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Various nonoperative treatments have been implemented to reduce pain and improve the quality of life in patients with ankle osteoarthritis. Among these treatments, intra-articular hyaluronate injection has proven efficacy and safety in patients with knee osteoarthritis. The purpose of this study was to evaluate the efficacy and complications of hyaluronate injection using various clinical scoring systems. This study included 37 patients with unilateral ankle osteoarthritis (grade 2 or 3 according to the Takakura classification) who did not respond to previous pharmacological treatment. 3 weekly hyaluronate injections (2 mL Hyruan Plus®) were administered. The efficacy of intra-articular hyaluronate injection was evaluated on the basis of patient-reported foot and ankle clinical assessment at a mean follow-up of 13.8 ± 8.3 (range 6-33) months. Ankle Osteoarthritis Scale scores for pain and disability, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, and visual analog scale for pain significantly improved at the final follow-up compared to that before intra-articular hyaluronate injection (p ≤.05). When patients were dichotomized according to age, sex, body mass index, symptom duration, and Takakura classification, all these factors were not related to clinical outcomes. This study suggests that 3 weekly intra-articular hyaluronate injections can be performed safely to reduce pain and improve function without serious complications in patients with early or intermediate-grade ankle osteoarthritis when patients inadequately respond to medication. Larger controlled studies are needed to clarify the effects of hyaluronate injection and identify patients who can benefit most from hyaluronate injection. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to compare the clinical and radiographic outcomes between feet with or without postoperative sesamoid reduction of proximal metatarsal chevron osteotomy for moderate to severe hallux valgus deformity.Methods: All of 110 feet were allocated into two groups (reduction group; 66 feet, non-reduction group; 44 feet) according to the reduction status of sesamoid at 6 months after surgery. The clinical and radiographic results of the two groups were compared preoperatively, 6 months follow-up, and at last follow-up.Results: The overall improvement in clinical outcomes was similar in both groups at average 4-year follow-up. However, the radiographic outcomes and recurrence rate were significantly worse in the sesamoid non-reduction group.Conclusions: Our results suggested that postoperative incomplete reduction of sesamoid may increase a risk for the recurrence of hallux valgus deformity. [ABSTRACT FROM AUTHOR]

Background: This study aims at determining the average long-term result of revision total hip arthroplasty (THA) using the acetabular reinforcement ring with a hook (ARRH) and bone grafting in severe acetabular bony defect. Expected 15-year survival of ARRH in revision THA is included in the study.Methods: Retrospective review of 48 patients (48 hips) with follow-up duration of average 11.4 years (range, 6.1-21.4 years) was conducted. At each follow-up, Harris hip score was used to assess functional outcome, and radiographic acetabular component osteolysis was measured by DeLee and Charnley classification. Bone defects were assessed preoperatively and intraoperatively using American academy of orthopedic surgeons and Paprosky classification. The common modes of ARRH failures were evaluated. Bone consolidation, presence of heterotopic ossification, and complications such as infection and dislocation were recorded.Results: The bone defects were varied and included cavitary, segmental, and combined defects without any pelvic discontinuity. Mean Harris hip score improved from 52.6 points preoperatively to 82.0 points postoperatively. Nine acetabular revisions and 3 stem revisions (2 concurrent with acetabular revisions and 1 isolated stem revision) were performed. There were 5 infected cases and 1 patient with recurrent dislocation. The 11.4-year survival of revision THA with ARRH was 71% as the end point for acetabular revision surgery for any reason. The expected 15-year survival of revision THA with ARRH was 60%. The most common failure mode of ARRH was superomedial migration followed by lateral migration.Conclusion: ARRH combined with bone grafting produces relatively good average long-term clinical results. [ABSTRACT FROM AUTHOR]

Background: In this work, we present relatively long-term results of femoral head fractures with a specific focus on Pipkin type I fractures. Methods: Fifty-nine femoral head fractures were treated according to modified Pipkin's classification as follows: type I, small fragment distal to the fovea centralis (FC); type II, large fragment distal to the FC; type III, large fragment proximal to the FC; type IV, comminuted fracture. There were 15 cases of type I, 28 of type II, 9 of type III, and 7 of type IV fractures. Conservative treatment with skeletal traction was performed in 4 type II cases, excision of the fragment in 15 type I and 10 type II cases, fixation of the fragment in 14 type II and all 9 type III cases, and total hip replacement in all 7 type IV cases. The overall clinical and radiographic outcomes were evaluated using previously published criteria, focusing on the results in Pipkin type I fractures with relatively large fragments. Results: Based on Epstein criteria, in type II fractures, excellent or good clinical results were seen in 6 of 10 patients (60.0 %) treated by excision of the fragment and 12 of 14 patients (85.7 %) treated by internal fixation ( p = 0.05). Also, excellent or good radiologic results were seen in 4 of 10 (40.0 %) patients treated by excision of the fragment and 12 of 14 (85.7 %) patients treated by internal fixation ( p = 0.03). Conclusions: Even in Pipkin type I fractures, if the fragment is large (modified Pipkin type II), early reduction and internal fixation can produce good results. [ABSTRACT FROM AUTHOR]

We compared the intraoperative varus-valgus stability from 0° to 90° of flexion and postoperative clinical outcomes in patients receiving TKA via either a single-radius femoral design (50 TKA, SR group) or multi-radius femoral design (50 TKA, MR group). We measured stabilities at 0°, 30°, 60° and 90° of flexion using a navigation system. The clinical outcomes including HSS scores, WOMAC scores and VAS score during stair climbing were compared after a minimum of 2-year follow-up. The single-radius femoral designs in TKA showed better intra-operative stability at 30° of flexion (7.6 vs. 8.3) compared with the multi-radius femoral design, but not at other angles. However, the clinical outcomes revealed no other significant differences in terms of HSS scores, WOMAC scores and VAS score between two groups. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this prospective study was to evaluate the clinical and functional outcomes of THA using large-diameter metal-on-metal articulation in patients with neuromuscular weakness. Nineteen consecutive patients (19 hips) with neuromuscular weakness and displaced femoral neck fractures were enrolled. Functional improvement and recovery, radiological evaluation of THA and surgical morbidity were assessed. Mean Harris hip and WOMAC scores at final follow-up were 81.0 and 42.9, respectively. At final follow-up, no dislocation, metal hypersensitivity, or osteolysis was observed and no patient required revision of THA. The findings of this study indicate that the functional results of THA using large-diameter metal-on-metal articulation in patients with neuromuscular weakness can produce satisfactory outcomes with early functional recovery and a low dislocation rate. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Abstract: The present study was undertaken to evaluate the clinical and radiological results of isolated femoral revisions conducted while retaining well-fixed cementless acetabular sockets. Thirty-nine patients that underwent isolated femoral stem revisions were reviewed. Mean age at time of surgery was 60.5 years, and mean follow-up duration was 4.2 years. Decisions to retain acetabular sockets were based on clinical and radiographic findings and intraoperative stabilities. During revisions, polyethylene liners were exchanged for metal-inlay polyethylene liners to have a metal-on-metal bearing surface in 23 cases. Mean Harris hip score improved from 58 points preoperatively to 85 points at final follow-up (P < .001). With the exception of one patient, no increases in acetabular radiolucent line numbers or thicknesses were observed during follow-up visits. Isolated femoral stem revisions with acetabular socket retention were found to provide excellent clinical and radiographic results. [Copyright &y& Elsevier]

Abstract: Thirty-four hips were treated with cementless acetabular socket revisions using a metal-on-metal bearing. The causes of revision were aseptic loosening in 33 hips and septic loosening in 1 hip. Revisions were performed for acetabular sockets in 28 hips and for acetabular sockets and femoral stems in 6 hips. Mean follow-up duration was 6.2 years (range, 4.0-9.1 years), and mean Harris Hip Scores improved from 56 to 92 points. No hip required further revision for aseptic loosening. Focal femoral osteolysis newly developed in zone I in 1 hip, which was treated by curettage and bone grafting. The authors suggest that second-generation metal-on-metal bearings in cementless acetabular socket revisions can achieve good medium-term clinical and radiographic results. [Copyright &y& Elsevier]

Abstract: Lee KB, Park YH, Song EK, Yoon TR, Jung KI. Static and dynamic postural balance after successful mobile-bearing total ankle arthroplasty. Objective: To investigate static and dynamic postural balance after successful total ankle arthroplasty by using dynamic posturography. Design: A controlled trial study. Setting: A national university orthopedic and rehabilitation hospital. Participants: Patients (n=30, 21 men, 9 women; mean age, 58y) and age- and sex-matched healthy controls (n=30). Interventions: Thirty patients who underwent unilateral total ankle arthroplasty with a cementless mobile-bearing ankle prosthesis and 30 age- and sex-matched healthy control subjects were included. Main Outcome Measures: Using computerized dynamic posturography, sensory (sensory organization test [SOT]), and motor (limit of stability [LOS], rhythmic weight shift [RWS], and weight bearing) impairment assessments were performed at an average of 15 months after total ankle arthroplasty. Results: In the SOT, results of the SOT-2 test reflecting mainly proprioception showed no significant difference between patients and controls, but patients demonstrated significantly lower scores for SOT-4, -5, and -6 as a measure of dynamic postural balance and required more hip movement to maintain balance. In the motor-control tests, patients showed significantly lower measures in indices of LOS test except the mean reaction time and the forward/backward directional control and on-axis velocity of the RWS test. Weight bearing was observed asymmetrically in patients. Conclusions: Patients had a higher degree of dynamic postural imbalance and relied less on ankle strategy to maintain balance than controls. Also, patients showed the deficit of motor control ability as compared with age- and sex-matched healthy controls. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to evaluate the results of posterior arthroscopic subtalar arthrodesis (ASTA) by use of a posterior 2-portal approach in the prone position and to describe the surgical technique. Methods: Between September 2004 and December 2006, posterior ASTA was performed in 16 patients (all men) with post-traumatic subtalar arthritis after an intra-articular fracture of the calcaneus. The mean age was 44 years (range, 20 to 64 years). The mean follow-up period was 30 months (range, 20 to 46 months). According to the Sanders classification of calcaneal fractures, 2 patients had type IIA fractures, 3 had type IIIB fractures, 6 had type IIIAC fractures, and 5 had type IIIBC fractures. The technique involved using posteromedial and posterolateral portals in the prone position, posterior talocalcaneal facet debridement, and percutaneous posterior fixation with 2 cannulated screws. Clinical results were evaluated by use of the ankle-hindfoot scale of the American Orthopaedic Foot & Ankle Society (AOFAS), the Angus and Cowell scoring system, and postoperative complications. To assess union rate and time to union, radiographic evaluations were also performed. Results: The mean modified AOFAS score (maximum, 94 points) improved from 35 points (range, 24 to 45 points) preoperatively to 84 points (range, 71 to 94 points) at final follow-up. According to the Angus and Cowell criteria, 13 patients had a good rating, 2 had a fair rating, and 1 had a poor rating because of nonunion. The union rate was 94% at a mean of 11 weeks, and nonunion occurred in 1 case. No other postoperative complications occurred. Conclusions: ASTA in the prone position through a posterior 2-portal approach provided safe access and superior visualization of the posterior talocalcaneal facet and easy fixation of posterior screws. This technique also provided good clinical outcomes (good results in 81% of patients according to the Angus and Cowell scoring system and a mean modified AOFAS score of 84 points) and a 94% union rate at a mean of 11 weeks. Level of Evidence: Level IV, therapeutic study. [Copyright &y& Elsevier]

Abstract: Arthroscopic subtalar arthrodesis was developed to improve on open methods of fusion. A posterior 3-portal arthroscopic approach with the patient in the prone position provides a new and optimal method for isolated subtalar arthrodesis. It facilitates safe access to the posterior talocalcaneal facet. The posterolateral portal was established using blunt dissection. The 3-mm, 30° arthroscope was inserted, the posterolateral portal was made, and synovectomy carried out. A large 4-mm arthroscope was used to improve fluid flow. The third portal was then established approximately 1 cm proximal and 1 cm posterior to the tip of the lateral malleolus. This portal was used for distraction by inserting a large blunt trocar into the joint. Most of the procedure was performed with the arthroscope in the posterolateral portal and the instruments posteromedial. Allograft was inserted through the posterolateral portal. Fixation was achieved using 2 cannulated 6.5- or 7.3-mm cancellous screws, inserted under fluoroscopic control. Postoperatively, patients were assigned to non-weight bearing cast immobilization with crutch ambulation for 6 weeks, followed by gradual weight bearing until radiographs showed union. Preliminary results have shown high patient satisfaction, an excellent fusion rate, and less postoperative morbidity than with open subtalar arthrodesis. [Copyright &y& Elsevier]

Purpose: The purposes of this study were to identify the pathologic findings of sinus tarsi syndrome (STS) by subtalar arthroscopy and to evaluate the results of arthroscopic treatments in 33 consecutive cases. Methods: A retrospective review was performed in 31 consecutive patients (33 cases) who underwent subtalar arthroscopic treatment for STS. The mean follow-up duration was 24 months (range, 18 to 36 months). Patients were evaluated by use of arthroscopic findings (recorded on videotapes and photographs) and clinical outcomes, which included visual analog scale and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores. Results: Arthroscopic findings showed partial tear of the interosseous talocalcaneal ligament in 29 cases (88%), synovitis in 18 (55%), partial tear of the cervical ligament in 11 (33%), arthrofibrosis in 8 (24%), and soft-tissue impingement in 7 (21%). The mean visual analog scale score improved from 7.3 points (range, 6 to 9 points) preoperatively to 2.7 points (range, 1 to 4 points) postoperatively (P < .005), and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43.1 points (range, 21 to 65 points) preoperatively to 86.2 points (range, 72 to 100 points) postoperatively (P < .005). Of the cases, 16 (48%) had an excellent result, 13 (39%) had a good result, and 4 (12%) had a fair result. Conclusions: Subtalar arthroscopy identified pathologies in the subtalar joint in patients with STS and showed that treatment of these pathologies led to improved function. Level of Evidence: Level IV, therapeutic case series. [Copyright &y& Elsevier]

Abstract: The authors analyzed a consecutive series of 20 total hip arthroplasties performed using a cementless conical stem with shortening osteotomy combined with greater trochanter transfer in cases with a highly dislocated hip secondary to sequelae of a septic hip in childhood. Mean patient age was 47.3 years and the mean follow-up period was 3.4 years. An acetabular metal cup was inserted in 5 cases, and only a liner was inserted after cementing in 15 cases. Mean Harris hip score improved from 42.4 preoperatively to 84.2 at final follow-up. Mean leg lengthening was 36.5 mm, and time to greater trochanter union was 3.72 months. No complete radiolucent line of thickness >2 mm was observed in any case. These surgical methods produced satisfactory clinical and radiological results. [Copyright &y& Elsevier]

Abstract: Displacement of a cemented femoral stem during attempted closed reduction of a dislocated total hip arthroplasty has been anecdotally described in the literature. All these reports involved use of cemented, highly polished, tapered stems. We report, the first to our knowledge, a case of displacement of a cemented, textured femoral stem, during attempted closed reduction. The case is being reported not only for its rarity but also to alert treating surgeons of this devastating complication which can expose the patient to the risks of open surgery. Gentle reduction, using the gravity method of Stimpson, under fluoroscopy control, may be safer and prevent this complication from occurring. If the cement mantle is intact, cement-within-cement is a reliable, quick, and simple technique to overcome this difficult problem. [Copyright &y& Elsevier]

Many studies have determined that PI3K-Akt signaling pathways play important roles in osteoclast differentiation and function. In the present study, we investigated the roles of B-cell adaptor for PI3K (BCAP), which is a PI3K binding molecule, in osteoclasts. Overexpression of BCAP in osteoclast precursor cells enhanced osteoclast differentiation induced by tumor necrosis factor alpha (TNF-α) as well as receptor activator of nuclear factor-κB ligand (RANKL). Conversely, osteoclast differentiation mediated by both cytokines was attenuated when BCAP expression was downregulated using small interfering RNA. Notably, BCAP induced Akt activation only upon stimulation by RANKL, but not by TNF-α. However, BCAP activated p38-dependent cAMP response element-binding protein (CREB) phosphorylation induced by both RANKL and TNF-α. Collectively, we showed that BCAP plays an important role in osteoclast differentiation by regulating the p38-dependent CREB signaling pathway, and that BCAP might be a new therapeutic target for bone diseases. [ABSTRACT FROM AUTHOR]

Background context Anterior cervical discectomy and fusion using cervical plates has been seen as effective at relieving cervical radiculopathy and myelopathy symptoms. Although it is commonly used, subsequent disc degeneration at levels adjacent to the fusion remains an important problem. However, data on the frequency, impact, and predisposing factors for this pathology are still rare. Purpose To evaluate the incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathologies after anterior cervical discectomy and fusion using cervical plates and to analyze the efficacy of this surgical method over the long term, after a minimum follow-up period of 10 years. Study design Retrospective clinical study. Patient sample Our study was a retrospective analysis of 177 patients who underwent anterior cervical discectomy and fusion using cervical plates, with follow-up periods of at least 10 years (mean 16.2 years). Outcome measures Radiographic adjacent-segment pathology using plain radiographs and clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates. Methods We defined a new grading system of plain radiographic evidence of degenerative changes in adjacent discs after anterior cervical discectomy and fusion using cervical plates; Grade 0 is considered normal, and Grade V consists the presence of posterior osteophytes and a decrease in disc height to less than 50% of normal. The incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathologies were analyzed according to etiologies, number of fused segments, and plate-to-disc distance. Results Radiographic and clinical adjacent-segment pathologies were found in 92.1% and 19.2%, respectively, of patients. By etiology, clinical adjacent-segment pathology was observed in 13.5% of patients who had sustained trauma, 12.7% of those with disc herniation, and 33.3% of those with spondylosis. By number of fused segments, clinical adjacent-segment pathology was found in 13.2% of patients who underwent single-level fusion and in 32.1% of those who underwent multilevel fusion surgeries. Patients with a plate-to-disc distance of less than 5 mm, who had spondylosis, or who underwent multilevel fusion had a higher incidence of clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates than other groups did (p<.05). Of all patients, only 6.8% needed follow-up surgery. Conclusions We found that over the long term, at a minimum follow-up point of 10 years, a plate-to-disc distance of less than 5 mm, having spondylosis, and undergoing multilevel fusion were predisposing factors for the occurrence of clinical adjacent-segment pathology. Nevertheless, the incidence of clinical findings of adjacent-segment pathology was much lower than the incidence of radiographic findings. Also, the rate of follow-up surgery was low. Therefore, anterior cervical discectomy and fusion using cervical plates can be considered a safe and effective procedure. [ABSTRACT FROM AUTHOR]