Clinical experience has shown the needs for high flexion. The aim of this study was to evaluate the clinical and radiological results of a fixed bearing high flexion posterior stabilized (PS) total knee arthroplasty (TKA). Between July 2001 and December 2005, 422 TKAs in 288 patients were performed with high flexion PS prosthesis and 378 knees of 258 patients had been followed up for 2 to 6.5 years (mean: 3 years 11 months). We evaluated range of motion (ROM), Knee rating system of the Hospital for Special Surgery (HSS) and Knee Society (KS) score, and radiological results. The mean flexion improved from 110.1 degrees to 126.7 degrees at the latest follow-up. 333 knees (88 %) showed more than 120 degrees of flexion, 105 knees (28 %) more than 140 degrees of flexion. The mean KS clinical score improved from 39 to 93 points (p<
0.01) and KS function score, from 40 to 85.4 points (p<
0.01). The mean HSS score improved from 41.2 to 86.3 points (p<
0.01). In 28 knees, radiolucent line of 1–2 mm in width was observed at zone 1 without symptoms. Aseptic loosening in 4 knees, Mid-flexion instability in 2 knees, superficial infection in 3 knees and deep infection in 3 knees were observed. Total knee arthroplasty with high flexion PS prosthesis showed good ROM and satisfactory early clinical results. Complication rate was similar to those of other series. Close observation and serial radiological evaluation are needed for long term results.
Arthrodesis is used most commonly as a salvage procedure for failed total knee arthroplasty (TKA). For successful arthrodesis, a stable fusion technique and acceptable limb mechanical alignment are needed. Although the use of intramedullary alignment rods might be helpful in terms of achieving an acceptable limb mechanical axis, fat embolism and intramedullary dissemination of an infection or reactivation of latent infection might occur in failed TKA cases. However, computer-assisted surgery allows precise cuts to be made without breaching medullary cavities. Here, the authors describe a case of knee arthrodesis performed by computer navigation and the Ilizarov method in a patient with a past history of infection. A 45-year-old man visited our hospital with failed total knee arthroplasy. Fortunately, even though infection was treated by debridement with component retention, mild heating was present over the knee, but ESR(erythrocyte sedimentation rate) and CRP(C-reactive protein) were within normal ranges. X-ray showed subsidence of the femoral component and a radiolucent line around the femoral component. Arthrodesis was planned for this patient due to disabling pain, a long-lasting severe functional deficit, failure of the primary TKA for ankylosed knee, and the patient’s poor economic status and his strong desire for arthrodesis. The computer navigation surgery system and the Ilizarov method were used for two reasons. The first reason was that the patient had a past history of infection. At pre-operative evaluation, even though ESR and CRP levels were within normal range, we could not completely rule out the possibility of latent infection due to suspicious findings such as long lasting disabling knee pain, mild heating over the knee, severe osteolytic radiographic changes around the femoral component. In that situation, inserting an IM rod to achieve acceptable mechanical alignment might have reactivated and disseminated a possible latent infection to the femoral or tibial medullary canals. The second reason was that we wanted to reduce the possibility of fat embolism by using computer navigation without instrumentation within the medullary canal. A CT-free, wireless computer navigation system was applied, with trackers fixed to the femur and tibia and no requirement for the use of an IM rod with component retention. Navigated femoral and tibial bone resections were then performed using Stryker software. The femoral resection was conducted at 0° of flexion to the sagittal axis, and the tibial resection at 7 ° of flexion to the sagittal axis. Arthrodesis was held in proper axial and rotational alignment with bone surfaces compressed together. Finally, knee arthrodesis was completed using the Ilizarov method. Based on our experience of the described case, we believe that arthrodesis for failed TKR, especially failure secondary to intraarticular infection, can be considered as another indication for computer navigation.
There was used cement in first generation total ankle arthroplasty, but first generation of ankle arthroplasty was abandoned because of aseptic loosening of component. For the treatment of aseptic loosening of ankle arthroplasty, there had been many methods. One of methods of revisional ankle arthroplasty is the ankle arthodesis. The authors report a case of revisional ankle arthroplasty using allograft with hybrid external fixation. 45 year old male had surgery of cemented total ankle arthroplasty on his right ankle 20 years ago. He went to our clinics because of motionless and pain of his right ankle. He got the mild pain on his right ankle after 5 years surgery. His pain was managed by oral NSAIDS for 15 years. The pain was aggravated recently. There were osteophytes on posterior aspect of ankle joint and radiolucency around the implant, subtalar arthrosis at the radiograph. There was also sclerosis around the ankle joint. The authors decided revisional surgery. At the operative findings, we can see the loosening of talar and tibial component and large posterior osteophyte bridging between remained talus and tibial bone. There were no infection signs. After remove the implant, there was big space remained. For the regaining the limb length, we used femoral head allograft. The graft was fixed with 6.5 mm cannulated screws and addition fixed with ilizarov external fixation. Also additional auto bone graft from the osteophytes was applied. Compression over the ilizarov external fixation was done at the end of the operation. Weight bearing was allowed immediate after surgery. Ilizarov ring was removed 6 weeks after surgery. At the 3 months after surgery, bony union was obtained on radiographs. AOFAS score was improved from 30 to 70 6 mo after surgery. There was no pain on his right ankle. Patient satisfied with arthrodesis with allograft at final follow-up.
Total Hip Arthroplasty (THA) has been more frequently performed for relatively young patients with osteonecrosis of the femoral head in Korea. Moreover, squatting and sitting with crossed legs are more common in Asian cultures than in Western cultures. Wear debris generated by conventional metal-on-PE articulations has been giving rise to extensive osteolysis. Due to these characteristics, higher incidence of pelvic osteolysis was observed after THA in Korea. As a result, interest in alternative bearings such as ceramic-on-ceramic bearing has been increased. Furthermore, the patients who require revision THA are still young in Korea. With this point of view, an application of ceramic-on-ceramic bearing throughout revision THA seems to be reasonable. The clinical and radiographical outcomes after revision THA with use of third generation ceramic-on-ceramic bearing in Korean patients were evaluated.
Extensive bone deficiencies in proximal femur remains a significant challenge in hip surgery. In such a situation, one alternative is to use a proximal femoral allograft-prosthesis composite (APC) to restore the mechanical integrity and bone stock. The current study was performed to analyze the results of APC in the treatment of femoral bone deficiency. From January 1996 to June 2006, 12 patients who received 15 APC (3 of them received repeated APC), were followed for a mean of 4.2 years (range 2.0 to 9.8 years) by one surgeon. 5 were males and 7 were females and the mean age of the patients was 60.9 years (range 32 to 84 years). 6 patients were diagnosed with septic loosening, 5 were with aseptic loosening, 4 were with re-revision arthroplasty, and 1 was with limb salvage procedure due to malignancy and all were treated with fresh-frozen allograft. The surgical technique was used to cement the femoral component into the allograft but not into the host bone except 1 case. The average Harris hip score improved from 21.8, preoperatively, to 83.2, the latest follow-up, and the all stems showed good stability except 3 cases of aseptic loosening. These 3 cases went through a repeated operation with another APC after mean 83.7 months (51,92,108 months) and their results showed good stability. 11 APC had a good junctional union. One case was showed junctional nonunion that needed onlay graft at 3.3 years after APC. There were no infections (or septic loosening), dislocations and allogragt fractures (except one great trochanter avulsion fracture, neither clinical symptoms nor went a surgical treatment). This study demonstrated that the use of APC for extensive proximal femoral bone deficiencies showed a clinically, functionally and radiologically good results. Therefore it is considered as a good options.
The treatment of rotator cuff arthropathy due to irreparable massive rotator cuff tear is still challenging. We performed reverse total shoulder arthroplasties for 2 cases of cuff tear arthropathy. The short term follow-up after the surgery reveal excellent results by ASES and UCLA score. However, these results still require long term follow-up and the study about implant design for the shoulder anatomy of the Koreans.
We report the case of a 24-year-old man with a congenital meniscoid articular disc of the triangular fibrocartilage complex with extensor carpi ulnaris tenosynovitis. His young age, the normal articular cartilage, the lack of degenerative changes at the margins of the defect and its bilateral occurrence made this diagnosis likely. A congenital defect of the articular disc of the triangular fibrocartilage complex should not be misinterpreted as a traumatic rupture and is usually asymptomatic.
The purpose of this study was to investigate the efficacy and fusion rates of a unilateral pedicle screw construct supplemented with a translaminar screw in transforaminal lumbar interbody fusion (TLIF). The construct was used with an aim of providing suitable spine stiffness with minimal implant load for spinal fusion. Nineteen consecutive patients who underwent single level TLIF were included in the study. All patients had posterior spinal instrumentation using a unilateral pedicle screw construct with a contralateral translaminar screw. Patients were assessed preoperatively and at two, six, twelve and twenty-four weeks following surgery and at the end of one and two years. At every visit Oswestry disability index score,Visual analogue scale for pain and a pain diagram were recorded. A radiographic exam was also conducted and CT scan was done if there was concern about fusion. The average follow up was twenty-four months. There were twelve males and seven females with an average age of forty-eight years. All patients went on to clinical and radiographic union. Sixteen of nineteen patients had significant clinical improvement on VAS for pain, Oswestry scores and pain medication. Three patients had recurrence of radicular pain on the side of the TLIF leading to reexploration. In all three patients solid fusion was observed but scar tissue was evident and symptoms resolved following redecompression of the foramen. The biomechanical competence of a construct is evidenced by successful fusion. With the advent of minimally invasive techniques to achieve spinal fusion the goal is to use minimal instrumentation without compromising on the final stiffness of the spine. The construct of unilateral pedicle screws supplemented with a trans-laminar screw led to fusion in all our cases. It requires lesser soft tissue dissection and the posterior implants are 56% cheaper.
The first metatarsophalangeal (MTP) joint is the key joint of the foot in terms of function during gait. Various replacement toe joint prostheses are commercially available but unlike other replacement joints such as the hip or knee, few simulator based studies have been conducted to evaluate the performance and reliability of these prostheses. Presented are results obtained using a newly developed and validated multi-station MTP joint test-rig that is able to simulate the natural biomechanics of the toe joint. The developed simulator is a multi-station computer controlled electro-pneumatic metataso-phalangeal joint simulator that applies dynamic loading and motions commensurate with the walking gait cycle. This involves the combination of plantar-dorsi flexion range of 32 degrees, 5 degrees of inversion/eversion and toe-off dynamic loading peaking at up to 820 N. Presented are the validation and in vitro test results of MTP joint simulations carried out on silastic and articulating metal and polymer designs of MTP prostheses. Despite being subjected to a reduced loading regime of 300 N peak force, the silastic prostheses were found to perform poorly in the simulator, ultimately failing due to a combination of fatigue crack growth and joint collapse. This behaviour and failure mode was consistent with that of ex vivo origin silastic MTP prostheses examined and provides confidence in the validity of the simulator.
We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck’s disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9° and 6°, respectively (p <
0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck’s disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate.
We carried out a study to determine the effect of facet tropism on the development of adolescent and adult herniation of the lumbar disc. We assessed 149 levels in 140 adolescents aged between 13 and 18 years and 119 levels in 111 adults aged between 40 and 49 years with herniation. The facet tropism of each patient was measured at the level of the herniated disc by CT. There was no significant difference in facet tropism between the herniated and the normal discs in both the adolescent and adult groups, except at the L4-L5 level in the adults. Facet tropism did not influence the development of herniation of the lumbar disc in either adolescents or adults.
We sought to determine the degree of correlation between the condition of the patellar articular cartilage and patellofemoral symptoms and function in osteoarthritic patients undergoing total knee arthroplasty. The depth of the osteoarthritic lesion, as graded by the Outerbridge classification and its size and location were assessed to determine the condition of the patellar cartilage in 80 consecutive osteoarthritic knees undergoing total knee arthroplasty. The association between the condition of the cartilage and patellofemoral symptoms and function was investigated by correlation analysis. The depth and size of the lesion had a significant but weak correlation with anterior knee pain (r = −0.300 and −0.289; p = 0.007 and 0.009, respectively), whereas location had no significant association (p >
0.05). None had a significant association with patellofemoral functional parameters (chair-rising, stair-climbing, and quadriceps power) (p >
0.05). Our study indicates that patellofemoral symptoms and function are not completely determined by the condition of the cartilage. Caution should be taken when the symptoms and functional limitations are attributed to a lesion in the patellofemoral joint in making a decision regarding patellar resurfacing in total knee arthroplasty.
Little is known about the increase in length of tendons in postnatal life or of their response to limb lengthening procedures. A study was carried out in ten young and nine adult rabbits in which the tibia was lengthened by 20% at two rates 0.8 mm/day and 1.6 mm/day. The tendon of the flexor digitorum longus (FDL) muscle showed a significant increase in length in response to lengthening of the tibia. The young rabbits exhibited a significantly higher increase in length in the FDL tendon compared with the adults. There was no difference in the amount of lengthening of the FDL tendon at the different rates. Of the increase in length which occurred, 77% was in the proximal half of the tendon. This investigation demonstrated that tendons have the ability to lengthen during limb distraction. This occurred to a greater extent in the young who showed a higher proliferative response, suggesting that there may be less need for formal tendon lengthening in young children.
The relatively large diameter of currently used cages dictates extensive manipulations, damaging structures that are crucial for spinal stability. The Expandable Spinal Fusion System, is 5 mm in diameter in closed configuration, applied in a minimally invasive technique, through a 6mm entering opening by an open or percutaneous posterior procedures. Once in position, its dimensions are increased to a precut size in a controlled procedure. Thus, this system maintains the integrity of facet joints, with no or minimal laminectomy, and minimal damage to the surrounding tissues.
Patient questionnaire pain and quality of life was evaluated using the Oswestry questionnaire and VAS measurement. The patient fill those pre-operatively and at each follow up visit.
It has been shown that the bone, nerve, tendon, and muscle can generate new tissue when a leg is lengthened. In this study we have examined the muscles to see whether the proliferative response occurs uniformly along the fibres or whether it is a disproportionate occurrence, and also to see whether the muscles of animals of different age responded differently. In five adult (more than 25 weeks) and five young (8 to 9 weeks) New Zealand White rabbits, a mid-diaphyseal tibial osteotomy was created and stabilised with an Orthofix (M-100) external fixator. After seven days, lengthening was carried out at a rate of 1.6 mm/day until a 20% increase in the tibial length had occurred. One hour prior to sacrifice, all of the animals were injected with bromodeoxyridine (BrdUrd, 40mg/kg). Proliferative response of muscle tissue was assessed by measuring the positive staining index (PSI) of BrdUrd in a two-step indirect immunohistochemistry using the monoclonal antibody Bu20a. We accomplished this staining in transverse sections (between the proximal and middle third, and between the middle and distal third of the muscle belly) and in longitudinal sections along the proximal, middle and distal third of the myotendinous junction (MTJ) of the lengthened flexor digitorum longus muscle belly. The opposite limb was used as a control for each animal. All of the muscles showed a proliferative response that was significantly higher on the experimental side. There was no difference between the PSI of the proximal transverse sections and the distal transverse sections. The young animals demonstrated significantly increased PSI in all sections compared with the adult animals (immature distal transverse section PSI: 4.91%; mature distal transverse section PSI: 1.67%). The PSI of the longitudinal sections of MTJ showed significantly higher values than in the muscle belly (PSI at the MTJ in adults: 5.23%; PSI at the MTJ in the young: 13.2 %). The PSI result was increased at the distal third of the MTJ in mature and immature rabbits (p0.05). The muscles show a proliferative response to elongation forming new muscle tissue. The proliferative reaction to lengthening is far greater in the muscles of growing animals compared to adults. The myotendinous junction demonstrates much more intensive proliferative activity than the muscle belly. The distal third of the myotendinous junction shows the highest PSI results. The results of this study help to interpret the results of the animal model for clinical studies and also indicate an advantage in carrying out lengthening on young individuals.
A patient with a chronic discharging sinus or an extensive adherent scar is never safe from the risk of malignant change. Examples are still occurring more than thirty years after the end of the first world war. The possibility should be kept in mind by those concerned with the long-term treatment of wounds of this kind. Reasonable prophylactic measures would be: excision of adherent or unstable scars with, if necessary, their replacement by suitable pedicle flaps having a good blood supply; and earlier amputation if a osteomyelitic sinus persists for several years and does not yield to treatment. Supervision of doubtful cases should be frequent and should not be relaxed with the passage of the years. Warty changes or indolent ulceration of scars should be regarded with grave suspicion and investigated by biopsy. Any increase in pain or discharge in association with a sinus should receive prompt attention. Finally, if malignant change supervenes, treatment should be as speedy and as radical as with any other cancer. At least thirteen of our twenty-four patients have died of cancer.