Comparison of Ulnar Collateral Ligament Reconstruction Techniques in the Elbow of Sports Players

Ulnar collateral ligament injuries have been increasingly common in overhead throwing athletes. Ulnar collateral ligament reconstruction is the current gold standard for managing ulnar collateral ligament insufficiency, and numerous reconstruction techniques have been described. Although good clinical outcomes have been reported regarding return to sports, there are still several technical issues including exposure, graft selection and fixation, and ulnar nerve management. This review article summarizes a variety of surgical techniques of ulnar collateral ligament reconstructions and compares clinical outcomes and biomechanics.

Microinstability of the Shoulder / 대한스포츠의학회지

A variety of theories have been reported as causes of shoulder pain in overhead throwing athletes. Recently, an explanation with microinstability of the shoulder and internal impingement has been proposed. The concept of the microinstability is that pathologic laxity of the anterior capsule caused by repeated abduction and external rotation of the shoulder leads to abnormal glenohumeral biomechanics and causes internal impingement of the shoulder. Based on the understanding of the pathology, it is recommended to identify the causes of shoulder pain in the overhead throwing athletes and perform appropriate rehabilitation or surgical treatment.

Pseudotumor and Subsequent Implant Loosening as a Complication of Revision Total Hip Arthroplasty with Ceramic-on-Metal Bearing: A Case Report / 대한고관절학회지

Pseudotumors are not uncommon complications after total hip arthroplasty (THA) and may occur due to differences in bearing surfaces of the head and the liner ranging from soft to hard articulation. The most common causes of pseudotumors are foreign-body reaction, hypersensitivity and wear debris. The spectrum of pseudotumor presentation following THA varies greatly-from completely asymptomatic to clear implant failure. We report a case of pseudo-tumor formation with acetabular cup aseptic loosening after revision ceramic-on-metal hip arthroplasty. The patient described herein underwent pseudotumor excision and re-revision complex arthroplasty using a trabecular metal shell and buttress with ceramic-on-polyethylene THA. Surgeons should be aware of the possibility of a pseudotumor when dealing with revisions to help prevent rapid progression of cup loosening and implant failure, and should intervene early to avoid complex arthroplasty procedures.

Healing Process of Osteonecrotic Lesions of the Femoral Head Following Transtrochanteric Rotational Osteotomy: A Computed Tomography-Based Study

BACKGROUND: Transtrochanteric rotational osteotomy (TRO) is a controversial hip-preserving procedure with a variable success rate. The healing process of femoral head osteonecrosis after TRO has been poorly explained till now. This study aimed to evaluate the healing process of previously transposed necrotic lesion after a TRO for nontraumatic osteonecrosis of the femoral head using computed tomography (CT). METHODS: Among 52 patients (58 hips) who had preserved original femoral head after TRO, we retrospectively reviewed 27 patients (28 hips) who had undergone sequential CT scans and had no major complication following TRO. The average age was 34 years (range, 18 to 59 years). The mean follow-up period was 9.1 years. We evaluated the reparative process of the transposed osteonecrotic lesion with CT scans. RESULTS: Plain radiographs of the osteonecrotic lesion revealed sclerotic and lucent changes in 14 hips (50%) and normal bony architecture in the other 14 hips (50%) at the final follow-up. CT scans of the osteonecrotic lesions showed cystic changes with heterogeneous sclerosis in 13 hips (46%), normal trabecular bone with or without small cysts in 9 hips (32%), and fragmentation of the necrotic lesion in 6 hips (22%). Seventeen hips (60%) showed minimal (13 hips) to mild (4 hips) nonprogressive collapse of the transposed osteonecrotic area. The collapse of the transposed osteonecrotic area on the CT scan was significantly associated with the healing pattern (p = 0.009), as all 6 patients (6 hips) with fragmentation of the necrotic lesion had minimal (5 hips) to mild (1 hip) collapse. Furthermore, a significant association was found between the collapse of the transposed osteonecrotic area on the CT scan of 17 hips (60%) and postoperative Harris hip score (p = 0.021). We observed no differences among the healing patterns on CT scans with regard to age, gender, etiology, staging, preoperative lesion type, preoperative intact area, percentage of necrotic area, direction of rotation and immediate postoperative intact area. CONCLUSIONS: The majority of the hips showed incomplete regeneration of the transposed osteonecrotic lesion with cysts, sclerosis, and fragmentation, whereas repair with normal trabecular bone was observed only in one-third of the hips that were preserved after Sugioka TRO.

Orthogonal versus Parallel Plating for Distal Humeral Fractures

In orthopedic trauma surgery, treatment of intraarticular distal humerus fractures is a challenge. With development of implants and biomechanical studies, surgical strategies with recommendations including preoperative computed tomography images, proper approaches and open reduction and internal fixation with dual plates have emerged. In addition, as an effort to provide stable fixation to permit early elbow motion, different methods of internal fixation, particularly plate configuration, have evolved. Using dual plates, either oriented parallel to each other or orthogonal, stable fixation has been achieved and satisfactory clinical outcomes have been reported. With rationales and advantages/disadvantages of each plate configuration, both techniques are selected according to surgeons' preference, and, in specific cases, one could be preferred over another. The key to successful fixation by either technique is obtaining anatomical reduction with restoration of two stable columns of the distal humerus.

Orthogonal versus Parallel Plating for Distal Humeral Fractures

In orthopedic trauma surgery, treatment of intraarticular distal humerus fractures is a challenge. With development of implants and biomechanical studies, surgical strategies with recommendations including preoperative computed tomography images, proper approaches and open reduction and internal fixation with dual plates have emerged. In addition, as an effort to provide stable fixation to permit early elbow motion, different methods of internal fixation, particularly plate configuration, have evolved. Using dual plates, either oriented parallel to each other or orthogonal, stable fixation has been achieved and satisfactory clinical outcomes have been reported. With rationales and advantages/disadvantages of each plate configuration, both techniques are selected according to surgeons' preference, and, in specific cases, one could be preferred over another. The key to successful fixation by either technique is obtaining anatomical reduction with restoration of two stable columns of the distal humerus.

Biomechanics of the Elbow

PURPOSE: Understanding elbow biomechanics is necessary to understand the pathophysiologic mechanism of elbow injury and to provide a scientific basis for clinical practice. This article provides a summary of key concepts that are relevant to understanding common elbow injuries and their management. MATERIALS AND METHODS: The biomechanics of the elbow joint can be divided into kinematics, stability and force transmission through the elbow joint. Active and passive stabilizers include bony articular geometry; soft tissues provide joint stability, compression force and motion. RESULTS AND CONCLUSION: Knowledge of elbow biomechanics will help (i) advance surgical procedures and trauma management, (ii) develop new elbow prostheses and (iii) stimulate future research.

2-5 Year Results of the Cemented Polished Versys Heritage(R) Femoral Stem / 대한정형외과학회잡지

PURPOSE: Surface finishing of a cemented femoral stem is a subject of controversy even though contemporary cementing techniques have improved results. Versys Heritage femoral stem was used with a contemporary cementing technique to determine the outcome of using a polished surface. MATERIALS AND METHODS: Between October 2000 and August 2003, 131 primary hybrid hip arthroplasty procedures were performed in 117 patients. The mean age at the time of the index arthroplasty was 52 years and 9 months (24-78 years). The average follow up period was 49 months (range, 24-71 months). All the hips were evaluated clinically by the Harris hip score and radiologically by the cement grade, osteolysis as well as stress shielding. RESULTS: At the final follow up, the Harris hip score for all patients had improved from preoperative 59.1 (range, 17-91) to post operative 92.8 (range, 78-100). The cement grade was measured using Barrack's method. Of 131 hips, 75, 54 and 2 were grade A, grade B and grade C1 at the final follow up, respectively. None of the hips showed a C2 or D grade. There was no evidence of aseptic loosening or osteolysis on the femoral side during follow up. 45% of stems showed grade 1 and 2 stress shielding according to Engh's criteria. CONCLUSION: In this study, the Polished Versys Heritage femoral stem(R) showed excellent results at the short to mid term follow up period. However, a longer-term follow-up study will be needed to clarify the implications of the femoral prosthesis surface finish or design.

Comparison of LC-DCP versus LCP for Internal Fixation of Humeral Shaft Fractures in Elderly Patient

PURPOSE: To compare outcomes of humeral shaft fractures fixed with locking compression plate and those fixed with dynamic compression plate in elderly patients. MATERIALS AND METHODS: Nineteen consecutive elderly patients with a fracture of the humeral diaphysis were evaluated retrospectively. Ten patients had been fixed with LC-DCP, and nine had been fixed with LCP. Radiological and clinical results were compared and comparison of implants was done. RESULTS: Loosening of the plate occurred in one case each from the LCP group and the LC-DCP group. The rest of the patients achieved union uneventfully without any complications. Union rate, clinical score and hardware were not significantly different between the two groups. One patient who developed loosening in the LC DCP underwent reoperation whereas one patient with loosening in the LCP was successfully managed conservatively. CONCLUSION: Principle of fracture fixation was more important than plate selection in humeral shaft fracture of elderly patient.

Metallic Radial Head Prosthesis in Korea

Purpose: The aim of this study was to report seven cases of metallic radial head prosthesis and present the limit of use in Korea. Materials and Methods: Metallic radial head arthroplasty was performed on 7 patients between April 2006 and December 2006, who had complex elbow injury including comminuted radial head fracture. Indication, operative findings and outcome were assessed. Availability and payment of implant were investigated. Results: All of the patients had more than one associated injury including coronoid fracture, olecranoan fracture, and ligament ruptures. According to Mason classification, there were three type III and four type IV fractures. All radial head fractures were too comminuted to reconstruct. There were two excellent results, four good, and one poor, as graded by Mayo score. There were no patient with instability and implant related complications. Insufficient supply of implant did not enable to do scheduled surgery in 2 cases. Current medical insurance did not cover charge for radial prosthesis, five patients could not help paying for that by themselves. Conclusion: Metallic radial head implants are useful when the radial head cannot be repaired reliably. Preoperative preparing and coverage by medical insurance based on appropriate indication are helpful for decision for a treatment option.

Bilateral Simultaneous Sleeve Fracture of the Patella : A Case Report

Sleeve fractures of the patella are cartilaginous avulsion fractures from the lower pole of the patella. They occur mainly due to sports injuries in adolescents. They may be missed in diagnosis due to rare incidence and small bony fragment on simple radiographs. In this report, an unusual bilateral simultaneous sleeve fracture in a healthy child is described.

The Incidence of Infection in Interlocking Intramedullary Nailing after Skeletal Traction of Distal Femur

PURPOSE: The insertion site of K-wire for skeletal traction is proximal part of tibia or distal part of femur. However, people prefer proximal tibia over distal femur due to lower risk of infection rate when change to interlocking IM nailing is needed. We evaluated the infection rate of interlocking IM nailing. MATERIALS AND METHODS: Fourty-seven patients were included in this study who underwent interlocking IM nailing due to femur shaft fracture. Traction was applied at the distal femur in 19 cases and proximal tibia in 10 cases before interlocking IM nailing. No skeletal traction was applied to the remaining 18 cases. Thirty-eight patients were male and 9 were female. The average age at the time of surgery was 36.7 years old (range, 15~17 years). The average traction period was 9.5 days (range, 3~33 days) and the average followed-up period was 17.2 months. RESULTS: In the distal femoral traction group, 8 cases of superficial pin tract infection developed, but no case of deep infection such as osteomyelitis occurred. In the proximal tibia traction group, 2 cases of superficial pin tract infection developed, but no case of deep infection occurred. In the group that received no skeletal traction before interlocking IM nailing, no case of infection developed. CONCLUSION: In femur shaft fracture, the distal femoral skeletal traction followed by interlocking IM nailing of femur, compared to proximal tibia skeletal traction, did not increase the risk of deep infection such as osteomyelitis.

Inferior Subluxation of Humeral of Head after Surgery for Fracture of Proximal Humerus

PURPOSE: To study the development of inferior shoulder subluxation after surgery for proximal humerus fractures. To analyze the mechanism development of such subluxation and the association between different types of proximal humerus fractures, quality of reduction achieved the method of operation performed. MATERIALS AND METHODS: A retrospective analysis of 45 proximal humerus fractures that were treated by surgery between March 1997 and July 2002 was done. All patients had a minimum of 12 months of postoperative follow up. Preoperative radiographs were classified by the Neer's classification. Different operative treatment methods, post reduction alignment and the degree of postoperative subluxation if present, were analysed. In order to evaluate effect of loss of negative intraarticular pressure, we compared this series with 15 cases of recurrent shoulder dislocation treated by open Bankart operation. RESULTS: 13 patients out of 45 (29%) developed immediate postoperative inferior shoulder subluxation. 3-part fractures of the proximal humerus showed a higher incidence of the same than the 2-part types. The better reduced fractures had lesser rates of subluxation. Open reduction (39%, 11 patients) results in an increased incidence of inferior subluxation than closed methods of reduction (13%, 2 patients). CONCLUSION: Inferior subluxation of the humeral head after surgery for the proximal humerus fracture can occur and persist till postoperative period of 2 months. Deltoid muscle tone affected by shortening of humeral neck plays an important role. Early active exercise for restoration deltoid tone may be effective in prevention of inferior subluxation.

Minimally Invasive Anterior Approach in Open Reduction of Displaced Supracondylar Fractures of Humerus in Children

PURPOSE: To evaluate the outcomes of minimal anterior approach and thumb assisted technique, in children with Gartland type III supracondylar humerus fracture, who were operated by this technique. MATERIALS AND METHODS: Forty two children with Gartland type III supracondylar fractures of the humerus with severe swelling were taken up for minimal open reduction and K-wire fixation. The technique used was a minimal incision in the cubital fossa and thumb assisted reduction of the fracture. Stabilization of fractures was done with 1.6 mm Kirschner wires. RESULTS: The outcomes were excellent in 40 cases good in 2 cases. No complications including malunion or scar contracture were seen. CONCLUSION: This technique is safe, effective and can be used for irreducible, displaced supracondylar fractures of the humerus in children

Comparison of the Results of Core Decompression and Sugioka's Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head / 대한정형외과학회잡지

PURPOSE: This study conducted a comparative analysis on 49 hips treated with a core decompression procedure and 19 hips treated with a Sugioka's transtrochanteric rotational osteotomy for a osteonecrosis of the femoral head (ONFH). MATERIALS AND METHODS: This study evaluated the relationship between the Ficat and Arlet Stage and the extent of the necrotic lesion (using Shimizu's Grade Classification), and the clinical outcome of each procedure. The patient's outcomes were assessed after a mean follow-up of 46 months (range=36-82 months) after the core decompression and 53 months (range=37-108 months) after the Sugioka's transtrochanteric rotational osteotomy. The results were considered successful if the patients were asymptomatic with no disease progression, and unsuccessful if there was radiographic (progression of the stage or collapse) or clinical failure (the need for an arthroplasty or subsequent salvage operation). RESULTS: Twenty one out of 49 cases (43%) in the core decompression group and 14 out of 19 (74%) in the rotational osteotomy group showed successful outcomes. In the core decompression group, among the 22 F-A Stage I hips, 15 (68%) hips had survived according to radiological criteria. All four (100%) Shimizu's Grade A hips of the F-A Stage I had successful results, which is in contrast to the 11 hips out of 18 hips (61%) of the Shimizu's Grade B and C hips (p<0.01). Six (38%) out of 16 F-A Stage IIA hips and two (25%) out of eight IIB hips in the core decompression group had successful results, while 11 (85%) out of 13 IIA and two (50%) out of four stage IIB hips in the rotational osteotomy group had successful results. In the F-A Stage III hips, all 2 hips in the Sugioka transtrochanteric rotational osteotomy treatment group had survived, while none of the three Shimizu's Grade C hips in the core decompression group were successful. CONCLUSION: A core decompression is effective only in the earliest stages of osteonecrosis (F-A Stage I), which means that its success strongly depends on the location and extent of the femoral head necrosis. Sugioka's transtrochanteric rotational osteotomy is a more dependable procedure than a core decompression for treating large lesions of nonsteroidal ONFH, particularly for patients under the age of 50.

Modified Step-cut Osteotomy of Distal Humerus for the Correction of Cubitus Varus Deformity in Children

PURPOSE: evaluate the radiologic and clinical results of modified step-cut osteotomy for correction of cubitus varus deformity in children. MATERIALS AND METHODS: We analysed 16 children who had varus deformity preoperatively and received modified step-cut osteotomy. The results were evaluated by final follow-up radiographs and clinical results, which were humeral-elbow-wrist angle, lateral prominence, range of motion and complications. RESULTS: The average preoperative humeral-elbow-wrist (HEW) angle was -15.8degrees and average last follow-up HEW angle was +6.7degrees Lateral prominence under 5 mm occurred in 3 cases and one children showed limited motion and transient ulna neuropathy. CONCLUSION: The results demonstrate that modified step-cut osteotomy achieve good correction of cubitus varus without lateral bony prominence or complications.