Extracorporeal Shock Wave Therapy in Musculoskeletal Disorders / 대한정형외과학회잡지

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles, and extracorporeal shock wave therapy (ESWT) appears to have mechanical and biological effects on tissue healing. The application of ESWT to musculoskeletal disorders has been around for more than a decade and is used primarily in the treatment of calcific or non-calcific tendinitis of the shoulder, lateral and medial epicondylitis of the elbow, patellar tendinopathy, Achilles tendinitis or proximal plantar fasciitis of the heel, myofascial pain syndrome, etc. ESWT is also used in the treatment of delayed union or non-union of long bone fractures, avascular necrosis of the femoral head, and chronic diabetic ulcers. The vast majority of papers have reported positive and beneficial effects with few complications. The clinical application of ESWT has increased steadily. This article reviews the current status of ESWT in musculoskeletal disorders.

Another Assessment of Fat Degeneration of Retracted Supraspinatus Muscle

BACKGROUND: The purpose of this study was to assess the relevance of preoperative magnetic resonance imaging (MRI) evaluation by occupation ratio (OR) at maximum diameter of supraspinatus muscle. METHODS: Patients from the Inje University Sanggye Paik Hospital who received rotator cuff repair and underwent pre- and postoperative MRI were selected as subjects of this study. On T1-weighted MRIs, OR of fat and muscle at Y-shaped view, OR at a location on supraspinatus muscle where its diameter was maximum on coronal view, and pre- and postoperative Goutallier Classification and changes in the tangent sign were measured. Statistical significance of postoperative OR was assessed regarding time from symptom onset to surgery, size of rotator cuff tear, preoperative OR, and the difference between ORs measured at maximum diameter of supraspinatus muscle and Y-shaped view. RESULTS: Preoperative OR at Y-shaped view was 52.28 ± 8.57 (32.5–65.3). Preoperative OR difference between maximum diameter and Y-shaped view was 13.76 ± 10.51 (2.38–42.04), and Pearson correlation coefficient was 0.604 (p=0.001). Postoperative OR at Y-shaped view was 63.77 ± 9.35 (37.3–76.1). Pearson correlation coefficient of pre- and postoperative Goutallier Classification was −0.579 (p=0.002) and Pearson correlation coefficient of the postoperative difference between ORs measured at maximum diameter of supraspinatus muscle and Y-shaped view was −0.386 (p=0.047). CONCLUSIONS: Fatty degeneration of supraspinatus muscle in rotator cuff tear patients should be evaluated not only in the conventional Y-shaped view, but also at location of maximum diameter of supraspinatus muscle to establish patients' therapeutic plan.

Internal Fixation with a Locking T-Plate for Proximal Humeral Fractures in Patients Aged 65 Years and Older

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of internal fixation with locking T-plates for osteoporotic fractures of the proximal humerus in patients aged 65 years and older. METHODS: From January 2007 through to December 2015, we recruited 47 patients aged 65 years and older with osteoporotic fractures of the proximal humerus. All fractures had been treated using open reduction and internal fixation with a locking T-plate. We classified the fractures in accordance to the Neer classification system; At the final follow-up, the indicators of clinical outcome-the range of motion of the shoulder (flexion, internal rotation, and external rotation) and the presence of postoperative complications-and the indicators of radiographic outcome-the time-to-union and the neck-shaft angle of the proximal humerus-were evaluated. The Paavolainen method was used to grade the level of radiological outcome in the patients. RESULTS: The mean flexion was 155.0° (range, 90°–180°), the mean internal rotation was T8 (range, T6–L2), and the mean external rotation was 66.8° (range, 30°–80°). Postoperative complications, such as plate impingement, screw loosening, and varus malunion were observed in five patient. We found that all patients achieved bone union, and the mean time-to-union was 13.5 weeks of the treatment. The mean neck-shaft angle was 131.4° at the 6-month follow-up. According to the Paavolainen method, “good” and “fair” radiographic results each accounted for 38 and 9 of the total patients, respectively. CONCLUSIONS: We concluded that locking T-plate fixation leads to satisfactory clinical and radiological outcomes in elderly patients with proximal humeral fractures by providing a larger surface area of contact with the fracture and a more rigid fixation.

Internal Fixation with a Locking T-Plate for Proximal Humeral Fractures in Patients Aged 65 Years and Older

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of internal fixation with locking T-plates for osteoporotic fractures of the proximal humerus in patients aged 65 years and older. METHODS: From January 2007 through to December 2015, we recruited 47 patients aged 65 years and older with osteoporotic fractures of the proximal humerus. All fractures had been treated using open reduction and internal fixation with a locking T-plate. We classified the fractures in accordance to the Neer classification system; At the final follow-up, the indicators of clinical outcome-the range of motion of the shoulder (flexion, internal rotation, and external rotation) and the presence of postoperative complications-and the indicators of radiographic outcome-the time-to-union and the neck-shaft angle of the proximal humerus-were evaluated. The Paavolainen method was used to grade the level of radiological outcome in the patients. RESULTS: The mean flexion was 155.0° (range, 90°–180°), the mean internal rotation was T8 (range, T6–L2), and the mean external rotation was 66.8° (range, 30°–80°). Postoperative complications, such as plate impingement, screw loosening, and varus malunion were observed in five patient. We found that all patients achieved bone union, and the mean time-to-union was 13.5 weeks of the treatment. The mean neck-shaft angle was 131.4° at the 6-month follow-up. According to the Paavolainen method, “good” and “fair” radiographic results each accounted for 38 and 9 of the total patients, respectively. CONCLUSIONS: We concluded that locking T-plate fixation leads to satisfactory clinical and radiological outcomes in elderly patients with proximal humeral fractures by providing a larger surface area of contact with the fracture and a more rigid fixation.

An Analysis on the Effect of Patient-controlled Analgesia Performed by Orthopaedic Department or Postoperative Pain Control after Shoulder and Elbow Surgery

BACKGROUND: We investigated the effectiveness of pain management and the adverse events of intravenous (IV) patient-controlled analgesia (PCA) after orthopedic surgery. METHODS: From September 2014 and August 2015, we performed a retrospective analysis of 77 patients who underwent orthopedic surgery of the shoulder or the elbow in our hospital. The composition of the intravenous PCA administered to the patients was as follows: 250 mg of dexketoprofen trametamol, 70 mg of oxycodone, and 0.6 mg of ramosetron, which were made up to 79 ml of normal saline. We evaluated and statistically analyzed the difference in the visual analogue scale (VAS) scores for pain at immediate postoperation, at 24 hours of PCA, at 72 hours of PCA, and after discontinuation of PCA and in the incidence of adverse events. RESULTS: We found that VAS score decreased for 3 postoperative days and that with discontinuation of IV PCA a meaningful change in VAS score was no longer seen. Of the 77 patients, 22 presented with adverse events (28.6%). We terminated IV PCA temporarily in the 21 patients who presented with adverse events; we terminated analgesia permanently in one patient (1.2%). Consequently, 76 of 77 patients carried out IV PCA till the designated period. CONCLUSIONS: Intravenous PCA after orthopedic surgery of the shoulder or the elbow may be accompanied with adverse events. Careful assessment of the patient and treatment of the adverse outcomes are key to a successful maintenance of PCA and to a successful management of postoperative pain.

An Analysis on the Effect of Patient-controlled Analgesia Performed by Orthopaedic Department or Postoperative Pain Control after Shoulder and Elbow Surgery

BACKGROUND: We investigated the effectiveness of pain management and the adverse events of intravenous (IV) patient-controlled analgesia (PCA) after orthopedic surgery. METHODS: From September 2014 and August 2015, we performed a retrospective analysis of 77 patients who underwent orthopedic surgery of the shoulder or the elbow in our hospital. The composition of the intravenous PCA administered to the patients was as follows: 250 mg of dexketoprofen trametamol, 70 mg of oxycodone, and 0.6 mg of ramosetron, which were made up to 79 ml of normal saline. We evaluated and statistically analyzed the difference in the visual analogue scale (VAS) scores for pain at immediate postoperation, at 24 hours of PCA, at 72 hours of PCA, and after discontinuation of PCA and in the incidence of adverse events. RESULTS: We found that VAS score decreased for 3 postoperative days and that with discontinuation of IV PCA a meaningful change in VAS score was no longer seen. Of the 77 patients, 22 presented with adverse events (28.6%). We terminated IV PCA temporarily in the 21 patients who presented with adverse events; we terminated analgesia permanently in one patient (1.2%). Consequently, 76 of 77 patients carried out IV PCA till the designated period. CONCLUSIONS: Intravenous PCA after orthopedic surgery of the shoulder or the elbow may be accompanied with adverse events. Careful assessment of the patient and treatment of the adverse outcomes are key to a successful maintenance of PCA and to a successful management of postoperative pain.

Pathologic Fracture Due to an Osteoblastoma of the Humerus Shaft: A Case Report / 대한골관절종양학회지

Osteoblastoma is rare, benign, bone-forming tumor that often occur in the spine. There are few reports of osteoblastomas resulting in pathologic fractures involving long bones. Authos report a unique case of a pathologic fracture due to an osteoblastoma of the humerus shaft. The tumor was treated successfully by curettage, intramedullary nailing and bone allograft.

Does Interfragmentary Cerclage Wire Fixation in Clavicle Shaft Fracture Interfere the Fracture Healing?

PURPOSE: A technique of cerclage wire fixation in comminuted fracture of the clavicle shaft is thought to interfere the fracture healing, so authors studied radiographically and clinically about the cases of cerclage wiring of the fracture fragments with the plate and screws fixation in the comminuted fracture of the shaft of the clavicle. MATERIALS AND METHODS: According to following inclusion criteria, total 18 patients (male: 15, female: 3) were investigated; Patients who visited hospital due to clavicle shaft comminuted fracture from February 2005 to April 2009, who underwent surgery utilizing more than 2 cerclage wire fixation for the fragments when open reduction and plate fixation were operated and who could be follow-up over one year. The duration for fracture union, functional outcome and complications were investigated retrospectively. RESULTS: Radiological bone union was accomplished in average 13.3 weeks (12~16 weeks) and there was no complication such as nonunion, delayed union or infection. Range of motion of ipsilateral shoulder joint was recovered in all patients except one at the final follow-up. CONCLUSION: The clinical and radiographical results of the plate and screws fixation with cerclage wiring of the fragments in comminuted clavicle shaft fracture showed that the cerclage wiring does not interfere the fracture healing, so authors think that this method is a good alternative operation if it is performed carefully to minimize soft tissue dissection.

The Internal Diameter of the Radius and Ulna in Korean Children / 대한정형외과학회잡지

PURPOSE: Flexible intramedullary nailing is a advanced method for treating forearm fractures with fewer complications. But sometimes these nails should not be used due to the narrower internal diameter of the forearm bones. We studied the inner diameter of the radius and ulna of children along with their age in relation to the width of the nail. MATERIALS AND METHODS: We reviewed the forearm AP radiographs of all the patients who visited our institute during a specific period, in which their age was between 6 and 19. We measured the inner diameters of the radius and ulna at their narrowest location, and we analyzed the diameter in relation to the patients' age groups, and we compared this data with the width for the nail. RESULTS: A total of 208 patients was included in this study. The inner diameter grew with their increasing age, and the younger the patients, the higher was the rate of inappropriate use of the nail. On linear regression analysis, the age plus or minus 1 SD for usage of the ready-made nail was 12.6 years-old for the male radius. CONCLUSION: The nail was sometimes too thick for the diameter of the forearm bones of Korean children. It is correct for the surgeon to select whatever material to fix the fracture, but appropriate thickness of the nail should be selected thoughtfully in preoperative planning.

Interlocking Intramedullary Nailing of Forearm Shaft Fractures in Adults

PURPOSE: To evaluate the usefulness of interlocking intramedullary nailing for operative treatment of forearm shaft fractures in adults. MATERIALS AND METHODS: Thirteen forearm shaft fractures in 12 patients were fixated with 13 Acumed forearm intramedullary rods (ulna: 8, radius: 5). The average age was 36.7 years and mean follow-up period was 15.2 months. The union time was measured when there was no tenderness over the fracture site and the bridging callus was evident in at least two sides of the cortex. The range of motion of the joint and the rotation of the forearm was measured and the functional results were evaluated with Grace and Eversmann's rating system. RESULTS: Radiologic union was observed at 11.8 weeks postoperatively in 11 cases out of 13. No limitation of motion was observed. Nine had excellent or good functional results. In one Galeazzi fracture, radial shaft became displaced after nailing and should be re-stabilized with plate. Proximal interlocking screws were improperly inserted in one ulnar nail. Implants were removed in 7 cases. Removal guide screw was broken while removing the intramedullary nail in one case of ulnar shaft fracture. CONCLUSION: Interlocking intramedullay nailing might be a treatment option for the middle 1/3 shaft fractures of the adult forearm bone with favorable results.

Mini-T Plate Fixation for Neer Type II Distal Clavicle Fracture

PURPOSE: To evaluate and report the clinical and radiological outcomes of open reduction and internal fixation with a mini-T plate for unstable distal clavicle fractures. MATERIALS AND METHODS: From December 2004 to July 2007, fifteen patients who had a fracture of the distal clavicle (Neer type II fracture) were treated with an open reduction and internal fixation using a mini-T plate. They were followed up for a minimum of one year and the clinical and radiological results were analyzed. RESULTS: The average time to fracture union was 3.1(3~4) months. There were no complications, such as deep infection or fixation loss. The mean ASES score was 97 points (85~100points) at the last follow up period, and 14 patients had a full range of motion of the shoulder. CONCLUSION: Open reduction and internal fixation with a mini-T plate for unstable distal clavicle fracture is a good surgical method with good clinical and radiological results.

Arthroscopic Rotator Cuff Repair by Single Row Technique

The goal of rotator cuff repairs is to achieve high initial fixation strength, minimize gap formation, maintain mechanical stability under cyclic loading and optimize the biology of the tendon-bone interface until the cuff heals biologically to the bone. Single row repairs are least successful in restoring the footprint of the rotator cuff and are most susceptible to gap formation. Double row repairs have an improved load to failure and minimal gap formation. Transosseous equivalent repairs (suture bridge technique) have the highest ultimate load and resistance to shear and rotational forces and the lowest gap formation. Even though the superior advantages of double row and transosseous equivalent repairs, those techniques take longer surgical time and are more expensive than single row repairs. Therefore single row repairs can be useful in bursal side partial thickness or small size full thickess rotator cuff tear.

Preoperative Three Dimensional Ultrasonographic Evaluation of the Rotator Cuff Tear

PURPOSE: We wanted to determine if preoperative three dimensional (3D) ultrasonographic evaluation for rotator cuff tear is useful to measure the real size of a torn rotator cuff for performing an operation MATERIALS AND METHODS: This study included 15 cases (7 males and 8 female), and these patients were confirmed to have a full thickness tear of the rotator cuff by 3D ultrasonography and the operative findings, as well as on the magnetic resonance imaging (MRI). The average age of the patients was 55.4yrs. RESULTS: The average difference between the 3D ultrasonographic and operative measurements of the full thickness tear of the rotator cuff was 0.7 mm in the transverse length and 2.0 mm in the longitudinal length. CONCLUSION: The low error between the 3D ultrasonographic and intraoperative measurements of rotator cuff tear shows the usefulness of preoperative 3D ultrasonographic evaluation for rotator cuff tear.

Arthroscopic Repair of Type II SLAP lesion with Bio-knotless Anchor

Purpose: This study reports the clinical results of the arthroscopic repair of type II SLAP lesion with bio-knotless anchor. Materials and Methods: 25 cases of 25 patients (20 male, 5 female) were included in this study. The average age was 44.5 years old. Preoperative ASES score was average 44. Arthroscopic SLAP repair with 1 or 2 bio-knotless anchors were performed in all cases. The average follow up period was 15 months. Results: The ASES score improved to average 92.7 at last follow up period and 23 cases had full range of motion of the shoulder. 2 case had mild limited range of motion of the shoulder without any problem in normal activity. Conclusion: Arthroscopic repair with bio-knotless anchor in type II SLAP lesion is one of the good methods because of the good clinical results.

Tenodesis of Long Head of the Biceps Brachii Tendon with Bioabsorbable Interference Screw

Purpose: This study reports the clinical results of the tenodesis of long head of the Biceps brachii tendon with bioabsorbable interference screw by minimal open procedure. Materials and Methods: Ten cases of 10 patients (7 male, 3 female) were included in this study. The average age was 45.8 years old and the average period from the symptom onset to operation was 13.7 months. Average preoperative ASES score was 38.5. The causes of injury was; sports activities in 4 patients, unknown in 4 patients, industrial accident in 1 patient and traffic accident in 1 patient. The average follow up period was 12.1 months. Tenodesis with bioabsorbable interference screw by minimal open precedure was performed in all cases. Results: The ASES score improved to 87.5 at last follow up period and 6 cases had full range of motion of the shoulder. 4 cases had mild limited range of motion of the shoulder without any problem in normal daily activity. Conclusion: It was assumed that tenodesis of long head of the biceps brachii tendon with bioabsorbable interference screw by minimal open precedure was one of the good methods with good clinical results.

Treatment of Highly Unstable Trochanteric Fractures

PURPOSE: This study analyzed the treatment results of highly unstable trochanteric fractures and made treatment guidelines. MATERIALS AND METHODS: Among three hundred six cases of trochanteric fractures from October 2001 to February 2006, the patients were divided into group 1(highly unstable trochanteric fracture, 69 cases) and group 2(age and gender-matched control group, 70 cases). The two groups were compared clinically and radiologically. A highly unstable trochanteric was defined as a fracture with a neck-shaft angle<100degrees and anterior angulation. The mean follow-up duration in groups 1 and 2 was 13.2 and 15.5 months, respectively. The mean neck-shaft angle in groups 1 and 2 was 92.1degrees and 118.9degrees , respectively. The mean anterior angulation in groups 1 and 2 was 23.0degrees and 4.6degrees. RESULTS: In group 1, 39 cases were treated with a dynamic hip screw (DHS), 22 cases were treated with a proximal femoral nail (PFN), and 8 cases(11.6%) were treated with primary bipolar hemiarthroplasty. The average amount of sliding of the lag screw in groups 1 and 2 was 10.5 mm and 3.7 mm, respectively (p<0.05). The average change in the neck-shaft angle in groups 1 and 2 was 7.0degrees 1 and 2.1degrees , respectively (p<0.05). There were 7 complications in group 1, including 5 cutting-out, 1 back-out and 1 Z-effect, and 2 cases of cutting-out in group 2. CONCLUSION: A highly unstable trochanteric fracture has a high risk of the need for additional surgery. Therefore, considerable care should be taken to treat it with a consideration of the possible need for arthroplasty.

Subtalar Distraction Arthrodesis for Calcaneal Malunion

PURPOSE: To evaluate the results and efficacy of the subtalar distraction arthrodesis on patients with complications due to malunion after intra-articular calcaneal fracture. MATERIALS AND METHODS: From October 2001 to September 2004, we operated on 10 patients (14 cases). There were 9 male patients and one female; their mean age was 41 years old. Ten cases among them were operated initially. The mean period between initial injury and arthrodesis was 18 months. The mean follow up period was 16 months. During the operation, we used extensile lateral approach and arthrodesis was performed using tricortical bone block and cannulated screws. The ankle-hindfoot scale was used for clinical evaluation. In radiologic analysis, plain X-ray and CT of the both feet were examined for union and various parameters. RESULTS: Thriteen cases achieved radiologic bone union. The mean ankle-hindfoot scale (maximum: 94 points) increased from 52.4 points preoperatively to points 77.2 at the final follow-up. The radiologic analysis of the pre and postoperative standing lateral radiograph showed mean increase of 6.9 mm in talo-calcaneal height, 5.2 degrees in talocalcaneal angle, 4.3 degrees in talar declination angle and average decrease of 4.5 degrees in talo-first metatarsal angle. CONCLUSION: The short term result of the subtalar distraction arthrodesis using tricortical bone block was promising, but longer follow-up will be needed.

Flexible Intramedullary Pin Fixation of Both Forearm Bone Fractures in Children

PURPOSE: To evaluate the efficacy of Flexible intramedullary pin fixation in pediatric forearm diaphyseal fractures. MATERIALS AND METHODS: In this retrospective study, we reviewed 15 cases of forearm diaphyseal fractures operated using flexible intra-medullary nail fixation technique between January 2000 and December 2004. Of these 15 children, there were 11 boys and 4 girls with an average age of 11.6 years (range, 7~15 years). The implants were introduced in the distal radius and proximal ulna in all patients. An average duration of fixation was 5.3 months in the radius, 4.7 months in the ulna. After operation, all patient were applied with a long arm cast and the duration of immobilization was 5.2 weeks (range, 4~6 weeks) on average. RESULTS: All fractures in this series healed with normal range of supination (average 80.0) and pronation (average, 71.6 degrees). Average operation time including anesthesia was 123 minutes and hospital stay was 5.4 days. Time to union was 8.4 weeks on average. Range of motion and functional results were satisfactory in all cases. There were one case of incomplete ulnar nerve injury and two cases of refracture which were treated conservatively without any permanent complication. CONCLUSION: Flexible intramedullary pin fixation technique is a good method in case of unstable displaced fracture and difficult or failed closed treatment.

Intramedullary Fixation in the Fracture of the Shaft of the Clavicle by Threaded Kirschner Wire

PURPOSE: To evaluate and report the clinical result of the intramedullary fixation by threaded Kirschner wire in the clavicle shaft fracture. MATERIALS AND METHODS: From May 2000 to April 2004, twenty patients who had the fracture of the shaft of the clavicle were treated by the intramedullary fixation with threaded Kirschner wire. Thirteen patients were followed up and the clinical and radiological results were analyzed. RESULTS: All of the cases had satisfactory fracture union but there were four cases of skin irritation signs by the tip of threaded Kirschner wire. In one case, the Kirschner wire was bent at the fracture site with malunion. According to the clinical scoring system of Kang et al, eight cases were excellent and five cases were good. CONCLUSION: Authors think that intramedullary fixation with threaded Kirschner wire in the fracture of the shaft of the clavicle is one of a good operative method because of small operative incision, easy operative method, satisfactory fracture union and easy removability of the implant.

Acute Osteomyelitis in the Shaft of the Radius after Contusion of the Forearm: A Case Report

Acute osteomyelitis after the contusion is a rare clinical entity. The complications of contusion are large hematoma formation, compartment syndrome, myositis ossificans and acute osteomyelitis. Authors experienced an acute osteomyelitis in the shaft of the radius after contusion of the forearm and report this case with references.