Many surgeons assess biological activity of fracture nonunion by the presence or absence of callus using radiograph. However, it is difficult to assess biological activity only by radiographic appearance. Bone scintigraphy reflects blood supply and bone metabolism and is possibly useful to assess biological activity in nonunion cases. We hypothesized that poor callus visualization did not always mean lack of biological activity.Introduction
Hypothesis
The therapeutic potential of hematopoietic stem cells for fracture healing has been demonstrated with mechanistic insight of vasculogenesis and osteogenesis enhancement. Lnk has recently been proved an essential inhibitory signaling molecule in SCF-c-Kit signaling pathway for stem cell self-renewal demonstrating enhanced hematopoietic and osteogenic reconstitution in Lnk-deficient mice. We investigated the hypothesis that down regulation of Lnk enhances regenerative response via vasculogenesis and osteogenesis in fracture healing. A reproducible model of femoral fracture was created in mice. Immediately after fracture creation, mice received local administration of the following materials with AteloGene, 10μM (1)Lnk siRNA, (2)control siRNA.Introduction
Methods
The cementless acetabular component fixed with several screws is one of the most widely used approaches in THA. These screws rely on contact pressure and the resultant friction between the screw head and the cup to control translation and angulation of the prosthesis. However, intraoperative change of the acetabular component alignment during screw fixation should be hardly detected. Acetabular component alignment can be assessed using computer-assisted navigation systems with realtime adjustments for component position. The purpose of the current study was to evaluate intraoperative change of acetabular component alignment during screw fixation using navigation system. Primary THAs were performed in 74 hips using CT based fluoroscopic matching navigation system (VectorVision, BrainLAB). The patients were 18 men and 56 women with a mean age of 64.4 years (range, 47–78 years) at operation. Intraoperative acetabular component inclination and anteversion were measured at the time of press-fit, and after screw fixation using the cup verification function in the system. Mean of the absolute difference between at the time of press-fit and after screw fixation was evaluated as intraoperative change of acetabular component. We measured the distance from the center of the femoral head to the inter-teardrop line as a horizontal and vertical reference on the postoperative radiograph. The number of screws was also investigated.Background
Patients and Methods
In order to permit soft tissue balancing under more physiological conditions during total knee arthroplasties (TKAs), we developed an offset type tensor to obtain soft tissue balancing throughout the range of motion with reduced patella-femoral (PF) and aligned tibiofemoral joints and reported the intra-operative soft tissue balance assessment in cruciate-retaining (CR) and posterior-stabilized (PS) TKA [1, 2]. However, the soft tissue balance in unicompartmental knee arthroplasty (UKA) is unclear. Therefore, we recently developed a new tensor for UKAs that is designed to assist with soft tissue balancing throughout the full range of motion. The first purpose of the present study is to assess joint gap kinematics in UKA. Secondly, we attempted to compare the pattern in UKA with those in CR and PS TKA with the reduced PF joint and femoral component placement, which more closely reproduces post-operative joint alignment. Using this tensor, we assessed the intra-operative joint gap measurements of UKAs performed at 0, 10, 30, 45, 60, 90, 120 and 135° of flexion in 20 osteoarthritic patients. In addition, the kinematic pattern of UKA was compared with those of CR and PS TKA that were calculated as medial compartment gap from the previous series of this study.Backgrounds
Methods
Appropriate intraoperative soft tissue balancing is recognized to be essential in total knee arthroplasty (TKA). However, it has been rarely reported whether intraoperative soft tissue balance reflects postoperative outcomes. In this study, we therefore assessed the relationship between the intra-operative soft tissue balance measurements and the post-operative stress radiographs at a minimum 1-year follow-up in cruciate-retaining (CR) TKA, and further analyzed the postoperative clinical outcome. The subjects were 25 patients diagnosed with osteoarthritis with varus deformity and underwent primary TKA. The mean age at surgery was 72.0 ± 7.5 years (range, 47–84 years). The Surgeries were performed with the tibia first gap technique using CR-TKA (e motion, B. Braun Aesculap) and the image-free navigation system (Orthopilot). We intraoperatively measured varus ligament balance (°, varus angle; VA) and joint component gap (mm, center gap; CG) at 10° and 90° knee flexion guided by the navigation system, with the patella reduced. At a minimum 1-year follow-up, post-operative coronal laxity at extension was assessed by varus and valgus stress radiographs of the knees with 1.5 kgf using a Telos SE arthrometer (Fa Telos) and that at flexion was assessed by epicondylar view radiographs of the knees with a 1.5-kg weight at the ankle. After calculating postoperative VA and CG from measurements of radiographs, measurements and preoperative and postoperative clinical outcome, such as Knee Society Clinical Rating System (Knee score; KSS, Functional score; KSFS) and postoperative knee flexion, were analyzed statistically using linear regression models and Pearson's correlation coefficient.Introduction
Methods
Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association proposed the clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the elderly population with high risk of fall and ambulatory disability caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS has not been well evaluated. In the present study, we analyzed the early post-operative functional recovery after TKA using 2 simple performance tests to diagnose MADS. Fifty patients with varus type osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 44 female and 6 male patients. The mean age of the patients was 71.6 years (range, 59 to 84 years). Patients were subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation. Secondary one leg standing time with open eyes was measured to assess balancing ability. 2 tests were performed pre-operatively, 2 weeks after surgery and at discharge (23.8 days po). MADS was defined to be diagnosed if TUG and one leg standing time was not less than 11 seconds and/or less than 15 seconds respectively. Each parameter was compared among at above mentioned three time points -using a repeated measured analysis of variance (p<0.05).Introduction
Material & Method
Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups.Background
Patients and Methods
Although both accurate component placement and adequate soft tissue balance have been recognized as essential surgical principle in total knee arthroplasty (TKA), the influence of intra-operative soft tissue balance on the post-operative clinical results has not been well investigated. In the present study, newly developed TKA tensor was used to evaluate soft tissue balance quantitatively. We analyzed the influence of soft tissue balance on the post-operative knee extension after posterior-stabilized (PS) TKA. Fifty varus type osteoarthritic knees implanted with PS-TKAs were subjected to this study. All TKAs were performed using measured resection technique with anterior reference method. The thickness of resected bone fragments was measured. Following each bony resection and soft tissue releases, we measured soft tissue balance at extension and flexion of the knee using a newly developed offset type tensor. This tensor device enabled quantitative soft tissue balance measurement with femoral trial component in place and patello-femoral (PF) joint repaired (component gap evaluation) in addition to the conventional measurement between osteotomized surfaces (osteotomy gap evaluation). Soft tissue balance was evaluated by the center gap (mm) and ligament balance (°; positive in varus) applying joint distraction forces at 40 lbs (178 N). Active knee extension in spine position was measured by lateral X-ray at 4 weeks post-operatively. The effect of each parameter (soft tissue balance evaluations, thickness of polyethylene insert and resected bone) on the post-operative knee extension was evaluated using simple linear regression analysis. P<0.05 was considered statistically significant.Objective
Materials and Methods
In cruciate-retaining total knee arthroplasty (TKA), among many factors influencing post-operative outcome, increasing the tibial slope has been considered as one of the beneficial factors to gain deep flexion because of leading more consistent femoral rollback and avoiding direct impingement of the insert against the posterior femur. In contrast, whether increasing the tibial slope is useful or not is controversial in posterior-stabilized (PS) TKA, Under such recognition, accurate soft tissue balancing is also essential surgical intervention for acquisition of successful postoperative outcomes in TKA. In order to permit soft tissue balancing under more physiological conditions during TKAs, we developed an offset type tensor to obtain soft tissue balancing throughout the range of motion with reduced patello-femoral(PF) and aligned tibiofemoral joints and have reported the relationship between intra-operative soft tissue balance and flexion angles. In this study, we therefore assessed the relationship between intra-operative soft tissue balance assessed using the tensor and the tibial slope in PS TKA. Thirty patients aged with a mean 72.6 years were operated PS TKA(NexGen LPS-Flex, Zimmer, Inc. Warsaw, IN) for the varus type osteoarthritis. Following each bony resection and soft tissue release using measure resection technique, the tensor was fixed to the proximal tibia and femoral trial prosthesis was fitted. Assessment of the joint component gap (mm) and the ligament balance in varus (°)was carried out at 0, 10, 45, 90and 135degrees of knee flexion. The joint distraction force was set at 40lbs. Joint component gap change values during 10-0°,45-0°, 90-0°, 135-0° flexion angle were also calculated. The tibial slopes were measured by postoperative lateral radiograph. The correlation between the tibial slope and values of soft tissue balance were assessed using linear regression analysis.Introductions
Materials and methods
Achieving high flexion after total knee arthroplasty (TKA) is one of the most important clinical results, especially in eastern countries where the high flexion activities, such as kneeling and squatting, are part of the important lifestyle. Numerous studies have examined the kinematics after TKA. However, there are few numbers of studies which examined the kinematics during deep knee flexion activities. Therefore, in the present study, we report analysis of mobile-bearing TKA kinematics from extension to deep flexion kneeling using 2D-3D image matching technique. The subjects were 16 knees of 8 consecutive patients (all women, average age 75.9), who underwent primary mobile-bearing PS TKA (P.F.C. sigma RP-F: Depuy Orthopedics Inc., Warsaw, IN, USA) between February 2007 and May 2008. All cases were osteoarthritis with varus deformity. Postoperative radiographs were taken at the position of extension, half-squatting and deep flexion kneeling 3 month after the surgery, and the degrees of internal rotation of the tibial component was measured by 2D-3D image matching technique. Pre- and post-operative ROM was recorded. Then, we compared the absolute value and relative movement of tibial internal rotation between extension, half-squatting and deep flexion kneeling, and evaluated the correlation of the ROM and the internal rotation.Introduction
Materials and Methods
Total knee arthroplasty (TKA) with a computer-assisted navigation system has been developed to improve the accuracy of the alignment of osteotomies and implantations. One of the most important goals of TKA is to improve the flexion angle. Although accurate soft tissue balancing has been recognized as an essential surgical intervention influencing flexion angle, the direct relationship between post-operative flexion angle and intra-operative soft tissue balance during TKA, has little been clarified. In the present study, therefore, we focused on the relationship between them in cruciate-retaining (CR) TKA with a navigation system. The subjects were 30 consecutive patients (2 men, 28 women), who underwent primary CR TKA (B. Braun Aesculap, e-motion) between May 2006 and December 2009. TKAs were performed using a image-free navigation system (OrthoPilot; B. Braun Aesculap, Tuttlingen, Germany). All cases were osteoarthritis with varus deformity. Average patient age at the time of surgery was 74.0 years (range, 62-86 years). After all bony resections and soft tissue releases were completed appropriately using a navigation system with tibia-first gap technique, a tensor was fixed to the proximal tibia and the femoral trial was fitted. Using the tensor that is designed to facilitate soft tissue balance measurements throughout the range of motion with a reduced patello-femoral (PF) joint and femoral component in place, the joint component gap and ligament balance (varus angle) were measured after the PF joint reduced and femoral component in place (Fig.1). Assessments of joint component gap and ligament balance were carried out at 0°, 30°, 60°, 90°, 120° flexion angle, which were monitored by the navigation system. Joint component gap change values during 30°- 0°, 60°- 0°, 90°- 0°, 120°- 0° flexion angle were calculated. The correlation between post operative flexion angles and pre-operative flexion angle, intra-operative joint component gaps, joint component gap change values and ligament balances were assessed using linear regression analysis.Introduction
Materials and methods
Using a tensor for total knee arthroplasty (TKA) that is designed to facilitate soft tissue balance measurements with a reduced patello-femoral (PF) joint, we examined the influence of pre-operative deformity on intra-operative soft tissue balance during posterior-stabilized (PS) TKA. Joint component gap and varus angle were assessed at 0, 10, 45, 90 and 135° of flexion with femoral trial prosthesis placed and PF joint reduced in 60 varus type osteoarthritic patients. Joint gap measurement showed no significant difference regardless the amount of pre-operative varus alignment. With the procedures of soft tissue release avoiding joint line elevation, however, intra-operative varus angle with varus alignment of more than 20 degrees exhibited significant larger values compared to those with varus alignment of less than 20 degrees throughout the range of motion. Accordingly, we conclude that pre-operative severe varus deformity may have the risk for leaving post-operative varus soft tissue balance during PS TKA.
Recently, many researches of minimal incision surgery (MIS) total knee arthroplasty (TKA) have been reported, however very few of these contain clinical results. Regardless of this, MIS TKA is widely promoted as an improvement over traditional TKA. Although traditional TKA allows for excellent visualization, component orientation, fixation, and has been associated with remarkable long-term implant survival, many patients expect an extremely small incision, minimal or no pain and discomfort associated with their surgery, and certainly no increase in the complication rate. While there is some evidence that short term benefits may occur, there is concern that there may be an increase in complications with the use of MIS technique. We report here cases that malalignments in early phase were occurred after MIS TKAs. A consecutive series of MIS TKA for varus osteoarthritis undertaken by 2 surgeons at 2 centers during 2-year priod (2006–2007) was reviewed. During this interval, 50 MIS TKAs were performed. The mean age was 75.6 years (range 54 to 88 years). Cases for post-operatively infection were excluded. There were 2 cases that early failures due to varus sinking of tibial component were confirmed in early phase (7 and 3 months after primary surgery). We analyzed data between early failed cases and non-failed cases. Patients with early failure were younger, which showed a trend toward significance (p=0.11; failed; 66.5, non-failed; 75.9 years). There was no difference in amount of both medial and lateral side of distal femoral cut between early failed cases and non-failed cases. Proximal tibial cut was significantly larger in early failed cases compared with non-failed cases (p=0.01; failed; 16.5±4.5, nonfailed; 11.4±6.6). There was no difference in Femorotibial angle (FTA) after surgery between them. Substantial backgrounds of occurring early failure after MIS TKA are not still clarified, however, very early failure were occurred in patients, who had significant large cut of proximal tibia, in our experienced cases. MIS TKA may lead to varus imbalance due to increased amount of bony cut and decreased medial soft tissue release. Henceforth, the high prevalence of MIS failures occurring in early phase is disturbing, because of limited working space and warrants further investigation.
However, optimal duration for CFNB to decrease pain and accelerate rehabilitation program after TKA has not been addressed. We, therefore, compared three groups of patients which had different duration of CFNB (0, 2, and 5days) in this study.
Outcomes including visual analog scale (VAS) pain scores and range of motion (ROM) were compared at 1st, 3rd, 6th, 14th and 21th days after surgery. In addition, the postoperative date when patients could walk stably with parallel bar, walker, or T-cane were recorded and compared.
ROM did not show significant difference among the three groups over postoperative days 1st to 21st (P>
0.05), although groups with the CFNB showed greater ROM at all time points. The CFNB 5 days group obtained stable walking ability with T-cane earlier than other groups (P<
0.05). No patient had any side effect by having CFNB in this study.
The French word debridement means the removal of the foreign matter or devitalised tissue from a lesion until surrounding healthy tissue is exposed. Arthroscopic techniques facilitated the removal of the intra-articular torn menisci, loose bodies, degenerated articular cartilage, and osteophytes. However, debridement procedure itself cannot induce tissue regeneration thus, the basic goal of the procedure is relief of pain. If pain can be relieved by non-surgical means very few patients can be considered for arthroscopic management. Debridement of early osteoarthritic knees can be carried out with a minimally invasive procedure with extremely low risk of infection and morbidity. However, it should be understood that this procedure is basically indicated for early degenerative knee disease with mechanical problems such as torn menisci or flap lesion of the cartilage. The general principle is to resect and remove less tissue and preserve the anatomical structure as much as possible. For example in the case of a degenerated horizontal tear of the medial meniscus, the torn fragment can be left alone as long as the remaining segment is not unstable. Arthroscopic removal and shaving of the fibrillated articular cartilage can minimise and reduce crepitation and abnormal sensation of the patello-femoral and tibio-femoral joint but the articular cartilage will not regenerate by this procedure. The longer-term knee function will be better if the anatomical structure is preserved as much as possible. With increasing awareness of the important functions of the meniscus and the improved understanding of the operative procedure, arthroscopic meniscal repair has become a widely accepted method of treatment for the symptomatic peripheral meniscal tears in the younger athletic population. However, in the patients with degenerative arthritis this procedure is rarely recommended due to the degenerative nature of the repaired meniscus itself. Recent studies and publications have shown that articular cartilage defects in the younger population can be managed by cartilage cell transplantation, periosteal or perichondral graft, osteochondral autograft, and osteochondral allograft. Good results can be expected by these procedures as long as the cartilage defect is contained and the rest of the cartilage is healthy. Unfortunately, this is not the story for most of the degenerative knee problems thus, excellent results are expected to be limited by arthroscopic treatment. Relatively large chondral defects with associated degenerative change can be managed by arthroscopic drilling, abrasion arthroplasty, and microfracture. Although cartilage regeneration by these techniques is not predictable and consistent, reasonable results can be obtained in the selective cases with controlled postoperative management. The patients should not be too old and 4 to 8 weeks postoperative non-weight-bearing is needed. Cases treated with this type of approach will be presented and discussed in this presentation.
Currently available knee prostheses can provide 100 to 110° of knee flexion and this is generally good enough to ascend and descend stairs, arise from a chair, and perform most of the daily life activity. However, in certain situations like gardening, sitting on the flat floor and activities that require a squatting position, deep knee bends are required. In some countries, such as Japan, deep knee flexion is very important for the activity of daily life such as leading a life on a Tatami mattress and using a Japanese style toilet. There are several crucial factors, which influence postoperative knee flexion. Those are 1.) preoperative range of motion, 2.) surgical technique, 3.) prosthesis design, and 4.) postoperative rehabilitation. If a patient has longstanding, poor, preoperative range of motion, then the extensor mechanism itself became stiff in addition to the periarticular fibrotic change of the soft tissue and severe destruction of the bony structure. In this circumstance, it is awfully difficult to obtain deep knee flexion with currently available prostheses and surgical techniques. This indicates that we cannot wait for the last minute to perform TKR if a patient desires to gain deep knee flexion after the surgery. Surgical technique influences postoperative range of motion significantly. Anatomically the structures that get tight in knee flexion are the extensor mechanism and PCL. Thus, to obtain more flexion you should recess tight PCLs if you choose PCR type prostheses. Since the appropriate amount of PCL recession is not always easy, PCS type prostheses generally yield better flexion. To reduce tension of the extensor mechanism you should resect more patella than usual but this may cause postoperative patellar fracture. Or you can deepen the patellar groove by prosthesis modification but we should remember that both of these techniques will cause loss of the extensor lever arm and power. All posterior overhanging bone should be knocked out after trial reduction of a femoral prosthesis. Slightly flexed positioning of the femoral component and posteriorly tilted positioning of the tibial component can provide better flexion although too much of this positioning causes postoperative extension block. Regarding the prosthesis design, PCS type prostheses can provide more predictable postoperative knee flexion. Other alternatives are a femoral component with a smaller AP dimension and deep patello-femoral groove. However, both of these will cause weaker extensor power. Posterior lip of the tibial polyethylene decreases the contact pressure in knee flexion but will prevent posterior roll back of the femur and can cause impingement in deep knee flexion. In the normal knee, extreme internal rotation of the tibia occurs in deep knee flexion and this rotation cannot be achieved by a currently available knee design. Mobile bearing prostheses may be needed to achieve better kinematics. Aggressive postoperative rehabilitation is advised to prevent postoperative contracture of the soft tissue. Finally, although getting deep knee flexion is needed it should be remembered that ensuring postoperative stability and long-term survivorship should always be the most important goal for successful TKR.