Outcomes of Arthroscopic Scaphoid Excision and Lunocapitate Fusion for Advanced Traumatic Arthritis of the Wrist

Background@#Arthroscopic lunocapitate (LC) fusion can be an alternative surgical treatment for scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist. We retrospectively reviewed patients who had arthroscopic LC fusion to estimate clinical and radiological outcomes. @*Methods@#From January 2013 to February 2017, all patients with SLAC (stage II or III) or SNAC (stage II or III) wrists, who underwent arthroscopic LC fusion with scaphoidectomy and were followed up for a minimum of 2 years, were enrolled in this retrospective study. Clinical outcomes included visual analog scale (VAS) pain, grip strength, active range of wrist motion, Mayo wrist score (MWS), and the Disabilities of Arm, Shoulder and Hand (DASH) score. Radiologic outcomes included bony union, carpal height ratio, joint space height ratio, and loosening of screws. We also performed group analysis between patients with 1 and 2 headless compression screws to fix the LC interval. @*Results@#Eleven patients were assessed for 32.6 ± 8.0 months. Union was achieved in 10 patients (union rate, 90.9%). There was improvmenet in mean VAS pain score (from 7.9 ± 1.0 to 1.6 ± 0.7, p = 0.003) and grip strength (from 67.5% ± 11.4% to 81.8% ± 8.0%, p= 0.003) postoperatively. The mean MWS and DASH score were 40.9 ± 13.8 and 38.3 ± 8.2, respectively, preoperatively and improved to 75.5 ± 8.2 and 11.3 ± 4.1, respectively, postoperatively (p < 0.001 for all). Radiolucent screw loosening occurred in 3 patients (27.3%), including 1 nonunion patient and 1 patient who underwent screw removal due to the screw migration encroaching the lunate fossa of radius. In group analysis, only the frequency of radiolucent loosening was higher in 1 screw (3 of 4) than 2 screw fixation (0 of 7) (p= 0.024). @*Conclusions@#Arthroscopic scaphoid excision and LC fusion for patients with advanced SLAC or SNAC of the wrist was effective and safe only in cases fixed with 2 headless compression screws. We recommend arthroscopic LC fusion using 2 screws rather than 1 to decrease radiolucent loosening, which might affect complications such as nonunion, delayed union, or screw migration.

Robot-Assisted Retroauricular Anterior Scalenectomy for Neurogenic Thoracic Outlet Syndrome

Background@#This study described the surgical technique of a robot-assisted retroauricular anterior scalenectomy and assessed clinical outcomes and complications for patients with neurogenic thoracic outlet syndrome (nTOS). @*Methods@#Between February 2014 and August 2016, 5 patients underwent robot-assisted retroauricular anterior scalenectomy using the da Vinci Xi system for nTOS. For clinical assessment, visual analog scale (VAS) symptom score, pinch and grip strength, and disabilities of arm, shoulder and hand (DASH) score were assessed to compare preoperative and postoperative outcomes. Postoperative complications were also reviewed. @*Results@#The VAS symptom, pinch and grip strength, and DASH scores improved 1 year after the operation. All patients were satisfied with the surgical scars. Temporary postoperative complications, which spontaneously resolved within 3 months, were noticed in 2 patients: one with vocal cord palsy and the other with upper brachial plexus palsy. @*Conclusions@#The robot-assisted retroauricular anterior scalenectomy for patients with nTOS seems feasible and safe, providing satisfactory cosmetic results.

Preservation of Scaphoid in Scaphoid Nonunion Advanced Collapse Stage II and III / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to investigate the outcome of open reduction and internal fixation with a headless screw and auto iliac bone graft for patients of scaphoid nonunion advanced collapse (SNAC) stage II and III. MATERIALS AND METHODS: A retrospective analysis was conducted for 10 patients diagnosed with stage II or III SNAC, and consequently treated with open reduction and internal fixation with a headless screw and auto iliac bone graft with or without radial styloidectomy between 2010 and 2013. Radiographic results were evaluated by bone union, the scapholunate angle and lateral intrascaphoid angle. Clinical results were evaluated by range of motion, pain, grip strength, Mayo wrist score, and assessment of Maudsley. RESULTS: All patients showed union after the operation. Final follow-up X-rays show smoothening of the articular surface with improvement of sclerotic lesions of the articular surface, cystic lesions and osteopenic lesions. Pain decreased after the operation compared with preoperative status, grip strength and Mayo wrist score showed significant improvement. Scapholunate angle and lateral intrascaphoid angle decreased after the operation, but it was not significant. According to assessment of Maudsley, among 10 cases, there were 4 excellent cases, 4 good cases and 2 fair cases. CONCLUSION: Restoration of stability of scaphoid is important to SNAC stage II and III, open reduction and internal fixation with a headless screw and auto iliac bone graft shows satisfactory clinical and radiologic outcomes. Thus it is considered a recommendable operation.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PURPOSE: Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years. MATERIALS AND METHODS: Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale. RESULTS: Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination. CONCLUSION: An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years.

Olecranon Nonunion after Operative Treatment of Fracture

PURPOSE: Olecranon nonunion after surgical management is relatively rare, but it leads to limitation of motion of joint or instability. This retrospective study was conducted in order to analyze the cause and result of treatment. MATERIALS AND METHODS: We analyzed 11 cases treated for nonunion of olecranon fractures. Nonunion was classified according to the spot of the lesion and the extent of articular surface damage. Evaluation was performed using Mayo elbow performance score (MEPS), Oxford elbow score (OES), Disabilities of the Arm, Shoulder and Hand (DASH) scores, and the range of motion. RESULTS: According to the spot of the lesion and the extent of articular surface damage, nonunion was categorized as IA (2 cases), IIA (5 cases), and IIIA (4 cases). One case of IA underwent nonunion fragment excision and the remaining cases were treated by bone grafting. A plate was used in seven cases and the other three cases had both plate and tension band wiring fixation. All nonunions finally became union. The 11 patients with one year follow-up had average MEPS of 87.7 points (range: 60-100 points), average OES of 43.2, and average DASH score of 18.8 points. Complications included limitation of motion (2 cases) and ulnar nerve symptoms (3 cases). CONCLUSION: Bone grafting and fixation by plate may be beneficial. In addition, excision can be useful in type I.

Passive Skeletal Muscle Excursion after Tendon Rupture Correlates with Increased Collagen Content in Muscle

PURPOSE: This study was designed to measure time-dependent changes in muscle excursion and collagen content after tenotomy, and to analyze the correlation between muscle excursion and collagen content in a rabbit model. MATERIALS AND METHODS: Twenty-four rabbits underwent tenotomy of the second extensor digitorum longus (EDL) muscles on the right legs and were randomly assigned to three groups based on the period of time after tenotomy (2, 4, and 6 weeks). The second EDL muscles on left legs were used as controls. At each time after tenotomy, passive muscle excursion and collagen content, determined by hydroxyproline content, were measured bilaterally, and the ratio of each value to the normal one was used. RESULTS: The mean ratio of muscle excursion after tenotomy to the value of the control decreased in a time-dependent fashion: 92.5% at 2 weeks, 78.6% at 4 weeks, and 55.1% at 6 weeks. The mean ratio of hydroxyproline content in muscle to the value of the control increased in a time-dependent fashion: 119.5% at 2 weeks, 157.3% at 4 weeks, and 166.6% at 6 weeks. There was a significant negative correlation between the ratio of hydroxyproline content in muscle after tenotomy to the control values and the ratio of muscle excursion after tenotomy to the control values (r=-0.602, p=0.002). CONCLUSION: The decrease in muscle excursion seems to correlate with the increase in collagen content in the muscle in a time-dependent fashion following tenotomy.

Headless Autocompression Screw Fixation of Scaphoid Fractures Using Open Dorsal Approach

PURPOSE: We present the clinical and radiological results of open reduction and internal fixation for scaphoid fracture with retrograde headless screw fixation via dorsal approach. METHODS: This study carried out a survey targeting 15 patients who have a retrograde headless screw fixation on nonunion of scaphoid fracture without previous operation, 2 patients who have a retrograde headless screw fixation on nonunion of scaphoid fracture with previous operation and 8 patients who have a trans-scaphoid perilunate dislocation. We figured out a mechanism of injury, and clinical symptom, radiologic findings. The surgery was done with open dorsal approach which is retrograde headless screw fixation internally, with or without bone graft. We analyzed the result by Maudsley method, in terms of bone union, duration for union, radiologic finding, clinical outcomes. RESULTS: After surgery, 22 of 25 patients had union result on fracture and other 3 patients had nonunion result. It took 12 weeks to achieve bone union on average. Based on radiograhs, we had one case of partial avascular necrosis of proximal fragment without clinical symptoms. We had one case of each scaphoid nonunion without previous operation, with operation and trans-scaphoid perilunate dislocation had arthritic change and non-symptomatic nonunion result. In terms of clinical outcome, 22 patients showed satisfactory results and 3 patients had slight limitation of range of motion. CONCLUSION: Retrograde headless screw fixation with or without bone graft for the treatment of scaphoid fracture is recommendable.

Fixation of Olecranon Fractures Using Plating System

PURPOSE: To evaluate the clinical and radiological outcomes of plate fixation for olecranon fractures which was difficult to be fixed firmly with tension band wiring alone. MATERIALS AND METHODS: From 1995 through 2008, 20 patients who underwent plate fixation of an olecranon fracture were included in this retrospective study. According to the Mayo classification, there were 3 type IIA fracture, 7 type IIB, and 10 type IIIB fractures. Clinical evaluation was done based on radiographic union of olecranon and measurements of range of motion at last follow-up. Disability of the arm, shoulder and hand (DASH) score and Mayo Elbow Performance score was used for evaluation of functional recovery. RESULTS: Union was achieved in 18 (90%) at an average of 5.6 months. The mean arc of elbow motion was 123degrees and the mean rotation arc was 81degrees. According to the MEPS, sixteen of twenty patients had a good or excellent outcome. The mean DASH score was 16.3. Most common complication was hardware irritation in 3 patients. CONCLUSION: Plate fixation is an effective treatment option for severe olecranon fracture pattern like comminuted fractures, Monteggia equivalent with unstable elbows and nonunions.

Surgical Removal of Calcific Lesions in the Hand

PURPOSE: Calcific lesion of the hand is infrequently recognized, presenting with severe pain and swelling of the affected joint. The purpose of this study is to describe clinical features associated with this condition by reviewing surgically treated patients. MATERIALS AND METHODS: A retrospective study was carried out in 11 patients who had operation clinical and radiographic data were collected by medical records. RESULTS: Eight patients were females and three were males with age ranging between 27-75 years (mean: 48 years). By location, five cases of interphalangeal joint, three cases of metacarpophalangeal joint of thumb, two cases of carpal tunnel and one case of distal ulna area were noted. Interval between symptom presentation and operation was 9.4 month (range: 6-18 month). During 10 month follow-up (range: 6-12 month), recurrence had not occurred. CONCLUSION: Although the prevalence of calcific lesion of hand and wrist is low, it may cause severe pain and swelling. If conservative treatment fails or any nerve compression symptom develops, surgical removal of the calcific lesion is recommended.

Treatment of Non-union Distal Humerus Fractures after Operation

PURPOSE: This study is a retrospective analysis of patients who had undergone surgical treatment for non-union of distal humerus fracture. We evaluated them in terms of causes of injury, radiologic findings, and clinical outcomes such as prognosis. MATERIALS AND METHODS: Seven consecutive radiologic patients who were confirmed to have nonunion of a distal humerus fracture underwent reoperations. These patients had already undergone operations for distal humerus fractures. This survey was held from 2005 to 2010. The average period up to diagnosis of non-union after the first operation was 7.4 months (4 to 16 months). The mean follow-up period was 24.6 months (12 to 65 months). Each patient was graded functionally according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand Score. RESULTS: Osteosynthesis was performed by internal fixation with plates and screws and then a bone graft for non-union of the distal humerus fracture. The average range of motion within the elbow joints was found to be a flexion contracture of 18.8 degrees (0~30 degrees) and further flexion of 120.2 degrees (102~140 degrees). Among postoperative complications, three cases of medium-degree stiffness, two cases of medial column nonunion, and one case of dissociation of the internal fixator were reported. CONCLUSION: Stable internal fixation for maintenance reduction status is essential after accurate initial anatomical reduction. We concluded that nonunion could be prevented by additional surgical treatment such as autogenous bone graft, if it is necessary.

Revision Osteosynthesis after Failed Surgery for Scaphoid Nonunion

PURPOSE: The purpose of this study was to evaluate the outcomes of revision osteosynthesis using Herbert screw fixation combined with autogenous cancellous bone grafting for scaphoid nonunions after failed primary surgery. MATERIALS AND METHODS: Twelve patients who underwent revision osteosynthesis for a scaphoid nonunion after a mean of 13.6 months following primary surgical failure were studied. There were 9 waist fractures and 3 proximal fractures. The revision osteosynthesis was performed using autogenous iliac cancellous bone grafting combined with Herbert screw fixation. RESULTS: Union was achieved in 11 of 12 cases. The results of eleven united cases were clinically satisfactory at the mean follow up of 16.9 months after revision. The motion range of wrist joint improved: average flexion was 51degrees, average extension was 65degrees, average radial deviation 15degrees, and average ulnar deviation was 21degrees. CONCLUSION: Herbert screw fixation and autogenous iliac cancellous bone grafting was proved to be a useful method as a revisional operation for a scaphoid nonunion after failed primary surgery.

Surgical Treatment of Ulnar Metaphyseal Fracture Associated with Distal Radius Fracture in Osteoporotic Patients

PURPOSE: To evaluate the results of operative treatment for the unstable ulnar metaphyseal fractures associated with a distal radius fracture in osteoporotic patients. MATERIALS AND METHODS: Retrospective study was done on 10 patients with a ulnar metaphyseal fracture which was remained unstable after reduction and fixation of the distal radius fracture between March 2002 and Feb 2006. The average age was 72 years old. The mean follow up period was 25 months. Of 5 cases of Biayni type 1, 2, 3 fracture, 4 cases were treated with closed reduction and percutaneous pinning and one with open reduction and internal fixation with plate. All type 4 fractures were treated with ulnar resection. Range of motion, visual analogue scale for pain and grip strength were measured and clinical results were evaluated by Cooney's method. RESULTS: In ulnar fixation group, average motion was 68.5, 45.5, 65.3 and 75.8 degrees for flexion, extension, supination and pronation, respectively. The average grip strength was 102% of uninjured hand. In ulnar resection group, average motion was 65.5, 50.4, 75.2 and 75.5 degrees for flexion, extension, supination and pronation, respectively. The mean grip strength was 86.7% of uninjured hand. According to Cooney's method, there were excellent in one patient, good in seven, fair in one and poor in one. Fair and poor results were noted in case of AO type C fractures. CONCLUSION: Unstable ulnar metaphyseal fractures associated with distal radius fractures in osteoporotic patients can be treated successfully with ulnar fixation or resection. Ulnar resection is useful option in selected cases such as severe comminuted fractures.

Single Portal Endoscopic Carpal Tunnel Release in Patients Older than 65 Years

PURPOSE: There have been few reports about the endoscopic carpal tunnel release (ECTR) in elderly patients and its efficacy and safety are not well-known. We evaluated the clinical outcomes of ECTR using Agee technique in patients older than 65 years. MATERIALS AND METHODS: From October 2000 to January 2007, thirty-five patients (42 hands) who underwent ECTR using Agee technique were enrolled. The average age of the patients was 67.2 years (range, 65-71 years). The duration of symptoms averaged 10 months (range, 6-33 months). For evaluation of the clinical outcomes, physical examination and subjective assessment of the hand function using the Boston carpal tunnel questionnaire were performed at postoperative 1-year follow-up and compared with those obtained at preoperative evaluation. The mean follow-up period was 18 months (range, 12-24 months). RESULTS: There were no neurovascular injury and scar tenderness. At postoperative 1-year follow-up, paresthesia, numbness, Phalen's sign, tinel sign, two point discrimation, and grip power were significantly improved compared with those obtained at preoperation. According to the Boston questionnaire, symptom severity score improved from 3.43 preoperatively to 1.89 postoperatively, and functional status score improved from 3.18 preoperatively to 2.21 postoperatively (p<0.05). Thenar atrophy still remained in 32 hands (76.2%). CONCLUSION: Although thenar atrophy did not improve in many cases, symptom severity and functional status scores improved in most patients treated with ECTR. The single portal ECTR is a safe and efficacious treatment option in elderly patients with carpal tunnel syndrome.

Comparison of Joint Line Change in Posterior Cruciate Retained versus Cruciate Sacrificed Total Knee Aarthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to compare the change of joint line and patellar position between posterior crucate ligament-retained and posterior cruciate ligament-sacrificed total knee arthroplasty. MATERIALS AND METHODS: Fifty posterior crucate ligament-retained and fifty posterior cruciate-sacrificed total knee arthroplasties were evaluated to compare the joint line height from tibial tuberosity, patella bone height from joint line, patella articular height from joint line, patella bone height from tibial tuberoisty and patella articular height from tibial tuberosity. The measurements were assessed preoperatively and postoperatively. RESULTS: No difference in joint line height from tibial tuberosity, patellar bone height from joint line, patellar articualr height from joint line, patellar bone height from tibial tuberosity and patellar articular height from tibial tuberosity were found with either design (p>0.05). CONCLUSION: This study demonstrates that the resection of the posterior cruciate ligament can be one of the preferable method to increase the flexion gap without influencing the joint line in Total knee arthroplasty.