Suprascapular nerve entrapment caused by a large hematoma of the scapula: a case report.

BACKGROUND: Suprascapular nerve entrapment is a rare disorder that is frequently misdiagnosed as another disease. The suprascapular nerve is commonly entrapped at the following two sites: the suprascapular and spinoglenoid notches. Nerve entrapment at the spinoglenoid notch causes infraspinatus muscle weakness and atrophy. Patients present with posterior shoulder pain and weakness. Magnetic resonance imaging is used to confirm the diagnosis of a spinoglenoid cyst and nerve compression. Open or arthroscopic aspiration or decompression is indicated for patients with cysts in whom conservative treatment has failed and those with cysts associated with suprascapular nerve compression. CASE PRESENTATION: Herein, we describe the case of a 49-year-old man with suprascapular nerve entrapment caused by a large cyst, namely, a hematoma, in the superior scapular and spinoglenoid notches. Open surgical decompression of the suprascapular nerve was performed owing to an intact rotator cuff and glenoid labrum. CONCLUSION: Posterior shoulder pain promptly resolved without complications.

Risk Factors Associated with Intraoperative Iatrogenic Fracture in Patients Undergoing Intramedullary Nailing for Atypical Femoral Fractures with Marked Anterior and Lateral Bowing.

Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49-87 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p < 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3° in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment.

An Unusual Case of Erdheim Chester Disease (ECD) with Knee Pain: A Case Report.

Background: Erdheim Chester disease (ECD) is a rare, non-Langerhans cell histiocytosis of unknown etiology that occurs in multiple organs. The clinical characteristics of ECD are unknown, making it difficult to diagnose. Case presentation: A 61-year-old woman presented with left knee pain and contracture. She had recent medical problems such as recurrent urinary tract infection, pericardial effusion, and pleural effusion. Simple radiography and magnetic resonance imaging of the knee revealed an osteosclerotic lesion. Under suspicion of malignancy, other radiologic modalities were performed, but there were no significant results showing malignancy. A bone biopsy of the knee lesion led to a final diagnosis of ECD. The patient was treated with systemic steroids and was ultimately tried on PEG-interferon. Conclusion: This report describes an unusual presentation of ECD involving the skeletal system and multiple extraskeletal organs. Owing to its non-specific nature, ECD was notably difficult to diagnose. Therefore, if a patient has knee pain and other multiorgan presentations without malignancy, clinicians should suspect ECD.

Clinical evaluation of usefulness and effectiveness of sitting type continuous passive motion machines in patients with total knee arthroplasty: a study protocol for a single-blinded randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is an important management strategy for patients with knee osteoarthritis (OA) refractory to conservative management. Postoperative range of motion (ROM) exercise is important to recover patients' activities of daily living. Continuous passive motion (CPM) is a machine that provides passive ROM exercises of the knee joint in a pre-defined arc of motion. The short- and long-term effects of CPM exercise are controversial. We hypothesized that the inconsistent results of the CPM exercise are due to poor fitting of CPM machines and measurement errors. This study aims to present a protocol for investigating a new type of CPM machine that could be applied in a sitting position in comparison with the conventional type of CPM machine for patients with unilateral TKAs. METHODS: This study presents the protocol of a prospective, multicenter, single-blinded, three-armed randomized controlled trial (RCT). One hundred and twenty-six patients receiving unilateral TKAs will be recruited at the physical medicine and rehabilitation clinics of two urban tertiary medical hospitals. The patients were randomly divided into three groups with a 1:1:1 allocation. The intervention group will receive two weeks of post-operative rehabilitation using a new type of CPM machine. The control group will receive 2 weeks of post-operative rehabilitation using conventional CPM machines. The third group will receive post-operative rehabilitation with both types of CPM machines. The primary outcome will be the change in the passive ROM of the affected knee joint from baseline to 2 weeks after baseline assessment. The secondary outcomes will be pain and functional measurements, and will include patient-reported outcomes and performance tests surveyed at multiple time points up to 3 months after TKA. DISCUSSION: This is the first RCT to investigate the effect of a new type of CPM machine. The results of this RCT will determine whether the position of the patients during CPM exercise is important in post-operative rehabilitation protocols after TKAs and will provide evidence for the development of proper rehabilitation guidelines after TKAs. TRIAL REGISTRATION: Clinical Research Information Service of Republic of Korea, KCT0005520, Registered on 21 October 2020, https://cris.nih.go.kr/cris/search/detailSearch.do/21750.

Topical Tranexamic Acid Can Be Used Safely Even in High Risk Patients: Deep Vein Thrombosis Examination Using Routine Ultrasonography of 510 Patients.

Background and Objectives: Previous studies regarding tranexamic acid (TXA) in total knee arthroplasty (TKA) investigated only symptomatic deep vein thrombosis (DVT), or did not include high risk patients. The incidence of DVT including both symptomatic and asymptomatic complications after applying topical TXA has not been evaluated using ultrasonography. Materials and Methods: The medical records of 510 patients who underwent primary unilateral TKA between July 2014 and December 2017 were retrospectively reviewed. Because TXA was routinely applied through the topical route, those who had a history of venous thromboembolism, myocardial infarction, or cerebral vascular occlusive disease, were not excluded. Regardless of symptom manifestation, DVT was examined at 1 week postoperatively for all patients using ultrasonography, and the postoperative transfusion rate was investigated. The study population was divided according to the use of topical TXA. After the two groups were matched based on the propensity scores, the incidence of DVT and the transfusion rate were compared between the groups. Results: Of the 510 patients, comprising 298 patients in the TXA group and 212 patients in the control group, DVT was noted in 22 (4.3%) patients. Two patients had DVT proximal to the popliteal vein. After propensity score matching (PSM), 168 patients were allocated to each group. In all, 11 patients in the TXA group and seven patients in the control group were diagnosed with DVT, which did not show a significant difference (p = 0.721). However, the two groups differ significantly in the transfusion rate (p < 0.001, 50.0% in the TXA group, 91.7% in the control group). Conclusions: The incidence of DVT, whether symptomatic or asymptomatic, was not affected by the use of topical TXA. The postoperative transfusion rate was reduced in the TXA group. Topical TXA could be applied safely even in patients who had been known to be at high risk.

Remodified Mason-Allen suture technique concomitant with high tibial osteotomy for medial meniscus posterior root tears improved the healing of the repaired root and suppressed osteoarthritis progression.

PURPOSE: To evaluate the results of the remodified Mason-Allen suture technique concomitant with high tibial osteotomy (HTO) for medial meniscal posterior root tears (MMPRTs). The hypothesis was that this procedure would improve clinical results, prevent progression of knee osteoarthritis and increase the healing rate of the repaired root. METHODS: Total 17 patients of mean 51.5 ± 4.4 years who were underwent this combined procedure for MMPRT completed this study. Lysholm and Hospital for Special Surgery (HSS) scores, Kellgren-Lawrence (KL) grade reflecting osteoarthritis progression were evaluated preoperatively and at the last follow-up. Medial meniscus extrusion (MME) was measured on magnetic resonance imaging preoperatively and at mean 26.1 ± 2.3 months postoperatively. Second-look arthroscopy was performed at mean 25.1 ± 5.3 months postoperatively. The healing status of the repaired root was classified as complete, partial and failed healing. The Outerbridge (OB) grade of the medial femoral condyle (MFC) was compared between index surgery and second-look arthroscopy. RESULTS: Mean follow-up duration was 66.4 ± 6.5 months. Mean Lysholm and HSS mean scores improved significantly from preoperatively to the last follow-up: Lysholm: 56.9 ± 5.4 to 83.5 ± 6.0 (P < 0.001); HSS: 56.1 ± 6.0 to 81.7 ± 7.7 (P < 0.001). The mean mechanical alignment of the lower extremity was corrected from varus to the neutral range at the last follow-up. The preoperative KL grade was not significantly different from the KL grade at the last follow-up (P = 0.071). On MRI, mean MME increased from 3.0 ± 0.7 mm to 3.1 ± 0.7 mm (P = 0.046). Second-look arthroscopy showed 64.7% complete, 29.4% partial and 5.9% failed healing of the repaired root. The initial OB grade of the MFC showed no progression (P = 0.103). CONCLUSIONS: The remodified Mason-Allen suture technique concomitant with HTO for MMPRTs significantly improved clinical outcomes and suppressed OA progression at 66.4 months. However, this procedure produced limited complete healing of the repaired roots in 64.7% of patients. LEVEL OF EVIDENCE: IV.

Patellar fractures in elderly patients: a multicenter computed tomography-based analysis.

INTRODUCTION: This study aimed to demonstrate the characteristics of patellar fractures and evaluate clinical outcomes in elderly patients. PATIENTS AND METHODS: Medical records of patients aged ≥ 60 years who presented with patellar fractures were retrospectively reviewed from an institutionally approved multicenter (five institutions) orthopedic database. Patient characteristics and fracture patterns were identified, and the clinical outcomes were investigated. We compared differences according to the injury mechanism (low- vs. high-energy). RESULTS: A total of 202 patients [mean age, 69.4 years (range, 60-88 years); male, 89, female, 113] were included in this study. The mean follow-up period was 14.8 months (range 6-58 months), and 75% of the fractures were from low-energy injuries. According to the AO /OTA classification, the most common type was type C (136 cases, 67.3%; 33 cases, C1; 23, C2; and 80, C3), followed by type A (39 cases), type B (26 cases), and unclassified (1 case). The unclassified case was an intra-articular marginal impaction without cortical breakage. Computed tomography (CT) revealed that of the cases, 66.8% had an inferior pole involvement; 80.7%, a comminuted fragment; and 10.4%, an impacted fracture. A total of 166 fractures (82.2%) were treated surgically. The mean union time and range of motion were 13.1 weeks and 123.8° (range 30-150°), respectively. The Lysholm score was 82.1 ± 12.0, with 65.7% of the cases having excellent or good function. The complication rate was 12.4% (24 cases), including ten, four, two, and five cases of infection, fixation failure, nonunion, malunion, and pin migration, respectively. The reoperation rate was 26.4%. CONCLUSION: Patellar fractures in the elderly were mostly from low-energy injuries, and types C3 and A1 were the most common. CT images demonstrated high rates of an inferior pole involvement and comminution. The complication and reoperation rates were relatively high.

Huge intrameniscal cyst successfully treated by open debridement and combined arthroscopic and open repair: a case report.

BACKGROUND: Meniscal cysts are not uncommon in clinical practice, with reported incidence rates varying from 1 to 22%. Most meniscal cysts are parameniscal cysts, which are created by extravasation of synovial fluid through the meniscal tear into the adjacent soft tissue. In contrast, intrameniscal cysts in which the fluid collects in the meniscus are very rare. We encountered a teenager with a huge intrameniscal cyst accompanied by a small vertical meniscal tear in the red-white zone of the upper surface of the medial meniscus. A literature search revealed no information regarding the appropriate treatment methods and results for this type of lesion. CASE PRESENTATION: A 14-year-old boy presented to our outpatient clinic because of right knee pain that had been present for the previous 2 months. The patient participated in Hapkido, but had no specific trauma history. Magnetic resonance imaging revealed a huge intrameniscal cyst located in the central parenchyma of the posteromedial corner of the medial meniscus. In addition, one sagittal slice on MRI revealed a vertical tear in the red-white zone of the upper surface of the medial meniscus. The presence of such a tear accompanied by a huge intrameniscal cyst is very unusual. The patient was treated via arthroscopic inside-out meniscal suture repair and open cystic debridement with additional meniscocapsular suturing. During 4 years of magnetic resonance imaging follow-up, the lesion has completely disappeared and the meniscus has successfully recovered its normal form. CONCLUSIONS: Our treatment method may be considered as the first choice for young patients who require surgical treatment for large intrameniscal cysts with accompanying small vertical meniscal tears.

Patella-patellar tendon angle decreases in patients with infrapatellar fat pad syndrome and medial patellar plica syndrome.

PURPOSE: Infrapatellar fat pad (IPFP) syndrome and medial patellar plica (MPP) syndrome are two recognized causes of anterior knee pain. However, diagnosing these syndromes is challenging without arthroscopic examination. The aim of this study was to evaluate sagittal patellar tilt in patients with IPFP syndrome or MPP syndrome by measuring the patella-patellar tendon angle (PPTA) in affected patients. METHODS: Eighty-three patients with anterior knee pain who underwent diagnostic arthroscopy that confirmed isolated IPFP or MPP syndrome from 2011 to 2016 were included in this retrospective study. Patients were divided into Group A (IPFP syndrome, n = 44) and Group B (MPP syndrome, n = 39). The control group included 78 patients without knee pathology who underwent magnetic resonance imaging (MRI) of the knee during the study period. Radiographic measurements, including PPTA, IPFP area, patellar height, axial patellar alignment, patellar tilt, sulcus angle, and lateral trochlear inclination, were made on MRI images by two experienced sports medicine orthopedists. RESULTS: The mean PPTA in each knee-pathology group was significantly smaller than that in the control group (Group A: 137.3° ± 4.9°; Group B: 138.1° ± 3.2°; control group, 141.4° ± 2.9°). There was no significant difference between groups for any other radiographic parameter evaluated. CONCLUSION: The PPTA was significantly smaller in patients with IPFP syndrome or MPP syndrome than in healthy controls. Therefore, sagittal patellar tilt should be included in the routine evaluation of patients with anterior knee pain. Evaluation of PPTA may help to diagnose IPFP syndrome or MPP syndrome. LEVEL OF EVIDENCE: Level IV.

Risk factors for failure of eradicating infection in a single arthroscopic surgical procedure for septic arthritis of the adult native shoulder with a focus on the volume of irrigation.

BACKGROUND: Septic arthritis of a native joint is relatively rare but is still a challenging and important orthopedic emergency. Most previous reports have focused on the clinical outcomes rather than the risk factors for failure in arthroscopic surgery. METHODS: We retrospectively reviewed the records of patients with septic monoarthritis of the shoulder who underwent arthroscopic irrigation and débridement between January 2007 and January 2019. All patients were divided into 2 groups according to recurrence after a single arthroscopic surgical procedure: eradicated group or recurred group. To identify risk factors affecting the recurrence of septic arthritis of the shoulder after arthroscopic surgery, the following parameters were considered: age; sex; involved side; presentation of rotator cuff tear; volume of irrigation; bacterial organism involved; preoperative erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count in blood and joint fluid; diabetes mellitus; and hypertension. We compared the eradicated and recurred groups regarding the presence of potential risk factors. RESULTS: The study included 97 patients with a mean age of 61 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgical procedure in 85 patients. However, a second arthroscopic surgical procedure was necessary in 12 patients (12.4%) because of infection recurrence. No significant differences were found between groups except in the volume of irrigation (P < .001). CONCLUSIONS: Most patients with septic arthritis (87.6%) of native shoulders were effectively treated with a single arthroscopic irrigation and débridement. The amount of irrigation may be the most important factor for preventing the need for additional surgical management.

Anteromedial Meniscofemoral Ligament of the Anterior Horn of the Medial Meniscus: Clinical, Magnetic Resonance Imaging, and Arthroscopic Features.

PURPOSE: To describe the clinical, arthroscopic, and magnetic resonance imaging (MRI) findings of knees with anomalous insertion of the anterior horn of the medial meniscus (AHMM) into the intercondylar notch via an anteromedial meniscofemoral ligament (AMMFL). METHODS: A total of 2,503 arthroscopic knee surgeries performed from July 2003 to October 2016 were reviewed retrospectively to identify knees with an AMMFL. Medical records, arthroscopic photographs, and MRI of identified cases were analyzed. Meniscus width and extrusion were measured on MRI. Fifty patients with a normal meniscus were selected as a control group. RESULTS: A total of 13 (0.52%) patients had an AMMFL with insertion at the intercondylar notch. All cases were diagnosed incidentally during arthroscopy. The characteristics of knee pain were related to surgical pathology. Arthroscopic examination revealed the AMMFL as a band-like structure covering the anterior cruciate ligament. In all cases, the AHMM had no bony attachment to the tibia, and increased mobility was observed on probing of the AHMM. The medial meniscus (MM) was significantly larger than the general size in 8 cases (61.5%). Twelve knees (92.3%) had meniscus tears. On MRI, the AMMFL appeared as a low-signal linear structure arising at the AHMM and coursing superiorly along the anterior cruciate ligament. The mean MM width was greater than that in the control group at the mid-body (P = .030), anterior horn (P = .002), and posterior horn (P = .001). CONCLUSIONS: All cases of AMMFL were found incidentally during arthroscopic surgery, and the AMMFL was a silent lesion. There was no significant meniscal extrusion, although the AHMM had no bony attachment. This is because the AMMFL may act as an anchor for the AHMM. Therefore, the AMMFL should not always be removed. The MM with an AMMFL tended to be larger than the typical MM and may be related to some degree of hypermobility, which raises the risk of meniscal tears. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Can ultrasound-guided nerve block be a useful method of anesthesia for arthroscopic knee surgery?

PURPOSE: This study was performed to compare general anesthesia, spinal anesthesia, and ultrasound (US)-guided nerve block for knee arthroscopic surgery. Also, whether US-guided nerve block is a useful method of anesthesia for arthroscopic knee surgery was investigated. METHODS: In this prospective, randomized study, 400 patients who underwent knee arthroscopy surgery between February 2011 and September 2012 were allocated to one of three groups: spinal anesthesia (n = 100), general anesthesia (n = 100), or US-guided nerve block (n = 200). All patients completed a questionnaire with three questions 6 months after surgery. For the nerve block group, the procedure duration, interval between the procedure and onset of the anesthetic effect, the point of loss of the anesthetic effect, intraoperative, postoperative visual analog scale (VAS) pain score, and discomfort during surgery were assessed. RESULTS: There was no patient in which the anesthetic was changed to another method during the operation. VAS pain score of postoperative 1 h was significantly different between the nerve block (1.4 ± 1.7), spinal anesthesia (1.5 ± 1.1), and general anesthesia groups (6.2 ± 5.1) (P < 0.05). In addition, VAS pain scores at postoperative 6 and 12 h were significantly different among the regional nerve block group (2.2 ± 1.5 and 3.0 ± 1.8, respectively), spinal anesthesia group (5.2 ± 3.2 and 5.1 ± 4.0, respectively), and general anesthesia group (5.2 ± 3.9 and 5.4 ± 4.5, respectively). One hundred and ninety regional nerve block (95 %), 68 spinal anesthesia (68 %), and 75 general anesthesia patients (75 %) reported that they would prefer the same type of anesthesia if they were to undergo knee surgery again; these differences were significant (P < 0.05). There were no long-term complications, such as neurological deficits or infection, after the procedure in all patients. CONCLUSION: Arthroscopic knee surgery, such as meniscal repair or meniscectomy, synovectomy, debridement, and other procedures, was performed safely and effectively under US-guided nerve block. These results indicated that US-guided nerve block for arthroscopic knee surgery is a highly satisfactory and safe procedure without complications and is available for use by any orthopedist. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Pullout failure strength of the posterior horn of the medial meniscus with root ligament tear.

PURPOSE: To evaluate the reparability of the posterior horn of the medial meniscus with root ligament tear by measuring the actual pullout failure strength of a simple vertical suture of an arthroscopic subtotal meniscectomized posterior horn of the medial meniscus. METHODS: From November 2009 to May 2010, nine posterior horns of the medial meniscus specimens were collected from arthroscopic subtotal meniscectomy performed as a treatment for root ligament rupture of the posterior horn of the medial meniscus. Simple vertical sutures were performed on the specimens, and pullout failure load was tested with a biaxial servohydraulic testing machine (Model 8874; Instron Corp., Norwood, MA, USA). The degree of degeneration, extrusion, and medial displacement of the medial meniscus were evaluated with magnetic resonance imaging (MRI). The Kellgren-Lawrence classification was used in standing plain radiography, and mechanical alignment was measured using orthoroentgenography. Tear morphology was classified into ligament proper type or meniscoligamentous junctional type according to the site of the torn root ligament of the posterior horn of the medial meniscus during arthroscopy. RESULTS: The mean pullout failure strength of the posterior horn of the medial meniscus was 71.6 ± 23.2 N (range, 41.4-107.7 N). The degree of degeneration of the posterior horn of the medial meniscus on MRI showed statistically significant correlation with pullout failure strength and Kellgren-Lawrence classification. Pullout failure strength showed correlation with mechanical alignment and Kellgren-Lawrence classification (P < 0.05). CONCLUSIONS: The measurement of pullout failure strength of the posterior horn of the medial meniscus with root ligament tear showed a degree of repairability. The degree of degeneration of the posterior horn of the medial meniscus on MRI showed a significant correlation with the pullout failure strength. The pullout failure strength was also not only correlated with the degree of degeneration of the posterior horn of the medial meniscus, but also with mechanical alignment and Kellgren-Lawrence classification, which represent bony degenerative change.

Preoperative intra-articular steroid injections within 3 months increase the risk of periprosthetic joint infection in total knee arthroplasty: a systematic review and meta-analysis.

OBJECTIVE: Albeit with no disease-modifying effects, intra-articular steroid injections (IASIs) are still widely used to relieve symptoms of knee osteoarthritis. Previous literature has reported conflicting results regarding the safety of IASI in terms of periprosthetic joint infection (PJI) in total knee arthroplasty (TKA). This study tried to determine whether preoperative IASIs increased the risk of PJI, with different time intervals between the injections and surgery. METHODS: A computerized search of MEDLINE, EMBASE, and Cochrane Library was conducted for studies published before October 2022, which investigated the PJI rates of patients who received IASIs before TKA and patients who did not. The primary outcome was the association between preoperative IASI and PJI in TKA. The time point from which IASIs could be applied without risking PJI was also assessed. RESULTS: Fourteen studies, with 113,032 patients in the IASI group and 256,987 patients in the control group, were included. The pooled odds ratio of PJI was 1.13 (95% confidence interval [CI] 1.00-1.27, p = 0.05), indicating no increased risk of PJI. With the time interval < 6 months, the pooled odds ratio was 1.19 (95% CI 0.99-1.43, p = 0.06). However, with the time interval < 3 months, the pooled odds ratio was 1.26 (95% CI 1.06-1.50, p < 0.01). CONCLUSION: IASI is not a safe procedure for patients who are expected to undergo TKA. The time interval between the injections and surgery was an important factor in assessing the safety of IASI. Preoperative injections that were applied within 3 months increased the risk of PJI in TKA.

Postoperative change in the joint-line convergence angle is associated with inaccurate correction in open-wedge high tibial osteotomy.

OBJECTIVE: Accurate correction is a prerequisite for the favorable outcomes of open-wedge high tibial osteotomy (OWHTO). However, previous studies have reported disappointing results regarding correction accuracy despite the use of intra-operative navigation, which implies that a certain factor other than bony components is involved in the inaccurate correction (mainly overcorrection). The joint-line convergence angle (JLCA) can represent soft tissue effects in OWHTO. This study tried to determine whether the postoperative change in the JLCA (∆JLCA) led to inaccurate correction. METHODS: Medical records of 78 OWHTO patients from 2005 to 2021 were retrospectively reviewed. The hip-knee-ankle angle (HKA) was measured with a positive value indicating varus alignment. Inaccurate correction was defined as postoperative HKA < - 3°. The JLCA was measured before and 6 months after surgery on long-standing hip-to-ankle radiographs, and ∆JLCA was defined as the difference between the preoperative and 6-month postoperative JLCAs. ∆JLCA was compared between the accurate correction group and the inaccurate correction group, and a receiver operating characteristic (ROC) curve was used to obtain the cutoff ∆JLCA at which the sensitivity and the specificity for inaccurate correction were maximized. Clinical outcomes were also compared between the groups using the knee injury and osteoarthritis outcome score (KOOS) at final follow-up (60.9 ± 53.3 months postoperatively). RESULTS: Of the 78 patients, inaccurate correction was noted in 10 patients. The overall preoperative and postoperative HKAs were 7.0 ± 3.1° and - 0.4 ± 1.5°, respectively. The accurate correction group and the inaccurate correction group had a difference in ∆JLCA (p = 0.010). However, no significant difference was found in the preoperative HKA (p = 0.529). An ROC curve showed that the cutoff ∆JLCA was 1.9°. In the patients having ∆JLCA ≥ 1.9°, the mean JLCA was 4.9 ± 1.6° preoperatively and 1.7 ± 1.2° postoperatively. In the other patients having ∆JLCA < 1.9°, the mean preoperative and postoperative JLCA were 2.5 ± 1.8° and 2.3 ± 1.8°, respectively. The difference in the preoperative JLCA was significant (p < 0.001). The postoperative KOOS subscales did not differ according to correction accuracy. CONCLUSION: Inaccurate correction in OWHTO, specifically valgus overcorrection, is associated with large ∆JLCA which represents the postoperative change of soft tissue effects. Overcorrection should be checked in cases of large preoperative JLCAs.

Role of the mechanical axis of lower limb and body weight in the horizontal tear and root ligament tear of the posterior horn of the medial meniscus.

PURPOSE: To compare and analyse the relationship between horizontal tear and root ligament tear of the posterior horn of the medial meniscus (PHMM) and the degree of varus in the axis of lower limb and body weight. METHODS: One hundred and nineteen patients underwent surgical treatment as they were diagnosed with medial meniscus tear in our hospital from May 2006 to December 2009. Of these, 19 cases (group 1), underwent partial meniscectomy as they were confirmed to solely have horizontal tear of the PHMM on arthroscopic examination and 27 cases (group 2), underwent subtotal meniscectomy as they were confirmed to solely have root ligament tear of the PHMM on arthroscopic examination, were chosen for retrospective study. Standing radiographs were taken of every case prior to arthroscopic surgery to measure varus angle. Also, we checked body mass index (BMI) of two groups. The difference of varus angle and BMI between two groups were statistically verified using the Levene's test, paired t-test. RESULTS: Group 1 showed mean value of varus angle of 2.30 ± 0.54, and BMI of 25.32 ± 3.23. Group 2 showed mean value of varus angle of 5.64 ± 0.54, and BMI of 25.67 ± 3.12. The degree of varus of group 2 was statistically significantly higher than group 1 (p = 0.002). Comparison between the BMI of two groups showed no statistical significance (p = 0.053). CONCLUSION: Through a comparative study of sole horizontal tear and root ligament tear of the PHMM, the authors have found that sole root ligament tear of the PHMM is more relative to the genu varum than sole horizontal tear of the PHMM. However, body weight was statistically irrelevant to the incidence of the two lesions.

Iatrogenic Vertebral Fracture During Intramedullary Nailing for Femoral Fracture: A Case Report.

CASE: A 73-year-old woman with advanced ankylosing spondylitis (AS) underwent closed reduction and internal fixation using antegrade intramedullary nailing because of midshaft fracture of her right femur. After the surgery had been performed, a fracture and dislocation at T12-L1 was detected. Therefore, emergency spinal decompression and posterior instrumentation placement from T11 to L5 were then performed. CONCLUSION: Patients with advanced AS have a high risk of vertebral fracture, so special care must be taken not to transmit excessive stress on the spine for surgical reduction and manipulation of the lower extremity.

Age and Meniscal Extrusion Are Determining Factors of Osteoarthritis Progression after Conservative Treatments for Medial Meniscus Posterior Root Tear.

BACKGROUND: With a growing understanding of biomechanical disadvantages following medial meniscus posterior root tear (MMPRT), recent studies have focused on surgical repair of MMPRT. Because not all tears are repairable, surgical indications can be properly established when the outcomes of conservative treatments are revealed. This study tried to identify risk factors for osteoarthritis progression after conservative treatments for isolated MMPRT. MATERIALS & METHODS: Patients who had conservative treatments for isolated MMPRT during 2013-2016 were retrospectively reviewed. To evaluate osteoarthritis progression, those who were followed up for ≤3 years and those who already showed advanced osteoarthritis of Kellgren--Lawrence (K-L) grade 4 at the time of diagnosis were excluded. Because patients with varus malalignment were candidates for realignment osteotomy, conservative treatments for MMPRT were applied to patients with well-aligned knees. Osteoarthritis progression was determined based on the K-L grading system, and risk factors including age, sex, body mass index, lower limb alignment, preoperative K-L grade, meniscal extrusion, and the presence of subchondral bone marrow lesion (BML) were analyzed using logistic regression analyses. RESULTS: A total of 42 patients were followed up for 57.4 ± 26.8 months. During that period, osteoarthritis progression was noted in 17 (40.5%) patients. Based on univariate analyses for each risk factor, age, meniscal extrusion, and the presence of subchondral BML were included in the multivariate logistic regression analysis. The results showed that age (p = 0.028, odds ratio = 0.87) and meniscal extrusion (p = 0.013, odds ratio = 9.65) were significant risk factors. A receiver operating characteristic curve found that the cutoff age was 63.5 years, with the area under the curve being 0.72 (sensitivity, 68.0%; specificity, 70.6%). CONCLUSIONS: About two-fifths of patients who had conservative treatments for MMPRT underwent osteoarthritis progression in the mid to long term. Age and meniscal extrusion were determining factors of osteoarthritis progression. The risk for osteoarthritis progression was decreased when the age of patients was over 63.5 years.

Hidden Unstable Flap Should Be Suspected in Treating Intractable Pain from Medial Meniscus Horizontal Tear.

(1) Background: The medial meniscus horizontal tear (MMHT) is known as a lesion that can be treated nonoperatively. However, some patients show persistent pain despite conservative treatments. In arthroscopic surgery for MMHT, surgeons often encounter unexpected unstable flaps, which can explain the intractable pain. This study aimed to determine whether preoperative factors could predict the hidden unstable flaps in MMHT. (2) Materials and Methods: Medical records of 65 patients who underwent arthroscopic partial meniscectomy (APM) for isolated MMHT during 2016-2020 were retrospectively reviewed. APM was indicated when there was no severe chondral degeneration and intractable localized knee pain in the medial compartment did not resolve despite conservative treatments. Unstable flap was confirmed based on arthroscopic images and operation notes. Each of the following preoperative factors were investigated using logistic regression analyses to determine whether they can predict an unstable flap: age, sex, body mass index, lower limb alignment, trauma history, mechanical symptoms, symptom duration, visual analogue scale (VAS), Lysholm score, cartilage wear of the medial compartment, and subchondral bone marrow lesion (BML). (3) Results: Hidden unstable flaps were noted in 45 (69.2%) patients. Based on univariate analyses for each preoperative factor, age, symptom duration, cartilage wear (of the femoral condyle and the tibial plateau), and subchondral BML were included in the multivariate logistic regression analysis. The results showed that symptom duration (p = 0.026, odds ratio = 0.99) and high-grade cartilage wear of the medial femoral condyle (p = 0.017, odds ratio = 0.06) were negatively associated with unstable flaps. A receiver operating characteristic curve was used to calculate the symptom duration at which the prediction of unstable flaps was maximized, and the cutoff point was 14.0 months. (4) Conclusions: More than two thirds of patients suffering intractable pain from MMHT had hidden unstable flaps. However, APM should not be considered when the symptom duration is more than 14 months or high-grade cartilage wear of the medial femoral condyle is noted.