Corrective Surgery Using Virtual Surgical Simulation and a Three-Dimensional Printed Osteotomy Guide: A Case Report / 대한족부족관절학회지

A 74-year-old female patient, who underwent surgery for a left distal tibiofibular fracture 40 years earlier, visited the hospital with an ankle varus deformity due to malunion. The patient complained of discomfort while walking due to the ankle and hindfoot varus deformity but did not complain of ankle pain. Therefore, correction using supramalleolar osteotomy was planned, and through virtual surgical simulation, it was predicted that a correction angle of 24° and an osteotomy gap open of 12 mm would be necessary. An osteotomy guide and an osteotomy gap block were made using three-dimensional (3D) printing to perform the osteotomy and correct the deformity according to the predicted goal. One year after surgery, it was observed that the ankle varus was corrected according to the surgical simulation, and the patient was able to walk comfortably. Thus, for correction of deformity, virtual surgical simulation and a 3D-printed osteotomy guide can be used to predict the target value for correction. This is useful for increasing the accuracy of correction of the deformity.

Feasibility of Loop-Mediated Isothermal Amplification for Rapid Detection of Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus in Tissue Samples

Background@#To date, few studies have investigated the feasibility of the loop-mediated isothermal amplification (LAMP) assay for identifying pathogens in tissue samples. This study aimed to investigate the feasibility of LAMP for the rapid detection of methicillin-susceptible or methicillin-resistant Staphylococcus aureus (MSSA or MRSA) in tissue samples, using a bead-beating DNA extraction method. @*Methods@#Twenty tissue samples infected with either MSSA (n = 10) or MRSA (n = 10) were obtained from patients who underwent orthopedic surgery for suspected musculoskeletal infection between December 2019 and September 2020. DNA was extracted from the infected tissue samples using the bead-beating method. A multiplex LAMP assay was conducted to identify MSSA and MRSA infections. To recognize the Staphylococcus genus, S. aureus, and methicillin resistance, 3 sets of 6 primers for the 16S ribosomal ribonucleic acid (rRNA) and the femA and mecA genes were used, respectively. The limit of detection and sensitivity (detection rate) of the LAMP assay for diagnosing MSSA and MRSA infection were analyzed. @*Results@#The LAMP result was positive for samples containing 10 3 colony-forming unit (CFU)/mL for 16S rRNA, 10 4 CFU/mL for femA, and 10 5 CFU/mL formecA. The limits of detection for 16S rRNA and femA were not different between MSSA and MRSA. For the 10 MSSA-positive samples, the LAMP assay showed 100% positive reactions for 16S rRNA and femA and a 100% negative reaction for mecA. For the 10 MRSA-positive samples, the LAMP assay showed 100% positive reactions for 16S rRNA and mecA but only 90% positive reactions for femA. The sensitivity (detection rate) of the LAMP assay for identifying MSSA and MRSA in infected tissue samples was 100% and 90%, respectively. @*Conclusions@#The results of this study suggest that the LAMP assay performed with tissue DNA samples can be a useful diagnostic method for the rapid detection of musculoskeletal infections caused by MSSA and MRSA.

Validation of Electronic Foot Function Index in Patients with Foot and Ankle Disease: A Randomized, Prospective Multicenter Study / 대한족부족관절학회지

PURPOSE: To evaluate the efficiency of the electronic foot function index (eFFI) through a prospective, random based, multi-institutional study. MATERIALS AND METHODS: The study included 227 patients ranging in age from 20 to 79 years, visited for surgery in different 15 institutes, and agreed to volunteer. The patients were assigned randomly into a paper-based evaluated group (n=113) and tablet-based evaluated group (n=114). The evaluation was done on the day of hospital admission and the method was changed on the second day of surgery and re-evaluated. PADAS 2.0 (https://www.proscore.kr) was used as an electronic evaluation program. RESULTS: There were no differences in age and sex in both groups. The intraclass correlation coefficient (ICC) evaluation revealed an eFFI ICC of 0.924, showing that both results were similar. The evaluation time was shorter in the tablet-based group than the paper-based group (paper vs tablet, 3.7±3.8 vs 2.3±1.3 minutes). Thirty-nine patients (17.2%) preferred to use paper and 131 patients (57.7%) preferred the tablet. Fifty-seven patients (25.1%) found both ways to be acceptable. CONCLUSION: eFFI through tablet devices appears to be more constant than the paper-based program. In addition, it required a shorter amount of time and the patients tended to prefer the tablet-based program. Overall, tablet and cloud system can be beneficial to a clinical study.

Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies

PURPOSE: To summarize and compare radiological and clinical outcomes of open wedge high tibial osteotomy (HTO) using imageless computer-assisted navigation with conventional HTO. METHODS: A literature search of online register databases was conducted. The risk ratio (RR) of radiological outliers and mean differences in clinical outcomes were compared between navigated and conventional HTOs. Radiological results were evaluated by subgroup analyses according to the study period (concurrent/consecutive) and the use of locking fixation device. RESULTS: Seven comparative studies with a total sample size of 406 knees were included in this review. Radiographically, the mechanical axis [MA] was within the acceptable range (0degrees-6degrees) in 83.7% of the navigation HTO group, showing significant difference from 62.1% of the conventional HTO group. Clinically, despite the forest plot demonstrating a general trend of favoring the navigation system, there were not sufficient studies to determine statistical significance in the meta-analysis. None of the subgroup analyses demonstrated significant differences in the RR of MA outliers. CONCLUSIONS: The present meta-analysis indicates that the use of navigation in open wedge HTO improves the precision of mechanical alignment by decreasing the incidence of outliers; however, the clinical benefit is not conclusive. Additionally, none of the subgroup analyses demonstrated significant difference in the RR of MA outliers.

The Indication of Ankle Lateral Ligament Reconstruction Using Tendon Graft in Chronic Ankle Instability / 대한족부족관절학회지

PURPOSE: The purpose of this study is to review the indications of ankle lateral complex reconstruction using tendon graft. MATERIALS AND METHODS: We searched PubMed using the index, "ankle, instability, lateral ligament, reconstruction" from 1990 to present (September 30, 2015). We excluded 1) modified Brostrom operation (MBO), 2) conventional tenodesis surgery, 3) review article, 4) technical note, and 5) articles written in another foreign language. We reviewed 24 papers through the publication events, operational method, the indications of surgery, and the specific features of the patient group. RESULTS: There were the indications of 1) previous ligament surgery failure, 2) situation when ligament repair is impossible due to the ligament defect, 3) severe instability (preoperative talar tilt >15degrees, anterior draw >10 mm or the difference of contralateral side talar tilt >5degrees, anterior draw >3 mm), and 4) overweight (body mass index >30 kg/m2). Other considerations included 1) generalized joint laxity and 2) workers, highly-demanded or athlete highly-affected by instability. CONCLUSION: The ankle lateral complex reconstruction using tendon graft could be indicated in patients with the possibility of MBO failure with several considerations.

Sex-Related Differences in Outcomes after Hallux Valgus Surgery

PURPOSE: With differences between the sexes in foot bone anatomy and ligamentous laxity, there is the possibility that the results of hallux valgus surgery may also differ between the sexes. We aimed to compare the results of hallux valgus surgery between the sexes. MATERIALS AND METHODS: The authors retrospectively reviewed 60 males (66 feet) and 70 females (82 feet) who underwent distal or proximal chevron osteotomy for the treatment of hallux valgus deformity between June 2005 and December 2011. We compared the clinical and radiologic outcomes between the sexes. RESULTS: There were no statistically significant differences in demographics between the sexes. The mean American Orthopedic Foot and Ankle Society score, visual analogue scale for pain, and patient satisfaction at the last follow-up did not differ significantly between the sexes. The mean preoperative hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were not significantly different between the sexes. At the last follow-up, the mean HVA was significantly greater in females (p=0.003) than in males; mean IMA was not significantly different between the sexes. The mean correction of HVA in males was significantly greater than that in females (p=0.014). CONCLUSION: There were no significant differences between the sexes regarding clinical outcomes after distal and proximal chevron osteotomy. However, male patients achieved greater correction of HVA than female patients. There is a possibility that sexual dimorphism of the foot may affect postoperative HVA.

Sex-Related Differences in Outcomes after Hallux Valgus Surgery

PURPOSE: With differences between the sexes in foot bone anatomy and ligamentous laxity, there is the possibility that the results of hallux valgus surgery may also differ between the sexes. We aimed to compare the results of hallux valgus surgery between the sexes. MATERIALS AND METHODS: The authors retrospectively reviewed 60 males (66 feet) and 70 females (82 feet) who underwent distal or proximal chevron osteotomy for the treatment of hallux valgus deformity between June 2005 and December 2011. We compared the clinical and radiologic outcomes between the sexes. RESULTS: There were no statistically significant differences in demographics between the sexes. The mean American Orthopedic Foot and Ankle Society score, visual analogue scale for pain, and patient satisfaction at the last follow-up did not differ significantly between the sexes. The mean preoperative hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were not significantly different between the sexes. At the last follow-up, the mean HVA was significantly greater in females (p=0.003) than in males; mean IMA was not significantly different between the sexes. The mean correction of HVA in males was significantly greater than that in females (p=0.014). CONCLUSION: There were no significant differences between the sexes regarding clinical outcomes after distal and proximal chevron osteotomy. However, male patients achieved greater correction of HVA than female patients. There is a possibility that sexual dimorphism of the foot may affect postoperative HVA.

Ankle Impingement Syndrome / 대한족부족관절학회지

The ankle impingement syndrome is an established cause of ankle dysfunction. In most cases with suspected ankle impingement, the diagnosis can be possible on the basis of mechanism of injury involved and the clinical examination. An appropriate imaging study should be selected where clinical doubt about the exact diagnosis exists. Radiography plays an important role in the initial assessment of these conditions, especially in anterior and posterior impingement. Magnetic resonance arthrography seems to be the most accurate means of assessing the capsular abnormalities present in anterolateral and anteromedial impingement and for confirmation of possible concomitant injury. Surgical treatment can be considered for the patients who did not respond to conservative treatment for more than 6 months, and has a low complication rate and a high level of success.

Total Ankle Replacement / 대한족부족관절학회지

Although first generation total ankle replacement (TAR) had high failure rates, recent investigations have reported good results of the newer generations of TAR due to advances in implant designs and techniques. Patient selection is critical to performing TAR to obtain promising outcomes and to decrease complication rate. As the current concepts of correcting the accompanying deformity have been established, TAR in moderate to severe varus deformity of the ankle result in favorable outcomes and indications for TAR are expanding. Correction of deformity and hindfoot fusion should be performed in conjunction with TAR if needed. If radiolucency around components or osteolysis is progressive during follow-up, CT should be carried out as a confirmative diagnostic method. TAR is an effective treatment modality alternative to ankle fusion. However, we should recognize that TAR is a demanding procedure, which requires accurate techniques, enough experience, and preoperative plan for a concomitant deformity.

Are Portable Imaging Intraoperative Radiographs Helpful for Assessing Adequate Acetabular Cup Positioning in Total Hip Arthroplasty?

Despite advances in surgical techniques and instrumentation, current intra-operative estimations of acetabular version in total hip arthroplasty are of limited accuracy. In the present study, two experienced orthopedic surgeons compared intra-operatively measured (using portable imaging) anteversions and vertical inclinations of acetabular components with those measured using standardized radiographs post-operatively in 40 patients. Of the all vertical inclinations measured from intra-operative radiographs, 72.5% (n=29) were within +/-2degrees, and 97.5% (n=39) were within +/-5degrees of those determined using post-operative radiographs, and for anteversion, 52.5% (n=21) were within +/-2degrees, and 97.5% (n=39) were within +/-5degrees. Post-operative radiographs demonstrated that 90.0% (n=36) of vertical inclinations and anteversions were within the adequate zone. Obviously, our method has its limitations, but the authors conclude that the method described in this article better allows surgeons to verify acetabular version intra-operatively. In particular, the described method is suitable in cases with a deformed acetabular anatomy and difficult revision surgery.

Bipolar Hemiarthroplasty for the Femoral Neck Fractures in Elderly Patients

PURPOSE: To evaluate the clinical results of bipolar hemiarthroplasty in elderly patients more than 65 years of age with a femoral neck fracture. MATERIALS AND METHODS: Forty-six bipolar hemiarthroplasties in 43 patients more than 65 years of age which could be followed more than 3 years were included in this study. The clinical outcomes were evaluated using Harris hip score, pain score and support score. The radiological results were analyzed by femoral stem loosening and bipolar cup migration. RESULTS: The average Harris hip score was 88.7 (62~96) points. An excellent score was recorded in 34 cases, good in 7 cases, fair in 3 cases and poor in 2 cases. The average pain score was 39.3 points and there were no pain in 20 cases, slight pain in 17 cases, mild pain in 6 cases and moderate pain in 2 cases. The average support score was 9.6 points and 32 patients could walk without the use of any assistive devices. Two cases were converted to total hip arthroplasty due to femoral stem loosening with or without bipolar cup migration. CONCLUSION: For the early ambulation and functional recovery of elderly patients with femoral neck fracture, bipolar hemiarthroplasty was considered as one of recommendable methods.

Comparative Study of Scar Formation at the Site of Sciatic Nerve Repair in Rats / 대한정형외과학회잡지

PURPOSE: To investigate the effectiveness and to compare the degree of axonal regeneration with the control after the topical application of dexamethasone, hyaluronic acid and amniotic fluid at the repair site of the peripheral nerve. MATERIALS AND METHODS: The left sciatic nerves of 40 adult Sprague-Dawley rats were transected and neurorrhaphy was performed. The nerves were divided into four groups according to the solution applied around the repair site: control group (group 1), 0.3 ml normal saline: experimental groups, 0.3 ml dexamethasone (group 2), 0.3 ml hyaluronic acid (group 3), and 0.3 ml amniotic fluid (group 4). The thickness of the perineural scar tissue, the count of the myelinated nerve fiber and axonal regeneration on the repair site were evaluated electromyographically and histologically 4 and 12 weeks after surgery. RESULTS: The peak amplitude of the compound motor action potential was observed in group 2, at postoperative 4 weeks and group 3 at postoperative 12 weeks. The increase in the number of myelinated nerve fibers was most prominently in group 3 at 4 and 12 weeks after surgery. The degree of perineural scarring was lowest in group 2 at postoperative 4 weeks and in group 3 at postoperative 12 weeks. CONCLUSION: A single dose topical application of Dexamethasone, HA and Amniotic fluid is more effective in preventing perineural scar formation as well as in facilitating the nerve regeneration process in a rat hind-limb model than using saline.

Primary Total Hip Arthroplasty Using Non-cemented Multilock Proximal Porous Coated Femoral Stem: Ten to Twelve Years Follow Up Study / 대한정형외과학회잡지

PURPOSE: This study evaluated the minimum ten-year result of primary total hip arthroplasty with a non-cemented Multilock femoral stem. MATERIALS AND METHODS: Fifty five total hip replacements in forty-four patients using a non-cemented Multilock femoral stem and Harris-Galante 2 acetabular component were performed between January 1992 and December 1994. Forty-four hips in thirty-six patients were available for follow up for an average of eleven years (range, ten to twelve years). The clinical results were evaluated based on the Harris hip scores. A detailed radiography analysis was performed by an evaluation of the radiolucent lines, femoral osteolysis, and fixation stability by Engh Method. RESULTS: The average Harris hip score improved from 54.3 points preoperatively to 93.6 points postoperatively. Non-progressive radiolucencies < 2 mm in width were observed in nine (20.5%), and femoral osteolysis was observed in thirteen cases (29.5%). For the fixation stability, osseous ingrowth was noted in thirty nine cases (88.6%) and fibrous ingrowth was observed in two (4.5%). There were three (6.8%) cases with unstable fixation. Two hips underwent revision. The survival rate of the femoral component was 93.2% (forty one cases) after a minimum ten-year follow up. CONCLUSION: The non-cemented Multilock femoral component provided excellent clinical and radiographic results. However, the rate of femoral osteolysis was relatively high (mostly restricted to zone 1 and 7).

The Treatment of Unstable Intertrochanteric Fractures with Dynamic Hip Screw and Trochanter Stabilizing Plate

PURPOSE: To analyze the effect of treatment of unstable intertrochanteric fractures with dynamic hip screw and additional trochanter stabilizing plate. MATERIALS AND METHODS: Among twenty three cases of unstable intertrochanteric fractures treated with DHS and additional TSP between January 2002 to December 2004, seventeen cases over sixty years old were reviewed with minimal follow up of one year. We analyzed the type of fracture by AO classification, the age of patient, sex, the cause of trauma in seventeen cases. We evaluated the lag screw slippage, the change of neck-shaft angle and lateral displacement of greater trochanter, the period of union by comparison of last follow up radiographs with immediate postoperative radiographs. The fixation failure is defined that displacement of lag screw tip is more than 3 mm or cut out of the screw from the femoral head. RESULTS: The period of union was average 12.8 weeks. The lag screw slippage was average 8.22 mm. The change of neck-shaft angle was average 2.66 degree. No lateralization of greater trochanter was noted in twelve cases, but five cases showed average 0.8 mm (range: 0.5~1 mm) of lateral displacement of greater trochanter. There was not fixation failure. CONCLUSION: In unstable intertrochanteric fracture, the addition of a TSP to the dynamic hip screw can decrease a change of neck shaft angle, a lag screw slippage, and prevent lateral displacement of greater trochanter.