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Purpose: We attempted to determine the degree of rotation of the femoral component to achieve an ideal rectangular flexion gap with minimal medial collateral ligament (MCL) release using a modified measured technique. Materials and Methods: Group I consisted of 60 osteoarthritis patients (72 cases) who underwent total knee arthroplasty (TKA) with minimal MCL release and Group II consisted of 48 patients without osteoarthritis (61 cases). We performed computed tomography (CT) scanning of the knee with 90 degree flexion in all of the patients and analyzed the angles between the distal femur landmarks and the tibial mechanical axis using a Picture Archiving Communication system. External rotation of the femoral component from the Whiteside line and posterior condylar line was measured in group I who underwent TKA with minimum MCL release. The variance in the mediolateral flexion gap according to the degree of rotation was also measured using an Auto-Computer Aided Design program. Results: The CT scans showed that the Whiteside line, posterior condylar line, and transepicondylar line was more internally rotated on average from the longitudinal axis of tibia by 4.12°, 5.54°, and 4.64°, respectively, in group I compared to group II. In group I, the femoral component was inserted with an average external rotation of 5.6° from the posterior condylar line and with an average external rotation of 2.0° from the Whiteside line with minimal MCL release. From the measurements of the femoral component size and the variance in the degree of rotation using an Auto-CAD program, it was found that the change in the mediolateral flexion gap was greater when the rotation angle was greater and it was greater when the size of femoral component was larger at the same rotation angle. Conclusions: The average rotation angle of the femoral component to achieve an ideal rectangular flexion gap with minimal MCL release in TKA was an external rotation of 5.6° from the posterior condylar line and an external rotation of 2.0° from the Whiteside line. We concluded that when a femoral component is small in size, greater than average external rotation needs to be applied and when a femoral component is large in size, less than average external rotation needs to be applied.

We modified the posterior approach by preserving the external rotator muscles to enhance joint stability after primary THA. We asked whether this modified posterior approach would have a lower dislocation rate than the conventional posterior approach, with and without a repair of external rotator muscles. We retrospectively divided 557 patients (670 hips) who had undergone primary THA into three groups based on how the external rotator muscles had been treated during surgery: (1) not repaired after sectioning, (2) repaired after sectioning, or (3) not sectioned and preserved. The minimum followup was 1 year. In the group with preserved external rotator muscles, we observed no dislocations; in comparison, the dislocation rates for the repaired rotator group and the no-repair group were 3.9% and 5.3%, respectively. This modified posterior approach, which preserves the short external rotator muscles, seemed effective in preventing early dislocation after primary THA.Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background : Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique emplying the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra. Materials and Methods : The study includes 15 Denis burst and two Denis type D compression fractures between T 12 and L 3 . The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patient′s after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in body height, segittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated. Results : The pre-operative and postreduction percentile vertebral heights at, zero (immediate post-operative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at pre operative, and post operative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively. The pre-operative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final follow-up. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications. Conclusion : Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.

Fifty-six adults (average age, 38 years) with active tuberculosis of the lumbar and lumbosacral spine were treated conservatively with triple chemotherapy for 12 to 18 months. The minimum followup was 3 years. Three methods of assessments of the chronologic changes of sagittal spinal deformity were used on lateral radiographs of the lumbar spine obtained with the patient standing: deformity, kyphos angles, and total lumbar lordosis. The lumbosacral joint angle was measured for tuberculosis of the lumbosacral joint. The disease healed in all patients with a minimum increase of kyphosis, although in 23 patients there was minimal new involvement of the adjacent vertebral bodies within 6 months of treatment. The pattern of the involved vertebral body collapse in tuberculosis of the lumbar and lumbosacral joints was vertical (telescoping), along a longitudinal axis that minimized the progression of kyphosis. The outcome was judged on the basis of residual kyphosis (British Medical Research Council criteria) and found to be favorable in 96.4% (54 patients). Triple chemotherapy for lumbar and lumbosacral tuberculosis is effective in curing the disease and in minimizing the residual kyphosis through early diagnosis and immediate initiation of chemotherapy. The pattern of vertebral body collapse is the telescoping type, which is the determining factor in minimizing residual spinal deformity.

This study was carried out to assess the effect of bone marrow transplant into the 47 ununited fracture sites of the long bones of the extremities in 46 patients on bone healing. Among 46 cases, there were 43 pure fractures; a case of simultaneous ipsilateral femoral and tibial osteotomies for leg lengthening; a case of ununited repositioned cryo-treated proximal half of tibia as a limb salvage; and a case of internal transport of proximal tibia. Among the 43 pure fractures, there were 11 hypertrophic, 30 oligotrophic, and 2 gap nonunions. Bone marrow transplant was performed for any type of the delayed union and nonunion, and was also indicated in the distraction callotasis site of poor osteogenesis. Overall union rate in 43 fractures was 55.8% (24 cases). In two gap nonunions, no callus was formed. Union was obtained in all the 11 hypertrophic nonunions and 13 (46.4%) of the 30 oligotrophic nonunions. The oligotrophic and gap nonunions responded poorly to the marrow transplant. One of the two tibial osteotomy gaps healed with good evidence of endosteal callus formation. In a femoral osteotomy site for lengthening and in an ununited repositioned site of the cryo-treated tibia, there were no visible callus at all. The average time for clinical and radiological unions in the fracture cases were 5 and 7 months on average. In our series, there were no complications, including infection. The results in this series suggest that bone marrow transplant is a good source of callus formation or stimulant in treating the delayed union and hyper- and oligotrophic nonunions of any origin, and also enhances the callus formation at the gap of the early stage of the internal transport.

Sixty-seven patients were treated for Pott's paraplegia: 58 were adults and 9 were children. Sixty-four patients had active disease, and 3 had healed disease. All patients had triple chemotherapy with or without decompression surgery. Thirteen patients, including 9 children, were treated conservatively, whereas 54 patients who met the selection criteria for surgery were treated surgically. Fifty-two patients had anterior radical decompression surgery, and for 14 of them, anterior surgery was preceded by posterior instrumental stabilization surgery. Two patients with healed disease had posterior decompressive corpectomy. There was functional recovery in 60 (89.6%) patients, including 13 who had active disease that was treated conservatively. In 47 of the 54 surgically treated patients there was neurologic recovery, and 2 of these recovered incompletely with some residual spasticity. In the remaining 7 patients, there was no recovery. It took 2 to 6 months for recovery for the patients with conservative treatment, whereas it took

Background: The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery. Methods: We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion. Results: Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head ( p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82). Conclusions: Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.

Stainless steel is one of the most widely used biomaterials for internal fixation devices, but is not used in cementless arthroplasty implants because a stable oxide layer essential for biocompatibility cannot be formed on the surface. We applied a Ti electron beam coating, to form oxide layer on the stainless steel surface. To form a thicker oxide layer, we used a microarc oxidation process on the surface of Ti coated stainless steel. Modification of the surface using Ti electron beam coating and microarc oxidation could improve the ability of stainless steel implants to osseointegrate.The ability of cells to adhere to grit-blasted, titanium-coated, microarc-oxidated stainless steel in vitro was compared with that of two different types of surface modifications, machined and titanium-coated, and microarc-oxidated.We performed energy-dispersive x-ray spectroscopy and scanning electron microscopy investigations to assess the chemical composition and structure of the stainless steel surfaces and cell morphology. The biologic responses of an osteoblastlike cell line (SaOS-2) were examined by measuring proliferation (cell proliferation assay), differentiation (alkaline phosphatase activity), and attraction ability (cell migration assay).Cell proliferation, alkaline phosphatase activity, migration, and adhesion were increased in the grit-blasted, titanium-coated, microarc-oxidated group compared to the two other groups. Osteoblastlike cells on the grit-blasted, titanium-coated, microarc-oxidated surface were strongly adhered, and proliferated well compared to those on the other surfaces.The surface modifications we used (grit blasting, titanium coating, microarc oxidation) enhanced the biocompatibility (proliferation and migration of osteoblastlike cells) of stainless steel.This process is not unique to stainless steel; it can be applied to many metals to improve their biocompatibility, thus allowing a broad range of materials to be used for cementless implants.

The purpose of this study was to determine the mortality rate and factors related to mortality in elderly patients with acute and monotraumatic femoral neck fractures. This study included 241 patients with femoral neck fractures after bipolar hemiarthroplasty. We analyzed the mortality rate and the relationship between postoperative mortality and risk factors, such as age, sex, body mass index, the time to surgery, and the Society of Anesthesiologists' score. The postoperative mortality rate 1 and 3 years after surgery was 11.2% and 19.5%, respectively. There proved to be a relationship between postoperative mortality and age, the time to surgery, and the Society of Anesthesiologists score. We recommend that surgery should not be delayed, and caution should be exercised for the high-risk group patients.

Microarc oxidation (MAO) is a surface treatment that provides nanoporous pits, and thick oxide layers, and incorporates calcium and phosphorus into the coating layer of titanium alloy. We presumed such modification on the surface of titanium alloy by MAO would improve the ability of cementless stems to osseointegrate. We therefore compared the in vitro ability of cells to adhere to MAOed titanium alloy to that of two different types of surface modifications: machined and grit-blasted. We performed energy-dispersive x-ray spectroscopy and scanned electron microscopy investigations to assess the structure and morphology of the surfaces. Biologic and morphologic responses to osteoblast cell lines (SaOS-2) were then examined by measuring cell proliferation, cell differentiation (alkaline phosphatase activity), and alpha v beta 3 integrin. The cell proliferation rate, alkaline phosphatase activity, and cell adhesion in the MAO group increased in comparison to those in the machined and grit-blasted groups. The osteoblast cell lines of the MAO group were also homogeneously spread on the surface, strongly adhered, and well differentiated when compared to the other groups. This method could be a reasonable option for treating the surfaces of titanium alloy for better osseointegration.

Study design: Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. Objectives: To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. Setting: Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. Method: In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2–29 years), and remained neurologically symptom free from an average of 16 years (range, 4–27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). Results: In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. Conclusion: The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.

Study design Thirty-nine adults and five children with active spinal tuberculosis and resulting kyphosis of the dorsal and lumbar spine who had combined posterior instrumentation and anterior interbody fusion were observed to determine whether the corrected spinal deformity could be maintained until solid fusion. Objective To evaluate the effectiveness of the combined two-stage procedure for treating kyphosis due to active spinal tuberculosis. Summary of background data Until 1970, with all methods of treatment, kyphosis due to active spinal tuberculosis tended to increase during therapy. Most of the patients treated with these methods were not happy with this residual kyphosis, even though their disease was arrested or cured. Kyphosis became their main concern regarding further treatment. Methods A combined two-stage procedure, under the cover of 18 months of triple chemotherapy, was used for all patients. For posterior stabilization, the Harrington distraction system, Rush nails or Steinmann pins and wires, and Texas Scottish Rite Hospital instrumentation were used. The diagnosis of successful interbody fusion was made if there was no loss of correction, no graft resorption or graft bed resorption, and if there was visible graft remodeling, such as trabeculation between the graft beds and graft and the graft hypertrophy. Results In the 39 adults, average preoperative, immediate postoperative, and last follow-up kyphosis angles were 37 degrees, 16 degrees, and 18 degrees, respectively. In four children, the average preoperative, immediate postoperative, and last follow-up kyphosis angles were 55 degrees, 28 degrees, and 31 degrees, respectively. The loss of correction did not exceed 3 degrees. For one-segment spondylodesis, the average fusion times were 4 months in adults and 3.5 months in children. For a two-segment fusion, the average fusion times were 6 months in adults and 6.3 months in children. Conclusion Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis.

목적: 고령의 환자들에서 불안정한 대퇴골 전자간 골절의 치료로써 무시멘트 고관절 인공관절 전치 환술은 대퇴골 전자간 골절 치료로써 금속판이나 금속정 등의 내고정술 이외의 또 하나의 수술법으로 생각되고 있으며 대전자부 골편의 유합이 중요한 관심사 중의 하나이다. 이에 저자들은 이중 강선, 이중 고리, 8자 고정술을 이용한 대전자부 골편의 고정에 있어서 고정 방법에 따른 임상 및 방사선학적 결과를 발표하고자 한다. 대상 및 방법: 2010년 4월부터 2012년 2월까지 고관절의 불안정한 전자간 골절로 무시멘트 인공관절 전치환술 및 직경 1.0 mm의 이중 강선, 이중 고리, 8자 고정술을 시행 받은 20명 20예를 대상으로 하였다. 평균 연령은 71.1세(57-86세)였고 남자가 9명, 여자가 11명이었으며, 평균 추적관찰 기간은 6개월이었다. 술 후 환자들의 상태를 Harris hip score를 이용하여 평가하였다. 결과: 본 연구에서 수술 시간은 평균 95분, 수술 시 실혈량은 평균 800 cc였다. 최종 추시에서 Harris hip score는 평균 92.7점이었으며, 15예에서 보행거리의 감소없이 일상생활이 가능하였다. 술 후 고관절 탈구가 발생한 것은 1예였고, 고정 강선의 파손은 1예였다. 욕창과 심부정맥 혈전증 및 폐색전증이 발생한 사례는 없었다. 또한, 방사선학적으로 모든 사례에서 대퇴 주대는 해리 없이 잘 유지되었고, 13예에서 골절주위의 골생성을 확인할 수 있었으며, 골용해 소견을 보인 예는 없었다. 결론: 불안정성 대전자 골절 치료시 무시멘트형 인공고관절 치환술을 시행할 때 대전자부 골편을 고정하는데 이중강선, 이중고리, 8자 고정술을 이용한 강선 결박술이 유용한 방법으로 사료된다. 그러나 정복 방법의 개발과 함께 장기간의 추시결과에 대한 연구가 더욱 필요 할 것으로 사료된다.

The objective of this study is to report on a case of a huge epidermoid cyst in the conus medullaris and cauda equina in a 43 year-old lady with the characteristic MRI and histologic findings. She suffered from low back pain, hypoesthesia around the anus and urinary incontinence for over 20 years. Since 15 years previously, she gradually developed right foot drop and muscle atrophy. She underwent surgery and unfortunately, she developed complete paralysis below T12 after complete tumor excision. At postoperative 4 weeks, evidence of partial neurological recovery down to the L3 roots was observed, but as yet there has been no further neurological recovery. Although total surgical excision is thought to be the only radical treatment, we recommend partial tumor excision to avoid damaging the spinal cord and cauda equina during the surgical procedure, than the radical excision, because this cyst is a very slowly growing benign tumor.

A Brodie's abscess is a localized form of subacute or chronic osteomyelitis that occurs most often in the long bones of the lower extremities of young adults. Before physeal closure, it most commonly occurs in the metaphysis. In adults, the metaphyseal-epiphyseal area is involved. Rarely Brodie's abscess traverses the open growth plate, affecting the epiphysis, although such extension does not commonly result in growth disturbance. We reported a subacute osteomyelitis that traversed the physis of the distal tibia in a child, which was treated by surgical curettage and intravenous antibiotics.

The outcome of total joint arthroplasty is determined by biological events at the bone-implant interface. Macrophages phagocytose implant or wear debris at the interface and release proinflammatory mediators such as interleukins 1 and 6, tumor necrosis factor-alpha, and prostaglandin E2. These mediators are thought to contribute to the resorption of periprosthetic bone. Previous studies of tissues harvested from the bone-implant interface of failed orthopaedic implants demonstrated a possible role for two other cytokines, granulocyte-macrophage colony-stimulating factor and interleukin-4. The present study examined the effects of in vitro challenge with polymethylmethacrylate particles on the expression of granulocyte-macrophage colony-stimulating factor by primary human monocytes/macrophages and the role of interleukin-4 in regulating this expression. The polymethylmethacrylate particles caused a dose-dependent release of granulocyte-macrophage colony-stimulating factor at 48 hours. This release was accompanied by increased expression of interleukins 6 and 1beta and tumor necrosis factor-alpha. Release of the lysosomal enzyme hexosaminidase also increased in response to the particles. Interleukin-4 inhibited the expression of granulocyte-macrophage colony-stimulating factor, interleukin-6, and tumor necrosis factor-alpha at 48 hours in a dose-dependent manner. The data presented in this study confirm the hypothesis that interleukin-4 downregulates particle-induced activation of macrophages, as demonstrated by the decreased release of proinflammatory mediators.