Cartilage regeneration and long term survival in medial OA knee patients treated with HTO and OATS.

Background: Osteoarthritis (OA) of the knee, in most instances primarily, affects medial compartment of knee. Combining Osteochondral Autologous Transfer System (OATS) with Medial Open-Wedge High Tibial Osteotomy (MOWHTO) may represent an integrated approach to sustaining long-term knee functionality in OA patients. Materials and methods: From 2009 to 2016, combined OATS and MOWHTO was performed in 66 knees of 63 patients with medial compartment knee OA. Cartilage regeneration was assessed by 2nd look arthroscopy and Knee function was assessed by knee society scoring (KSS) pre-operatively and post-operatively. The survival rate of MOWHTO plus OATS was assessed. Failure is characterized by the need to convert into total knee replacement. Results: The KSS knee score (from 48.3 to 90.4) and function score (from 42.6 to 88.7) showed a statistically significant improvement (p-value of <0.0001) at a mean follow-up period of 9.49 years. Second look arthroscopy done at the time of implant removal showed 100 % cartilage regeneration with even hyaline cartilage regeneration in 49 out of 57 knees assessed and partial regeneration in 8 knees. The Kaplan Meier survivorship analysis was 96.7 % at the mean 9.49 years after surgery. Only 2 patients needed TKA conversion in follow-up. Conclusion: Combining OATs and valgus MOWHTO provides good option to successfully manage patients of OA and varus malalignment. This resulted in significant improvement in knee function, lowering pain intensity, good cartilage regeneration, and a high survivorship rate for 10 years postoperatively.

ACL Reconstruction using Achilles Allograft in a Case of Genu Recurvatum with Supracondylar Osteotomy.

Introduction: People with post-polio syndrome usually have some residual deformities. Genu recurvatum is very commonly seen in such cases which are a risk factor for anterior cruciate ligament (ACL) injury due to the altered biomechanics. To the best of our knowledge, this is the first report in literature presenting ACL reconstruction in a limb with genu recurvatum deformity treated with supracondylar osteotomy. Case Report: A 49-year-old female with genu recurvatum and history of polio presented with pain and instability. Staged procedure of supracondylar osteotomy and ACL reconstruction Achilles allograft was done. Conclusion: ACL tears in a poliotic limb with genu recurvatum deformity can be a challenging case. Precise pre-operative preparation can aid in managing the case successfully.

Can status of superficial medial collateral ligament proximal tibial attachment predict progression of OA knee?

Objective: This study aims to identify, whether knee OA progression is affected by the sMCL proximal tibial attachment status and probably is the first one trying to identify such association. Methods: 90 OA knees and 80 normal knees were evaluated using radiographs and MRI for severity of OA knee (K-L grade), sMCL length (L), distance of distal tibial attachment of sMCL from tibial articular surface (I), MCL ratio (L/I) and proximal tibial attachment of sMCL, attached or detached. Results: Mean age of the study population was 52.93 ± 19.52 years. 106 were female knees and 59 were male. Status of sMCL proximal tibial attachment had highly statistically significant negative correlation with severity of OA knee (p-value <0.001). The status of sMCL proximal tibial attachment shows statistically significant negative correlation with sMCL distal tibial attachment and significant positive correlation MCL ratio. But there was no significant correlation with sMCL length. Knees with lower MCL ratio (L/I) have significant higher grade of OA knee as they shows statistically significant negative correlation. Conclusion: Detached sMCL proximal tibial attachment is found to be a strong predictor of OA knee progression. Assessing the status of sMCL proximal tibial attachment will not only help the physician identifying medial stability of the knee, but also assist in planning therapy for the knee in question.

Association of Gap Healing With Angle of Correction After Opening-Wedge High Tibial Osteotomy Without Bone Grafting.

BACKGROUND: Studies have reported that opening wedge high tibial osteotomy (OWHTO) without bone grafting has outcomes that are similar to or even better than those of OWHTO with bone grafting, especially after use of a locking plate. However, a consensus on managing the gap after OWHTO has not been established. PURPOSE: To determine the degree of gap healing achieved without bone grafting, the factors associated with gap healing, and whether additional gap healing would be obtained after plate removal. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective study included 73 patients who underwent OWHTO without bone grafting between 2015 and 2018. Patients in the study were divided into 2 groups based on the correction angle: small correction group (<10°; SC group) and large correction group (≥10°; LC group). The locking plate used in OWHTO was removed at a mean of 13.5 months after surgery in 65 patients. Radiographic indexes were measured: gap filling height, gap vacancy ratio (GVR), and osteotomy filling index. The acceptable gap healing was defined as an osteotomy filling index ≥3. The factors related to gap healing around the osteotomy site were selected after multicollinearity analysis. RESULTS: Although both groups achieved acceptable gap healing regardless of the correction angle, the SC group showed higher and earlier gap healing than did the LC group (gap healing rate 81.4% in the SC group vs 41.7% in the LC group at 3 months postoperatively). The GVR was 8.6% in the SC group and 15.3% in the LC group at 12 months after surgery (P = .005). Both the amount of time that elapsed after surgery and the correction angle were associated with gap healing (P < .05). Additional gap healing was observed after plate removal, as the GVR decreased 2.7% more in the patients with plate removal than in patients who did not have plate removal (P = .012). CONCLUSION: All patients achieved acceptable gap healing without bone graft. The degree of gap healing was higher in the SC group and increased over time. Gap healing was promoted after plate removal. Considering the results of this study, a bone graft is not necessary in routine OWHTO in terms of gap healing.

Combination of Cylindrical Autologous Bone Grafting Technique With a Metallic Block Insertion in Open-Wedge High Tibial Osteotomy.

Open-wedge high tibial osteotomy (OW-HTO) is an effective surgical intervention for medial-compartment knee osteoarthritis. However, the osteotomized gap might be a disadvantage in OW-HTO because it can cause problems such as delayed bone union or loss of correction. These issues can be minimized by using autologous bone graft in the osteotomized gap, which is known to be the fastest and most clinically satisfactory gap filler. The primary mechanical stability of the osteotomy site in OW-HTO is essential for early weight bearing after surgery. Therefore, we introduce the combination of a cylindrical autologous bone grafting technique and a metallic block insertion for faster bone union and better primary stability of the site in OW-HTO. We expect that the described procedure will enable early postoperative weight bearing and, thereby, allow an early return to normal function.

Preventing ceramic liner fracture after Delta ceramic-on-ceramic total hip arthroplasty.

BACKGROUND: The results of total hip arthroplasty (THA) with use of Delta ceramic articulation were successful at medium term follow-up. The use of this newest ceramic has markedly reduced the incidence of ceramic head fractures, but not the incidence of ceramic liner fractures. We tested a hypothesis that the ceramic fractures are prevented by use of a metal shell with 18° inner taper angle and a stem design with a reduced neck geometry. METHODS: We conducted a prospective multicenter study of cementless THA with use of 32/36-mm Delta ceramic bearing, Exceed ABT metal shell and Taperloc stem. We evaluated ceramic fracture, noise, clinical results, radiological changes and survival rate at a minimum of 5-year follow-up. RESULTS: From April 2010 to February 2012, 246 patients (274 THAs) were enrolled. Among them, 224 patients (130 men and 94 women, 250 hips) were followed-up for 5-8 years (mean 6.0 years). Ceramic malseating or fracture did not occur in any patient. Eight patients (8 hips, 3.2%) reported noise. Mean Harris hip score was 84 points at the latest follow-up. All acetabular and femoral components had bone-ingrown stability. Two hips were revised due to recurrent dislocation and periprosthetic fracture. The survival rate was 99.6% at 8 years postoperatively. CONCLUSION: Ceramic fractures can be prevented by a use of (1) 32/36-mm Delta ceramic bearing, (2) metal shell with 18° taper angle, and (2) stem with a reduced neck geometry. However, noise remains a concern of the Delta ceramic bearing. LEVEL OF EVIDENCE: Therapeutic level II.

Optimal rotational positioning of tibial component in total knee arthroplasty: determined by linker surgical technique using a high definition CT.

INTRODUCTION: The rotational alignment of femoral and tibial components is an important determinant of the success of Total Knee Arthroplasty (TKA). The optimal rotational position of the tibial component is still unclear. The purpose of this study was (1) to determine the pre-operative S-TEA (surgical-transepicondylar axis) derived tibialanteroposterior (AP) axis angle and postoperative tibial component axis angle using a "Bird's eye" high-definition CT image in TKA performed by Linker surgical technique; (2) to determine the femorotibial mismatch angle; and (3) to determine the optimal tibial component rotation in a well-aligned femoral and tibial components. MATERIALS AND METHODS: 55 knees in 49 osteoarthritis patients who underwent primary TKA by Linker surgical technique were evaluated. Preoperative tibial AP axis angle, and the postoperative tibial component axis angle were measured. Rotational mismatch between femoral and tibial components was also measured. RESULTS: The mean angle of the pre-operative tibial AP axis was 17.8° ± 4.0°, ranging from 4.3° to 25.4°. The mean angle of the post-operative tibial component axis was 16.2° ± 4.9°, ranging from 3.8° to 25.2°. The mean postoperative tibial component axis line was at 14.2% ± 11.9%. CONCLUSION: Because of the variability of pre-operative S-TEA derived tibial AP axis angle, the tibial component axis angle was also variable among the knees, but the two angles bore a strong correlation to each other. Based on our results, the optimal axis of the tibial component passes about halfway through the medial edge and medial one-third of the tibial tuberosity. LEVEL OF EVIDENCE: Level II.

Faster union rate and better clinical outcomes using autologous bone graft after medial opening wedge high tibial osteotomy.

PURPOSE: To compare the radiological bone union rate after medial opening wedge high tibial osteotomy (MOW-HTO) and stabilization using a TomoFix™ plate (Synthes, Oberdorf, Switzerland) in three patient groups. METHODS: Retrospective analysis of 137 knees that underwent MOW-HTO between January 2014 and January 2017 was using a TomoFix™ plate. Osteotomy gaps were filled with ß-tricalcium phosphate (ß-TCP) (group A), left unfilled (group B), and subject to autologous bone graft and ß-TCP (group C). Radiological bone union using simple radiography was determined by a modified version of the Brosset et al. osteotomy filling index. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and Lysholm score. Statistical analyses using the Chi-square and ANOVA tests were performed between the groups. RESULTS: The mean time for radiological bone union was 8.3 ± 3.1 months in group A, 7.2 ± 3.2 in group B and 3.4 ± 1.5 in group C (p = 0.001). There was statistically significant faster bone union in Group C. If the opening distance was more than 10 mm, group A united in 8.6 ± 3.6 months, group B in 8.8 ± 3.4, and group C in 3.5 ± 1.7 (p = 0.001). IKDC and Lysholm knee scores improved significantly (p = 0.004 for IKDC and 0.001 for Lysholm knee scores) in group C when compared to groups A and B at sixth month follow-up. At final follow-up, there was no difference in IKDC and Lysholm knee scores. Less delayed union occurred in group C. CONCLUSIONS: MOW-HTO with autologous bone graft and ß-TCP had the fastest radiological bone union and best clinical scores at 6 month follow-up. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

D-hole breakage of 2 angular stable locking plates for medial opening-wedge high tibial osteotomy: Analysis of results from 12 cases.

An adequate stable fixation implant should be used for medial opening-wedge high tibial osteotomy (MOWHTO) to promote rapid bone healing without complications. To date, the highest fixation stability has been observed for angular stable locking plates. However, there is still little medical literature regarding breakage of these plates. The purpose of the present study was to report the results of plate breakage around D-hole with the use of both types of locking plate fixation for MOWHTO.Medical records of 12 patients who experienced plate breakage after MOWHTO with either a TomoFix or OhtoFix plate between August 2013 and August 2016 were retrospectively reviewed.A total of 12 patients (7 males and 5 females) who experienced plate breakage at the screw hole just above the osteotomy were evaluated (age, 63 ±â€Š8 years; body mass index (BMI), 28 ±â€Š2 kg/m; opening gap height, 12 ±â€Š2 mm). There were 9 patients (75%) with plate breakage and loss of correction necessitating revision surgery, and 11 patients (92%) had lateral cortical hinge fractures postoperatively. Of the 9 patients with loss of correction necessitating revision surgery, 4 had a TomoFix plate and 5 had an OhtoFix plate. The only statistically significant association with broken plates lost reduction was the presence of lateral cortical hinge fractures (P = .003), but there was no significant association with age, gender, BMI, diabetes, smoking, plate type, opening gap height, and material used to fill the wedge. In addition, mean knee society score in the 12 patients was significantly higher postoperatively than preoperatively (P < .001).Since the amount of plate breakage was just over 1% and with only 12 in total, no true conclusion can be made with certainty. However, in the face of no lateral hinge or cortical disruption, there is a 99% success rate with the plate described. If the lateral hinge is disrupted, a restriction of activity or weight bearing may be needed.

Hybrid closed wedge high tibial osteotomy improves patellofemoral joint congruity compared with open wedge high tibial osteotomy.

PURPOSE: To evaluate clinical outcomes and radiographic changes in patellofemoral (PF) joint congruity between open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge HTO (HCWHTO). METHODS: From 2011 to 2013, 36 knees in 31 patients who underwent OWHTO and 21 knees in 17 patients who underwent HCWHTO were evaluated in this retrospective study with a minimum 5-year follow-up. Radiological outcomes including hip-knee-ankle angle (HKA), femoral patellar height index (FPHI), preoperative PF osteoarthritis (OA) grade, medial and lateral joint spaces of the PF joint, and congruence angle were measured. Clinical parameters including the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee Score (OKS) were also evaluated. Preoperative and final follow-up values for each procedure were compared in outcome analyses. RESULTS: Mean preoperative HKA and the degree of PF-OA were significantly more severe for patients treated with HCWHTO compared with those treated with OWHTO (p = 0.001, p = 0.0001). Mean postoperative FPHI was significantly decreased with proximalization of the patella in HCWHTO (p = 0.01) but showed no significant change in OWHTO (n.s.). Regarding PF joint congruity after HCWHTO, lateral joint space and congruence angle were significantly improved (p = 0.0001, p = 0.005), while medial joint space was not significantly changed (n.s.). After OWHTO, congruence angle showed no significant difference (n.s.), but medial and lateral joint spaces were significantly decreased (p = 0.0001, p = 0.018). There were no significant differences in KOOS and OKS between the groups (n.s., n.s.). CONCLUSIONS: Although degrees of varus knee and PF-OA were more severe in HCWHTO than those in OWHTO, HCWHTO led to improved PF joint congruity, and its mid-term clinical outcomes were equivalent to those of OWHTO. Therefore, in patients with varus knee combined with PF-OA preoperatively, HCWHTO is a more effective treatment than OWHTO. LEVEL OF EVIDENCE: Therapeutic level III.

Could larger diameter of 4th generation ceramic bearing decrease the rate of dislocation after THA?

BACKGROUND: Fourth generation (Delta) ceramic bearing was developed to reduce dislocation after total hip arthroplasty (THA) by increasing the head diameter. We tested a hypothesis that 32/36 mm Delta ceramic bearing decreases the dislocation rate. We also evaluated ceramic-related complications and early outcome of this thin liner-on-large head ceramic bearing. METHODS: We performed a prospective study on patients who underwent THA with use of 32/36 mm Delta ceramic bearing. The dislocation rate was compared with the historical dislocation rate of third generation 28 mm ceramic bearing. We also evaluated ceramic fracture, squeak, short-term results and survival. Follow-up period was minimum 2 years. RESULTS: Between April 2010 and February 2012, we enrolled 250 consecutive patients (278 hips). All patients received cementless prostheses. Four patients (4 hips) who received metal shells ≤ 46 mm and 28 mm heads were excluded. Three patients died and 2 patients were lost within 2 years. The remaining 241 patients (269 hips) were followed for 24-46 months. There were 142 men (161 hips) and 99 women (108 hips) with a mean age of 53.7 years (range, 17-75 years) at the index operation. Dislocation occurred in three hips (1.1%). An old age was a risk factor for dislocation. Ceramic fracture and squeaking did not occur in any patient. Mean Harris hip score was 90.3 points at the latest follow-up. All acetabular and femoral components had bone-ingrowth stability. No hip had detectable wear or osteolysis. The survival was 99.3% in the best case scenario and 97.8% in the worst at 48 months. CONCLUSIONS: Total hip arthroplasty with use of 32/36 mm Delta ceramic bearing showed lower incidence of hip dislocation compared with 28 mm third generation ceramic bearing. A caution should be paid to prevent a fall in senile patients even though a large head is used. The short-term results of THA with this type of ceramic articulation are encouraging and we did not find any ceramic-related complications.

Comparison of results of medial opening-wedge high tibial osteotomy with and without subchondral drilling.

PURPOSE: The purposes of this study were to compare the results of medial opening-wedge high tibial osteotomy (MOWHTO) with and without subchondral drilling and to assess the formation of fibrocartilage at 2 years postoperatively. METHODS: Patients were divided into 2 groups. Thirty knees were treated with osteotomy and subchondral drilling (group 1), and 31 knees were treated with osteotomy alone (group 2). Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of formation of fibrocartilage on second-look arthroscopy, the articular cartilage was classified as having either no change from initial surgery (grade I) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade II). In addition, maturation of the appearance of the cartilage was defined. The appearance was considered mature if the chondral defects were evenly covered with fibrocartilage. It was considered immature if there was white scattering or only partial coverage with fibrocartilage. RESULTS: In group 1 the mean Knee Society knee score and function score were 67.3 ± 8.2 points and 66.5 ± 14.3 points, respectively, preoperatively. At 2 years postoperatively, they improved to 91.2 ± 6.4 and 92.8 ± 10.0, respectively (P = .001 and P = .001, respectively). In group 2 the mean Knee Society knee score and function score were 63.7 ± 13.9 points and 66.8 ± 9.1 points, respectively, preoperatively. At 2 years postoperatively, they improved to 92.5 ± 5.3 points and 92.2 ± 8.0 points, respectively (P = .001 and P = .001, respectively). There were no significant differences in the postoperative Knee Society knee score and function score at 2 years' follow-up between the groups (P = .389 and P = .806, respectively). Grade II regeneration was achieved in the medial femoral condyle articular cartilage in 100% of knees in group 1 and 94% of knees in group 2 (P = .492). Maturation of the cartilage was found in the medial femoral condyle articular cartilage in 10% of knees in group 1 and 3% of knees in group 2 (P = .354). There was no significant difference in the formation of fibrocartilage between the groups. CONCLUSIONS: Subchondral drilling had no effect on the outcome at 2 years after MOWHTO. In addition, there was no significant difference in the formation of fibrocartilage with or without subchondral drilling. Therefore subchondral drilling is not necessary after MOWHTO. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy: a randomized, controlled study.

PURPOSE: The purpose of this study was to evaluate the efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy regarding the postoperative pain level. METHODS: From January 2011 to January 2012, 70 patients underwent medial opening-wedge high tibial osteotomy. Thirty-five patients were randomly assigned to receive no injection (group I), and 35 patients were assigned to receive periarticular multimodal drug injection (group II). These 2 groups were compared regarding the postoperative pain level, frequency of additional nonsteroidal anti-inflammatory drug injections, total amount of patient-controlled analgesia, and number of times that patients pushed the patient-controlled analgesia button at each time interval. Statistical results were based on multivariate analysis of variance and repeated-measures analyses. RESULTS: Multivariate analysis of variance of mean visual analog scale (VAS) scores over the 2-week postoperative period showed statistical significance (P < .001). Repeated-measures analysis yielded a statistically significant difference (P = .001) for the time-by-treatment interaction, showing a clear periarticular multimodal drug injection benefit over time based on VAS scores. In addition, the mean number of times that patients pushed the patient-controlled analgesia button differed significantly between groups over time (P = .01). The VAS scores, frequency of additional nonsteroidal anti-inflammatory drug injections, mean number of times that patients pushed the patient-controlled analgesia button, and mean total amount of fentanyl consumption differed significantly within each group over time (P < .001 for all variables). However, the frequency of additional nonsteroidal anti-inflammatory drug injections and mean total amount of fentanyl consumption did not differ significantly between groups over time (P = .822, P = .529, and P = .282). Opioid- and injection-related complications were not found. CONCLUSIONS: This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively. LEVEL OF EVIDENCE: Level I, high-quality randomized controlled trial with statistically significant differences.

Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy.

PURPOSE: The purposes of this study were to evaluate regeneration of the articular cartilage after medial opening-wedge high tibial osteotomy for knees with medial-compartment osteoarthritis and to assess the clinical outcome and cartilage regeneration according to the postoperative limb alignment at 2 years postoperatively. METHODS: The study involved 159 knees in 159 patients. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of cartilage regeneration, the articular cartilage was classified into 2 stages as no regenerative change (grade 1) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade 2) on second-look arthroscopy. Maturation of the cartilage regeneration was defined as even coverage with fibrocartilage. "Immaturation" of the cartilage regeneration was defined as white scattering with fibrocartilage or partial coverage with fibrocartilage. Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. We divided the knees into 3 groups according to the postoperative limb alignment. Group A comprised knees with a mechanical tibiofemoral angle of 0° or less. Group B comprised knees with a mechanical tibiofemoral angle greater than 0° and less than 6°. Group C comprised knees with a mechanical tibiofemoral angle of 6° or greater. RESULTS: Grade 2 regeneration was achieved in the medial femoral condyle articular cartilage in 92% of knees and in the medial tibial plateau articular cartilage in 69% of knees. Maturation of the cartilage regeneration was found in the medial femoral condyle articular cartilage in 4% of knees and in the medial tibial plateau articular cartilage in 1% of knees. At follow-up, no significant differences were seen between clinical outcomes and initial cartilage degeneration (P = .338) or cartilage regeneration (P = .699). Regeneration of the medial femoral condyle articular cartilage was found in 75% of group A knees, 95% of group B knees, and 92% of group C knees. Significant differences were seen between cartilage regeneration and clinical outcomes (P = .001), as well as postoperative limb alignment (P = .018). Clinical and regeneration results were better in group B than in groups A and C. CONCLUSIONS: The degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by newly regenerated cartilage at 2 years after adequate correction of varus deformity by medial opening-wedge high tibial osteotomy without cartilage regeneration strategies. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Comparative study of medial opening-wedge high tibial osteotomy using 2 different implants.

PURPOSE: The purpose of this study was to perform a retrospective clinical and radiographic evaluation after opening-wedge high tibial osteotomy (HTO) using a short spacer plate (Aescula; B. Braun Korea, Seoul, South Korea) and rigid long plate (TomoFix plate; Mathys, Bettlach, Switzerland) at follow-up 2 years postoperatively. METHODS: We performed 94 opening-wedge HTOs with the Aescula plate (group I) and 92 HTOs with the TomoFix plate (group II). Patients underwent clinical and radiographic evaluations preoperatively and at 2 years postoperatively. Clinical evaluations were performed with Knee Society scores. Radiographic analysis included the mechanical tibiofemoral angle (mTFA) and the slope of the tibia angle with preoperative and postoperative full weight-bearing anteroposterior whole-leg views, as well as anteroposterior, lateral, and Merchant views of the knee. We measured the mTFA. In addition, we evaluated the complications in each group. The follow-up period was 2 years. RESULTS: At follow-up 2 years postoperatively, we observed an overall complication rate of 38% in group I and 26% in group II (P = .083). We found plate-related complication rates of 20% in group I and 9% in group II (P = .039). Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. The mean mTFA was -6.0° ± 3.2° in group I and -4.6° ± 2.8° in group II preoperatively (P = .262). The mean mTFA was 1.0° ± 3.1° in group I and 1.5° ± 2.3° in group II at the latest follow-up (P = .034). In group I, the mean Knee Society knee score and function score were 60.0 ± 12.9 and 57.9 ± 26.8, respectively, preoperatively. They improved to 92.1 ± 8.1 and 89.0 ± 15.1, respectively, at follow-up (P = .001 and P = .001, respectively). In group II, the mean Knee Society knee score and function score were 57.5 ± 14.8 and 57.4 ± 22.1, respectively, preoperatively. They improved to 95.5 ± 5.4 and 95.0 ± 7.6, respectively, at follow-up (P = .001 and P = .001, respectively). In addition, the mean postoperative knee score and function score in group II were higher than those in group I (P = .001 and P = .001, respectively). CONCLUSIONS: We have shown a high plate-related complication rate and a significant loss of correction during a short-term follow-up period (2 years) after opening-wedge HTO using the new short spacer HTO plate compared with the rigid long plate. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The accuracy of the extramedullary and intramedullary femoral alignment system in total knee arthroplasty for varus osteoarthritic knee.

PURPOSE: The intramedullary (IM) femoral alignment system does not alway guarantee accuracy of the component position in the total knee arthroplasty (TKA). In some cases, the extramedullary (EM) femoral alignment system in total knee arthroplasty (TKA) is a useful alternative surgical option to adjust femoral component alignment. In the EM technique, accuracy of the femoral head center location is mandatory. The purpose of this prospective randomized study was to compare the alignment after TKA using two different femoral alignment systems. METHODS: From January 2009 to December 2009, 91 patients (106 knees) with osteoarthritis underwent TKA. The IM femoral alignment system was used in 50 TKAs, and the EM system was used in 56 TKAs. We measured the coronal, sagittal alignment of the femoral component, and overall alignment from full-length standing. Anteroposterior radiographs were taken 1 year after surgery. RESULTS: The overall limb alignment was 0.2° ± 1.9° varus in the EM group and 1.1° ± 1.9° valgus in the IM group (p = 0.001). The coronal alignment of the femoral component was 90.0° ± 1.1° in the EM group and 90.3° ± 1.2° in the IM group, not statistically different (n.s.). The sagittal alignment of the femoral component was 2.3° ± 1.7° in the EM group and 2.5° ± 1.0° in the IM group (n.s.). Clinically acceptable overall limb alignment was achieved in 91.1 % of EM group and 84.0 % of IM group (n.s.). CONCLUSION: The present study suggests that by applying our EM technique that uses a newly designed mechanical axis marker system, the alignment of the femoral component and overall limb alignment is reliable and at least as accurate as the standard IM technique. LEVEL OF EVIDENCE: I.

No difference in total blood loss, haemoglobin and haematocrit between continues and intermittent wound drainage after total knee arthroplasty.

PURPOSE: The purpose of this prospective randomized study was to compare the visible, hidden, total blood loss and postoperative haemodynamic change of 4-h clamping and nonclamping of the drain after TKA. The hypothesis in the present study was that intermittent drain clamping with injection of diluted epinephrine solution would decrease the visible, hidden blood loss and reduction of postoperative haemoglobin or haematocrit change after TKA. METHODS: From January 2010 to January 2011, 100 TKAs were performed at our hospital. In group I (50 knees), drainage was clamped for the first 4 postoperative hours with injection of diluted epinephrine solution. In group II (50 knees), drainage was not clamped without injection of diluted epinephrine solution. Two drains with an external diameter of 3.2 mm were inserted into the knee joint. We checked the amount of drainage recorded at 6, 12, 24, and 48 h postoperatively. Also, we checked the haemoglobin and haematocrit on the preoperation, first, 5th and 10th postoperative days. We analysed the transfusion rate, the possible adverse issues with clamping drainage, and the range of motion of the knee. RESULTS: The mean total bloody drainage was significantly less in group I than group II (560.7 ± 249.9 mL vs 978.3 ± 327.5 mL) (p < 0.001). The decrease of haemoglobin and haematocrit after surgery was not significant between the two groups (n.s.). The hidden blood loss was significantly more in group I than group II (541.1 ± 439.4 mL vs 32.1 ± 21.9 mL) (p < 0.001). So, total blood loss showed no significant difference between the two groups (1,101.8 ± 373.6 mL vs 1,010.4 ± 385.9 mL) (n.s.). The postoperative range of motion and transfusion rate between the two groups were not significant (n.s.). But immediate wound problem, such as oozing, was significantly more in group I (p < 0.001). CONCLUSION: It is not necessary to perform the intermittent drain clamping with injection of the diluted epinephrine solution in TKA because there is no impact on the postoperative haemoglobin and haematocrit. If anything, the intermittent drain clamping with injection of the diluted epinephrine solution increased the hidden blood loss and immediate wound problem than nonclamping without injection of the diluted epinephrine solution.

Arthroscopic, suture anchor repair through a novel medial quadriceptal portal for medial meniscal root tear.

Current options for meniscal root repair include repair into trans-osseous bone tunnels, trans-osseous suture passage for surface fixation, and suture anchor fixation. Suture anchor repair techniques have been developed since it eliminates the issue of the suture abrasion, tunnel drilling, and distal fixation inherent to trans-osseous tunnel. We present a description of a new variation in the more vertical suture anchor repair technique for meniscal root tear using a novel medial quadriceptal portal. Level of evidence Therapeutic, Level V.

High early failure rate of the Columbus posterior stabilized high-flexion knee prosthesis.

BACKGROUND: Most studies report high survivorship rates for TKAs, however, we observed higher than anticipated rates of dislocation and femoral component loosening after implanting a Columbus posterior stabilized prosthesis. QUESTIONS/PURPOSE: We therefore determined (1) the incidence of dislocation and aseptic loosening that occurred after implantation of posterior stabilized high-flexion prostheses in TKAs, (2) the causative factors of dislocation and aseptic femoral component loosening when comparing two designs of prostheses, and (3) the mechanisms of dislocation. METHODS: We retrospectively reviewed 319 patients who underwent 384 TKAs from May 2007 to July 2008. These patients had been assigned alternately to receive a Scorpio posterior stabilized knee prosthesis (Group I, 158 patients, 187 knees) or a Columbus posterior stabilized knee prosthesis (Group II, 161 patients, 197 knees). We followed the patients with clinical and radiographic evaluations for a minimum of 24 months (mean, 26 months; range, 24-38 months). Ten retrieved prostheses were examined visually. RESULTS: Ten dislocations (5.1%; 10 of 197 knees) and seven aseptic loosenings of femoral components (3.6%; seven of 197 knees) occurred in Group II at a mean of 10.9 months postoperatively. However, no dislocation or loosening occurred in patients in Group I. Most dislocations were associated with varus flexion or flexion rotation movements during normal daily activities. The cam jump distance at 90º flexion for the Columbus prosthesis was lower than for the Scorpio prosthesis. CONCLUSIONS: We observed a high rate of early failure during short-term followup after implantation of a Columbus posterior stabilized prosthesis. It appears that early failures of the Columbus design were related to a different cam-post design attributable to a low jump distance during knee flexion. We no longer recommend using this device. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Isolated fracture of the ceramic head after third-generation alumina-on-alumina total hip arthroplasty.

BACKGROUND: While most reports of component fracture following alumina-on-alumina total hip arthroplasty have involved the acetabular liner, few have involved fracture of the alumina femoral head. In the present multicenter study, we investigated ceramic head fractures in a cohort of patients who underwent third-generation alumina-on-alumina total hip arthroplasty. METHODS: We performed a retrospective study of 312 patients (367 hips) who underwent alumina-on-alumina total hip arthroplasty without cement at four participating centers with the use of a 28-mm BIOLOX forte femoral head and a BIOLOX forte liner from July 2001 to October 2003. Three hundred and five patients (359 hips) were evaluated at a mean of forty-five months postoperatively. Clinical follow-up with use of the Harris hip score and radiographic evaluation were performed at six weeks; at three, six, and twelve months; and every six months thereafter. Retrieved ceramic implants were examined by means of visual inspection. RESULTS: Five hips (1.4%) in five patients were revised because of a ceramic head fracture during the follow-up period. The ceramic head fractures occurred during normal daily activities at a mean of 22.6 months postoperatively. A short neck had been used in all five hips in which a fracture occurred, compared with 121 (34.2%) of the 354 hips in which a fracture did not occur (p = 0.009). The fracture involved a circular crack along the circumference of the thinnest portion of the head component at the proximal edge of the bore. The fracture also involved multiple vertical cracks extending radially along the longitudinal axis from the circumference of the circular crack line to the lower edge of the head component. CONCLUSIONS: In the present study, the rate of ceramic head fracture associated with one design of a short-neck modular alumina femoral head was 1.4% (five of 359). The extent to which these findings are generalizable to other designs that utilize this type of femoral head is unknown.