무릎관절 전치환술 후 초기에 선 자세에서 하지 관절의 각도를 경 과 기간과 수술 측과 비수술 측에 따라 측정하고, 수술 후 환자의 자세 변화를 알아보고자 하였다. 그 결과 수술 전 선 자세 에서 무 릎관절 비대칭이 수술 후에도 남아 있었으며, 이러한 현상은 수술 전 무릎관절 구축과 넙다리뒤근육의 긴장이 수술 후에도 계속 지 속되는 것으로 생각된다. 따라서 무릎관절 전치 환술(totalkneereplacement)을 시행한 환자에게 수술 후 초기 상태에서 물리치 료 시 운동치료 계획을 수립할 때에는 하지 관절의 구축 및 근육의 긴장을 고려한 운동치료프로그램을 적용하는 것이 필요할 것으로 생각된다.
2 Department of Orthopedic Surgery, Medical College of Ajou University, Suwon, Korea
Background: There are few reports on bone mineral density (BMD) changes of axial bones aftertotalkneereplacement (TKR) due to severe osteoarthritis (OA) of the kneejoint and its results are controversial. The purpose of our study was to measure the BMD changes of hip and spine in patients receiving TKR due to severe OA and to identify clini- cal factors relating BMD changes. Methods: Among 66 female patients above 65 years old who underwent TKR due to severe OA and checked preoperative BMD, 52 patients who checked 1 year follow up BMD were enrolled. We investigated the association of the BMD changes with bilaterality of operation, obesity, preoperative knee functional scores, bisphosphonate medication, and diagnosis of osteoporosis. Results: We found no correlation between BMD changes and bilaterality of operation, obesity, preopera- tive knee functional scores and diagnosis of osteoporosis. Spine BMD increased in non- treatment and bisphosphonate treatment group but total hip BMD significantly increas- ed in bisphosphonate treatment group. Conclusions: Bisphosphonate treatment for 1 year prevents early reduction of hip BMD just after TKR regardless osteoporosis diagno- sis. We considered that the bisphosphonate medication would be beneficial to preven- tion of later hip fracture in elderly patient receiving TKR due to severe OA of knee joints.
iv - 국문요약 -
65 세 이상의 여자환자에서 인공 슬관절 치환술 후 골밀도 변화
퇴행성 슬관절염으로 인공 슬관절 치환술을 시행한 65세 이상의 여자환자 중 수술시 골밀도 측정을 하고 1년 이상 골밀도 추시 검사를 시행한 환자 66명 중 수술 후 1년에 골밀도 측정을 시행한 52명을 대상으로 하였다. 수술 부위의 양측 성, 비만 정도, 수술 시 골다공증 여부는 인공관절 치환술 일년 후 골밀도 변화 에 영향을 주지 않았으나 수술 후 일년간 비스포네이트 치료를 한 경우에는 total hip 골밀도가 유의하게 증가하였다. 따라서 퇴행성 슬관절염으로 인공 슬관절 치 환술을 시행한 환자에서 비스포스포네이트 약물의 투여는 수술 후 초기 고관절 부위의 골밀도 감소를 예방할 수 있어 수술 후 비스포스포네이트 약물의 투여가 수술 당시의 골다공증 진단 여부에 관계없이 추 후 고관절 골절 예방에 유익할 것으로 사료된다.
Total 2,315 2,315 2,315 2,315 2,315 2,315 2,315 2,315
Valid % 97.5 99.9 44.5 76.4 79.3 49.3 29.4 60.6
*Preop., preoperative period; † POD, postoperative day.
로서 염증의 정도 파악 및 치료 반응 여부를 예측하는 주 요 지표로서 연구되어 왔다. 3-6) CRP는 감염 외에도 염증 성 자극, 허혈, 수술 등으로 인한 조직 손상 시에도 증가 하기 때문에 술 후 급성 감염이 동반되는 경우에는 통상 적인 경우보다 그 회복이 늦어지며 오히려 상승할 수도 있다고 생각한다. 특히 동시 양측성 슬관절 치환술 후 CRP의 자연 회복 양상에 대한 자료는 매우 드물다. 따라 서 저자들은 슬관절 전치환술 후 혈청 CRP의 자연적인 회복 양상을 분석하고 심부감염군과 비교하여 어느 시점 부터 CRP 회복 양상에 의미 있는 차이를 보이는지 조사 하고자 하였다. 본 연구에서는 술 후 CRP가 재상승되는 단계별 슬관절 치환술은 제외하고 일측성 및 동시 양측성 치환술만을 대상으로 하였다.
Fat embolism syndrome is usually manifested as a mul- tiorgan disorder that typically involves the respiratory sys- tem, central nervous system, cardiovascular system, skin and eyes. Gurd and Wilson have suggested criteria for the diagnosis of fat embolism syndrome, with three major cri- teria including respiratory insufficiency, cerebral involve- ment, petechial rash and nine minor criteria such as pyrexia, tachycardia, retinal changes, jaundice, renal change, anemia, thrombocytopenia, increased erythrocyte sedimentation rate (ESR) and fat macroglobulinemia . These investigators have suggested that at least two symptoms for the major cri- teria or one symptom for the major criteria and four symp- toms for the minor criteria must be present to diagnose the syndrome.
These devices have almost no risk or side effects and instead tend to minimize tissue damage during electrotherapy. 6
Interference current therapy mainly utilizes medium frequencies between 3000 Hz and 6000 Hz and causes an interference current in the range of 1 to 250 Hz at a desired treatment area by mixing two similar currents, such as 4000 Hz and 4100 Hz. 7 Interference current therapy is a widely used electric therapy that is reported to be effective for backache, musculoskeletal pain, joint pain, and pain due to fractures. 8 However, recent reports on the pain relief of interference wave therapy indicate that it differs from that of existing interference current therapy. Ward and Robertson 9 reported that pain relief is greater when using a frequency of 10 KHz, whereas Dermmink 10 found that the bipolar method using two electrodes caused a more accurate interference wave than using four electrodes. Hurley 8 et al. reported that an electrode attachment site is more effective for an attachment in accordance with spinal nerves than a pain site. These reports indicate that changes are needed to interference current therapy to improve its therapeutic effect. These differences compared to existing interference current therapy can be attributed to the fact that information on existing interference current therapy is mostly derived from clinical experience rather than from randomized double-blind studies, and some information comes directly from transcutaneous electrical nerve stimulation therapy.
2. Experiment method 1) Measuring instrument
(1) Kinematic measurement of lower limb joints
The three-dimensional motion analysis device (Motion Analysis Corp, Santarosa, CA, US) used in this study consisted of eight infrared cameras to capture the three- dimensional trajectory data of markers attached to each lower limb of the subject. During stair walkingat a camera frame rate of 120Hz using the motion capture software Cortex 18.104.22.1686, the subject’ s pelvic, hip, knee, and ankle movements were measured. The markers of the three- dimensional motional analysis device were attached using the Helen-Hayes market set. 21 markers were used intotal while being attached to each side of the body except the sacrum. The attachment areas included the ASIS, PSIS, sacral, thigh, medial knee, lateral knee, shank, medial malleolus, lateral malleolus, heel, and the region between the second and third toes. The markers for the heel and the region between the second and third toes were attached above the shoe surface. 11
Since Campbell and Boyd first developed a mold hemi- arthroplasty in 1940, the procedure for a totalknee arthro- plasty has advanced greatly with the development of new materials and the increasing understanding of the kneejoint biomechanics. Along with the advances in the prosthetic hardware, the recent development of the computer and navi- gation systems has led to the introduction of robotic surgery and computer-assisted surgery 1,5,9,11,19) . The long-term sur- vival rate of a totalknee arthroplasty after a 10-year follow up was reported to be 80% to 95% 7,14,17) . Various factors affect this long-term survival, the most closely related factor being the physiologic recovery of the leg alignment 8,16) . Upon a follow-up study of more than 8 years, the loosening rate
Pain afterknee arthroplasty is closely related to the pas- sage of time. In the early days, pain in present in almost all patients but it tends to disappear with the passage of time . In addition, the patient’s age, height, weight, and body mass index may be risk factors for infection, malnutrition, steroid use, long hospital care and diabetes, rheumatoid ar- thritis and psoriasis [19,20]. However, the personality and psychological state of the patient is also very important. In the present study, there was a significant difference in the amount of pre- and post-intervention pain between the groups over time, but no significant difference was found between groups. In this study, too, the center of mass was shifted during balance training using the Slalom Ski pro- gram. Because the legs must be used safely and effectively when moving the center of mass of the body, muscles are constantly used for the extension moment of the hips, knees and ankles, which assist to increase the strength of the ex- tension, and furthermore.
If a certain area of an object under loading shows a change in material property or mechanical property or mi- crostructure, the transmission of stress is changed. Chang- es of the knee, such as osteoarthritis or TKA would have an effect on the mechanical properties of surrounding regions. 13,14) Many studies have reported that knee osteo- arthritis influences bone strength of the proximal femur and patients with osteoarthritis usually have increased BMD in the femur neck. 15-18) In our study, preoperatively, BMD of the hip on the operative side was lower than on the nonoperative side in accordance with the study re- ported by Ishii et al. 7) However, no statistical differences were observed. Soininvaara et al. 6) reported that preopera- tive BMD of the proximal femur on the operative side was significantly lower than that of the contralateral side in all region of interests. Considering the results, degree of exercise restriction due to pain and limited range of mo- tion of the joint, degree of osteoarthritis, pain scale before operation, dominant-leg, individual demands in daily life, and discordance between BMD of the left- and right-hip were considered compositively. 19-22) Also, according to the results of our analysis, the fact that 83% of the nonopera- tive side showed Kellgren-Lawrence stage II or less (83%) should be considered, and there was a limit to the applica- tion of the result to severe osteoarthritis of both knees.
Kyoung-Jin Park, M.D., Eui-Sung Choi, M.D. , Yong-Min Kim, M.D., Dong-Soo Kim, M.D., Hyun-Chul Shon, M.D., Byung-Ki Cho, M.D., Ji-Kang Park, M.D., Seung-Myung Choi, M.D., and Hyeon-Jun Eun, M.D.
Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
Subcutaneous emphysema of lowerextremity is a rare disease entity. Crepitation and swelling on physical examination and gas on radiographs raise the concern of infection due to the presence of gas gangrene forming organisms. Therefore, delay of diagnosis and appropriate management can be a major predisposing factor for sepsis and further associated high mortality. We experienced a rare case of subcutaneous emphysema of the right lowerextremityafterknee arthroscopy; life-threatening infection was ruled out by physical examination and laboratory testing. The patient recovered uneventfully with conservative management. Therefore, we report on this case with a review of current literature.
Fig. 1. Anteroposterior (A) and lateral (B) view of the photograph shows the nail's compatibility with femoral component in saw bone model.
슬관절 전치환술 후 동측에 발생한 대퇴골 과상부 골절 은 1981년 Hirsh 등 12) 에 의해 처음 발표되었다. 최근에는 슬관절 전치환술을 받은 동측의 대퇴골 과상부 골절에 대 한 빈도는 0.3%에서 2.5%까지 보고되나, 고령의 환자에서 시행한 경우나 술 후 활동성이 높은 경우에 증가하는 경향 을 보이고 있다 21) .
The SF-36 PCS results showed that the slight OA group scored 1.5 and the severe OA group scored 6.4, indicating a considerable difference (p<0.01). However, in other re-
search, the slight OA group scored 0.1 and the severe group scored −0.3 in SF-36 mental component summary (MCS), which indicates no significant difference. Compared to these results, in the current study, the group that did not re- ceive TKR scored 32.5 and those who had TKR operation scored 30.1 on the SF-36 PCS, therefore a significant differ- ence was observed (p<0.000). In a previous study, the groups who did not have TKR scored 39.2 while those who had TKR scored 38.8, with considerable differences (p<0.046). Compared to the previous research, both studies had differences in PCS scores. However, only this study ob- served for difference in MCS scores. This is attributed to the gap between the influence of the physical factors and psy- chological factors of OA. Thus, TKR is considered to have a positive effect on physical activity when performed in se- vere stages of OA.
The economic burden of PJI can be reduced by making health policies as well as implementing preventive measures to attenuate the risk of PJI. Knowledge of the cost related to PJI is necessary to optimize existing health re- sources in developing countries such as Pakistan. Although treatment protocols and guidelines exist to prevent the incidence of PJI following a jointreplacement procedure, a more proactive, individualized approach may be necessary to sort out this issue. 16,17) There is a need to identify high- risk patients with proactive implementation of pre- and postoperative protocols in order to prevent this devastating complication, thereby reducing financial burden. Previous studies reported a number of evidence-based protocols, which have proven to be effective in reducing PJI such as the use of prophylactic antibiotics and negative pressure wound therapy on surgical incisions. 18,19) According to data from OECD (organization for economic cooperation and development), the U.S. spent 17.8% of its gross domestic product (GDP) on health care, while the average spend- ing level among all high-income countries was 11.5% of GDP. 20) On the other hand, the share of total public health expenditure in Pakistan as percentage of GDP is only 0.7%.
Written informed consent was obtained from the patients for the use of their images.
An 82-year-old woman visited our hospital and was admitted to the orthopedic sur- gery department because of a deep infection after TKR. Her underlying diseases were
1. 환자 정보
74세 여자 환자로 2012년경부터 양측 슬관절 통증이 발생하여, 2014년 10월경 단순방사선검사 및 컴퓨터 단층 촬영 상 양측 퇴행성 슬관절염 진단 및 슬관절 전치환술 (Totalknee arthroplasty)(우측-2014.10.14, 좌측-2014.10.21) 후, 2014년 10월 30일까지 입원 치료하였으나 수술 부위 통증 및 양측 슬관절 가동범위 제한 지속되어 본원 내원 하였다. 신장 141.8 cm, 체중 65 kg, 신체질량지수 32.33 kg/cm 2 로 고도비만이며 식욕 및 소화, 대소변 상태는 양 호하였다. 슬관절 굴곡 각도는 90 o /80 o , 신전 각도는 －15 o /