Jisu Park

Background/Objectives: Opening-wedge high tibial osteotomy (OWHTO) may alter patellar position and patellofemoral (PF) loading, raising concerns about postoperative PF deterioration. This study evaluated compartment-specific changes in SPECT/CT bone tracer uptake (BTU), a marker of subchondral osteoblastic activity, and factors associated with increased PF BTU. Methods: This retrospective study included 35 knees in 34 patients. SPECT/CT was obtained preoperatively and 12–24 months postoperatively. An exploratory 20% relative-change threshold was used to classify BTU responses. Clinical and radiographic variables were compared between PF BTU-increased and non-increased groups. Exploratory multivariable binary logistic regression was used to assess factors associated with a >20% increase in PF BTU, coded as 1, versus no such increase, coded as 0. Results: Mean medial BTU decreased (4.61 ± 2.46 to 3.38 ± 1.50; p = 0.005), whereas mean lateral and PF BTU did not change significantly. PF BTU increased by >20% in 12 knees (34%), decreased by >20% in 16 knees (46%), and remained within ±20% in 7 knees (20%). The increased group had a greater posterior tibial slope angle (PTSA) increase (2.87 ± 1.79° vs. 0.73 ± 2.93°; p = 0.029). In exploratory multivariable logistic regression, greater PTSA change was associated with higher odds of a >20% increase in PF BTU (adjusted OR = 1.5275; 95% CI, 1.0003–2.3325; p = 0.04985). International Knee Documentation Committee (IKDC) and anterior knee pain (AKP) scores did not differ significantly between groups. Conclusions: An exploratory association between PF BTU increase and PTSA change was observed, but it was sensitive to the analysis conditions. No significant between-group differences in short-term clinical scores were detected. These findings do not establish cartilage degeneration, causation, or a preventive benefit from controlling PTSA. Longer-term metabolic, structural, and clinical validation is needed.

Background/Objectives: Thrombocytopenia increases bleeding tendency and may complicate perioperative management in total knee arthroplasty (TKA), yet data on both in-hospital burden and post-discharge adverse events are limited. This study evaluated the association between preoperative platelet count and outcomes after primary TKA. Methods: In total, 3474 primary TKAs performed for osteoarthritis at a single institution (2008–2023) were retrospectively reviewed. Patients were classified as Normal, Mild, Moderate, or Severe by preoperative platelet count; the Severe group (N = 6) was excluded from comparative analyses and reported descriptively. Inverse probability of treatment weighting (IPTW) balanced baseline covariates. In-hospital outcomes were red blood cell (RBC) transfusion, intensive care unit (ICU) admission, and length of stay; follow-up outcomes were 30-day readmission, 1-year periprosthetic joint infection (PJI), and 1-year mortality. Results: After IPTW, the RBC transfusion rate rose with lower platelet count (Normal, 14.0%; Mild, 27.0%; Moderate, 32.5%; p < 0.001), and transfusion volume peaked in the Moderate group. ICU admission was more frequent (Moderate, 6.0%; Normal, 0.7%; Mild, 0.4%; p = 0.002), and length of stay increased with severity (p = 0.008). Readmission, 1-year PJI, and mortality were comparable across groups. In multivariable analysis, moderate thrombocytopenia was independently associated with RBC transfusion (adjusted odds ratio [aOR], 3.26; 95% confidence interval [CI], 1.51–6.59; p < 0.001) and ICU admission (aOR, 5.46; 95% CI, 1.37–17.41; p = 0.008), but not PJI or mortality. Conclusions: Preoperative thrombocytopenia—particularly in the mild-to-moderate range evaluated in this study—increased perioperative burden after TKA, with higher RBC transfusion and ICU utilization, but was not associated with a significant increase in major postoperative adverse events during 1-year follow-up. Even if not causally responsible, a low preoperative platelet count is a routinely available marker that may flag patients requiring closer perioperative attention. As the associated burden appears largely limited to the hospitalization period, such attentive in-hospital management may allow these patients to achieve favorable outcomes.

Background: Perioperative corticosteroids, particularly dexamethasone, have become a widely adopted component of multimodal pain management in total knee arthroplasty (TKA). While clinical practice guidelines strongly recommend their use, detailed guidance on optimal dosing, frequency, and safety in special populations, especially patients with diabetes mellitus, is still limited. Main text: This narrative review synthesizes the current evidence on systemic perioperative dexamethasone use in TKA, focusing on clinical questions: agent and route selection, dose optimization, dosing frequency, and safety, including considerations for patients with diabetes. A literature search of PubMed, EMBASE, and the Cochrane Library was conducted for studies published between January 2015 and April 2026. Randomized controlled trials, systematic reviews, meta-analyses, clinical practice guidelines, and observational studies addressing systemic corticosteroid use in primary TKA were included. Recent evidence supports intravenous (IV) dexamethasone as the most commonly studied and clinically practical systemic agent. A 16 mg dose provides greater early analgesic and antiemetic benefit than lower doses, and repeat dosing through postoperative day (POD) 1 is supported, with extension to POD 2 emerging but not yet definitive. Perioperative dexamethasone has not been associated with increased infection or wound complications. In patients with well-controlled diabetes, it appears safe with appropriate glycemic monitoring, although safety data are largely limited to doses of 8–10 mg. Conclusions: Current evidence supports IV dexamethasone as an effective component of multimodal analgesia after TKA. In the general TKA population, 16 mg appears more effective than lower doses for early postoperative pain, opioid consumption, and postoperative nausea and vomiting (PONV)-related outcomes. Repeat dosing through POD 1 is supported by available evidence, whereas extension to POD 2 remains promising but requires further validation. In patients with well-controlled diabetes, perioperative dexamethasone appears safe with appropriate glycemic monitoring, although safety data are largely limited to doses of 8–10 mg, and the safety of the 16 mg dose in this population remains insufficiently defined.

Rationale: Distal femoral derotational osteotomy (DFDO) is widely performed to correct excessive femoral anteversion in patients with patellofemoral instability. However, unintended changes in coronal alignment can occur depending on the orientation of the cutting plane. We present a case of unintentional femoral valgization after DFDO in a patient with a recurrent patellar dislocation. Patient concerns: A 23-year-old female presented with multiple episodes of recurrent patellar dislocation of her right knee. Diagnoses: Physical examination revealed a positive apprehension test, positive J-sign, and generalized joint laxity. An effusion was observed in the right knee. Radiologic findings included increased femoral anteversion (30.3°), ruptured medial patellofemoral ligament (MPFL), mild varus alignment (hip-knee-ankle angle 0.4°), mechanical lateral distal femur angle (mLDFA) of 86.6°, patella alta, and increased tibial tuberosity–trochlear groove (TT–TG) distance. Interventions: The patient underwent MPFL reconstruction and DFDO with target correction of femoral anteversion of 15°. Osteotomy was performed perpendicular to the real anatomical shaft axis. Outcomes: Postoperative imaging revealed an unintended valgus malalignment (HKA angle −3.0°) and decrease of mLDFA (83.6°). Despite the altered alignment, no recurrence of dislocation was noted during the 18-month follow-up period, and the clinical outcome was satisfactory. Lessons: Unintentional valgus alignment may result from osteotomies oriented perpendicular to the real anatomical shaft axis. Surgeons should consider using the virtual anatomical shaft axis to determine the cutting plane and minimize the risk of iatrogenic malalignment during DFDO.

Purpose: The purposes of this study were threefold: (1) to evaluate the influence of femoral antecurvature on coronal alignment changes following supracondylar femoral derotational osteotomy (FDO); (2) to investigate the combined effects of derotation angle and osteotomy orientation in relation to femoral antecurvature and (3) to propose a practical strategy for minimising valgus deviation after FDO based sagittal femoral bowing. Materials and Methods: Sixty‐six cadaveric femoral computed tomography (CT) scans were analysed using three‐dimensional (3D) simulation. Femurs were classified into three groups based on the degree of antecurvature using the distal diaphyseal angle (DDA). Virtual surgery was simulated at 7 cm above the joint line using two osteotomy methods (shaft‐perpendicular and distal femur condylar line [DFC]‐parallel) and two derotation angles (10° and 20°). Mechanical lateral distal femoral angle (mLDFA) was measured before and after simulation. Multivariable and stratified regression analyses were performed. Results: Greater antecurvature led to larger mLDFA decrease, with more pronounced valgus shifts at higher derotation angles. Making DFC‐parallel osteotomy significantly reduced valgus change regardless of bowing ( β = −0.331, p = 0.005). A significant interaction was found between DDA and derotation angle ( β = 0.015, p < 0.001). The combination of DFC‐parallel osteotomy with 10° derotation provided the least valgus change ( R ² = 0.84). The allowable derotation angle to maintain <1° valgus shift decreased as DDA increased. Conclusion: Femoral antecurvature significantly affects coronal alignment after supracondylar FDO. Although the optimal target angle for derotation remains a surgical choice, understanding the relationship between sagittal bowing and coronal alignment can help tailor patient‐specific decisions. To minimise valgus shift after supracondylar FDO, aligning the osteotomy plane parallel to the distal femur condylar line can be effective. This method is simple and practical for standard surgical procedures. Level of Evidence: Level IV.

The purpose of this study was to evaluate whether intravenous (IV) dexamethasone, within the current multimodal pain management protocol, (1) could maintain postoperative pain at a comparable level without IV patient-controlled analgesia (PCA), (2) could reduce opioids-related side effects, and (3) whether an additional dose of dexamethasone on postoperative day (POD) 2 would offer further pain-relieving effect without increasing the risk of complications. A total of 178 patients (182 knees) who underwent total knee arthroplasty for osteoarthritis were included in the study. The patients were divided into Dexa 2 & PCA and Dexa 3 & NoPCA groups. From operative day to POD 5, pain visual analogue score (VAS), rescue opioids consumption, episodes of postoperative nausea and vomiting (PONV), antiemetics usage, and side effects of opioids such as postoperative urinary retention (POUR) and constipation were checked. For safety, wound complication and infection were checked. There was no difference in pain VAS between the two groups during all six perioperative days. Rescue opioids consumption was lower in Dexa 2 & PCA group. Total dosage of used opioids for six perioperative days was lower in Dexa 3 & NoPCA group. Dexa 3 & NoPCA group had less PONV and POUR. There was a marked increase in pain VAS and the use of rescue opioids from POD 1 to POD 2 in the Dexa 2 & PCA. There were no wound problems or infections in either group. Under the current multimodal pain management protocol, comparable level of postoperative pain could be achieved by dexamethasone without the need of IV PCA. By not using IV PCA, overall opioid usage was reduced, which could lead to a lower frequency of PONV and POUR. While there is still room for further research on the duration and frequency of administering dexamethasone, additional administration on POD 2 is believed to provide additional pain management benefits compared with administering only until POD 1.

Park J, et al. Clin Orthop Surg. 2025 Jun;17(3):408-416. https://doi.org/10.4055/cios24250

Background: Osteochondral lesions of the talus are uncommon in children and adolescents. Surgical procedures differ from those used for adults to avoid iatrogenic physeal injuries. This study aimed to evaluate the clinical and radiological outcomes of surgical treatment in pediatric patients with osteochondral lesions, specifically investigating the patient age and the status of distal tibial physis as factors associated with surgical success. Methods: We retrospectively reviewed 28 patients who had symptomatic osteochondral lesions of the talus that were treated surgically between 2003 and 2016. If the lesion was stable and articular cartilage was intact, retrograde drilling was performed under fluoroscopic guidance. Lesions with detached overlying cartilages were treated by debridement of the cartilage combined with microfracture and drilling. Radiographic outcomes, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and skeletal maturity were evaluated. Results: Radiological improvement was observed in 24 (24/28, 86%) patients and complete and incomplete healing in 8 and 16 patients, respectively. Changes in pain grades, American Orthopaedic Foot & Ankle Society scores, and radiological healing after surgery were significant (pain grade, p < 0.001; American Orthopaedic Foot & Ankle Society, p = 0.018; radiological healing, p < 0.001). In addition, patients in the younger age group (≤13 years) showed greater improvements in pain grades than older patients (p = 0.02). Improvement in pain grade after surgery was better in the skeletally immature group than in the skeletally mature group (p = 0.048). Conclusion: Clinical and radiological improvements were observed after surgical treatment. The younger age group and open physis group showed more pain improvement. Level of evidence: Therapeutic level IV.