Hinged Roof Reconstruction of Anterior Iliac Crest after Harvesting Bicortical Strut Graft for Anterior Cervical Fusion.

Introduction: The strut iliac bone graft has been widely used to achieve fusion in various anterior cervical spinal surgeries but some complications often remain, such as pain and gross deformity. Considering these, we designed a new technique to restore the iliac ridge, using the outmost part of the iliac crest. We aim to assess the efficacy of our new restoration technique of the iliac ridge after harvesting strut bone graft for anterior cervical fusion. The clinical and radiological outcomes of our hinged roof method were evaluated. Technical Note: A retrospective review was conducted of 29 patients who underwent hinged roof reconstruction of the iliac ridge after harvesting a bicortical strut bone graft for anterior cervical fusion using a cervical plate system. The clinical outcome for pain and gross appearance and radiological results were evaluated. Three months after the surgery, pain at the donor site became minimal or absent in all cases. At 1 year follow-up, no patient had reported pain and palpable discomfort, such as step-off on the donor site. Final X-ray and follow-up computed tomography revealed a bony union of the reconstructed iliac ridge to both margins. Conclusions: By showing good clinical and radiological outcomes, the authors' hinged roof reconstruction of the iliac crest after harvesting strut bone graft seemed to be a simple and effective technique that can reduce complications, such as pain and deformity on the donor iliac crest.

Effect of Sarcopenia on Postoperative Mortality in Osteoporotic Hip Fracture Patients.

BACKGROUND: Few studies have investigated the effects of sarcopenia on postoperative outcomes including mortality rates following surgery for osteoporotic hip fractures. The purpose of the present study was to determine the prevalence of sarcopenia and the relationship between sarcopenia and 1- and 5-year mortality rates in a consecutive series of patients with osteoporotic hip fractures. METHODS: Among patients who underwent hip surgery for osteoporotic hip fractures, this study included 91 patients subjected to abdominal computed tomography within 1 year of hip surgery. We defined sarcopenia using sex-specific cut-off points for the skeletal muscle index at the level of the third lumbar vertebra. All patients were divided into 2 groups according to the presence or absence of sarcopenia and the 1- and 5-year mortality rates were compared. To confirm factors affecting mortality in addition to sarcopenia, we examined patient age, sex, American Society of Anesthesiologists grade, location of fracture, type of surgery, and bone mineral density. RESULTS: The 1- and 5-year mortality rates were 20.9% and 67.2%, respectively. Among the 45 patients with sarcopenia, the 1- and 5-year mortality rates were 22.2% and 82.7%, respectively. Of the 46 patients without sarcopenia, the 1- and 5-year mortality rates were 19.6% and 52.7%, respectively. Results of the Kaplan-Meier analysis showed that sarcopenia did not affect the 1-year mortality rate (P=0.793), but had a significant effect on the 5-year mortality rate (P=0.028). Both perioperative sarcopenia (P=0.018) and osteoporosis (P=0.000) affected the 5-year mortality rate. CONCLUSIONS: Sarcopenia increases the risk of 5-year mortality in patients with osteoporotic hip fractures.

Acute Isolated Tear of Gluteus Medius in Young Male.

The hip rotator cuff tear usually develops in the middle-aged through gradual degenerative changes, similar to rotator cuff tears in the shoulder. An acute tear in the hip abductor by a traumatic event in young ages is very uncommon. The authors experienced an unusual case of an acute traumatic tear isolated to the gluteus medius in a young male; thus, we report the treatment results in this rare case with a review of the literature.

Ischial Tuberosity Avulsion Stress Fracture after Short Period of Repetitive Training.

Fatigue fracture of the pelvis is the form of fracture due to repetitive micro-stress accumulation, can be affected by a number of factors such as patient's nutritional status, biomechanics, social status and so on. Still there is no study about precise standard degree of external force that lead to stress fracture, but it may caused by compression force, traction force or complex force and others. Avulsion stress to ischial tuberosity or anterior superior iliac spine by attached muscle is known as the main factor for the avulsion fracture. This report will deal with 19 years old conscripted policeman who occurred ischial tuberosity avulsion fracture after training of 6-hour running for 5 days accompanying hip hyper-flexion motion. This reports aims to provide case study of stress fracture occurred after 5 days of exercise which is relatively short period who had no specific trauma history or pain.

Characterizing the Progression of Varying Types of Calcific Tendinitis around Hip.

PURPOSE: To assess the progression of clinical symptoms and disease course of calcific tendinitis in the hip region according to types of calcification. MATERIALS AND METHODS: Among patients with the hip pain, 28 patients (21 males and 7 females; mean age 51 years, range 32-74 years) showing calcified lesions in simple radiography without other possible sources of pain were analyzed retrospectively. Twelve patients displayed a symptom duration of less than three weeks (acute; average=1±0.9 week) and 16 displayed greater than three weeks (chronic; average=21.0±19.5 weeks). Lesions were classified as nodular (11, 39.3%), nodular-fragmented (13, 46.4%), or amorphous (4, 14.3%). Initial symptoms, progression of clinical features, radiological findings and prognosis were investigated and analyzed according to calcification type. RESULTS: In 15 patients (53.6%), lesions were located superior to the great trochanter. On average, the acute group was younger (44.58 vs. 55.44 years, P=0.006), suffered more (mean pain Numeric Rating Scale [NRS], 6.3 vs. 3.8; P<0.001), and recovered more (difference between initial and follow-up NRS, 5.1 vs. 2.63; <<0.001) than the chronic group. The mean length of initial lesions was longer in the acute group than the chronic group (15.8 vs. 9.1 mm, P=0.008). When compared to patients with distinctive margins (15, 53.6%), those with nondistinctive margins showed better improvement (difference between initial and follow-up NRS, 4.7 vs. 2.8; P=0.01) and more significant decrease in lesion size (difference between initial and follow-up length, 10.8 vs. 2.6 mm; P=0.003). CONCLUSION: Calcific tendinitis occurring in the hip area displayed a variety of characteristics. Although complaining of more severe pain in the initial phase, patients with acute pain or calcific lesions with nondistinctive margins showed better symptom improvement when compared to their counterparts.

Bilateral Bone Marrow Edema Syndrome of the Femoral Head with a Unique Onset: A Case Report.

Bone marrow edema syndrome (BMES) is a rare condition which mainly affects the hip area. The etiology and pathogenesis of BMES is still unclear. Pain near the affected area, regional osteoporosis, bone marrow edema (identified using magnetic resonance imaging) and spontaneous regression within 6-12 months are the main characteristics of BMES. In this case, a 52-year-old male was diagnosed with BMES of the right hip followed by spontaneous subsiding of symptoms. After 3 years, and under nearly the same social and physical conditions, he was admitted again with newly developed left hip pain and again diagnosed with BMES. We report this rare case since a similar one has not been previously reported in the domestic literature and may be considered valuable for basic research relating to the pathogenesis of BMES.

Bilateral Necrotizing Fasciitis around the Hips Differentiated from Fournier Gangrene: A Case Report.

As an emergency encountered in orthopedic practice requiring prompt diagnosis and aggressive treatment, necrotizing fasciitis around the hip must be discriminated from Fournier gangrene. The current case report describes a patient who suffered from bilateral type I necrotizing fasciitis around the hips, which was alleviated by prompt surgical debridement and intensive postoperative care.

Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique.

PURPOSE: The purpose of this study was to compare clinical outcomes after single-bundle anterior cruciate ligament (ACL) reconstruction with a free Achilles tendon allograft using either a transtibial or an anteromedial portal technique and then to quantify the difference in femoral tunnel position between these 2 approaches. This assessment was to be performed with a new method using conventional magnetic resonance imaging (MRI) with a digital imaging system. METHODS: In this prospective randomized comparative study, 53 young male patients with ACL rupture underwent ACL reconstruction with the transtibial technique (group 1) or the anteromedial portal technique (group 2). We assessed clinical outcomes with the Lachman test, pivot shift test, International Knee Documentation Committee (IKDC) classification, Lysholm score, Tegner activity scale, and single leg hop (SLH) test. Radiologic assessments included the position of the femoral tunnel aperture and the posterior cruciate ligament (PCL) index on conventional MRI and the side-to-side difference (SSD) on stress radiographs. RESULTS: Sixty-one participants had follow-up. The mean follow-up period was 30.2 months. At the last follow-up, there were no significant differences between the 2 groups in results from the Lachman test, pivot shift test, IKDC classification, Tegner activity scale, and SLH test. The Lysholm score and SSD results in group 2 were superior to those in group 1 (P < .001). The femoral tunnel aperture was positioned more posteriorly in group 2 than in group 1 (P < .001). Changes in the PCL index were greater in group 1 than in group 2 (P < .001). CONCLUSIONS: The position of the femoral tunnel aperture created with the anteromedial portal technique was more posterior than that made with the transtibial technique. Knees reconstructed with the anteromedial portal technique were more stable in Telos testing, and were 3 points higher on the Lysholm score. However, there were no statistically significant differences in the Tegner activity scale or IKDC classification between the 2 groups. LEVEL OF EVIDENCE: Therapeutic level I, randomized controlled clinical trial.

Single-bundle anterior cruciate ligament reconstruction in active young men using bone-tendon achilles allograft versus free tendon achilles allograft.

PURPOSE: The purpose was to prospectively compare the outcomes of anterior cruciate ligament (ACL) reconstruction using bone-tendon Achilles allograft with those of free tendon Achilles allograft in 2 groups of active young men. METHODS: We enrolled 72 subjects in the study. Of these, 33 subjects who had ACL reconstruction with Achilles allograft with calcaneal bone block on its end (group I) and 34 who had ACL reconstruction with free tendon Achilles allograft (group II) were followed up for a minimum of 2 years. The Lachman test, pivot-shift test, and 1-leg hop test were evaluated at the last follow-up. The International Knee Documentation Committee classification, Lysholm score, and side-to-side difference were assessed preoperatively and at the last follow-up. The Tegner activity scale was evaluated before injury and at the last follow-up. RESULTS: The mean follow-up period was 30.9 months (range, 26 to 38 months). At the last follow-up, there were no statistically significant differences between the 2 groups for the Lachman test, pivot-shift test, 1-leg hop test, International Knee Documentation Committee classification, Lysholm score, and side-to-side difference (P > .05). Three subjects in group I and three in group II showed an activity level 2 steps below the preinjury activity level. The rest of the subjects returned to the preinjury activity level or showed a level 1 step below the preinjury activity level. CONCLUSIONS: There were no significant differences in clinical outcomes of ACL reconstructions using Achilles allograft between the bone-tendon group and the free tendon group in active young men. Free tendon Achilles allograft may be considered an option for ACL reconstruction. LEVEL OF EVIDENCE: Level II, therapeutic study, randomized controlled trial.

Hybrid tibial fixation for anterior cruciate ligament reconstruction with Achilles tendon allograft.

PURPOSE: To compare clinical outcomes of tibial fixation between a biodegradable interference screw only and a biodegradable interference screw supplemented by a post-tie using a washer screw in single-bundle anterior cruciate ligament (ACL) reconstruction with 2-strand free tendon Achilles allograft in active young men. METHODS: A prospective study was performed in 80 subjects who underwent single-bundle ACL reconstruction. A 2-strand free tendon Achilles allograft fixed with an EndoButton (Smith & Nephew, Andover, MA) in the femoral tunnel and with a Bio-Interference screw (Arthrex, Naples, FL) in the tibial tunnel was used in group I. Supplementary fixation was performed with a post-tie using a washer screw in group II. The Lachman test, pivot-shift test, International Knee Documentation Committee classification, Lysholm score, range of knee motion, and side-to-side difference were evaluated preoperatively and at the last follow-up. The Tegner activity scale was evaluated before injury and at the last follow-up. The 1-leg hop test was assessed at the last follow-up. RESULTS: Of the patients, 36 in group I and 35 in group II could be followed up for at least 2 years. At the last follow-up, 7 patients in group I and 1 in group II showed a 2+ or 3+ on the Lachman test (P = .027). The mean side-to-side difference was 2.9 ± 2.3 mm in group I and 1.4 ± 1.6 mm in group II at the last follow-up (P = .002). The other clinical outcomes were not significantly different between the 2 groups. CONCLUSIONS: Supplementary tibial fixation with a post-tie in ACL reconstruction using 2-strand free tendon Achilles allograft was more effective than a biodegradable interference screw only in restoration of the anterior stability of the tibia. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Intra-articular corticosteroid injection in diabetic patients with adhesive capsulitis: a randomized controlled trial.

PURPOSE: An intra-articular corticosteroid injection is considered an effective treatment for idiopathic adhesive capsulitis of the shoulder. This study examined the efficacy of corticosteroid injections for the treatment for adhesive capsulitis in patients with diabetes mellitus. METHODS: Forty-five diabetic patients were randomized into a corticosteroid injection group or non-injection control group and received the same instruction for a home stretching exercise. The corticosteroid group patients were administered intra-articular corticosteroid injection composed of 40 mg triamcinolone acetonide. Pain by a visual analogue scale, shoulder range of motion, and functional state by the American Shoulder and Elbow score were assessed at the baseline, 4-, 12-, and 24-week follow-up. RESULTS: Diabetic patients treated with corticosteroid injections showed significant improvement in the pain score at 4 weeks and in the functional score at 12 weeks (P = 0.020 and P = 0.042, respectively). The range of motion in forward elevation and internal rotation was significantly higher in the corticosteroid group than in the non-corticosteroid group at the 12-week follow-up (P = 0.030 and 0.045, respectively), but there were no significant differences at the final follow-up between the corticosteroid and non-corticosteroid groups. CONCLUSIONS: A corticosteroid injection in diabetic patients decreases the pain perception and accelerates the functional recovery in the early post-injection period. An intra-articular corticosteroid injection is considered a viable option for the treatment for adhesive capsulitis with diabetes. LEVEL OF EVIDENCE: Randomized clinical trial, therapeutic study, Level II.

Comparison between hamstring autograft and free tendon Achilles allograft: minimum 2-year follow-up after anterior cruciate ligament reconstruction using EndoButton and Intrafix.

PURPOSE: This study is to compare the clinical and radiographic results of anterior cruciate ligament (ACL) reconstruction with four-stranded autogenous hamstring tendon and two-stranded free tendon Achilles allograft fixed with EndoButton in the femoral tunnel and Intrafix in the tibial tunnel. MATERIALS AND METHODS: 106 patients diagnosed with ACL rupture underwent ACL reconstruction. Autogenous hamstring tendon was used in 33 patients (group I) and free tendon Achilles allografts were used in 32 patients (group II). Median age was 23 years old (20-51) in group I and 22 years old (20-55) in group II. Range of motion, Lachman test, Pivot shift test, IKDC score, Lysholm score and side-to-side difference (SSD) were evaluated preoperatively and at the last follow-up. Tegner activity scale was evaluated before injury and at the last follow-up. RESULTS: The mean follow-up periods were 28.1 months in group I and 31.6 months in group II. Range of motion of the knee was not different from that of the unaffected side in most cases except one flexion deficit in group I and three in group II (n.s.). One in group I and three in group II showed grade two or three laxity on Lachman test at the last follow-up. One in group I and three in group II showed clear positive results on Pivot shift test at the last follow-up. Thirty in group I and 26 in group II were classified to IKDC A or B at the last follow-up (n.s.). Median Lysholm scores were 98 (85-100) in group I and 99 (85-100) in group II at the last follow-up (n.s.). Median Tegner activity scales were 6 (5-9) in group I and 6 (4-9) in group II at the last follow-up (n.s.). The mean SSD at the last follow-up were 1.4 ± 2.0 mm in group I and 1.9 ± 2.4 mm in group II (n.s.). CONCLUSION: Clinical and radiological outcomes of ACL reconstruction with two-stranded free tendon Achilles allograft were comparable to those of four-stranded autogenous hamstring tendon. This technique is reasonable to accomplish good results without some weaknesses when using allograft with bone block. LEVEL OF EVIDENCE: Therapeutic randomized controlled prospective study, Level I.

Outcome of the functional treatment of first-time ankle inversion injury.

BACKGROUND: Avulsion fractures of the lateral malleoli in ankle inversion injuries are often undetected on routine radiographs. Undetected avulsion fractures have been managed as ankle sprain, which may affect the outcome of the treatment of the ankle sprain. The purposes of this study are to compare the outcomes of functional treatment between the first-time severe ligament injury and avulsion fracture of the lateral ankle, and to investigate how the anterior talofibular ligament (ATFL) view or the calcaneofibular ligament (CFL) view affects the diagnosis of the avulsion fracture and outcome of functional treatment of the ankle inversion injury. METHODS: A total of 276 consecutive patients with a first-time severe ankle inversion injury were classified into a ligament injury group (group I) or an avulsion fracture group (group II) on the basis of physical examination and radiographs. The patients with a negative finding on routine radiographs and a positive finding on the ATFL or CFL view derived from group II (group IIA). Age, sex, and activity level were analyzed. Patients were treated by stirrup splint. RESULTS: A total of 202 (73.2%) patients were in group I and 74 (26.8%) were in group II. In all, 50 patients in group II showed negative standard radiographs and a positive ATFL or CFL view. Altogether, 240 patients were followed up for at least 1 year and assessed clinically and radiographically. Differences in age, sex, and activity level before injury between groups were not statistically significant. Clinical and radiographic results of group II were inferior to those of group I. The outcome of group IIA was comparable to that of group I. CONCLUSIONS: The outcome of functional treatment of avulsion fracture was inferior to that of ligament injury. The ATFL and CFL views provide a more precise diagnosis but do not affect the outcome of the functional treatment.

The prone kneeling view of the intercondylar notch for radiographic assessment of the femoral tunnel position in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to verify the relevance of a novel radiograph, named the prone kneeling (PK) view of the intercondylar notch, for the assessment of femoral tunnel position in anterior cruciate ligament reconstruction. METHODS: The PK view is taken with the subject prone, kneeling on the film, with the hip and knee joint flexed 90 degrees . The beam projects 20 degrees to the longitudinal axis of the femur posteroanteriorly. We used 5 human cadaveric femora in the experiment. A radio-opaque marker was applied in the intercondylar notch from the 12- to 8-o'clock position, which represented the tunnel position during arthroscopy. Radiographs simulating the anteroposterior (AP), tunnel, and PK view were obtained, and the positional data in angles were compared with the designated positions in the notch during arthroscopy. RESULTS: From 12:00 to 11:00, all 3 radiographs gave comparable values to the true angle. At 10:30 and 10:00, only the PK view provided a comparable value whereas the other 2 radiographs yielded significantly different values. From 9:30 to 8:00, even though all 3 radiographs showed significantly different values from the true angle, the PK view was closest to the true angle, followed by the tunnel view and AP view. CONCLUSIONS: The PK view shows the intercondylar notch with the femoral tunnel angle more accurately than the AP or tunnel view. This most closely represents the true angle of the femoral tunnel and is very similar to the angle seen at arthroscopy. CLINICAL RELEVANCE: The position of the femoral tunnel seen on the postoperative plain AP radiograph might not appear identical to that determined during arthroscopy, probably because of the different knee position.

A case of delayed recurrent hemarthrosis after posterolateral reconstruction of the knee with a staple fixation at the lateral femoral epicondyle.

We present a case of delayed recurrent hemarthrosis after posterolateral reconstruction of the knee with staple fixation of the tendon graft at the lateral femoral condyle. A 20-year-old man had undergone a reconstructive surgery of the knee with allogeneic Achilles tendon aimed to reinforce lateral collateral ligament and popliteofibular ligament. At 4 months after surgery, recurrent swelling of the operated knee after minor exertion developed. The radiographs showed prominent staples at the lateral side of lateral femoral condyle. The arthroscopy revealed that the staples were salient intra-articularly at lateral gutter of the knee, and the adjacent lateral capsule seemed abraded, through which the longitudinal fibers of iliotibial band were seen. Iatrogenic iliotibial band syndrome owing to the prominent staple was speculated. The staples were removed under arthroscopic guidance, and there has been no recurrence thereafter. A staple fixation over bony prominence is not advisable and the interference screw might be a better alternative method of fixation.

The geometry of patella and patellar tendon measured on knee MRI.

This study provides the geometry of patella and patellar tendon measured on sagittal and axial magnetic resonance images of 172 knees (142 males, 30 females) of 163 subjects (135 males, 28 females) whose mean age was 26.7. The gender difference and the relationship with anthropometry were also given. As for patella, the longitudinal lengths of the whole and articulating surface were 44.6, 32.9 mm, and the thickness was 22.3 mm. The mediolateral width was 45.8 mm, and the central ridge was located 19.9 mm or 43% lateral from the medial border. As for patellar tendon, the longitudinal length was 40.2 mm. The widths of proximal and distal part were 30.3, and 24.0 mm. The thicknesses of proximal and distal part were 3.2, and 5.0 mm. The geometry of the patella and patellar tendon was larger in male than in female (P < 0.001). Anthropometry including weight, height, body mass index corresponds well with the thickness of patella but poorly with the length of patellar tendon. These data can provide useful information in the field of knee surgery and sports medicine.

Posterior double PCL sign: a case report of unusual MRI finding of bucket-handle tear of medial meniscus.

Among the MRI signs of bucket-handle tears of medial meniscus, double posterior cruciate ligament (PCL) sign denotes a low signal band anterior and parallel to the PCL, which looks like another PCL in MR images. If the bucket-handle fragment subsequently tears at the anterior horn, the torn meniscal substance can be displaced to the posterosuperior region of the PCL, and looks like another PCL behind the original PCL. We propose the lesion be called the "posterior double PCL sign" in contrast to the ordinary double PCL sign. We present a case showing the posterior double PCL sign.

An en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle in an adolescent basketball player: a case report.

We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy's tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy's tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy's tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.

Core Decompression and Impaction Bone Graft in Avascular Necrosis of the Femoral Head / 대한정형외과학회잡지

PURPOSE: To evaluate the effectiveness of core decompression with impaction bone graft in regard to the stage of the disease. MATERIALS AND METHODS: Forty-two cases in 32 patients were classified using ARCO (Association Research Circulation Osseous, 1992) classification and twenty-five cases were compared with postoperative follow-up MRI evaluation. There were 26 male and 6 female patients. Ten patients among 32 were bilatellally involved. RESULTS: There were 9 hips of stage 1 (A,O; B,1; C,8), 29 hips of stage 2 (A,1; B,6; C,22) and 4 hips of stage 3 (only C). Radiological progression was seen in 21 of 42 hips (50%); 22% of stage 1 (2/9), 59% of stage 2 (16/29) and 75% of stage 3 (3/4). Clinical failure with total hip arthroplasty conversion was seen in 11 of 42 hips (26%); 28% of stage 2 (8/29) and 75% of 3 (3/4). Forty-three percents of lateral lesions (11/26 cases) and all cases with femoral head involvement more than 30% showed clinical failure and radiologic progression. CONCLUSIONS: When the outcome of core decompression with impaction bone graft was evaluated according to ARCO classification, the progression of the stage or conversion to total hip arthroplasty was more common in the larger lesion and lateral location of necrosis. So, we could predict that core decompression with impaction bone graft was ineffective in preventing the progression of disease in the case of large extent and/or lateral location of necrosis.