Seung Beom Han

Unfavorable Results of Partial Meniscectomy for Complete Posterior Medial Meniscus Root Tear With Early Osteoarthritis: A 5- to 8-Year Follow-Up Study

PURPOSE The aim of this retrospective study was to evaluate the clinical and radiographic outcomes of arthroscopic partial meniscectomy for complete posterior medial meniscus root tear (PMMRT) in patients with early radiographic evidence of knee osteoarthritis at a minimum follow-up of 5 years. METHODS Forty-six cases had complete PMMRT with follow-up of at least 5 years and were treated with arthroscopic partial meniscectomy. On the basis of medical records, we reviewed the arthroscopic findings of joint degeneration (Outerbridge grading), clinical results using the modified Lysholm (ML) knee score and a patient questionnaire, and radiographic evaluation of degeneration using Kellgren-Lawrence (KL) grading. RESULTS The incidence of complete PMMRT in the study population was 15%. At a mean follow-up of 78 months (range, 60 to 103 months), the mean ML score significantly improved from 72 (range, 62 to 78) preoperatively to 77 (range, 70 to 98) at final follow-up (P < .01), 16 patients (35%) showed progression of degeneration from KL grade 0 to 2 preoperatively to KL grade 2 to 4, 56% of patients indicated improvement in pain, 67% of patients were satisfied with the results of the procedure, and 19% of patients underwent reoperation. There was a significant negative correlation between chondral wear during arthroscopy (ρ = -0.516, P = .002) and preoperative KL grade (ρ = -0.429, P = .004) with ML score at final follow-up. CONCLUSIONS Although arthroscopic partial meniscectomy for complete PMMRT significantly improved ML scores postoperatively, only 56% of patients had improvement in pain, 67% were satisfied with the outcome of the procedure, and 35% showed radiographic progression of osteoarthritis at a mean follow-up of 77 months. LEVEL OF EVIDENCE Level IV, therapeutic study.

Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections Implications for Trigger Finger Treatment

Trigger finger is frequently treated with tendon sheath injections. This cadaveric study evaluated the accuracy and safety of blind and sonographically guided tendon sheath injections. To our knowledge, a study that precisely mapped the locations of material injected into the tendon sheath has not been reported previously.

Biomechanical Properties of a New Anatomical Locking Metal Block Plate for Opening Wedge High Tibial Osteotomy: Uniplane Osteotomy

Purpose The purpose of this study was to evaluate the biomechanical properties of a new anatomical locking metal block plate by comparing the initial biomechanical stability of three different fixation constructs for open wedge high tibial osteotomy (HTO). Materials and Methods Sawbones composite tibiae were used to make a 10-mm opening osteotomy model with uniplane technique. The osteotomy was secured with three different types of plates: Group I, new osteotomy plate without a metal block (n=5); Group II, new osteotomy plate with a 10-mm metal block (n=5); and Group III, two short metal block plates (n=5). Single load to failure test and staircase load-controlled cyclical failure test were performed. In the single load to failure test, the yield load, maximum failure load, and the displacement of the osteotomy gap were measured. In the staircase cyclical load to failure test, the total number of cycles to failure was recorded. Failure modes were observed during both single and cyclic load tests. Results Group II showed the highest yield and ultimate loads (1829±319 N, 3493±1250 N) compared to Group I (1512±157 N, 2422±769 N) and Group III (1369±378 N, 2157±210 N, p<0.05). The displacement of the opening gap in Group II (0.34±0.35 mm) was significantly lesser than the other groups (p<0.05). In the staircase cyclical load to failure test, the total number of cycles to failure was 12,860 at 950 N in Group III, 20,280 at 1,140 N in Group I, and 42,816 at 1,330 N in Group II (p<0.05). All the specimens showed complete fracture of the intact lateral sawbones area and slight displacement of the distal fragment of the specimens in the single load to test. None of the specimens showed deformed or broken screws and plates during the single load to test. During the fatigue test with staircase cyclic loading, no fracture of the lateral sawbones area was observed. Conclusions This study demonstrated that the new anatomical locking metal block plate could provide sufficient primary stability for open wedge HTO. The addition of a metal block to this new plate can increase the stability of the osteotomy compared to the one without a metal block.

Preoperative and Postoperative Comparisons of Navigation and Radiologic Limb Alignment Measurements After High Tibial Osteotomy

PURPOSE To determine whether navigation-assisted intraoperative lower limb alignment in open wedge high tibial osteotomy (HTO) correlates with preoperative and postoperative radiographic alignment. METHODS This prospective study involved 35 patients (39 knees) who underwent navigation HTO for primary medial osteoarthritis. The mechanical axis (MA) and weight-bearing line (WBL) ratio were calculated from preoperative radiographs, intraoperative navigation, and postoperative (6 months) radiographs. Reliability between navigation and radiographic alignment was analyzed by use of intraclass correlation coefficients (ICCs) with thresholds as follows: good, greater than 0.75; fair, 0.4 to 0.75; and poor, less than 0.4. The surgical target for the MA was a final valgus overcorrection of 2° to 8°, and the WBL ratio target was between 50% and 70%. Outliers for differences between intraoperative navigation and postoperative radiographic results were defined as greater than ±3° for the MA and greater than ±10% for the WBL ratio. RESULTS The MA target was achieved in 33 of 39 knees (84.6%), and the WBL ratio target was achieved in 30 of 39 knees (74.4%). ICCs for navigational reliability were good for preoperative MA and WBL ratio and fair for postoperative MA and WBL ratio. The ICCs for the MA were better than those for the WBL ratio for both preoperative and postoperative measurements. The differences between the number of outliers between the navigation and radiographic MA and WBL were greater postoperatively than preoperatively. In addition, the postoperative differences in the extent of the outliers between navigation and radiographic measurements were greater for WBL ratios than the MA (P = .023). CONCLUSIONS This study found that use of a navigation system achieved the target value for MA lower limb correction in over 80% of open wedge HTO cases, using radiographic data as the gold standard for alignment. Because the navigational measurements of lower limbs during open wedge HTO did not correlate with postoperative radiographic alignment, corrections should not be based solely on navigational results. In assessing the reliability of navigational open wedge HTO for correction of lower limb alignment, the MA is a better radiologic parameter than the WBL ratio. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Postoperative Ileus After Total Joint Arthroplasty

We evaluated the incidence and risk factors for postoperative ileus (POI) after total joint arthroplasty in a consecutive group of patients between January 2004 and December 2005 using regional anesthesia and multimodal pain management protocols. Postoperative ileus developed in 31 (0.7%) of 4567 patients. Of these patients, 21 (67.7%) were men, and 10 (32.3%) were women, with a mean age of 68 years (range, 52-91 years). The ileus was treated successfully in 29 patients during the hospitalization. One patient died from this complication, and another one required sigmoid colon resection due to perforation. The risk factors for developing POI after joint arthroplasty were older age, male sex, hip arthroplasty, and prior history of abdominal surgery. The type and dose of narcotic medications, as administered using our current protocol, did not appear to influence the development of POI.

Pseudoaneurysm of the Popliteal Artery Complicating Medial Opening Wedge High Tibial Osteotomy

The popliteal artery is vulnerable to injury during surgeries performed around the knee joint. Pseudoaneurysm of the popliteal artery following a high tibial osteotomy is rare. Few case reports describe the development of this complication after a lateral closing wedge high tibial osteotomy. Our patient underwent an uneventful medial opening wedge high tibial osteotomy and autogenous bone grafting fixed with dual plating for medial osteoarthritis of the knee. The procedure was performed under tourniquet control, which was released only once after the wound closure. Postoperatively, the dressing was soaked, and a large volume of hemorrhagic collection was present in the suction drain. The patient experienced decreased sensation over the sole, which was successfully treated conservatively with medication. Other clinical parameters like motor function and distal pulses were normal. The patient was discharged after 2 weeks. Two days later, the patient presented with pain and numbness over the entire lower limb and a pulsatile swelling in the popliteal fossa. A femoral angiogram revealed a pseudoaneurysm arising from the popliteal artery just below the osteotomy site. Open vascular surgery with resection of the pseudoaneurysm and end-to-end anastomosis using contralateral saphenous vein interposition graft was performed. During the vascular surgery, a pinhead-sized tear was clearly identified on the anterior wall of the popliteal artery, which may have occurred while using the oscillating saw during opening wedge high tibial osteotomy. Careful placement of retractors around the osteotomy site during sawing and flexing the knee to displace the popliteal artery away are recommended to prevent this complication. To our knowledge, this is the first report of a popliteal artery pseudoaneurysm occurring after a medial opening wedge high tibial osteotomy.

Platelet-Rich Plasma Therapy for Knee Joint Problems: Review of the Literature, Current Practice and Legal Perspectives in Korea

Platelet-rich plasma (PRP) is a concentrate extract of platelets from autologous blood, and represents a possible treatment option for the stimulation and acceleration of soft-tissue healing and regeneration in orthopedics. Currently, the availability of devices for outpatient preparation and delivery contributes to the increase in the clinical use of PRP therapy in practical setting of orthopedic fields. However, there is still paucity of scientific evidence in the literature to prove efficacy of PRP therapy for the treatment of ligament or tendon problems around the knee joint. Moreover, strong evidence from well-designed clinical trials to support the PRP therapy for osteoarthritis of the knee joint is yet scanty in the literature. Scientific studies need to be performed to assess clinical indications, efficacy, and safety of PRP, and this will require high powered randomized controlled trials. Nonetheless, some hospitals exaggeratedly advertise PRP procedures as the ultimate treatment and a novel technology with abundant scientific evidence for the treatment of knee problems. As a matter of fact, PRP protocols are currently approved only for use in clinical trials and research, and are not allowed for treatment purpose by any institutions in Korea. At present, clinical use of PRP therapy for ligament or tendon problems or osteoarthritis of knee joint is defined as illegal medical practice, regardless of whether it is performed as a sole procedure or as a part of prolotherapy, because the safety and validity are not yet approved by the Ministry of Health and Welfare and Health Insurance Review and Assessment Service. Practicing physicians should remember that injection of PRP to patients by imposing medical charge is still illegal as per the current medical law in Korea.

Isolation and expansion of synovial CD34−CD44+CD90+ mesenchymal stem cells: comparison of an enzymatic method and a direct explant technique

Synovium-derived mesenchymal stem cells (MSCs) offer a promising therapeutic option for cartilage regeneration. The conventional method of MSC isolation involves single-cell suspensions using collagenases. Recently, a nonenzymatic explant technique was developed to isolate MSCs. We compared these techniques in the isolation of functional MSCs. MSCs were isolated from human fibrous and adipose synovium of osteoarthritic patients using explants or enzymatic methods. Total cell number, percentage of MSCs, and surface marker expression of MSCs were measured following expansion. Multipotentiality was determined using a MSC functional identification kit. MSCs isolated from fibrous or adipose synovium using these two techniques expressed similar levels of the surface markers CD44, CD90, and CD105, and displayed similar multipotentiality in generating adipocytes, osteoblasts, and chondrocytes. Total cell number and number of CD34–CD44+CD90+ MSCs after 10-day expansion were similar in each culture, regardless of the source and method used, although the percentage of MSCs was slightly higher in explant cultures. There were no correlations between MSC yield and patient age, Hospital for Special Surgery score, and degree of deformity under all culture conditions. Both the enzymatic and explant techniques yielded similar yields of MSCs with similar characteristics. Because the explant technique is simpler and less invasive, it may be preferred over enzymatic techniques for isolating MSCs from the synovium of osteoarthritic patients for cartilage regeneration.

Spontaneous Late Dissociation of the Tibial Insert After High-Flex Posterior-Stabilized Genesis II Total Knee Arthroplasty

We report a rare complication of spontaneous late dissociation of the tibial insert 2 years after total knee arthroplasty using a high-flex posterior-stabilized Genesis II prosthesis (Smith & Nephew, Memphis, Tenn). It appears that 2 factors may have contributed to dissociation, namely, incomplete seating of the insert and the design of the prosthesis, which involves a shallow anterior tab snap-fit locking mechanism and thin dovetail lips.

Unintended Rotational Changes of the Distal Tibia After Biplane Medial Open-Wedge High Tibial Osteotomy.

This study involved 35 knees undergoing biplane medial open-wedge high tibial osteotomy (OWHTO) to assess the axial rotation of the distal tibia. The distal tibiae were internally rotated by 3.0° ± 7.1° after OWHTO. The opening width showed a Pearson correlation coefficient of -0.743 (P < .001), and the tuberosity osteotomy angle showed that of -0.678 (P < .001) with distal tibial rotation. However, changes in hip-knee-ankle angle, medial proximal tibial angle, and posterior tibial slope were not significantly correlated with the change in distal tibial rotation. In conclusion, there was an unintended tendency of increasing internal rotation of the distal tibia after biplane medial OWHTO, and this tendency was positively related to the opening width and tuberosity osteotomy angle.