The long-term structural effect of orthoses for pediatric flexible flat foot: A systematic review.

BACKGROUND: We aimed to evaluate the structural effects of the long-term use of orthoses for pediatric flexible flat foot (PFFF) using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies. METHODS: A comprehensive literature search using five databases, namely MEDLINE, the Cochrane Library, Scopus, the Web of Science, and EMBASE, was performed for pertinent articles published before March 30, 2018. Studies with quantitative data on the effects of the long-term use of orthoses for PFFF were included. The search strategy was adapted as appropriate for all other databases searched considering the differences in indexing terms and search syntax for each database. RESULTS: Randomized controlled trials and prospective cohort studies could not prove the estimated effects of orthoses on the medial longitudinal arch. They revealed that flexible flat feet in young children slowly improved with growth, regardless of the type of footwear used. However, three of four case series studies revealed that positive long-term effects could be achieved using orthoses. CONCLUSION: There is no strong evidence that the long-term use of orthoses improved the structural problem of PFFF.

Locking plate versus non-locking plate in open-wedge high tibial osteotomy: a meta-analysis.

PURPOSE: The purpose of this study was to conduct a meta-analysis to determine whether the locking plate or non-locking plate results in better opening-wedge high tibial osteotomy (OWHTO) outcomes. METHODS: The MEDLINE, EMBASE, COCHRANE, and KOREAMED register databases were searched for studies. The eligibility criteria for inclusion in the review were studies that compared the locking plate with the non-locking plate for OWHTO, and those that provided clear descriptions of surgical techniques and outcomes. The key outcomes of interest were union rate, correction loss angle, correction loss rate, and full weight-bearing starting point. The statistical software "RevMan" was used in statistical analysis. RESULTS: Five studies were included in the meta-analysis. Among their reported results, there were no differences in the incidence of union [risk ratio (RR) = 1.01, p = 0.34], non-locking plate was associated with lower incidence of correction maintenance (RR = 1.13, p = 0.0006) and greater angle of correction loss [mean difference (MD) = -2.06, p < 0.00001], and locking plate was associated with a significant improvement in Knee society score and function score (MD = 5.77, p < 0.0001; MD = 7.50, p = 0.0005). CONCLUSIONS: Locking plate provides better clinical outcomes and reduced correction loss rates and angles as compared to non-locking plate for fixation with OWHTO. LEVEL OF EVIDENCE: IV.

Medial Soft-Tissue Realignment Versus Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation: Systematic Review.

PURPOSE: To compare the clinical outcomes between medial soft-tissue surgery and medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation without any evident predisposing factors. METHODS: A literature search was performed on the established medical databases MEDLINE, EMBASE, and the Cochrane register. The inclusion criteria were as follows: English-language papers for recurrent patellar dislocation without any evident predisposing factors, clinical trial(s) with clear description of surgical technique, adult subjects, medial soft-tissue surgery or MPFL reconstruction without combined surgery, and a follow-up longer than 2 years. The methodological quality of all articles was assessed by 2 authors according to the Coleman methodology score. RESULTS: Thirteen studies (mean Coleman methodology score value, 74.1; standard deviation, 11.5) were included in the analysis. Five studies reported the outcomes of patients undergoing medial soft-tissue surgery, compared with 7 studies reporting MPFL reconstruction. Overall, 109 patients underwent medial soft-tissue surgery with a minimum 2-years follow-up, compared with 308 patients of MPFL reconstruction. There was one direct comparative study between medial soft-tissue surgery and MPFL reconstruction. Of the patients who received medial soft-tissue surgery, 0 to 9.7% experienced redislocation, compared with 0 to 10.7% of the MPFL reconstruction group. The ranges of differences in Kujala scores were 23.6 to 31.7 points in patients who underwent medial soft-tissue surgery and 23.11 to 38.8 points in patients who underwent MPFL reconstruction. The ranges of postoperative congruence angles were -14.4° to 8.2° for medial soft-tissue surgery and -7.7° to -5.2° for MPFL reconstruction. The ranges of postoperative lateral patellofemoral angles were 7.9° to 9.4° for medial soft-tissue surgery and 5° to 5.3° for MPFL reconstruction. CONCLUSIONS: All studies on medial soft-tissue surgery and MPFL reconstruction for recurrent patellar dislocation without predisposing factors showed satisfactory outcomes despite the use of numerous surgical techniques, graft types, and follow-up periods. LEVEL OF EVIDENCE: Level IV, Systematic Review.

Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus closed wedge osteotomy.

PURPOSE: Medial opening wedge high tibial osteotomy (HTO) has become increasingly popular as an alternative to lateral closing wedge osteotomy for the treatment of medial compartment knee osteoarthritis with varus deformity. The present systematic review was conducted to provide an objective analysis of total knee arthroplasty (TKA) outcomes following previous knee osteotomy (medial opening wedge vs. lateral closing wedge). METHODS: A literature search of online databases (MEDLINE, EMBASE, Cochrane Library database) was made, in addition to manual search of major orthopaedic journals. The methodological quality of each of the studies was assessed on the Newcastle-Ottawa Scale and Effective Practice and Organization of Care. A total of ten studies were included in the review. There were eight studies with Level IV and two studies with Level III evidence. RESULTS: Eight studies reported clinical and radiologic scores. Comparative studies between TKA following medial opening and lateral closing wedge HTO did not demonstrate statistically significant clinical and radiologic differences. The revision rates were similar. However, more technical issues during TKA surgery after lateral closing wedge HTO were mentioned than the medial open wedge group. The quadriceps snip, tibial tubercle osteotomy, and lateral soft tissue release were more frequently needed in the lateral closing wedge HTO group. In addition, because of loss of proximal tibia bone geometry in the lateral closing wedge HTO group, concerns such as tibia stem impingement in the lateral tibial cortex was noted. CONCLUSION: The present systematic review suggests that TKA after medial opening and lateral closing wedge HTO showed similar performance. Clinical and radiologic outcome including revision rates did not statistically differ from included studies. However, there are more surgical technical concerns in TKA conversion from lateral closing wedge HTO than from the medial opening wedge HTO group. LEVEL OF EVIDENCE: IV.

Clinical Outcome of Posterior Cruciate Ligament Reconstruction With and Without Remnant Preservation.

PURPOSE: The purpose of this study was to analyze clinical outcomes in patients who underwent posterior cruciate ligament reconstruction (PCLR) with and without remnant preservation. METHODS: A search of the literature was performed with the established medical databases Medline, Embase, and the Cochrane Register. Two authors screened the selected articles for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria. The inclusion criteria were as follows: English-language articles on isolated posterior cruciate ligament injury; clinical trials with a clear description of surgical technique; outcome evaluation using a well-defined knee score, arthrometry, and posterior stress radiography; follow-up longer than 2 years; and a Coleman Methodology Score (CMS) of 65 points or greater. The methodologic quality of all articles was assessed by 2 authors according to the CMS. RESULTS: Eleven studies were included, with a mean CMS of 78.9 points (SD, 5.37 points). There was no direct comparative study between remnant-preserving PCLR and standard PCLR. At final follow-up, the knees of 72% to 100% of patients who underwent remnant-preserving PCLR and 41% to 95% of patients who underwent standard PCLR were rated as normal or nearly normal on the International Knee Documentation Committee subjective knee assessment. Patients who underwent remnant-preserving PCLR showed an increase of 16.4 to 47 points in Lysholm scores, and patients who underwent standard PCLR showed an increase of 22 to 29 points. The ranges of mean postoperative side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing were 0.7 to 2.8 mm in patients who underwent remnant-preserving PCLR and 1 to 3.5 mm in patients who underwent standard PCLR. The ranges of mean postoperative side-to-side differences on stress radiography were 2.2 to 5 mm in patients who underwent remnant-preserving PCLR and 4.7 to 6 mm in patients who underwent standard PCLR. CONCLUSIONS: All studies on PCLR with remnant preservation showed satisfactory outcomes despite using numerous surgical techniques, graft types, intervals from injury to surgery, and follow-up periods. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Tunnel volume enlargement after posterior cruciate ligament reconstruction: comparison of achilles allograft with mixed autograft/allograft--a prospective computed tomography study.

PURPOSE: The purpose of this study was to evaluate and compare femoral and tibial tunnel volume enlargement (TVE) after arthroscopic posterior cruciate ligament (PCL) reconstruction by remnant bundle preservation using Achilles allograft or mixed graft. METHODS: Seventy-eight patients undergoing primary arthroscopic single-bundle PCL reconstruction were initially included. Fifty-six of these patients underwent follow-up for a minimum of 1 year postoperatively and were divided into 2 groups: group A received Achilles allograft (n = 27), and group B received mixed graft (n = 29). The clinical evaluation included the International Knee Documentation Committee rating, Lysholm score, Tegner activity score, and Telos stress test (Telos, Weiterstadt, Germany). All of the patients were evaluated for TVE by computed tomography scanning at the 1-year follow-up; the results were compared with the data from 1 week postoperatively. A volume increment of more than 44%, which indicates 2 mm of widening of the tunnel diameter, was defined as TVE. RESULTS: The overall incidence of TVE after single-bundle PCL reconstruction was 3.6% (2 of 56 patients) for the femoral tunnel and 5.4% (3 of 56 patients) for the tibial tunnel. The overall mean tunnel difference between 1 week postoperatively and the final follow-up was 12.0% for the femoral tunnel and 10.6% for the tibial tunnel. The mean femoral TVE was 10.1% in group A and 13.8% in group B; the mean tibial TVE was 9.9% in group A and 11.2% in group B. These differences were not statistically significant. The functional outcome was improved in both groups, showing no statistical difference at the 1-year follow-up. CONCLUSIONS: The femoral and tibial TVE caused by single-bundle PCL reconstruction using the remnant bundle-preservation technique showed no significant differences between the Achilles allograft and the mixed graft over a short-term follow-up. Furthermore, the overall incidence of TVE in PCL reconstruction in this study was low. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Effect of Medial Closing Wedge Distal Femoral Varization Osteotomy on Coronal Ankle and Hindfoot Alignment.

BACKGROUND: To date, only a few studies have reported postoperative changes in coronal ankle alignment after valgus knee correction through medial closing wedge distal femoral varization osteotomy (MCWDFO). This study aimed to measure the changes of MCWDFO on coronal ankle and hindfoot alignment. METHODS: We retrospectively reviewed the radiographic findings of 27 consecutive patients (34 cases) with knee valgus malalignment who underwent MCWDFO for either lateral knee joint osteoarthritis (OA) or recurrent patellar subluxation/dislocation (RPD). Several radiographic parameters were measured and compared based on the reason for operation, followed by the status of preoperative hindfoot alignment (hindfoot alignment angle [HAA] > 4 degrees, varus; -4 degrees ≤HAA ≤ 4 degrees, neutral; HAA < -4 degrees, valgus) in each group. RESULTS: Overall, pre- and postoperative hindfoot alignments were within the neutral alignment range and were not significantly changed after the operation (P > .05). Nineteen cases were for lateral knee OA and 15 were for RPD, respectively. In both groups, preoperative neutral hindfoot alignments accounted for the largest portion (52.6% in the lateral OA group; 80.0% in the RPD group). Postoperatively, regardless of the reason for operation, hindfoot alignments changed toward the neutral range in all subgroups (ie, no changes in the preoperative neutral group; increased in the valgus group; decreased in the varus group). CONCLUSION: We recommend that surgeons leave the hindfoot untouched when they plan the MCWDFO to correct knee joint valgus malalignment concomitant with hindfoot valgus or varus deviation as the hindfoot malalignment appears to change toward the neutral range postoperatively. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Avascular necrosis of the capitellum after surgical treatment of a coronal shear fracture of the distal humerus: A case report.

INTRODUCTION AND IMPORTANCE: Coronal shear fractures of the distal humerus are rare and are expected to have a high incidence of avascular necrosis (AVN) due to the avascular nature of the capitellar bone fragment and limited soft tissue attachment. However, according to the literature published thus far, AVN is infrequently reported, and some studies suggest that it does not have a significant impact on clinical outcomes. CASE PRESENTATION: Two female patients, one aged 72 and the other 70, presented with coronal shear fractures of distal humerus. Both patients were diagnosed with AVN of the capitellum 7 and 10 months after undergoing open reduction and internal fixation. One patient underwent hardware removal, while the other patient declined due to the absence of discomfort. However, at their final follow-up, both patients exhibited good clinical results. CLINICAL DISCUSSION: The occurrence of AVN may be related to the severity of the initial injury, including posterior comminution. While some studies suggest that AVN of the capitellum may not affect clinical outcomes, hardware removal may be required in cases where there is intra-articular protrusion of the hardware. CONCLUSION: Although AVN is a rare occurrence, even when it does occur, it may not significantly affect clinical outcomes. In this study, AVN may be associated with initial injury severity, and surgical treatment may make it possible to develop AVN. Moreover, considering the timing of the occurrence of AVN, it is believed that a close follow-up of more than one year will be required.

Diagnosis and treatment for primary Candida parapsilosis infection of the native knee joint: A case report.

INTRODUCTION AND IMPORTANCE: Candida arthritis is a very rare disease and Candida parapsilosis infection of the native knee joint is extremely rare. It is challenging to diagnose and treat because the clinical manifestations, laboratory and radiologic findings are not specific and not well defined. We report the rare case of C. parapsilosis infection of the native knee joint. CASE PRESENTATION: A 67-year-old man visit outpatient clinic for persistent right knee pain and effusion. Inflammatory markers were elevated and the biochemical studies of joint fluid showed elevated WBC counts. Under assumption of septic arthritis, arthroscopic irrigation and debridement were performed. C. parapsilosis was isolated on intraoperative knee joint culture. Fluconazole was used under diagnosis of Candida arthritis. Once there were no relapse of infection, total knee arthroplasty was implemented. CLINICAL DISCUSSION: As Candida arthritis can be lead to poor prognosis, Candida arthritis should be considered in patients with untreated knee infections. Blood and radiographic examination, and fungus culture from the knee joint should be accompanied for early diagnosis. Total knee arthroplasty may be considered after treatment of Candida infection with fluconazole. Prognosis was similar compared with patients who underwent total knee arthroplasty for primary knee osteoarthritis. CONCLUSION: If patients complaint persistent knee pain with or without effusion, surgeons should consider the possibility of Candida infection. After diagnosis of Candida arthritis, proper antifungal agents should be used for treatment of infection. After the infection has cleared up, total knee arthroplasty can be planned.

A rare intramuscular osteolipoma: A case report.

INTRODUCTION: Lipomas are frequently presented in adults and account for almost 50% of all soft-tissue tumors. Osteolipomas are rare and usually located in the intraosseous region or adjacent to bone. It is very unusual for osteolipomas with no connection to bony structures. We report a rare intramuscular osteolipoma independent of bone tissue. PRESENTATION OF CASE: We report a case of a 58-year-old man with painful and progressively enlarging mass in the right lower leg. A plain X-ray and computed tomography (CT) scans revealed a large homogeneous, low-fat density mass containing an oval shape calcification without bone connection. MRI showed a circumscribed mass in the peroneus muscle with a large calcified component. The patient underwent surgical excision of the mass. Histologically, benign osteolipoma was the final diagnosis. No recurrence was observed at six months follow-up. DISCUSSION: Lipoma is a common benign soft tissue neoplasm but osteolipoma is rare. Most cases osteolipomas are connected with bone. independent of bone tissue has been reported in very few cases. Most of them occurred in the head and neck area. The pathogenesis of osteolipoma is still not clear. Although CT and MRI are useful for differential diagnosis, care should be taken because sometimes they are indistinguishable from well-differentiated liposarcomas. Excisional biopsy is useful for definitive diagnosis. CONCLUSION: Although ossifying lipomas are very rare, it is important to keep them in mind when a lesion with adipose tissue in combination with ossification is encountered.

Safe Zone for Medial Open-Wedge Supramalleolar Osteotomy of the Ankle: A Cadaveric Study.

BACKGROUND: The purpose of this present study was to determine the incidence of lateral cortical fracture depending on the plane of osteotomy in medial open-wedge supramalleolar osteotomy (SMO) and to define a safe zone through which a medial open-wedge SMO could be performed with minimal risk of lateral cortical fracture. MATERIALS AND METHODS: Matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from 7 males and 3 females (average age = 63.9 [range 49-75] years). In group A, a safe zone-level medial open-wedge SMO (plane of osteotomy oriented to the proximal one-third of the intrasyndesmosis) was performed, and in group B, a higher-level medial open-wedge SMO (plane of osteotomy oriented to the suprasyndesmosis) was performed. RESULTS: In group A, 7 of the 10 limbs had no lateral cortical fracture, and 3 had lateral cortical fracture, but all of the fractured limbs were stable during the medial open-wedge SMO procedure. In group B, 2 of 10 limbs had no lateral cortical fracture and 8 had lateral cortical fracture. Three of the 8 fractured limbs were stable, but 5 were unstable during the medial open-wedge SMO procedure. The incidence of lateral cortical fracture in group B was significantly higher compared to group A (P = .04). CONCLUSIONS: According to the present findings, lateral cortical fracture was less likely to occur when open-wedge SMO was at the plane of the proximal one-third of the intrasyndesmosis, the so-called "safe zone," than at the plane of the suprasyndesmosis. CLINICAL RELEVANCE: A safe zone for medial open-wedge SMO to prevent lateral cortical fracture during the medial open-wedge SMO procedure was identified.

Is Bone Grafting Necessary in Opening Wedge High Tibial Osteotomy? A Meta-Analysis of Radiological Outcomes.

PURPOSE: Bone grafting in opening wedge high tibial osteotomy (OWHTO) is still controversial. The purpose of this study is to compare the radiological outcomes of OWHTO with bone graft (autogenous, allogenous, and synthetic bone graft) and those without bone graft. MATERIALS AND METHODS: PubMed, MEDLINE, EMBASE and Cochrane Register of Studies databases were searched using specific inclusion and exclusion criteria for radiological studies involving OWHTO with bone graft and without bone graft groups. All reported delayed union, nonunion and correction loss were analyzed. Data were searched from the time period of January 2000 through July 2014. In addition, a modified Coleman methodology score (CMS) system was used to assess the methodological quality of the included studies. RESULTS: Twenty-five studies with a mean CMS value of 77 (range, 61 to 85 score) were included. In total, 1,841 patients underwent OWHTO using 4 different procedures for bone graft: autobone graft (n=352), allobone graft (n=547), synthetic bone graft (n=541) and no bone graft (n=401). There was a similar tendency for delayed union, nonunion and correction loss rate among the osteotomy space filling methods. CONCLUSIONS: The meta-analysis showed there was a similar tendency for radiological union and correction maintenance among patients undergoing OWHTO regardless of the type of bone in all of the studies. However, the currently available evidence is not sufficient to strongly support the superiority of OWHTO with bone graft to OWHTO without bone graft.

Anatomical Single-bundle Anterior Cruciate Ligament Reconstruction Using a Freehand Transtibial Technique.

PURPOSE: In anatomical single-bundle (SB) anterior cruciate ligament (ACL) reconstruction, the traditional transtibial approach can limit anatomical placement of the femoral tunnel. SURGICAL TECHNIQUE: We present a novel three-point freehand technique that allows for anatomic SB ACL reconstruction with the transtibial technique. MATERIALS AND METHODS: Between January 2012 and December 2012, 55 ACL reconstructions were performed using the three-point freehand technique. All the patients were followed for a minimum of 12 months post-operatively. Clinical evaluation was done using the Lysholm score and International Knee Documentation Committee (IKDC) grade. All patients were analyzed by 3-dimensional computed tomography (3D CT) at 1 week after surgery. RESULTS: The mean Lysholm score improved from 68.2±12.7 points preoperatively to 89.2±8.2 points at final follow-up. At final follow-up, the IKDC grade was normal in 42 patients and nearly normal in 13 patients. None of the patients had a positive pivot shift test, anterior drawer test and Lachman test at final follow-up. The anatomical position of the femoral tunnel was confirmed on 3D CT scans. CONCLUSIONS: The three-point freehand technique for SB transtibial ACL reconstruction is a simple, anatomic technique showing good clinical results.

Radiographic evaluation of complete and incomplete discoid lateral meniscus.

OBJECTIVES: The aim of this retrospective study was (1) to evaluate the radiographic features to differentiate arthroscopically confirmed complete and incomplete discoid lateral meniscus (DLM) (2) to determine the cutoff values for any parameter that was found to differentiate complete from incomplete DLM. MATERIALS AND METHODS: We retrospectively analyzed plain knee radiographs of 130 arthroscopically proven DLM. Seventy-nine patients had complete DLM and 51 patients incomplete DLM. Knee radiographs from 52 patients with arthroscopically proven normal lateral meniscus acted as control group. Radiographic parameters measured included fibular height, lateral joint space, condylar cutoff sign, height of lateral tibial spine, obliquity of lateral tibial spine, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. RESULTS: Among radiographic parameters, high fibular head, widening of the lateral joint space and femoral condylar cutoff sign showed statistically significant (p<0.0001) differences between complete and incomplete DLM. At specific threshold points of fibular height<11 mm, lateral joint space>6 mm and condylar cutoff sign<0.80, the diagnosis of complete DLM revealed 87.3% sensitivity, 81.6% specificity and 78.4% positive predictive value (PPV) for the fibular height, 81.0% sensitivity, 86.6% specificity and 83.1% PPV for the lateral joint space, and 86.1% sensitivity, 83.5% specificity and 80% PPV for the condylar cutoff sign. CONCLUSIONS: Radiographic features of fibular height, lateral joint space and condylar cut off sign can be used for screening of a complete type of DLM. However, radiographs are not a reliable screening tool for an incomplete DLM. LEVEL OF EVIDENCE: IV, Case Series.

Spontaneous healing of a displaced bucket-handle tear of the lateral meniscus in a child.

Bucket-handle tears less frequently occur in the lateral meniscus than in the medial meniscus. An 11-year-old male patient complained of painful swelling and locking due to a displaced bucket-handle tear of the lateral meniscus. We recommended an arthroscopic surgery; however, the patient left the hospital without surgical treatment. Six weeks afterwards, he returned without any complain of pain and he regained full range of motion. The final follow-up magnetic resonance imaging showed reduction of the torn meniscal fragment without any signal changes suggestive of a meniscal tear. We report a rare case of an isolated displaced bucket-handle tear of the lateral meniscus in an 11-year-old patient that healed spontaneously without surgical intervention.

Localized pigmented villonodular synovitis of the proximal tibiofibular joint.

Pigmented villonodular synovitis (PVNS) is a rare disease. It is a benign neoplastic process typically affecting young to middle-aged adults and most commonly involving the knee, hip, and shoulder joints. The symptoms include diffuse pain and swelling with discomfort. We report a rare case of localized PVNS originating at the proximal tibiofibular joint in a 39-year-old female patient with radiologic changes for short duration of time. The clinical history, plain radiographs, magnetic resonance imaging, and pathologic findings of the reported patient were reviewed. Complete surgical excision was performed and there was no evidence of recurrence after one-year follow-up.