Sang Cheol Seong

Causes and Predictors of Patient's Dissatisfaction After Uncomplicated Total Knee Arthroplasty

We aimed to identify the causes and predictors of patients dissatisfaction after total knee arthroplasty (TKA). Patients satisfaction was evaluated in 438 TKAs. Causes of patient dissatisfaction were identified using patient interview, physical examinations, laboratory and radiographic tests, and relevant medical consultations. Investigation of 33 dissatisfied knees identified knee-related symptoms in 16 knees (48.5%) and the symptoms unrelated to the replaced knee in 17 knees (51.5%). Multivariate logistic regression analysis revealed that worse preoperative Western Ontario McMaster University Osteoarthritis Index scale pain score and postoperative decrease in range of motion were significantly associated with postoperative dissatisfaction (odds ratio, 7.6 and 2.1, respectively). This study demonstrates that residual symptoms or dysfunctions not directly associated with the replaced knee could be a frequent cause of postoperative dissatisfaction after TKA in osteoarthritic patients.

Anatomical References to Assess the Posterior Tibial Slope in Total Knee Arthroplasty: A Comparison of 5 Anatomical Axes

There has been no consensus on an ideal anatomical reference to determine the posterior slope of tibia plateau. Posterior slope of the medial tibia plateau was measured with reference to a proposed mechanical axis (MA) and 5 clinically relevant anatomical references in 90 osteoarthritic knees of 66 female patients undergoing total knee arthroplasty. The MA was defined as the line connecting the midpoints of the medial tibia plateau and the tibial plafond, and 5 anatomical references included the anterior cortical line of tibia, anatomical axis of proximal and central tibia, posterior cortical line of proximal tibia, and fibular shaft axis. The average posterior slope was 10.6 degrees with reference to the MA, and the amount of posterior slope varied widely among the patients and depending on the anatomical reference used to measure. This study indicates that the anatomical reference used to measure the posterior slope should be identified in studies where posterior slope is used to evaluate the sagittal alignment of total knee arthroplasty.

Oblique Femoral Tunnel Placement Can Increase Risks of Short Femoral Tunnel and Cross-Pin Protrusion in Anterior Cruciate Ligament Reconstruction

Background: A more horizontal femoral tunnel has been emphasized for contemporary anterior cruciate ligament (ACL) reconstruction. However, lowering the femoral tunnel may result in a shorter tunnel. In addition, a more horizontally placed femoral tunnel may have inadequate bone stock at the posterior portion of the tunnel, which can lead to protrusion of the cross-pin (Rigidfix) system for femoral fixation. Hypothesis: A more horizontal femoral tunnel position, particularly via the anteromedial (AM) portal technique, will reduce femoral tunnel length, and a more horizontal femoral tunnel position and anterior-to-posterior pin insertion will increase the risk of Rigidfix pin protrusion. Study Design: Controlled laboratory study. Methods: In 10 cadaveric knees, we measured maximum lengths of the femoral tunnels at the positions of 11:30, 10:30, and 9:30 o’clock using the transtibial technique and at the 10:30 and 9:30 o’clock using the AM portal technique. Then, for each femoral tunnel via the transtibial technique at 11:30, 10:30, and 9:30 o’clock positions, tests were performed for 3 directions of Rigidfix pin insertion using the lateral epicondyle as an anatomical landmark, namely, 15° anterior to posterior (A-P), neutral, and 15° posterior to anterior (P-A). It was then determined whether pins protruded from the posterior cortex. Results: The lengths of femoral tunnels produced using the transtibial technique became shorter as the femoral starting position became more horizontal (51.1 mm, 40.0 mm, and 34.2 mm on average at the 11:30, 10:30, and 9:30 o’clock position, respectively). Tunnels made using the AM portal technique were significantly shorter than those made using the transtibial technique: by 7.6 mm at the 10:30 o’clock and 4.5 mm at the 9:30 o’clock positions on average (P < .001). In addition, increasing obliquity increased the likelihood of Rigidfix pin protrusion, especially when pins were inserted in the A-P direction. Conclusion: The current effort to lower the femoral tunnel position in ACL reconstruction can shorten the tunnel length and compromise the graft fixation at the femur using the Rigidfix system. Clinical Relevance: When an intended femoral tunnel position is more horizontal than the 10:30 o’clock position for ACL reconstruction, a surgeon needs to be cautious regarding a short femoral tunnel, particularly when using the AM portal technique, and possible protrusion of the cross-pin (Rigidfix) fixator.

Functional Disabilities and Satisfaction After Total Knee Arthroplasty in Female Asian Patients

This study was conducted to investigate functional disabilities and patient satisfaction in Korean patients after total knee arthroplasty (TKA). Of 372 female patients who had undergone TKA with a follow-up longer than 12 months, 261 patients (70.2%) completed a questionnaire designed to evaluate functional disabilities, perceived importance, and patient satisfaction. The top 5 severe functional disabilities were difficulties in kneeling, squatting, sitting with legs crossed, sexual activity, and recreational activities. The top 5 in order of perceived importance were difficulties in walking, using a bathtub, working, recreation activities, and climbing stairs. Severities of functional disabilities were not found to be correlated with perceived importance. The 23 patients (8.8%) dissatisfied with their replaced knees had more severe functional disabilities than the patients satisfied for most activities. The dissatisfied patients tended to perceive functional disabilities in high-flexion activities to be more important than the satisfied.

Synovial membrane-derived mesenchymal stem cells supported by platelet-rich plasma can repair osteochondral defects in a rabbit model.

PURPOSE The aim of this study was to determine the in vivo effectiveness of synovial membrane-derived mesenchymal stem cell (SDSC)-encapsulated injectable platelet-rich plasma (PRP) gel in the repair of damaged articular cartilage in the rabbit. METHODS An osteochondral defect was created in the trochlear groove of the rabbit femur, and the defects were divided into 3 treatment groups: untreated control group, PRP group, and PRP-SDSC group. After 4, 12, and 24 weeks, the tissue specimens were assessed by macroscopic examination and histologic evaluation and stained immunohistochemically for type II collagen and proliferating cell nuclear antigen. In addition, total glycosaminoglycan content was determined at 24 weeks. RESULTS Rabbit PRP contained a high concentration of platelets and high concentration of growth factors compared with those in whole blood. Twenty-four weeks after transplantation, there was fibrous tissue in the control group. In both the PRP group and the PRP-SDSC group, the defects were repaired with hyaline cartilage and exhibited significantly higher safranin O staining, type II collagen immunostaining, glycosaminoglycan content, cumulative histologic scores, and number of proliferating cell nuclear antigen-positive cells. However, incomplete bone regeneration and irregular cartilage surface integration were observed in the PRP group. CONCLUSIONS Our results indicate that SDSC-embedded PRP gel could successfully resurface the defect with cartilage and restore the subchondral bone in the rabbit model. CLINICAL RELEVANCE This study indicates that in an animal model, the application of PRP and SDSC in combination for the treatment of local cartilage defects appears promising; however, PRP-SDSC products might be more or less appropriate to treat different types of tissues and pathologies. The clinical efficacy of PRP remains under debate. Therefore further research is needed at both the basic science and clinical levels.

Anterior cruciate ligament reconstruction with use of autologous quadriceps tendon graft.

Anterior cruciate ligament rupture is the most common knee ligament injury. Of the grafts that are used for anterior cruciate ligament reconstruction, bone-patellar tendon-bone is still the most common because of its initial fixation stability and its ultimate tensile strength and elastic modulus, which are superior to those of other graft sources. Hamstring tendon grafts recently have demonstrated functional results equivalent to those of bone-patellar tendon-bone grafts. While most recent studies have failed to demonstrate significant differences between the two types of grafts, many authors have reported on their strengths and weaknesses1-12. While there has been a trend toward better stability in association with bone-patellar tendon-bone grafts, postoperative complications, including anterior knee pain and patellofemoral problems, have been reported frequently13-20. Knee-extension deficits have been reported to occur more frequently in association with bone-patellar tendon-bone grafts as compared with hamstring tendon grafts1,7. Graft laxity and tunnel enlargement have been reported in association with hamstring tendon grafts, and some authors have found persistent muscular deficits in knee flexion and internal rotation strength after treatment with hamstring tendon grafts5,21. In 2004, we reported the early results for a series of patients undergoing anterior cruciate ligament reconstruction with use of a quadriceps tendon autograft22. The central quadriceps tendon-patellar bone autograft has been proposed as a reasonable source of anterior cruciate ligament graft by some authors as it offers adequate mechanical strength and easier rehabilitation, while some postoperative complications can be avoided23-28. The anatomy and mechanical properties of the quadriceps tendon were well described in a series of studies by Staubli et al.27,29-31. The cross-sectional area of the quadriceps tendon was almost twice that of the patellar …

Evaluation of anatomic references for tibial sagittal alignment in total knee arthroplasty.

The authors aimed to demonstrate the relationship between the sagittal mechanical axis of the tibia and other reference axes of the tibia and fibula in patients with advanced osteoarthritis of the knee joints, and then to identify a reliable landmark in order to minimize posterior tibial slope measurement errors. We evaluated 133 osteoarthritic knees with neutral or varus deformity in 64 female and 8 male patients. Axial computed tomographic images of whole tibiae including knee and ankle joints were obtained and reconstructed using 3-dimensional imaging software. Angles between the mechanical axis (MA), the tibial anatomical axis (TAA), the anterior tibial cortex (ATC) and the fibular shaft axis (FSA) were measured, and then medial and lateral tibial slope angles were measured using all axes. Mean angles between MA and the other anatomical reference lines (TAA, ATC and FSA) were 0.9, 2.2 and −2.1°, respectively. The mean values of lateral tibial slopes with respect to MA, TAA, ATC and FSA were 8.7, 10, 12 and 7.3, respectively, and their intra- and inter-observer reliabilities were higher than those of medial tibial slopes. Although posterior tibial slope change markedly according to the reference axis used, the axes used in conventional TKA showed significant correlations with each other, and thus, may be used safely if differences with the mechanical axis are considered. Moreover, the lateral tibial slope might have advantages over the medial tibial slope in terms of restoration of the natural tibial slope.

Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study.

The authors investigated the clinical value of intraoperative periarticular multimodal drug injections (PMDI) in patients on continuous epidural analgesia after simultaneous bilateral TKAs. In 55 patients scheduled to undergo simultaneous bilateral TKAs, one knee was randomly assigned to the PMDI group for which intraoperative periarticular injections were administered and the other knee was assigned to the No-PMDI group for which the injections were not done. These two groups were compared for pain level (during the operation night and on postoperative days (POD) 1, 4, and 7), functional recovery (ability to perform straight leg raising on POD 1 and maximum flexion on POD 7), patient satisfaction (POD 7), and the incidence of wound complications. The PMDI group showed a lower pain level during the operation night and on POD 1 than the No-PMDI group, but no differences in pain levels were observed between the groups on POD 4 or 7. Furthermore, no significant group differences were found in terms of functional recovery, patient satisfaction. No wound complication has been occurred in the PMDI group. This study demonstrates that PMDI provides additional pain relief limited to the immediate postoperative period but does not improve pain relief after POD 1, patient satisfaction and functional recovery.

Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA?: A randomised, controlled study

Although the analgesic effects of periarticular multimodal drug injection (PMDI) after TKA have been well documented, there is little information about additional pain relieving effects of PMDI incorporated to contemporary multimodal pain control protocols which have been proved to provide excellent analgesia. We performed a parallel-group, randomised, controlled study to determine whether PMDI provides additional clinical benefits on contemporary multimodal analgesic protocols including preemptive analgesics, continuous femoral nerve block, and IV-PCA. Eighty-seven patients were randomized to a PMDI group (n=45) or to a No-PMDI group (n=42). Pain level and opioid consumption were compared as primary outcomes. The incidences of narcotic and ropivacaine related side effects and complications, functional recovery, and satisfaction were also compared. The PMDI group experienced less pain during the operation night and the 1st postoperative day and showed lower opioid consumption over 24h after surgery. However, the PMDI group had a higher VAS pain score on the 1st postoperative day than during the operation night. No group differences in side-effects and complication incidences, functional recovery, and satisfaction were found. This study demonstrates that PMDI provides additional pain relief and reduces opioid consumption only during the early postoperative period in patients managed by the contemporary pain management protocol following TKA.

Correlations Between Commonly Used Clinical Outcome Scales and Patient Satisfaction After Total Knee Arthroplasty

UNLABELLED Patient satisfaction is becoming increasingly important as a crucial outcome measure for total knee arthroplasty. We aimed to determine how well commonly used clinical outcome scales correlate with patient satisfaction after total knee arthroplasty. In particular, we sought to determine whether patient satisfaction correlates better with absolute postoperative scores or preoperative to 12-month postoperative changes. Patient satisfaction was evaluated using 4 grades (enthusiastic, satisfied, noncommittal, and disappointed) for 438 replaced knees that were followed for longer than 1 year. Outcomes scales used the American Knee Society, Western Ontario McMaster University Osteoarthritis Index scales, and Short Form-36 scores. Correlation analyses were performed to investigate the relation between patient satisfaction and the 2 different aspects of the outcome scales: postoperative scores evaluated at latest follow-ups and preoperative to postoperative changes. The Western Ontario McMaster University Osteoarthritis Index scales function score was most strongly correlated with satisfaction (correlation coefficient=0.45). Absolute postoperative scores were better correlated with satisfaction than the preoperative to postoperative changes for all scales. LEVEL OF EVIDENCE Level IV (retrospective case series).