Heui-Chul Gwak

Predictors of reduction loss in tibial plateau fracture surgery: Focusing on posterior coronal fractures

INTRODUCTION Some studies have reported that fracture pattern was associated with reduction loss after surgery. The purpose of this study was to evaluate various factors that can influence reduction loss, including fracture patterns in unicondylar and bicondylar tibial plateau fractures. MATERIALS AND METHODS A total of 138 tibial plateau fractures that underwent open reduction and internal fixation using plates were retrospectively reviewed. The OTA/AO classification, fracture pattern, degree of comminution, and existence of reduction loss were evaluated based on simple radiographs and computed tomography. Patient information, including age, gender, and occupation, were acquired through chart reviews. The effect of each variable on reduction loss was evaluated through multiple logistic regression analysis. RESULTS Of 138 knees, reduction loss was observed in 40 knees (29.0%). Reduction loss was found in 11 (20.4%) of the type B knees (54 knees) and 29 (34.5%) of the type C knees (84 knees), according to the OTA/AO classification. The multiple logistic regression analysis for all cases revealed that the existence of comminution and coronal fracture influenced the occurrence of reduction loss, with odds ratios of 9.148 and 4.823, respectively (P<0.001 and P=0.001, respectively). In type B and type C, according to the OTA/AO classification, the existence of comminution and coronal fracture had causal relationships with the occurrence of reduction loss. The odds ratios of comminution and coronal fracture for reduction loss for type B were 9.114 and 9.117, respectively (P=0.019 and P=0.031, respectively), and the odds ratios for type C were 8.490 and 4.782, respectively (P=0.001 and 0.009, respectively). CONCLUSIONS When a tibial plateau fracture has a coronal fracture, if it is difficult to fix its fragments rigidly with medial or lateral plate fixation; therefore, buttress plating or direct fixation of fragments through the posteromedial, posterolateral, or posterior approach should be considered.

Delaminated rotator cuff tear: extension of delamination and cuff integrity after arthroscopic rotator cuff repair

BACKGROUND The purpose of this study was to evaluate the extension of delamination and the cuff integrity after arthroscopic repair of delaminated rotator cuff tears. METHODS Sixty-five patients with delaminated rotator cuff tears were retrospectively reviewed. The delaminated tears were divided into full-thickness delaminated tears and partial-thickness delaminated tears. To evaluate the medial extension, we calculated the coronal size of the delaminated portion. To evaluate the posterior extension, we checked the tendon involved. Cuff integrity was evaluated by computed tomography arthrography. RESULTS The mean medial extension in the full-thickness and partial-thickness delaminated tears was 18.1 ± 6.0 mm and 22.7 ± 6.3 mm, respectively (P = .0084). The posterior extension into the supraspinatus and the infraspinatus was 36.9% and 32.3%, respectively, in the full-thickness delaminated tears, and it was 27.7% and 3.1%, respectively, in the partial-thickness delaminated tears (P = .0043). With regard to cuff integrity, 35 cases of anatomic healing, 10 cases of partial healing defects, and 17 cases of retear were detected. Among the patients with retear and partial healing of the defect, all the partially healed defects showed delamination. Three retear patients showed delamination, and 14 retear patients did not show delamination; the difference was statistically significant (P = .0001). CONCLUSION The full-thickness delaminated tears showed less medial extension and more posterior extension than the partial-thickness delaminated tears. Delamination did not develop in retear patients, but delamination was common in the patients with partially healed defects.

Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair.

BACKGROUND An infected Achilles tendon after tendon repair is particularly difficult to treat because of the poor vascularity of the tendon as well as the thin surrounding soft tissue. For treatment of an infected Achilles tendon following tendon repair, we first focused on complete debridement and then promoted fibrous scar healing of the Achilles tendon using functional treatment. METHODS We retrospectively reviewed all of the medical records of 15 tertiary referral patients with postoperative infection of the Achilles tendon occurring between 2007 and 2012. The mean follow-up time was 33 months (range, 22 to 97 months). The infected tissue and the necrotic tendon were debrided, and the ankle was placed in a short leg splint for 2 weeks. The splint was then replaced with an ankle brace for the next 4 weeks. Partial weight-bearing was allowed immediately, and full weight-bearing was allowed at 2 weeks postoperatively. We assessed and recorded the physical parameters such as the range of motion, calf circumference, ability to perform a single-limb heel rise, patient satisfaction, and Arner-Lindholm scale. Laboratory tests, postoperative ultrasonography, and isokinetic plantar flexion power tests were also performed. RESULTS At a mean time of 17 days (range, 8 to 30 days) after debridement, infection signs such as discharge from the wound, redness, and local warmth resolved. The wound had healed and the stitches were removed at a mean of 17 days following the wound repair. At the time of the latest follow-up, there were no signs of active infection. Achilles tendon continuity recovered in all patients by fibrous scar healing. Compared with the contralateral side, there was no difference in the ankle range of motion in 8 patients. According to the Arner-Lindholm scale, 9 of the 15 results were excellent and 6 were good. Ten patients were able to perform a single-limb heel rise. Eleven of 15 patients returned to their pre-injury recreational activities. Diffuse homogeneous echotexture of the Achilles tendon with continuity was observed on the ultrasonographic examination. CONCLUSIONS In this retrospective series, radical debridement, combined with antibiotic therapy and functional rehabilitation, was successful in eradicating infection and maintaining function in patients with postoperative infection following Achilles tendon repair. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Morton's neuroma (interdigital neuralgia) treated with metatarsal sliding osteotomy

Background: Mortons neuroma is a common cause of metatarsalgia and many treatments had been described in literature. However, there have been only a few reports that treat the neuroma with an osteotomy on the proximal, not distal portion of the metatarsal bone using a plate. This study describes the clinical outcome of sliding osteotomy on the proximal metatarsal bone for the treatment of Mortons neuroma. Materials and Methods: Sixty five consecutive patients (85 feet) who underwent surgery for Mortons neuroma between November 2010 and February 2013 were identified from hospital records to include in this retrospective study. Average followup period was 37.3 months (range 24–51 months). Mean patient age at surgery was 50.2 years (range 23–75 years). Metatarsal sliding osteotomies were only performed on the third metatarsal bone. Clinical evaluations with the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal Interphalangeal Scale (AOFAS LMIS) and Foot Function Index (FFI) were performed. The length of the lesser toe was measured for radiologic evaluation. Results: Postoperatively, AOFAS LMIS and FFI were improved from 52.1 (range 45–60) and 62.4 (range 54–73) to 74.2 (range 68–86) and 31.3 (range 26–37). At the last followup, preoperative pain was dissolved in 79 feet (93% of overall 85 feet). A shortened 3.2 mm (±1.1) metatarsal bone following osteotomy was radiographically measured. There were six cases of complications (soft tissue infection, early numbness, delayed union, limitation of dorsiflexion and metal failure, etc.). Conclusions: This proximal metatarsal sliding osteotomy can be a relatively effective operative method in relieving pain from Mortons neuroma.

Change of ankle pain after total knee replacement arthroplasty

Methods We performed prospective analysis and followed up 76 patients enrolled from January 2012 to December. 2013 for at least 6 months excepting the 5 patients who were lost follow-up, 71 patients (bilateral: 9, unilateral: 62, total 80 cases) were analyzed. There were 8 men, 63 women and the average age were 69.6 years old (56-79). All surgery were performed by one operator and posterior cruciate ligament stabilized knee arthroplasty was done in all cases. Subjective ankle pain was evaluated by visual analogue scale (VAS) and clinical results were evaluated by AO-FAS ankle-hindfoot scale and SF-36. We described radiologic parameters around the hindfoot and ankle joint including talar tilt, tibial-ankle surface angle, medial clear space, frontal tibial ground angle, frontal talar gound angle, hindfoot alignment view angle and measured the amount of change of knee alignment by comparing preoperative and postoperative X-rays. We divided cases into 4 groups, two with increased ankle pain postoperatively in previous ankle pain group and newly developed pain postoperatively. Pain was aggrevated compared preoperatively was other subgroup, and the other had no change. We compared 4 groups in each parameter and analyzed statistically (SPSS v13.0).

Radiologic Factors Affecting Ankle Pain Before and After Total Knee Arthroplasty for the Varus Osteoarthritic Knee

Abstract The aim of the present study was to evaluate the radiologic factors related to ankle pain before and after total knee arthroplasty (TKA) among patients with a varus osteoarthritic knee. Fifty‐five patients (65 ankles) with a varus osteoarthritic knee who had undergone TKA and were followed up for >24 months were enrolled. For clinical assessment, the visual analog scale for pain and the American Orthopaedic Foot and Ankle Society ankle‐hindfoot scale were used. For radiologic assessment, the mechanical axis deviation angle, talar tilt, tibial anterior surface angle, distal medial clear space, medial tibiotalar joint space, frontal tibial ground angle, and hindfoot alignment view angle were measured. The patients with ankle pain before TKA (11 ankles) had a larger hindfoot alignment view angle (9.2° ± 2.6°) than that of patients without ankle pain before TKA (54 ankles; 5.5° ± 4.8°; p = .007). The patients with newly developed ankle pain or experienced an aggravation of existing pain after TKA (8 ankles) had a significantly larger degree of residual varus (5.1° ± 2.1°) than did the patients without ankle pain before and after TKA or those with ankle pain before surgery. However, the severity of the pain was not different during the follow‐up period (52 ankles; 1.6° ± 2.5°; p = .001). The results of the present study showed that residual varus deformity was associated with ankle pain after TKA. Surgeons should perform evaluations of the ankles of patients who complain of pain before and after TKA and should give careful attention to the correction of alignment during TKA. &NA; Level of Clinical Evidence: 3

Ankle Arthrodesis: A Comparison of Anterior Approach and Transfibular Approach

Background The purpose of this study was to compare clinical and radiological results of arthrodesis performed by the anterior approach and by the transfibular approach in ankle osteoarthritis. Methods Sixty patients underwent open arthrodesis (38 by the anterior approach and 22 by the transfibular approach). The visual analogue scale score and the American Orthopedic Foot and Ankle Society (AOFAS) score were examined clinically, and radiological examination was performed on the alignment of the lower extremity and bone union. Results Both groups showed significant improvement in AOFAS score (from 39.8 to 58.3 in the anterior approach group and from 44.5 to 60.7 in the transfibular approach group). There was no significant difference in AOFAS score at the last follow-up in both groups. The time to fusion was 13.5 weeks in the anterior approach group and 11.8 weeks in the transfibular approach group. Nonunion occurred in four cases in the anterior approach group and in one case in the transfibular approach group. Conclusions Ankle arthrodesis by the anterior approach and the transfibular approach showed comparably good clinical results.

Factors affecting articular cartilage repair after open-wedge high tibial osteotomy

BACKGROUND To evaluate the factors that affect articular cartilage repair after open-wedge high tibial osteotomy (OWHTO) and the relationship between regeneration of articular cartilage repair and clinical outcomes. METHODS Among the cases of OWHTO that were performed from March 2005 to February 2012, the patients who followed up for >2years and received a second-look arthroscopy were retrospectively reviewed. For clinical evaluation, the Knee Society scores and Western Ontario and McMaster Universities Osteoarthritis Index score were measured. For radiologic evaluation, the Kellgren-Lawrence scale, mechanical femorotibial angle, and joint line obliquity were used. In the initial and second-look arthroscopy, the status of the articular cartilage of the medial compartment was evaluated. RESULTS A total of 62 knees (61 patients) were included in this study. Articular cartilage repair was observed in 18 knees (29.0%). In multiple logistic regression analysis, patients with Kellgren-Lawrence Grade 4 (OR 0.076; 95% CI 0.007-0.822; P=0.034), the existence of a bipolar lesion (OR 0.108; 95% CI 0.016-0.724; P=0.022), or joint line obliquity >5° (OR 0.109; 95% CI 0.013-0.936; P=0.043) had significantly lower odds of articular cartilage repair compared to the corresponding counter group. In a comparison of clinical outcomes between a group that had articular cartilage repair and a group without repair, no significant difference was observed (P>0.05). CONCLUSIONS Severe arthrosis, existence of a bipolar lesion, and marked postoperative joint line obliquity had a negative impact on articular cartilage repair after OWHTO. However, articular cartilage repair showed unknown clinical significance.

Comparison of histologic healing and biomechanical characteristics between repair techniques for a delaminated rotator cuff tear in rabbits

BACKGROUND The purpose of this study was to compare histologic healing and biomechanical characteristics between 2 repair techniques (layer by layer, repair of each layer to bone separately; and whole layer, repair of each layer to the bone en masse) for delaminated rotator cuff tear. MATERIALS AND METHODS Rabbits were used as subjects and classified into 2 groups: group A, right side, the layer-by-layer repair group; and group B, left side, the whole-layer repair group. Histologic evaluations were done at 3 weeks (n = 7) and 6 weeks (n = 4) after operation. Biomechanical tests to evaluate the tensile property were done at time 0 (n = 5) and 3 weeks (n = 5) after operation. RESULTS Histologic healing improved in all groups. A smaller cleft was found between layers in group B compared with the cleft in group A at 3 weeks after operation. At time 0, group A showed a higher yield load and ultimate failure load (67 ± 10.5 N and 80 ± 7.8 N, respectively). However, at 3 weeks after operation, group B showed a higher yield load (48 ± 7.6 N). CONCLUSIONS In the delaminated rotator cuff tear model in the rabbit, the whole-layer repair showed a narrow gap between layers and a higher yield load at 3 weeks after operation. Surgical techniques that unite the cleft in a delaminated tear could improve biomechanical strength after operation.

Second-Look Arthroscopic Findings and Clinical Outcomes After Management of Intra-Articular Lesions in Acute Ankle Fractures with Arthroscopy

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: Anatomically successful surgical reduction of ankle fractures does not always result in a clinically favorable outcome. The purpose of the present study was to compare initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. Methods: A total of 39 patients (40 ankles, 20 male, 20 female) who underwent surgery for ankle fracture between March 2009 and August 2016 were retrospectively reviewed. All patients gave consent to the exploratory arthroscopic surgery for the removal of internal fixation devices placed in the initial surgery. Intra-articular lesions (osteochondral lesion, loose body, injury of ligaments and fibrosis) were evaluated via ankle arthroscopy. Arthroscopic finding of osteochondral lesion were classified using the Ferkel and Cheng staging system, and cartilage repair was assessed using the international Cartilage Repar System (ICRS). Clinicial outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Visual Analogue Scale (VAS) Results: Chondral lesions were found in 26 ankles (65%) with initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in second-look arthroscopy was 15 cases. Accoding to the Ferkel and Cheng staging at second-look arthroscopy, 4 of 23 ankles with chondral lesions of talus was getting worse (more than stage D). In terms of ICRS overall repair grades, 4 ankle (15%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles respectively in second-look arthroscopy. Correlation were found between AOFAS scores, VAS and intra-articular lesions with second-look arthroscopy. Conclusion: Second-look arthroscopic examination combined with treatment of intra-articular lesion arising from ankle fracture surgery may consider to improve clinical outcomes.