It is challenging to reproduce both anatomical and functional aspects of anterolateral reconstruction: postoperative 3D-CT analysis of the femoral tunnel position.

BACKGROUND: This study aimed to evaluate the femoral tunnel position and fiber length of the anterolateral ligament (ALL) reconstruction compared with the natural anatomy of the ALL. We also evaluated whether the femoral tunnel position would affect residual pivot shift. METHODS: This study was a retrospective review of 55 knees that underwent ALL reconstruction considering the anatomical and functional aspects, during primary anterior cruciate ligament (ACL) reconstruction in the presence of a high-grade pivot shift or revisional ACL reconstruction. We determined the position of the femoral tunnel and the length of graft using a three-dimensional (3D)-computed tomography (CT) model after ALL reconstruction. We also measured graft excursion during surgery and examined pivot shift 2 years after surgery. We conducted a subgroup analysis of femoral tunnel position, fiber length, isometricity, and residual pivot shift depending on whether the tunnel was anterior or posterior to the lateral epicondyle (LE). We also performed a subgroup analysis depending on whether the ACL reconstruction was primary or revisional. RESULTS: The mean femoral tunnel position was 2.04 mm posterior and 14.5 mm proximal from the center of the LE. The mean lengths of the anterior and posterior fibers were 66.6 and 63.4 mm, respectively. The femoral tunnel was positioned more proximally than the anatomical position, and both anterior and posterior ALL fibers were longer than the natural anatomy. The anteroposterior femoral tunnel position was significantly correlated with anterior (p = 0.045) and posterior (p = 0.037) fiber excursion. In the subgroup analysis, there was no significant difference in the residual pivot shift between the posterior and anterior tunnel positions. However, there were significant differences for proximal position (p < 0.001) and fiber length (p = 0.006). There was no significant difference between primary and revisional ACL regarding femoral tunnel position and fiber lengths. CONCLUSION: It is challenging to reproduce both anatomical and functional aspects of ALL reconstruction in both primary and revision ACL reconstruction. Especially for functional reconstruction, the femoral tunnel tended to be positioned more proximally than the anatomical position. However, the femoral tunnel position did not affect functional clinical outcomes at the 2-year follow-up. LEVEL OF EVIDENCE: Level IV Case series.

Clinical Outcomes and Repair Integrity After Double-Row Modified Mason-Allen Repair Technique With a Single Knot in Small to Medium Supraspinatus Tears.

Background: Various arthroscopic rotator cuff repair techniques are being used for the treatment of rotator cuff tears with the development of surgical instruments. However, retears after repair are not completely avoidable, and efforts to reduce retears remain a challenge. Purpose/Hypothesis: To introduce a new repair technique, the double-row modified Mason-Allen technique with a single knot, and to compare clinical outcomes and retear rates with the single-row modified Mason-Allen technique. It was hypothesized that this new technique would have a better clinical outcome and significantly lower retear rate than the single-row modified Mason-Allen technique. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 110 patients with small- to medium-sized (<1.5 cm) full-thickness supraspinatus tears were enrolled into 2 groups, with 65 patients receiving the single-row modified Mason-Allen technique (group A) and 45 patients receiving the double-row modified Mason-Allen technique with a single knot (group B). The clinical and functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of the Arm, Shoulder and Hand (DASH) score; and visual analog scale (VAS) for pain and satisfaction scores. All patients enrolled in this study were monitored for a minimum of 24 months. Magnetic resonance imaging was performed to analyze the integrity of tendons and retear at 6 months after surgery. Results: No statistically significant differences between the 2 groups were found regarding the VAS for pain, ASES, and DASH scores. However, retear was found in 9 patients (13.8%) in group A and 1 patient (2.2%) in group B. The difference in the retear rate was statistically significant between the 2 groups (P = .037). Conclusion: A significantly lower retear rate and comparable clinical outcomes were seen after the double-row modified Mason-Allen repair technique with a single knot when compared with the single-row modified Mason-Allen technique. Based on these findings, the double-row modified Mason-Allen repair technique with a single knot can be considered a surgical treatment option that can provide sufficient stability in small- to medium-sized supraspinatus tears.

Do Magnets Have the Potential to Serve as a Stabilizer for the Shoulder Joint in Massive Rotator Cuff Tears?: A Biomechanical Cadaveric Study.

Background: Disruption of the rotator cuff muscles compromises concavity compression force, which leads to superior migration of the humeral head and loss of stability. A novel idea of using the magnetic force to achieve shoulder stabilization in massive rotator cuff tears (MRCTs) was considered because the magnets can stabilize two separate entities with an attraction force. This study aimed to investigate the biomechanical effect of the magnetic force on shoulder stabilization in MRCTs. Methods: Seven fresh frozen cadaveric specimens were used with a customized shoulder testing system. Three testing conditions were set up: condition 1, intact rotator cuff without magnets; condition 2, an MRCT without magnets; condition 3, an MRCT with magnets. For each condition, anterior-posterior translation, superior translation, superior migration, and subacromial contact pressure were measured at 0°, 30°, and 60° of abduction. The abduction capability of condition 2 was compared with that of condition 3. Results: The anterior-posterior and superior translations increased in condition 2; however, they decreased compared to condition 2 when the magnets were applied (condition 3) in multiple test positions and loadings (p < 0.05). Abduction capability improved significantly in condition 3 compared with that in condition 2, even for less deltoid loading (p < 0.05). Conclusions: The magnet biomechanically played a positive role in stabilizing the shoulder joint and enabled abduction with less deltoid force in MRCTs. However, to ensure that the magnet is clinically applicable as a stabilizer for the shoulder joint, it is necessary to thoroughly verify its safety in the human body and to conduct further research on technical challenges.

Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial.

PURPOSE: To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial. METHODS: From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups. RESULTS: Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups. CONCLUSIONS: The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Palliative arthroscopic debridement with continuous irrigation for infected total knee arthroplasty in high mortality risk patients.

PURPOSE: This study aimed to evaluate the infection control rate of palliative arthroscopic debridement, antibiotics, and implant retention (DAIR) for the high mortality risk or terminal cancer stage patients. METHODS: From March 2018 to August 2021, 21 patients met the following inclusion criteria: old age of more than 80, diagnosed as a terminal stage of cancer, high risk of mortality and morbidity representing as Charlson comorbidity index (CCI) ≥ 5, low daily activity with disabled extremity, and re-infection after two-stage revision. Each patient underwent arthroscopic DAIR and additional continuous irrigation for 48 hours. The need for subsequent re-arthroscopic DAIR or two-stage revision was determined by the post-operative trends of C-reactive protein (CRP) levels. Infection control was defined as continuing controlled status of infection based on clinical and laboratory results by one or two times of arthroscopic DAIR within initial two months. Treatment failure was defined as more than three times arthroscopic debridement, two-stage revision surgery, or expired due to uncontrolled infection. RESULTS: Arthroscopic DAIR controlled the infection in 19 (90.5%) of the 21 cases. The other knee underwent a total of three times of re-arthroscopic DAIR and the other one underwent two-stage revision. Although five patients expired during the follow-up period due to worsening medical problems or terminal cancer, there were no deaths from uncontrolled infection, sepsis, or surgery-related complications. CONCLUSIONS: Arthroscopic debridement with continuous irrigation for the infection TKA with high mortality risk or terminal cancer patients showed a 90.5% infection control rate. For high-risk patients, arthroscopic debridement with continuous irrigation can be an alternative treatment to improve the quality of life during survival.

Avoiding Overcorrection to Increase Patient Satisfaction After Open Wedge High Tibial Osteotomy.

BACKGROUND: Achieving the postoperative mechanical axis passing through 62.5% of the tibial plateau is considered successful osteotomy surgery. Despite precise preoperative planning and surgical techniques, some procedures result in under- or overcorrection. Few studies have investigated the relationship between clinical outcomes and unintentional under- or overcorrection after open wedge high tibial osteotomy (OWHTO) using whole-leg standing radiographs. PURPOSE: To investigate the relationship between postoperative alignment using whole-leg standing radiographs and clinical outcomes after OWHTO. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 89 knees (72 patients) that underwent OWHTO between October 2013 and September 2018 were included. Patients with postoperative weightbearing line (WBL) ratios within 57% to 67% were classified as appropriate correction (group A; 45 cases), whereas ratios <57% and >67% were classified as undercorrection (group U; 20 cases) and overcorrection (group O; 24 cases), respectively. The following patient-reported outcomes (PROs) were investigated: International Knee Documentation Committee (IKDC) subjective score, Kujala score, and Knee injury and Osteoarthritis Outcome Score (KOOS). The correlation between postoperative WBL and PROs was analyzed. PROs were compared among the 3 groups. RESULTS: Regarding the correlation between postoperative WBL ratio and PROs, a larger postoperative WBL ratio was significantly correlated with a poor IKDC subjective score (P = .002), Kujala score (P = .009), and KOOS. Group O showed inferior postoperative PRO scores when compared with group A or U, whereas group U showed a similar result to group A (mean IKDC subjective scores: group U, 62.0; group A, 61.2; group O, 47.6; P = .004). CONCLUSION: Overcorrection after OWHTO surgery correlated with inferior PROs; therefore, overcorrected alignment should be avoided for patient satisfaction. Knees with an undercorrected alignment showed clinical results similar to those with appropriate correction.

Effectiveness of continuous femoral nerve block for pain relief after total knee arthroplasty: comparison with epidural patient-controlled analgesia and periarticular injection.

OBJECTIVE: To compare the clinical outcomes among three analgesic techniques, continuous femoral nerve block (CFNB), epidural patient-controlled analgesia (EPCA) and periarticular injection (PAI), in patients undergoing total knee arthroplasty (TKA). METHODS: This retrospective case-control study enrolled patients that underwent TKA. Visual analogue scale (VAS) pain scores, sleep disturbance, additional opioid consumption and incidence of opioid-related side-effects were assessed. RESULTS: A total of 120 patients were categorized into three groups: EPCA (group A, n = 40), PAI (group B, n = 40) and CFNB (group C, n = 40). Group C had significantly lower VAS pain scores than groups A and B at 8, 12 and 24 h after TKA. There were no significant differences in VAS pain scores among the three groups from 48 h after TKA. Sleep quality on the first day after surgery was significantly better in group C than in groups A and B. Additional opioid consumption was significantly lower in the group C than in the groups A and B. Group C showed a lower rate of opioid-related side-effects than groups A and B. CONCLUSION: CFNB was a more effective additional analgesic technique than EPCA or PAI for acute postoperative pain control within 24 h of TKA.

State of the Art: The Immunomodulatory Role of MSCs for Osteoarthritis.

Osteoarthritis (OA) has generally been introduced as a degenerative disease; however, it has recently been understood as a low-grade chronic inflammatory process that could promote symptoms and accelerate the progression of OA. Current treatment strategies, including corticosteroid injections, have no impact on the OA disease progression. Mesenchymal stem cells (MSCs) based therapy seem to be in the spotlight as a disease-modifying treatment because this strategy provides enlarged anti-inflammatory and chondroprotective effects. Currently, bone marrow, adipose derived, synovium-derived, and Wharton's jelly-derived MSCs are the most widely used types of MSCs in the cartilage engineering. MSCs exert immunomodulatory, immunosuppressive, antiapoptotic, and chondrogenic effects mainly by paracrine effect. Because MSCs disappear from the tissue quickly after administration, recently, MSCs-derived exosomes received the focus for the next-generation treatment strategy for OA. MSCs-derived exosomes contain a variety of miRNAs. Exosomal miRNAs have a critical role in cartilage regeneration by immunomodulatory function such as promoting chondrocyte proliferation, matrix secretion, and subsiding inflammation. In the future, a personalized exosome can be packaged with ideal miRNA and proteins for chondrogenesis by enriching techniques. In addition, the target specific exosomes could be a gamechanger for OA. However, we should consider the off-target side effects due to multiple gene targets of miRNA.

Enhanced osseointegration through direct energy deposition porous coating for cementless orthopedic implant fixation.

Direct energy deposition (DED) is a newly developed 3D metal printing technique that can be utilized on a porous surface coating of joint implants, however there is still a lack of studies on what advantages DED has over conventional techniques. We conducted a systematic mechanical and biological comparative study of porous coatings prepared using the DED method and other commercially available technologies including titanium plasma spray (TPS), and powder bed fusion (PBF). DED showed higher porosity surface (48.54%) than TPS (21.4%) and PBF (35.91%) with comparable fatigue cycle. At initial cell adhesion, cells on DED and PBF surface appeared to spread well with distinct actin stress fibers through immunofluorescence study. It means that the osteoblasts bind more strongly to the DED and PBF surface. Also, DED surface showed higher cell proliferation (1.27 times higher than TPS and PBF) and osteoblast cell activity (1.28 times higher than PBF) for 2 weeks culture in vitro test. In addition, DED surface showed better bone to implant contact and new bone formation than TPS in in vivo study. DED surface also showed consistently good osseointegration performance throughout the early and late period of osseointegration. Collectively, these results show that the DED coating method is an innovative technology that can be utilized to make cementless joint implants.

A Useful MRI Classification for Symptomatic Discoid Lateral Meniscus.

PURPOSE: The purpose of this study is to classify the discoid lateral meniscus (DLM) according to the signal and shape in magnetic resonance imaging (MRI), and to provide information not only in diagnosis but also in treatment. MATERIALS AND METHODS: We reviewed 162 cases who diagnosed with DLM by MRI and underwent arthroscopic procedures from April 2010 to March 2018. Three observers reviewed MRI findings of all cases and predicted arthroscopic tear using three MRI criteria (criterion 1,2 and 3). Among three criteria, the criterion that most accurately predicts arthroscopic tear was selected. Using this criterion, the cases of predicted tear were named group 1. In addition, group 1 was divided into three subgroups (group 1a, 1b and 1c) by deformation or displacement on MRI and arthroscopic type of tear and procedures were analyzed according to these subgroups. RESULTS: The intra-meniscal signal change itself (criterion 3) on MRI showed the highest agreement with the arthroscopic tear. No meniscal deformation and displacement on MRI (group 1a) showed no specific type of tear and more cases of meniscal saucerization. The meniscal deformation on MRI (group 1b) showed more simple horizontal tears and more cases of meniscal saucerization. The meniscal displacement on MRI (group 1c) showed more peripheral tears and more cases of meniscal repair and subtotal meniscectomy. Comparing arthroscopic type of tear and type of arthroscopic procedure between three subgroups, there were significant differences in three groups (P < .05). CONCLUSIONS: Intra-meniscal signal change itself on MRI is the most accurate finding to predict arthroscopic tear in symptomatic DLM. In addition, subgroup analysis by deformation or displacement on MRI is helpful to predict the type of arthroscopic tear and procedures.

Editorial Commentary: Posterolateral Malposition of the Cortical Hinge During Medial Open-Wedge High Tibial Osteotomy Increases Posterior Tibial Slope: Incomplete Posterior Osteotomy May Shift the Hinge From Lateral to Posterolateral.

Medial open-wedge high tibial osteotomy is an established treatment option for relatively young patients with medial-compartment osteoarthritis and varus deformity. This procedure is mainly focused on correcting coronal malalignment; however, it inevitably affects the posterior tibial slope (PTS) in the sagittal plane. The alteration of the PTS significantly affects knee stability and kinematics. When medial open-wedge high tibial osteotomy is performed, incomplete osteotomy of the posterior cortex could lead to a cortical hinge shift from the lateral side to the posterolateral side, which indicates the alteration of the axial hinge axis. In this case, there is a risk of an increasing PTS. In addition, incomplete posterior cortex osteotomy can lead to a lateral hinge fracture.

The Reliability of Remote Patient-Reported Outcome Measures via Mobile Apps to Replace Outpatient Visits After Rotator Cuff Repair Surgery: Repetitive Test-Retest Comparison Study for 1-Year Follow-up.

BACKGROUND: With the development of health care-related mobile apps, attempts have been made to implement remote patient-reported outcome measures (PROMs). In order for remote PROMs to be widely used by mobile apps, the results should not be different depending on the location; that is, remote PROM results performed in locations other than hospitals should be able to obtain reliable results equivalent to those performed in hospitals, and this is very important. However, to our knowledge, there are no studies that have assessed the reliability of PROMs using mobile apps according to the location by comparing the results performed remotely from the hospital and performed at the outpatient visits. OBJECTIVE: The purpose of this study was to evaluate the reliability of remote PROMs using mobile apps compared to PROMs performed during outpatient follow-up visits after arthroscopic shoulder surgery. METHODS: A total of 174 patients who underwent arthroscopic rotator cuff repair completed questionnaires 2 days before visiting the clinic for the 1-, 2-, 3-, 6-, and 12-month follow-ups (test A). The patients completed the questionnaires at the clinic (test B) using the same mobile app and device for the 1-, 2-, 3-, 6-, and 12-month follow-ups. Test-retest comparisons were performed to analyze the differences and reliability of the PROMs according to the period. RESULTS: Comparisons of tests A and B showed statistically significant differences at 1, 2, and 3 months (all Ps<.05 except for the ASES function scale at 3-months) but not 6 or 12 months after surgery (all Ps>.05). The intraclass correlation values between the two groups were relatively low at the 1-, 2-, and 3-month follow-ups but were within the reliable range at 6 and 12 months after surgery. The rate of completion of tests A and B using the mobile app was significantly lower in the group older than 70 years than in the other groups for all postoperative periods (P<.001). CONCLUSIONS: PROMs using mobile apps with different locations differed soon after surgery but were reliably similar after 6 months. The remote PROMs using mobile apps could be used reliably for the patient more than 6 months after surgery. However, it is to be expected that the use of mobile app-based questionnaires is not as useful in the group older than 70 years as in other age groups.

Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications.

BACKGROUND: The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns. METHODS: A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification. RESULTS: Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05). CONCLUSION: Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.

Comparison of Bone Marrow Aspirate Concentrate and Allogenic Human Umbilical Cord Blood Derived Mesenchymal Stem Cell Implantation on Chondral Defect of Knee: Assessment of Clinical and Magnetic Resonance Imaging Outcomes at 2-Year Follow-Up.

Biological repair of cartilage lesions remains a significant clinical challenge. A wide variety of methods involving mesenchymal stem cells (MSCs) have been introduced. Because of the limitation of the results, most of the treatment methods have not yet been approved by the Food and Drug Administration (FDA). However, bone marrow aspirate concentrate (BMAC) and human umbilical cord blood derived mesenchymal stem cells (hUCB-MSCs) implantation were approved by Korea FDA. The aim of this study was to evaluate clinical and magnetic resonance imaging (MRI) outcomes after two different types of MSCs implantation in knee osteoarthritis. Fifty-two patients (52 knees) who underwent cartilage repair surgery using the BMAC (25 knees) and hUCB-MSCs (27 knees) were retrospectively evaluated for 2 years after surgery. Clinical outcomes were evaluated according to the score of visual analogue scale (VAS), the International Knee Documentation Committee (IKDC) subjective, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Cartilage repair was assessed according to the modified Magnetic Resonance Observation of Cartilage Repair Tissue (M-MOCART) score and the International Cartilage Repair Society (ICRS) cartilage repair scoring system. At 2-year follow-up, clinical outcomes including VAS, IKDC, and KOOS significantly improved (P < 0.05) in both groups; however, there were no differences between two groups. There was no significant difference in M-MOCART [1-year (P = 0.261), 2-year (P = 0.351)] and ICRS repair score (P = 0.655) between two groups. Both groups showed satisfactory clinical and MRI outcomes. Implantation of MSCs from BMAC or hUCB-MSCs is safe and effective for repairing cartilage lesion. However, large cases and a well-controlled prospective design with long-term follow-up studies are needed.

Outcomes of U-Blade Lag Screw for Cephalomedullary Fixation of Unstable Trochanteric Femur Fractures: A Case Control Study.

BACKGROUND: Unstable trochanteric femur fractures in elderly patients with osteoporosis are still challenging. Gamma3 nail with the U-blade lag screw (U-blade gamma nail) has been developed to improve mechanical stability of proximal femoral fragment. This study aimed to compare the clinical and radiologic outcomes of U-blade gamma nail to proximal femoral nail antirotation (PFNA), and standard Gamma3 nail (gamma nail) for unstable trochanteric femur fractures. METHODS: A retrospective matched-pair case study was performed with U-blade gamma nail, PFNA, and gamma nail. During 2012-2018, 970 patients with unstable trochanteric femur fractures were reviewed. Matching criteria were set as follows: 1) sex; 2) age (± 3 years); 3) body mass index (± 2 kg/m2); 4) bone mineral density (± 1 T-score in femur neck). Finally, a total of 159 patients were enrolled. We assessed the tip-apex distance (TAD), neck shaft angle, and hip screw sliding distance using plain radiographs. Also, we evaluated the clinical outcomes with Koval's grade and fixation failure during 2 years. RESULTS: The mean postoperative TAD was not significantly different among the 3 groups (p = 0.519). However, the change in the TAD at 1 year (p = 0.027) and 2 years (p = 0.008) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. The hip screw sliding distance at 1 year (p = 0.004) and 2 years (p = 0.001) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. However, there was no significant difference of Koval's grade and fixation failure among the 3 groups (p = 0.535). CONCLUSION: U-blade gamma nail showed favorable radiologic results in terms of the change in the hip screw position. However, U-blade gamma nail was not superior to PFNA and gamma nail in clinical outcomes.

Actinomycotic osteomyelitis of a long bone in an immunocompetent adult: a case report and literature review.

BACKGROUND: Actinomycosis is a rare, chronic granulomatous disease caused by Gram-positive anaerobic bacteria that colonize the oral cavity. Cervicofacial actinomycosis is the most frequent clinical presentation of actinomycosis, but hematogenous osteomyelitis at distant sites can occur in rare instance in immunocompromised or pediatric patients, only a few cases have been reported in healthy patients. Here we described a new case of distal femur osteomyelitis caused by Actinomyces in an adult patient who was immunocompetent and had no predisposing factors. CASE PRESENTATION: A woman aged 52 years with no history of trauma presented with severe pain, swelling, and increased local heat in the proximal area of the right knee 3 weeks after she first noticed discomfort. Magnetic resonance imaging showed persistent osteomyelitis of the distal metaphysis and diaphysis of the femur with a multifocal intraosseous abscess pocket. An incision and drainage of the abscess were conducted. The tissue culture, fungus culture, acid fast bacillus (AFB) culture, AFB smear, and tuberculosis polymerase chain reaction test results were negative. A pathologic examination confirmed the presence of actinomycosis. The patient was successfully treated with intravenous penicillin G for 8 weeks followed by oral amoxicillin-clavulanate for 6 weeks with repeated surgical debridement and drainage. After a 5-year follow up, the patient had no signs of recurring infection or complications and she had full range of movement in the affected knee. CONCLUSIONS: Although rare, actinomycotic osteomyelitis can occur in healthy people. Furthermore, actinomycotic osteomyelitis is easily misdiagnosed as tuberculosis in areas with a high prevalence of tuberculosis. To detect and identify the bacteria accurately, pathologic examination should be performed as well as culture tests, because the probability for culture confirmation of actinomycosis is quite low. The initial treatment is vital to a successful outcome without ostectomy or amputation.

Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression.

BACKGROUND: To date, several trials have reported the use of mesenchymal stem cell (MSC) implantation for osteonecrosis of the femoral head (ONFH). However, the clinical outcomes have not been conclusive. This study compared the clinical and radiological results of bone marrow mesenchymal stem cell (BMMSC) implantation with traditional simple core decompression (CD) using a matched pair case-control design. METHODS: We retrospectively reviewed 100 patients with ONFH (106 hips) who had been treated by CD alone (50 patients, 53 hips) and CD + BMMSC implantation (50 patients, 53 hips) between February 2004 and October 2014. We assessed the total hip replacement arthroplasty (THA) conversion rate and ARCO (Association Research Circulation Osseous) stage progression. Survivor rate analysis was performed using the Kaplan-Meier method, and an additional THA was defined as the primary endpoints. RESULTS: The mean follow-up period was 4.28 years. There was a difference in the THA conversion rate between the CD (49%) and CD + BMMSC groups (28.3%) (p = 0.028). ARCO stage progression was noted in 20 of 53 hips (37.7%) in the CD group and 19 of 53 hips (35.8%) in the CD + BMMSC group. Among collapsed cases (ARCO stages III and IV), there was no difference in clinical failure rate between the two groups. Conversely, in the pre-collapse cases (ARCO stages I and II), only 6 of 30 hips (20%) progressed to clinical failure in the CD + BMMSC group, whereas 15 of 30 hips (50%) progressed to clinical failure in the CD group (p = 0.014). Kaplan-Meier survival analysis showed a significant difference in the time to failure between the two groups up to 10-year follow-up (log-rank test p = 0.031). There was no significant difference in terms of age (p = 0.87) and gender (p = 0.51) when comparing THA conversion rates between groups. No complication was noted. CONCLUSIONS: These results suggest that implantation of MSCs into the femoral head at an early stage of ONFH lowers the THA conversion rate. However, ARCO stage progression is not affected by this treatment. TRIAL REGISTRATION: Retrospectively registered.

Concomitant Contracture of the Knee and Ankle Joint After Gastrocnemius Muscle Rupture: A Case Report.

Injury of the medial head of the gastrocnemius, also called "tennis leg," is known to heal uneventfully in most cases with compression and immobilization therapy. Failure to heal or long-term complications, including ongoing pain and pes equinus, have been documented in only a limited number of case reports. To the best of our knowledge, a severe concomitant contracture of the knee and ankle joint as a consequence of a maltreated gastrocnemius muscle rupture has not been previously reported in English-language reports. The purpose of the present study was to report a serious complication of neglected tennis leg with a review of the published data.

Clinical results of auto-iliac cancellous bone grafts combined with implantation of autologous bone marrow cells for osteonecrosis of the femoral head: a minimum 5-year follow-up.

PURPOSE: There are no reports about bone graft and cell therapy for the osteonecrosis of femoral head (ONFH). We prospectively evaluated the clinical results of auto-iliac cancellous bone grafts combined with implantation of autologous bone marrow cells for ONFH. MATERIALS AND METHODS: Sixty-one hips in 52 patients with ONFH treated with bone graft and cell therapy were enrolled, and the average follow-up of the patients was 68 (60-88) months. Necrotic lesions were classified according to their size by the Steinberg method and location of necrosis. RESULTS: At the last follow-up, the percentage of excellent or good results was 80% (12/15 hips) in the small lesion group, 65% (17/26 hips) in the medium size group, and 28% (6/20 hips) in the large size group. The procedures were a clinical success in 4 of 5 hips (80%) of stage I, 23 of 35 hips (65.7%) of stage II, 7 of 18 hips (38.9%) of stage III, and 1 of 3 hips (33.3%) of stage IV grade, according to the Association Research Circulation Osseous grading system. Among the 20 cases with large sized necrotic lesions, 17 cases were laterally located and this group showed the worst outcomes, with 13 hips (76.5%) having bad or failed clinical results. CONCLUSION: The results of the present study suggested that patients who have a large sized lesion or medium sized laterally located lesion would not be good candidates for the head preserving procedure. However, for medium sized lesions, this procedure generated clinical results comparable to those of other head preserving procedures.