Clinical Outcome of Lateral Wedge Osteotomy of the Radius in Advanced Stages of Kienböck's Disease

BACKGROUND: Radius osteotomies showed favorable clinical outcome in Kienböck's disease. However, few articles have been published on the long-term outcome of lateral wedge osteotomy of the radius in patients with advanced stage Kienböck's disease. METHODS: Eleven patients with Lichtman stage IIIB/IV Kienböck's disease (group A; mean follow-up period, 86.1 months; range, 48 to 163 months) and 14 patients with Lichtman stage IIIA Kienböck's disease (group B; mean follow-up period, 85.1 months; range, 49 to 144 months) underwent radial wedge osteotomy between August 2004 and August 2012. Radiological changes of the lunate and radiocarpal joint were compared between two groups after osteotomy. The wrist flexion/extension angle, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were evaluated preoperatively and at the final follow-up. The Nakamura Scoring System (NSSK) was used for comprehensive understanding of radiological and clinical outcomes. RESULTS: Nine patients of group A and 11 patients of group B showed radiological improvement in the lunate regarding sclerosis, cystic changes, or fragmentation. No patients showed progression of arthritic changes in radiocarpal and midcarpal joints. The wrist flexion/extension angle, grip strength, and DASH score were significantly improved in both groups after operation, but intergroup difference was not statistically significant at the final follow-up (p = 0.149, p = 0.267, and p = 0.536, respectively). The mean NSSK was 21.6 (range, 15 to 27) in group A and 21.8 (range, 15 to 26) in group B. CONCLUSIONS: Radial wedge osteotomy yielded excellent radiological and functional outcomes in advanced stages of Kienböck's disease and these results were comparable to those of Lichtman stage IIIA disease. This technique could be a useful alternative to salvage procedures in the treatment of Lichtman stage IIIB/IV Kienböck's disease without severe radiocarpal arthritis.

Treatment of Bunionette Deformity with Diaphyseal Oblique Osteotomy / 대한족부족관절학회지

PURPOSE: The purpose of this study is to evaluate the clinical and radiographic results of symptomatic bunionette treated with a diaphyseal oblique osteotomy. MATERIALS AND METHODS: We retrospectively reviewed 12 feet of nine patients diagnosed as symptomatic bunionette and treated with diaphyseal oblique osteotomy. All patients were female and the average age at the time of surgery was 48 years. We checked the foot standing anteroposterior, oblique, and lateral images pre- and post-operatively. We measured the fourth intermetatarsal angle and fifth metatarsophalangeal angle and evaluated the clinical results using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal (MTP-IP) scale preoperatively and six months postoperatively. RESULTS: Of the nine patients, hallux valgus was combined with symptomatic bunionette in seven feet of five patients. In all of our cases, the average AOFAS lesser MTP-IP scale showed improvement after surgery. Painful callosity around the fifth metatarsophalangeal joint disappeared after surgery in all of our cases. The fourth intermetatarsal angle improved from 12.7degrees to 3.1degrees and the fifth metatarsophalangeal angle improved from 16.6degrees to 2.3degrees. CONCLUSION: Diaphyseal oblique osteotomy of the fifth metatarsal appears to be a safe and satisfactory surgical procedure for treatment of symptomatic bunionette.

Surgical Treatment of the Fifth Metatarsal Base Fracture Using Multiple Kirschner Wires / 대한족부족관절학회지

PURPOSE: The purpose of this study is to evaluate the clinical and radiographic results of internal fixation using multiple Kirschner wires (K-wires) for the fifth metatarsal base fracture. MATERIALS AND METHODS: We retrospectively reviewed 14 patients with a displaced fifth metatarsal base fracture. We measured the distance of fracture displacement on the foot oblique radiograph pre- and post-operatively. We evaluated the clinical results using the visual analog pain scale at six weeks and three months postoperatively and the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score at six months postoperatively. RESULTS: In our series, 10 cases were zone I fracture and four cases were zone II fracture. We achieved anatomical reduction and bony union in all of our cases. The average time to bone union was 43 days. The degree of pain around the fifth metatarsal base was significantly decreased after surgery. The average AOFAS score was 95 at six months postoperatively. CONCLUSION: Multiple K-wire fixation is a relatively simple fixation method for displaced fifth metatarsal base fractures. If we place a K-wire into the medial cortex of the fifth metatarsal, we could prevent proximal migration of the K-wire.

Korean Type Distal Radius Anatomical Volar Plate System: A Preliminary Report

BACKGROUND: Distal radius fracture is the most common fracture of the upper extremity, and approximately 60,000 distal radius fractures occur annually in Korea. Internal fixation with an anatomical volar locking plate is widely used in the treatment of unstable distal radius fractures. However, most of the currently used distal radius anatomical plate systems were designed based on the anatomical characteristics of Western populations. Recently, the Korean-type distal radius anatomical volar plate (K-DRAVP) system was designed and developed based on the anatomical characteristics of the distal radius of Koreans. The purpose of this study was to evaluate the preliminary results of the new K-DRAVP system, and to compare its radiologic and functional results with those of the other systems. METHODS: From March 2012 to October 2012, 46 patients with acute distal radius fractures who were treated with the K-DRAVP system at three hospitals were enrolled in this study. Standard posteroanterior and lateral radiographs were obtained to assess fracture healing, and three radiographic parameters (volar tilt, radial inclination, and radial length) were assessed to evaluate radiographic outcomes. The range of motion and grip strength, the Gartland and Werley scoring system, and the disabilities of the arm, shoulder and hand (DASH) questionnaire were used to assess clinical and functional outcomes. RESULTS: All radiologic parameters were restored to normal values, and maintained without any loosening or collapse until the time of final follow-up. Grip strength was restored to 84% of the value for the unaffected side. The mean range of motion of the wrist at final follow-up was restored to 77%-95% of the value for the unaffected side. According to the Gartland and Werley scoring system, there were 16 excellent, 26 good, and 4 fair results. The mean DASH score was 8.4 points. There were no complications after surgery. CONCLUSIONS: The newly developed K-DRAVP system could be used to restore and maintain good anatomical parameters, and provide good clinical outcomes with low complication rates. This system is a promising surgical option for the treatment of distal radius fractures in the Korean population.

Volar Ligament Reconstruction or Trapeziectomy for Thumb Carpometacarpal Joint Osteoarthritis

PURPOSE: The purpose of this study was to evaluate surgical outcomes of thumb carpometacarpal osteoarthritis treated either by volar ligament reconstruction or trapeziectomy with suspensionplasty. MATERIALS AND METHODS: From July 2004 to January 2011, we treated 43 patients with thumb carpometacarpal joint arthritis by volar ligament reconstruction in stages I and II, and by trapeziectomy with suspensionplasty in stages III and IV. Out of the 43, we evaluated 19 patients (9 treated by volar ligament reconstruction, 10 treated by trapeziectomy with suspensionplasty) at an average of 36.8 months (range: 8 to 65 months) after surgery. Outcome measures included pain visual analogue scale (VAS), ranges of motion, and grip and pinch strengths. RESULTS: The mean VAS was 1.2 in the volar ligament reconstruction group and 2.0 in the trapeziectomy with suspensionplasty group at final follow-up. The ligament reconstruction group had significantly better thumb radial abduction and opposition ranges of motion, and key grip strength. No further radiographic arthritic changes were noted in the ligament reconstruction group at a mean follow-up of 39 months. CONCLUSION: The authors obtained satisfactory pain control in patients with thumb carpometacarpal osteoarthritis by volar ligament reconstruction for stages I-II and trapeziectomy with suspensionplasty for stages III-IV.

Retrograde Intramedullary Nailing for Distal Femur Fracture with Osteoporosis

BACKGROUND: The incidence of distal femur fracture in the elderly has been increasing recently, and commonly occurs with osteoporosis. Retrograde intramedullary nailing has been considered a good surgical option for distal femur fracture. The purpose of the present study was to present our surgical results with retrograde intramedullary nailing for distal femur fractures with osteoporosis. METHODS: Thirteen patients diagnosed with extra-articular distal femur fracture and osteoporosis and managed with retrograde intramedullary nailing were retrospectively reviewed. Cement augmentation was used in four patients, shape memory alloy was used in eight patients and both were used in one patient. All patients were followed up for more than 2 years. Radiologic alignments. were scored and Tegner and the Lysholm activity score was used for a functional assessment. RESULTS: The average time to clinical union was 13 weeks (range, 10 to 15 weeks). In 12 of our cases, the total alignment scores were excellent. At the last follow-up, the mean range of motion was 116degrees (range, 110degrees to 125degrees). The average functional score at postoperative 1 year was 2.6 (range, 1 to 5). CONCLUSIONS: Retrograde intramedullary nailing is a good surgical option for distal femur fracture with osteoporosis. Cement augmentation and shape memory alloy can also be used for added mechanical stability. This surgical technique is very useful for distal femur fracture with osteoporosis as it promotes fracture healing and early rehabilitation.

Minimum 5-Year Results of Titanium Tapered Stem with Alumina Bearing in Cementless Total Hip Arthroplasty Using a Modified Direct Lateral Approach / 대한정형외과학회잡지

PURPOSE: The purpose of the current study is to evaluate the clinical and radiographic outcomes of primary total hip arthroplasty (THA) using a single titanium tapered stem with alumina bearing, which was performed through a modified direct lateral approach. MATERIALS AND METHODS: One hundred twenty consecutive primary THAs were performed in 102 patients, and retrospectively reviewed. There were 53 men and 49 women of mean age 54 years, and all patients were followed for a minimum follow-up period of 5 years (range, 5-8.1 years). Clinical outcomes assessment consisted of calculation of the Harris hip score (HHS), and evaluation of the presence of thigh pain or limp. Sequential radiographs were evaluated for implant migration, osteolysis, reactive line, cortical hypertrophy, or evidence of component loosening. RESULTS: At the final follow-up, the mean preoperative HHS of 46 points improved to 94 points; and activity-related thigh pain occurred in two hips, and mild limps in four hips. There was no evidence of implant migration, osteolysis, or component loosening. Audible squeaking was present in two hips, without pain and radiographic abnormality. Dislocation occurred in three hips. CONCLUSION: The minimum 5-year results of titanium tapered stem with alumina bearing in cementless primary THA, using a modified direct lateral approach, were encouraging.

Long-term Outcomes of Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction Syndrome: At Least 5-Years Follow-up

BACKGROUND: There have been few outcomes studies with follow-up after performing ulnar shortening osteotomy for ulnar impaction syndrome. We investigated the long-term clinical and radiological outcomes of ulnar shortening osteotomy for the treatment of idiopathic ulnar impaction syndrome. METHODS: We retrospectively reviewed 36 patients who had undergone ulnar shortening osteotomy for idiopathic ulnar impaction syndrome for a mean follow-up of 79.1 months (range, 62 to 132 months). The modified Gartland and Werley scores were measured pre- and postoperatively. The radiographic parameters for the assessment of the distal radioulnar joint (DRUJ) as well as the relationship between these radiographic parameters and the clinical and radiological outcomes were determined. RESULTS: The average modified Gartland and Werley wrist score improved from 65.5 +/- 8.1 preoperatively to 93.4 +/- 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 +/- 2.0 mm was reduced to an average of -0.6 +/- 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 +/- 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ. CONCLUSIONS: The clinical outcomes are satisfactory for even more than 5 years after ulnar shortening osteotomy for treating idiopathic ulnar impaction syndrome despite the osteoarthritic changes of the DRUJ. The patients who need a larger degree of ulnar shortening may develop DRUJ arthritis.

Surgical Outcomes of Schwannoma Occurred at the Brachial Plexus

Schwannoma of the brachial plexus region is very rare. There has not been general agreement in terms of surgical outcome from limited number of studies. We analyzed surgical outcomes from 11 cases of schwannomas which occurred in the brachial plexus. From February 2000 to August 2009, 11 patients with schwannomas of the brachial plexus region were surgically treated by a single surgeon. We retrospectively reviewed the medical records and MRI of our cases, and evaluated the neurologic deficit and the recurrence of tumors after surgery. All the cases were proven histologically as schwannomas. The mean age of the patients was 52.6(36~67) years old, 4 of them were male and 7 were female. The tumor was located in the left side in 9 patients, and right in 2. The mean postoperative follow-up was 24.7(6~78) months. Initial presentation was usually painless, palpable mass. The mass was located in various level of the brachial plexus such as root, trunk, cord, or terminal branch level. The size of mass was from 1.5x1.5x0.5 cm to 11.0x10.0x6.0 cm. Eight of 11 patients showed no neurologic deficit. Three patients showed postoperative neurologic deficit; two of them had transient sensory deficit, and one of them had weakness of flexor pollicis longus and 2nd flexor digitorum profundus. There were no recurrences. The schwannoma of the brachial plexus region should be considered as a curable lesion with an acceptable surgical risk of injury to neurovascular structures. With precise surgical techniques, these tumors can be removed to improve patient's symptoms with minimal morbidity.

Lateral Calcaneal Artery Adipofascial Flap for Reconstruction of the Posterior Heel of the Foot

BACKGROUND: Soft tissue defects of the posterior heel of the foot present difficult reconstructive problems. This paper reports the authors' early experience of five patients treated with a lateral calcaneal artery adipofascial flap. METHODS: Between 2003 and 2007, five patients (3 males and 2 females) with soft-tissue defects over the posterior heel underwent a reconstruction using a lateral calcaneal artery adipofascial flap and a full-thickness skin graft. The flap sizes ranged from 3.5 x 2.5 cm to 5.5 x 4.0 cm. RESULTS: All five flaps survived completely with no subsequent breakdown of the grafted skin, even after regularly wearing normal shoes. The adipofascial flap donor sites were closed primarily in all patients. CONCLUSIONS: Lateral calcaneal artery adipofascial flaps should be included in the surgical armamentarium to cover difficult wounds of the posterior heel of the foot. These flaps do not require the sacrifice of a major artery to the leg or foot, they are relatively thin with minimal morbidity at the donor site, and leave a simple linear scar over the lateral aspect of the foot.

Staged Reconstruction of the Mangled Hand with the Combined Use of Pedicled Groin Flap and Free Wrap Around Flap

PURPOSE: Despite the free tissue transfer using microsurgical technique being the current trend of soft tissue reconstruction of the hand, the pedicled groin flap has the advantage to provide coverage for the mangled hand without necessitating the use of a damaged arterial system and also providing the benefit of saving the arterial system for later free tissue transfer. This report presents the author's experience using pedicled groin flap in four cases of mangled hands with massive bone and soft tissue defects requiring later thumb reconstruction with the free wrap around flap. MATERIALS AND METHODS: The patients' age ranged from 30 to 51 years; three patients were male and one was female. The causes of mangled hand included two machinery crush injuries, one laboratory explosion and one motor vehicle accident. While evaluating the post-operative results, factors like flap survival, complications, stability in opposition, pinch power and 2 point discrimination were taken into account. RESULTS: All massive soft tissue defects of the hands were completely covered with pedicled groin flap successfully. The reconstructed thumb using free wrap around flap did not have any limitation in opposition. There was no occurrence of post-operative infection and all the flaps survived completely. The average pinch power was 70% of the contralateral intact thumb and average 2 point discrimination was 10 mm. CONCLUSION: The pedicled groin flap for the reconstruction of the massive soft tissue defects of the hand with subsequent reconstruction of the thumb with a wrap around flap is a very useful procedure. The combined use of pedicled groin flap and wrap around flap allows adequate coverage of sizable soft tissue defects and functional thumb opposition in cases of reconstruction of the mangled hands.

Early Results of Hemicondylar Hamate Replacement Arthroplasty in Proximal Interphalangeal Fracture-Dislocation Injury

PURPOSE: We assessed early clinical and radiological results of hemicondylar hamate replacement arthroplasty in fracture-dislocation injury of the proximal interphalangeal joint. MATERIALS AND METHODS: From March 2007 to February 2008, four patients who had suffered from comminuted unstable fracture-dislocation of the proximal interphalangeal joint were treated by hemicondylar hamate replacement arthroplasty. All patients were male, and average age at operation was 21.5(range, 14~27) years. All cases showed subluxation of the proximal interphalangeal joint, and mean articular surface involvement was 50.8(range, 42.1~62.5)%. We clinically measured ROM, grip strength, pain of donor & recipient site, and radiologically assessed whether or not union, malalignment, or step-off occurred. RESULTS: Average follow-up period was 9.5(range, 6~14) months. Mean flexion contracture was 12.5 (range, 10~15)degrees in affected side and 0degrees in unaffected side. Mean further flexion was 92.5 (range, 85~100)degrees in affected side and 95.0 (range, 90~100)degrees in unaffected side. Mean VAS pain scores was 1.75 (range, 1~3) in recipient site and 1.25 (range, 0~2) in donor site. Mean grip strength was 11 (range, 8~15) lb in affected side and 14 (range, 10~17) lb in unaffected side. Union without malalignment was achieved in all cases. CONCLUSIONS: Early results of hemicondylar hamate replacement arthroplasty in the treatment of fracture-dislocation of the proximal interphalangeal joint showed satisfactory functional and radiological outcome.

Neuropathic Arthropathy of the Elbow / 대한정형외과학회잡지

PURPOSE: Neuropathic arthropathy of the elbow is extremely rare and is characterized by painless destruction of the joint due to diminished proprioception. We report five cases of neuropathic arthropathy of the elbow with review of pertinent literature. MATERIALS AND METHODS: We analyzed records of five patients who were diagnosed with neuropathic arthropathy of the elbow. There were three men and two women with a mean age of 38.6 years (range, thirteen to fifty years). The conditions associated with the arthropathy were three cases of syringomyelia, one tabes dorsalis, and one neurofibromatosis. One patient was conservatively treated and was followed periodically and others underwent operative procedures. The mean duration of follow-up was 8.5 years (range, one to nineteen years). Changes of symptoms, range of motion (ROM), and functional satisfaction were assessed. RESULTS: The conservatively treated patient maintained the function of the elbow. In the surgically treated group, one case of ulnar nerve decompression and one case of osteosynthesis of the fractured olecranon showed improvement of symptoms, ROM, and function. But two patients who underwent reconstructive procedures had decreased ROM after complication of deep infection. Concluson: Neuropathic arthropathy of the elbow causes few functional problems despite of the radiologic destruction and instability of the elbow. Therefore symptomatic management is considered more preferable than surgical correction of destruction or instability of the elbow.

A Comparative Study on the Treatment of Scaphoid Nonunion with Matti-Russe Technique and Fisk-Fernandez Technique / 대한정형외과학회잡지

PURPOSE: Established scaphoid nonunion may lead to carpal instability and osteoarthritis. The purpose of this study is to compare the clinical and radiological results of the osteosynthesis between Matti-Russe group and Fisk-Fernandez group. MATERIALS AND METHODS: Our retrospective study included 21 nonunion cases in 20 patients treated by Matti-Russe or Fisk-Fernandez technique from September 2001 to August 2006. The mean duration of follow up was 31 months. Based on the questionnaire which included clinical information and the radiologic evaluation, we compared the objective and subjective results between two surgical groups. RESULTS: There were no significant differences between two groups in respect of the postoperative satisfaction and the pain. Both the range of motion and the grip power decreased compared to that of the unaffected side, but there were no significant differences between two groups. Also, there were no significant differences in the union rate and the rate of successful correction of DISI deformity. In all cases in which DISI deformity was detected preoperatively, the deformity was corrected postoperatively. There were 7 cases of osteoarthritis, but among them only one case appeared newly after the surgery. CONCLUSION: There were no significant differences between two surgical groups in clinical and radiological results. Both techniques were effective in achieving bony union and functional recovery.

Phocomelia: The Clinical Manifestation, Classification and Surgical Treatment of Korean Patients with Phocomelia / 대한정형외과학회잡지

PURPOSE: Phocomelia is an extremely rare congenital anomaly of the upper extremity. There have been no clinical reports about phocomlia in Korea except for five birth reports. We present here the clinical features, classifications and surgical treatments of our phocomelia cases. MATERIALS AND METHODS: From January 1993 to August 2007, seven patients were diagnosed as having phocomelia in 9 upper extremities at our clinic. Surgical treatments were performed for five patients on their hand anomalies. We retrospectively reviewed the medical records and radiographs of our cases, and we tried to classify them by the previously suggested systems. We evaluated the functional improvement and measured the VAS scale for parental satisfaction with the operative outcomes. RESULTS: We could not find any problems during the fetal periods or any hereditary features. The bilaterally-affected patients also had deformities of the lower extremity, while the unilaterally-affected patients did not. We couldn't classify our cases according to the Frantz and O'Rahilly system. We found that the classifications suggested by Tytherleigh-Strong and Hooper (2003) and Goldfarb et al. (2005) could be promising alternatives for classification. One upper extremity was classified as type A, one as type B, and 7 as type C by Tytherleigh-Strong and Hooper's system. Using the Goldfarb's system, two upper extremities were classified as proximal radial longitudinal dysplasia, and seven were classified as proximal ulnar longitudinal dysplasia. Three patients who underwent pollicization showed opposition and tip pinch. Two patients who underwent syndactyly division could do lateral pinch. The VAS scale for parental satisfaction with the functional improvement averaged 8.2 postoperatively. CONCLUSION: The bilateral cases had different clinical features from unilateral ones. Phocomelia could not simply be classified by the Frantz and O'Rahilly system, and it may not be a true transverse intercalary deficiency. We could gain functional improvement after operations on the hand anomalies.

Subcutaneous Fascial Pedicled Lateral Supramalleolar Flap

Soft-tissue reconstruction of the foot and ankle has long been a challenge for reconstructive surgeons. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these difficult problems, the authors have begun to use a subcutaneous fascial pedicled lateral supramalleolar flap. This report presents the authors' experience with five patients treated with this flap. The patients' ages ranged from 26 to 72 years; four of the patients were male and one was female. The cause of the soft-tissue defects involved acute trauma and malignant melanom. All flaps survived and provided satisfactory coverage of the defect. Compared with the classic lateral supramalleolar flap, when the perforating branch is interrupted in its course, it is possible to elevate this subcutaneous fascial pedicled flap. The distally based flap with a compound pedicle which is continuous with a vascular axis and a band of subcutaneous fascial pedicle has long pedicle. This procedure is valuable for remote defect of the foot. It is believed that this flap is versatile and effective and is a good addition to the available techniques used by reconstructive surgeons for coverage of the foot and ankle.

Anatomical Assessment of Distal Femur for Optimal Femoral Component Rotational Alignment in TKA / 대한정형외과학회잡지

PURPOSE: We evaluated the relationship among the various rotational reference axes of femoral component in TKA, and the potential change in rotational alignment when a posterior condylar axis (PCA) was used as a reference for different cartilage erosions between the medial and lateral posterior femoral condyles. MATERIALS AND METHODS: The study subjects included twenty male and twenty female volunteers. Axial MR image of the distal femur were used to measure the angles among the clinical transepicondylar axis (cTEA), surgical transepicondylar axis (sTEA), the PCA, and the AP axis. We then evaluated the difference in the amount of rotation between a normal and osteoarthritic model when the PCA was used as a rotational reference. RESULTS: The mean angle between cTEA and PCA was 5.4 degrees, and it was significantly greater in the female (6.5 degrees) than in the male group (4.3 degrees). The cTEA demonstrated a perpendicular relationship with the AP axis in both groups. The average angles between cTEA and sTEA were 3.2 degrees in the male group and 3.8 degrees in the female group. When we assumed complete erosion of the cartilage on the medial posterior condyle with preservation on the lateral side, the angles between the cTEA and PCA decreased by an average of 1.9 degrees in both groups. CONCLUSION: This study suggests that the two transepicondylar axes, which demonstrated greater than 3 degrees in angle-difference, should be defined clearly in scientific reports and in their application as rotational references in TKA. Some significant gender differences in the rotational profile were noted. When the PCA is used as a rotational reference, potential errors caused by the different amounts of cartilage erosion between the medial and lateral posterior condyles should be considered.