The Natural History of Kienböck’s Disease Diagnosed at More than 50 Years of Age

Background@#Previous literatures suggest that the prognosis of Kienböck’s disease might be favorable despite no surgery if it is diagnosed in late age, but the evidence is not clear. The aim of this study was to determine the radiographic and clinical progression of Kienböck’s disease diagnosed at more than 50 years of age. @*Methods@#Data of 27 patients diagnosed with Kienböck’s disease at more than 50 years of age between 2000 and 2016 were investigated. During the study period, no treatment, either surgical or nonsurgical, was applied. We explained to the patients that the affected lunate was not expected to collapse further if found late in age. Annual visits were recommended, through which radiographic and clinical observation was made. We assessed changes in Stahl index and radioscaphoid angle between the initial assessment and the final follow-up, and clinical assessment was made using pain in visual analog scale (VAS) and Dornan’s criteria. @*Results@#Initially, 2 patients were in Lichtman stage 1, 6 in stage 2, 5 in stage 3A, 11 in stage 3B, and 3 in stage 4. Radiographic follow-up of at least 5 years (mean, 7.8 years) was made in 14 patients, whose Stahl index and radioscaphoid angle did not differ significantly from their initial measurements. Arthritic appearance was not found, and progression in the Lichtman stage was detected in 1 lunate, from 3A to 3B. Despite no surgical treatment for an average of 7.5 years (range, 5.0–15.7 years) of observation period in the 27 patients, average pain in VAS improved from 3.5 (range, 1–7) to 0.8 (range, 0–2), with excellent or good clinical status by Dornan’s criteria. @*Conclusions@#Our study suggests that Kienböck’s disease diagnosed at more than 50 years of age can follow a benign natural course in radiographic and clinical aspects. Therefore, surgical interventions should be considered carefully in this age group.

Surgical Treatment of Pediatric Intra-Articular Proximal Phalangeal Head Fracture of the Big Toe

PURPOSE: Pediatric intra-articularproximal phalangeal head fractures of the big toe are very rare and few studies on this have been published. The purpose of this study is to present the diagnostic approach and surgical management of these extremely rare fractures, which might be easily underestimated or misdiagnosed.MATERIALS AND METHODS: The study retrospectively reviewed all the patients who were diagnosed as intra-articular proximal phalangeal head fracture of the big toe and who underwent surgical intervention in our institution. The size of the bony fragment and hallux valgus interphalangeus angle were measured on the preoperative X-rays. The size and rotation of the osteochondral fragment, the presence of avascular necrosis, ligamentous injury and soft tissue entrapment were assessed on the preoperative magnetic resonance images (MRIs). The radiologic and functional evaluation were performed at 1 year postoperatively.RESULTS: The average size of the bony fragments measured on the X-rays was 4.1 mm in width and 2.3 mm in length. Two cases showed hallux valgus interphalangeus. Preoperative MRI was performed in four cases and the average size of any osteochondral lesion was 5.3 mm in width, 3.9 mm in length, and 4.7 mm in height. Rotation of the osteochondral fragment was observed in one patient, and soft tissue entrapment was noted in two patients. Postoperatively, successful bony union was achieved in all the patients and the average time to union was 74.4 days.CONCLUSION: Intra-articular proximal phalangeal head fractures of the big toe are very rare and often neglected due to incomplete ossification in the pediatric population. It is important to suspect the presence of this intra-articular fracture and to appropriately implement further evaluation. Nonunion of chronic cases as well as acute fractures can be successfully treated through open reduction and internal fixation using multiple K-wires.

Evaluation and Management of Osteoporosis and Sarcopenia in Patients with Distal Radius Fractures

Distal radius fractures (DRFs) are one of the most common fractures seen in elderly people. Patients with DRFs have a high incidence of osteoporosis and an increased risk of subsequent fractures, subtle early physical performance changes, and a high prevalence of sarcopenia. Since DRFs typically occur earlier than vertebral or hip fractures, they reflect early changes of the bone and muscle frailty and provide physicians with an opportunity to prevent progression of frailty and secondary fractures. In this review, we will discuss the concept of DRFs as a medical condition that is at the start of the fragility fracture cascade, recent advances in the diagnosis of bone fragility including emerging importance of cortical porosity, fracture healing with osteoporosis medications, and recent progress in research on sarcopenia in patients with DRFs.

Multimodal Diagnostic Approach for Synovitis of the Wrist / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to suggest a multimodal diagnostic approach to determine the cause of the disease in patients diagnosed with synovitis of the wrist and who underwent synovectomy. MATERIALS AND METHODS: Twenty-nine patients, who underwent contrast magnetic resonance imaging (MRI) preoperatively and synovectomy from January 2000 to December 2013, were reviewed retrospectively. Among them, 17 patients underwent a Tc99m white blood cell (WBC) scan preoperatively. In patients who met the diagnostic criteria of rheumatoid arthritis (RA), the diagnosis was confirmed as RA if the MRI finding or histology was compatible with RA. If the MRI finding and histology were disparate, the final diagnosis was made based on the histologic finding. RESULTS: Of the nine patients who met the diagnostic criteria of RA, seven patients were finally diagnosed as RA and two patients as tuberculous arthritis. Of the 20 patients who did not meet the diagnostic criteria of RA, the MRI findings and histology were consistent with the same disease in 12 patients. In the remaining eight patients, five were diagnosed with nonspecific chronic synovitis, one with RA, and two with tuberculous arthritis based on the clinical findings, MRI, and histology findings. CONCLUSION: MRI and a WBC scan are very useful imaging modalities for diagnosing the causative condition of the wrist synovitis. A histology evaluation after synovectomy can also be useful in cases with a difficult diagnosis or are refractory to medications.

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.

Updates on Ulnar Impaction Syndrome / 대한정형외과학회잡지

Ulnar impaction syndrome is one of the common causes of ulnar-sided wrist pain. The pain is usually aggravated by ulnar deviation during a power grip, especially when the forearm is in a pronated position. The most common predisposing factor of ulnar impaction syndrome is ulnar positive variance, which is an increased ulnar length relative to the radius of the radiocarpal joint. However, it can also occur in patients with ulnar neutral or negative variance because ulnar variance can increase during functional activities, including pronation and power gripping. In these patients, the triangular fibrocartilage complex (TFCC) may be thickened. If conservative treatments—lifestyle modification, medication, or wrist splinting—are unsuccessful, surgical treatments, such as wafer procedure or ulnar shortening osteotomy can be considered. The wafer procedure is an effective treatment for ulnar impaction syndrome. It removes the distal 2 to 4 mm of the ulnar head, while preserving the ulnar styloid process from fracturing via a limited open or an arthroscopic approach. The advantages of the wafer procedure are that it does not require bone healing or internal fixation and provides direct access to TFCC. However, it is a technically demanding procedure and is contraindicated in patients with distal radio-ulnar joint (DRUJ) instability, lunotriquetral instability, ulnar minus variance, and with an ulnar positive variance of more than 4 mm. Ulnar shortening osteotomy is the most popular method for the treatment of ulnar impaction syndrome. It can effectively relieve ulnar impaction symptoms and stabilize DRUJ. However, an excessive amount of shortening may increase the peak pressure at DRUJ, which results in DRUJ arthritis. There is also a possibility of delayed union or nonunion in the osteotomy site. To prevent delayed union or nonunion, we should make an effort to decrease the gap in the osteotomy site during surgery. A serial follow-up is also recommended to evaluate the occurrence of arthritis in DRUJ after ulnar shortening.

Common peripheral neuropathies of the upper extremity

No abstract available.

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.

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.

Comparison of Wrist Extension Stretching Exercise and a Wait-and-see Policy for Treatment of Lateral Epicondylitis

PURPOSE: The aim of this study was to evaluate the effects of the wrist stretching exercise on the results of treatment for lateral epicondylitis by comparing with wait-and-see policy. MATERIALS AND METHODS: The patients who had lateral elbow pain associated with a lateral epicondyltitis were divided into wrist extension stretching exercise group (group 1) and wait-and-see policy group (group 2). Group 1 pateitns were educated to perform the wrist stretching exercise; maintenance of the position with the elbow extended, the forearm pronated, and the wrist flexed for more than 1 minute, more than 50 times per day. Group 2 patients were educated that they reduced the activities that provoked pain. The end point of follow-up was when symptoms were disappeared completely. RESULTS: Two hundred twenty seven patients were enrolled into this study. One hundred forty eight patients were allocated to group 1, 79 patients to group 2. The mean duration of follow-up of group 1 was 10.2 weeks and group 2 was 22.6 weeks. The median survival time from symptom onset to the time of resolution was 8.0 weeks in group 1, 16.0 weeks in group 2. CONCLUSION: This study suggests that wrist stretching exercise may be more effective than the wait-and-see policy in the patients with a lateral epicondylitis. The wrist stretching exercise can be recommended as the treatment of lateral epicondylitis.