Comparative study of the simple curettage versus the curettage with bonegraft in enchondroma of the hand

의학과/석사[한글] 내연골종은 수부에 발생하는 골종양중 가장 흔한 종양이고, 양성종양으로 알려져있다. 내연골종의 치료법으로는 여러 가지 방법이 있으나 일반적으로 소파술후 골이식술이 가장 많이 시행되어왔다. 그러나 수부에 발생한 고립성 내연골종은 단순 소파술만으로도 만족 할 만한 결과가 보고되고 있다. 이에 저자는 단순 소파술 또는 소파술후 골이식술로 치료받은 환잗들을 대상으로 수술소요시간, 신생골 형성의 차이, 치유기간의 차이를 비교 검토하여, 단순소파술이 수부의 고립성 내연골종의 치료법으로 적절한 방법인지 평가하고자 하였다. 1988년 1월부터 1992년 3월까지 만 4년 2개월간 연세대학교 의과대학 정형외과학 교실에서 치료받은 수부에 발생한 고립성 내연골종 환자 42예중 일년이상 원격추시가 가능하였던 35예를 대상으로 단순 소파술 또는 소파술후 골이식술의 신생골 형성 정도, 치유기간, 수술소요시간의 차이를 분석하였다. 다발성으로 발생하거나 병적골절이 있었던 경우는 연구에서 제외하고, 단일골에 발생한 고립성 내연골종만을 대상으로 하였다. 환자의 병력기록지와 방사선사진을 토대로 병변의 위치, 수술시간, 재발여부, 수술후 신생골 형성의 정도, 치유기간들을 조사하였다. 수 술후 마지막 추시방사선사진의 신생골형성 정도를 Tordai(1990)이 제안한 방법을 이용하여 분류하였다. 35예 모두 조직학적으로 내연골종으로 진단되었고 수술후 평균 16개월(13-36개월) 추시되었다. 병소의 위치는 척측의 2개 수지에 60%가 발생하였고, 요측의 2개 수지에는 23%가 발생하였다. 각 지골과 중수골별로 보았을 때는 근위지골에 57%가 발생하여 가장 호발하 였다. 수술시간은 단순 소파술을 시행한 경우는 평균 46분(20-90분)이었고 소파수술후 골이식술을 시행한 경우는 평균 75분(45-125분)이 소요되었다. 두 군사이에 수술소요시간이 통계학적으로 유의있는 차이가 있었다.(P=0.0005). Tordai가 제안한 추시 방사선 소견을 분류하는 기준에 따르면, 단순 소파술만 시행한 경우 제1군이 9예(64%), 제2군이 5례(36%)이고, 소파술후 골이식술을 시행한 경우에는 제1군이 16예(76%), 제2군이 4예(19%), 제3군이 1예(5%)이었으며, 소파술만 시행한 환자군 과 소파술후 골이식술을 시행한 환자군 사이에 신생골 형성의 정도에 통계학적으로 유의있는 차이는 없었다(P>0.05). 병소가 완전히 골수주로 채워지거나 3mm미만의 골음영만 남아 완전치유 되는데 소요되는 기간은, 소파술만 시행한 경우는 평균 7.4개월, 소파술후 골이식술을 시행한 경우는 4.6개월이었다. 두 환자군 사이에는 병소의 치유기간이 통계학적으로 유의있는 차이가 있 었다(P<0.05). 소파술만 시행한 환자나 소파후 골이식술을 시행한 환자나 수술후 병적 골절은 없었으며, 소파술후 골이식을 시행한 환자중 1예에서만 재발하였다. 단순소파술만을 시행한 군에서 골 결손부위의 신생골형성, 즉 병소의 직경이 3mm미만으로 회북되는 기간은 소파술후 골이식술을 시행한 환자군에 비하여 길었으나, 양 환자군사이에 신생골 형성도에는 차이가 없었다. 단순소파술의 경우 골이식을 하지않으므로 공여부 특히 장골능 부위의 동통이 없으며, 수술시간이 짧아서 경제적으로 이득이 있다. 또한 술후 병적골절이나 재발율에서도 양 환자군사이에 차이가 없다. 이상의 결과로 미루어 수부에 발생한 고립성 내연골종의 치료로 단순 소파술이 추천될 수 있다고 생각된다. [영문] Enchondroma is the most common benign bone tumor of the hand. Although several methods of treatment have been tried, the curettage with bonegraft is still widely accepted as the treatment of choice. Recently the simple curettage was reported as effective as the curettage with bonegraft for the treatment of solitary enchondroma of hand. To determine whether or not simple curettage is recommendable procedure for the solitary enchondroma of hand, the results of the simple curettage and the curettage with bonegraft were compared in the respects of operation time, degree of new bone formation., duration of healing and other possible complications. At the Department of Orthopaedic Surgery, Yonsei University, College of Medicine, fourty two patients with solitary enchondroma in the hand have been treated from January 1988 to March 1992. Excluding the patients with multiple lesions or pathologic fracture, 35 solitary enchondroma patients with at least more than one year follow-up were evaluated to assess the result of treatment. The bone healing, the degree of new bone formation, was evaluated according to the criteria of Tordai(1990). All 35 cases had the histologic diagnosis of enchondroma. Mean follow-up period was 16 months (range 13 to 36 months). Sixty percents of lesions were located in the lettle and ring fingers, 23% in thumb and index finger. Proximal phalanges were the most often affected in the proportion of 57%. Average operation time was 46 minutes (range 20 to 90 minutes) in the simple curettage patients, 75 minutes (range 45 to 125 minutes) in the curettage with bonegraft patients(P=0.0005) The bone healng was achieved at average 7.4 months after operation in the simple curettage patients and at average 4.6 months in the curettage with bonegraft patients(P<0.05). According to Tordai's criteria, among the simple curettage patients, 9 cases(64%) were group I, 5 cases(36%) were group II, no case was group III, Among the curettage with bonegraft patients, 16 cases(76%) were group I, 4 cases(19%) were group II, 1 case(5%) was group III, No significant difference was observed between the two patients groups in the degree of new bone formation(P>0.05). No pathologic fracture was found in both patients groups and one recurrence was found in the curettage with bonegraft patinets. Although the duration of healing was longer in the simple curettage patients, no significant difference was found in the degree of new bone formation. Also, no difference in postoperative pathologic fracture and recurrence were found between two patinets groups. Additionally, the simple curettage can eliminate the pain and discomfort from the bone donor sites, and can reduce the opertion time. These results suggest that the curettage alone is a recommendable treatment for solitary enchondroma in hand.restrictio

Comparison of the ACL and ACL graft forces before and after ACL reconstruction: An in-vitro robotic investigation

Background: Long-term follow-up studies have indicated that there is an increased incidence of arthrosis following anterior cruciate ligament (ACL) reconstruction, suggesting that the reconstruction may not reproduce intact ACL biomechanics. We studied not only the magnitude but also the orientation of the ACL and ACL graft forces. Methods: 10 knee specimens were tested on a robotic testing system with the ACL intact, deficient, and reconstructed (using a bone-patella tendon-bone graft). The magnitude and orientation of the ACL and ACL graft forces were determined under an anterior tibial load of 130 N at full extension, and 15, 30, 60, and 90° of flexion. Orientation was described using elevation angle (the angle formed with the tibial plateau in the sagittal plane) and deviation angle (the angle formed with respect to the anteroposterior direction in the transverse plane). Results: ACL reconstruction restored anterior tibial translation to within 2.6 mm of that of the intact knee under the 130-N anterior load. Average internal tibial rotation was reduced after ACL reconstruction at all flexion angles. The force vector of the ACL graft was significantly different from the ACL force vector. The average values of the elevation and deviation angles of the ACL graft forces were higher than that of the intact ACL at all flexion angles. Interpretation: Contemporary single bundle ACL reconstruction restores anterior tibial translation under anterior tibial load with different forces (both magnitude and orientation) in the graft compared to the intact ACL. Such graft function might alter knee kinematics in other degrees of freedom and could overly constrain the tibial rotation. An anatomic ACL reconstruction should reproduce the magnitude and orientation of the intact ACL force vector, so that the 6-degrees-of-freedom knee kinematics and joint reaction forces can be restored. Copyright© Taylor &amp;amp;amp; Francis 2006. all rights reserved

Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cell Implantation Versus Microfracture for Large, Full-Thickness Cartilage Defects in Older Patients: A Multicenter Randomized Clinical Trial and Extended 5-Year Clinical Follow-up

Background: There is currently no optimal method for cartilage restoration in large, full-thickness cartilage defects in older patients. Purpose: To determine whether implantation of a composite of allogeneic umbilical cord blood-derived mesenchymal stem cells and 4% hyaluronate (UCB-MSC-HA) will result in reliable cartilage restoration in patients with large, full-thickness cartilage defects and whether any clinical improvements can be maintained up to 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A randomized controlled phase 3 clinical trial was conducted for 48 weeks, and the participants then underwent extended 5-year observational follow-up. Enrolled were patients with large, full-thickness cartilage defects (International Cartilage Repair Society [ICRS] grade 4) in a single compartment of the knee joint, as confirmed by arthroscopy. The defect was treated either with UCB-MSC-HA implantation through mini-arthrotomy or with microfracture. The primary outcome was proportion of participants who improved by &amp;amp;gt;= 1 grade on the ICRS Macroscopic Cartilage Repair Assessment (blinded evaluation) at 48-week arthroscopy. Secondary outcomes included histologic assessment; changes in pain visual analog scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and International Knee Documentation Committee (IKDC) score from baseline; and adverse events. Results: Among 114 randomized participants (mean age, 55.9 years; 67% female; body mass index, 26.2 kg/m(2)), 89 completed the phase 3 clinical trial and 73 were enrolled in the 5-year follow-up study. The mean defect size was 4.9 cm(2) in the UCB-MSC-HA group and 4.0 cm(2) in the microfracture group (P = .051). At 48 weeks, improvement by &amp;amp;gt;= 1 ICRS grade was seen in 97.7% of the UCB-MSC-HA group versus 71.7% of the microfracture group (P = .001); the overall histologic assessment score was also superior in the UCB-MSC-HA group (P = .036). Improvement in VAS pain, WOMAC, and IKDC scores were not significantly different between the groups at 48 weeks, however the clinical results were significantly better in the UCB-MSC-HA group at 3- to 5-year follow-up (P &amp;amp;lt; .05). There were no differences between the groups in adverse events. Conclusion: In older patients with symptomatic, large, full-thickness cartilage defects with or without osteoarthritis, UCB-MSC-HA implantation resulted in improved cartilage grade at second-look arthroscopy and provided more improvement in pain and function up to 5 years compared with microfracture. Registration: NCT01041001, NCT01626677 (ClinicalTrials.gov identifier)

Efficacy and safety of single injection of cross-linked sodium hyaluronate vs. three injections of high molecular weight sodium hyaluronate for osteoarthritis of the knee: A double-blind, randomized, multi-center, non-inferiority study

Background: This randomized, double-blind, multi-center, non-inferiority trial was conducted to assess the efficacy and safety of a cross-linked hyaluronate (XLHA, single injection form) compared with a linear high molecular hyaluronate (HMWHA, thrice injection form) in patients with symptomatic knee osteoarthritis. Methods: Two hundred eighty seven patients with osteoarthritis (Kellgren-Lawrence grade I to III) were randomized to each group. Three weekly injections were given in both groups but two times of saline injections preceded XLHA injection to maintain double-blindness. Primary endpoint was the change of weight-bearing pain (WBP) at 12 weeks after the last injection. Secondary endpoints included Western Ontario and McMaster Universities Osteoarthritis index; patient&amp;amp;apos;s and investigator&amp;amp;apos;s global assessment; pain at rest, at night, or in motion; OMERACT-OARSI responder rate; proportion of patients achieving at least 20 mm or 40% decrease in WBP; and rate of rescue medicine use and its total consumption. Results: Mean changes of WBP at 12 weeks after the last injection were -33.3 mm with XLHA and -29.2 mm with HMWHA, proving non-inferiority of XLHA to HMWHA as the lower bound of 95% CI (-1.9 mm, 10.1 mm) was well above the predefined margin (-10 mm). There were no significant between-group differences in all secondary endpoints. Injection site pain was the most common adverse event and no remarkable safety issue was identified. Conclusions: This study demonstrated that a single injection of XLHA was non-inferior to three weekly injections of HMWHA in terms of WBP reduction, and supports XLHA as an effective and safe treatment for knee osteoarthritis. Trial registration: ClinicalTrials.gov (NCT01510535). This trial was registered on January 6, 2012. © 2017 The Author(s)

Causes, Risk Factors, and Trends in Failures After TKA in Korea Over the Past 5 Years: A Multicenter Study

Failure after total knee arthroplasty (TKA) may be related to emerging technologies, surgical techniques, and changing patient demographics. Over the past decade, TKA use in Korea has increased substantially, and demographic trends have diverged from those of Western countries, but failure mechanisms in Korea have not been well studied. We determined the causes of failure after TKA, the risk factors for failure, and the trends in revision TKAs in Korea over the last 5 years. We retrospectively reviewed 634 revision TKAs and 20,234 primary TKAs performed at 19 institutes affiliated with the Kleos Korea Research Group from 2008 to 2012. We recorded the causes of failure after TKA using 11 complications from the standardized complication list of The Knee Society, patient demographics, information on index and revision of TKAs, and indications for index TKA. The influences of patient demographics and indications for index TKA on the risk of TKA failure were evaluated using multivariate regression analysis. The trends in revision procedures and demographic features of the patients undergoing revision TKA over the last 5 years were assessed. The most common cumulative cause of TKA failure was infection (38%) followed by loosening (33%), wear (13%), instability (7%), and stiffness (3%). However, the incidence of infections has declined over the past 5 years, whereas that of loosening has increased and exceeds that of infection in the more recent 3 years. Young age (odds ratio [OR] per 10 years of age increase, 0.41; 95% confidence interval [CI], 0.37-0.49) and male sex (OR, 1.88; 95% CI, 1.42-2.49) were associated with an increased risk of failure. The percentage of revision TKAs in all primary and revision TKAs remained at approximately 3%, but the annual numbers of revision TKAs in the more recent 3 years increased from that of 2008 by more than 23%. Despite a recent remarkable increase in TKA use and differences in demographic features, the causes and risk factors for failures in Korea were similar to those of Western countries. Infection was the most common cause of failure, but loosening has emerged as the most common cause in more recent years, which would prompt us to scrutinize the cause and solution to reduce it. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence

The effect of anterior cruciate ligament reconstruction on knee joint kinematics under simulated muscle loads

Background: Numerous studies have investigated anterior stability of the knee during the anterior drawer test after anterior cruciate ligament reconstruction. Few studies have evaluated anterior cruciate ligament reconstruction under physiological loads. Purpose: To determine whether anterior cruciate ligament reconstruction reproduced knee motion under simulated muscle loads. Study Design: Controlled laboratory study. Methods: Eight human cadaveric knees were tested with the anterior cruciate ligament intact, transected, and reconstructed (using a bone-patellar tendon-bone graft) on a robotic testing system. Tibial translation and rotation were measured at 0°, 15°, 30°, 60°, and 90° of flexion under anterior drawer loading (130 N), quadriceps muscle loading (400 N), and combined quadriceps and hamstring muscle loading (400 N and 200 N, respectively). Repeated-measures analysis of variance and the Student-Newman-Keuls test were used to detect statistically significant differences between knee states. Results: Anterior cruciate ligament reconstruction resulted in a clinically satisfactory anterior tibial translation. The anterior tibial translation of the reconstructed knee was 1.93 mm larger than the intact knee at 30° of flexion under anterior load. Anterior cruciate ligament reconstruction overconstrained tibial rotation, causing significantly less internal tibial rotation in the reconstructed knee at low flexion angles (0°-30°) under muscle loads (P &amp;amp;lt; .05). At 30° of flexion, under muscle loads, the tibia of the reconstructed knee was 1.9° externally rotated compared to the intact knee. Conclusions: Anterior cruciate ligament reconstruction may not restore the rotational kinematics of the intact knee under muscle loads, even though anterior tibial translation was restored to a clinically satisfactory level under anterior drawer loads. These data suggest that reproducing anterior stability under anterior tibial loads may not ensure that knee joint kinematics is restored under physiological loading conditions. Clinical Relevance: Decreased internal rotation of the knee after anterior cruciate ligament reconstruction may lead to increased patellofemoral joint contact pressures. Future anterior cruciate ligament reconstruction techniques should aim at restoring 3-dimensional knee kinematics under physiological loads

A comparative study of clinical outcomes and second-look arthroscopic findings between remnant-preserving tibialis tendon allograft and hamstring tendon autograft in anterior cruciate ligament reconstruction: Matched-pair design

Background: This study aimed to compare stability, functional outcome, and second-look arthroscopic findings after anterior cruciate ligament reconstruction between remnant-preserving tibialis tendon allograft and remnant-sacrificing hamstring tendon autograft. Methods: We matched two groups (remnant-preserving tibialis tendon allograft group and hamstring tendon autograft group) in terms of demographic characteristics, associated injury, and knee characteristics. Each group consisted of 25 patients. Results: Operation time was longer in the remnant-preserving tibialis tendon allograft group, but there was no significant intergroup difference in stability, clinical outcome, and second-look arthroscopic findings. Conclusions: When an autograft is not feasible in anterior cruciate ligament reconstruction, the remnant-preserving technique can produce comparable results in terms of restoration of function, stability of the knee, and degree of synovium coverage at second-look arthroscopy compared to remnant-sacrificing hamstring autograft. © 2017 by The Korean Orthopaedic Association

Microfractures Versus a Porcine-Derived Collagen-Augmented Chondrogenesis Technique for Treating Knee Cartilage Defects: A Multicenter Randomized Controlled Trial

Purpose: The purpose of this study was to evaluate the clinical efficacy and safety of treating patients with a cartilage defect of the knee with microfractures and porcine-derived collagen-augmented chondrogenesis technique (C-ACT). Methods: One hundred participants were randomly assigned to the control group (n = 48, microfracture) or the investigational group (n = 52, C-ACT). Clinical and magnetic resonance imaging (MRI) outcomes were assessed 12 and 24 months postoperatively for efficacy and adverse events. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) assessment was used to analyze cartilage tissue repair. MRI outcomes for 50% defect filling and repaired tissue/reference cartilage (RT/RC) ratio were quantified using T2 mapping. Clinical outcomes were assessed using the visual analogue scale (VAS) for pain and 20% improvement, minimal clinically important difference (MCID), and patient acceptable symptom state for Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee score. Results: MOCART scores in the investigation group showed improved defect repair and filling (P = .0201), integration with the border zone (P = .0062), and effusion (P = .0079). MRI outcomes showed that the odds ratio (OR) for &amp;amp;gt;= 50% defect filling at 12 months was statistically higher in the investigation group (OR 3.984, P = .0377). Moreover, the likelihood of the RT/RC OR becoming &amp;amp;gt;= 1 was significantly higher (OR 11.37, P = .0126) in the investigation group. At 24 months postoperatively, the OR for the VAS 20% improvement rate was significantly higher in the investigational group (OR 2.808, P = .047). Twenty-three patients (52.3%) in the control group and 35 (77.8%) in the investigation group demonstrated more than the MCID of KOOS pain from baseline to 1 year postoperatively, with a significant difference between groups (P = .0116). Conclusion: In this multicenter randomized trial, the addition of C-ACT resulted in better filling of cartilage defect of the knee joint

Efficacy and safety of short-term use of a pelubiprofen CR and aceclofenac in patients with symptomatic knee osteoarthritis: A double-blinded, randomized, multicenter, active drug comparative, parallel-group, phase IV, non-inferiority clinical trial

Introduction At present, information about clinical efficacy and adverse events of controlled release (CR) form of pelubiprofen, a prodrug of 2-arylopropionic acid with relatively selective effects on cyclooxygenase-2 activity, remains scarce. In this study, we sought to determine non-inferiority of pelubiprofen CR 90 mg/day compared to aceclofenac 200 mg/day regarding clinical efficacy and adverse events after a 4-week course of medication in the patients with symptomatic knee osteoarthritis. Materials and methods A total of 191 patients were randomly assigned to take either pelubiprofen CR 90 mg (n = 95) or aceclofenac 200 mg (n = 96). The primary outcome variable was non-inferiority of pain reduction between baseline and week 4 when assessed using a 100 mm pain visual analogue scale (VAS). Pelubiprofen was considered non-inferior to aceclofenac if the upper limit of the one-sided 97.5% confidence interval for the difference in terms of pain VAS was above 15 mm (the average change of pain VAS in the pelubiprofen group-pain VAS reduction in the aceclofenac group). Secondary outcome variables were the changes in 100 mm pain VAS at week 2 versus baseline, K-Western Ontario, and McMaster University Arthritis Index (K-WOMAC) changes at weeks 2 and 4 as compared to baseline, patient global assessment at weeks 2 and 4. The frequency and amount of rescue medicine usage at weeks 2 and 4 were also evaluated as the secondary outcome variable. For safety analysis, adverse events, clinical laboratory tests, vital signs, and physical examinations were assessed and conducted at each follow-up visit. Results At week 4, the pain VAS values were significantly reduced in both groups receiving either pelubiprofen CR 90 mg or aceclofenac 200 mg as compared to the baseline. However, the pelubiprofen group and the aceclofenac group respectively showed the pain VAS changes of -22 and -21.9 in the pre-protocol set and -20.8 and -21.7 in the full analysis set, confirming non-inferiority. The pelubiprofen CR 90 mg showed a reduced incidence of adverse events compared to the aceclofenac 200 mg (p = 0.005). Conclusions Pelubiprofen CR 90 mg is as effective as aceclofenac 200 mg with reduced adverse events for the treatment of symptomatic knee osteoarthritis