Usefulness of the Kinect-V2 System for Determining the Global Gait Index to Assess Functional Recovery after Total Knee Arthroplasty.

OBJECTIVE: The Korean Knee Society (KKS) score is used for functional evaluation during follow-up after total knee arthroplasty (TKA), but it is time-consuming to measure and is limited by its subjective nature. We investigated whether the global gait asymmetry index (GGA) that can be obtained using the Kinect-V2 system could overcome the KKS limitations. METHODS: Forty-three patients who underwent TKA from January 2019 to December 2019 were included. Postoperatively, regular follow-up was performed at 2, 4, 6, 8, and 12 weeks, and at 4, 6, and 12 months. At each follow-up visit, the KKS was measured, and the walking path was followed with six Kinect-V2 systems. After allowing the participants to walk naturally, the range of motion of each joint of the lower extremity and GGA were obtained. Changes in the KKS and GGA scores and measurement times were investigated until the final follow-up. A statistical model was made to predict the KKS from the GGA score using data at all observed time points, and analysis of variance (ANOVA) with Turkey's post-hoc tests and Pearson correlation tests were used for evaluation. RESULTS: Both the KKS and GGA scores improved significantly from 4 weeks postoperatively until the final follow-up. The measurement time was significantly shorter for the GGA (9.3 ± 1.4 min) than for the KKS (32.4 ± 9.2 min; P < 0.001) score. The predicted and actual KKS values clustered close to a straight line on the scatter plot, but the prediction was less accurate in the initial stage (2 weeks post-surgery) than at later time points. The mean absolute error (MAE) and root mean square of the error (RMSE) were considered to be poorly predicted in the initial stage (8 weeks post-surgery) compared to the later time-points (MAE ≥ 5 and RMSE ≥ 6 for 8 weeks post-surgery). CONCLUSION: In the early phase after knee joint surgery (up to 12 weeks post-surgery), the GGA index does not predict the KKS well. However, after this time point, the GGA index can be simply measured in the outpatient department and may be able to replace the KKS. Thus, evaluation of the GGA index using the Kinect-V2 may be a useful method to evaluate functional recovery in the outpatient clinic after knee joint surgery.

A finite element analysis and cyclic load experiment on an additional transcortical-type hole formed around the proximal femoral nail system's distal locking screw.

BACKGROUND: A complication associated with the distal locking screw used in the proximal femoral nail (PFN) system is the formation of accidental additional holes. We hypothesized that an increase in stress around additional holes is a relevant factor contributing to fractures. This study aimed to evaluate stress changes in the cortical bone around additional screw holes using finite element analysis. METHODS: Proximal femoral nail antirotation (PFNA)-II (Synthes, Solothurn, Switzerland) was inserted into a femur model. An additional 4.9-mm transcortical hole was made either anteriorly (anterior hole model) or posteriorly (posterior hole model) to the distal locking screw. Finite element analysis was used to calculate compression, tension, and load limits to investigate stress around additional holes with respect to the direction of screw penetration and degree of osteoporosis. The results were then compared with those of mechanical testing. A 31A-21 type intertrochanteric fracture was applied. As a control group, a model without additional holes (no-hole model) was developed. Repeated load-loading tests were performed on 10 model bones per model group. RESULTS: Tensile stress was significantly greater in the no-hole model when additional screw holes were present, and the anterior hole showed a higher maximum stress value than the posterior hole, suggesting that the anterior hole was more susceptible to fracture. The change in tensile stress first appeared in the hole around the lateral cortical bone and proceeded to the medial side. Biomechanical testing showed that fractures around the distal locking screw occurred in 0 cases of the no-hole, 10 of the anterior hole, and 9 of the posterior hole models. CONCLUSIONS: During PFN surgery for intertrochanteric fracture, holes with distal locking screws fixed and removed at the anterior and posterior of the nail can be a risk factor for fractures in the surrounding area.

Screw penetration of the iliopsoas muscle causing late-onset pain after total hip arthroplasty: A case report.

BACKGROUND: Postoperative pain following total hip arthroplasty (THA) may occur in a few patients but may pose a significant challenge to surgeons if the etiology is not identified. Herein, we report the case of a patient who developed late-onset pain following THA due to screw penetration of the iliopsoas tendon. CASE SUMMARY: We report the case of a 77-year-old man who developed inguinal pain 7 years after THA. While the symptoms resembled that of iliopsoas impingement by the acetabular cup, the pain resolved only when the supplementary acetabular screw protruding through the ilium was decompressed. Decompression was performed using the pararectus approach. The patient was able to ambulate pain-free immediately after surgery. CONCLUSION: A protruded screw through the ilium may penetrate the iliopsoas muscle, causing pain following THA. Pain may resolve with the decompression of the protruded screw.

Is it advantageous to use the intraoperative compression option of proximal femoral nail antirotation in the treatment of osteoporotic intertrochanteric fractures? A retrospective comparative study.

OBJECTIVE: The aim of this study was to retrospectively compare the radiological and clinical results of intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA) that were either intraoperatively compressed or non-compressed. METHODS: Ninety-four patients (64 female, 30 male; mean age = 77.6 years; age range = 68-81) who underwent intraoperative fracture compression (IOFC) (94 hip joints, group A) and 88 patients (64 female, 24 male; mean age = 77.1 years; age range = 67- 80) who underwent postoperative impaction (POI) alone (88 hip joints, group B) from2012 to 2017 met the following six conditions were observed for over 2 years: AO Foundation/Orthopaedic Trauma Association 31-A1 and 31-A2 trochanteric fractures; Singh index grade ≥ 3; positive or neutral medial cortical support position with slightly valgus reduction; possible compression of more than one cortical bone in the anterior or medial region of the fracture site based on preoperative imaging test; blade position within the center-center; andtip-apex distance of < 25 mm. During the follow- up periods, changes of pain and time to fracture union were evaluated clinically, and the lateral extension distance (for screw back-up) was evaluated radiologically which measuredbetween the lateral end of the screw and lateral edge of the intramedullary nail. RESULTS: The mean follow-up was 38.4 (range = 24-48) months in Group A and 36.7 (24-48) months in Group B. The mean operation time was 68 (range = 40-100) min in group A and 71 (range = 40-105) min in Group B (P = 0.521). Intraoperative blood loss was 78 (range = 50-110) mL in Group A and 81 (range = 50-100) mL in Group B (p=0.715). The mean fluoroscopy time was 2.8 (range = 2.2-3.5) min in Group A and 2.6 (range = 2.1-3.5) min in Group B (P = 0.631). The acute phase pain scores measured by visual analog scale at postoperative 3 months were 35.5 in Group A and 37.6 in Group B (P = 0.073). The lateral extension of the PFNA blade showed significant difference at 24 months after surgery (Group A, 3.6±3.1 mm; group B, 7.8±3.7 mm, P = 0.017). Fracture gaps after surgery were 1.8 (range = 0.5-2.5)mmin Group A and 2.6 (range = 0.7-4.6)mmin Group B, showing significant difference (P = 0.001). The average fracture union time was 16.7 (range = 14-20) weeks in Group A) and 19.7 (range = 16-22) weeks in Group B (P = 0.065). The mean Harris Hip Scores at postoperative 24 months were 84.3 (range = 65-100) in Group A and 85.5 (range= 69-100) in Group B (P = 0.545).p Conclusion: If all the six conditions are met, IOFC seems to appropriate for AO/OTA 31-A1 and 31-A2 intertrochanteric fractures with the smaller postoperative fracture gap and lateral protrusion of the blade, which may contribute to the shortening of fracture union periods. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Bilateral Avascular Necrosis of the Femoral Head in a Patient with Asymptomatic Adrenal Incidentaloma.

Except when caused by direct and definite mechanisms (e.g., injury of the vessels to the femoral head), the pathophysiology of avascular necrosis of the femoral head has not yet been fully elucidate. While non-traumatic avascular necrosis of the femoral head is known to be caused by alcohol, steroids and various diseases, it may also occur without such events in a patient's history. Herein, a case of bilateral avascular necrosis of the femoral head caused by asymptomatic adrenal cortex incidentaloma which was initially misdiagnosed as idiopathic is reported along with a literature review.

Effect of surgical approach for contralateral side hip arthroplasty in below knee amputees: a retrospective cohort study.

BACKGROUND: The gluteus medius muscle plays a very important role in the stability of the gait, especially in patients with amputation of the lower limbs. Therefore, choosing the appropriate type of approach for hip arthroplasty is very important. Hence, this study aimed to compare the outcomes and complications between the anterolateral approach (ALA) and posterior approach (PA) for hip arthroplasty in patients with contralateral below knee amputation. METHODS: From January 1999 to November 2014, 67 patients who underwent hip arthroplasty with contralateral below knee amputation were retrospectively analyzed. The study subjects were divided into two groups: the PA group (33 cases) and the ALA group (34 cases). The results of the clinical functional recovery with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Harris Hip Score, and activity of daily living scale were compared between the two groups. During the follow-up period, complications related to gait such as fall, dislocation, and periprosthetic fractures (PPFs) were investigated. RESULTS: The Harris Hip Score (p = 0.024) and the activity of the daily living scale (p = 0.043) of the ALA group were significantly lower at 3 months compared to the PA group, but no significant difference was observed between the two groups from 6 months postoperatively to the last follow-up. The WOMAC score was not significantly different between the two groups. Within 3 months after surgery, falls occurred in 3 cases in the PA group and in 11 cases in the ALA group (p = 0.019) Dislocation and PPF were caused by prosthesis-related trauma. Two dislocations and 1 PPF occurred 8 years postoperatively in the PA group. PPF occurred in 3 patients in the ALA group, of which 2 occurred within 3 months after surgery. CONCLUSION: Orthopedic surgeons should pay particular attention in patients with hip arthroplasty on the contralateral side hip who had below knee amputation because functional recovery is delayed until 3 months after ALA compared with PA.

Mid-to long-term results of total hip arthroplasty after contralateral lower extremity amputation.

OBJECTIVE: There is limited literature concerning the outcomes and role of THA as a surgical option for amputee patients. The aim of this study is to determine the mid-to long-term survival and complication rates of cementless total hip arthroplasty (THA) in patients with contralateral below knee amputations. METHODS: A retrospective review of 54 patients with below knee amputation were perfomed who underwent THA for osteoarthritis of the contralateral hip over a 5-year period between 1999 and 2014. Patients were monitored for at least 5 years and assessed with the Harris Hip Score and activities of daily living scale and by evaluating migration or osteolysis around the acetabular cup and femoral stems (amputee group). The amputee group was compared with a control group (non-amputee group) with the same number of patients. RESULTS: Differences in the Harris Hip Score (p = 0.021) and activities of daily living scale (p = 0.043) between the two groups were statistically significant lower in the amputee group at 3 months after surgery. However, no differences were found between the groups from 6 months postoperatively to the last follow-up (Harris Hip Score p = 0.812, activities of daily living scale p = 0.885). Radiologically, any cups or stems showed no signs of migration or osteolysis. In the amputee group, dislocation was found in 1 patient 2 months after arthroplasty (p = 0.315) and long stem revision surgery were performed on two patients due to periprosthetic fracture (p = 0.153). CONCLUSIONS: THA performed on the contralateral side of patients with below knee amputation is considered to be an effective treatment with good clinical and radiological results at mid-to long-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study.

One-year Survival Rates and Functional Recovery in Veterans Who Suffer from Hip Fractures: Evaluation of Commissioned Hospitals' System through Comparison between Veterans Hospitals and Commissioned Hospitals.

PURPOSE: This study was performed to compare the: i) 1-year survival rate of patients with hip fractures, ii) factors affecting mortality in patients with hip fractures, and iii) results of functional recovery at commissioned hospitals (CH) and veterans hospitals (VH) to characterize the quality of care provided in the Korean commissioned hospital system. MATERIALS AND METHODS: The study population consisted of 183 veteran patients (84 and 99 treated at a single VH and 39 CH, respectively) who underwent hip fracture surgery between January 2010 and February 2015. This study compared baseline characteristics (i.e., age, comorbidities, fracture types and surgical treatment approaches) of the two groups vs. clinical outcomes, and evaluated the waiting time, length of hospital stay, total medical expenses, mortality rate within one year, and functional recovery at last follow up. RESULTS: There were no significant differences in age, fracture types, comorbidities, ambulatory status before fracture, waiting time, or length of hospital stay between the two groups, however, the total medical cost was higher in the CH group (P=0.009). There was no significant difference in mortality within one year after hip fracture (P=0.224) or functional recovery at last follow-up (P=0.463) between the two groups. CONCLUSION: The results of this study confirm that the Korean commissioned hospitals system is operating in accordance with its purpose. However, further studies are needed to better characterize the medical expenses of CHs vs. veterans hospitals.

Acute Arterial Occlusion Following Primary Total Knee Arthroplasty.

Acute arterial occlusion is a rare complication following total knee arthroplasty (TKA). This is a report of a case of acute femoral artery occlusion and its sequelae following TKA in a patient with a history of atrial fibrillation. Arterial circulation of the lower limb could not be restored by thrombectomy treatments, and above-knee amputation had to be carried out.

Clinical and Functional Outcomes of Treatment for Type A1 Intertrochanteric Femoral Fracture in Elderly Patients: Comparison of Dynamic Hip Screw and Proximal Femoral Nail Antirotation.

PURPOSE: We aimed to evaluate and compare the clinical and functional outcomes of dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA) treatment of AO type 1 intertrochanteric fractures in elderly patients. MATERIALS AND METHODS: We retrospectively reviewed 194 consecutive patients with type A1 intertrochanteric femoral fractures who were treated with DHS (n=113) or PFNA (n=81). We evaluated operation time, intraoperative blood loss, and functional outcomes, walking ability, and the Barthel activities index. Fracture union, sliding of hip screw, proximal femur shortening, and presence of complications were assessed radiologically at relevant follow-up intervals. RESULTS: The mean operation time and blood loss were significantly lower for the PFNA group, but walking ability and Barthel index decreased to a similar extent for both groups. However, patients in the DHS group complained of significantly more pain (P=0.049). Although there were no significant differences between the two groups with respect to the time until fracture union was achieved, patients in the DHS group exhibited a higher extent of proximal femoral shortening and sliding of the hip screw. Differences about hip screw sliding and proximal femur shortening within each subgroup were not significant. CONCLUSION: Compared to DHS treatment, PFNA treatment of type A1 intertrochanteric fractures is associated with reduced blood loss, shorter operation time, and less severe pain after surgery. Additionally, sliding of the hip screw and proximal femur shortening are expected to occur more frequently after DHS.

Surgical Treatment of Undisplaced Femur Neck Fractures in Dementia Patients Using Proximal Femoral Nail Antirotation.

PURPOSE: People with dementia have poor mobility and discharge outcomes following hip fractures. The purpose of this study was to evaluate the clinical and radiological results of internal fixation of undisplaced femur neck fractures (Garden types 1 and 2) by proximal femoral nail antirotation (PFNA) in dementia patients. MATERIALS AND METHODS: We studied retrospectively 19 patients with undisplaced femur neck fracture. All patients were over 70 years of age, walked independently with a cane or crutches and suffered moderate-to-severe dementia. Patients were treated with PFNA and followed-up for more than 2 years. Revision, loss of fixation, complications, and walking ability outcomes were measured. RESULTS: In walking-ability evaluation, patients showed an average decrease of just 0.2 points at the final follow-up. Walking ability was evaluated from before injury to 4 weeks after surgery and decreased by less than 0.5 points. Radiological bone union was achieved in 17 cases; the average time to bone union was 4.14 months (range, 2.5-7 months). Complications included non-union in two cases and femoral head avascular necrosis in one case of non-union. CONCLUSION: We found that for patients with osteoporotic bone tissues in their femoral heads or patients (e.g., those suffering dementia) for whom cooperating with medical workers for postoperative walking control or rehabilitation exercises is difficult, implanting a mechanically stable spiral blade for fixation of femoral neck fractures could facilitate walking after surgery.

Internal fixation of femoral head fractures (Pipkin I) using hip arthroscopy.

A hip arthroscopy technique for the reduction and internal fixation of a displaced femoral head fracture is presented. Open treatment is often required for femoral head fractures. However, it is shown below how large fragments of a femoral head fracture-dislocation were reduced and internally fixated using hip arthroscopy. This was performed in the supine position using skeletal traction. The accessory distal anterior portal was used for internal fixation when a hip was positioned in abduction with external rotation. A satisfactory outcome was reported. Recovery was immediate and cosmetics were excellent. We conclude that hip arthroscopy is a valuable option for managing femoral head fracture-dislocations (Pipkin I).

Eleven-year follow-up of second-generation metal-on-metal total hip arthroplasty.

PURPOSE: To investigate the cause of failure in matte-surface cemented stems in second-generation metal-on- metal total hip arthroplasty (THA). METHODS: Records of 26 men and 11 women (39 hips) aged 29 to 72 years who underwent primary cementless THAs by a single surgeon using second-generation metal-on-metal prostheses and were followed up for a mean of 122 (range, 120-141) months were reviewed. Two types of femoral stems were used: a cementless Ti-alloy stem (n=21) and a matte-surface, iron-based alloy, cemented stem (n=18). Clinical outcomes were measured using the Harris hip score. Radiographs were assessed for stem loosening and osteolysis. Patient activity levels were graded. Surfaces of the retrieved femoral stems and periprosthetic tissue samples were examined. Metallic and cement particles were studied. Hypersensitivity to metal was tested. RESULTS: None of the cementless stems were revised; no osteolysis or stem loosening occurred. In contrast, 7 of 18 matte-surface cemented stems were revised owing to stem loosening or osteolysis. Periprosthetic tissues revealed abundant cement-related particles; 90% were zirconium oxides but a few were iron particles. Histological examination of periprosthetic tissues showed perivascular infiltration of lymphocytes and macrophages containing tiny foreign materials. Metal hypersensitivity was not associated with aseptic loosening. CONCLUSION: Metal-on-metal THA with cementless components could be recommended for young, active patients to prevent wear and osteolysis. The matte-surface cemented stem is more likely to fail owing to friction during the earlier stage and cement-related biological processes during the later stage.

Ischemic optic neuropathy after hemiarthroplasty for femoral neck fracture.

Ischemic optic neuropathy due to hemorrhaging remote from visual pathway can occur after surgery. This complication is usually associated with a chronic bleeding disorder, such as gastrointestinal hemorrhage, diabetes, arteriosclerosis, and/or metal poisoning. There are many complications related to cemented hemiarthroplasty in patients who have a femoral neck fracture, such as dislocation, infection, leg length discrepancy, peroneal nerve palsy, and embolism. However, visual loss after this procedure has not previously been reported. In the case reported here, the operation time was short, and there was no massive hemorrhaging. Unilateral visual loss occurred within 3 days of an apparently safe and simple unilateral hemiarthroplasty of the hip.