Comparison of monoplanar versus biplanar medial opening-wedge high tibial osteotomy techniques for preventing lateral cortex fracture.

PURPOSE: The purpose of this study was to investigate the mechanical strength of both monoplanar and biplanar medial opening-wedge high tibial osteotomy (MOWHTO) procedures and assess the risk of lateral cortex disruption for both techniques. METHODS: Twelve synthetic tibia models with cortical shells were used as test models. Saw cuts for monoplanar MOWHTO and biplanar MOWHTO were generated on the test models in equal numbers (n = 6 for both groups). Wedge opening load and wedge gap distance were evaluated via compressive tests. RESULTS: The mean gap distance just before the lateral cortex fracture in the monoplanar group was 14.7 ± 2.9 mm, which was significantly narrower than that in the biplanar group of 19.1 ± 2.0 mm (p = 0.015). The mean load just before the occurrence of lateral cortex fracture of 32.4 ± 3.2 N in the monoplanar osteotomy group was significantly lower than that in the biplanar osteotomy group of 111.8 ± 9.3 N (p = 0.009). CONCLUSION: Performing a MOWHTO via the biplanar rather than the monoplanar technique allows larger-sized wedges to be opened with less risk of lateral cortical fracture. Thus, larger gaps can be opened and higher angle corrections can be achieved using the biplanar osteotomy procedure. From a clinical viewpoint, the biplanar osteotomy technique reduced the risk of lateral cortical hinge fracture during MOWHTO.

Percutaneous Release of the First Dorsal Extensor Compartment: A Cadaver Study.

BACKGROUND: To evaluate the efficiency of the percutaneous 18-G needle technique in releasing the fibro-osseous sheath over the first dorsal extensor compartment of the hand. METHODS: Using anatomic landmarks, percutaneous release was performed with an 18-G needle on 48 wrists of 24 cadavers. The specimens were then dissected and examined for the completeness of the first dorsal extensor compartment release and any tendon or neurovascular injuries. The tunnel length, number of abductor pollicis longus and extensor pollicis brevis tendons, presence of an intertendinous septum, and the effects of these parameters on percutaneous release were evaluated. RESULTS: Percutaneous release was performed on all of the wrists, and the evaluation of the adequacy of release revealed 25 complete releases, 21 partial releases, and 2 missed releases. There were 19 cases of tendon complications. No neurovascular injuries were noted. The mean tunnel length was 2.66 ± 30 cm, and the mean number of tendons was 2.75 ± 0.86. A septum was present in 33.3% of cases. Tunnel length and tendon number had no statistically significant effect on release, whereas the presence of a septum was significantly associated with inadequate tunnel release and the development of tendon complications. CONCLUSIONS: Percutaneous release of the first dorsal extensor compartment using an 18-G needle was associated with high rates of incomplete release and tendon damage in the presence of an intertendinous septum. Further study is required under ultrasound guidance to determine the usefulness of percutaneous release in the first dorsal extensor compartment. CLINICAL RELEVANCE: Release with a percutaneous needle tip in De Quervain's syndrome may provide the advantages of better cosmetic results with less scar formation and an early return to work.

Comparison of lateral versus triceps-splitting posterior approach in the surgical treatment of pediatric supracondylar humerus fractures.

BACKGROUND: Supracondylar humerus fracture is the most common fracture of the elbow in children. Closed reduction and percutaneous pinning is considered to be the optimal treatment strategy; however, in some instances, open reduction may be necessary. The aim of this retrospective study was to compare clinical and functional results of triceps-splitting posterior versus lateral approach in pediatric supracondylar humerus fracture surgery. METHODS: A total of 38 patients underwent surgery; Group 1 consisted of 30 patients on whom posterior approach was used, while lateral approach was used on the 8 patients in Group 2. Flynn criteria were used to evaluate cosmetic and clinical results. Fracture healing was assessed with anteroposterior and lateral x-rays. Patients and parents were asked to describe time needed for complete return of full elbow range of motion (ROM) and overall satisfaction. RESULTS: Mean fracture union time was 44.1 days and 46.3 days, and time required to regain complete or near complete elbow ROM was 57.5 days and 55.7 days after splint removal for Group 1 and Group 2, respectively. Twenty-one of 30 (70%) patients (and parents) in Group 1, and 6 of 8 (75%) patients (and parents) in Group 2 were totally satisfied with the results. Twenty-one of 30 (70%) patients in Group 1, and 6 of 8 (75%) patients in Group 2 had excellent cosmetic and functional results according to Flynn outcome criteria. CONCLUSION: In cases of pediatric supracondylar humerus fracture, early closed reduction and percutaneous pinning is preferred; however, when this method is not applicable, triceps-splitting posterior approach is a safe and comparable method to lateral approach with advantages of easier fracture reduction and shorter operating time.

A new diagnostic parameter for patellofemoral pain.

PURPOSE: Q-angle measurement procedure have not been well standardised. There is a lack of consensus about subject position and knee flexion angle while measuring the Q-angle. Morover Q-angle value which obtained in a single position is a static value and gives an information about the subject's current position. The aim of this study is to obtain a more significant parameter which includes different postures (supine, standing, sitting) and different knee flexion angles instead of a single Q-angle in a fixed position. At the same time this parameter must be functional and dynamic,not a static value like Q-angle. We named this parameter as ΔQ. METHODS: Our study was applied on case and control groups. All subjects in both groups were male. Case group was consisted of 14 subjects who had patellofemoral pain. Control group was consisted of 14 subjects who had normal knees and normal lower extremities with no reported knee problems. We obtained 3 different Q-angle values and 3 different ΔQ values for each subject in both groups. Pearson correlation analysis was used for investigation of continuous variables in normal distribution, Spearman correlation analysis was used in abnormal distribution. t test was used in the comparison of values. Logistic regression analysis(forward conditional mod) was used for detecting of determinants of pain. RESULTS: ΔQ1s of both groups were found as the only statistical significant predictive value for patellofemoral pain. CONCLUSION: There is not an agreement about a standardised q-angle measurement procedure in the literature. Moreover, present procedures provide information about a single and fixed position. In this situation Q-angles which obtained in these fixed positions are static values. We think that we can overcome these problems with this new value. ΔQ contains multiple q-angles and gives information about all. Also it is a dynamic value for being oriented to position change. Therefore, ΔQ is an useful indicator for evaluating patellofemoral pain.

Extension Block Pinning Versus Hook Plate Fixation for Treatment of Mallet Fractures.

PURPOSE: To compare the outcomes and associated costs of the treatment of mallet fractures with either extension block pinning or open reduction and hook plate fixation. METHODS: We treated 22 patients for a mallet fracture that involved at least 25% of the distal phalanx articular surface. Three joints demonstrated concomitant volar subluxation. Extension block pinning was used to treat 16 fractures (group 1) and 6 were treated with open reduction and hook plate fixation (group 2). All patients were evaluated at the second, fourth, and sixth weeks after surgery. Collected data included range of motion, extensor lag, and pain status. Patients were asked to grade preoperative and postoperative pain levels on a visual analog scale. Functional outcomes were determined by Crawford criteria. We retrospectively performed a cost analysis using our institutional records. RESULTS: Mean follow-up was 12.7 months. Visual analog scale pain scores improved by a similar amount for both groups. Preoperative pain scores were 7.0 for group 1 and 7.5 for group 2. Postoperative levels were 2.0 and 2.0, respectively. Mean extensor lag was identical for both groups, 5°. Mean flexion was 70° for group 1 and 80° for group 2. Based on the Crawford criteria, group 1 had 5 patients rated as excellent, 6 as good, 3 as fair, and 2 as poor. Group 2 outcomes were 2 excellent, 2 good, and 2 fair. Five complications occurred in group 1, and 1 in group 2. Differences noted between groups were not statistically significant. Extension block pinning was more cost-effective than hook plate fixation. CONCLUSIONS: We find extension block pinning to be an equally effective but more cost-efficient treatment than open reduction and hook plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The biomechanical and histological effects of platelet-rich plasma on fracture healing.

PURPOSE: Platelet-rich plasma (PRP) includes growth factors and proteins that accelerate and stimulate bone regeneration and tissue recovery. The aim of this study was to evaluate the effects of PRP on fracture healing in terms of biomechanics and histology. METHODS: Seventy female rats were included in this experimental study. They were divided into three groups: Group I (no PRP, n = 30), Group II (PRP added, n = 30) and Group III (control, n = 10). The left femurs of the rats in Groups I and II were osteotomized and fixed by K-wires. Although no additional intervention was performed on Group I rats, PRP was applied to the fracture sites of Group II rats. The remaining ten rats were used as the control group of the biomechanical test (Group III). In the fourth week, nine femurs from Group I and ten femurs from Group II, and in the ninth week, nine femurs from each group were removed, and bone recovery was assessed histologically according to Modified Lane-Sandhu histological scoring criteria. Three-point bending test was applied to femurs for biomechanical evaluation in the ninth week. RESULTS: Histological healing was found to be significantly higher in Group II than in Group I (p < 0.05). Furthermore, biomechanical test results showed that healing quantity and bone strength were significantly better in Group II than in Group I (p < 0.05). CONCLUSION: PRP is a widely studied material in the physiology of fracture healing. The results of this study demonstrated the ameliorative biomechanical effects of PRP on fracture healing, in addition to accelerating the histological union of fractures. In the light of these results, PRP could be a viable alternative to accelerate the healing of fractures, late unions or non-unions. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Free medial meniscal fragment which mimics the dislocated bucket-handle tear on MRI.

The bucket-handle meniscal tear is a specific type of meniscal injuries which has specific signs on MRI. An attached fragment displaced away from the meniscus with any type of tear causes bucket-handle tear of the meniscus. Magnetic resonance imaging (MRI) is the most commonly used diagnostic tool for meniscal injuries. We present a case of free medial meniscal fragment which mimics the dislocated bucket-handle tear on MRI. The presence of "fragment within the intercondylar notch sign" and "the absence of the bow tie sign" may be an indication of a free meniscal fragment. This should be considered during diagnosis.

Adherence to therapy after flexor tendon surgery at a level 1 trauma center.

BACKGROUND: Nonadherence to postoperative therapy protocols can adversely affect the outcome after flexor tendon surgery. In this study, we hypothesize that patients with partial or no insurance coverage for their aftercare are less likely to attend postoperative therapy sessions and have a higher incidence of a poorer outcome than those who have full insurance coverage. METHODS: We analyzed 159 patients with flexor tendon injuries at a level 1 trauma center. Demographic variables along with the clinical outcome data were collected and cross-tabulated. Associations among descriptive and clinical variables were assessed using Fisher's Exact tests and chi-square analyses. Comparisons for continuous variables were performed using the Kruskal-Wallis Test. RESULTS: Eighteen patients (11.3 %) had an injury in zone 1, followed by 68 (42.8 %) in zone 2, 15 (9.4 %) in zone 3, 9 (5.7 %) in zone 4, 38 (23.9 %) in zone 5, and 11 (6.9 %) in zone 6. Patients completed 8.2 therapy sessions on average. Patients had state assistance program (40.3 %), private insurance (35.2 %), Medicaid/Medicare (11.3 %), worker's compensation (8.8 %) insurance, or paid themselves (13.2 %). Fifty-three (33.3 %) patients had excellent outcomes, 46 (29 %) had good, 40 (25 %) had fair, and 20 (12.5 %) had a poor outcome. Patients responsible to pay for their aftercare were significantly less likely to be adherent to therapy and had poorer outcomes than those with full coverage. CONCLUSION: Patients responsible for the pay of their postoperative rehabilitation are less likely to participate in therapy and may be at a higher risk of having a poor outcome.

Medical photography: principles for orthopedics.

BACKGROUND: Medical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics. PURPOSE: This study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area. METHODS: Clinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique. RESULTS: In this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions. CONCLUSIONS: Standards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.

Isolated fracture of the coracoid process.

Coracoid fractures are rarely seen fractures. In the shoulder girdle, coracoid process fractures generally accompany dislocation of the acromioclavicular joint or glenohumeral joint, scapula corpus, clavicula, humerus fracture, or rotator cuff tear. Coracoid fractures can be missed and the treatment for coracoid process fractures is still controversial. In this paper, a 34-year-old male manual labourer presented to the emergency department with complaints of pain and restricted movement in the left shoulder following a traffic accident. On direct radiographs and computerised tomography images a fragmented fracture was observed on the base of the coracoid process. In addition to the coracoid fracture, a mandibular fracture was determined. The patient was admitted for surgery on both fractures. After open reduction, fixation was made with a 3.5 mm cannulated screw and washer. At the postoperative 6th week, bone union was determined. The patient returned to his previous occupation pain-free and with a full range of joint movement. In conclusion, in the current case of isolated fragmented coracoid process fracture showing minimal displacement in a patient engaged in heavy manual work, surgery was preferred as it was thought that nonunion might be encountered particularly because of the effect of forces around the coracoid.

Medial opening-wedge high tibial osteotomy fixation with short plate without any graft, synthetic material or spacer.

PURPOSE: Medial opening-wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure for patients who have medial compartmental osteoarthritis of the knee with varus deformity of the limb. The abnormal load on the medial compartment of the knee is directed to the lateral compartment with this procedure. A gap occurs on the proximal tibia while providing adequate correction. Filling this gap with bone grafts or synthetic materials has gained wide acceptance for preventing bone union problems or osteotomy site collapse. The aim of this study is to report our results of MOWHTOs performed without any bone graft or any other synthetic materials. METHODS: We evaluated 41 MOWHTOs that have been performed between 2009 and 2012 with no use of any grafts or synthetic materials and spacer. Age of the patients ranged from 43 to 67. Thirty-five of the patients were females and three of them were males. The follow-up time was 6 months. RESULTS: Seven knees had opening at the osteotomy site <10 mm, 26 knees had 10-12.5 mm, and eight knees had >12.5 mm (range 7.5-14 mm, mean 11.07 mm). All osteotomies united without loss of correction. The mean bone union time was 12.8 weeks. We did not have any major complication regarding the technique. CONCLUSION: The results of our study have shown that we can achieve satisfactory and good results by performing MOWHTO procedure without using any bone grafts or synthetic materials and spacer.

Schwannoma of the median nerve at the wrist and palmar regions of the hand: a rare case report.

Schwannomas are also known as neurolemmas that are usually originated from Schwann cells located in the peripheric nerve sheaths. They are the most common tumours of the hand (0.8-2%). They usually present solitary swelling along the course of the nerve however multiple lesions may be present in cases of NF type 1, familial neurofibromatosis, and sporadic schwannomatosis. Schwannomas are generally represented as an asymptomatic mass; however pain, numbness and fatigue may take place with the increasing size of the tumour. EMG (electromyelography), MRI (magnetic resonance imagination), and USG (ultrasound) are helpful in the diagnosis. Surgical removal is usually curative. In this paper, we present a 24-year-old male referred to our clinic for a lump located at the volar side of the left wrist and a lump located in his left palm and numbness at his 3rd and 4th fingers. Total excision was performed for both lesions. Histopathological examination of the masses revealed typical features of schwannoma. At the 6th-month followup the patient was symptom-free except for slight paresthesia of the 3rd and the 4th fingers. For our knowledge, this is the second case in the literature presenting wrist and palm involvement of the median nerve schwannoma.

Transverse carpal ligament and forearm fascia release for the treatment of carpal tunnel syndrome change the entrance angle of flexor tendons to the A1 pulley: the relationship between carpal tunnel surgery and trigger finger occurrence.

PURPOSE: The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers. METHODS: The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other. RESULTS: We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger. DISCUSSION: Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area. CLINICAL RELEVANCE: This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients.

BACKGROUND: Establishing the minimal clinically important difference for patient-reported outcomes questionnaires is essential in outcomes research to evaluate the patient's perspective of treatment effectiveness. The authors aim to determine the minimal clinically important difference after carpal tunnel release in diabetic and nondiabetic patients using the Boston Carpal Tunnel Questionnaire. METHODS: The authors prospectively evaluated 114 patients (87 nondiabetic and 27 diabetic patients) undergoing carpal tunnel release. In addition to standard history and physical examination, the authors obtained preoperative electrodiagnostic studies to confirm carpal tunnel syndrome. The Boston Carpal Tunnel Questionnaire was administered before and after surgery at 3 and 6 months. Patients were asked about their level of satisfaction at the final follow-up visit. The authors applied the receiver operating characteristic curve approach to determine the minimal clinically important difference of symptom and function severity scales of the questionnaire. The authors used patient satisfaction as the reference standard to compare against the standardized change in scores after surgery for the two groups. RESULTS: For both diabetic and nondiabetic patients, symptom and function severity scales showed large effect sizes of greater than 0.8 at 3 and 6 months after surgery. At 6 months after surgery, to be satisfied, diabetic patients required a minimal clinically important difference of 1.55 and 2.05 for symptom and function scales, respectively, whereas nondiabetic patients required 1.45 and 1.6, respectively. CONCLUSIONS: Diabetic patients needed a greater improvement in Boston Carpal Tunnel Questionnaire score to be satisfied on functional and symptom severity scales than nondiabetic patients. Overall, diabetic patients had less improvement in Boston Carpal Tunnel Questionnaire final scores compared with nondiabetics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Deep vein thrombosis prophylaxis in trauma patients.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients.

Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixed-angle plating.

BACKGROUND: Extensor tendon irritation and attritional tendon ruptures are well-recognized complications, secondary to dorsal screw penetration following volar plating of the distal radius. Lateral and oblique views of the wrist have limited ability to detect such penetration, particularly at the ulnar side of the Lister's tubercle. In this report, we conducted an intraoperative fluoroscopic study to determine dorsal screw penetration in various positions of the wrist/forearm and compared the standard radiographic views (lateral, supination, and pronation views) with dorsal tangential view of the wrist. MATERIALS AND METHOD: Standard lateral, oblique (in pronation and supination), and dorsal tangential views were obtained in 27 consecutive patients undergoing fixation a distal radius fractures using a volar plate. The number of penetrating screws in each dorsal compartment (second, third, fourth) was recorded in each view. Dorsal tangential view was obtained using a mini C-arm intraoperatively and sending the beam parallel to the dorsal aspect of the wrist in transverse plane. RESULTS: Of the 125 distal screws, 8 screws were seen to be penetrating the dorsal cortex in lateral and oblique views, whereas 11 screws were detected in dorsal tangential view. CONCLUSION: The screw penetration to the third dorsal compartment was missed in standard views, but visualized in dorsal tangential view. We recommend the use of dorsal tangential view in addition to standard lateral and oblique views during volar plating of the distal radius.

Avascular necrosis of the capitate.

Although a large portion of the capitate is supplied by a single nutrient vessel, avascular necrosis of the capitatum is a rare condition. Its etiology is not clear, but a number of factors are linked to its pathogenesis including: repetitive trauma, dorsal instability of the carpus, Gaucher disease, systemic lupus erythematosus, gout, and steroid use. A 24-year-old woman presented with right wrist pain of 12 months duration. She reported no major trauma and reported that her pain had begun during the third month of her pregnancy. She had a history of hyperemesis gravidarum treated with 2 to 4 mg/daily of prednisone during her pregnancy for 6 weeks. She had 70° extension and 45° flexion of her wrist. Radiographs showed a hypodense area at the capitate head and midcarpal joint arthritis. Magnetic resonance imaging demonstrated avascular necrosis of the capitate and midcarpal collapse at the lunocapitate joint. Lunocapitate fusion with a partial scaphoidectomy was performed. At final follow-up 28 months postoperatively, she had 60° of volar flexion, and 50° of dorsiflexion. She was pain free in the majority of her activities of daily living. A small dose of steroid use during pregnancy, even in a short period of time, is a potential risk for avascular necrosis of the capitate and patients with a gradual onset of wrist pain during pregnancy may need to be investigated further if symptoms are not resolved with basic nonoperative measures within a reasonable time frame.