Search

Introduction To determine the optimal entry point (EP) of intramedullary nail (IMN) fixation and introduce a consistent landmark for practical application by analyzing three-dimensional (3D) modeling and virtual implantation. Materials and methods A total of 104 cadaveric femurs (50 males and 54 females) underwent continuous 1.0 mm slice computed tomography (CT) scans. CT images were imported into Mimics® software to reconstruct 3D model of tibiofibular bone with medullary canal. Expert Tibial Nail (ETN®, O12mm/Length 315 mm) was processed into a 3D model at the actual size and optimally implanted in the tibia. After IMN was aligned in a neutral position, it was defined as a true AP projection. In the true AP projection, optimal EP and relationship with adjacent structures were assessed based on the degree of tibial rotation. Results EP was placed eccentrically around the lateral tibial spine in cephalad view and in true AP projection in all models. In true AP projection, the overlapping point between fibular tip and cortical margin of lateral condyle was placed lateral to the fibular tip in 62 models, and exactly matched with fibular tip in 42 models. As tibia rotates, the position of EP in the AP view changes. When tibia was externally rotated, EP was located to the lateral, not the medial side of the lateraltibialspine. The obliquity of guide wire also changed withtibialrotation; the obliquity of guide wire aligned in a straight in true AP projection. Conclusion Optimal determination of EP and guide wire direction should be performed by considering the overlapping point that should be placed to just or lateral side of fibular tip in AP projection. Compared with fibular bisector line, the overlapping point is also useful as a practical landmark for making true AP projection and determining optimal EP.

Introduction Ilio-sacral screw fixation has been used for sacral fractures and sacroiliac joint dislocations. However, it is associated with significant complications including screw loosening with backing-out and loss of reduction. Trans-sacral screw fixation is indicated for rigid fixation in specific circumstances including bilateral posterior ring injuries, osteoporotic bone, or to supplement other types of posterior ring fixation. Hypothesis The reformatting the CT scanning plane may distinguish sacral dysmorphism and predict the possibility of trans-sacral screw fixation by introducing the new indicator. Material and methods The CT data of 112 adult cadavers (61 males and 51 females) were imported into Mimics® software and a 7.0 mm-sized trans-sacral screw was virtually placed in the ideal position of S1. The osseous widths around screw in the axial images (AxWS1) were measured. By reformatting the CT scanning plane parallel to the superior endplate of S1, the AxWRS1 was measured and the height of elevated segment in the upper sacrum (elevated height) was assessed as a new preoperative indicator. Results Cortical violation around screw was detected in 26 models and was considered as sacral dysmorphism. The average AxWS1 was measured as 13.70 ± 2.76 mm in the non-dysmorphism group, and 5.81 ± 2.19 mm in the dysmorphism group, with statistical difference (p Discussion By reformatting the CT scanning plane, the osseous width around screw was widened, and the new preoperative indicator of elevated height could be introduced to predict the possibility of trans-sacral screw fixation into S1. If the elevated height exceeded 13 mm, the pelvis was assigned to sacral dysmorphism and thus, could not apply the trans-sacral screw fixation into S1. Level of evidence III, controlled laboratory study.

Purpose: The objective of this study was to improve the three-dimensional (3D) understanding of optimal lateral cortical hinge in medial open-wedge high tibial osteotomy (MOWHTO) via a computational cadaveric simulation of actual size. Methods: The computed tomography data of 117 adult cadavers were imported into Mimics® software to design 3D models of tibia and fibula. To simulate the MOWTHO, a virtual cutting plane was developed inside the safe zone based on established landmarks. After splitting and distracting through the cutting plane, the 10-mm cylinder (Ø 30 mm; height 10 mm) was placed vertically to be occupied properly in the nonosteotomized lateral cortex. The cross points between the round cylinder and cutting plane represented the anterior and posterior hinge points, which were used to validate the 3D position and direction of cortical hinge. Results: A 10-mm cylinder did not violate the proximal tibiofibular joint (PTFJ) and the protruding segment of the condylar area was less than 2 mm in 115 models. The connecting line between anterior and posterior hinge points was an average of 12.1° (range 0–24.1°, SD 4.64) to the lateral side. In the nonoverlapping anteroposterior projection between proximal fibula and tibia, the posterior hinge point was laid over the PTFJ as close as possible. Based on free 360° rotation and magnification without any tilt, no posterior cortical disruption of PTFJ was observed while securing a minimum width of 10 mm. Conclusion: If the posterior hinge point was placed immediately above the PTFJ without involvement, the nonosteotomized portion carried sufficient width greater than 10 mm, despite lateral rotation at an average hinge direction of 12.1°.

Purpose The aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures. Methods Thirty-four patients with acute distal third fibular shaft fractures (4F2A(c) and 4F2B(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up. Results All fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16–35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57–80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients. Conclusion With the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.

Objective The fluoroscopically-guided procedure of antegrade posterior lag screw in posterior column fixation through anterior approach is technique-dependent and requires an experienced surgeon. The purpose of this study was to establish the safe zone for the antegrade posterior lag screw by using computational analysis. Method The virtual three-dimensional model of 178 hemi-pelvises was created from the CT data (DICOM format) by using Mimics® program, and were used to measure the safe zone of antegrade lag screw fixation on the inner table of the iliac wing, and the largest diameter of cylindrical implant inside safe zone. The central point (point A) of the cylinder was assessed and was compared with the intersection point (point B) between the linea terminalis and the anterior border of the sacroiliac articulation. Results The safe zone was triangular with an average area of 670.4 mm2 (range, 374.8–1084.5 mm2). The largest diameter of the cylinder was a mean 7.4 mm (range, 5.0–10.0 mm). When height was under 156.3 cm, the diameter of the cylindrical implant was smaller than 7.0 mm (p

Objectives The aim for the present study was to determine whether projection error of measuring Pauwels’ angle in young femur neck fracture could be eliminated by CT plane manipulation. Methods Clinical data of displaced femur neck fractures in young adults aged 20 to 64 years old (13 females and 17 males) were retrospectively analyzed. Their average age was 47.9 years (range: 22–64 years; SD: 11.3). Using modified measurement method for Pauwels’ angle using central line of the shaft as a guideline, the angle of a conventional coronal CT image was measured. CT images were imported into Mimics® software. The scanning plane was then reformatted parallel to the neck axis to eliminate projection error of injured limb. Measured angles were classified into three types (I 50°) and differences were analyzed. Results Average Pauwels’ angle was 52.9° (range: 28.6–68.3°; SD: 9.9; type II, 17 cases; type III, 13 cases) for conventional CT images and 68.7° (range: 29.8–91.2°; SD: 13.4; type II, 1 cases; type III, 29 cases) for reformatted CT images. Difference between these two measurements on average was 15.7° (range: 1.2–34.9°; SD: 7.3). Conclusions Reformatting CT scanning plane by manipulating the proximal fragment to be parallel with the neck axis of the distal neck-shaft fragment is a convenient and reliable technique for eliminating the projection error of measuring Pauwels’ angle in the femur neck fractures. Level of evidence IV, cohort study.

Purpose To determine an easy and convenient method of sacral-alar-iliac (S2AI) screw fixation and introduce the surgical landmarks for fluoroscopic procedure by analyzing 3-D models of pelvis and virtual implantation in a 3-D model. Materials and methods Eighty-two cadavers underwent computed tomography scans and the images imported into Mimics® software to make the 3-D pelvis model. The pedicle screw (O 8.5 mm/length 115 mm) was processed into a 3-D model using a 3-D-sensor (Comet5®) at the actual size and virtually placed as the S2AI screw. The ideal screw position was defined as the maximal intraosseous length without cortical perforation along the entire path. The ideal entry point and screw trajectory were verified and assessed to introduce the surgical landmark for fluoroscopic procedure. Results There was no cortical violation around nerve root canal and greater sciatic notch through the entry point between first and second dorsal sacral foramen. There was no impossible model of S2AI screws. The average screw length was 99.8 mm (range, 59.8-115 mm; standard deviation, 16.1) and just one model had shorter than 65 mm S2AI screw. The factors limiting the intra-iliac screw length were sex ( p = 0.000) and the iliac groove around the sacroiliac joint ( p = 0.000). A free 360° rotation with magnification revealed that the screw trajectory was consistently directed toward the anteroinferior iliac spine (AIIS) in any plane. Conclusion The ideal entry point of S2AI screw showed a wide range of tolerance between the first and second dorsal sacral foramen; and thus, there was no need for deep dissection to identify the first dorsal sacral foramen. Considering the tendency to shift the pilot hole laterally and the ideal screw trajectory was consistently directed toward AIIS, the entry point is better to be located with a medial shift.

Background Volar locking plating through the flexor carpi radialis is a well-established technique for treating unstable distal radial fractures, with few reported complications. In certain circumstances, including metaphyseal comminuted fractures, bridge plating through a pronator quadratus (PQ)-sparing approach may be required to preserve the soft tissue envelope. This study describes our prospective experience with bridge plating through indirect reduction. Methods Thirty-three wrists (four 23A2, six 23A3, 15 23C1, and eight 23C2) underwent bridge plating through a PQ-sparing approach with indirect reduction from June 2006 to December 2010. Mean patient age was 56.8 years (range, 25–83 years), and the mean follow-up period was 47.5 months (range, 36–84 months). Changes in radiologic parameters (volar tilt, radial inclination, radial length, and ulnar variance) were analyzed, and functional results at final follow-up were evaluated by measuring the Modified Mayo Wrist Score (MMWS) and Modified Gartland-Werley Score (MGWS). Results All wrists achieved bone healing without significant complications after a single operation. At final follow-up, radial length was restored from an average of 3.7 mm to 11.0 mm, as were radial inclination, from 16.4° to 22.5°, and volar tilt, from − 9.1° to 5.5°. However, radial length was overcorrected in three wrists, and two experienced residual dorsal tilt. Excellent and good results on the MGWS were achieved in 30 wrists (90.9%). The average MMWS outcome was 92.6 (range, 75–100). Conclusion Our experience with bridge plating was similar to that previously reported in the earlier publications. Compared with the conventional technique, bridge plating through a PQ-sparing approach may help in managing metaphyseal comminuted fractures of both cortices with a reduced radio-ulnar index.

Background Open total extrusion of the talus without concomitant fracture is an extremely rare injury. We present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation. Case presentation A 55-year-old Asian man who had a totally extruded talus without fracture underwent immediate reimplantation surgery. A spanning external fixator with single antegrade K-wire fixation was applied to maintain the reimplanted talus. During 6 years of follow-up, he could walk without aids and could squat, corresponding to an American Orthopaedic Foot and Ankle Society score of 85. We found that the suspect lesion that was evident at 6 months after surgery had disappeared at 12 months postoperatively on the basis of sequential follow-up magnetic resonance imaging. There was no evidence of osteonecrosis of the dislocated talus at the final follow-up. Conclusions In patients with a totally extruded talus, a surgical strategy including immediate reimplantation of the talus and a temporary spanning fixator with single K-wire fixation might be useful to allow early mobilization around the ankle joint and to prevent additional damage of the foot without significant complications.

Background: As there is substantial variation in the classification and diagnosis of lateral clavicle fractures, proper management can be challenging. Although the Neer classification system modified by Craig has been widely used, no study has assessed its validity through inter- and intrarater agreement. Purpose: To determine the inter- and intrarater agreement of the modified Neer classification system and associated treatment choice for lateral clavicle fractures and to assess whether 3-dimensional computed tomography (3D CT) improves the level of agreement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Nine experienced shoulder specialists and 9 orthopaedic fellows evaluated 52 patients with lateral clavicle fractures, completing fracture typing according to the modified Neer classification system and selecting a treatment choice for each case. Web-based assessment was performed using plain radiographs only, followed by the addition of 3D CT images 2 weeks later. This procedure was repeated 4 weeks later. Fleiss κ values were calculated to estimate the inter- and intrarater agreement. Results: Based on plain radiographs only, the inter- and intrarater agreement of the modified Neer classification system was regarded as fair (κ = 0.344) and moderate (κ = 0.496), respectively; the inter- and intrarater agreement of treatment choice was both regarded as moderate (κ = 0.465 and 0.555, respectively). Based on the plain radiographs and 3D CT images, the inter- and intrarater agreement of the classification system was regarded as fair (κ = 0.317) and moderate (κ = 0.508), respectively; the inter- and intrarater agreement of treatment choice was regarded as moderate (κ = 0.463) and substantial (κ = 0.623), respectively. There were no significant differences in the level of agreement between the plain radiographs only and plain radiographs plus 3D CT images for any κ values (all P > .05). Conclusion: The level of interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice. To eliminate a common source of disagreement among surgeons, a new classification system to focus on unclassifiable fracture types is needed.

Despite a high possibility of technique-related complications, ilio-sacral (IS) screw fixation is the mainstay of operative management in posterior pelvic ring injuries. We aimed to make IS screw trajectory with fully intraosseous path that was optimal and consistent, and confirm the possibility of transiliac–transsacral (TITS) screw fixation in Asian sacrum. Eighty-two cadaveric sacra (42 males and 40 females) were enrolled and underwent continuous 1.0-mm slice computed tomography (CT) scans. CT images were imported into Mimics® software to reconstruct three-dimensional model of the pelvis. To simulate IS screws, we inserted 7.0-mm-sized TITS cylinder for first (S1) and second (S2) sacral segment and 7.0-mm oblique cylinder for S1. TITS cylinder could not be inserted into S1 of 14 models (sacral variation models) but could be inserted into the S2 of all models. The actual length of virtual IS screws was measured, and anatomic features of safe zone (SZS2) including the area, horizontal distance (HDS2), and vertical distance (VDS2) were evaluated by the possibility of TITS screw fixation in the S1. When the oblique cylinder was directed toward the opposite upper corner of S1 at the level of the first foramen, there was no cortical violation regardless of sacral variation. The average length of TITS cylinder was 152.3 mm (range 127.9–178.2 mm) in S1 and 136.0 mm (range 97.8–164.1 mm) in S2, and for oblique cylinder it was 99.2 mm (range 82.4–132.2 mm). The average VDS2, HDS2, and the area of SZS2 were 15.5 mm (range 8.7–24.4 mm), 18.3 mm (range 12.7–26.6 mm), and 221.1 mm2 (range 91.1–386.7 mm2), respectively. The VDS2 and SZS2 of sacral variation were significantly higher than those of normal (both p = 0.001). Considering the high variability of the S1, it is better to direct the IS screw trajectory toward the opposite upper corner of the S1 at the level of first sacral foramen. If a TITS screw is needed, the transverse fixation for the S2 could be performed alternatively due to its sufficient osseous site even in Asian sacrum.

Objectives The purpose of this study was to predict the possibility of transverse iliosacral (TIS) screw fixation into the first sacral segment (S1) and introduce practical anatomical variables using conventional computed tomography (CT) scans. Materials and methods A total of 82 cadaveric sacra (42 males and 40 females) were used for continuous 1.0-mm slice CT scans, which were imported into Mimics® software to produce a three-dimensional pelvis model. The anterior height (BH) and superior width (BW) of the elevated sacral segment was measured, followed by verification of the safe zone (SZS1 and SZS2) in a true lateral view. Their vertical (VDS1 and VDS2) and horizontal (HDS1 and HDS2) distances were measured. VDS1 less than 7 mm was classified as impossible sacrum, since the transverse fixation of 7.0 mm-sized IS screw could not be done safely. Results Fourteen models (16.7%; six females, eight males) were assigned as the impossible sacrum. There was no statistical significance regarding gender (p = 0.626) and height (p = 0.419). The average values were as follows: BW, 31.4 mm (SD 2.9); BH, 16.7 mm (SD 6.8); VDS1, 13.4 mm (SD 6.1); HDS1, 22.5 mm (SD 4.5); SZS1, 239.5 mm2 (SD 137.1); VDS2, 15.5 mm (SD 3.0); HDS2, 18.3 mm (SD 2.9); and SZS2, 221.1 mm2 (SD 68.5). Logistic regression analysis identified BH (p = 0.001) and HDS1 (p = 0.02) as the only statistically significant variables to predict the possibility. Receiver operating characteristic curve analysis established a cut-off value for BH and HDS1 of impossible sacrum of 20.6 mm and 18.6 mm, respectively. Conclusion BH and HDS1 could be used to predict the possibility of TIS screw fixation. If the BH exceeds 20.6 mm or HDS1 is less than 18.6 mm, TIS screw fixation for S1 should not be undertaken because of narrowed SZ.

Benign bone tumor is a typical disease encountered in the field of orthopedic surgery. As one of the palliative treatments, invasive curettage of the lesion has been widely used.1) It is unavoidable, however, that palliative curettage is extremely invasive to soft tissue and the cortical bone in the lesions depending on the size of lesions. It is thus disadvantageous in that it may lead to various complications such as delayed union or bleeding, postoperative fracture due to a loss of the cortical bone and delayed wound healing and recovery at the operated sites.2-4) To reduce these undesirable side effects, Stricker5) first reported on endoscopic curettage in 1995. In 1999, Bonnel et al.6) reported that endoscopic curettage and bone graft were performed for simple bone cyst of the calcaneus. Thereafter, several authors have confirmed an excellent profile of efficacy for endoscopic curettage. In Korea, however, there is a dearth of studies evaluating the treatment. Most reports have been made regarding clinical cases (case studies). A comparative analysis of other types of bone tumor has been performed only in a limited scope. Based on the above background, we examined the clinical usefulness of endoscopic curettage, one of the non-invasive treatment modalities, and assessed which benign bone tumors could be effectively treated with endoscopic curettage.

As a treatment method of degenerative arthritis of knee, this study evaluated the clinical efficacy of the intra-articular injection of autologous bone marrow aspirates concentrate (BMAC) with adipose tissue.Between April 2011 and May 2012, 41 patients (75 knees) who were diagnosed as a degenerative knee arthritis and underwent the BMAC injection with adipose tissue were included in this study. Mean age was 60.7 years old (ranged 53-80). Kellgren-Lawrence grade was used for assessing radiologic degree of osteoarthritis; there were each 12, 24, 33, and 6 cases of grade I, II, III, and IV. At preoperative and postoperative 3, 6, and 12 months, pain score using visual analogue scale (VAS) and functional scales were used for evaluation.After the procedure, mean VAS score was decreased from 7.0 preoperatively to 4.1, 3.5, and 3.3 postoperatively 3, 6, and 12 months. And functional scores were also improved; International Knee Documentation Committee score (from 37.7 preoperatively to 59.3, 66.3, 69.3 postoperatively), SF-36 health score (from 31.5 to 43.5, 45.6, 47.7), knee and osteoarthritis outcome score (from 43.1 to 64.9, 68.5, 70.6), Lysholm Knee Questionnaire (from 37.3 to 65.4, 68.6, 71.0) were all increased after the procedure. When classified according to K-L grade, the improvement of VAS score in grade IV group was 8.2 preoperatively to 5.5, 5.3, and 5.7 postoperatively, which was significantly poorer than those of grade I-III groups. In the knee functional scales, similar pattern was checked.BMAC injection significantly improved both knee pain and functions in the patients with degenerative arthritis of knee. Also, the injection would be more effective in early to moderate phases.

The purpose of this study was to compare the outcomes of volar plating using two different implants for distal radius fractures. Fifty-two patients with AO type C fractures were placed in either of two groups: the AO LDRS group (26 patients) or the Acu-Loc group (26 patients). Radiological parameters including radial length, radial inclination, volar tilt, and intra-articular step-off were significantly improved after surgery. The mean Mayo Wrist Performance Score was 84.6 in the AO LDRS group and 81.1 in the Acu-Loc group. The mean Subjective Wrist Value was 86.7% in the AO LDRS group and 86.3% in the Acu-Loc group. There were no significant differences between the two groups with respect to both radiological and clinical outcomes at the final follow-up evaluation. Volar fixed-angle plating for unstable distal radius fractures had satisfactory radiological and clinical outcomes. The difference of implant design did not influence overall final outcomes.

Purpose To verify the practical correlation between the topographical features of the femur neck base and the ideal entry point by analyzing three-dimensional (3D) models virtually implanted with an antegrade femoral nail. Materials and methods A total of 103 cadaveric femurs (50 males and 53 females) were enrolled. Specimens underwent continuous 1.0 mm slice computed tomography (CT) scans. CT images were rendered into 3D images using image-processing software (Mimics ® ) to reconstruct the geometry of the cortex and medullary canal. A real cannulated femoral nail (CFN) ® was processed into a 3D image using a 3D sensor at the actual size and optimally placed in the femur model using Mimics ® for virtual implantation. The correlation between the ideal entry point in the cranial view of the proximal femur and the trochanteric fossa was assessed and overlap of trochanter overhang was verified. Results The entry point of 68 models (66.0%) was the trochanteric fossa, while the others were placed around the anterior border of the trochanteric fossa. The proximal end of the nail overlapped in 50 models (48.1%), and among them, the central point of 23 models (22.3%) was obscured by trochanteric overhang. There was a statistically significant risk associated with female gender (6.02 times) and type IV overhang of Grenchenig’s classification (4.56 times). Despite the precise positioning of the trochanteric fossa, 11 models (10.7%) had the entry point covered by trochanteric overhang. Conclusion The ideal entry point was over the trochanteric fossa in just half of the models, and could be hindered by trochanteric overhang even though the CFN was ideally positioned.

The aim of the study reported here was to compare the efficacy and safety of postoperative analgesia provided by interscalene block with multimodal pain control (IB-MPC) versus that provided by multimodal pain control (MPC) alone after arthroscopic rotator cuff repair. Sixty consecutive patients were assigned to either the IB-MPC group (30 patients) or the MPC group (30 patients). Visual analogue scale (VAS) pain scores before surgery and through day 5 after surgery, consumption of rescue analgesic, adverse effects and complications were evaluated. Mean VAS pain scores immediately after surgery and on days 1 through 5 after surgery were 3.9 ± 2.6, 4.4 ± 1.5, 3.4 ± 1.3, 2.7 ± 1.3, 2.4 ± 1.2, and 2.0 ± 1.0, respectively, in the IB-MPC group and 6.2 ± 1.8, 4.1 ± 1.7, 3.2 ± 1.9, 2.7 ± 1.4, 2.5 ± 1.3, and 2.0 ± 1.2, respectively, in the MPC group. The IB-MPC group had significantly lower VAS pain score immediately after surgery than the MPC group did (P

Most studies suggested that arthroscopic microfracture is effective method at only less than 40 years of age. Thus, the authors thought that "how can this indication regarding age be extended?," and tried to find a way to use this technique effectively over 40 years of age. The aim of this study was the first to report the results regarding the PRP as an adjunct for arthroscopic microfracture in the early osteoarthritic (OA) knee with cartilage lesion over 40 years of age. 49 patients who underwent arthroscopic microfracture for cartilage lesion sized less than 4 cm(2) with early OA, aged 40-50 years, were enrolled and randomly divided into 2 groups: a control group with only arthroscopic microfracture (25 patients) and a study group with arthroscopic microfracture and PRP (24 patients). The patients were prospectively evaluated with VAS, IKDC score at preoperative and postoperative 1, 6, 12, and 24 months. And we perform second arthroscopies in 10 patients of each group to identify the extent of cartilage restoration at 4-6 months postoperatively. There were significant improvements in clinical results between preoperative evaluation and postoperative 2 years in both groups (p = 0.017). In the postoperative 2 years, clinical results showed significantly better in the study group than in the control group (p = 0.012). In post-arthroscopic finding, hardness and elasticity degree was better in the study group. The PRP injection with arthroscopic microfracture would be improved the results in early osteoarthritic knee with cartilage lesion in 40-50 years old, and the indication of this technique could be extended to 50 years.

This study was undertaken to introduce an anterolateral approach for mini-open rotator cuff repair and evaluate its clinical outcome and effectiveness.We evaluated 128 consecutive cases that were repaired by mini-open repair using an anterolateral approach. There were 80 men and 48 women, with an average age of 56.2 years. Average follow-up was 25.7 months. There were eight partial-thickness, 26 small, 40 medium, 39 large and 15 massive tears. After arthroscopic glenohumeral examination and subacromial decompression, we made a 3- to 4-cm skin incision from anterolateral edge of the acromion and dissected to the raphe between the anterior and middle deltoid. The torn tendon was repaired with single- or double-row technique using suture anchors. To prevent avulsion of the deltoid from the acromion, additional suturing within the bone tunnel was performed. We retrospectively evaluated clinical outcomes using the American Shoulder and Elbow Surgeon (ASES) scoring system.The average visual analogue scale (VAS), activity of daily living (ADL) and ASES scores improved, respectively, from 6.6, 12.0 and 36.7 preoperatively to 1.2, 26.6 and 88.2 postoperatively. There were 71 excellent, 39 good, ten fair and eight poor results. There were no statistically significant difference between final ASES scores and age, symptom duration, tear size or preoperative stiffness, but men had significantly higher final ASES scores than women (P = 0.014).Anterolateral approach for mini-open rotator cuff repair produces satisfactory results. It may also provide better visualisation for rotator cuff tears of all sizes.

BACKGROUND The purpose of this study is to evaluate the disease-free survival (DFS) and overall survival (OS) of patients with stage IIB osteosarcoma at a single institution for 20 years and to compare the results according to the chemotherapy protocols. METHODS From Jan 1988 to Nov 2008, 167 patients with osteosarcoma were treated at our hospital and among them, 117 patients (67 males and 50 females) with stage IIB osteosarcoma were evaluable. Their mean age was 22.6 years (range, 8 months to 71 years). Seventy-eight cases underwent the modified T10 (M-T10) protocol (group 1), 23 cases underwent the T20 protocol (group 2) and 16 cases underwent the T12 protocol (group 3). The DFS and OS were calculated and compared according to the chemotherapy protocols. RESULTS At a mean follow-up of 78.9 months, 63 patients were continuously disease-free (63/117), 6 patients were alive after having metastatic lesions, 7 patients died of other cause and 41 patients died of their disease. The 5- and 10-year OS rates were 60.2% and 44.8%, respectively and the 5- and 10-year DFS rates were 53.5% and 41.4%, respectively. There was no significant difference of the OS and DFS between the chemotherapy protocols (p = 0.692, p = 0.113). CONCLUSIONS At present, we achieved success rates close to the internationally accepted DFS and OS. We were able to achieve the higher survival rates using the M-T10 protocol over the 20 years. However, there was no significant difference of results between the chemotherapy protocols. We think the M-T10 protocol will achieve more favorable results in the near future.

In posterolateral insufficiency, many investigators have proposed a lateral tunnel for PT reconstruction. Although they were usually located at the anterior and proximal to the lateral femoral epicondyle, there are still controversies regarding the exact location of PT tunnel. The aim of the present study was to describe our novel findings of femoral attachment of popliteus tendon (PT) and lateral collateral ligament (LCL) and to present an adequate femoral tunnel site, based on the cadaver dissection. Nine embalmed cadavers (18 knees), which were fully extended, were dissected to determine a precise anatomic description of the PT attachment compared to the femoral epicondyle and the LCL. The anatomic variations and attachment of the LCL and PT around the epicondyle were described. The LCL (mean length: 53 mm, mean width 9 mm) was attached uniformly at the lateral epicondyle of the femur, which was slightly inferior and posterior to the top of the lateral epicondyle, but the PT (mean length: 36 mm, mean width: 8 mm) had the multiform attachments around the epicondyle and our dissection identified three different locations of the PT’s attachment; postero-inferior attachment (13 knees), just inferior attachment (2 knees), and double attachment by bifurcate bundles (3 knees). These results demonstrate that the attachment for the PT is mostly located at the postero-inferior site of the epicondyle in the fully extended position and can be seen only when the knee is fully extended because the attachment of the PT shifts anteriorly with regard to the LCL in higher flexion angles. If the original site of the PT’s attachment cannot be seen, the recommendation of the femoral tunnel for the PT reconstruction should be located at the postero-inferior site as compared with the LCL attachment in the fully extended position.

Phosphaturic mesenchymal tumor is an extremely rare disease and is frequently associated with oncogenic osteomalacia showing paraneoplastic syndrome, which is characterized by phosphaturia, hypophosphatemia, normocalcemia, and decreased levels of 1,25-dihydroxyvitamin D3 associated with a tumor. A 2-year-old boy, who had a soft tissue tumor on his right thigh and previously diagnosed as myositis ossificans at 9-months-old, was presented with rachitic rosary and mildly enlarged tumor. Biochemical investigations showed hypophosphatemia, hyperphosphaturia, and an increased alkaline phosphatase level of 440 U/l (25-100 U/l), suggesting rickets, which was resistant to vitamin D dietary supplementation. We were certain of intractable rickets because of oncogenic hypophosphatemia and thus decided to excise the soft tissue mass. We observed laboratory improvement of rickets after 2 weeks. On the basis of surgical and histopathological examinations, the tumor was finally diagnosed as the phosphaturic mesenchymal tumor.

Osteochondromas are one of the most common benign bone tumors. They usually arise from the metaphyses of long bones. Involvement of the bicipital tuberosity is rare. To date, no reports have described avulsed rupture of the distal biceps tendon caused by an osteochondroma of the bicipital tuberosity. This article presents a case of avulsion of the distal biceps tendon secondary to sessile osteochondroma of the bicipital tuberosity in a 65-year-old right-handed sedentary worker who presented with insidious pain and limited motion in his left elbow for 2 months. Intraoperative findings showed a bony mass of 25×23×5 mm with osteocartilaginous nodules on the bicipital tuberosity. The distal biceps tendon with an avulsed bony fragment was displaced proximally, with a 20-mm gap between the tendon and the bicipital tuberosity. After complete excision of the mass, footprint preparation at the bicipital tuberosity was performed using a 4.0-mm burr and anatomic reattachment of the distal biceps tendon with a 5.0-mm suture anchor. The pathologic diagnosis of osteochondroma was confirmed microscopically. We suggest that osteochondroma of the bicipital tuberosity be considered as a cause of painful limitation of forearm rotation or avulsed rupture of the distal biceps tendon.

The purpose of this study was to compare early postoperative outcomes between arthroscopic and mini-open repair for rotator cuff tears smaller than 3 cm to determine whether arthroscopic repair causes less postoperative pain and allows for faster recovery of range of motion. Sixty patients scheduled for rotator cuff repair were randomized to either an arthroscopic repair group (30 patients) or a mini-open repair group (30 patients). Pain level, range of motion, shoulder stiffness, and complications were compared between the 2 groups from immediately postoperatively to 6 months postoperatively. Although no statistically significant difference was found in mean visual analog scale pain scores between the 2 groups during the 6 months postoperatively, mean visual analog scale pain score was significantly lower in the arthroscopic repair group compared with the mini-open repair group at postoperative days 1 and 2 ( P =.02 and P =.04, respectively). No significant difference existed in postoperative range of motion, duration of rehabilitation, shoulder stiffness, or complications between the 2 groups; however, the use of additional analgesics in the arthroscopic repair group was significantly lower than in the mini-open repair group ( P =.03). Arthroscopic and mini-open repair had equivalent clinical outcomes in the early postoperative period. The hypothesis that arthroscopic repair would cause less postoperative pain and allow faster recovery of range of motion in the early postoperative period compared with mini-open repair was not supported.

For comminuted shaft fracture of clavicle, the operative goal, aside from sound bone healing without complications of direct reduction, is maintenance of the original length in order to maintain the normal biomechanics of adjacent joint. Our bridge plating technique utilizing distraction through a lumbar spreader was expected to be effective for restoring clavicular length with soft tissue preservation. However, there are two disadvantages. First, there is more exposure to radiation compared to conventional plating; and second, it is difficult to control the rotational alignment. Despite these disadvantages, our technique has important benefits, in particular, the ability to preserve clavicular length without soft tissue injury around the fracture site.

The spontaneous and serial rupture of the bilateral Achilles tendons without history of significant trauma is an uncommon complication in long-term hemodialysis (HD) patients. The majority of these patients have additional predisposing factors, such as previous use of fluoroquinolone antibiotics or corticosteroids. In general, this condition is associated with a coexisting systemic disease, including chronic kidney disease (CKD), secondary hyperparathyroidism, systemic lupus erythematosus (SLE), and diabetes mellitus (DM). Here, we report a 46-year-old man who had been undergoing regular HD for 11 years. He developed a spontaneous and consecutive rupture of both Achilles tendons. Based on previous reports of tendon ruptures in uremic patients and on the patient’s lack of corticosteroid or fluoroquinolone use, we believe that secondary hyperparathyroidism was the predisposing factor in this patient. The mechanism seems to be related to a high parathyroid hormone (PTH) level, which results in osteolytic bone resorption at the tendon insertion site. Treatment and prevention of such tendon ruptures include early surgical repair and control of secondary hyperparathyroidism, by use of vitamin D analogs, and total parathyroidectomy, with or without autotransplantation of a parathyroid gland.