Excision of Rudimentary Preaxial Polydactyly of the Hand with Use of Electrocautery

Background@#Suture ligation has been used widely for the treatment of rudimentary type extra digits, but several complications related to this treatment have been reported. The purpose of this study was to describe a new technique for excision of rudimentary preaxial polydactyly of the hand using electrocautery and assess its clinical outcomes. @*Methods@#The authors performed a retrospective study of 34 thumbs (32 patients) that had undergone excision of rudimentary preaxial polydactyly using electrocautery under local anesthesia. The mean follow-up period was 16.5 months. @*Results@#All children had full range of thumb motion without angular deformity at the most recent follow-up. There were no postoperative complications such as bleeding or infection. In 33 thumbs (97.1% of 34 thumbs), there were no signs of residual digit prominence. One thumb had a residual digit prominence at the extra digit removal site. In two thumbs, scar hypertrophy was evident at the operation site. All parents of the patients except two were very satisfied with this technique and the mean visual analog scale score for satisfaction was 9.5 ± 2.0 (range, 0–10). @*Conclusions@#Excision of rudimentary preaxial polydactyly of the hand with the use of electrocautery could remove an extra digit completely in 97.1% of the cases. This technique would be a useful alternative to suture ligation, surgical clip application, or surgical excision for the treatment of rudimentary preaxial polydactyly of the hand.

Nonsurgical Treatment of a Distal Radius Fracture: When & How?

Distal radius fractures are a common upper extremity fracture and a considerable number of patients have a stable fracture. In the treatment of distal radius fractures, there is considerable disagreement regarding the need for a strict anatomical restoration with operation in elderly patients. Therefore, nonsurgical treatment is a still important treatment option in distal radius fractures. The radiological parameters of before or after manual reduction are important for deciding whether to perform operation or not. The radiological parameters include dorsal angulation of the articular surface, radial shortening, extent of dorsal comminution, intra-articular displacement, concomitant ulnar metaphyseal fracture, shear fracture, and fracture-dislocation of the distal radio-ulnar joint. In addition, clinical situations of patients, including age, activity level, underline disease, and recovery level, which the patients wish should be considered, comprehensively. For the duration of a splint or cast, three to four weeks are recommended in impacted or minimally displaced fractures and five to six weeks in displaced fractures. After reduction of the displaced fractures, patients should undergo a radiologicical examination every week to check the redisplacement or deformity of the fracture site until two or three weeks post trauma. Arm elevation is important for controlling fracture site swelling and finger exercises, including metacarpophalangeal joint motion, are needed to prevent hand stiffness. Active range of motion exercise of the wrist should be initiated immediately after removing the splint or cast.

Nerve Repair and Nerve Grafting in Brachial Plexus Injuries

Brachial plexus injuries (BPI) can have devastating effects on upper extremity function, however, treatment in this injuries remains a difficult problem. Several kinds of surgical methods have been used to treat BPI, and nerve repair and nerve grafting have been traditionally used in postganglionic injury of brachial plexus. Because the several studies reported that nerve transfer to restore shoulder and elbow function has yielded superior results to historical reports for nerve grafting in partial BPI, the indication of nerve repair and nerve grafting has been decreased. Nonetheless, nerve repair and nerve grafting is still useful in focal damage in brachial plexus, such as laceration or gunshot wound and postganglionic neuroma in continuity without conduction of nerve action potential. In this paper, we described the basic concept, detailed indication and outcomes of nerve repair or nerve grafting in BPI.

Bone Mineral Density and Prevalence of Osteoporosis in Postmenopausal Korean Women with Low-Energy Distal Radius Fractures

The aim of this study was to evaluate the bone mineral density and the prevalence of osteoporosis in postmenopausal Korean women with low-energy distal radius fractures and compared with those of aged-matched normal Korean women. Two hundred and six patients with distal radius fractures between March 2006 and March 2010 were included in this study. Patients were divided into three groups by age; group 1 (50-59 years), group 2 (60-69 years), and group 3 (70-79 years). Controls were age-matched normal Korean women. The bone mineral density values at all measured sites, except for the spine, were significantly lower in group 1 than those of control. While the bone mineral density values in group 2 and 3 were lower than those of controls, these differences were not statistically significant. All groups had significantly higher prevalence of osteoporosis at the Ward's triangle; however, at the spine, femoral neck and trochanteric area it was not significantly different from those of age-matched controls. Although the prevalence of osteoporosis of the postmenopausal women with low-energy distal radius fractures may not be higher than that of the control, osteoporosis should be evaluated especially in younger postmenopausal patients to prevent other osteoporotic hip and/or spine fractures.

Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist

PURPOSE: The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes. METHODS: 10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively. RESULTS: Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20degrees, volar flexion 15degrees, radial deviation 0degrees, ulnar deviation 15degrees. CONCLUSION: Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist.

Musicians' Medicine: Musculoskeletal Problems in String Players

There is increasing attention to medical problems of musicians. Many studies find a high prevalence of work-related musculoskeletal disorders in musicians, ranging from 73.4% to 87.7%, and string players have the highest prevalence of musculoskeletal problems. This paper examines the various positions and movements of the upper extremities in string players: 1) basic postures for holding instruments, 2) movements of left upper extremity: fingering, forearm posture, high position and vibrato, 3) movements of right upper extremity: bowing, bow angles, pizzicato and other bowing techniques. These isotonic and isometric movements can lead to musculoskeletal problems in musicians. We reviewed orthopedic disorders that are specific to string players: overuse syndrome, muscle-tendon syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Symptoms, interrelationships with musical performances, diagnosis and treatment of these problems were then discussed.

Osteosynthesis with Structural Bone Grafting and Plate-screw Fixation for the Treatment of Forearm Bone Nonunion

PURPOSE: We reported clinical results of autologous tricorticocancellous bone grafting and plate-screw fixation for nonunion of the forearm bones. MATERIALS AND METHODS: Ten patients with nonunion of the forearm bones that underwent surgical treatment were evaluated. Tricorticocancellous bone grafting which was harvested from the iliac crest and plate-screw fixation were performed. Radiologic bone union was evaluated based on the simple radiographs. At the final follow-up, range of motion was measured and the Anderson scale was used for functional evaluation. RESULTS: Radiologic bone union was achieved in all cases. The mean range of motion was 139degrees of elbow flexion, 3degrees of flexion contracture, 73degrees of forearm pronation, 72degrees of supination, 70degrees of wrist flexion, and 70degrees of wrist extension. Anderson scale was excellent in 6 patients, satisfactory in three, and unsatisfactory in one. CONCLUSION: Autologous tricorticocancellous bone grafting and rigid plate-screw fixation is a reliable method to achieve successful healing of forearm bone nonunions.

Treatment of Wrist Ganglion Using Nd: YAG Laser

PURPOSE: We evaluated the results of treatment for a ganglion with catheterized Nd: YAG laser assisted arthrotomy. MATERIALS AND METHODS: Twenty-five patients with a ganglion underwent laser assisted arthrotomyt. The first procedure was the puncturing and aspiration of the ganglion using an 18 G needle under local anesthesia. The joint capsule and ligament near the origin of the ganglion were cauterized using a catheterized laser instrument (ACCUSCULPT(R), Lutronic Inc.). The patients was observed clinically and evaluated by ultrasonography. RESULTS: The average period of follow-up was 12.3 months. Among the 25 patients presented during follow-up period, 22 patients (88%) had no recurrence. Two patients had partial recurrence and 1 patient had complete recurrence. CONCLUSION: Catheterized Nd: YAG laser assisted arthrotomy is considered to be an effective non-invasive method with a relatively low recurrence rate for the treatment of wrist ganglion.

Surgical Treatment of Chronic Flexor Carpi Ulnaris Tendinopathy

PURPOSE: The purpose of this study was to evaluate the results of surgical treatment in patients with chronic flexor carpi ulnaris tendinopathy. MATERIALS AND METHODS: Five patients with 7 wrists underwent surgical treatment for chronic flexor carpi ulnaris tendinopathy. The degenerative tissue inside the tendon over the pisiform was debrided and partial release of the tendon was performed. The clinical outcome was evaluated using pre and postoperative visual analogue scale (VAS) pain score and modified Mayo wrist score at the final follow-up. RESULTS: The mean VAS score was 7.3 preoperatively, which was significantly improved to 3.6 at postoperative 2 weeks, 1.9 at 6 weeks, 1.1 at 3 months, 0.7 at 6 months, and 0.7 at the final visit. Modified Mayo wrist score showed 3 excellent, 3 good, and one fair result. Biopsy showed degenerative tissue findings in all cases. CONCLUSION: Chronic flexor carpi ulnaris tendinopathy is a degenerative disease and surgical treatment of refractory cases can decrease clinical symptoms in the early postoperative period and enable patients to return to activities of daily-living.

Arthrodesis for the Trapeziometacarpal Arthritis

PURPOSE: We evaluated clinical outcomes of the trapeziometacarpal arthrodesis as a treatment for trapeziom-etacarpal arthritis. MATERIALS AND METHODS: Nineteen patients that received trapeziometacarpal arthrodesis for Eaton & Litter stage III(n=18) and IV(n=1) arthritis were enrolled in this study. Mean age was 45.8(43~67) and mean follow up duration was 2.3 years(1~4 years). Posttraumatic arthritis and idiopathic arthritis were 9 and 10 cases, respectively. The assessment included a preoperative and postoperative Visual Analogue Scales (VAS) (0~10) and overall satisfaction with Roles & Maudsley score. Functional outcomes were assessed by measuring of grip and pinch strength and range of thumb motion. The evaluation also included postoperative complications. RESULTS: Mean preoperative VAS score was 6.6 points and improved to average 1.4 points postoperatively. Mean grip and pinch strength was improved from 12.1 kg to 26.5 kg and from 2.7 kg to 5.2 kg, respectively. The mean radial abduction arc of motion was 42.9 degrees. Metacarpophalangeal and thumb interphalangeal joint arc of motion was averaged 63.3 degrees and 73 degrees, respectively. Complications consisted of scaphotrapezoidal arthritis(n=1) and nonunion(n=1). CONCLUSION: The trapeziometacarpal arthrodesis could afford good functional results, pain relief in advanced arthritis patient.

Treatment of Recalcitrant Medial and Lateral Epicondylitis with Autologous Platelet Rich Plasma; Preliminary Report

PURPOSE: We evaluated the clinical outcomes of the autologous platelet rich plasma injection for the treatment of recalcitrant medial and lateral epicondylitis. MATERIALS AND METHODS: Nineteen cases with recalcitrant medial and lateral epicondylitis despite of conservative treatment for 1 year were enrolled in this study. Each patient underwent autologous platelet rich plasma injection and followed up minimally of 40 weeks. The assessment included a preoperative and postoperative Visual Analogue Scale (VAS) (0~10) at 4, 8, 12, 24 and 36 weeks and overall satisfaction was evaluated with Roles & Maudsley score at 36 weeks after injection. We also compared the clinical outcomes between medial and lateral epicondylitis group. RESULTS: Mean preoperative VAS was 8.7 points and improved to 5.1, 5.2 and 4.7 at 12, 24 and 36 weeks follow up, respectively. Roles & Maudsley score was excellent in 5 cases(26%), good in 7 cases(37%), acceptable in 4 cases(21%) and poor in 3 cases(16%). On the comparison of medial and lateral epicondylitis group, there was no statistical significant difference (p=0.38). CONCLUSION: The autologous platelet rich plasma injection for recalcitrant medial & lateral epicondylitis is thought to be a alternative treatment option.

The Availability of Three-Dimensional Computed Tomography Reconstructions on the Classification and Treatment Plan of Distal Radius Fractures

PURPOSE: The purpose of this study is to determine whether the three-dimensional computed tomography (3D-CT) images would increase the reliability of fracture classification and influence treatment plan of distal radius fractures. MATERIALS AND METHODS: Four independent observers evaluated radiographic images of thirty patients with distal radius fractures. The fracture classification has been performed based on (1) AO classification, (2) Fernandez classification, (3) Frykman classification. And then treatment plan was planned based on (1) closed reduction with Sugar-tong splint, (2) closed reduction with pinning, (3) closed reduction with external fixator, (4) open reduction with plate (volar approach), (5) open reduction with plate (dorsal approach). Two rounds of evaluation were compared regarding: (1) simple radiographs alone, and (2) simple radiographs and 3D-CT together two weeks after that. This cycle was then repeated to assess intraobserver reliability. RESULTS: 3D-CT improved the intraobserver and interobserver reliability regarding the fracture classification and treatment plan. And the addition of 3D-CT to simple radiographs influenced treatment recommendations, resulting in a significantly greater number of decisions for an open approach (p<0.05, McNemar test). CONCLUSIONS: 3D-CT is a reliable tool of fracture classification and improves treatment plan of distal radius fractures.

The Reverse Sural Artery Flap for Soft Tissue Defect of Foot and Ankle in Diabetic Patient / 대한정형외과학회잡지

PURPOSE: A reverse sural artery flap is a useful method for the soft tissue coverage of the lower leg, around the foot and ankle. We present our experience with the reverse sural artery flap for the coverage of a soft tissue defect due to ulceration, necrosis, and trauma in diabetic patients. MATERIALS AND METHODS: We treated 5 diabetic patients who showed soft tissue defects around their lower leg, foot and ankle. The causes of the soft tissue defect were an ulcer and infection in 4 cases, and trauma in 1 case. The sites of the soft tissue defect were around the ankle in 2 cases. In the other cases, the defect site were the lower third of the leg, the hind foot, the foot dorsum. The mean follow up period was 12.4 months. The size of the soft tissue defect ranged from 4 x 3 cm to 15 x 10 cm. RESULTS: All the flaps survived. The donor site was covered with a split thickness skin graft. There was no recurrence of the soft tissue defect during the follow-up period. Conclusion: The reverse sural artery flap is a valuable method for covering certain types soft tissue defect of foot and ankle in diabetic patients.

Arterialized Venous Free Flap with Palmaris Longus Tendon for the One-Stage Reconstruction of Defects of Skin and Extensor Tendon / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to introduce our new modified surgical method using a tendocutaneous flap, which is an arterialized venous free flap with palmaris longus tendon, to reconstruct composite defects of the dorsal skin and extensor tendons of the hand and to evaluate the clinical results. MATERIALS AND METHODS: Between March 1994 and December 2001, composite defects of the hands in 39 patients were reconstructed using various modifications of arterialized venous free flap. Among these patients, eight cases of tendocutaneous type were included in this study. The mean age of the patients was 33.2 years (ranging from 19 to 49), and the flap sizes ranged from 1.5x2 cm to 4x7 cm. In 2 of the 8 cases, neurorrhaphy using forearm cutaneous nerve was performed simultaneously for of digital nerve reconstruction. RESULTS: All flaps survived successfully and covered exposed bone and tendon. Marginal necrosis occurred partially in one case by less than 10% and this was completely recovered without any further surgical treatment. A functional range of motion (ROM) at the involved joint was achieved in an average ROM of 70 degrees at the PIP joint and 25 degrees at the DIP joint. CONCLUSION: Tendocutaneous arterialized venous free flap with palmaris longus tendon, is was found to be especially useful surgical foro reconstruct in a composite defects of the dorsal skin and extensor tendon of the hand.

Detection of Synovial Hypertrophy in Idiopathic Carpal Tunnel Syndrome Using Ultrasongraphy / 대한정형외과학회잡지

OBJECTS: Synovial thickness in carpal tunnel was measured by high-resolution ultrasonography to evaluate the relation of synovial hypertrophy in idiopathic carpal tunnel syndrome. MATERIALS AND METHODS: Thickness of synovium of flexor tendons in 46 hands of idiopathic carpal tunnel syndrome and 50 hands of normal control were measured quantitatively by high-resolution ultrasonography. The patients were classified into three groups according to the clinical severity: Group I had typical clinical symptoms and positive provocation test (17 cases) , Group II had sensory decreation on the dermatome of median nerve (21 cases) , and Group III had sensory decreation and thenar muscle weakness. The thickness of flexor tendons in the three groups and control group were statistically compared. RESULTS: The mean value of thickness of carpal tunnel syndrome was 1.06mm and that of control group was 0.87mm (p=0.012) . Positive correlation was revealed according to the clinically classified three groups. CONCLUSION: Synovial hypertrophy in carpal tunnel has positive relationships with idiopathic carpal tunnel syndrome, and it reveal possibly the progression of the disease.

Biomechanical Study of the Partial Tear of the Rotator Cuff: Experimental Study in Rabbits / 대한정형외과학회잡지

Purpose of this study was to investigate the biomechanical fates of the partial thickness tear of the rotator cuff in rabbit, and try to provide guideline of treatment for the partial thickness tear of the rotator cuff tendon. Infraspinatus tendons of fifty rabbits were used for study. The rabbits were divided into three groups, twenty for one-third resection(superficial partial resection group), twenty for two-thirds resection(deep partial resection group) and ten for control group. Extraarticular portion of the infraspinatus tendons of the rabbits were resected partially with one-third or two-thirds thickness for each experimental group. We sacrificed five rabbits of each experimental group at 3, 6, 9, and 12 weeks after the resections, and five rabbits for the control group at 6 and 12 weeks. Average maximal load per area of the infraspinatus tendons was measured by tension test. There was significant difference between the deep partial resection group, 5.3 and 6.3 N/emat 6 and 12 weeks respectively, and the control group, 13.2 N/mm(P<0.05). There was no difference between the control and superficial partial resection group, 12.8 and 14.1 N/mm at 6 and 12 weeks, respectively. Shallow partial tears might be healed spontaneously. Deep partial tears would not be healed naturally. When surgical treatment is indicated for deep partial tears of the rotator cuff, tendon repair, rather than debridement, would provide more predictable results.

Treatment of Hallux Valgus with a Proximal Metatarsal Osteotomy and Distal Soft: Tissue Procedure / 대한정형외과학회잡지

The deformity of hallux valgus is associated with three hasic prohlems: a prominent rnedial eminence, contracted soft-tissue structures on the lateral side of the great toe, and an altered intermetatarsal angle between the first and second metatarsal. We retrospectively have reviewed the results for thirty-one patients(47 feet) in whom a hallux vaigus deformity had heen conected with the release of the distal soft tissues, excision of the medial eminence, plication of the medial part of the capsule, and proximal crescentic osteotomy of the first metatarsal. The patients were followed for an average of twenty months(range, twelve to twenty-eight months). There were nine cases with mild defoimity, twenty-nine cases with moderate deformity, nine cases with severe deformity. The preoperative hallux valgus angle averaged 38.1 degrees, and the immediate postoperative angle averaged 6.7 degrees. The preoperative intermetatarsal angle averaged 17.1 degrees, and the immediate postoperative angle, 7.6 degrees. At the latest follow-up, the hallux valgus angle averaged 19.3 degrees, the intermetatarsal angle averaged 9.9 degrees. We found that the more the deformity, the lesser the congruency. 74.5% of the patients were satisfied with the result of the procedure. They stated that, eiven the same circumstances, they would have the operation again. The most common complication was recurrence of the nallux valgus, which occurred in nine feet(five patients). The other complications included pain under a fibular sesamoid in one foot, severe hypoesthesia on the medial aspect ot the big toe in one foot, and superficial wound infection in one foot.

Plate Designed for Wiring ( CHO Plate ) / 대한정형외과학회잡지

Although intramedullary nailing is mostly used in the management of fractures in the long bone shaft, plate fixation is still alternative option in periprosthetic or metaphyseal fractures. For the rigid fixation during plating, sometimes we need wiring. Many surgeons experience slippage of wire resulting in loss of rigid fixation because plate and wire is so slippery and the diameter of bone is changing by level especially in the metaphyseal area. Wiring plate(CHO plate) was designed to prevent slippage. This plate has transverse holes for wires between screw holes on traditionally used dynamic compression plate. Sixteen fractures of long bone shaft were fixed with wiring plate and 11 cases which were followed up for more than one year were evaluated. There were periprosthetic fractures(4 cases), spiral or butterfly fractures(4 cases) and fractures of poor bone quality(two cases of malignancy and one case of osteoporosis). Nine cases were successfully reduced and the healed without loss of fixation. In two cases, delayed union and nonunion were observed due to wire breakage with plate loosening. Preliminarily, wiring plate fixation can be used for the periprosthetic fracture and one of alternative option in butterfly or spiral fracture and fracture in osteoporotic bone or pathologic fracture.

Treatment of Brachymetatatsia / 대한정형외과학회잡지

A total of 16 metatarsal bones were treated for ten with brachymetatarsia using two different methods: single staged lengthening by bone graft(2 cases) and gradual distraction lengthening using unilateral external fixator(14 cases). Three cases of first metatasal bone and thirteen cases of fourth metatarsal bone were operated. All of the cases of the brachymetatarsia were congenital. The average amount of lengthening was 16.1 mm in gradual distraction lengthening while 10.5mm in single staged lengthening. Average percentile increase was 38.8% in gradual distraction lengthening and 23% in single staged lengthening. The average healing index of gradual distraction lengthening was 1.7(months/cm). Although single staged lengthening has advantage of cosmetics, gradual distraction lengthening using unilateral external fixator was thought to be effective functionally for metatarsal lengthening.

Combinded Bankart and Putti-Platt operation for the anterior recurrent dislocation of shoulder / 대한정형외과학회잡지

No abstract available.