Reconstruction of the coracoclavicular ligament with palmaris longus tendon and Mersilene tape for acromioclavicular dislocations.

BACKGROUND: Acromioclavicular (AC) joint dislocation is common among shoulder injuries, and various surgical methods have been introduced for effective ligament reconstruction. Reconstruction of the coracoclavicular (CC) ligament in the anatomical position using autologous tendons is a recent surgical trend. This study is to report clinical and radiologic results of reconstruction of the CC ligament using an autologous palmaris longus tendon interweaved with Mersilene tape (PLMT) with a minimum 2-year follow-up. METHODS: This retrospective study analyzed 76 patients (mean age, 43.4 ± 11.2 years) with AC joint dislocation treated by reconstruction of the CC ligament with PLMT, from March 2004 to February 2017. The mean follow-up period was 28 ± 6.7 months (range, 24-66 months). The Visual Analog Scale (VAS) for pain assessment, American Shoulder and Elbow Surgeons rating scale (ASES), and Constant Score (CS) were used to evaluate clinical outcomes at the preoperative and the final follow-ups. CC and AC distances were measured using anteroposterior (AP) X-ray preoperatively and at the final follow-up for radiologic outcomes. Complications were also assessed. RESULTS: The mean preoperative VAS for pain, ASES, CS were 5.7 ± 0.7, 77.1 ± 6.2, and 61.5 ± 5.2, respectively. These scores at the final follow-up improved to 2.1 ± 0.5, 90.9 ± 4.3, and 94 ± 7.0, respectively (p = 0.043, p <  0.001, p <  0.001). The mean preoperative CC and AC distances were 16.49 ± 3.73 mm and 13.84 ± 3.98 mm, respectively. The final follow-up CC and AC distances were 9.29 ± 2.72 mm and 5.30 ± 2.09 mm, respectively (p <  0.001, p <  0.001). Although a slight re-widening of the CC distance occurred in 10 patients (13.1%), most patients regained full range of motion of the affected shoulder at the final follow-up. CONCLUSION: The CC ligament reconstruction with PLMT for the treatment of AC joint dislocation showed good clinical and radiological results. This technique could be a good alternative treatment for AC dislocations.

Reconstruction of large bone defect using autogenous fibular strut and iliac bone graft for revision total elbow arthroplasty.

ABSTRACT: The stability and longevity of the prosthesis after revision total elbow arthroplasty (TEA) are greatly influenced by the reconstruction of bone defects around the distal humerus and proximal ulna. This study evaluated the clinical and radiological results of reconstruction of a large bone defect using an autogenous fibular strut and iliac bone graft in revision TEA.This retrospective study reviewed 10 patients who underwent revision TEA with autogenous fibular strut and iliac corticocancellous bone graft between March 2007 and May 2016. Range of motion (ROM), Visual Analog Scale (VAS), and Mayo Elbow Performance Score were used to evaluate clinical outcomes at the final follow-up. Plain radiographs were reviewed for bone union and the presence of re-loosening or for the presence of peri-prosthetic fractures.At the final follow-up, the ROMs of the elbow was 102.5° (range, 90-120°) from extension to flexion, 60.0° (range, 40-80°) in pronation, and 58.5° (range, 35-80°) in supination. The mean preoperative VAS and Mayo Elbow Performance Score were 5.1 and 46.5, and theses scores were improved to 2.6 and 79.0, at the final follow-up (P < .05). Union of the grafted bone with the distal humerus was achieved at an average of 4.5 months (range, 3-6 months). Re-osteolysis recurred in 2 cases, and additional surgery for bone grafting was performed in 1 case.Autogenous fibular strut bone grafting is an effective technique when revision TEA has large bone defects around the prosthesis resulting in a relatively stable prosthesis fixation and good union rate with a satisfactory clinical outcome after TEA revision.

Double trapezia sign: A new radiologic sign of scaphoid nonunion.

In scaphoid nonunion, pseudarthrosis and sclerotic change occur at the nonunion site. These changes make a distal fragment look like a trapezium on plain radiographs and we called this phenomenon the double trapezia sign. The purpose of this study was to estimate the diagnostic reliability of the double trapezia sign and its clinical and prognostic implications for the scaphoid nonunion.A retrospective review of 124 patients who underwent surgical treatment because of scaphoid nonunion between January 2007 and December 2017 was performed. Two hand surgeons and 1 musculoskeletal radiologist reviewed preoperative plain radiographs independently. Each observer evaluated the plain radiographs in 2 separate sessions at least 3 weeks apart to assess intraobserver and interobserver reliabilities of the double trapezia sign. To assess clinical and prognostic implications of the double trapezia sign, the patients were divided into the positive and nonpositive groups, and several variables such as age, sex, duration of nonunion, size of the distal fragment, avascular necrosis (AVN) of the proximal fragment, type of bone graft, healing time, and failure rate were compared between the 2 groups.The kappa values of intraobserver and interobserver reliabilities were >0.8, corresponding to almost perfect agreement. There were 58 patients in the positive group and 66 patients in the nonpositive group. The mean duration of nonunion was 38.5 months in the positive group and 12.2 months in the nonpositive group (P < .001). The size of distal fragment was 49.6% and 60.9%, respectively (P < .001). The AVN of proximal fragment was 24.1% and 54.5%, respectively (P = .001). The mean healing time was 4.1 and 6.4 months, respectively (P < .001). The failure rate was 13.8% and 27.3%, respectively (P = .066).In conclusion, the double trapezia sign is a valuable radiographic sign of scaphoid nonunion. The double trapezia sign is easily identifiable on plain radiographs and has excellent intra- and interobserver reliabilities. The positive double trapezia sign implies mid-waist nonunion, long duration of nonunion, less possibility of AVN, and favorable postoperative prognosis.

Carpal Tunnel Syndrome Caused by Lipofibromatous Hamartoma of the Median Nerve.

Lipofibromatous hamartoma (LFH) is a rare tumor of the peripheral nerves, which usually involves the median nerve. The authors reported on two rare cases of carpal tunnel syndrome due to LFH of the median nerve. A 49-year-old female patient complained of the mass and symptoms consistent with LFH. Magnetic resonance imaging (MRI) showed typical LFH findings. The symptoms were successfully ameliorated with carpal tunnel release and external neurolysis. A 37-year-old female patient complained of weakening thumb abduction and the mass where the MRI showed atypical findings. Opponensplasty and debulking operations were performed after which thumb abduction was improved; however, neurological sequelae remained. LFH of the median nerve is managed on a case-by-case basis as treatment guidelines are not very clearly defined yet. However, the less invasive treatment such as carpal tunnel release and external neurolysis than more aggressive surgical treatment should be recommended as a treatment option.

Small joint arthrodesis technique using a dowel bone graft in a rabbit model.

The dowel bone graft fusion technique for the ankle is a well-known and useful method. However, clinical results of dowel bone graft for small joint fusion are unknown. The objective of the present study is to evaluate the effects of dowel bone graft technique for small joint arthrodesis in an in vivo arthrodesis of rabbit elbow model compared with the conventional arthrodesis technique (open, joint surface debridement, and internal fixation method). We assigned 28 young adult New Zealand white rabbits to one of two groups: Group 1, the conventional fusion technique group; Group 2, the dowel bone graft fusion technique group. We performed arthrodesis surgery in two different ways for each group. Eight weeks after the operation, specimens were harvested, radiographed, mechanically tested for torque to failure and stiffness, and evaluated for histology. Fusion rates were 77% (10/13) in Group 1 and 93% (13/14) in Group 2 (p = 0.326). Torque to failure showed a mean of 0.86 Nm in Group 1 and 0.77 Nm in Group 2 (p = 0.464). The mean value of stiffness was 0.11 Nm/deg in Group 1 and 0.11 Nm/deg in Group 2 (p = 0.832). In Group 2, histological examination showed residual cartilage absorption and inflammatory response in all cases. In this model, we have been unable to show a difference in either the union rate or strength of fusion between the two methods. However, the dowel bone graft technique is an easy and less invasive method and has some advantages over the conventional method.

Trapeziometacarpal Arthrodesis Using a Combination of Chevron Osteotomy, Longitudinal K-wire, and K-wire Compression Staples.

Among surgical methods for advanced trapeziometacarpal arthrosis, arthrodesis may benefit high-demand patients such as laborers because it preserves the osseous foundation of the thumb. The authors achieved successful trapeziometacarpal arthrodesis in 3 patients by a combination of chevron osteotomy, longitudinal K-wire, and K-wire compression staples without using bone graft. There were no complications specifically associated with the surgery other than asymptomatic slight pull-out of a staple. This combination is a good option for trapeziometacarpal arthrodesis, having the advantages of using a small incision and common devices and being low cost. [Orthopedics. 2018; 41(6):e894-e896.].

Modified triceps fascial tongue approach for primary total elbow arthroplasty.

BACKGROUND: Triceps weakness is a common complication of total elbow arthroplasty (TEA). Many posterior approaches for TEA have been introduced to maintain triceps function. The present study evaluated the clinical outcomes and extensor strengths of primary TEA with modified triceps fascial tongue approach. METHODS: Twenty-one primary TEAs performed in 20 patients by a single surgeon were reviewed with a mean of 64.2 months (range, 24-127 months) of follow-up. Every TEA was performed using the modified triceps fascial tongue approach, with the Coonrad-Morrey prosthesis. Patient demographics, range of motion, pain visual analog scale, and triceps strength (Medical Research Council [MRC] scale) were compared before and after the operation. The Mayo Elbow Performance Score was evaluated at the latest follow-up. RESULTS: Triceps strength was normal (MRC grade V) in 10 elbows (48%) and good (MRC grade IV) in 11 (52%). Triceps strength after arthroplasty was significantly improved compared with the preoperative strength (P < .001). Mean flexion arc was improved from 78° to 100° after arthroplasty (P = .004). However, mean flexion contracture (preoperative; 29°, postoperative; 26°) was not improved after surgery (P = .377). The mean visual analog scale pain score improved from 7.7 preoperatively to 2.4 postoperatively (P < .001). Postoperative Mayo Elbow Performance Scores were excellent in 13 elbows, good in 6, and fair in 2. The only complications were 3 intraoperative condylar fractures. CONCLUSIONS: Modified triceps fascial tongue approach is an easy and effective approach for primary TEA.

Two-dimensional Morphological Characteristics of the Distal Radius on Axial Magnetic Resonance Image and the Effects on Distal Screw Length.

BACKGROUND: Detection of dorsal cortical penetration of distal locking screws is difficult owing to the irregular shape of the dorsal surface of the distal radius. This study was designed to analyze two-dimensional morphological characteristics of the distal radius on axial magnetic resonance image, and to suggest a guideline for evaluation of screw length in distal radius fractures on the fluoroscopic or plain X-ray true lateral image. METHODS: Anteroposterior length and lateral width of the distal radius, distance between the highest and the lowest point of the dorsal cortex (deceptive length), and widths of the first to second (hazard zone) and the third to fifth extensor compartments (safe zone) at the Lister tubercle level were measured on 104 axial magnetic resonance images by two hand surgeons. RESULTS: The mean length and width of the distal radius at the Lister tubercle level were 22.96 mm and 30.42 mm, respectively. The mean hazard zone and safe zone widths were 8.72 mm and 19.43 mm, respectively. The mean deceptive length was 4.07 mm and the deceptive length did not have a relationship with height, sex, and age of subjects. CONCLUSIONS: We suggest that 4 mm be used as a reference value for the evaluation screw length at the safe zone. If the vertical distance between a distal screw tip and the peak of the Lister tubercle is lesser than 4 mm on a fluoroscopic or plain X-ray true lateral image, dorsal cortical penetration should be suspected. When dorsal cortical penetration at the hazard zone is suspected, both oblique or pro-supination views should be checked.

Trigger Wrist.

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.

Flexor carpi radialis brevis: an unusual anomalous muscle of the wrist.

During imaging studies or surgical procedures, anomalous forearm and wrist muscles are occasionally encountered. Among them, the flexor carpi radialis brevis is very rare. Because the trend is growing toward treating distal radius fractures with volar plating, the flexor carpi radialis brevis is worth knowing. Here, we report two cases with a review of the literature.

Complete dislocation of the thumb metacarpal with extreme displacement.

This study reports a rare case of complete dislocation of the thumb metacarpal with extreme displacement. Although there are several reported cases of similar injury in earlier published reports, metacarpals of all the cases remained in situ. In this case, the metacarpal was totally displaced out of the hand. Although open reduction and internal fixation were performed, the clinical outcome was unsatisfactory because of severe soft tissue damage.

Comparison of the effects of subcutaneous anterior transposition and in situ decompression on the histologic and electrophysiologic properties of the ulnar nerve: an experimental study in a rabbit model.

PURPOSE: Although anterior transposition of the ulnar nerve is a commonly performed procedure for treatment of cubital tunnel syndrome, there are concerns that surgical mobilization puts blood supply to the nerve at risk. The purpose of this study was to compare the effects of subcutaneous anterior transposition (SAT) and in situ decompression (ISD) on the ulnar nerve's histologic and electrophysiologic properties in a rabbit model. METHODS: We assigned 30 male, young adult New Zealand white rabbits to 1 of 3 groups (each group, n = 10). The extensive dissection-SAT group underwent complete neurolysis of the right ulnar nerve from brachial plexus to wrist and a subsequent SAT, the ISD group underwent ISD with 4-cm-long exposure of the ulnar nerve, and the SAT group underwent SAT with 4-cm-long circumferential neurolysis of the ulnar nerve. We killed the animals 7 days after the operation. We assessed electrophysiologic changes by finding the percentage of compound motor action potential of the surgical limb compared with the contralateral limb, and histologic changes by ischemic fiber degeneration. RESULTS: The extensive dissection-SAT group showed a significantly lower percentage of compound motor action potential and higher grade of ischemic fiber degeneration than the ISD and SAT groups. On the other hand, the percentage of compound motor action potential and the grade of ischemic fiber degeneration were similar between the latter 2 groups without a statistically significant difference. CONCLUSIONS: This study demonstrated that surgical mobilization of the ulnar nerve during SAT has an effect similar to ISD on the nerve's histologic and electrophysiologic properties at the 7th postoperative day in a rabbit model. CLINICAL RELEVANCE: In a rabbit model, ISD and SAT appear to affect histologic and electrophysiologic findings of the ulnar nerve equally at postoperative day 7, which suggests that they would have the same relative safety in a clinical setting.

Correlation of MR arthrographic findings and range of shoulder motions in patients with frozen shoulder.

OBJECTIVE: The purpose of this article is to correlate MRI arthrographic findings with range of shoulder motions in patients with frozen shoulder. MATERIALS AND METHODS: Shoulder MRI studies of 40 patients (22 women and 18 men; mean age, 52.8 years) with frozen shoulder were retrospectively compared with MRI studies of 40 age- and sex-matched control subjects without frozen shoulder. The thickness of the coracohumeral ligament and the capsule in axillary recess were measured retrospectively. The range of shoulder motions, including external rotation (ER), internal rotation (IR), lateral abduction, and forward flexion (FF), were prospectively evaluated by one experienced orthopedic surgeon. RESULTS: The mean (±SD) thickness of the coracohumeral ligament (4.13±1.04 vs 2.51±0.59 mm; p=0.000) and the capsule in axillary recess (3.97±1.45 vs 2.33±0.87 mm; p=0.000) were significantly greater in the patient group than in the control group. Multiple linear regression showed that only coracohumeral ligament thickness was significantly associated with ER (R2=0.418; p=0.000) and IR (R2=0.346; p=0.001), but not with lateral abduction and FF. Capsular thickness in axillary recess was not significantly correlated with any shoulder motion. CONCLUSION: Coracohumeral ligament thickness on MR arthrography correlates with the range limitation of ER and IR in patients with frozen shoulder.

Ankle deformity secondary to acquired fibular segmental defect in children.

BACKGROUND: The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children. METHODS: Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs. RESULTS: In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2 degrees (range, 5 degrees to 35 degrees) and 10 degrees (range, 5 degrees to 12 degrees), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times. CONCLUSIONS: A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiöld supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.

Pediatric posterior monteggia lesion: a greenstick fracture of the proximal ulnar metaphysis with radial neck fracture. A case report.

We report a case of posterior Monteggia lesion in a 12-year-old girl consisting of a greenstick fracture of the proximal ulnar metaphysis and a radial neck fracture with a proximal and posterior 90-degree rotational displacement of the radial head. Closed reduction of the radial head resulted in complete reversal of the radial head, which was corrected by open reduction and internal fixation. Cast immobilization without correction of the plastic deformation of the proximal ulna caused posterior bowing of the ulna and posterior displacement of the fractured radial neck. Corrective osteotomy of the ulna and third operation of radius resulted in bony union and acceptable alignment.

Extension limitation and deviation of fingers by the scarred junctura tendinum: a case report.

The juncturae tendinum (inter-extensor connections) are structures connecting each of the extensor digitorum communis (EDC) tendons. Nine months before the presentation to us, this 21-year-old man had painful swelling on the dorsum of the right hand after punching. At present, the patient showed an ulnar deviation of the long finger and a limited extension of the ring finger. The scarred junctura tendinum between long and ring fingers inhibited proximal sliding of the EDC tendon of ring finger, and affect the functions of adjacent metacarpophalangeal joint. The scarred junctura tendinum was resected, while the sagittal band was preserved to prevent subluxation of the EDC tendon of long finger. One year after operation, the range of motion of fingers was full.

The course of the nerve root in the neural foramen and its relationship with foraminal entrapment or impingement in adult patients with lumbar isthmic spondylolisthesis and radicular pain.

The purpose of this study was to demonstrate the course of a nerve root in the neural foramen and its relationship with foraminal entrapment or impingement in 19 adult patients with isthmic spondylolisthesis and radicular pain. Myelo-computed tomography and magnetic resonance imaging showed that the course of the nerve root was normal (ie, medial and then inferior, along the pedicle) in 10 patients and was deviated posteriorly in 9 patients. The patients with a normal nerve root course (N-NRC) had either a bony callus projecting medially into the spinal canal (n = 6) or a low mean percentile of vertebral slip (n = 4; 13.9 +/- 1.3). Those nine patients with a posteriorly deviated nerve root course (PD-NRC) had no medially projecting bony callus in the spinal canal but had a higher mean percentile of vertebral slip (n = 9; 31.5 +/- 10.1; P = 0.005). In the neural foramen, nerve roots of the N-NRC patients were entrapped craniocaudally between the pedicle and superior part of the intervertebral disc. In contrast, nerve roots of the PD-NRC patients were impinged ventrodorsally between the posterosuperior part of the intervertebral disc and either bony callus projecting inferiorly toward the neural foramen or fibrocartilaginous mass arising around the isthmic defect. The foraminal craniocaudal entrapment and ventrodorsal impingement highly agreed with the side of radicular pain (kappa= 0.73, P < 0.001). Our results demonstrate that the medially projecting bony callus and the percentile of vertebral slip affect the course of the nerve root in the neural foramen, which in turn determines the foraminal craniocaudal entrapment or ventrodorsal impingement. These two mechanisms, based on the course of the nerve root, correlate well with the side of radicular pain.