Clinical Outcomes of Arthroscopic Debridement for Lateral Epicondylitis with Partial Injury of the Lateral Collateral Ligament Complex

Background@#Lateral collateral ligament injuries may occur in patients with chronic lateral epicondylitis. The present study aimed to compare the clinical outcomes of arthroscopic debridement between patients with chronic lateral epicondylitis combined with a partial ligament injury and those without a ligament injury. @*Methods@#Between 2016 and 2018, patients who underwent arthroscopic debridement for lateral epicondylitis were evaluated. Partial injury to the lateral collateral ligament was defined as discontinuity or thinning with increased signal of the lateral ligament on magnetic resonance imaging and laxity with a firm endpoint in the varus or posterolateral rotatory stress test. Arthroscopic debridement was performed when there was no apparent instability in the stress test under fluoroscopic guidance after anesthesia. Patients with a ligament injury were compared with those without a ligament injury in terms of physical examination (varus stress test and posterolateral rotatory drawer test), pain visual analog scale, Mayo elbow performance score, and quick disabilities of the arm, shoulder and hand score. @*Results@#There were 38 patients in the intact ligament group and 15 patients in the partial ligament injury group. There were 23 men and 30 women, and the mean patient age was 50 years (range, 27–77 years). The mean follow-up period was 30 months (range, 24–49 months). Instability was not observed in both groups at the last follow-up, and clinical scores improved significantly after surgery. Postoperative results did not show significant difference between the two groups. One patient in the partial injury group underwent revision open debridement owing to persistent pain. @*Conclusions@#The clinical outcomes of arthroscopic debridement for lateral epicondylitis did not show significant differences between patients with a partial ligament injury and those without a ligament injury.

Anatomical Relationships between Muscles Overlying Distal Transverse Carpal Ligament and Thenar Motor Branch of the Median Nerve

BACKGROUND: The purpose of the current study is to investigate anatomical relationships between the muscle overlying the distal transverse carpal ligament (TCL) and the thenar motor branch of the median nerve. METHODS: Of the 192 wrists that underwent open carpal tunnel release, a muscle belly overlying the TCL was observed on the distal margin of TCL in 25 wrists and ligament exposure could not be achieved without transection of it. We recorded surgical findings of these 25 wrists. The origin of the recurrent motor branch arising from the major median nerve was marked on the axial and coronal section diagrams of the wrist. RESULTS: The presence of muscle overlying the TCL was seen in 25 wrists (21 patients, 13%). The locations of origin were distributed not only on the radial side but anterior or ulnar side of the major median nerve. Abnormal branches originated from the unusual side in 14 cases (56% of those with a muscle overlying the TCL): central-anterior side in eight cases, ulnar-anterior side in five cases, and ulnar side in one case. These anomalous branches were frequently associated with the muscle belly overlying the TCL in our study regardless of the origin site. The branches were prone to cut if careless midline incision along the third web space was performed. Unusual origin and aberrant pathway of the recurrent thenar motor branch were associated with the presence of a muscle overlying the TCL. CONCLUSIONS: A thorough knowledge of the standard and variant anatomy of the muscle belly and recurrent motor branch in the carpal tunnel is fundamental to prevention of complications such as muscle wasting or atrophy by iatrogenic motor branch injury during carpal tunnel release.

Symptomatic Neural Loop of the Distal Ulnar Nerve / 대한정형외과학회잡지

We found a unique anatomical variant of the distal ulnar nerve, a neural loop encompassing the flexor carpi ulnaris during Guyon's canal exploration. Compression by the flexor carpi ulnaris during active wrist movement was suspected as the cause of ulnar neuropathy. The symptom was relieved after neurolysis and release of surrounding tissue. With regard to the ulnar side wrist pain, which is suspicious for ulnar compression syndrome at the wrist level, the surgeon should always suspect anomalous nerve branch as source of compressive neuropathic pain.

The Results of Conservative Management for Early Stage Kienbock's Disease

PURPOSE: Early stage Kienbock's disease is commonly treated with a surgical intervention to avoid progression to degenerative change. The purpose of this study was to evaluate the clinical and radiographic outcomes of conservative management in patients with an early stage Kienbock's disease with a hypothesis that the lunate can be maintained in patients with no pain or tolerable pain. METHODS: Twenty-three patients with a Lichtman stage I, II or IIIA Kienbock's disease were managed conservatively and investigated prospectively. There were ten men and thirteen women. Mean age at first visit was 53.9 years old and mean follow-up period was 51.3 months. The clinical outcomes were evaluated by range of motion, subjective satisfaction of patients at final follow-up. Radiographic measurements of the Lichtman stage were assessed at first visit and at the final follow-up. Three patients were Lichtman stage I, eleven patients were II and nine patients were IIIA. RESULTS: Range of motion improved in all cases. According to Dornan's criteria, eleven patients were excellent, another eleven patients were good and one patient was fair. Based on Lichtman stage, no change was seen in sixteen patients, while seven showed progression. Three patients revealed improved radiographic findings of the lunate at final follow-up. CONCLUSION: We found that conservative management including close observation of clinical and radiographic changes can provide satisfactory clinical improvement in patients with no pain or tolerable pain in early stage Kienbock's disease.

Current Concept of Surgical Management for Rheumatoid Arthritis of the Wrist

Rheumatoid arthritis is a systemic inflammatory disorder inducing multiple joint destruction. The wrist joint is frequently involved in early stage and proper management can preserve the ability to maintain a daily living and to work. Advances in medical treatment modalities can halt most joint destruction, however, not in all instances of joint inflammation and deformities. Most patients want to improve their own functional disability, pain, aesthetic problems in addition to medication. We review the current concept of rheumatoid wrist surgery and discuss the surgical treatment strategies for optimizing outcomes for patients with rheumatoid wrist.

Low-energy Extracorporeal Shock Wave Therapy on Chronic Epicondylitis of the Elbow: Clinical and Sonographic Study

OBJECTIVE: To evaluate the effect of extracorporeal shock wave therapy (ESWT) and the improvement of ultrasonographic findings in refractory chronic epicondylitis of the elbow. METHOD: Twenty seven patients (7 men, 20 women, mean age 47) with minimum 1 year history of chronic epicondylitis of the elbow that was unresponsive to conventional therapy were included. Each patient was treated with 3~4 sessions of low-energy (0.06~0.12 mJ/mm2, 2000 impulses) ESWT. A 100-point scoring system, Nirschl score and Roles and Maudsley score were evaluated before treatment and at the 3- and 6-month follow-up. Ultrasonography was performed before treatment and at the 3-month follow-up. RESULTS: Total score of a 100-point scoring system and Nirschl score were significantly improved at the 3- and 6-month follow-up compared to before treatment (p<0.05). Follow up ultrasonography was performed in twenty one patients. Eighteen of 21 patients (85.7%) showed improvement of tendinosis and 4 of 6 patients (66.7%) showed improvement of tear and 3 of 10 patients (30.0%) showed improvement of calcification on ultrasonography. CONCLUSION: ESWT is safe and effective modality in the treatment of refractory chronic epicondylitis of the elbow. And ultrasonography can be a useful method to evaluate the therapeutic effect of ESWT.

Anatomic Reconstruction of the Distal Radioulnar Ligament for Posttraumatic Distal Radioulnar Joint Instability

BACKGROUND: To analyze clinical outcomes after anatomical reconstruction of distal radioulnar ligaments in patients with chronic post-traumatic instability of the distal radioulnar joint. METHODS: Anatomical reconstruction was performed in 16 patients with subluxation or dynamic instability of distal radioulnar joint following trauma. Osteotomy was performed simultaneously in 10 patients with radial malunion. The average follow-up period was 18.9 months. For clinical outcome assessment, we performed the anteroposterior stress test, measured the range of motion and grip strength, and performed radiological examination. For assessment of the pain and function, we used the Patient Rated Wrist Evaluation, the Disabilities of the Arm, Shoulder and Hand, and the Modified Mayo Wrist Score. RESULTS: Anteroposterior stress test performed at the last follow-up showed normal in 12 patients, mild laxity in 3, and residual subluxation in one. The average Patient Rated Wrist Evaluation was 9.1 for pain and 11.2 for function. The average Disabilities of the Arm, Shoulder and Hand score was 10.5. The average Modified Mayo Wrist Score was 92.8; there were 10 excellent, 5 good, and 1 poor case. The average grip strength improved from 69.7 1b to 80.9 1b. A revision osteotomy was performed on the patient with residual subluxation in order to obtain normal alignment of the joint. CONCLUSIONS: Anatomical reconstruction of the distal radioulnar ligaments is recommended to restore distal radioulnar joint stability. In addition to ligament reconstruction, realignment of the distal radioulnar joint seems critical when the instability is combined with malunion of the radius.

The Change in Position between the Ulnar Head and Radiusin Distal Radiounlar Joint following Distal Radius Malunion : Analysis on the Axial Planeusing Computed Tomography / 대한정형외과학회잡지

PURPOSE: This study examined the displacement of the ulnar head with respect to the distal radius after distal radius malunion on the axial plane using computed tomography. MATERIALS AND METHODS: Twenty-four patients with a residual dorsal tilt > 10degrees or radial shortening > 2 mm than the normal side, and no limitation in wrist rotation after radius union were enrolled in this study. The bilateral CT scans were obtained in 70degrees pronation, neutral, 70degrees supination. The radioulnar ratio was measured and the ratios of the abnormal side were compared with those of the opposite normal side. The results were statistically analyzed using a two-tailed paired t-test. RESULTS: The ulnar head of the patients with a malunited radius had a tendency for anterior translation compared with the normal side. In patients with a dorsal tilt deformity, the anterior translation of the ulnar head with respect to the radius was significant, particularly in the supination and neutral position. However, no significant difference was found in patients with radial shortening in terms of the ulnar head translation between the normal and abnormal side. CONCLUSION: These results might explain the mechanism of distal radioulnar joint instability and low incidence of ulnocarpal impingement in patients with distal radius malunion.

Treatment of Scaphoid Nonunionusing a Pedicled Vascularized Bone Graft / 대한정형외과학회잡지

PURPOSE: This study examined the clinical usefulness of a pedicled vascularized bone graft for the treatment of a scaphoid nonunion. MATERIALS AND METHODS: Twenty-one patients with a scaphoid nonunion were treated with a pedicled vascularized bone graft using the 1, 2 intercompartmental supraretinacular branch of the radial artery. The average age of the patients was 29.3 years (range, 16-47) and the mean follow-up period was 19.6 months (range, 12-36). Punctate bleeding of the proximal fragment was evaluated intraoperatively and complete avascular necrosis was observed in 10 patients (47.5%). RESULTS: Radiographic union was observed in 19 patients (90%). The other 2 patients were considered to have clinical union although it was unclear radiographically. The average union time was 10.7 weeks (range, 6-16). Eight of the ten patients with an avascular proximal pole showed radiographic union. Sixteen patients (76%) showed satisfactory subjective results at the time of the last follow up based on the scaphoid score. CONCLUSION: Pedicled vascularized bone graft is a good method for treating a scaphoid nonunion and is strongly recommended in cases of scaphoid nonunion with proximal pole avascular necrosis.

Triscaphe Fusion in the Treatment of Kienbock's Disease : Comparison of Lunate Preservation and Excision / 대한정형외과학회잡지

PURPOSE: To evaluate the necessity and effectiveness of a lunate excision in triscaphe fusion for the treatment of advanced Kienbock's disease. MATERIALS AND METHODS: Twenty-six patients who underwent a triscaphe fusion for Kienbock's disease (IIIb) were analyzed. Fifteen patients received triscaphe fusion only and 11 patients received triscaphe fusion and a lunate excision. The indication for a lunate excision included pain and limited motion due to posterior impingement associated with a severely collapsed lunate. The range of motion and modified Mayo wrist score in the two groups were compared. The carpal height ratio, ulnocarpal distance ratio and radioscaphoid angle were measured on the plain radiographs, and the presence of degenerative change was evaluated. RESULTS: The mean extension range was more preserved in the lunate excision group than in the lunate preserving group. Several radiology indices were similar in the two groups, but a degenerative change in the radioscaphoid joint was observed in 45.5% of the lunate excision group and in 13% of the lunate preserving group. CONCLUSION: When performing the triscaphe fusion in advanced Kienbock's disease, excision of the lunate can relieve the symptoms of posterior impingement. However, this procedure should be carried out carefully because degenerative changes in the radioscaphoid joint are frequently observed.

Clinical Assessment of the Distal Radioulnar Joint Instability After Treatment of Intra-articular Fractures of the Distal Radius using Computed Tomography / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to make an assessment of distal radioulnar joint (DRUJ) instability after the treatment of intra-articular fractures of the distal radius using computed tomography (CT) including contralateral normal wrist. MATERIALS AND METHODS: Twenty-seven intra-articular fractures of the distal radius in twenty-seven patients who had had the surgical treatment were evaluated at follow-up of mean 17.9 months (range, 10-36 months). The DRUJ was assessed with clinical examination, plain radiography, and bilateral CT. CT scans were obtained in 70degrees pronation, neutral, and 70degrees supination. The radioulnar ratio and the subluxation ratio which was modified radioulnar line method were used to measure DRUJ instability. RESULTS: Eight patients were diagnosed as DRUJ instability based on CT assessment. Nine patients were considered to have DRUJ instability in clinical examination, but 4 patients of them were confirmed to have DRUJ instability based on CT measurements. Nonunions of ulnar styloid or malunions of the distal radius were not found to have statistical correlation with DRUJ instability (p>0.05). CONCLUSION: In patient with suspicious DRUJ instability following distal radius fractures, we recommend computed tomography scans of both the injured and uninjured wrists in pronation, neutral, and supination position for objective assessment.

Treatment of Intra-articular Fractures of the Distal Radius using Wrist Arthroscopy / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to investigate the usefulness of wrist arthroscopy for treating intra-articular fractures of the distal radius. MATERIALS AND METHODS: Twenty-two patients with intra-articular fracture of the distal radius received arthroscopic s rgery. Fourteen patients with displaced intra-articular fractures were managed by arthroscopically assisted reduction and fixation. Three patients were treated with limited open reduction and fixation. We analysed the radiologic results, and measured the ranges of motion and grip strengths. Fuctional results were evaluated using the Modified Mayo Wrist Scoring System. The postoperative follow-up period averaged 16.8 months. RESULTS: All showed articular step-off of less than 1 mm on wrist X-rays taken at the final follow-up (mean 0.3 mm; range, 0-1 mm). The mean arc of range of motion was 89.6% of that on the uninjured side, and the mean grip strength was 87.3% of that of the uninjured side. The average Modified Wrist Score was 91.8 (range, 75-100). CONCLUSION: Arthroscopic-assisted surgery is an useful method that provides excellent results with few complications in the treatment of intra-articular fractures of the distal radius.

Surgical Treatment of Post-traumatic Elbow Stiffness / 대한정형외과학회잡지

PURPOSE: We analyzed the clinical results of surgical treatment in patients with post-traumatic stiff elbow. MATERIALS AND METHODS: We performed surgical release in 22 elbows with posttraumatic stiffness of extraarticular origin. The average preoperative arc was 48.3 degrees, with an average flexion contracture of 39.5 degrees and an average further flexion of 87.2 degrees. Depending on their radiographic findings, cases were divided on the basis of whether ectopic ossification was present (16 cases) or not (6 cases); and as to whether the articular surface was involved (11 cases) or not (11 cases). The postoperative final arc and ratio of desired gain were compared between the groups. RESULTS: The average final arc was 108.9 degrees in the ectopic ossification group and 85.7 degrees in the non-ectopic ossification group, and showed a significantly higher arc in the ectopic ossification group. The ratios of desired gain were 89.3% and 62.6%, respectively, being significantly higher in the ectopic ossification group. In terms of articular surface involvement, no significant difference was observed between the two groups. CONCLUSION: When performing operative treatment for post-traumatic stiff elbow, assessment of the cause plays an important role. In case of ectopic ossification, satisfactory results can be expected with operative treatment after the ectopic bone has matured.

Operative Treatment of Cubital Tunnel Syndrome: A Comparison of Medial Epicondylectomy and Anterior Transposition of the Ulnar Nerves / 대한정형외과학회잡지

PURPOSE: The aim of this study was to compare the results of medial epicondylectomy and anterior submuscular transposition of the ulnar nerve in patients with primary cubital tunnel syndrome. MATERIALS AND METHODS: Thirty patients with primary cubital tunnel syndrome formed the basis of this study. Eighteen patients underwent medial epicondylectomy and twelve patients underwent anterior submuscular transposition of the ulnar nerve. The mean follow-up period was 35 months. Postoperative clinical results were assessed using Gabel and Amadio's rating scale which evaluats pain, sensory and motor function in four grades. Clinical results were compared between two groups in McGowan grades two and three. RESULTS: Two excellent, twelve good and six fair results were obtained in patients with McGowan grade II. In McGowan grade III, three were good, six fair and one was poor. No significant difference in the results was observed between two surgical groups. CONCLUSION: Medial epicondylectomy and anterior submuscular transposition of the ulnar nerve showed no difference in results between patients with primary cubital tunnel syndrome. It seems that medial epicondylectomy is more appropriate because of its simplicity during operation and in terms of postoperative management.

Ulnar Neuropathy Combined with Post-Traumatic Conditions of the Elbow / 대한정형외과학회잡지

PURPOSE: We evaluated surgical cases of ulnar neuropathy combined with post-traumatic conditions of the elbow. MATERIALS AND METHODS: Fourteen patients who received ulnar nerve decompression at the cubital tunnel combined with elbow injury were assessed retrospectively. Ulnar nerve showed McGowan grade I in eight patients, grade II-A in one, grade II-B in four and grade III in one. The decompression procedures included nine anterior transpositions, four epicondylectomy, and one in situ decompression. Pain, sensory and motor status were evaluated after a mean follow up of 17.9 months. RESULTS: Symptoms were completely resolved in ten patients and markedly improved in four. Decreased motor function was improved by at least one grade in all patients. Ulnar neuropathy did not compromise flexion exercise in postoperative rehabilitation. CONCLUSION: Development of ulnar neuropathy has close relationships with elbow trauma and its symptoms tend to be underestimated because elbow flexion is frequently limited due to post-traumatic contracture. Proper evaluation and decompression of the ulnar nerve should be considered as one of the factors influencing the clinical result in the management of post-traumatic problems of the elbow.

Arthroscopic Treatment for Triangular Fibrocartilage Complex Lesion / 대한정형외과학회잡지

PURPOSE: We analyzed the results and prognostic factors for patients with triangular fibrocartilage complex lesions who underwent arthroscopic surgery. MATERIALS AND METHODS: According to Palmer classification, there were 10 type Ia, 5 Ib, 2 Ic, 1 IIb and 7 IIc lesions. Twenty patients received arthroscopic debridement and 5 patients arthroscopic repair. To assess the clinical outcomes, the degree of pain, range of motion, grip strength, returning to previous job and patient's satisfaction were investigated. RESULTS: Among 25 patients, 20 showed pain relief and improved clinical symptoms after the operation. Sixteen of the seventeen traumatic lesions showed excellent or good results, while 4 of the 8 degenerative lesions showed good results. Among 20 patients who received arthroscopic debridement, 15 patients showed good results, while all 5 patients who underwent arthroscopic repair produced good results. CONCLUSION: Wrist arthroscopy allows accurate diagnosis of triangular fibrocartilage complex lesions, and arthroscopic debridement or repair produces good clinical outcomes. Traumatic triangular fibrocartilage complex lesions tend to have better results than degenerative lesions.

Arthroscopic Synovectomy of the Wrist in Rheumatoid Arthritis / 대한정형외과학회잡지

PURPOSE: We evaluated the therapeutic effectiveness of arthroscopic synovectomy in patients with rheumatoid wrists. MATERIALS AND METHODS: Nineteen wrists in 18 patients (4 males and 14 females, average age 49.2 years) who had not responded to anti-rheumatic medications, were treated with arthroscopic synovectomy. Patients 'subjective symptoms were evaluated using a visual analogue scale for pain and satisfaction. Standard posteroanterior radiographs taken preoperatively and at the final follow up were ana-lyzed using the modified Larsen/Rau score system (normal, 0; total destruction, 40). The average follow up period was 29.5 months. RESULTS: The mean preoperative pain score was 8.6 and this decreased to 3.6 one year after the operation, but increased to 4.4 at the final follow-up, suggesting a tendency of pain aggravation with time. The average satisfaction score at the final follow up was 6.3. The mean modi-fied Larsen/Rau score was 6.1 preoperatively and this increased to 8.4 at the final radiographs, demonstrating the slow progression of degen-erative changes. The severity of joint degeneration showed no correlation with the postoperative results. CONCLUSION: Arthroscopic synovectomy of rheumatoid wrists results in an effective reduction of pain and high satisfaction. Prolonged bene-fit should be observed by long term follow-up.

Radiological Analysis of the Scaphoid Shift Test / 대한정형외과학회잡지

PURPOSE: To evaluate the carpal behaviors during the scaphoid shift test and to compare the results of clinical examination to findings of the radiological analysis. MATERIALS AND METHODS: Sixty patients who suffered from chronic wrist pain were evaluated clinically and radiologically when the scaphoid shift test was performed. Clinical findings were graded on the basis of the degree of palpable scaphoid shift and degree of pain on the dorsal aspect of the wrist. The scaphoid shift test was repeated under fluoroscopy. Radiological paramenters of displacement (scaphoid-lunate displacement index and scaphoid-radius displacement index) and rotation (change of scaphoid-radius angle and lunate-radius angle) were measured. Radiological parameters were evaluated according to the degree of clinical severity. RESULTS: Degree of clinical shift during the test was significantly associated with both scaphoid-lunate displacement and scaphoid-radius displacement, whereas degree of pain was significantly associated with scaphoid-lunate displacement,.not scaphoid-radius displacement. Patients who complaint pain during the test showed significantly higher radiological scaphoid-lunate displacement index when compared to those who did not have pain, but not significantly different scaphoid-radius displacement index. CONCLUSION: This study revealed that the presence of pain reflected the instability between the scaphoid and lunate rather than the degree of dorsal scaphoid shift. We conclude that radiological observation during the scaphoid shift test would be helpful in diagnosing the pathologic scapho-lunate instability.

A Comparative Study on Healing of Bone - Tendon Autograft and Bone - Tendon - Bone Autograft Using Patellar Tendon in Rabbits / 대한정형외과학회잡지

The purpose of this study is to compare the biologic properties of tendon to hone healing and hone to hone healing in knee ligament reconstruction. The lateral 4mm of patellar tendon which was detached from its tihial insertion site either subperiostcally(group I) or with a bone block(group II) was implanted and fixed using pullout method to the proximal tihia. Ten rabbits were killed at each of four time periods (two, four, eight and twelve weeks after the implantation), and the histological and biomechanical characteristics of thc graft healing sites were evaluated. Serial histological analysis of tendon to hone healing group revealed organization of the healing site similar to normal tendon to hone attachment by twelve weeks, while hone to bone healing group demonstrated direct hony union by eight weeks. The tension failure test for the patellapatellar tendon graft - tihia complex revealed that group II had significantly higher values than group I at four and eight weeks. The findings ot this study demonstrated that bone to hone healing has more rapid process than tendon to hone healing, although no significant difference was noted once the healing has matured. We can suggest lhat the duration and extent of postoperative protection of the knee for pntients who had a reconstruction of a ligament using hone - lendon autograft should be longer and higher than lor patients who had a reconstruction using hone - tendon hone autogralf.

Clinical Results of Open versus Endoscopic Carpal Tunnel Release / 대한정형외과학회잡지

Open carpal tunnel release has been the standard method of sumical treatment of carpal tunnel syndrome. Recently endoscopic carpal tunnel release has been introduced and is heing used by many authors. The advantages of this new technique are less postoperative pain, rapid restoration of power and rapid return-to-work. However many considerate authors, in spite of these advantages. insist that the inevitahle risk of neurovascular injury during the endoscopic procedure should not he underestimated. The purpose of our study is to compare the clinical results of endoscopic carpal tunnel release with those of open release. 20 open carpal tunnel releases in 16 patients and 15 endoscopic carpal tunnel reieases (single-portal technique) in 11 patients were performed hy the first author. Preoperative conditions of both groups are not different. Authors compared the clinical results between the two groups with some parameters. The overall clinical results were not different significantly hetween two groups. Rapid return-to-work(36 days in endoscopic group versus 60 days in open group) and less postoperative scar and pillar pain in endoscopic group were demonstrated. However, the major complication of one median nerve injury in endoscopic group seemed to overweigh these some benefits. We suggest that the standard operative technique for carpal tunnel syndrome should be open carpal tunnel release and more considerations should be takcn in choosing endoscopic method because of its inherent risk.