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Background We sought to determine (1) the success rate of debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infection (PJI) of the knee in patients with acute postsurgical infection and in those with acute hematogenous infection via a multicenter study, (2) the factors related to the failure of DAIR for overall acute PJI and acute hematogenous PJI via subgroup analysis, and (3) whether the PJI recurrence patterns differed between the two groups over time after DAIR. Methods This retrospective multicenter study included 101 acute knee PJI. Acute postsurgical PJI was defined as PJI diagnosed Results The overall success rate of DAIR was 77%. The success rate tended to be higher in the postsurgical group than in the hematogenous group (p = 0.060). However, there was no significant factor related to DAIR failure in the subgroup analysis of acute hematogenous PJIs. In the postsurgical group, the recurrence of PJI occurred until 3 months, whereas in the hematogenous group, recurrence occurred for up to 2 years. Conclusions The failure rate tended to be higher in the acute hematogenous PJI group than in the acute postsurgical PJI group. Since acute hematogenous infections may recur for a longer period than postsurgical infections, careful follow-up is required after DAIR.

The purpose of this study was to analyze the epidemiology of T-score discordance between the spine and femur in the South Korean population and compare the prevalence of T-score discordance between the Korean osteoporosis population and atypical femoral fracture (AFF) patients.A total of 12,422 subjects from the Korea National Health and Nutrition Examination Survey were reviewed retrospectively. T-score discordance was defined as a difference of ≥ 1 standard deviation between the lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD). The prevalence of T-score discordance (low LS [LS BMDFN BMD], low FN [LS BMDFN BMD], and total [low LS + low FN]) was investigated in the osteoporosis and non-osteoporosis groups and stratified by sex and age. T-score discordance of 63 patients with AFFs diagnosed at a single institution was compared with that of the Korean osteoporosis population using propensity score matching.T-score discordance was prevalent in the Korean osteoporosis population (44.8%), and low LS discordance (37.5%) was more frequently seen than low FN discordance (7.2%) (T-score discordance was highly prevalent in the Korean osteoporosis population, and low LS discordance was more common than low FN discordance. Nevertheless, the prevalence of low LS discordance was significantly higher in AFF patients than in the Korean osteoporosis population.

Background With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully. Main body Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary. Conclusion The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

BACKGROUND Tranexamic acid (TXA) is typically discontinued on the day of total knee arthroplasty (TKA). However, bleeding may persist for several days. We sought to determine whether sequential administration of intravenous (IV) and oral TXA could reduce hemoglobin (Hb) drop more than IV TXA alone. We also wanted to determine whether the use of additional oral TXA increased the rate of complications of deep vein thrombosis (DVT) or symptomatic pulmonary embolism (PE). METHODS This prospective, randomized controlled trial included 141 patients. We compared the Hb drop, estimated blood loss (EBL), and transfusion rate of patients receiving IV TXA alone (group IV, n = 48) to those of patients who received IV TXA followed by oral TXA for 2 days (group 2D, n = 46) or 5 days (group 5D, n = 47). IV TXA was administered 10 minutes prior to the tourniquet release and 3 hours after the first IV TXA administration. Computed tomography (CT) was performed on postoperative day 6 to identify radiographic evidence of DVT. We also assessed the prevalence of symptomatic DVT and PE. RESULTS There were no differences in maximal Hb drop, Hb drops measured at each time point, EBL, or transfusion rate among the 3 groups. The mean maximal Hb drop was 3.5 g/dL in group IV, 3.2 g/dL in group 2D, and 3.4 g/dL in group 5D. The mean EBL was 999.9 mL in group IV, 886.4 mL in group 2D, and 972.5 mL in group 5D. One patient in each group required a transfusion. There were no differences in the prevalence of radiographic evidence of DVT or symptomatic DVT. Symptomatic DVT occurred in 3 patients in group IV and 2 patients in group 5D. One patient in group IV developed a symptomatic PE. CONCLUSIONS Although there was no increase in the complication rate, the sequential administration of oral TXA for up to 5 days after IV TXA did not decrease Hb drop. Therefore, our findings suggest that sequential use of oral and IV TXA is not recommended. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The viability of augmenting small-diameter hamstring autografts with allografts remains unclear. Recent studies have reported different clinical results after allograft augmentation. Hence, we sought to determine whether hamstring autografts and hybrid grafts differed in terms of failure rates and functional outcomes after anterior cruciate ligament (ACL) reconstruction. We also evaluated whether the results of the comparisons differed based on allograft sterilization methods.This systematic review and meta-analysis were performed by searching the PubMed, Cochrane Library, and EMBASE databases to identify prospective or retrospective studies (evidence levels 1, 2, or 3) that compared the failure rates and functional outcomes of ACL reconstruction using autografts and hybrid grafts.We identified 15 relevant studies, including 1,521 patients, with 798 and 723 treated using autografts and hybrid grafts, respectively. Fourteen studies were retrospective comparative studies, and one was a prospective randomized controlled trial. Of these, three studies used non-irradiated allografts. In the analysis of all participants, no significant differences in failure rates and subjective International Knee Documentation Committee (IKDC) scores were observed between the autograft and hybrid graft groups. Comparing the autograft and hybrid graft groups that used non-irradiated allografts, no differences in the failure rates and subjective IKDC scores were also noted. Meanwhile, in the groups that used irradiated allograft, the autograft group demonstrated higher Lysholm knee scores and reduced anterior laxity than the hybrid graft group.Overall, ACL reconstruction using hybrid grafts may not reduce failure rates compared to reconstructions using hamstring autografts, although hybrid grafts with irradiation may decrease functional outcomes.III; systematic review of level II and III studies.

The purpose of this study aimed to identify the proportion of patients with delayed normalization of C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) after TKA, to determine postoperative thresholds predictive of prolonged elevation. Further, we aimed to determine if the clinical outcomes of patients with prolonged elevation were inferior to those without prolonged elevation.The records of 211 unilateral and 320 bilateral TKA were reviewed. Patients were divided into the normal and elevation group based on CRP and ESR levels at 6 weeks and 3 months. The temporal pattern of CRP and ESR change in both groups was compared, and thresholds predictive of elevation at 6 weeks and 3 months were identified. Further, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Tegner activity scale of both groups at 6 months, 1 year, and 2 years after TKA were compared.The proportion of patients with elevated CRP and ESR at 6 weeks and 3 months was CRP: 24.2%, 10%, ESR: 51.6%, 29.9% in unilateral and CRP: 31.5%, 10.6%, ESR: 58.1%, 42.7% in bilateral TKA. The thresholds for elevation at 6 weeks and 3 months were 9.5 mg/dL, 11.4 mg/dL (CRP at 6 weeks) and 81.5 mm/h, 74.5 mm/h (ESR at 3 months). There was no difference in the WOMAC score and Tegner activity scale between both groups.CRP and ESR are often elevated for a prolonged period even in the absence of infection after TKA. Such cases show distinct temporal patterns, which are predictable, and do not appear to have a significant effect on clinical outcome.

Studies regarding the best strategy to determine appropriate femoral component rotation during bilateral total knee arthroplasty (TKA) in wind swept deformities (WSD) are very limited. The purpose of this study was (1) to evaluate whether femoral rotational profiles differ between varus and valgus osteoarthritic knees in WSD and (2) to analyze the correlation between femoral rotational profiles and coronal radiologic parameters. A total of 40 patients who were diagnosed with bilateral knee osteoarthritis with WSD between January 2010 and December 2020 at a single institution were retrospectively reviewed. On axial computed tomography scans, femoral rotational profile parameters such as the clinical transepicondylar axis (cTEA) and anterior–posterior (AP) axis were compared between valgus and varus osteoarthritic knees. In standing full-limb AP radiographs, coronal radiographic parameters including hip–knee–ankle angle (HKA), valgus correction angle (VCA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA) were measured in both knees. The correlation between the varus-valgus cTEA difference, and differences in coronal radiologic parameters was analyzed. In valgus osteoarthritic knees, cTEA was significantly increased compared to varus osteoarthritic knees by 1.5° (valgus: 7.65° ± 1.82°, varus: 6.15° ± 1.58°, p

The role of unicompartmental knee arthroplasty (UKA) in spontaneous osteonecrosis of the knee (SONK) remains controversial, even though SONK involves only one compartment of the knee joint. We aimed to compare the survival rate and clinical outcomes of UKA in SONK and medial compartment osteoarthritis (MOA) via a meta-analysis of previous studies. MEDLINE, Embase, and Cochrane Library were searched up to January 2018 with keywords related to SONK and knee arthroplasty. Studies were selected with predetermined inclusion criteria: (1) medial UKA as the primary procedure, (2) reporting implant survival or clinical outcomes of osteonecrosis and osteoarthritis, and (3) follow-up period > 1 year. Quality assessment was performed using the risk of bias assessment tool for non-randomized studies. A random-effects model was used to estimate the pooled relative risk (RR) and standardized mean difference. The incidence of UKA revision for any reason was significantly higher in SONK than in MOA group (pooled RR = 1.83, p = 0.009). However, the risk of revision due to aseptic loosening was not significantly different between the groups. Moreover, when stratified by the study quality, high-quality studies showed similar risk of overall revision in SONK and MOA (p = 0.71). Subgroup analysis revealed no significant difference in failure between SONK and MOA after cemented mobile and fixed bearing UKA. Results of uncemented UKA were reported only in one study, which showed higher failure of SONK compared to MOA. Clinical outcomes after UKA were similar between SONK and MOA (p = 0.66). Cemented UKA has similar survival and clinical outcomes in SONK and MOA. Prospective studies designed specifically to compare the UKA outcomes in SONK and MOA are necessary.

The degree of cartilage degeneration assessed intraoperatively may not be sufficient as a criterion for patellar resurfacing in total knee arthroplasty (TKA). However, single-photon emission tomography/computed tomography (SPECT/CT) is useful for detecting osteoarthritic involvement deeper in the subchondral bone. The purpose of the study was to determine whether SPECT/CT reflected the cartilage lesion underneath the patella in patients with end-stage osteoarthritis (OA) and whether clinical outcomes after TKA without patellar resurfacing differed according to the severity of patellofemoral (PF) OA determined by visual assessment and SPECT/CT findings. This study included 206 knees which underwent TKA. The degree of cartilage degeneration was graded intraoperatively according to the International Cartilage Repair Society grading system. Subjects were classified into low and high uptake groups according to the degree of bone tracer uptake (BTU) on SPECT/CT in the PF joint. The Feller's patella score and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed preoperatively and postoperative 1 and 2 years. The increased BTU in the PF joint was associated with more severe degenerative cartilage changes underneath the patella (p

Background This study aimed to determine the prevalence of excessive lateral pressure syndrome (ELPS) in potential candidates for high tibial osteotomy (HTO) using single-photon emission computed tomography–computed tomography (SPECT–CT). We also sought to identify risk factors related to the presence of ELPS. Methods This retrospective study included 150 patients (216 knees) who were candidates for HTO from an initial screening of 3579 patients (7158 knees). There were 183 female and 33 male knees with a mean age of 58 years. The presence of ELPS was defined as a grade 3 uptake on the SPECT–CT at the lateral PF joint. To determine the risk factors related to the ELPS, multivariate regression analysis was performed with independent demographic and radiographic variables. Results Increased uptake on the lateral side of the PF joints was detected in 120 knees (56% of total subjects). Of these, 34 (16%) knees presented with a grade 3 uptake, which indicated the presence of ELPS. No single risk factor had significant associations with the presence of ELPS. Conclusions A considerable number of the knees that were candidates for HTO had ELPS. Nonetheless, we did not find any risk factor related to the presence of ELPS. These results suggest that surgeons should be cautious when diagnosing concomitant ELPS despite acceptable radiographic findings from patellofemoral joints when performing HTO.

The purpose of this study is to compare the progression rate of bone union and clinical outcomes of opening wedge high tibial osteotomy (OWHTO) using allogenous bone chip or tri-calcium phosphate (TCP) granule as bone graft materials. The hypothesis was that the bone union progression in OWHTOs using TCP granule grafts would be comparable to that of OWHTOs using allogenous bone chip grafts. Between 2011 and 2013, 54 patients who had undergone OWHTO for genu varum and osteoarthritis were randomized to one of the two groups at five centres. TCP granule was used to fill the defect in 27 patients and lyophilized allogenous bone chip was used in the other 27 patients. The degree of bone union was classified on a five-point scale and evaluated using plain radiographs of the knee at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, pain Visual Analogue Scale (VAS) score and complications were also evaluated. The highest degree of bone union observed at 6 and 12 months postoperatively was grade 4, and the number of cases of union progression at each time-point was not significantly different between the two groups (p > 0.05). WOMAC and pain VAS scores also showed no differences between the two groups. No complications were observed during the 12-month period following OWHTO in either group. OWHTO using TCP granule bone substitute showed similar bone union rates and clinical outcomes compared to allogenous bone chip grafts. TCP granule can be used as bone substitutes instead of allogenous bone chip grafts in OWHTO. Level 1.

BACKGROUND Some patients with recurrent symptomatic instability after primary anterior cruciate ligament (ACL) reconstruction have an extension deficiency (ED). This study (a) compared preoperative clinical conditions between the ED and non-ED groups undergoing revision ACL reconstruction, (b) documented clinical and arthroscopic findings in ACL-reconstructed patients with reinstability and ED, and (c) determined whether the ED could be resolved and whether the clinical results of revision surgery differed between the ED and non-ED groups. METHODS This study included 58 patients who underwent revision ACL reconstruction. Patients were divided into the ED and non-ED groups. Preoperatively, the demographics and clinical conditions of the two groups were compared. Intraoperatively, the pathological structures that related to ED were documented. After surgery, the degree of postoperative ED and functional outcomes were compared between the two groups at 2-year follow-up. RESULTS The International Knee Documentation Committee subjective score and SF-36 physical component summary scores were worse in the ED group than the non-ED group preoperatively (54 vs 48 [P = 0.014]; 42 vs 39 [P = 0.031], respectively). Intraoperatively, the ED group showed significantly more frequent graft malposition (50% vs 5%), anvil osteophytes (44% vs 0%), and scarring around posterior intercondylar notch (100% vs 0%). However, there was no difference in the degree of postoperative ED and functional outcome between the two groups at follow-up. CONCLUSIONS ED in patients with recurrent instability after primary ACL reconstruction could be treated with good clinical result by addressing the pathological conditions causing ED in addition to ACL re-reconstruction.

Background We sought to document the incidences of deep vein thrombosis (DVT) before and after total knee arthroplasty (TKA). In addition, we aimed to explor whether routine preoperative DVT evaluation was useful to establish DVT treatment strategies after TKA. Finally, we wanted to evaluate whether the incidences of DVT differed between patients undergoing unilateral and staged bilateral TKA within the same hospitalization period. Methods The retrospective study included 153 consecutive patients (253 knees) with osteoarthritis who underwent primary TKA. After surgery, mechanical compression devices (only) were used for DVT prophylaxis. DVT status before and after TKA was determined via 128-row, multidetector, computed tomography/indirect venography. Results Overall, the preoperative DVT incidence was 2.6% per patient and 1.6% per knee. All preoperative DVTs were distal in nature and asymptomatic. After TKA, newly developed thrombi were evident in various calf veins, without propagation of any pre-existing thrombi. Postoperatively, the overall incidences of DVT were 69.9% per patient and 58.5% per knee. The DVT incidences were 66% per patient and 69.8% per knee in the unilateral TKA group. In contrast, the incidences were 72% per patient and 55.5% per knee in the staged bilateral TKA group. There was one case of symptomatic distal (unilateral TKA; 0.65% per patient and 0.4% per knee) and proximal DVT (bilateral TKA; 0.65% per patient and 0.4% per knee), respectively. Conclusions The incidence of symptomatic DVT was low in Asian patients treated with mechanical compression devices alone, although substantial portion of patients had DVT after surgery. Routine preoperative DVT evaluation is probably not necessary; preoperative DVT was rare and of limited clinical relevance. Furthermore, staged bilateral TKA during a single period of hospitalization does not increase the incidence of DVT.

Background We sought to determine the 10-year survivorship of single-radius, posterior-stabilized total knee arthroplasty (TKA) in Asian patients. We also aimed to determine whether the long-term clinical and radiographic results differed between patients with and without patellar resurfacing. Methods This retrospective study included 148 (115 patients) consecutive single-radius, posterior-stabilized TKAs. Ten-year survivorship analysis was performed using the Kaplan–Meier method with additional surgery for any reason as the end-point. Furthermore, long-term clinical and radiographic results of 109 knees (74%; 84 patients) with more than 10-year follow-up were analyzed. Ten-year survivorship and long-term outcomes after surgery were determined, and outcomes were compared between patients with and without patellar resurfacing. Results The cumulative survival rate of the single-radius posterior-stabilized TKA of 148 knees was 97.7% (95% confidence interval, 93.1%–99.3%) at 10 years after surgery. Three knees required additional surgery during the 10-year follow-up because of one case of instability and two cases of periprosthetic infections. Mean postoperative Knee Society knee score and function score were 97 points and 75 points, respectively. There were no cases of aseptic loosening of the prosthesis, even though a non-progressive radiolucent line was found in 10 (9%) knees. There were no differences in postoperative scores and degree of patellar tilt and displacement between patients with and without patellar resurfacing. Conclusions Single-radius, posterior-stabilized TKA showed satisfactory long-term clinical and radiographic outcomes in Asian patients regardless of patellar resurfacing, with comparable survivorship to that reported in westerners.

Background: Although a few studies have reported the incidence of deep vein thrombosis (DVT) after opening-wedge high tibial osteotomy (OWHTO), previous studies focused only on symptomatic DVT. Information is lacking regarding the overall incidence of DVT after OWHTO, thrombus location, and the relationship between DVT and clinical outcome. Purpose: To determine the overall incidence of DVT and classify the location of DVT after OWHTO. We also determined whether significant differences in clinical improvement exist in patients with and without DVT at 6 months and at 2 years after OWHTO. Study Design: Case-control study; Level of evidence, 3. Methods: This study included 46 patients (47 knees) who underwent OWHTO. All patients were instructed to perform knee range of motion exercises and partial weightbearing after drain removal. None of the patients received a chemoprophylaxis for DVT except intermittent pneumatic compression. DVT was diagnosed using 128-row multidetector computed tomography performed before discharge on the fourth postoperative day. The location was classified into 6 segments in the distal portion (muscular and axial veins) and proximal portion (popliteal, femoral, and common femoral veins and veins located above the iliac vein). International Knee Documentation Committee (IKDC) score was assessed preoperatively and postoperatively at 6 months, 1 year, and 2 years using a linear mixed model. Results: Although the incidence of symptomatic DVT was 8.5% (n = 4), the overall incidence of early DVT was 44.7% (n = 21). All DVTs were located in the distal portion of the lower extremity vein, and 76.2% of the DVTs were located in an axial vein. The IKDC scores were 33.6 ± 7.2 and 35.3 ± 9.1 ( P = .910) preoperatively, 38.1 ± 5.6 and 40.6 ± 8.4 ( P = .531) at 6 months after surgery, and 44.8 ± 6.9 and 45.9 ± 11.4 ( P = .786) at 2 years after surgery in patients without and those with DVT, respectively. Conclusion: The overall incidence of early DVT after OWHTO was 44.7%. DVT after OWHTO was found particularly around the osteotomy site (76.2%). Patients with DVT did not have inferior short-term clinical outcomes after surgery.

BackgroundWe sought to determine whether there was a difference in the posterior condylar offset (PCO), posterior condylar offset ratio (PCOR) and clinical outcomes following total knee arthroplasty (TKA) with anterior referencing (AR) or posterior referencing (PR) systems. We also assessed whether the PCO and PCOR changes, as well as patient factors were related to range of motion (ROM) in each referencing system.MethodsThis retrospective study included 130 consecutive patients (184 knees) with osteoarthritis who underwent primary posterior cruciate ligament (PCL)-substituting fixed-bearing TKA. The difference between preoperative and postoperative PCO and PCOR values were calculated. Clinical outcomes including ROM and Western Ontario and McMaster University (WOMAC) scores were evaluated. Furthermore, multiple linear regression analysis was performed to determine the factors related to postoperative ROM in each referencing system.ResultsThe postoperative PCO was greater in the AR group (28.4 mm) than in the PR group (27.4 mm), whereas the PCO was more consistently preserved in the PR group. The mean postoperative ROM after TKA was greater in the AR group (129°) than in the PR group (122°), whereas improvement in WOMAC score did not differ between the two groups. Preoperative ROM was the only factor related to postoperative ROM in both groups.ConclusionsThere was no difference in postoperative PCO in AR and PR group and the PCO was not associated with postoperative ROM. PCO was more consistently preserved after surgery in the PR group. The postoperative PCO and PCOR changes did not affect the postoperative ROM. Furthermore, similar clinical outcomes were achieved in the AR and PR groups.Trial registrationRetrospectively registered (Trial registration number:06-2010-110).

There is little information about the management and clinical outcomes of the periprosthetic fracture after total knee arthroplasty (TKA) with a stem extension. The purposes of this study were to demonstrate management of the periprosthetic fractures after TKA with a stem extension, to report treatment outcomes, and to determine whether dual-plate fixation is superior to single-plate fixation regarding the radiographic bone union time and incidence of metal failure. This retrospective study included 15 knees with periprosthetic fractures after TKA using a stem extension. We demonstrated the fracture characteristics and management according to the fracture location and implant stability. The radiographic union time was determined. Complications, range of motion, and functional outcomes, including Western Ontario and McMaster Universities Osteoarthritis Index and Knee Society Score were assessed. Periprosthetic fractures after TKA with stem extension were 1 metaphyseal fracture without implant loosening, 7 diaphyseal fractures adjacent to the stem without implant loosening, 3 diaphyseal fractures away from the stem without implant loosening, and 4 fractures with implant loosening. Treatment included immobilization using a long leg cast, open reduction and internal fixation (ORIF), and re-revision TKA. There was no difference in functional outcomes and range of motion pre- and posttreatment. The complications included 2 cases of subsequent implant loosening. Patients in the dual-plating required a shorter bony union time than those in the single-plating (2.4 ± 1.1 vs 7.4 ± 2.2 months; P = .003). Periprosthetic fractures after TKA with stem extension could be managed individually according to the fracture location and implant stability. Complications were not uncommon even if patients were able to return to their preinjury functional level posttreatment. To avoid complications after ORIF, the dual plate was superior to the single plate, and subtle implant loosening should not be overlooked.

The aim of this study was to determine whether the infection control rate of a modified debridement, antibiotics, and implant retention (DAIR) protocol (DAIR with antibiotic-impregnated cement beads) is comparable to that of 2-stage revision for acute periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We also aimed to determine whether this modified DAIR technique produced better clinical results than those obtained using 2-stage revision in terms of functional outcome, range of motion (ROM), and patient satisfaction at 2 years after surgery. This retrospective comparative study included patients who underwent modified DAIR (7 patients, 9 knees) or 2-stage revision (8 patients, 9 knees) for acute PJI of the knee joint. Infection control rate, functional outcome measured using Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, ROM and patient satisfaction were compared between the two groups. There was no difference in infection control rates between the modified DAIR and 2-stage revision groups (78% vs 78%, respectively). In contrast, surgical outcome in the modified DAIR group was tended to be better than 2-stage revision group, but it did not reach statistical significance. Median maximal range of flexion was 103° in the modified DAIR group and it was 90° in the 2-stage group (P = .191). In addition, the median WOMAC function score was 24 in the modified DAIR group and it was 30 in the 2-stage group (P = .076). Median patient satisfaction measured using visual analogue scale was 8 in the modified DAIR group and 5 in the 2-stage group (P = .069). The infection control rates of the modified DAIR protocol and 2-stage revision protocol were similar for the treatment of acute PJI of the knee joint. However, the modified DAIR protocol could not provide substantially increased functional outcomes and patient satisfaction compared to 2-stage revision. Therefore, the modified DAIR technique should be considered to be of limited use in patients with high surgical morbidity.

A two-stage approach to total knee arthroplasty (TKA) using an antibiotic-impregnated articulating cement spacer is an option for an infected arthritic knee. Vancomycin combined with broad-spectrum antibiotics can be used to make an antibiotic-impregnated articulating cement spacer. Causative organisms are sometimes not confirmed before surgery. Joint infections of multidrug-resistant organisms are increasing. Therefore, routine combinations of antibiotics may not be effective. We present a case of a patient who developed vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee. A 71-year-old man was initially diagnosed with pyogenic arthritis caused by Staphylococcus aureus. He underwent arthroscopic debridement elsewhere. However, the infection persisted. He was referred to our hospital, and we performed a two-stage TKA using a vancomycin-based antibiotic-impregnated articulating cement spacer. Vancomycin-resistant P. aeruginosa was identified after surgery. Intravenous colistin was added. However, this failed, either because vancomycin was not effective against P. aeruginosa, or because insufficient systemic colistin due to colistin-induced acute kidney injury. Therefore, debridement was repeated, and colistin-loaded cement spacer was inserted. The spacer delivered high concentrations of colistin to the infected joint with decreased systemic effects. Thus, less systemic colistin was used. The infection was controlled without recurrent acute kidney injury. One year after surgery, conversion to TKA was successfully performed. A two-stage approach to TKA using a colistin-loaded articulating cement spacer can be used for an arthritic knee infected by vancomycin-resistant P. aeruginosa. Furthermore, local administration of colistin using a cement spacer can reduce the systemic side effects of colistin.

Background Occasionally, patients experience new or increased ankle pain following total knee arthroplasty (TKA). The aims of this study were to determine (1) how the correction of varus malalignment of the lower limb following TKA affected changes in alignment of the ankle and hindfoot, (2) the difference in changes in alignment of the ankle and hindfoot between patients with and without ankle osteoarthritis (OA), and (3) whether the rate of ankle pain and the clinical outcome following TKA differed between the 2 groups. Methods We retrospectively reviewed prospectively collected data of 56 patients (99 knees) treated with TKA. Among these cases, concomitant ankle OA was found in 24 ankles. Radiographic parameters of lower-limb, ankle, and hindfoot alignment were measured preoperatively and 2 years postoperatively. In addition, ankle pain and clinical outcome 2 years after TKA were compared between patients with and without ankle OA. Results The orientation of the ankle joint line relative to the ground improved from 9.4° of varus to 3.4° of varus, and the valgus compensation of the hindfoot for the varus tilt of the ankle joint showed a 2.2° decrease following TKA. Patients in the group with ankle OA showed decreased flexibility of the hindfoot resulting in less preoperative valgus compensation (p = 0.022) compared with the group without ankle OA. The postoperative hindfoot alignment was similar between the 2 groups because of the smaller amount of change in patients with ankle OA. The group with ankle OA had a higher rate of increased ankle pain (38% compared with 16%) as well as a worse Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (mean of 22.2 compared with 14.2) following TKA. Conclusions A considerable proportion of patients who underwent TKA had concomitant ankle OA with reduced flexibility of the hindfoot. These patients experienced increased ankle pain following TKA and a worse clinical outcome. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to assess the overall clinical results and range of motion (ROM) after total knee arthroplasty (TKA) in patients with preoperative stiffness. We also aimed to determine whether the severity or cause of the stiffness can affect the clinical outcome after surgery. This retrospective study included 122 knees (117 patients) with follow-up of more than 2 years (mean age, 64.3 years). TKA was performed using posterior-stabilized, varus-valgus constrained (VVC), and hinged prostheses. To determine the effect of the severity of stiffness on the clinical outcome, the subjects were divided into two groups: the severe group (preoperative ROM ≤ 50°; 18 knees) and the moderate group (preoperative ROM, 50°-90°; 104 knees). Then, clinical results and ROM were compared according to the severity or cause of preoperative stiffness. After surgery, preoperative ROM (mean, 78°; range, 25°- 90°) was improved (mean, 107°; range, 70°- 130°). The severe group more frequently used the VVC or hinged prostheses (72% vs. 18%). Furthermore, the severe group had worse knee and function scores as well as more complications (33% vs. 13%), even though the severe group had a greater ROM increment (47° vs. 27°) after surgery. Patients with osteoarthritis and rheumatoid arthritis showed better ROM and clinical results compared to patients with infectious or traumatic arthritis. Although TKA in stiff knees can be successful, the results are inferior in knees with severe stiffness and knees with infectious or traumatic arthritis.

Purpose To determine what proportion of patients visiting a tertiary knee clinic had pre-obtained knee magnetic resonance imaging (MRI) and to assess the impact of pre-obtained knee MRI on the selection of treatment plans. Materials and Methods Six hundred and eighty patients were enrolled from patients who visited our knee clinic during a 6-month period. The proportion of patients with pre-obtained knee MRI was calculated, and associations of sociodemographic factors, disease category, and finally selected treatment options with knee MRI pre-obtainment were investigated. A utility assessment panel of five orthopaedic surgeons was formed and established utility assessment criteria. Two rounds of utility assessment (before and after MRI review) were performed. Results Of the 680 patients, 185 (27%) had pre-obtained knee MRI. In the first round of utility assessment, 39%, 18%, and 43% of the 185 knee MRIs were evaluated as useful, equivocal, and arguably useless, respectively, and almost identical results were obtained in the second round. The proportion of assessed 'useful MRI' was higher in sports related injury (84%) and other conditions (91%) than in degenerative joint disease (18%) and nonspecific knee pain (31%). Utility assessment results among panels varied little for practice patterns and education duration. Conclusions This study suggests clinicians should reconsider and counsel patients the expected utility of knee MRI acquisition.

Purpose The aim of this study was to determine the outcomes of bursoscopic ossicle excision in young and active patients with unresolved Osgood-Schlatter disease. Methods This retrospective study included 18 male military recruits. A direct bursoscopic ossicle excision was performed using low anterolateral and low anteromedial portals. Outcomes were evaluated using the Lysholm knee score, pain score on a visual analog scale (VAS) (from 0 to 10), and Tegner activity scale score. In addition, patients were asked whether they could kneel or squat and whether they were able to return to their duty after surgery. Patient satisfaction was evaluated using the VAS and by asking whether patients thought that the prominence of the tibial tuberosity was reduced and whether they would recommend the same surgical treatment to others. Complications after surgery were also evaluated. Results The mean Lysholm knee score was 71 preoperatively and improved to 99 after surgery. The mean VAS pain score was 6.5 in the preoperative period and decreased to 0.9 after surgery. In addition, the mean Tegner activity scale score improved from 2.7 preoperatively to 6.2 at final follow-up. However, 4 patients were not able to return to their duty, and 4 patients still had difficulties with kneeling after surgery. A superficial infection occurred in 1 patient, and a recurrent ossicle formation was found in 1 patient. Of 18 patients, 17 were satisfied with their surgical outcomes, and the mean VAS score for patient satisfaction was 8.8. Furthermore, all but 1 patient would recommend the same surgical treatment to others. However, 6 patients did not believe that the prominence of the tibial tuberosity was reduced. Conclusions Bursoscopic ossicle excision showed satisfactory outcomes in selective young and active patients with persistent symptoms. However, bursoscopic surgery showed limitation in reducing the prominence of the tibial tuberosity. Level of Evidence Level IV, therapeutic case series.

Purpose To determine whether there are differences between adjustable-length loop and fixed-length loop devices in terms of the amount of displacement, temporal pattern of displacement, and ultimate failure load when tested using 4,500 cycles of sinusoidal loading with high loads (100-400 N). Methods Two cortical suspension devices with a fixed- or adjustable-length loop were tested. For our comparisons, a 20-mm fixed-length loop device and a fixed-length loop device with the same loop length were used. Comparisons between the devices used both a device-only model (DOM) and a device–bone–soft-tissue graft construct model (CM). Results In the DOM, the adjustable-length loop device showed weaker mechanical properties. Mean cumulative peak displacement was 1.91 mm for the adjustable-length loop device and 0.74 mm for the fixed-length loop device ( P = .001). The displacement of the adjustable-length loop device increased between 1,000 and 4,500 cycles; in contrast, that of the fixed-length loop device reached a plateau. However, there was never displacement greater than 3 mm. In addition, the adjustable-length loop device showed a weaker ultimate failure load (925 N vs 1,410 N, P = .001). In the CM, the difference in cumulative peak displacement between the 2 groups decreased and did not reach statistical significance. The displacement of both devices showed a similar pattern. In addition, there was no difference in ultimate failure load between the 2 groups. Conclusions There was no significant difference in terms of total displacement, temporal pattern of displacement, and ultimate failure load between the 2 devices in the CM, which is the more clinically relevant model. Furthermore, even in the DOM, the difference in total displacement was small and did not reach a clinically meaningful level. Therefore, both devices can be used effectively during anterior cruciate ligament reconstruction with soft-tissue graft. Clinical Relevance Both femoral cortical suspension devices with adjustable- and fixed-length loops can be used with similar mechanical properties during anterior cruciate ligament reconstruction.

Purpose We aimed to determine 1) whether dropout rate decreased and 2) whether health care providers' perceptions were changed with continued improvements of contents of clinical pathway (CP) for total knee arthroplasty (TKA). Materials and Methods This retrospective study included two separate analyses of patients and health care providers. In the analysis of patients, dropout rates and reasons were evaluated in two cohorts of patients who underwent TKA with CP applied at two different time periods (384 patients from 2009 to 2010 and 242 patients from 2012 to 2013). Contents of CP were continuously improved during the 3-year interval. Self-administered questionnaire surveys targeted to health care providers were carried out twice (2010 and 2013) and compared. Results Dropout rate decreased from 19.1% in the first time period to 10.4% in the second time period. Although overall satisfaction of care providers was high at both time-points, doctors had more favorable perceptions than nurses; most positive changes of perception were noted in nurses. The health care providers' perceptions for potential concerns of CP were improved while the perceptions for potential benefits and satisfaction were maintained. Conclusions Continuously improved CP has increased feasibility for TKA patients and reduced health care providers' concern about its value. We propose that CP can be implemented and actively used to improve the outcomes and efficacy of patient care for TKA, regardless of the rotation of care providers.

We hypothesized that the circumstances of the two consecutive operations of a simultaneous bilateral total knee arthroplasty (TKA) are different, and could lead to different outcomes of overlapping bilateral TKAs. Both knees of 420 subjects were evaluated in the current study. In the second TKA, there were more incidence rates of outlier in mechanical femoro-tibial angle (16.2% vs. 9.0%), more blood loss (735 vs. 656 mL), and longer operation time (61, 58 minutes respectively), as compared to the first TKA, while no significant differences in clinical outcomes. In conclusion, there were no significant differences in the clinical outcomes even though few distinct outcomes due to different circumstances of the surgery. Awareness of these findings can help the continued success of bilateral TKA in an increasing patient population.

Staged bilateral total knee arthroplasty (TKA) may provide an ideal clinical model for the study of central sensitization. In staged TKA, hyperalgesia may be induced as a result of repeated surgical injury possibly via central sensitization, which can decrease functional outcomes. Therefore, we hypothesized that in staged bilateral TKA, patients would have greater pain in the second operated knee than in the first. Thirty patients undergoing staged bilateral TKA at a 1-week interval were enrolled. Postoperative pain, which was reported on the basis of a visual analog scale (VAS; primary outcome) at rest and at maximum knee flexion, and the amount of patient-controlled analgesic (i.v. fentanyl) and rescue analgesic (i.v. ketoprofen; secondary outcomes) administered during the 48 h after the operation, were compared between the first and second TKA. VAS scores at rest and at maximum knee flexion were greater on the second operated knee (P.001 and P.01, respectively). The cumulative amounts of patient-controlled analgesic and the rescue analgesic were greater in the second than in the first TKA (P.001 and P.05, respectively). Patients undergoing staged bilateral TKA experience greater postoperative pain in the second operated knee than the first. This suggests extension of hyperalgesia beyond the initially injured site to remote regions after surgical injury, in which central sensitization may be involved. Therapeutic approaches to reduce such hyperalgesia induced in the course of staged operations are required.

Background Failed ACL reconstruction frequently is accompanied by irreparable medial meniscal tear and/or visible osteoarthritis (OA) in the medial tibiofemoral joint. Thus, assessment for the presence of varus malalignment is important in caring for patients in whom revision ACL reconstruction is considered.

Background Selective bundle anterior cruciate ligament (ACL) reconstruction and/or remnant ACL preservation may be reasonable options for some patients. However, the frequency of isolated anteromedial (AM) or posterolateral (PL) bundle injuries in patients undergoing ACL reconstruction is unknown, and the value of MRI for prediction of this injury pattern is likewise unknown.

In studies of TKA, treating each knee as an independent case in patients with bilateral TKAs can lead to errors, because patients with bilateral and unilateral TKAs may achieve different levels of function and because the assumption of statistical independence is violated.We determined whether (1) patients undergoing bilateral TKAs have different demographics and preoperative and postoperative function from those undergoing unilateral TKAs, and (2) means, SEs, and p values change substantially based on how the two cases of bilateral TKAs are treated in statistical analyses.We retrospectively compared 513 patients undergoing unilateral TKAs and 602 patients undergoing bilateral TKAs regarding demographics (age, gender, BMI), preoperative and 1-year postoperative function (motion arc, American Knee Society score, patellofemoral score, WOMAC(TM), SF-36). Each case of a bilateral TKA was treated as independent in the reference analyses. Then changes of mean, SEs, and p values were compared with those of the reference method when three other methods of analysis were used: using mean values of both knees, randomly selecting one side, and using a generalized estimating equation.Patients undergoing bilateral TKAs had higher female predominance (95% versus 90%) and BMI (27.4 versus 26.1 kg/m(2)) than those undergoing unilateral TKAs. Although patients undergoing bilateral TKAs had worse preoperative function, they achieved comparable function at 1 year. The mean values did not differ considerably depending on the four methods. The SEs and p values of the reference method were generally the smallest, but the differences appeared negligible.Our analyses suggest bilaterality can be ignored in the analysis of TKA, since postoperative function is comparable between unilateral and bilateral TKAs and the theoretical errors in statistical analysis had little effect on the results.

The purpose of this study was to examine a developed surgical technique by performing a mid-term evaluation of clinical and stability results and complications.Thirty patients who underwent transtibial posterior cruciate ligament (PCL) reconstruction using a bioabsorbable cross-pin tibial back side fixation method were enrolled in this prospective study. Lysholm and International Knee Documentation Committee (IKDC) knee scales were used to evaluate clinical outcomes. Stability was evaluated using a Telos device with a 150 N force at 90 degrees of knee flexion. Follow-up magnetic resonance imaging (MRI) was also performed in 20 (66.7%) patients, and complications were evaluated. Those with complication by MRI were assigned to an abnormal MRI group.The follow-up period was 47 (range, 25-62) months. On comparing preoperative and final follow-up clinical results, Lysholm and IKDC knee scale scores were found to have improved significantly (P 0.001). The mean side-to-side difference in posterior translation measured using a Telos device was 13.4 ± 3.1 mm (range 10-20 mm) preoperatively and 3.2 ± 1.5 mm (range 1-7 mm) at last follow-up, which represented a significant improvement in stability (P 0.001). Five patients showed cyst formation in the tibial tunnel and two patients showed a significant signal increase at the anterior portion of the tibial tunnel, which was believed to indicate a pro-cystic status. The normal and abnormal MRI groups had similar Lysholm and IKDC knee scale scores and stress radiographs (P 0.05).Single-bundle transtibial PCL reconstruction using a bioabsorbable cross-pin tibial back side fixation was found to produce satisfactory clinical and stability results. However, despite these satisfactory results, a potential complication of tibial cyst formation was observed.Case series, Level IV.

The purpose of this study was to evaluate the accuracy of the characteristic magnetic resonance imaging (MRI) findings of medial meniscal root tear in the coronal, sagittal and axial planes. Thirty arthroscopically diagnosed patients who had undergone preoperative knee MRI were included in this study. They were compared to 30 age-matched patients with medial meniscus tears without root tears. The findings used for imaging analysis were as follows: the radial tear on the meniscal root of the medial meniscus in the axial plane, the presence of the truncation sign in the coronal plane and the ghost meniscus sign in the sagittal plane. Meniscal extrusion in the coronal plane was also evaluated. All the MRI findings of both groups were statistically analyzed. All the findings were more frequently found in the root tear group than those in the control group (P

Background: The correlation between graft appearance and clinical outcome after double-bundle anterior cruciate ligament (ACL) reconstruction is a major concern. In this study, the graft appearance was assessed with use of second-look arthroscopy and was correlated with the clinical outcome. Overall clinical outcomes after double-bundle ACL reconstruction with use of a single tibial tunnel were analyzed. Methods: Thirty-seven knees that underwent second-look arthroscopy after double-bundle ACL reconstruction and sixty-two knees that underwent double-bundle ACL reconstruction without subsequent second-look arthroscopy were included in this retrospective study. The ninety-nine patients enrolled were followed for thirty-five months (range, twenty-four to fifty-eight months), and the mean duration from ACL reconstruction to second-look arthroscopy was twenty-five months (range, twelve to thirty-six months). Graft thickness, apparent graft tension, and synovial coverage were graded during second-look arthroscopy. Correlations were sought between graft appearance and Lysholm knee scores, International Knee Documentation Committee (IKDC) grades, anterior laxity, and pivot-shift test results. Results: Postoperatively, ninety-four (94.9%) of the ninety-nine knees had an IKDC rating of B or higher, mean anterior laxity was 1.29 mm (range, 0 to 6 mm), and ninety-two knees (92.9%) had a negative pivot-shift result. With regard to graft thickness and tension, anteromedial bundles were graded as A in twenty-eight (75.7%) of the thirty-seven second-look knees and as B in nine knees (24.3%). Posterolateral bundles were graded as A in twenty-five knees (67.6%), B in six knees (16.2%), and C in six knees (16.2%). With regard to synovial coverage, anteromedial bundles were graded as C in only two knees (5.4%) and posterolateral bundles were graded as C in six knees (16.2%). No correlation was found between graft appearance and clinical outcome. Conclusions: In the present study, we observed that clinical outcomes were as satisfactory with a single tibial tunnel as with two tibial tunnels. However, more tears and poorer synovial coverage were observed for posterolateral than for anteromedial bundles during second-look arthroscopy. No significant correlation was found between graft appearance and clinical outcome. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Introduction][1] We describe a surgical release for patients who have a lack of elbow flexion limiting the ability to perform activities of daily living after trauma. ![Figure][2] ![Figure][2] [Step 1: Mobilize the Ulnar Nerve][3] Mobilize the ulnar nerve through the cubital tunnel with the accompanying superior ulnar collateral vessels. ![Figure][2] [Step 2: Dissect the Triceps and Resect the Posterior Aspect of the Capsule][4] Dissect the triceps from the distal part of the humerus and resect the posterior aspect of the capsule to expose the olecranon tip and fossa. ![Figure][2] [Step 3: Resect the Posterior Band of the Medial Collateral Ligament][5] Release the posterior band of the medial collateral ligament while continually checking the flexion arc until >130° of flexion can be achieved. ![Figure][2] [Step 4: Resect the Anterior Aspect of the Capsule][6] Perform an anterior approach if there is persistent flexion contracture or any impingement restricting full flexion. [Step 5: Lengthen the Triceps If Indicated][7] Consider triceps lengthening if you cannot achieve >130° of passive flexion with two fingers. ![Figure][2] [Step 6: Transpose the Ulnar Nerve Anteriorly][8] Locate the released ulnar nerve over the medial humeral epicondyle on the fascia overlying the common flexor-pronator muscles. [Step 7: Postoperative Management][9] Physical therapy consists of active-assisted and gentle passive flexion and extension exercises of the elbow, usually for two to six months. [Results][10] Forty-two patients with 130° of flexion can be achieved. ![Figure][2] [Step 4: Resect the Anterior Aspect of the Capsule][6] Perform an anterior approach if there is persistent flexion contracture or any impingement restricting full flexion. [Step 5: Lengthen the Triceps If Indicated][7] Consider triceps lengthening if you cannot achieve >130° of passive flexion with two fingers. ![Figure][2] [Step 6: Transpose the Ulnar Nerve Anteriorly][8] Locate the released ulnar nerve over the medial humeral epicondyle on the fascia overlying the common flexor-pronator muscles. [Step 7: Postoperative Management][9] Physical therapy consists of active-assisted and gentle passive flexion and extension exercises of the elbow, usually for two to six months. [Results][10] Forty-two patients with

This study examined whether or not conservative treatment of an acutely injured anterior cruciate ligament (ACL) could be successful in a select group of patients. Routine ACL reconstruction surgery in all acute ACL-injured patients should be avoided. We hypothesize that acutely injured ACL with mild instability at the initial physical examination could be improved even if there is disruption of ACL fibers on magnetic resonance images (MRI).Among 232 acute ACL-injured patients who visited our institution from March 1997 to April 2006, 48 were treated non-operatively. Patients diagnosed with an acute ACL injury by MRI with Lachman testor =grade 1 were treated non-operatively. In this study, 30 male and 18 female patients with a mean age of 31.8 years were enrolled. The initial and follow-up Lachman test and pivot shift test were performed 3 weeks after the injury. The Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) score and KT-2000 were obtained at the last follow-up.There were 12 complete (25%) and 36 incomplete ACL ruptures (75%). The patients were followed up clinically and with MRI for 21.5 and 11.3 months, respectively. The follow-up Lachman test improved to grade 0 in 41 patients (87%). Thirty-six patients (76%) showed no laxity in the follow-up pivot shift test. The last follow-up IKDC score was a mean value of 91.1 points. KT 2000 was performed in 40 patients with a mean side-to-side difference of 2.85 mm. Of 48 patients, 46 showed restored ACL continuity and 39 (84%) showed restored low signal intensity on MRI.A selective group of ACL tears with mild instability (Lachmanor =grade 1), though these seem to be complete tears on MRI, can show restoration of their continuity and signals on the MRI. Joint laxity on physical examination was improved at follow-up. These results suggest that a select group of patients with an acute ACL injury can successfully undergo non-operative treatment. In addition, unnecessary early ACL reconstruction surgery should be avoided.

The purpose of this study was to assess the correlations between dynamic postural stability and muscle strength, anterior instability, and knee scores in anterior cruciate ligament (ACL) deficient knees.We examined 40 male patients with ACL injury prior to surgery. Maximal torques of flexors and extensors of the injured knee at 60 and 180 degrees /s were evaluated using an isokinetic testing device. Anterior translations of the tibia were measured using a KT-2000 arthrometer, and dynamic postural stabilities were measured during single-leg stance using the Biodex Stability System (BSS). Knee statuses were evaluated using Lysholm and International Knee Documentation Committee (IKDC) knee scores. Correlations between dynamic postural stability and muscle strength, anterior instability, and knee scores were determined.Significant correlations were found between maximal torques of the extensor of injured knees at 60 and 180 degrees /s (r = -0.52, p = 0.048 and r = -0.46, p = 0.019, respectively) and dynamic postural stability, and maximal torques of flexors of injured knees showed similar relations (r = -0.51, p = 0.0048 and r = -0.47, p = 0.016, respectively). Lysholm and IKDC knee scores were also found to be correlated with dynamic postural stability (r = -0.49, p = 0.001 and r = -0.52, p = 0.005, respectively). However, no correlation was found between grade of anterior translation measured using the KT-2000 arthrometer and dynamic postural stability (p = 1.0).Dynamic postural stability determined using the BSS appears to be influenced by muscle strength, as determined by isokinetic testing, but not with grade of anterior translation measured using a KT-2000 arthrometer. Subjective knee scores appear to improve in parallel with dynamic postural stability.

BackgroundTears of the medial meniscus posterior horn (MMPH) are frequently found in knees with deficient anterior cruciate ligaments (ACLs). There are few studies that have evaluated healing of the menisci and the factors associated with healing.HypothesisThe repaired menisci would show good healing in the knees with reconstructed ACLs, and the healing capacity of the menisci would differ according to the size, type, and location of the tear as well as the age and gender.Study DesignCase series; Level of evidence, 4.MethodsFrom August 1997 to February 2007, 311 knees underwent MMPH repair using either a modified all-inside or inside-out technique with concomitant ACL reconstruction. Among these patients, a second-look arthroscopy was performed at a mean of 37.7 months postoperatively (range, 12-128 months) in 140 patients. Clinical parameters and outcomes were evaluated. The repaired menisci were divided into complete, incomplete, and failure-to-heal groups. The factors associated with meniscal healing were statistically assessed.ResultsAmong 140 patients, 118 (84.3%) showed complete healing, 17 (12.1%) had incomplete healing, and 5 (3.6%) failed to heal. The clinical success rate was 96.4% (135/140) because patients in the incomplete group showed no clinical symptoms associated with meniscal tears. Healing was associated with the tear location (P < .001) and type of tear (P = .0237) on the univariate analysis and the location (P = .0401) only on the multivariate analysis.ConclusionRepaired MMPH tears in knees with reconstructed ACLs healed without complications and had satisfactory clinical results. The tear location and type were factors associated with healing on the univariate analysis and location only on the multivariate analysis.

Purpose To evaluate the effectiveness of all-inside repair of posterior lateral meniscus root full-thickness tears with preoperative and postoperative magnetic resonance imaging (MRI) and to propose a system of classifying posterior lateral meniscus root tears. Methods From June 2003 to March 2007, 27 (6.95%) of a consecutive series of 388 anterior cruciate ligament reconstructions had a concomitant posterior lateral meniscus root tear. Of the patients, 25 (92.6%) were followed up for a more than 1 year. There were 22 male and 3 female patients, with a mean age of 28.8 years. The mean timing of surgery after injury was 40.8 months. The preoperative and postoperative MRI scans were analyzed and compared. We classified posterior lateral meniscus root tears according to arthroscopic findings. Results There was no postoperative effusion, joint-line tenderness, or positive McMurray provocation testing observed at the last follow-up. No statistically significant improvement was observed in the coronal plane in the 18 follow-up MRI scans ( P = .096); however, sagittal extrusion improved significantly ( P = .007). Posterior lateral meniscus root tears were classified based on arthroscopic findings: type I, oblique flap; type II, T shape; type III, longitudinal cleavage; or type IV, chronic inner loss. A type I tear was found in 7 patients, type II in 4, type III in 4, and type IV in 10. Conclusions After repair of posterior lateral meniscus root tears, MRI showed that the displaced lateral meniscus was reduced, mainly in the sagittal plane. Posterior lateral meniscus root tears were classified based on arthroscopic findings: type I, oblique flap; type II, T shape; type III, longitudinal cleavage; or type IV, chronic inner loss. Level of Evidence Level IV, therapeutic case series.

We sought to determine the usefulness and the disadvantages of the navigation in medial opening wedge high tibial osteotomy (MOWHTO) compared to the conventional technique, in terms of target coronal alignment achievement, tibial slope maintenance, radiation exposure and operative time. We retrospectively compared 40 knees treated with navigated MOWHTO by one surgeon with 20 knees treated with conventional MOWHTO by another surgeon. Screw length of the plate was predetermined using validated simple algorithms only in the navigation group to facilitate the operation. The acceptable range of the postoperative coronal alignment was defined as 2°–6° of the mechanical tibiofemoral angle (mTFA) and 55 %–70 % of the weight loading line coordinate (WLL). The proportion of the coronal alignment outlier, posterior tibial slope change, fluoroscopy time and operative time were compared. The coronal alignment outliers were fewer in the navigation group, but the differences were not significant (mTFA outlier 18 % vs. 30 %, p = 0.326; WLL outlier 20 % vs. 30 %, p = 0.519). Tibial slope was maintained in the navigation group (+0.3°, p = 0.732), whereas increased in the conventional group (+3°, p

Background Magnetic resonance imaging (MRI) may be useful to diagnose a posterolateral plica syndrome of the elbow joint because this syndrome has less clear clinical features. The purposes of this study were to document mediolateral and sagittal dimensions of a posterolateral synovial fold and to determine the proportion of subjects with the posterolateral plica in asymptomatic elbows. We also aimed to determine whether the dimensions of the posterolateral synovial fold and the prevalence of the plica differ between symptomatic and asymptomatic subjects. Materials and methods This retrospective review of prospectively collected data included 50 asymptomatic elbows (asymptomatic group) and 14 elbows with arthroscopically confirmed posterolateral plicae (plica group). The mediolateral and sagittal dimensions of the posterolateral synovial fold were measured. In addition, the criteria for the prevalence of posterolateral plica was determined with conventional MRI as synovial fold dimension ≥ 3 mm and coverage of radial head by synovial fold ≥ 30%. Results The plica group showed larger posterolateral synovial fold dimensions compared to the asymptomatic group. The median mediolateral and sagittal dimensions of the synovial fold in the asymptomatic group were 3.8 mm and 4.7 mm, respectively. Dimensions in the plica group were 7.0 mm and 7.4 mm, respectively. When the presence of posterolateral plica was determined using the dimension criteria, there was no difference in the prevalence of the plica between the asymptomatic and the plica group. However, using the coverage criteria, the prevalence of posterolateral elbow plica was significantly greater in the plica group than the asymptomatic group (64% vs. 18%; p < 0.001). Conclusions The patients who underwent arthroscopic surgery for posterolateral plica syndrome had larger dimensions of the posterolateral synovial fold and higher prevalence of the posterolateral plica on conventional MRI compared to the asymptomatic subjects.

The aim of this study was to determine whether pain intensity and wound complication rates differ between patients with and without preservation of the infrapatellar fat pad (IPFP) after minimally invasive total knee arthroplasty (TKA). The authors also sought to determine whether IPFP preservation affects operation time.This retrospective study included 448 knees with primary TKA. The IPFP was totally resected in 201 knees (IPFP-R group), and was preserved in 247 knees (IPFP-P group). Pain score was determined using the visual analog scale during the first 72 h after surgery. Wound complication rates and operation times were also evaluated. A wound complication was defined as persistent wound drainage for three or more days after surgery.There was no difference in pain levels between the two groups. However, there were fewer wound complications in the IPFP-P group (3 %) than in the IPFP-R group (13 %). The operation time was longer in the IPFP-P group than in the IPFP-R group (70 vs. 64 min, respectively).Although IPFP preservation delayed operation time, it decreased wound complications after MIS TKA. These findings are important to consider when deciding whether or not to resect the IPFP. Whenever possible, IPFP preservation is probably the preferred technique to reduce wound complications.

In total knee arthroplasty (TKA), the gap expansion effect by soft tissue laxity and bone resection amount influence directly on the proper gap size and ideal polyethylene insert thickness. In this study, we hypothesized if bone resection level could be controlled lesser as gap expansion effect resulted in the effects on gap expansion of the collateral release and lax lateral structure, appropriate gap size would be attained without extensive medial soft tissue release even in severe varus deformed knee. The purpose of this study was to show the usefulness of preoperative calculation of soft tissue laxity for determining the appropriate gap size for the targeted PE thickness in TKA. The preoperative varus stress view was used to estimate the effect of soft tissue release on extension gap expansion after primary bone resection. The amount of bone resection was determined with a parallel bone resection device used in our institution. Lateral laxity amount was applied into the device. This study was a retrospective review of 850 TKAs [451 with

Instability following total knee arthroplasty is one of the major causes of revision surgery. In most cases, it can be prevented by using an appropriate prosthesis and a good surgical technique. Particular attention should be given to confirmation of diagnosis for which thorough history taking, complete physical examination and radiographic evaluation are needed. With regard to treatment, identification of the etiology of instability is crucial for establishing proper treatment plans; instability would persist without correction of the cause of the initial instability. For successful revision surgery, balanced medio-lateral and flexion-extension gaps should be achieved. Constrained or rotating-hinge total knee prosthesis should also be considered as an alternative option for certain subsets of patients with instability.

Pseudo-patella baja (PPB) is a surgical complication that can arise from total knee arthroplasty and occurs when the patella tendon is not shortened but the level of the femorotibial joint line is elevated. The goal of this study was to assess the performance of a technique specifically designed to prevent the occurrence of PPB and its radiological results.Ninety-nine patients undergoing total knee arthroplasty were included. Patients were divided into a non-correction group and a correction group. The correction group were applied an additional metal block in order to reduce the excess resection of the distal femur. To evaluate PPB, the change in the pre- and postoperative joint line was measured using the modified Blackburne-Peel Index (BPI).In the non-correction group, 68 of 74 cases showed an occurrence of PPB (92 %), in the correction group, 6 of 57 cases showed an occurrence of PPB (11 %). The preoperative-modified BPI of the non-correction group was not significantly different from that of the correction group (0.6 ± 0.1 vs. 0.6 ± 0.2). The modified BPI decreased significantly in the non-correction group after TKA (0.6 ± 0.1 vs. 0.2 ± 0.1, p0.05). However, the modified BPI did not change significantly in the correction group after TKA (0.6 ± 0.2 vs. 0.6 ± 0.2).The comparison of preoperative and postoperative radiological results showed that our intervention maintained the joint line without elevation. We proposed an effective method to prevent various complications due to the joint line elevation that occur in PPB.III.

The objective of this retrospective review of 466 patients was to document changes in limb length, leg length discrepancy (LLD), height, weight, and body mass index (BMI) 1 year after TKA and the patterns of height, weight, and BMI during 5 years. To determine change patterns over 5 years, the data of 291 patients were analyzed and compared with those of age and gender-matched normal subjects. Limb length, height, and weight increased, BMI remained unchanged, and LLD decreased 1 year after TKA. The bilateral group had a greater height increase and lower rate of LLD. Preoperative mechanical tibiofemoral angle was related to limb length increase, and patients with a smaller preoperative BMI showed more weight gain. During the 5 years, weight and BMI at 1 year were maintained, but height diminished, while the healthy population showed a decreasing trend in weight.

Purpose The primary aim was to determine the rate and risk factors of double biodegradable femoral cross-pin breakage after anterior cruciate ligament reconstruction using a hamstring autograft. In addition, we compared clinical outcomes and magnetic resonance imaging (MRI) findings related to grafts for knees with and without a broken cross-pin. Methods A retrospective review of 53 knees (53 patients) was performed. Cross-pin breakage was determined by follow-up MRI. Age, sex, weight, height, presence of a posterior transcortical cross-pin breach, time between surgery and follow-up MRI, graft diameter, and cross-pin position (superior or inferior) were included in the analysis. Differences in Lysholm knee scores, International Knee Documentation Committee grades, anterior laxity, and pivot-shift test results were examined in relation to cross-pin breakage. In addition, anterior cruciate ligament graft integrity and osseous graft integration by MRI were assessed and compared between knees with broken cross-pins and knees with intact cross-pins. Results A cross-pin was broken in 25 of 53 knees. A cross-pin posterior transcortical breach was the only factor found to be significantly correlated with cross-pin breakage (odds ratio, 6.117; P = .033) by univariate analysis. No significant differences in clinical outcomes were found to be related to cross-pin breakage, but femoral tunnel enlargement was more frequent in knees with breakage than in those without ( P = .002). Conclusions Breakage of biodegradable cross-pins used for femoral fixation is relatively common but did not affect clinical outcomes. However, femoral tunnel enlargement was found to be greater in knees with a broken cross-pin. The only significant relation found was between a cross-pin posterior transcortical breach and breakage, which suggests that pin breakage is related to a technical error. These findings should be borne in mind when a double biodegradable cross-pin is being considered for femoral fixation. Level of Evidence Level IV, therapeutic case series.

Anomalies associated with a discoid medial meniscus have been described. However, the clinical relevance of these anomalies has not been previously reported. Therefore, we report the clinical relevance of some of these anomalies based on our experience with a 21-year-old soldier with a 3-month history of medial right knee pain. Magnetic resonance imaging (MRI) revealed bilateral discoid medial menisci, cupping of the medial tibial plateau, and an abnormal anteroinferior transposition of the anterior horn of the meniscus. Partial meniscectomy was performed in the usual manner and the meniscus reshaped, including its anteromedial corner. Six weeks postoperatively, the patient reported knee pain. Follow-up MRI showed that the anteromedial edge of the cup shaped tibial plateau directly contacted the femoral condyle and subchondral signal changes at the contact point. Several reports have addressed subluxation or dislocation of the anterior horn of the medial meniscus. However, the clinical significance of these lesions has not been clearly defined. In our case, however, subluxation of the anterior horn was combined with a discoid medial meniscus and cupping of the tibial plateau, which may have increased contact stress between the tibia and femur. Our experience suggests that in cases with combined anomalies, anteroinferior transposition of the anterior horn of the discoid medial meniscus, and cupping of the tibial plateau, trimming of the anteromedial corner should be performed conservatively, because even minimal trimming or reshaping of anteromedial corner of the meniscus can cause direct bone-to-bone contact due to insufficient anterior coverage.

We studied 75 primary total knee arthroplasties (TKAs) performed using a single-radius, high-flex posterior-stabilized insert design with a minimum 5-year follow-up to document its implant specific complications and clinical results. Nonprogressive osteolysis was observed at zone 4 of the femoral component in 6 knees (8%) and at zone 1 of the tibial component in 6 knees (8%). However, no complications associated with high flexion designs, such as early aseptic loosening, were observed. Preoperatively, mean Knee Society Knee Score and Knee Society Function Score were 55.1 and 45.5, respectively (range, 10–83 and 20–80, respectively). At last follow-up, mean Knee Society Knee Score and Knee Society Function Score improved to 94.9 and 85.9, respectively (range, 70–100 [ P P P P P =.0020) and multivariate analysis ( P