there was no redundancy; this indicated that each domain addressed a somewhat different aspect of functional disability. The test-retest reliability equalled or exceeded 0.86 for 12 scales. Factor analysis provided a three-factor health status model explaining 58.2% of the variance. The upper limb function scales formed the first factor. Psycho-social scale were loaded on the second factor. Arthritis pain together with physical scales for mobility level and walking and bending were loaded on the third factor (the lower limb function). The scale for support from family and friends was not loaded on any factors. These results demonstrate that the physical health status scales of the K-AIMS2 are valid, as shown by the significant, moderate to high correlations between the K-AIMS2 subscales and the majority of the clinical measures. CONCLUSION: Our data suggest that, like the original questionnaire, the Korean version of AIMS2 is a reliable, consistent and valid instrument for measuring health status and physical functioning in patients with OA of the knee.

Clinical Application of N+7 Method for the Solution of Graft: Tibial Tunnel Discrepancy in Anterior Cruciate Ligament Reconstruction

PURPOSE: The purpose of this study is to prevent the graft-tunnel mismatching by N+7 method and to present the experience of the authors in anterior cruciate ligament reconstruction, using the patellar ten- don by N+7 method. MATERIALS AND METHODS: Authors analyzed 34 cases who had taken the anterior cruciate ligament reconstruction from April 1998 to July 1999, at Asan Medical Center, by N+7 method. By measuring the patellar tendon length(N), tibial guide was set an angle of N+7 degree. We analyzed the results by dividing the cases into 3 groups by the degree of extrusion of the bone plug from the tibial tunnel. RESULTS: Clinical results were acceptable in 79.4%(27 cases), protrusion in 8.8%(3 cases) and recession in 11.8%(4 cases). When the angle of tibial tunnel was less than 50 degrees, there wasn't a protruded case in 19 cases. Comparing with 15 cases of the angle which was larger than 50 degrees, there were three protruded cases. CONCLUSION: Clinical results of anterior cruciate ligament reconstruction using the patellar tendon, with N+7 method is superior to empirical methods which was performed by authors, previously at the point of positioning of ideal tibial tunnel and conveniency of the technique. Especially, if the graft tendon length is shorter than 43mm, N+7 method is preferable.

A Radiological Analysis of the Patients with Patellofemoral Pain Syndrome / 대한정형외과학회잡지

PURPOSE: We intend to provide more objective data for diagnosis of the patellofemoral pain syndrome by analyzing the positional changes of the patella radiologically. MATERIALS AND METHODS: In 42 normal knees and in 91 knees of patients with the patellofemoral pain syndrome, the following 6 parameters were analyzed using a 30 degree flexion lateral view and a Merchant axial view: 1) the Insall and Salvati method, 2) the Blackburne and Peel method, 3) the Saille method, 4) the depth of the trochlea, 5) the sulcus angle, 6) and the congruence angle. RESULTS: Using the Blackburne and Peel method of assessing the height of patella, the ratio was 0.86 in the control group, in contrast to 0.92 in the patellofemoral pain syndrome group (P<0.05). The average value of the congruence angle was 2.9 in the control group, while it was -9.2 in patellofemoral pain syndrome group (P<0.05). The other parameters showed no statistical significance. CONCLUSION: This indicates that the patella alta by the Blackburne and Peel method and the increase of congruence angle are useful in the diagnosis of the patellofemoral pain syndrome.

Interleukin-6 and Soluble Interleukin-6 Receptor in Degenerative Arthrits / 대한류마티스학회지

Unlike other soluble receptors, the soluble interleukin-6 receptor (sIL-6R) cooperates with IL-6 to activate gp130 of effector cell. As the IL-6 and sIL-6R are important in the rheumatoid disease, this study was designed to measure concentration of IL-6 and sIL-6R in synovium and synovial fluid of the degenerative arthritis. The synovium and synovial fluid were obtained during total knee replacement arthroplasty. The synovium was taken from eleven patients, and synovial fluid taken from sixteen patients. Same patients between two groups were seven. Tissue cultures of the synovial tissues were done with 10% FBS for 72 hours. After irrigation, thery were incubated for 48 hours without FBS, and the culture media and the synovial fluid were collected after centrifuged at 2500rpm for 10 minutes. The level of IL-6 and sIL-6R were measured by quantitative sandwich enzyme immunoassay technique. RESULTS: In the synovium, the IL-6 level was 5.1+/-0.12ng/ml, and the sIL-6R level was 0.41+/-0.25ng/ml. In the synovial fluid, the IL-6 level was 0.09+/- 0.15ng/ml, and the sIL-6R level was 10.37+/-3.28ng/ml. These results show that IL-6 concentration was measured highly in two groups, especially in synovium (sixty times), and the sIL-6R concentration was measured significantly high in synovial fluid (twenty-five times). CONCLUSION: The IL-6 and sIL-6R were elevated in degenerative arthrits. We confirmed the source of IL-6 was synovium (very high in synovial tissue culture media), but we need further study for the source of sIL-6R as it was remarkably elevated as IL-6 and its level was lower than serum.

The Clinical Study of Meniscal Repair / 대한정형외과학회잡지

PURPOSE: To analyze and report the analyzed clinical results of meniscal repair. MATERIALS AND METHODS: Thirty-two cases were reviewed after arthroscopic meniscal repair. The meniscal repair was indicated by unstable tears in red-red or red-white zone with the tear size longer than 10mm. The location, pattern of the tear and associated injury were examined respectively, and the clinical results were evaluated with preoperative, postoperative Lysholm score and findings of physical examination. Physical examination was focused on tenderness, click, effusion and McMurray test. Also, a second look arthroscopy was performed in the case of bucket-handle tears and other types with recurring symptoms and positive physical findings. RESULTS: The number of medial meniscus tear was higher than lateral meniscus tear and the were no considerable differences in the number between the right and the left knees. The most common location of tear was the red-red zone tear in 30 cases, and the most common tear pattern was longitudinal tear in 22 cases. The number of bucket-handle tear was nine. The most common associated injury was ACL injury. Acording to clinical assessment, 29 out of 32 cases showed satisfactory results, and the results of 7 out of 9 bucket-handle tears were good. CONCLUSION: An analysis of the clinical results of meniscal repair has been carried out, showing that meniscal repair is regarded as a reliable treatment modality in meniscal tear with proper patient selection.

Microbial Features and Antibiotic Prophylaxis of Prosthetic Joint Infection / 감염

BACKGROUND: Success in orthopedic implant surgery relies on reducing infection by preventive methods including antibiotic prophylaxis. The lack of published data on orthopedic implant infections with methicillin-resistance Staphylococcus aureus (MRSA) and methicillin-resistance coagulase-negative staphylococcus (MRCNS) makes it difficult to choose correct prophylactic antibiotics. We therefore reviewed the etiology of prosthetic joint infection and the effectiveness of current antibiotic prophylaxis. METHODS: We reviewed retrospectively the clinical notes and microbial records of patients with prosthetic joint infection who had admitted in Asan Medical Center from June 1989 to July 1999. RESULTS: During a eleven-year period, prosthetic joint infections occurred in 18 (0.9%) of 2,028 patients who received a total hip or total knee arthroplasty at Asan Medical Center (AMC). The cephalosporins were administered to most of patients before surgery for prophylaxis. Twenty two patients were referred to our institution because of prosthetic joint infection. Thirty five patients had positive bacteriological cultures from tissue removed at the time of surgery or joint aspiration. Staphylococci were the most common pathogens and accounted for twenty four (68.8%) of the 35 isolates. Seven (50%) of the fourteen isolates of coagulase-negative staphylococci were MRCNS. Eight (80 %) of the ten ioslates of S. aureus were MRSA. Gram-negative bacilli accounted for five (14.3%) of the isolates and included Escherichia coli, Serratia marcescens, Pseudomonas aeruginosa. CONCLUSION: First-or second-generation cephalosporins were effective prophylatic antibiotics in total hip or total knee arthroplasty because the rate of prosthetic joint infections was low (0.9%). But the prevalence of MRCNS or MRSA prosthetic joint infection was high, we must consider glycopeptides prophylaxis if there is, or has been, infection or carriage with MRCNS or MRSA.

Management of Acute Combined Injuries of the Medial Supporting Structures and Anterior Cruciate Ligament of the Knee

PURPOSE: We introduce the management protocol of medial structures-ACL combined injury patients in Asan Medical Center and evaluate the results of the management according to severity of medial injuries. MATERIALS AND METHODS: From Jan.1994 to May 1998, we treated 30 cases of acute combined injuries of medial structures and ACL. Unless the medial structures shows grade IIIwithout end point, we man-aged the medial structures conservatively and conducted ACL reconstuction . After that, we analysed the results of the management. Evaluation was based on the Lysholm knee scoring system, physical examina-tion and stress radiographs. RESULTS: The functional result by Lysholm knee scoring revealed 92.4/95.3(medial structures conserva-tive / repair groups) respectively. Except 1 case of persistent medial laxity in medial structures repair group, there was no severe complication in both groups. CONCLUSIONS: There was no significant medial laxity after conservative management in grade I,II,III with end point injury of medial supporting structures and we had good results in severe medial injury involving MCL, posterior oblique ligament in terms of ROM and stability with open repair of medial structures and delayed arthroscopic ACL reconstruction.