Dong-Il Chun

Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty: Its relationship to the axis of the tibia and the positioning of the talar component

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.The purpose of this study was to evaluate thenchange in sagittal tibiotalar alignment after total ankle arthroplasty (TAA)nfor osteoarthritis and to investigate factors affecting the restorationnof alignment. This retrospective study included 119 patients (120 ankles) whonunderwent three component TAA using the Hintegra prosthesis. A totalnof 63 ankles had anterior displacement of the talus before surgeryn(group A), 49 had alignment in the normal range (group B), and eightnhad posterior displacement of the talus (group C). Ankles in groupnA were further sub-divided into those in whom normal alignment wasnrestored following TAA (41 ankles) and those with persistent displacementn(22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly morenvarus than that in group B, and the posterior slope of the tibialnplafond was greater (p < 0.01 in both cases). The posterior slopenof the tibial component was strongly associated with restorationnof alignment: ankles in which the alignment was restored had significantlynless posterior slope (p An anteriorly translated talus was restored to a normal positionnafter TAA in most patients. We suggest that surgeons performingnTAA using the Hintegra prosthesis should aim to insert the tibialncomponent at close to 90° relative to the axis of the tibia, hencenreducing posterior soft-tissue tension and allowing restorationnof normal tibiotalar alignment following surgery. Cite this article: Bone Joint J 2015;97-B:1525–32.

Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction With Remnant Preservation Using Outside-In Technique

This report describes a modified anatomic single-bundle anterior cruciate ligament (ACL) reconstruction technique using the FlipCutter guide pin (Arthrex, Naples, FL) as a retrograde drill and a cortical suspensory fixation device (TightRope; Arthrex) with an adjustable graft loop length. Preservation of the ACL remnant as a biological sleeve for the graft is an important issue from the viewpoints of acceleration of revascularization and ligamentization, preservation of the proprioceptive nerve fibers, enhancement of the biological environment for healing, and maintenance of the anchor point at the native tibial attachment, in addition to yielding a lower incidence of tibial bone tunnel enlargement. The goal of our technique is to obtain some advantages of the remnant-preserving technique through an anatomic single-bundle ACL reconstruction, which is performed to minimize damage to the ACL tibial remnant.

Pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B: A case report

Rationale: We report a case of a hepatitis B virus (HBV)-positive patient with preexisting bone disease who developed tenofovir-induced Fanconi syndrome and subsequently sustained pathologic fracture. To our best knowledge, this is the first report in the English literature about pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B (CHB). The present report describes detailed our experience with the diagnosis of pathologic femoral fracture due to tenofovir-induced Fanconi syndrome and treatment. Patient concerns: A 45-year-old man visited our hospital with pain in the right thigh region and gait disturbance which had started 3 months ago and worsened 1 week before admission. The patient was diagnosed with CHB in 2004. He was on lamivudine medication for 2 years. Medication for the patient was subsequently changed to adefovir in 2009 and tenofovir disoproxil fumarate (TDF) in 2013. He was on TDF since 2013. Diagnosis: His hip joint magnetic resonance imaging (MRI) revealed hypointensity lesions and cortical bone destruction in fat-saturated MR image at the iliopsoas muscle attachment site of the lesser trochanter of both femur. On blood test showed 25-OH vitamin D level at 6.42u200ang/mL (normal range, >20u200ang/mL) and U-deoxypyridinoline level at 7.60u200anM/mMcr (normal range, 2.30–5.40u200anM mMcr). However, osteocalcin and parathyroid hormone levels were within normal range. Based on these findings, the present case was concluded as tenoforvir-induced Fanconi syndrome. Interventions: TDF treatment was discontinued. After cooperation with internal medicine department, in order to prevent further fractures of the right lesser trochanter, internal fixation was performed under spinal anesthesia using compression hip nails (APIS, TDM, Korea). Outcomes: Positive outcome by medication and operation demonstrates that his phosphorus and serum calcium levels were maintained within normal range and pain in the right thigh region was improved from visual analogue pain score (VAS) 7 before surgery to VAS 2 after surgery. Lessons: Physicians need to regularly monitor bone metabolism in patients with take in tenofovir for early diagnosis before its progression to pathologic fractures.

Pro-oxidant status and Nrf2 levels in psoriasis vulgaris skin tissues and dimethyl fumarate-treated HaCaT cells

Reactive oxygen species (ROS) contribute to pathogenesis of many inflammatory skin diseases, including psoriasis. The aim of this study is to compare antioxidant protein expression in psoriasis vulgaris (PV) skin tissues with that in normal skin tissues in vivo and to evaluate the effects of dimethyl fumarate (DMF), used for the treatment of psoriasis, on ROS generation and apoptosis in a human keratinocyte cell line HaCaT. Compared with normal skin tissues, PV skin tissues showed increased protein oxidation as well as down-regulation of Nrf2 and its regulatory proteins such as HO-1 and AKR1C3. Using HaCaT cells to model DMF-induced pro-oxidant effects in the skin cells, we found that DMF treatment induced increased ROS levels and apoptotic cell death, as signified by increased proportion of cells with Annexin V-PE(+) staining and a sub-G0/G1 peak in the cell cycle. Preceding these changes, DMF treatment resulted in up-regulation of Nrf2, HO-1, and AKR1C3 proteins in these cells. Collectively, increased oxidative stress and impaired cellular anti-oxidant enzyme systems may participate in the pathogenesis of PV. DMF may exert an additive therapeutic efficacy in PV by attenuating the redox burden and subsequent oxidative damage to normal keratinocytes through activation of Nrf2 pathway relative to PV.

Change of the tunnel configuration in the non-anatomic trans-tibial double bundle ACL reconstruction

BACKGROUNDnThe objectives of this study were to evaluate tunnel widening and morphologic change at the tunnel aperture.nnnMETHODSnA prospective study that included 17 trans-tibial double bundle anterior cruciate ligament (ACL) patients was conducted for the evaluation of serial computed tomography (CT) scan. The OsiriX was used for remodeling of CT images with a tunnel direction. Tunnel widening and change of the aperture morphology were assessed.nnnRESULTSnWith regard to the comparison of tunnel widening of the anteromedial (AM) tunnel, the entrance (p=0.01) and mid (p=0.02) of the coronal image, and the entrance (p < 0.01) and mid (p < 0.01) of the sagittal image showed statistically significant differences. The entrance (p=0.01) of the sagittal image only showed statistical significance in the posterolateral (PL) tunnel. With regard to the comparison between the AM and PL tunnels, the mid-portion (p = 0.04) of the sagittal image showed statistical differences, and the AM tunnel showed larger widening than the PL tunnel. Change of tunnel aperture was observed in the posterior, medial, and lateral portions of the AM tunnel and the anterior, posterior, and lateral portions of the PL tunnel.nnnCONCLUSIONSnIn some aspects, occurrence of tunnel widening was observed in most sites. Widening occurred mainly at the entrance and mid-portions of the AM tunnel and the entrance of the PL tunnel. Change of tunnel aperture was observed at most directions in both tunnels. This is a non-anatomic ACL reconstruction and similar study with anatomic ACL reconstruction would be required in the future.

Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study

BackgroundThe posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images.MethodsWe retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF.ResultsThe PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (Pxa0=u20090.02). The average cross angle was not significantly different between the two groups (SER groupu2009=u200919.4°, PER groupu2009=u200917.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (Pxa0=u20090.024, Pxa0=u20090.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (Pxa0=u20090.017).ConclusionsWith regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.

Necrotizing Sweet's syndrome presenting as necrotizing fasciitis with a good response to immune suppressant treatment

Dear Editor, Sweet’s syndrome (SS) is diagnosed by fever, neutrophilia, diffuse dermal neutrophilic infiltrate without infection and painful, erythematous papules or plaques on the extremities, face, and neck. Treatment with systemic corticosteroids results in a swift and dramatic improvement in both dermatosis-related symptoms and skin lesions. On the other hand, necrotizing fasciitis (NF) is a potentially fatal soft tissue infection most commonly resulting from a polymicrobial infection. NF is an emergent condition requiring broad-spectrum antibiotics, prompt surgical debridement and fasciotomy. Although SS and NF are different diseases, a new variant of necrotizing SS that mimics NF has been reported in immunocompromised patients. A 27-year-old man presented with painful erythematous lesions to both legs and a fever. He had a 3-year history of treatment with infliximab for inflammatory bowel disease up until 2 months earlier. With elevated C-reactive protein (CRP) levels (23.4 mg/dL) and leukocytosis (white blood cell count 19 400/mm), the lesions rapidly progressed to painful bullae and became necrotized (Fig. 1a). T2-enhanced magnetic resonance imaging (MRI) of the lower area of the left leg showed enhancement along the superficial fascia of the distal region (Fig. 2a), which was suggestive of NF. Although treated with piperacillin/tazobactam 4.5 g every 8 h for 3 days, the extent of the necrotic vesicles on the tibial area rapidly progressed and became aggravated (Fig. 1b), and the fever was sustained. Gram stain, viral markers, tissue culture and blood culture results were repeatedly negative. He had no other autoimmune disease feature. A re-evaluation of the pathologic review concluded that the patient was suffering from necrotizing SS consistent with intense deep infiltration of neutrophils and necrosis of soft tissue. After starting high-dose methylprednisolone pulse therapy (250 mg/ day), instead of maintaining antibiotics and performing

Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.The purpose of this study was to evaluate thenchange in sagittal tibiotalar alignment after total ankle arthroplasty (TAA)nfor osteoarthritis and to investigate factors affecting the restorationnof alignment. This retrospective study included 119 patients (120 ankles) whonunderwent three component TAA using the Hintegra prosthesis. A totalnof 63 ankles had anterior displacement of the talus before surgeryn(group A), 49 had alignment in the normal range (group B), and eightnhad posterior displacement of the talus (group C). Ankles in groupnA were further sub-divided into those in whom normal alignment wasnrestored following TAA (41 ankles) and those with persistent displacementn(22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly morenvarus than that in group B, and the posterior slope of the tibialnplafond was greater (p < 0.01 in both cases). The posterior slopenof the tibial component was strongly associated with restorationnof alignment: ankles in which the alignment was restored had significantlynless posterior slope (p An anteriorly translated talus was restored to a normal positionnafter TAA in most patients. We suggest that surgeons performingnTAA using the Hintegra prosthesis should aim to insert the tibialncomponent at close to 90° relative to the axis of the tibia, hencenreducing posterior soft-tissue tension and allowing restorationnof normal tibiotalar alignment following surgery. Cite this article: Bone Joint J 2015;97-B:1525–32.

Failure to restore sagittal tibiotalaralignment in total ankle arthroplasty

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.The purpose of this study was to evaluate thenchange in sagittal tibiotalar alignment after total ankle arthroplasty (TAA)nfor osteoarthritis and to investigate factors affecting the restorationnof alignment. This retrospective study included 119 patients (120 ankles) whonunderwent three component TAA using the Hintegra prosthesis. A totalnof 63 ankles had anterior displacement of the talus before surgeryn(group A), 49 had alignment in the normal range (group B), and eightnhad posterior displacement of the talus (group C). Ankles in groupnA were further sub-divided into those in whom normal alignment wasnrestored following TAA (41 ankles) and those with persistent displacementn(22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly morenvarus than that in group B, and the posterior slope of the tibialnplafond was greater (p < 0.01 in both cases). The posterior slopenof the tibial component was strongly associated with restorationnof alignment: ankles in which the alignment was restored had significantlynless posterior slope (p An anteriorly translated talus was restored to a normal positionnafter TAA in most patients. We suggest that surgeons performingnTAA using the Hintegra prosthesis should aim to insert the tibialncomponent at close to 90° relative to the axis of the tibia, hencenreducing posterior soft-tissue tension and allowing restorationnof normal tibiotalar alignment following surgery. Cite this article: Bone Joint J 2015;97-B:1525–32.