Eun-Kyoo Song

A Comparative Study of Meniscectomy and Nonoperative Treatment for Degenerative Horizontal Tears of the Medial Meniscus

Background: It is still debated whether a degenerative horizontal tear of the medial meniscus should be treated with surgery. Hypothesis: The clinical outcomes of arthroscopic meniscectomy will be better than those of nonoperative treatment for a degenerative horizontal tear of the medial meniscus. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 102 patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus on magnetic resonance imaging were included in this study between January 2007 and July 2009. The study included 81 female and 21 male patients with an average age of 53.8 years (range, 43-62 years). Fifty patients underwent arthroscopic meniscectomy (meniscectomy group), and 52 patients underwent nonoperative treatment with strengthening exercises (nonoperative group). Functional outcomes were compared using a visual analog scale (VAS) for pain, Lysholm knee score, Tegner activity scale, and patient subjective knee pain and satisfaction. Radiological evaluations were performed using the Kellgren-Lawrence classification to evaluate osteoarthritic changes. Results: In terms of clinical outcomes, meniscectomy did not provide better functional improvement than nonoperative treatment. At the final follow-up, the average VAS scores were 1.8 (range, 1-5) in the meniscectomy group and 1.7 (range, 1-4) in the nonoperative group (P = .675). The average Lysholm knee scores at 2-year follow-up were 83.2 (range, 52-100) and 84.3 (range, 58-100) in the meniscectomy and nonoperative groups, respectively (P = .237). In addition, the average Tegner activity scale and subjective satisfaction scores were not significantly different between the 2 groups. Although most patients initially had intense knee pain with mechanical symptoms, both groups reported a relief in knee pain, improved knee function, and a high level of satisfaction with treatment (P < .05 for all values). Two patients in the meniscectomy group and 3 in the nonoperative group with Kellgren-Lawrence grade 1 progressed to grade 2 at the 2-year follow-up. Conclusion: There were no significant differences between arthroscopic meniscectomy and nonoperative management with strengthening exercises in terms of relief in knee pain, improved knee function, or increased satisfaction in patients after 2 years of follow-up.

The complications of high tibial osteotomy: CLOSING- VERSUS OPENING-WEDGE METHODS

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m(2)), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis. The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy. Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity.

Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty

Infection after total knee arthroplasty (TKA) is a devastating complication, and two-stage reimplantation has evolved as an effective treatment option. This study was undertaken to compare the clinical results and radiological changes associated with static or mobile cement spacer placement for the treatment of infected TKA. Between July 2000 and February 2007, 36 consecutive patients were treated by two-stage reimplantation using antibiotic-impregnated cement spacers (AICS) for infected TKAs. Static spacers were used in 20 knees and mobile spacers in 16 knees. Clinical outcomes included success rates of TKR revisions, ranges of motion (ROM), and Hospital for Special Surgery knee scores (HSS), pain and function scores of the Knee Society (KS), joint exposure methods, and bone loss. In this study, mobile spacers provided better ranges of motion and functional knee scores without concomitant increases in infection rate and bone loss in the initial and mid-term periods.

Erratum to: Robotic-assisted TKA Reduces Postoperative Alignment Outliers and Improves Gap Balance Compared to Conventional TKA

In the third sentence of the Patients and Methods section it states, ‘‘We considered patients with primary osteoarthritis of the knee and a mechanical axis between 20 and 5 valgus’’. However, the sentence should state, ‘‘We considered patients with primary osteoarthritis of the knee and a mechanical axis between 20 varus and 5 valgus’’. In addition, Dr. Yim’s degree is MD rather than MD, PhD. He currently is studying for his PhD degree.

Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction.

Background: No consensus has been reached on the advantages of double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) over the single-bundle (SB) technique, particularly with respect to the prevention of osteoarthritis (OA) after ACLR. Purpose: To evaluate whether DB ACLR has any advantages in the prevention of OA or provides better stability and function after ACLR compared with the SB technique. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 130 patients with an ACL injury in one knee were prospectively randomized into a DB group (n = 65) or an SB group (n = 65). For the radiologic evaluation, we determined the degree of OA based on the Kellgren-Lawrence grade before the operation and at the time of the final follow-up and determined the number of patients with progression of OA more than one grade from pre- to postoperation. We evaluated the stability results using the Lachman and pivot-shift tests and stress radiography. We also compared the functional outcomes based on the Lysholm knee score, Tegner activity score, and International Knee Documentation Committee (IKDC) subjective scale. Results: Six patients (4 in the DB group and 2 in the SB group) suffered graft failure during the follow-up and had ACL revision surgery (P = .06). A total of 112 patients were observed for a minimum of 4 years (DB group, n = 52; SB group, n = 60). Five patients (9.6%) in the DB group and 6 patients (10%) in the SB group had more advanced OA at the final follow-up (P = .75). All patients recovered full range of motion within 6 months from surgery. Stability results of the Lachman test, pivot-shift test, and the radiographic stability test failed to reveal any significant intergroup differences (P = .37, .27, and .67, respectively). In the pivot-shift result, the DB group had 4 patients with grade 2 and the SB group had 3 patients with grade 2 (P = .27). Clinical outcomes, including Lysholm knee and Tegner activity scores, were similar in the 2 groups. Statistical significance was achieved only for the IKDC subjective scale (78.2 in DB group vs 73.1 in SB group; P = .03). Conclusion: The DB technique, compared with SB, was not more effective in preventing OA and did not have a more favorable failure rate. Although the DB ACLR technique produced a better IKDC subjective scale result than did the SB ACLR technique, the 2 modalities were similar in terms of clinical outcomes and stability after a minimum 4 years of follow-up.

Heterotopic Ossification After Primary Total Ankle Arthroplasty

BACKGROUND Heterotopic ossification following lower-limb joint arthroplasty is a challenging clinical problem. No comprehensive study has been conducted on heterotopic ossification after total ankle arthroplasty, to our knowledge. The purpose of this study was to evaluate the prevalence and location of heterotopic ossification after primary total ankle arthroplasty, predisposing factors, and effects on clinical outcomes, and to develop a method of classification. METHODS Eighty ankles in eighty patients with a primary total ankle arthroplasty were followed for a mean (and standard deviation) of 31.9 ± 11.3 months (range, twenty-four to sixty-five months). The prevalence and location of heterotopic ossification, predisposing factors, and outcomes were analyzed, and a method of classification was developed. RESULTS Twenty (25%) of the eighty ankles demonstrated postoperative heterotopic ossification, with the majority of the cases in the posterior aspect of the ankle. The heterotopic ossification was Class I in four cases (20%); Class II, in five (25%); Class III, in four (20%); and Class IV, in seven (35%). Symptomatic heterotopic ossification was reported in eight patients (10%), and two required surgical resection because of intractable pain. Ankles that developed heterotopic ossification had significantly longer operative times, less postoperative motion, and lower American Orthopaedic Foot & Ankle Society ankle-hindfoot scores at the six, twelve, and twenty-four-month follow-up examinations (p < 0.05 for all). CONCLUSIONS This study demonstrates that the prevalence of heterotopic ossification following primary total ankle arthroplasty is considerable, and that heterotopic ossification is associated with reduced ankle motion and a poor clinical outcome at a mean of two years postoperatively. Care is needed to attempt to reduce the occurrence of heterotopic ossification.

Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty.

This study was undertaken to compare the clinical and radiological results achieved using navigation-assisted minimally invasive surgery (NA-MIS) and conventional (CON) techniques in 42 bilateral total knee arthroplasty (TKA) patients with a minimum follow-up of one year. Clinical evaluations were performed using range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores (pain, functional, and total) at 3, 6 and 9 months and one year postoperatively. Patients’ subjective preferences and radiological indices, including mechanical axis and coronal inclinations of the prostheses, were compared at one year postoperatively. NA-MIS TKA yielded better HSS and WOMAC total scores than CON TKA up to six months, and a better WOMAC pain score up to 9 months. However, these differences were not significant at one year postoperatively. ROM was comparable in both groups at all times, but more patients preferred the NA-MIS side to the CON side. Radiological results showed no differences in mean values between the two surgical groups, although the NA-MIS group contained fewer outliers than the CON group. In conclusion, NA-MIS TKA was associated with better clinical results up to 6 or 9 months after surgery, giving more accurate leg alignment than CON TKA.

Transtibial versus tibial inlay techniques for posterior cruciate ligament reconstruction: long-term follow-up study.

Background: The most common technique for posterior cruciate ligament (PCL) reconstruction is transtibial or tibial inlay. However, few studies have reported long-term outcome comparisons between the 2 techniques. Hypothesis: Tibial inlay PCL reconstruction with patellar tendon autograft will exhibit better clinical and radiographic outcomes than transtibial PCL reconstruction with hamstring autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 66 patients (66 knees) treated with PCL reconstruction for chronic injuries constituted the study cohort. Patients were divided into 2 groups: transtibial with hamstring (36 patients) and tibial inlay with patellar tendon (30 patients). The mean time from injury to reconstruction was 12.2 months (range, 2-60 months), and the mean follow-up was 148 months (range, 98-196 months). Outcomes were measured by use of Lysholm knee scores, Tegner activity scores, return to preinjury sports activity, posterior drawer test, laxity test with a Telos device, and development of osteoarthritis. Results: The preoperative mean Lysholm knee score was 59.9 (range, 37-70) in the transtibial group and 54.5 (range, 22-76) in the tibial inlay group, improving postoperatively to 89.9 (range, 74-100) and 92.1 (range, 80-100), respectively. The mean Tegner activity scores increased from 2.5 (range, 2-5) to 5.9 (range, 4-7) in the transtibial group and 2.3 (range, 2-4) to 6.0 (range, 3-8) in the tibial inlay group. Twenty-one patients (58.3%) in the transtibial group and 19 patients (63.3%) in the tibial inlay group were able to return to preinjury sports activity. In the posterior drawer test, 6 patients in the transtibial group and 4 patients in the tibial inlay group showed grade II laxity. The mean side-to-side difference was 10.1 mm (range, 7-12 mm) in the transtibial group and 10.4 mm (range, 9-13 mm) in the tibial inlay group, improving postoperatively to 4.1 mm (range, 0-8 mm) and 4.2 mm (range, 1-8 mm), respectively. There was significant improvement between preoperative and final follow-up values. However, there were no significant differences between the 2 groups in final follow-up outcomes. Final follow-up radiographs showed that 6 patients (16.7%) in the transtibial group and 3 patients (10.0%) in the tibial inlay group were rated grade C according to International Knee Documentation Committee guidelines. Conclusion: Clinical and radiographic outcomes between the 2 PCL reconstruction techniques were comparable. Osteoarthritis was observed in patients, with a significant proportion presenting loss of joint space. Examined factors, excluding meniscectomy, were not correlated with the development of osteoarthritis.

Patellofemoral Alignment and Anterior Knee Pain After Closing- and Opening-Wedge Valgus High Tibial Osteotomy

PURPOSE The purpose of this study was to compare the clinical and radiographic outcomes of opening- and closing-wedge valgus high tibial osteotomy (HTO) for the treatment of medial unicompartmental knee osteoarthritis with a minimum follow-up of 3 years, with a focus on patellofemoral alignment and anterior knee pain. METHODS We performed a retrospective comparison of 50 patients who underwent closing-wedge HTO and 50 patients who underwent opening-wedge HTO for isolated medial joint arthritis of the knee with varus deformity. All patients were evaluated and the 2 study groups were compared after a minimum follow-up of 3 years with a focus on patellofemoral alignment, patellofemoral osteoarthritis, and anterior knee pain while climbing stairs. RESULTS Patellar alignment (patellar tilt and lateral patellar displacement) was not significantly different in the 2 groups either preoperatively or at follow-up. Furthermore, there were no significant differences in the extent of patellofemoral arthritis and incidence of anterior knee pain at follow-up between the 2 groups. In addition, no significant intergroup difference was found in terms of the incidence of anterior knee pain (28% in closing-wedge group and 32% in opening-wedge group at follow-up). CONCLUSIONS The results of closing- and opening-wedge valgus HTO were not found to be significantly different with respect to patellar alignment, osteoarthritis of the patellofemoral joint, or anterior knee pain. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Navigated open wedge high tibial osteotomy.

Computer navigation for high tibial osteotomy allows multiplane measurements of leg axis to be made intraoperatively in real time, and allows, to some extent, compensations to be made for preoperative planning of shortcomings. Clinically, computer navigation significantly improves postoperative leg axis accuracy, and reduces correction variability with fewer outliers, and furthermore, it significantly reduces radiation time. This paper reviews the advantages, clinical results, complications, pitfalls, and the posterior tibial slope control in navigated open wedge high tibial osteotomy.