Sang-Rim Kim

Isolated fracture of the ceramic head after third-generation alumina-on-alumina total hip arthroplasty.

BACKGROUND While most reports of component fracture following alumina-on-alumina total hip arthroplasty have involved the acetabular liner, few have involved fracture of the alumina femoral head. In the present multicenter study, we investigated ceramic head fractures in a cohort of patients who underwent third-generation alumina-on-alumina total hip arthroplasty. METHODS We performed a retrospective study of 312 patients (367 hips) who underwent alumina-on-alumina total hip arthroplasty without cement at four participating centers with the use of a 28-mm BIOLOX forte femoral head and a BIOLOX forte liner from July 2001 to October 2003. Three hundred and five patients (359 hips) were evaluated at a mean of forty-five months postoperatively. Clinical follow-up with use of the Harris hip score and radiographic evaluation were performed at six weeks; at three, six, and twelve months; and every six months thereafter. Retrieved ceramic implants were examined by means of visual inspection. RESULTS Five hips (1.4%) in five patients were revised because of a ceramic head fracture during the follow-up period. The ceramic head fractures occurred during normal daily activities at a mean of 22.6 months postoperatively. A short neck had been used in all five hips in which a fracture occurred, compared with 121 (34.2%) of the 354 hips in which a fracture did not occur (p = 0.009). The fracture involved a circular crack along the circumference of the thinnest portion of the head component at the proximal edge of the bore. The fracture also involved multiple vertical cracks extending radially along the longitudinal axis from the circumference of the circular crack line to the lower edge of the head component. CONCLUSIONS In the present study, the rate of ceramic head fracture associated with one design of a short-neck modular alumina femoral head was 1.4% (five of 359). The extent to which these findings are generalizable to other designs that utilize this type of femoral head is unknown.

Revision of Ceramic Head Fracture After Third Generation Ceramic-on-Ceramic Total Hip Arthroplasty

We performed 24 revisions of fractures of third generation ceramic heads. The stem was not changed in 20 revisions; a new ceramic-on-ceramic bearing was used in four and a metal-on-polyethylene bearing in 16. The stem was changed in four revisions; a new ceramic-on-ceramic bearing was used in three and a metal-on-polyethylene bearing in one. During the follow-up of 57.5 months, complications occurred in five hips among the 20 stem retained revisions: a fracture of the new ceramic head in two, metallosis with pseudocyst in two, and femoral osteolysis with stem loosening in one. However, there were no complications in the four revisions where the stem was changed. Revision surgery after ceramic head fracture shows high rates of early complications. We recommend stem revision in cases of THA failure due to fracture of a modern ceramic head.

Morbidity and Mortality in Jeju Residents over 50-Years of Age with Hip Fracture with Mean 6-Year Follow-Up: A Prospective Cohort Study

This prospective cohort study was performed to estimate the morbidity and mortality with 790 patients over 50-yr of age that sustained a femoral neck or intertrochanteric fracture from 2002 to 2006, followed-up for a mean of 6 yr (range, 4 to 9 yr). Crude and annual standardized mortality ratios (SMRs) were calculated; and mortalities in the cohort and the age and sex matched general population were compared. The risk factors on mortality and activities pre- and post-injury were assessed. Accumulated mortality was 16.7% (132 patients) at 1 yr, 45.8% (337 patients) at 5 yr, and 60% (372 patients) at 8 yr. SMR at 5 yr post-injury was 1.3 times that of the general population. Multivariate analysis demonstrated that age (OR, 1.074; 95% CI, 1.050-1.097; P<0.001), woman (OR, 1.893; 95% CI, 1.207-2.968; P=0.005), and medical comorbidity (OR, 1.334; 95% CI, 1.167-1.524 P<0.001) were independently associated with mortality after hip fracture. Only 59 of the 150 patients (39.3%) who were able to ambulate normally outdoors at preinjury retained this ability at final follow-up. Patients with a hip fracture exhibits higher mortality at up to 5 yr than general population. Age and a preinjury comorbidity are associated with mortality.

Modified tension band fixation and coracoclavicular stabilisation for unstable distal clavicle fracture

BACKGROUND The purpose of this study was to report a new surgical technique for the treatment of unstable distal clavicle fracture with modified tension band fixation (MTBF) and coracoclavicular (CC) stabilisation, and evaluate the radiologic and clinical outcome of these patients. MATERIAL AND METHODS Thirteen patients who had a fracture of the distal clavicle (Neer classification type IIb) were treated with MTBF and CC stabilisation. After the CC stabilisation was performed with a suture anchor or flip button, internal fixation using MTBF was carried out. Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analysed. RESULTS The mean period required for fracture union was 12.6 (range, 8-24) weeks and union was successfully completed in all cases. The mean Constant score at the final follow-up was 94.7 (88-100); the modified University of California, Los Angeles (UCLA) shoulder rating scale was 31.3 points (range, 22-35). All patients returned to normal daily activities at an average of 3.7 months postoperatively (range, 3-5 months). One patient had a new fracture around drilled holes for CC stabilisation by inappropriate tunnelling. CONCLUSION MTBF and CC stabilisation is a useful technique for treating an unstable distal clavicle fracture. This procedure provides minimal incision and stable fixation without causing any further acromioclavicular joint injury to those with distal clavicle fractures.

Closed intramedullary nailing with percutaneous cement augmentation for long bone metastases

AIMS The purpose of the study was to investigate whether closed intramedullary (IM) nailing with percutaneous cement augmentation is better than conventional closed nailing at relieving pain and suppressing tumours in patients with metastases of the femur and humerus. PATIENTS AND METHODS A total of 43 patients (27 men, 16 women, mean age 63.7 years, standard deviation (sd) 12.2; 21 to 84) underwent closed IM nailing with cement augmentation for long bone metastases. A further 27 patients, who underwent conventional closed IM nailing, served as controls. Pain was assessed using a visual analogue scale (VAS) score pre-operatively (pre-operative VAS), one week post-operatively (immediate post-operative VAS), and at six weeks post-operatively (follow-up post-operative VAS). Progression of the tumour was evaluated in subgroups of patients using F-18-fludeoxyglucose (F-18-FDG) positron emission tomography (PET)/computed tomography (CT) and/or bone scintigraphy (BS), at a mean of 8.8 and 7.2 months post-operatively, respectively. RESULTS The mean pain scores of patients who underwent closed nailing with cement augmentation were significantly lower than those of the control patients post-operatively (immediate post-operative VAS: 3.8, sd 0.9 versus 6.0, sd 0.9; follow-up post-operative VAS: 3.3, sd 2.5 versus 6.6, sd 2.2; all p < 0.001). The progression of the metastasis was suppressed in 50% (10/20) of patients who underwent closed nailing with augmentation, but in only 8% (1/13) of those in the control group. CONCLUSION Percutaneous cement augmentation of closed IM nailing improves the relief of pain and limits the progression of the tumour in patients with metastases to the long bones. TAKE HOME MESSAGE Percutaneous cement augmentation while performing closed IM nailing has some advantages for long bone metastases. Cite this article: Bone Joint J 2016;98-B:703-9.

The effect of mechanical massage on early outcome after total knee arthroplasty: a pilot study

[Purpose] The aim of this study was to evaluate the efficacy of mechanical massage via Endermologie® after total knee arthroplasty in reducing edema and pain and improving knee range of motion, in the early postoperative period. [Subjects and Methods] Eighteen patients with knee edema following total knee arthroplasty were randomly assigned to the intervention group (n=8) or the control group (n=10). The intervention group received mechanical massage therapy using Endermologie® and the control group received conventional physical therapy for 20 minutes a day, 5 times a week from the seventh day postsurgery. Clinical assessments included active knee flexion and extension range of motion, knee pain using a numeric rating scale, the operated limb circumference, the soft tissue cross-sectional area using ultrasonography, the extracelluar fluid volume, and single frequency bioimpedance analysis at 5 kHz using bioelectrical impedance spectroscopy. [Results] Both groups showed significant reduction in edema and pain, and improvement in active knee flexion at the end of treatment. There were no significant inter-group differences before or after treatment. [Conclusion] Mechanical massage could be an alternative way of managing knee edema after total knee arthroplasty in early postoperative recovery.

Improvement of Osteoporosis Medication after Multimodal Intervention in Patients with Hip Fracture: Prospective Multicenter Study

Background The authors had earlier conducted a retrospective cohort study from 2008 to 2011 in Jeju Island, among 945 hip fracture patients above 50 years of age. Of these 945 patients, 344 patients (36.4%) underwent a bone mineral density test and 218 patients (23.1%) received treatment for osteoporosis. The purpose of this study was to determine whether a patient education program could improve osteoporosis management after hip fracture. The data of the previous study was used for comparison. Methods From November 1, 2014 to September 30, 2015, 190 patients above 50 years of age who were admitted for hip fractures at six different hospitals, were enrolled in the present study. During the hospitalization period, patients underwent education sessions and were provided brochures. Patients were evaluated for diagnosis and treatment of osteoporosis at six months after discharge and were followed-up for at least a year. Results Of the 222 patients with hip fractures, 190 patients (37 men, 153 women) were enrolled at six hospitals in 2015. Dual energy X-ray absorptiometry was performed on 115 patients (60.5%) and 92 patients (48.4%) were prescribed medication for osteoporosis at the time of discharge. A total of 43.7% and 40.2% of the patients were found to be compliant with osteoporosis medication at 6 months and 12 months follow-up respectively. Conclusions This interventional multicenter study demonstrated that a patient education program in patients with hip fractures can improve compliance to osteoporosis medication up to 12 months of follow-up.

PPARγ agonist rosiglitazone inhibits migration and invasion by downregulating Cyr61 in rheumatoid arthritis fibroblast-like synoviocytes

Peroxisome proliferator‐activated receptor gamma (PPARγ) agonists have anti‐inflammatory properties that reduce inflammatory cytokine production in rheumatoid arthritis (RA). Cysteine‐rich angiogenic inducer 61 (Cyr61) is associated with diseases related to chronic inflammation. The aim of this study was to investigate the mechanisms underlying the effects of PPARγ agonists on tumor necrosis factor (TNF)‐α‐induced fibroblast‐like synoviocyte (FLS) invasion and migration, as well as Cyr61 production, in RA‐FLS.

Multiple Nodular Form of Localized Pigmented Villonodular Synovitis in the Infrapatellar Fat Pad: A Case Report

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative disease of the synovial membrane of joints, tendon sheaths, and bursas. It usually presents in two forms, diffuse and localized. A 35-year-old male, since adolescence, presented left knee pain with palpable, multiple nodular tumorous lesions in the infrapatellar fat pad. An arthroscopic excisional biopsy was performed. Multiple brown-colored pedunculated synovial nodules were limited to the infrapatellar fat pad area. The histology of the resected specimens showed proliferation of mononuclear histiocytes with multinucleated giant cells and hyperplasia of the synovium, diagnosed as PVNS. LPVNS is usually a single mass with a pedunculated or, less frequently, a sessile appearance. This report describes a rare case of a multiple nodular form of LPVNS, localized at the infrapatellar fat pad. This case highlights the need to consider LPVNS one of the causes of vague and long-lasting knee pain. Abbreviations: PVNS: Pigmented Villonodular Synovitis; DPVNS: Diffuse Pigmented Villonodular Synovitis; LPVNS: Localized Pigmented Villonodular Synovitis; MRI: Magnetic Resonance Imaging Introduction Pigmented villonodular synovitis (PVNS), also known as pigmented villonodular bursitis and pigmented villonodular tenosynovitis, is a benign, proliferative disease that occurs at the synovial membrane of joints, bursas, and tendon sheaths. There are two distinct forms: diffuse (DPVNS) and localized (LPVNS) pigmented villonodular synovitis [1]. The diffuse form affects the whole synovium of the joint, while the localized form is characterized by focal involvement of the synovium [2]. The localized form is usually a single pedunculated mass or, less frequently, two or three nodules. Finding multiple nodules in LPVNS is extremely rare. To the best of our knowledge, there are only two reported cases [3]. Here, we describe a case of the multiple nodular form of LPVNS in the knee joint. It should be included as an atypical form of LPVNS in the differential diagnosis of knee problems. Case report A 35-year-old male visited our hospital with left knee pain and a palpable mass which developed since adolescence. Physical examination revealed neither effusion nor restriction of knee motion. Modest swelling was palpable over the infrapatellar area of the left knee versus the right side. He had tenderness around the patella tendon and tibial tuberosity. Laboratory studies revealed no abnormal findings. Plain radiographs showed a slightly increased radiopacity in the infrapatellar area and soft tissue swelling versus the contralateral side (Figure 1). Magnetic resonance imaging (MRI) showed multiple well-demarcated masses, with intermediate to low signal intensity on T1and T2-weighted images, surrounded by fluid signals in the anterior compartment of the knee joint (Figure 2). He underwent an arthroscopic excisional biopsy to remove the mass. Multiple brown-colored pedunculated nodules were found; they were limited to the infrapatellar fat pad (Figure 3). No other lesion was found throughout the knee joint. A pathology examination revealed the nodules surrounded by fibrous septa and foci of hemosiderin-laden macrophages and the proliferation of polyhedral mononuclear histiocytic cells, some of which had formed multinucleated giant cells. There was mild hyperplasia of the synovium, with focal layers of fibrin consistent with pigmented PVNS (Figure 4). Three years later, he had neither pain nor a mass on palpation over the lesion. On follow-up MRI, no sign of recurrence was noted (Figure 5). Discussion The incidence of PVNS is ~1.8 cases per million people [4]. The etiology of PVNS is still uncertain: chronic inflammation, trauma, hemarthrosis, neoplastic origin, and chromosomal disorders have been Correspondence to: Yong-Geun Park, Department of Orthopedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Aran 13gil 15, Jeju 690-767, South Korea, Tel: +82-64-754-8116; Fax: +82-64-7171131; E-mail: pyk184@hanmail.net

Vascular Malformations Corresponding to Sclerotomes in Multifocal Melorheostosis: Painful Hip and Knee Contractures Treated with Total Joint Arthroplasty

CASE A forty-three-year-old male patient complained of difficulty walking due to severe hip and knee pain and stiffness, which had persisted for twenty years. He was found to have multifocal melorheostosis involving the axial skeleton and the entire left lower limb, along with complex vascular and lymphatic malformations corresponding to the sclerotomes related to the skeletal anomalies. Total hip and knee arthroplasties were performed. He was eventually free of pain during walking, and joint motion of the hip and knee was substantially improved after surgery. CONCLUSION Hip and knee pain and contracture resulting from multifocal melorheostosis were successfully treated with total hip and knee arthroplasty.Case: A forty-three-year-old male patient complained of difficulty walking due to severe hip and knee pain and stiffness, which had persisted for twenty years. He was found to have multifocal melorheostosis involving the axial skeleton and the entire left lower limb, along with complex vascular and lymphatic malformations corresponding to the sclerotomes related to the skeletal anomalies. Total hip and knee arthroplasties were performed. He was eventually free of pain during walking, and joint motion of the hip and knee was substantially improved after surgery. Conclusion: Hip and knee pain and contracture resulting from multifocal melorheostosis were successfully treated with total hip and knee arthroplasty.