Cross-Sectional Area of the Median Nerve as a Prognostic Indicator in Carpal Tunnel Syndrome Treated With Local Steroid Injection.

PURPOSE: Local steroid injection is an effective treatment modality for carpal tunnel syndrome. This study aimed to investigate the success rate of ultrasonography-guided local steroid injection and determine the prognostic value of the cross-sectional area (CSA) of the median nerve for steroid injection. METHODS: We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm2 (large-CSA group; n = 16) or ≤15 mm2 (small-CSA group; n = 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period. RESULTS: The treatment success rate was 45% (n = 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively. CONCLUSIONS: Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies.

STUDY DESIGN: This was a systematic review with a meta-analysis. INTRODUCTION: Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery. PURPOSE: We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF. METHODS: Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications. RESULTS: This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss. CONCLUSION: Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.

Carpal tunnel release can be a risk factor for trigger finger: National Health Insurance data analysis.

PURPOSE: We aimed to compare trigger finger (TF) development between patients with carpal tunnel syndrome (CTS) treated with carpal tunnel release (CTR) and those treated conservatively, using the National Health Insurance Services data of Korea. We also aimed to investigate risk factors for post-CTR TF development. METHODS: We selected CTS patients with or without CTR (3543 patients in each group) between 2002 and 2015. Sex, age, follow-up duration after CTS diagnosis, and comorbidities associated with TF-development were matched using propensity score. We compared the rates of TF diagnosis and subsequent TF operations between groups. Thereafter, we selected patients with CTS undergoing CTR, for whom minimum follow-up exceeded five years. We compared sex, age, height, weight, and comorbidities associated with TF risk factors between the TF-occurrence and non-TF-occurrence groups. RESULTS: On comparing CTR-treated patients with those treated conservatively for CTS, CTR-treated patients presented with significantly higher rates of TF diagnosis (12.2%) and TF operations (4.7%) than patients without CTR (6.2% and 1.2%, respectively). Among 433 TF-diagnosed patients and 166 TF-operated patients after CTR, most were identified < 5 years after CTR, with 379 diagnosed (87.5%) and 147 operated (88.5%) patients. A total of 240 patients presented with newly developed TF over a five year period. Patients with subsequent TF exhibited a higher female sex rate and shorter height. None of the variables was significant risk factors for TF development in logistic regression analysis. CONCLUSION: We confirmed high incidences of post-CTR TF diagnosis and operations. TF develops most frequently in the first postoperative year.

The inter-and intra-observer reliability of volar angulation measurements in a fifth metacarpal neck fracture.

INTRODUCTION: The fifth metacarpal neck fracture is the most common metacarpal fracture. The palmar angulation from the fracture displacement is critical for determining treatment, yet there is no consensus regarding the angulation measurement method or the surgical cut-off value. This study aimed to identify a reliable measurement method for assessing palmar angulation. We evaluated inter-observer and intra-observer validation of measuring palmar angulation in oblique plain X-ray and computed tomography (CT) sagittal cuts. MATERIALS AND METHODS: We identified surgically treated patients for acute isolated fifth metacarpal neck fracture between January 1, 2008, and December 31, 2020, and obtained preoperative, opposite hand, and final follow-up oblique X-rays and sagittal computed tomography (CT) radiograms. The oblique radiograph was taken with a 45° posteroanterior pronation. The metacarpal neck palmar angulation was measured in the radiograms using the metacarpal neck-shaft center (MNSC) angle and the shaft articular surface (SAS) angle methods by three orthopedic surgeons in two sessions. For the CT radiograms, each measurer selected the sagittal slot at their discretion to measure the angle. The final palmar angulation was the average of six measurements (two sessions, three measurers per session). RESULTS: The study included 51 patients; the average age was 32.5 (range 18-73) years, with 46 men and 5 women. The MNSC angle inter-observer reliability was better than the SAS angle. The MNSC angle inter-observer reliability was better than that of SAS angle. Intraclass coefficients (ICCs) for the MNSC angle demonstrated an excellent inter-observer agreement among the three measurers in the first (0.93) and second (0.88) session compared to ICCs for the SAS angle in the first (0.81) and second (0.87) session. The MNSC angle intra-observer reliability was also better than the SAS angle, with higher ICCs. Preoperative CT radiograms were available for 42 patients. Using CT scans for measurements, in the two sessions, the MNSC angle inter-observer reliability was higher than that of the SAS angle [MNSC: 0.83; SAS: 0.35], second [MSNC: 0.85; SAS: 0.81]. The intra-observer reliability was also better in the MNSC angle. When comparing average value among obtained radiograms, the physiologic angulation of the opposite hand oblique X-ray had the smallest average value, followed by preoperative CT and preoperative oblique radiography. Overall, the SAS angle measurement had a slightly larger angle than the MNSC method in the fractured and non-fractured hand measurements. Finally, a serial comparison of the oblique X-rays (pre-and postoperative, final follow-up, and the opposite hand with closed reduction and internal fixation) indicated that the angulation significantly decreased, and the post-operative values did not differ from the final follow-up X-ray for either method. CONCLUSIONS: The palmar angulation measurement in 45° pronated oblique X-ray using the MNSC angle method had good-to-excellent reliability, with superior results to sagittal CT radiograms. Although the angle is likely overestimated, the MNSC method is reliable for judging the fracture degree and reduction adequacy after surgery compared to the non-fractured hand physiologic angulation.

The patient-rated tennis elbow evaluation questionnaire was successfully translated to Korean.

INTRODUCTION: Lateral epicondylitis is a common tendinopathy of the elbow. An adequately validated questionnaire is essential to compare the various treatment options, because there is still controversy regarding the best treatment for lateral epicondylitis. PURPOSE OF THE STUDY: The patient-rated tennis elbow evaluation (PRTEE) was introduced to measure the degree of symptoms and the limitation of function in these patients. This English questionnaire was previously translated into several languages and validated; however, it has not been translated into Korean. The aim of this study was to translate and cross-culturally adapt the PRTEE questionnaire into Korean, and to assess the reliability and validity of the translated questionnaire. METHODS: Eighty-three patients were asked to complete the Korean version of the PRTEE and other questionnaires related to the upper extremity or to the general health condition (the Disabilities of Arm, Shoulder, and Hand questionnaire, Short Form-12, and EQ-5D). The PRTEE responses were recorded twice to evaluate test-retest reliability. Internal consistency, test-retest reliability, concurrent validity, and ceiling and flooring effects were evaluated. RESULTS: The Korean version of the PRTEE showed high internal consistency (Cronbach's alpha = 0.968). The overall test-retest reliability was good (intra-class correlation score = 0.94). High correlation efficiencies between the PRTEE and other questionnaires were observed, supporting high concurrent validity (Spearman's correlation = 0.83 for the Disabilities of Arm, Shoulder, and Hand questionnaire; -0.73 for Short Form-12; and -0.57 for EQ-5D). Ceiling and floor effects were not observed on this test. CONCLUSION: We successfully translated the PRTEE into the Korean language; this version of the PRTEE showed good reliability and construct validity in Korean-speaking patients with lateral epicondylitis.

Comparison of Clinical and Radiographic Outcomes According to the Presence or Absence of a Posterior Draw Force during Graft Fixation in Anterior Cruciate Ligament Reconstruction.

Background and Objectives: A reduction forced toward the posterior side during graft fixation may help to lessen anterior tibial translation after ACL reconstruction. The purpose was to compare the clinical and radiological outcomes of graft fixation when a posterior draw was used and when it was not used during anterior cruciate ligament (ACL) reconstruction surgery. Materials and Methods: Of 110 patients who had undergone primary arthroscopic ACL reconstruction between January 2017 and August 2020, in all, 76 patients had been operated on without a posterior draw (non-draw group), and 34 patients had received surgery with a posterior draw (draw group). The results of the Lachman test and the pivot-shift test, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) indexes, the Lysholm scores, the International Knee Documentation Committee (IKDC) subjective scores, and side-to-side difference (STSD) on stress radiography were compared between the two groups. Results: The postoperative WOMAC indexes, Lysholm scores, and IKDC subjective scores were similar across both groups. Postoperative STSD (2.4 ± 2.2 for the non-draw group vs. 2.0 ± 2.2 for the draw group; p = 0.319) and change in STSD (3.5 ± 3.5 for preoperative STSD vs. 4.3 ± 4.4 for postoperative STSD; p = 0.295) were not superior in the draw group. Conclusions: The take-home message is that graft fixation with a posterior draw during ACL reconstruction did not result in significantly better postoperative stability. The postoperative clinical outcomes were similar between both groups.

Low serum vitamin B12 levels are associated with degenerative rotator cuff tear.

BACKGROUND: Vitamin B12 (Vit B12) deficiency results in elevated homocysteine levels and interference with collagen cross-linking, which may affect tendon integrity. The purpose of this study was to investigate whether serum Vit B12 levels were correlated with degenerative rotator cuff (RC) tear. METHODS: Eighty-seven consecutive patients with or without degenerative RC tear were enrolled as study participants. Possible risk factors (age, sex, medical history, bone mineral density, and serum chemistries including glucose, magnesium, calcium, phosphorus, zinc, homocysteine, Vitamin D, Vit B12, homocysteine, and folate) were assessed. Significant variables were selected based on the results of univariate analyses, and a logistic regression model (backward elimination) was constructed to predict the presence of degenerative RC tear. RESULTS: In the univariate analysis, the group of patients with degenerative RC tear had a mean concentration of 528.4 pg/mL Vit B12, which was significantly lower than the healthy control group (627.1 pg/mL). Logistic regression analysis using Vit B12 as an independent variable revealed that Vit B12 concentrations were significantly correlated with degenerative RC tear (p = 0.044). However, Vit B12 levels were not associated with tear size. CONCLUSION: Low serum levels of Vit B12 were independently related to degenerative RC tear. Further investigations are warranted to determine if Vit B12 supplementation can decrease the risk of this condition.

Clinical comparison of the over-the-top and flexor carpi ulnaris split approaches for the treatment of anteromedial facet fracture of the coronoid process.

BACKGROUND: The flexor carpi ulnaris (FCU)-split approach and the over-the-top approach have been used frequently for the fixation of anteromedial facet (AMF) fractures of the coronoid process. Clinical studies have not compared functional recovery and complication rates associated with these approaches. This study aimed to compare the clinical effectiveness of the over-the-top and FCU-split approaches for the treatment of AMF fractures of the coronoid process. METHODS: Thirty-two patients who underwent surgery for AMF fractures between January 2013 and August 2019 were divided into the FCU-split and over-the-top groups. The FCU-split approach was used from January 2013 to March 2016, and the over-the-top approach was used from April 2016 to August 2019. Bony union, radiographic signs of osteoarthritis (Broberg and Morrey classification), and development of heterotopic ossification were evaluated. Postoperative pain score (visual analog scale at 2 days after the operation), surgical time (minutes), range of motion of the elbow, elbow function (Mayo Elbow Performance Score [MEPS]), and the presence of postoperative ulnar neuropathy were also compared between the 2 groups. RESULTS: The FCU-split and over-the-top approaches were performed in 15 and 17 patients, respectively. The mean age was 46 ± 13 years (range, 22-67 years), and the mean follow-up duration was 19± 6.7 months (range, 13-38 months). All coronoid fractures had a solid osseous union during the follow-up, and no subluxation or dislocation was observed in the 2 groups. The occurrence of heterotopic ossification and the grade of post-traumatic arthritis did not differ significantly between the groups (all P > .05). There were also no significant differences between the groups in terms of postoperative pain score, range of motion, and MEPS (all P > .05). However, the surgical time was shorter for the over-the-top approach than that for the FCU-split approach (79± 23 vs. 101 ± 14, P = .008), and the surgical time was significantly associated with the fracture classification and surgical approach (P = .001 and .003, respectively). In addition, postoperative ulnar neuropathy occurred less with the over-the-top approach than with the FCU-spilt approach (5.9% vs. 46%, P = .013). CONCLUSION: Both the FCU-split and over-the-top approaches were appropriate for performing the buttress plate fixation for AMF fractures of the coronoid process and for restoring the elbow stability. The fixation of AMF fractures through the over-the-top approach was technically easier and had less incidence of postoperative ulnar neuropathy.

Radiographic measurements on hindfoot alignment view in 1128 asymptomatic subjects.

BACKGROUND: The primary aim of this study was to determine the mean values for three of the most common parameters measured to assess hindfoot alignment in asymptomatic subjects: hindfoot alignment angle (HAA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA). The secondary aim was to evaluate the mean value of each parameter according to age and sex. METHODS: We assessed 1128 asymptomatic subjects from January 2014 to June 2019. HAA, HAR and HMA were measured to evaluate the degree of hindfoot varus or valgus deviation on the hindfoot alignment view, described by Saltzman and el-Khoury. All subjects were divided into subgroups according to sex and age (<45 years versus ≥45 years). RESULTS: The overall mean HAA, HAR, and HMA were -4.07 ± 3.48°, 0.21 ± 0.15, and -6.12 ± 5.22 mm, respectively. Female subjects ≥45 years old had the largest valgus deviation (HAA, -7.08 ± 6.34°; HAR 0.09 ± 0.25; HMA, -10.58 ± 11.46 mm). CONCLUSIONS: HAA, HAR, and HMA evaluation revealed that asymptomatic subjects had a hindfoot alignment with valgus deviation. Furthermore, the degree of valgus deviation was the largest in female subjects aged ≥45 years. We hope that the results of our study will be helpful to inform other researchers about the usefulness of these parameters as references.

Measurement of Carpal Alignment Indices Using 3-Dimensional Computed Tomography.

PURPOSE: This study aimed to establish normal values for wrist carpal alignment measured by 3-dimensional computed tomography (CT) and to show the inter- and intraobserver reliability of this measurement compared with simple radiography. METHODS: The study utilized 3-dimensional CT and simple radiography of wrist joints in 30 asymptomatic volunteers. The wrist position was standardized using a custom-designed positioning device. Three independent observers measured carpal alignment parameters including distal radius articular angle, radiolunate angle, radioscaphoid angle, radiocapitate angle, radius-third metacarpal angle, scapholunate angle, lunocapitate angle, and lunate-third metacarpal angle. RESULTS: Based on 3-dimensional CT measurement, the mean values of these parameters were: 12.9° ± 1.8° for the distal radius articular angle; 1.2° ± 3.8° for the radiolunate angle; 54.2° ± 5.6° for the radioscaphoid angle; 1.9° ± 2.2° for the radiocapitate angle; -1.0° ± 2.5° for the radius-third metacarpal angle; 52.9° ± 6.9° for the scapholunate angle; 0.7° ± 4.1° for the lunocapitate angle; -2.3° ± 4.6° for the lunate-third metacarpal angle. All parameters showed high inter- and intraobserver reliability in the 2 modalities. CONCLUSIONS: The normal values and ranges for carpal alignment angles were evaluated by using 3-dimensional CT. We could obtain high reliability in 3-dimensional CT as well as plain radiograph for the measurement of carpal alignment. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinico-radiologic correlation.

BACKGROUND: Thickened synovial plicae in the radiocapitellar joint have been reported as a cause of lateral elbow pain. However, few reports regarding diagnosis based on detailed physical examination and magnetic resonance imaging (MRI) findings are available. The aims of this study were to characterize the clinical manifestations of this syndrome and to investigate the clinical outcomes of arthroscopic surgery. METHODS: We analyzed 20 patients who received a diagnosis of plica syndrome and underwent arthroscopic débridement between 2006 and 2011. The diagnosis was based on physical examination and MRI findings. Elbow symptoms were assessed using a visual analog scale for pain; the Mayo Elbow Performance Index; and the Disabilities of the Arm, Shoulder and Hand score at a minimum of 2 years after surgery. The thickness of plicae on MRI was compared with the normal data in the literature. RESULTS: Plicae were located on the anterior side in 1 patient, on the posterior side in 15, and on both sides in 4. Radiocapitellar joint tenderness and pain with terminal extension were observed in 65% of patients. MRI showed enlarged plicae consistent with intraoperative findings. The mean plica thickness on MRI was 3.7 ± 1.0 mm, which was significantly thicker than the normal value. The mean lengths (mediolateral length, 9.4 ± 1.6 mm; anteroposterior length, 8.2 ± 1.7 mm) were also greater than the normal values. The visual analog scale score for pain decreased from 6.3 to 1.0 after surgery. The Mayo Elbow Performance Index and Disabilities of the Arm, Shoulder and Hand scores improved from 66 to 89 and from 26 to 14, respectively. CONCLUSIONS: Specific findings of the physical examination and MRI provide clues for the diagnosis of plica syndrome. Painful symptoms were successfully relieved after arthroscopic débridement.

Pisiform excision for refractory flexor carpi ulnaris tendinopathy of the wrist.

The aim is to report the long-term clinical results after pisiform excision in patients with refractory flexor carpi ulnaris (FCU) tendinopathy. We performed pisiform excision in 14 patients with recalcitrant FCU tendinopathy, who had failed conservative treatment. Nine patients were followed-up for more than 2 years. Pre-operative pain visual analog scale (VAS) was extracted from the electronic medical records. Post-operative symptoms and function were assessed with pain VAS, quick disabilities of arm, shoulder and hand (DASH) score, patient rated wrist evaluation (PRWE) score, and satisfaction VAS for surgery at the final follow-up. After the mean follow-up period of 6 years, all patients showed improvement in pain VAS (from 5.9 to 1.2). The post-operative scores of quick DASH and PRWE were 3.5 and 13.1, respectively. Satisfaction VAS score was 8.8 and all patients returned to their work. Excision of the pisiform bone improved symptoms in patients with refractory FCU tendinopathy.

Reverse Sural Artery Island Flap With Skin Extension Along the Pedicle.

The distally based sural flap is an efficient flap for reconstruction of soft tissues defects of lower limb. The unstable vascular pedicle, however, is prone to compression by the subcutaneous tunnel, especially when a long pedicle covers the distal area of the foot. The aim of the present study was to introduce a modified surgical technique that leaves the skin extension over the pedicle and to report the clinical results of this modification. A total of 25 consecutive patients with a mean age of 51.7 ± 14.7 years underwent surgery. We modified the conventional sural flap technique by leaving a skin extension over the entire length of the pedicle, creating a fasciocutaneous vascular pedicle. The postoperative flap survival rates, complications, and the characteristics of the flaps such as flap size, pedicle length, and the most distal area that could be covered with this modification, were reviewed. At the last clinical follow-up examination, all the flaps survived, although partial necrosis was observed in 2 (8%) cases. Four cases of venous congestion developed but healed without additional complications. The mean flap size was 5.9 ± 1.8 × 9.2 ± 2.7 cm. With this modification, the sural flap could cover the defect located in extreme distal areas, such as the medial forefoot and dorsum of the first metatarsophalangeal joint, with a longer pedicle (≤27 cm) in 7 patients (28%). A skin extension along the pedicle achieved the favorable survival rate of the sural flap and successfully extended the surgical indications to more distal areas.

Comparison of Flexor Tendon Suture Techniques Including 1 Using 10 Strands.

PURPOSE: To compare mechanical properties of a multistrand suture technique for flexor tendon repair with those of conventional suture methods through biomechanical and clinical studies. METHODS: We describe a multistrand suture technique that is readily expandable from 6 to 10 strands of core suture. For biomechanical evaluation, 60 porcine flexor tendons were repaired using 1 of the following 6 suture techniques: Kessler (2-strand), locking cruciate (4-strand), Lim/Tsai's 6-strand, and our modified techniques (6-, 8-, or 10-strand). Structural properties of each tenorrhaphy were determined through tensile testing (ultimate failure load and force at 2-mm gap formation). Clinically we repaired 25 flexor tendons using the described 10-strand technique in zones I and II. Final follow-up results were evaluated according to the criteria of Strickland and Glogovac. RESULTS: In the biomechanical study, tensile properties were strongly affected by repair technique; tendons in the 10-strand group had approximately 106%, 66%, and 39% increased ultimate load to failure (average, 87 N) compared with those in the 4-, 6-, and 8-strand groups, respectively. Tendons in the 10-strand group withstood higher 2-mm gap formation forces (average, 41 N) than those with other suture methods (4-strand, 26 N; 6-strand, 27 N; and 8-strand, 33 N). Clinically, we obtained 21 excellent, 2 good, and 2 fair outcomes after a mean of 16 months (range, 6-53 mo) of follow-up. No patients experienced poor results or rupture. CONCLUSIONS: The 10-strand suture repair technique not only increased ultimate strength and force at the 2-mm gap formation compared with conventional suture methods, it also showed good clinical outcomes. This multistrand suture technique can greatly increase the gap resistance of surgical repair, facilitating early mobilization of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Long-term results of arthroscopic wrist synovectomy in rheumatoid arthritis.

PURPOSE: To investigate the effects of arthroscopic wrist synovectomy on the clinical course of rheumatoid arthritis in a large series with long-term follow-up. METHODS: We performed arthroscopic synovectomy on 56 wrists in 49 patients with rheumatoid arthritis. At a mean follow-up of 7.9 years (range, 5-12 y), we evaluated pain and patient satisfaction using a visual analog scale and assessed overall function using the Mayo wrist score. Radiographic stage was graded according to Larsen stage. We determined clinical outcomes on the recurrence of wrist synovitis, which we evaluated by symptoms of pain and swelling and physical examination. Preoperative variables were statistically analyzed to find factors that could influence the results. RESULTS: The mean visual analog scale score for wrist pain decreased from 6.3 to 1.7, and the mean Mayo wrist score (evaluated in 39 wrists) improved from 48 (range, 5-70) to 76 (range, 55-100). The mean visual analog scale score for patient satisfaction was 7.9. At final follow-up, synovitis was controlled in 42 wrists (75%) and recurred in the others. The mean Larsen stage progressed from 2.2 to 3.3. Analysis of preoperative variables revealed no factors that significantly affected clinical outcomes in terms of sex, age, duration of wrist symptom, preoperative serologic inflammatory markers, or Larsen stage. CONCLUSIONS: Arthroscopic synovectomy of the wrist can provide pain relief and functional improvement with control of synovitis in 75% of rheumatoid wrists that have not responded to medication. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic débridement for primary osteoarthritis of the elbow: analysis of preoperative factors affecting outcome.

BACKGROUND: The purposes of this study were to evaluate the clinical results of arthroscopic débridement and to identify preoperative factors that influence the outcome. METHODS: Forty-three elbows with primary osteoarthritis in 43 patients treated with arthroscopic débridement were retrospectively evaluated. At a mean follow-up of 38 months (range, 18-77 months), the visual analog scale (VAS) score for pain, the arc of elbow motion, and the Mayo Elbow Performance Index (MEPI) score were assessed. The relationships between postoperative MEPI score and postoperative motion arc and preoperative factors including age, sex, involvement of the dominant arm, duration of symptoms, demand of elbow activity, VAS score, previous history of failed surgery, and arc of elbow motion were statistically evaluated. RESULTS: The mean VAS score for pain, the mean arc of flexion-extension, and the mean MEPI score significantly improved after the operation (all P values < .001). Multivariate regression analysis revealed that among preoperative variables, arc of motion was found to be the only independent prognostic factor that affected both postoperative elbow function (P = .024) and final arc of motion (P < .001). The cutoff value of preoperative arc of motion for the final arc of motion was determined to be 80° (P < .001). Involvement of the dominant arm was found to be another independent factor that affected postoperative MEPI scores (P = .016). CONCLUSIONS: Arthroscopic débridement for elbow osteoarthritis provides satisfactory pain relief, improvement of elbow motion, and good functional outcome. Based on the fact that preoperative motion arc is the independent factor that can predict clinical outcome, arthroscopic treatment is highly recommended for patients who have a motion arc of 80° or more as it yields reliable results.

Clinical and radiologic results of arthroscopic biceps tenodesis with suture anchor in the setting of rotator cuff tear.

BACKGROUND: The purpose of this study was to report clinical and radiologic results of arthroscopic biceps tenodesis with 1 suture anchor in rotator cuff tear patients. METHODS: During a 2-year period, 84 consecutive patients (45 men; 39 women) who underwent arthroscopic tenodesis were evaluated retrospectively. Mean age was 58 years. The primary indication for surgery was rotator cuff tear in 96.4%. Tenodesis was performed with 1 suture anchor placed in the bicipital groove with 2 knots, 1 lasso-type and 1 that pierced the tendon. At final follow-up at a mean of 33.2 months, visual analog scale pain (pain-VAS) score, shoulder scores (American Shoulder and Elbow Surgeons [ASES] and Constant score), Popeye deformity (PD), anterior arm pain, and elbow flexion power were evaluated. Postoperative magnetic resonance images were evaluated in 60 patients to determine the integrity of the tenodesis and the location of the suture anchor. RESULTS: The average pain-VAS decreased from 5.3 to 1.4 (P < .001). ASES and Constant scores significantly increased, from 42.9 and 56.2 to 85.2 and 82.5, respectively. PD occurred in 11 patients (12.9%), and 2 (2.3%) had self-consciousness; however, no patients complained about the deformity and the PD did not correlate with poorer clinical scores. Six patients (7.1%) complained of anterior cramping pain. Elbow flexion power was similar compared with the contralateral side. In postoperative magnetic resonance imagine analysis, 15 patients (25%) showed distal migration of tenodesed biceps tendon, although only 6 (7.1%) had clinical PD. Postoperative clinical outcomes were not influenced by the location of the suture anchor within the bicipital groove. CONCLUSIONS: Arthroscopic biceps tenodesis with 1 suture anchor resulted in good clinical outcomes at 2 years postoperatively. PD was seen in 12.9% of the patients.

Cutaneous nerve distribution around first extensor compartment of the wrist: Clinical implications for ultrasound-guided injections.

Purpose: To evaluate the course of the cutaneous nerve regarding the first extensor compartment to determine whether the dorsal or volar approach is safer for local injection into the first extensor compartment guided by ultrasound. Methods: We dissected the radial side of the wrists from 28 cadavers (52 wrists). Four-points along the imaginary line were set: the styloid process and 1 cm, 2 cm, and 3 cm proximal to the styloid process. The numbers of superficial radial nerve (SRN) and lateral antebrachial cutaneous nerve (LACN) branches were counted, and distances from the imaginary line at these points and nerve diameters were recorded. Digital images were superimposed to observe overall distribution of cutaneous nerve. Results: There were means of 3.3 SRN and 0.9 LACN branches observed in each wrist. The mean number of both SRN and LACN branches was 2.3 on the dorsal side and 1.9 on the volar side. The superimposed images indicated that both the dorsal and volar sides comprised abundant cutaneous nerves and that their paths varied markedly between patients. However, we observed that larger nerves with meaningful diameters were more abundant on the dorsal than the volar side. Conclusion: There were similar numbers of cutaneous nerves on both the dorsal and volar sides; however, we observed greater abundance of thicker cutaneous nerves on the dorsal side, and these were closer to the reference line than on the volar side. This anatomical study suggests that the risk imposed to cutaneous nerves would therefore be reduced when injection on the volar side.

Magnetic resonance imaging analysis of the distribution of cartilage damage in scaphoid nonunion.

This study aimed to evaluate the distribution and severity of cartilage damage using magnetic resonance imaging in patients with scaphoid nonunion without advanced wrist arthritis. We retrospectively analysed MRI of patients who underwent osteosynthesis for scaphoid nonunion. Cartilage damage was assessed in eight wrist regions using a modified Whole-Organ Magnetic Resonance Imaging Score. The frequencies of regions affected by any cartilage damage (Score ≥2.5) depicted on MRI were analysed. The study included 32 patients (31 men and one woman), with a mean age of 32 years (SD 11). The distal radioscaphoid (29/32), scaphotrapeziotrapezoid (STT) (22/32), proximal radioscaphoid (14/32) and scaphocapitate (11/32) joints were most commonly affected by degenerative cartilage damage. The STT and proximal radioscaphoid joint were especially likely to be involved in early-stage scaphoid nonunion advanced collapse. We recommend that surgeons should investigate the cartilage status of these joints during decision-making for scaphoid nonunion surgery.Level of evidence: III.

High tibial open wedge osteotomy below the tibial tubercle: clinical and radiographic results.

PURPOSE: The purpose of this study was to evaluate the clinical and radiographic results of open wedge HTO below the tubercle for genu varum in relatively young patients. METHODS: Thirty-seven knees in 19 patients with genu varum treated by open wedge HTO below the tubercle between 2001 and 2008 were retrospectively studied. Median follow-up was 36 months (12-108), and median patient age at the time of surgery was 26 years (16-45). Clinical results were evaluated using Lysholm knee scores and Hospital for Special Surgery knee scores. Satisfaction with the results of surgery (0-10 points) was subjectively evaluated using operative scar (1-5 points) and leg shape (1-5 points) results at follow-up. Radiographic evaluations were made using: (1) tibiofemoral angles, (2) mechanical axis deviations, (3) varus-valgus inclinations of the tibial plateau, (4) tibial slopes, and (5) Insall-Savati and (6) Blackburne-Peel ratios. RESULTS: All but one patient achieved radiographic healing and union at the osteotomy site at an average of 3 months postoperatively. Average Lysholm knee score improved from 89.4 ± 8.7 preoperatively to 98.6 ± 2.5 at final follow-up (P = 0.0001), and mean HSS score improved from 91.1 ± 5.6 preoperatively to 98.5 ± 2.0 at final follow-up (P = 0.0001). Mean patient satisfaction score at final follow-up was 8.6 ± 1.0, and mean tibiofemoral angle increased from -1.6° preoperatively to 7.7° at final follow-up (P < 0.0001). The point where the mechanical axis crosses the tibial plateau also shifted significantly from 15.0% preoperatively to 50.6% at final follow-up (P = 0.0002). However, mean posterior tibial slope did not change significantly (9.7° preoperatively and 8.7° at final follow-up; P = NS), and neither did patella heights as measured by Insall-Savati and Blackburne-Peel ratios. CONCLUSION: Both functional assessment and radiographic measures indicated that HTO below the tibial tubercle leads to significant improvements in radiographic parameters and knee function without changes in patellar height or posterior tibial slope. The results obtained support the hypotheses that opening wedge HTO below the tibial tubercle should be recommended in relatively young patients with genu varum. LEVEL OF EVIDENCE: Therapeutic study, Level IV.