Retro-Tubercle Biplanar Opening Wedge High Tibial Osteotomy Is Favorable for the Patellofemoral Joint But Not for the Osteotomized Tubercle Itself Compared With Supra-Tubercle Osteotomy.

PURPOSE: To identify whether retro-tubercle opening-wedge high tibial osteotomy (RT-OWHTO) produces more favorable radiographic outcomes on patellofemoral joint alignment and clinical outcomes than supra-tubercle opening-wedge high tibial osteotomy (ST-OWHTO). METHODS: From January 2017 to July 2018, patients who underwent biplanar OWHTO were allocated to 1 of 2 groups (ST-OWHTO and RT-OWHTO). Plain radiographs and computed tomography were used to analyze patellofemoral alignment and other radiologic parameters representing osteotomy configurations. Clinical outcomes were assessed using American Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: In total, 50 knees that underwent ST-OWHTO and 44 knees that underwent RT-OWHTO were enrolled. Patellar height was significantly decreased only after ST-OWHTO (Caton-Deschamps ratio: P = .007; Blackburne-Peel ratio: P = .012). Patellar tilt angle was decreased in both groups (P = .009 and .004, respectively). Postoperative posterior tibial slope (PTS) (P = .013), PTS (Δ) (P < .001), retro-tuberosity gap distance (P = .001), and retro-tuberosity tip distance (P = .001) were significantly larger in RT-OWHTO. Retro-tuberosity tip distance was significantly correlated with retro-tuberosity gap distance (P = .002), thickness of second plane osteotomy fragment (P = .027), and anterior osteotomy ratio (P = .031) in ST-OWHTO. In RT-OWHTO, it was significantly correlated with PTS (△) (P < .001), retro-tuberosity gap distance (P < .001), and sagittal angle of bi-planar osteotomy (P = .005). There were 2 cases of tibial tuberosity fracture, 9 cases of delayed union on second plane osteotomy and 5 cases of tuberosity protrusion in RT-OWHTO. CONCLUSIONS: Although the RT-OWHTO technique maintains patellofemoral joint alignment, no difference in clinical outcome was detected. The RT-OWHTO has increased risk of tuberosity fracture, delayed union, and prominent tibial tuberosity. The surgeon should consider these negative aspects of the technique and consider adjusting additional stabilization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Difference of preoperative varus-valgus stress radiograph is effective for the correction accuracy in the preoperative planning during open-wedge high tibial osteotomy.

PURPOSE: This study aimed to evaluate (1) the efficacy of varus-valgus stress radiographs to adjust the preoperative soft-tissue imbalance and (2) ascertain whether varus-valgus stress radiographs are effective for the correction accuracy in the preoperative planning of the opening wedge high tibial osteotomy (OWHTO). METHODS: From February 2017 to December 2018, a total of 121 consecutive knees that underwent bi-planar OWHTO were enrolled in this retrospective analysis. Preoperative planning was performed using a weight-bearing line (WBL). Target WBL was determined according to the status of the medial compartments such as cartilage, meniscus, and preoperative arthritic grade. Preoperative varus-valgus stress radiographs were used to assess the preoperative mediolateral ligament imbalance. The final target correction length of the opening gap was determined by subtracting the difference between the varus-valgus stress radiographs (VVD). All patients were divided into two groups according to the preoperatively planned correction degree: (group A), smaller than average; (group B), larger than average. Patients were also divided into two other groups (VVD adjusted and neglected groups). RESULTS: Groups A and B were 56 and 54 knees, respectively. The preoperatively planned correction lengths of the opening gap were 9.33 ± 1.5 and 14.16 ± 3.96 mm, respectively (p < 0.01). Mean values of the VVD were 0.85 ± 0.72, and 1.27 ± 1.78 mm, respectively (p < 0.01). Correction errors were 2.17 ± 2.06 and 3.52 ± 2.16%, respectively (p < 0.01). Planned and final correction degrees were also significantly larger (p < 0.01, and p < 0.01, respectively), because the preoperative WBL ratio was significantly smaller in the VVD adjusted group (p < 0.01). CONCLUSION: The VVD values could reproduce the preoperative soft-tissue imbalance and it was more prominent as the correction degree increased. The strategy of subtracting the VVD as assumed soft-tissue imbalance in the preoperative planning worked well for the correction accuracy during OWHTO. LEVEL OF EVIDENCE: Level IV, retrospective study.

Comparison of postoperative pain control methods after bony surgery in the foot and ankle.

BACKGROUND: We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. METHODS: Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. RESULTS: The mean VAS pain score was lower in group B, with a statistically significant difference (P<.05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. CONCLUSION: The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. LEVEL OF EVIDENCE: II.

The Fate of Bone Marrow Lesions After Open Wedge High Tibial Osteotomy: A Comparison Between Knees With Primary Osteoarthritis and Subchondral Insufficiency Fractures.

BACKGROUND: Subchondral insufficiency fracture of the knee (SIFK) is characterized by a subchondral lesion that may lead to end-stage osteoarthritis (OA). In patients who have SIFK in a precollapse state with varus malalignment, a joint-preserving technique such as open wedge high tibial osteotomy (OWHTO) should be considered. PURPOSE: To evaluate the efficacy of OWHTO in primary OA and SIFK-dominant OA by clinical and radiological evaluations including magnetic resonance imaging (MRI). STUDY DESIGN: Cohort study; Level of evidence 3. METHODS: A total of 33 SIFK-dominant OA knees and 66 with primary OA that underwent biplanar OWHTO between March 2014 and February 2016 were included after 1:2 propensity score matching. The MRI Osteoarthritis Knee Score was used to assess bone marrow lesions (BMLs) preoperatively and at follow-up. The weightbearing line ratio, the hip-knee-ankle angle, and the joint line convergence angle were measured. The clinical outcomes assessed were range of motion, the American Knee Society Score, and the Western Ontario and McMaster University (WOMAC) score. RESULTS: The mean follow-up period was 41.2 ± 12.6 months. The distribution of preoperative BML grade in the SIFK-dominant OA group was significantly higher in both the femur and tibia (P < .001 and <.001, respectively) than that in the primary OA group. However, the difference was not significant postoperatively (femur, P = .425; tibia, P = .462). In both groups, postoperative BMLs showed significant improvement compared with preoperative BMLs (primary OA [femur, P < .001; tibia, P = .001] and SIFK-dominant OA [femur, P < .001; tibia, P < .001]). The WOMAC pain score was higher in the SIFK-dominant OA group preoperatively (primary OA, 7.0 ± 3.73; SIFK-dominant OA, 9.17 ± 2.6; P = .032) even though it was not different at the final follow-up (primary OA, 2.11 ± 1.7; SIFK-dominant OA, 1.79 ± 1.32; P = .179). CONCLUSION: OWHTO is an effective procedure not only for primary OA but also for SIFK-dominant OA. OWHTO can improve BMLs, which represent the main pathological feature of SIFK. Therefore, in patients who have SIFK with varus malalignment, OWHTO can be an attractive treatment option for preserving the joint and enhancing subchondral bone healing.

Prediction and Development of Preventive Strategies for Lateral Hinge Fracture During Opening Wedge High Tibial Osteotomy Based on Osteotomy Configurations.

BACKGROUND: Lateral hinge fracture (LHF) is a major complication of opening wedge high tibial osteotomy (OWHTO) and may result in poor outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to develop preventive strategies by identifying factors that affect LHFs. We hypothesized that (1) each LHF type would have different affecting factors and that (2) specific operative strategies that can contribute to the prevention of each LHF type can be developed. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We retrospectively analyzed 261 consecutive knees treated with biplanar OWHTO between March 2014 and December 2017. Perioperative radiological variables that can affect LHFs were measured and divided into 2 categories: unmodifiable and modifiable. A regression model was developed, and subgroup analyses involving comparisons between the non-LHF group and each LHF group were performed. The weightbearing line (WBL) ratio was measured at 2 weeks and 1 year after surgery to determine the serial changes in each LHF type. RESULTS: A total of 66 knees (25.3%) were diagnosed with LHFs. From these, 26 (39.4%), 13 (19.7%), 15 (22.7%), and 12 (18.2%) showed type I, II, III, and I-variant LHFs, respectively. In the subgroup analysis, a larger posterior gap and distance X and a smaller fibular height (FH) were significant unmodifiable factors, while the retrotubercular thickness was a significant modifiable factor, for type I LHF. For type II LHF, a smaller lateral condylar slope and a larger distance X were significant unmodifiable factors, while the lateral distal fragment thickness and the osteotomy-condylar angle were significant modifiable factors. For type III LHF, a larger lateral condylar width and distance X and a smaller FH were significant unmodifiable factors, while the lateral proximal fragment thickness and the retrotubercular angle (RA) were significant modifiable factors. A smaller FH and a larger distance X were significant unmodifiable factors for type I-variant LHFs, while the lateral thickness ratio and the RA were significant modifiable factors. Between postoperative week 2 and 1 year, the WBL ratio decreased in cases with type I LHFs (P < .001) and increased in those with type II (P = .001) and type I-variant (P = .006) LHFs. CONCLUSION: Unmodifiable and modifiable factors for the development of LHFs after OWHTO differ among LHF types. To prevent LHFs, the causes of each LHF must be identified, the patient's specific geometry be considered in the preoperative planning, and the surgical technique be modified according to the modifiable factors. In addition, during the rehabilitation period after OWHTO, specific caution and close observation are necessary for alignment changes related to each LHF type.

Do optional implants improve the femoral fit during total knee arthroplasty in Asians? Comparison of the femoral fit between single- and dual-option implants.

BACKGROUND: The purpose of this study was to evaluate the femoral fit in Asian patients during total knee arthroplasty by examining whether (1) the advanced single-option implant improves the fit of the femoral component in both the anterior flange and distal cutting surface and (2) the dual-option implants show better fit than the advanced single-option implant. METHODS: A total of 950 knees that underwent primary total knee arthroplasty were included. Two types of single-option implant systems (Optetrak Logic and Truliant) and three types of dual-option implant systems (Anthem, Attune, and Persona) were used. The difference between the resected surface of the femur and femoral component dimensions was analyzed in predefined six zones. Appropriateness of fit (good-fit, over-hang, under-hang) was also evaluated. RESULTS: The advanced single-option implant showed higher rates of good-fit and lower rates of over-hang and under-hang in almost all distinct zones than the old version single-option implant. The advanced single-option implant demonstrated similar good-fit, higher over-hang and lower under-hang rates than the dual-option implants. All single-option implants showed significantly higher over-hang rate (P < 0.05) and lower under-hang rate (P < 0.05) than all dual-option implant systems in the anterior flange transverse area. The narrow option was only selected in 12-20% of all cases. CONCLUSIONS: The advanced single-option implant system improved the fit of the femoral component when compared with the old version and showed similar good-fit rates when compared with the dual-option implant systems. The narrow option of the dual-option implant systems was used less frequently than expected in Asian knees.

High frequency of gross deletions in the 5' LTR and gag regions in HIV type 1-infected long-term survivors treated with Korean red ginseng.

Our previous studies have shown that gross deletions in the nef gene as well as slow decreases in CD4 T cell numbers are associated with Korean red ginseng (KRG) intake in HIV-1-infected patients. To determine whether there might be an association between KRG intake and occurrence of gross deletions (gDelta) in the 5' LTR and gag regions, we examined the 1125 base pair (bp) sequences encompassing these regions in 10 long-term survivors (LTSs) treated with KRG (total of 13,364 +/- 5364 g) for > 12 years, and in 8 LTS control patients with no or minimal (total of 1436 +/- 1027 g) KRG intake (LTS controls). In the 10 LTSs, 189 PCR products were obtained from 80 peripheral blood mononuclear cell (PBMC) samples. In total, 44 of the 80 PBMC samples (55%) and 71 of the 189 PCR products (37.6%) displayed gDelta. While 55% of PBMC samples and 37.6% of PCR products showed gDelta in the 10 LTSs, the corresponding figures for the eight LTS controls were 30.3% and 14.8%. These differences were significant (p < 0.05 and p = 0, respectively). In addition, the proportions of 28 patients in the general population (without KRG intake) displaying PBMC and PCR gDelta were 13.3% and 8.3%, respectively. Our data strongly suggest that gDelta occurrence in the HIV-1 5' LTR and gag regions is associated with KRG intake.

New Technique for Removal of the Ulnar Intramedullary Nail Failed to Remove: Broken Assembly Piece in the Nail.

Methods about removal of intramedullary nail in complicated cases were reported in some literatures but there are no reports about nail removal in the ulna. The authors would like to report such a case and the technique. We removed bone of the inlet site and created another bony window using an osteotome to expose the interlocking screw holes. Only a bony window the size of 2 inter-interlocking holes at the most proximal part of the nail can be used to remove the nail with minimal damage of the triceps brachii tendon and soft tissue.

Phylogenetic analysis of full-length pol gene from Korean hemophiliacs and plasma donors infected with Korean subclade B of HIV type 1.

There was an outbreak of HIV-1 transmission among 20 out of 122 Korean hemophiliacs from 1990. We assessed the genetic relationships among HIV-1 viruses found in three cash-paid plasma donors whose preseroconversion plasma was used to produce Korean-made clotting factor, 20 hemophiliacs infected with HIV-1 in Korea, three hemophiliacs infected with HIV-1 from clotting factor manufactured outside Korea, and 71 local control patients infected with the Korean subclade of HIV-1 subtype B (KSB). Full-length pol gene sequences (2841 bp) of viruses from frozen stored serum, samples obtained 1-3 years after diagnosis, were amplified by RT-PCR and sequenced by direct DNA sequencing. Phylogenetic and signature pattern analyses were used to investigate the relationships among the sequences. Donors O and P were associated with two clusters, of 8 and 12 hemophiliacs, respectively, which were demarcated from the 71 KSB-infected local control patients and donor R. These data confirm that HIV-1 transmission to 20 hemophiliacs occurred through infusion of Korean-made clotting factor.

Frequent gross deletion in the HIV type 1 nef gene in hemophiliacs treated with Korean Red Ginseng: inhibition of detection by highly active antiretroviral therapy.

Twenty hemophiliacs were infected with Korean subclade B (KSB) of HIV-1 from two cash-paid plasma donors in Korea in 1990. Our previous studies revealed that Korean red ginseng (KRG) intake increases the frequency of gross deletion in the nef gene (gDeltanef). We investigated whether KRG and highly active antiretroviral therapy (HAART) affected the frequency of gDeltanef in the 20 hemophiliacs who share common characteristics of the HIV-1 source, mode of transmission, and infection time. Over a 10-year period, we obtained 522 nef amplicons by nested PCR using 172 samples of peripheral blood mononuclear cells. Of the 522 nef amplicons, 69 (13.2%) were gDeltanef. Despite a 2-fold higher monthly dose of KRG, the frequency of gDeltanef detection (3.2%) was significantly reduced during HAART compared with that prior to HAART (20.6%) (p < 0.001). gDeltanef was detected significantly more in patients treated with a monthly KRG intake of more than 60 g (26.8%) than in patients treated with a monthly KRG intake of less than 60 g (10.5%) (p < 0.05). These finding suggest that the frequency of gDeltanef is dependent on the amount of KRG intake, although further study is needed. These data might provide a new perspective on the pathogenesis of HIV-1.

Beneficial effects of a combination of Korean red ginseng and highly active antiretroviral therapy in human immunodeficiency virus type 1-infected patients.

To determine whether Korean red ginseng (KRG) has beneficial effects on human immunodeficiency virus type 1 (HIV-1)-infected patients administered highly active antiretroviral therapy (HAART), we analyzed the CD4 T-cell count, viral load, and resistance mutations to HAART in 46 individuals. Thirteen patients harbored resistance mutations at baseline. The study population was divided into two groups: specifically, a group treated with a combination of HAART plus KRG (23 patients) and a group treated with HAART alone (23 patients). The annual increase in CD4 T-cell count in the combination group was significantly higher than that in the group treated with HAART alone (P < 0.05). Overall, 21 patients harbored resistance mutations after 3 years of therapy. Following exclusion of 13 patients displaying baseline resistance mutations, 7.1% of patients (1/14) in the combination group and 42.1% (8/19) in the HAART group were identified with resistance mutations. One patient with baseline resistance mutations in the combination group did not display resistance mutations 3 years after HAART therapy. High-level resistance mutations were significantly lower in the combination group than in the group treated with HAART alone. Five patients showed no improvement in viral copy number (26.3% [5/19]) in the combination group and 9 (45.0% [9/20]) showed no improvement in the HAART-only group. Our data support the clinical utility of KRG intake during HAART therapy.

High frequency of gross deletions in 5' LTR/gag and nef genes in patients infected with CRF02_AG of HIV type 1 who survived for over 20 years: an association with Korean red ginseng.

Abstract We have shown that Korean red ginseng (KRG) intake is associated with gross deletions in the 5' LTR/gag (gDeltaLTR/gag) and nef genes (gDeltanef) of patients infected with subtype B of HIV-1. Here, we investigated these effects in three long-term survivors (LTSs) of subtype CRF02_AG of HIV-1. The three LTSs were diagnosed with HIV in 1987, 1988, and 1989, and have been treated with KRG for 7-15 years. Thirty-two samples of peripheral blood mononuclear cells were obtained from the subjects and used to amplify the 5' LTR/gag and nef genes via nested PCR. We obtained 88 amplicons in 5' LTR/gag and 128 amplicons in nef. The frequency of gDeltaLTR/gag was significantly higher (37.5%) in three LTSs than in control patients (8.6%, p < 0.01). Eight amplicons (9.5%) contained premature stop codon(s) in the gDeltaLTR/gag in three LTSs. Fourteen of the 128 nef amplicons (10.9%) contained the gDeltanef, which was present in only two (7.7%) of the 26 amplicons from control subjects. Interestingly, gDeltanef was detected 7 years after the reinitiation of KRG intake in an LTS and, coincidently, CD4 T cell counts and CD4/CD8 ratios rapidly increased. These data indicate that long-term intake of KRG has the therapeutic potential to induce gross deletions in HIV-1.

The effect of short-term exposure of triamcinolone acetonide on fibroblasts and retinal pigment epithelial cells.

PURPOSE: We investigated the effects of short-term exposure to triamcinolone on cultured choroidal fibroblast (CFB) cells and retinal pigment epithelial (RPE) cells. METHODS: To evaluate the effect of triamcinolone on cell proliferation, CFB and RPE cells were divided into three groups: a short-term exposure group; a longterm exposure group, and a non-treated control group. Cells in the short-term exposure group were briefly exposed (5, 15 or 30 mins) to triamcinolone (0.01 mg/ml, 1 mg/ml or mitomycin C (0.01 microg/ml, 1 microg/ml). Cells in the longterm exposure group were continuously incubated in culture medium containing the drug until assessment. The control group was cultured without drugs. Cell viability and the number of cells were assessed at day 5 after exposure. To investigate the direct toxicity of triamcinolone on confluent RPE cells, completely confluent cells were exposed to the drugs in the manner as described above. Cell viability was determined on days 0, 3 and 5 after treatment. RESULTS: In the short-term exposure group, 1 mg/ml triamcinolone caused a significant reduction in the proliferation of CFB and RPE cells. The proliferation of CFBs decreased even with exposure to 0.01 mg/ml triamcinolone. In the longterm exposure group, triamcinolone and mitomycin C reduced the proliferation of both CFB and RPE cells. Even very short periods of exposure to triamcinolone caused a significant reduction in the viability of completely confluent RPE cells. CONCLUSIONS: Even short periods of exposure to triamcinolone inhibited the proliferation of fibroblasts and RPE cells and were significantly toxic to completely confluent RPE cells.