Failure of the linkage mechanism in a semi-constrained total elbow arthroplasty is a rare and unpredictable event: a review of seven cases.

PURPOSE: Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries. METHODS: Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism. RESULTS: All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure. CONCLUSION: Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

A Functional Polymorphism Downstream of Vitamin A Regulator Gene CYP26B1 Is Associated with Hand Osteoarthritis.

While genetic analyses have revealed ~100 risk loci associated with osteoarthritis (OA), only eight have been linked to hand OA. Besides, these studies were performed in predominantly European and Caucasian ancestries. Here, we conducted a genome-wide association study in the Han Chinese population to identify genetic variations associated with the disease. We recruited a total of 1136 individuals (n = 420 hand OA-affected; n = 716 unaffected control subjects) of Han Chinese ancestry. We carried out genotyping using Axiom Asia Precisi on Medicine Research Array, and we employed the RegulomeDB database and RoadMap DNase I Hypersensitivity Sites annotations to further narrow down our potential candidate variants. Genetic variants identified were tested in the Geisinger's hand OA cohort selected from the Geisinger MyCode community health initiative (MyCode®). We also performed a luciferase reporter assay to confirm the potential impact of top candidate single-nucleotide polymorphisms (SNPs) on hand OA. We identified six associated SNPs (p-value = 6.76 × 10-7-7.31 × 10-6) clustered at 2p13.2 downstream of the CYP26B1 gene. The strongest association signal identified was rs883313 (p-value = 6.76 × 10-7, odds ratio (OR) = 1.76), followed by rs12713768 (p-value = 1.36 × 10-6, OR = 1.74), near or within the enhancer region closest to the CYP26B1 gene. Our findings showed that the major risk-conferring CC haplotype of SNPs rs12713768 and rs10208040 [strong linkage disequilibrium (LD); D' = 1, r2 = 0.651] drives 18.9% of enhancer expression activity. Our findings highlight that the SNP rs12713768 is associated with susceptibility to and severity of hand OA in the Han Chinese population and that the suggested retinoic acid signaling pathway may play an important role in its pathogenesis.

Functional Outcomes Are Similar After Arthroscopic Capsular Repair of Triangular Fibrocartilage Complex Tears Between Outside-In Technique and All-Inside Technique Using Pre-Tied Suture Device.

PURPOSE: To compare outcomes of arthroscopic triangular fibrocartilage complex capsular repair at 2-year follow-up between outside-in and all-inside techniques. METHODS: In total, 58 consecutive patients (wrists) with a Palmer 1B triangular fibrocartilage complex tear without symptomatic distal radioulnar joint instability underwent arthroscopic suture repair from 2011 to 2019 including 31 patients via the outside-in technique (group A) and 27 via the all-inside technique using a pre-tied needle device (group B). Two-year follow-up included visual analog scale (VAS) pain score, motion range, grip strength, Mayo Modified Wrist Score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and complication rate. Correlation between functional result and patient satisfaction was analyzed. RESULTS: Score changes in VAS, wrist flexion-tension, supination-pronation, grip strength, MMWS, and QuickDASH at 2-year follow-up were not significantly different between group A (3.4 ± 0.8, 18.4 ± 17.5, 12.9 ± 13.3, 30.7 ± 11.2, 26.6 ± 7.9 and 19.4 ± 9.9 and group B (3.4 ± 1.0, 18.5 ± 18.3, 15.6 ± 13.7, 30.8 ± 11.4, 28.1 ± 8.6, and 7.6 ± 7.2) with P values of .400, .489, .223, .486, .240, and .223 respectively. Surgical time averaged 105 minutes (78 to 136) in group A and 94 minutes (61-126) in group B with significant difference (P = .012). Patient satisfaction averaged 1.1 (0-3.5) in group A and 1.0 (range 0-3.0) in group B. Satisfaction score was more strongly correlated with QuickDASH (coefficients: 0.863 in group A and 0.918 in group B) than with MMWS (-0.693 in group A and -0.465), grip strength (-0.619 in group A and -0.417 in group B) and VAS score (0.607 in group A and 0.222 in group B). CONCLUSIONS: Both techniques achieved comparable outcomes with shorter surgical time in all-inside repair using pre-tied needle device. Patient satisfaction was strongly correlated with QuickDASH score. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative investigation.

Retrospective cohort study on radial head arthroplasty comparing long-term outcomes between valgus type injury and fracture dislocation.

BACKGROUND: Radial head arthroplasty (RHA) has been commonly adopted for irreparable radial head fractures while little information is addressed on valgus type injury. The purpose of this study is to report long-term outcomes and radiographic analysis in RHA for valgus type injury with comparison to fracture dislocation injury. METHODS: A retrospective cohort study was conducted in patients receiving unilateral RHA with loose-fit, modular metal prosthesis for irreparable radial head fractures between 2004 and 2012. Totally, 33 patients with a mean follow up of 9 years (range, 7 to 15 years) were enrolled and divided into two groups including 14 valgus injuries and 19 fracture-dislocations. Demographics of the patients, injury details, clinical and radiographic outcomes, and correlation analysis were investigated and compared between two groups. RESULTS: In patient demographics, significant difference was noted in sex distribution (p = 0.001), lateral collateral ligament involvement (p = 0.000) and time from injury to RHA (p = 0.031) between two groups. No patient underwent subsequent removal or revision of prosthesis. Good to excellent results according to Mayo Elbow Performance Score (MEPS) was achieved in 13 and 14 patients in group A and B respectively. Final motion range and Disabilities of the Arm, Shoulder, and Hand score was significantly better in valgus injury group. Radiographic analysis demonstrated fewer patients in valgus injury group presented periprosthetic osteolysis with weak to moderate negative correlation between radiolucency score and MEPS. CONCLUSIONS: With an average of 9 years follow-up, RHA using loose-fit, modular metal prosthesis achieves encouraging outcomes for both valgus injury and fracture dislocation. In valgus type injury, better motion range, lower disability score and lower incidence of periprosthetic osteolysis is noted while correlation analysis of radiolucency score suggests extended, long-term investigation.

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study.

BACKGROUND: Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy. METHODS: We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups. RESULTS: All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms. CONCLUSIONS: Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.

Anteromedial fractures of the ulnar coronoid process: correlation between surgical outcomes and radiographic findings.

BACKGROUND: This study aimed to report the radiographic findings and surgical outcomes of anteromedial facet (AMF) fracture of the ulnar coronoid process and to suggest an optimal approach. METHODS: In this retrospective study, 20 consecutive patients with unilateral AMF fracture of coronoid process were surgically treated and divided into two groups without (group A) and with (group B) additional proximal ulnar fractures in equal case number. Time from injury to surgery averaged 4.38 ± 2.56 weeks. Mayo Elbow Performance Score (MEPS) and Shortened Disability of the Arm and Shoulder and Hand (quickDASH) score were used for functional evaluation. Cohen kappa coefficient (kappa) analysis was used to determine interobserver reliability on a radiographic reading. RESULTS: All cases had a mean follow-up of 2.3 years. MEPS at 2 years averaged 87.75 ± 12.51; quickDASH, 7.05 ± 6.19. A significantly higher MEPS was found in subtype 3 than in subtype 2 (p = 0.036) and in group B than in group A (p = 0.020). Significantly lower quickDASH cores were found in group B than in group A (p = 0.011). Kappa analysis showed moderate agreement in the O'Driscoll classification (kappa = 0.56) and substantial agreement in categorization of the additional proximal ulnar fractures (kappa = 0.76). CONCLUSIONS: Additional proximal ulnar lesions were considered an integral part of varus posteromedial rotatory instability and required further categorization in the management of AMF fractures. Significantly better functional outcomes were achieved when those lesions were fully addressed.

Intramedullary nailing for correction of post-traumatic deformity in late-diagnosed distal radius fractures.

BACKGROUND: Post-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius. MATERIALS AND METHODS: From July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months. RESULTS: All fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8. CONCLUSION: Surgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius. LEVEL OF EVIDENCE: IV.

Arthroscopy-assisted reduction of posteromedial tibial plateau fractures with buttress plate and cannulated screw construct.

PURPOSE: To present the radiologic and clinical results of posteromedial fractures treated with arthroscopy-assisted reduction and buttress plate and cannulated screw fixation. METHODS: Twenty-five patients with posteromedial tibial plateau fractures treated by the described technique were included in this study. According to the Schatzker classification, there were 5 type IV fractures (20%), 2 type V fractures (8%), and 18 type VI fractures (72%). The mean age at operation was 46 years (range, 21 to 79 years). The mean follow-up period was 86 months (range, 60 to 108 months). Clinical and radiologic outcomes were scored by the Rasmussen system. Subjective data were collected to assess swelling, difficulty climbing stairs, joint stability, ability to work and participate in sports, and overall patient satisfaction with recovery. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up in comparison with the films taken at the time of injury. RESULTS: The mean postoperative Rasmussen clinical score was 25.9 (range, 18 to 29), and the mean radiologic score was 15.8 (range, 10 to 18). All 25 fractures achieved successful union, and 92% had good or excellent clinical and radiologic results. The 3 fracture types did not significantly differ in Rasmussen scores or rates of satisfactory results (P > .05). Secondary osteoarthritis was noted in 6 injured knees (24%). CONCLUSIONS: Arthroscopy-assisted reduction with buttress plate and cannulated screw fixation can restore posteromedial tibial plateau fractures of the knee with well-documented radiographic healing, good clinical outcomes, and low complication rates. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Radiographic Analysis in Extra-Articular and Intra-Articular Distal Radius Fractures Treated with Variable-Angle Volar Locking Plate Fixation.

(1) Background: Different distal radial fracture types have different prognosis after fixation. Our study aim is to evaluate the differences in radiographic parameters by using variable-angle volar locking plate (VAVLP) fixation according to extra-articular and intra-articular distal radial fracture. (2) Methods: There are two groups: extra-articular group (21) and intra-articular group (25). Forearm radiographs immediately after surgery and at 3 months after operation were reviewed for analyzing radial height (RH), ulnar variance (UV), radial inclination (RI), volar tilt (VT), tear drop angle (TDA), distal dorsal cortical distance (DDD), and Soong classification (SC). (3) Results: There were no significant differences in the above parameters between two groups at either immediately post-operative or at 3-month follow-up, except for TDA (p = 0.048). Most patients in both groups were at low risk of flexor tendon rupture, except for two cases. We observed a positive correlation between post-operative DDD and 3-month change in the intra-articular group, but not the extra-articular group. (4) Conclusions: Our study demonstrates that VAVLP fixation is effective in maintaining the stability of most radiographic parameters and reduces the risk of tendon rupture in both extra-articular and intra-articular distal radial fractures. Post-operative DDD can be used to predict the degree of subsequent displacement in patients with intra-articular fractures fixed with VAVLP.

Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament.

PURPOSE: The purpose of the study was to highlight our surgical technique of arthroscopic suture fixation for acute tibial eminence posterior cruciate ligament (PCL) avulsion fractures, clinical and radiographic outcomes, and complication rates. METHODS: This prospective study enrolled patients who had undergone arthroscopic reduction and suture fixation by use of 4 No. 5 Ethibond sutures (Ethicon, Somerville, NJ) for image-proven displaced PCL attachment fractures of the tibial eminence with posterior knee instability of grade II or higher. The mean follow-up period was 36 months (range, 24 to 45 months). Follow-up assessment included 3 different functional scores, KT-1000 arthrometry (MEDmetric, San Diego, CA), and radiographic evaluation. RESULTS: The mean preoperative Lysholm score in the 36 patients was 35 (range, 26 to 55); the mean postoperative Lysholm score was 95 (range, 80 to 100). The mean preinjury and preoperative Tegner scores in the 36 patients were 7.4 ± 1.6 (range, 5 to 9) and 3.2 ± 1.5 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.0 ± 1.8 (range, 5 to 9). At the final follow-up, the International Knee Documentation Committee scores were observed to be normal (grade A) or nearly normal (grade B) in 33 patients (91.7%) and abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved union within 3 months. No significant complications such as arthrofibrosis, loss of initial fixation, or wound infection were noted. CONCLUSIONS: Treatment of tibial PCL avulsion fractures by arthroscopic suture fixation is a successful technique to restore tibial avulsion injuries of the PCL with well-documented radiographic healing, good clinical outcomes, and low complication rates. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Percutaneous screw and axial Kirschner wire fixation for acute transscaphoid perilunate fracture dislocation.

PURPOSE: In this retrospective, nonrandomized study, we evaluated the clinical outcomes of percutaneous screw and K-wire fixation in the treatment of acute transscaphoid perilunate fracture dislocation. METHODS: Between 2004 and 2009, we studied 24 patients treated by fixation with a 2.0-mm (0.078-in) axial K-wire across the capitolunate joint and a percutaneous screw (3.0-mm AO cannulated screws were used in 13 patients, and Herbert-Whipple screws were used in 11 patients) within 7 days of the injury. We performed a comparative radiographic assessment of the scapholunate angle, radiolunate angle, capitolunate angle, revised carpal height ratio, and gap between the scapholunate joint between the injured wrist and the contralateral, healthy wrist. Clinical outcomes were evaluated on the basis of range of motion, pain, functional status, and Mayo scores. RESULTS: Twenty-three patients (96%) achieved scaphoid union at a mean union time of 18 weeks (range, 14-28 wk). Radiographic assessments revealed no statistically significant difference between the injured wrist and the contralateral, healthy wrist. However, significant differences were noted in the mean range of motion during flexion and forearm supination between the injured wrist and contralateral healthy wrist. The mean wrist function results were encouraging, and the average Mayo score was 83. CONCLUSIONS: A percutaneous procedure involving screw fixation for the scaphoid fracture and an axial K-wire fixation for intercarpal dislocation is a successful treatment for acute transscaphoid perilunate fracture dislocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Single portal endoscopic carpal tunnel release: modification of Menon's technique and data from 65 cases.

The purpose of our study is to make a follow-up evaluation of endoscopic carpal tunnel release under focal anesthesia using the Wolf single portal system. A total of 65 patients with a mean age of 50 years undergoing 79 procedures were retrospectively studied. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were recorded. Follow-up was conducted at 1, 5, 12, and 24 weeks and at 1 year postoperatively. Wound pain, analysis of satisfaction, Levine functional status scales, and surgical complications were included. No patients sustained iatrogenic neurovascular injury or hematoma formation. The average Levine functional severity score decreased from 2.82 points preoperatively to 1.2 points at the most recent survey. One case recurred at 1 year after the surgery and subsequently underwent open release. Surgery using the Wolf single portal system under focal anesthesia is a safe and efficacious option for endoscopic carpal tunnel release.

All-arthroscopic repair of Atzei class II and III triangular fibrocartilage complex tears using the FasT-Fix suture device.

BACKGROUND: The study is aimed to propose an arthroscopic repair technique using a pre-tied suture device for peripheral TFCC (triangular fibrocartilage complex) tear with proximal component involvement. METHODS: Through a retrospective review in the medical records of patients who underwent unilateral arthroscopic repair for TFCC Palmer IB lesion between 2017 and 2019, 12 patients were arthroscopically diagnosed as proximal component tear and received more than 1 year follow-up postoperatively. The arthroscope was introduced from 6R portal to discriminate Atzei class II from III lesions by a "visualization test" and to supervise the repair procedure using pre-tied FasT-Fix suture device from 3-4 portal. Two poly-ether-ether-ketone (PEEK) blocks were further advanced along the device needle to finally seat outside the ulnar joint capsule, followed by gradually tightening the pre-tied suture loop until the TFCC periphery was securely repositioned and held stably. RESULTS: Operation time averaged 87 min. Hook test and DRUJ arthroscopy confirmed proximal component tear in all 12 wrists. Four patients were diagnosed to be Atzei class II lesion as full thickness tear of distal component was arthroscopically identified from 6R portal while the other 8 exhibited partial thickness tear and were categorized as class III lesion. Follow-up averaged 15 months with a range of 12 to 24 months. Mayo modified wrist score improved from an average of 61.3 preoperatively to 90.4 at the latest visit. CONCLUSIONS: A modified technique for diagnosis and all-arthroscopic repair in TFCC Atzei class II and III lesions using a pre-tied suture device is a feasible and safe option with promising results.

Long-Term Outcomes of Radial Head Arthroplasty in Complex Elbow Fracture Dislocation.

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was -0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.

Repositioning osteotomy for intra-articular malunion of distal radius with radiocarpal and/or distal radioulnar joint subluxation.

BACKGROUND: Intra-articular malunion of the distal radius may be complicated with radiocarpal and radioulnar joint subluxation, which may result in joint stiffness and loss of function. Conventional corrective osteotomy emphasizes on the restoration of the articular step-off. However, little information is available concerning the restoration of a concentric functioning joint through osteotomy. METHODS: From 2002 to 2007, 12 patients with chronic intra-articular distal radius fractures were evaluated at an average follow-up of 33.6 months after repositioning osteotomy. The average time from initial injury to reconstructive operation was 11.3 months. The indication for osteotomy included dorsal or volar subluxation of the radiocarpal joint, distal radioulnar joint, or both in addition to articular incongruity. A preoperative computed tomography scan or rapid prototyping (RP) models were performed as part of the surgical planning. Operation was preceded by volar, dorsal, or both approaches. Repositioning osteotomy and internal fixation were also performed. Radiographic analysis and the Disability of Arm, Shoulder and Hand score were used for the outcome assessment. RESULTS: All osteotomy sites healed and all events of radiocarpal and radioulnar subluxation were corrected. The average correction was 13.8 degrees (palmar tilt of the radius) and 1.9 mm in ulnar variance. The mean Disability of Arm, Shoulder and Hand score improved from 64 to 18. DISCUSSION: Conventional corrective osteotomy via an extra-articular approach was favorably performed to correct an extra-articular malalignment or nascent intra-articular malunion. Problems of abnormal architecture after an intra-articular fracture of the radius are complicated with subluxation of carpus or distal radioulnar joint, which require repositioning via precise articular approach. Both reconstructed computed tomography images and rapid prototyping models are very useful tools in preoperative planning for intra-articular osteotomy. Simulated osteotomy and joint repositioning can be performed in solid models before commencement of actual operation. CONCLUSION: Repositioning osteotomy consistently restores joint alignment and achieves functional improvement either in cases of nascent simple malunion or complex intra-articular malunion.

Surgical management of ulnar styloid fractures: comparison of fixation with anchor suture and tension band wire.

BACKGROUND: Limited reference is available regarding surgical management in symptomatic ulnar styloid fractures with small bony avulsion. The study goal is to report the surgical outcomes using anchor suture fixation with comparison to traditional tension band wire fixation. METHODS: We retrospectively reviewed the medical records in patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2017. A total of 31 patients were enrolled including two kinds of fixation methods. Anchor suture fixation plus distal radioulnar joint pinning was performed in ten patients with tiny avulsion bony fragments (group A); tension band wire fixation was performed in 21 patients with big styloid fracture fragments (group B). Patient characteristics and 2-year treatment outcomes were compared between two groups based on Mayo Modified Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); visual analog scale (VAS), and surgical complication. Descriptive statistics were used for calculation of key variables; a p value of < 0.05 was considered statistically significant. RESULTS: Based on Gaulke classification, there were five subtypes in group A and three subtypes in group B. Incidence of concomitant distal radius fractures was significantly higher in group B; other patient characteristics including age, sex, injury side, and time to surgery showed no significant difference. Outcome assessment regarding MMWS, QuickDASH, and VAS was comparable between two groups. Bone-related complications including nonunion, DRUJ subluxation, and styloid resorption were analyzed; the difference was not significant. Incidence of implant-related complications including migration and secondary removal surgery was significantly higher in group B (p = 0.021). CONCLUSION: Surgical fixation in symptomatic ulnar styloid fractures yields comparable treatment outcomes in both fracture patterns. Implant-related complication with secondary removal surgery is more common in tension band wire group. Anchor suture fixation is a feasible option for tiny styloid avulsion fragments with limited surgical complication.

Arthroscopy-Assisted Corrective Osteotomy, Reduction, Internal Fixation and Strut Allograft Augmentation for Tibial Plateau Malunion or Nonunion.

PURPOSE: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. METHODS: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion (n = 44) or nonunion (n = 14), were included in this study. There were 19 Schatzker type II fractures (32.7%), 2 type III fractures (3.4%), 7 type IV fractures (12%), 20 type V fractures (34.5%), and 10 type VI fractures (17.2%). The mean follow-up period was 46.2 ± 17.6 months. Clinical and radiologic outcomes were scored by the Rasmussen system. Articular depression was measured from computed tomography. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up. RESULTS: Mean clinical score improved from 15.4 ± 3.9 (pre-revision) to 23.2 ± 4.5 (post-revision). Mean radiologic score improved from 7.7 ± 2.5 (pre-revision) to 12.0 ± 3.9 (post-revision). Fifty-six fractures achieved successful union. The average union time was 19.6 ± 7.5 weeks. Post-revision, 81% had good or excellent clinical results and 62% had good or excellent radiological results. Secondary osteoarthritis (OA) was noted in 91% of all injured knees, where 25.8% were mild OA, 25.8 % were moderate OA, and 38% were severe OA. There were 6 cases of deep infection (10.3%) and 1 case of wound edge necrosis (1.7%). Five cases were converted to total knee replacement after the index surgery with an average period of 13.5 months (range 8-24 months). CONCLUSIONS: Arthroscopy-assisted corrective osteotomy, reduction, internal fixation, and strut allograft augmentation can restore tibial plateau malunion/nonunion with well-documented radiographic healing and good clinical outcomes.

Application of Bone Marrow-Derived Mesenchymal Stem Cells for Muscle Healing After Contusion Injury in Mice.

BACKGROUND: Skeletal muscle injuries are very common in sports medicine. Conventional therapies have limited clinical efficacy. New treatment methods should be developed to allow athletes to return to play with better function. PURPOSE: To evaluate the in vitro differentiation potential of bone marrow-derived mesenchymal stem cells and the in vivo histologic and physiologic effects of mesenchymal stem cell therapy on muscle healing after contusion injury. STUDY DESIGN: Controlled laboratory study. METHODS: Bone marrow cells were flushed from both femurs of 5-week-old C57BL/6 mice to establish immortalized mesenchymal stem cell lines. A total of 36 mice aged 8 to 10 weeks were used to develop a muscle contusion model and were divided into 6 groups (6 mice/group) on the basis of the different dosages of IM2 cells to be injected (0, 1.25 × 105, and 2.5 × 105 cells with/without F-127 in 100 µL of phosphate-buffered saline). Histological analysis of muscle regeneration was performed, and the fast-twitch and tetanus strength of the muscle contractions was measured 28 days after muscle contusion injury, after injections of different doses of mesenchymal stem cells with or without the F-127 scaffold beginning 14 days after contusion injury. RESULTS: The mesenchymal stem cell-treated muscles exhibited numerous regenerating myofibers. All the groups treated with mesenchymal stem cells (1.25 × 105 cells, 2.5 × 105 cells, 1.25 × 105 cells plus F-127, and 2.5 × 105 cells plus F-127) exhibited a significantly higher number of regenerating myofibers (mean ± SD: 111.6 ± 14.77, 133.4 ± 21.44, 221.89 ± 32.65, and 241.5 ± 25.95, respectively) as compared with the control group and the control with F-127 (69 ± 18.79 and 63.2 ± 18.98). The physiologic evaluation of fast-twitch and tetanus strength did not reveal differences between the age-matched uninjured group and the groups treated with various doses of mesenchymal stem cells 28 days after contusion. Significant differences were found between the control group and the groups treated with various doses of mesenchymal stem cells after muscle contusion. CONCLUSION: Mesenchymal stem cell therapy increased the number of regenerating myofibers and improved fast-twitch and tetanus muscle strength in a mouse model of muscle contusion. However, the rapid decay of transplanted mesenchymal stem cells suggests a paracrine effect of this action. Treatment with mesenchymal stem cells at various doses combined with the F-127 scaffold is a potential therapy for a muscle contusion. CLINICAL RELEVANCE: Mesenchymal stem cell therapy has an effect on sports medicine because of its effects on myofiber regeneration and muscle strength after contusion injury.

The Effect of Hyperbaric Oxygen Treatment on Myoblasts and Muscles After Contusion Injury.

The recommended treatment varies depending on the severity of muscle injuries. The aim of this study was to evaluate the in vitro myoblast proliferation and the in vivo histologic and physiologic effects of hyperbaric oxygen treatment on muscle healing after contusion. Cells from the C2C12 myoblast cell line were exposed to 100% O2 for 25 min then to air for 5 min at 2.5 atmospheres absolute in a hyperbaric chamber for a total treatment duration of 90 min per 48 h at intervals of 2, 4, 6 and 8 days. Cell growth measurements and western blot analysis of myogenin and actin were performed. Then, 18 mice aged 8-10 weeks were used in the muscle contusion model. The histologic and physiologic effects and muscle regeneration after hyperbaric oxygen treatment were evaluated. The myoblast growth rate was significantly higher (p < 0.05) after hyperbaric oxygen treatment. Densitometric evaluation demonstrated a 39% (p < 0.05) and 25% (p < 0.05) increase in myogenin and actin protein levels, respectively, in the cells treated with 1 dose of hyperbaric oxygen. Similarly, the myogenin and actin protein levels increased for samples receiving multiple hyperbaric oxygen treatments when compared with the control. Physiologic evaluation of fast twitch and tetanus strength revealed a significant difference between the control group and the 14-day hyperbaric oxygen group. In conclusion, hyperbaric oxygen treatment increases the myoblast growth rate and myogenin and actin production. Better histologic and physiologic performance were found after hyperbaric oxygen treatment in animal contusion model. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:329-335, 2020.

Arthroscopic suture fixation of tibial eminence avulsion fractures.

PURPOSE: This study presents the clinical results of a procedure for treating tibial eminence fractures of the anterior cruciate ligament (ACL) using arthroscopic reduction and No. 5 Ethibond sutures (Ethicon, Somerville, NJ). METHODS: This prospective study analyzed 36 patients who underwent arthroscopic reduction and suture fixation for image-proven ACL avulsion fractures of the tibial eminence. The classification of Meyers and McKeever identified 6 type II, 16 type III, and 14 type IV fractures. The mean follow-up period was 34.4 months (range, 24 to 91 months). Follow-up assessment included Lysholm knee score, Tegner activity score, International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer (MEDmetric, San Diego, CA) and radiographic evaluation. RESULTS: The mean preoperative Lysholm score in the 36 knees was 38 (range, 28 to 54); the mean postoperative Lysholm score was 98 (range, 83 to 100). The mean preinjury and preoperative Tegner scores in the 36 knees were 7.5 +/- 1.5 (range, 5 to 9) and 3 +/- 1.7 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.3 +/- 1.7 (range, 5 to 9). At final follow-up, 34 patients (94.5%) were classified by IKDC score as normal or nearly normal (grade A or B). The IKDC classification was abnormal (grade C) in 2 patients (5.5%). All 36 fractures achieved union within 3 months. No significant complications, such as arthrofibrosis, loss of initial fixation, or wound infection, were noted. CONCLUSIONS: Treating ACL avulsion fracture by arthroscopic suture fixation by use of 4 No. 5 Ethibond sutures can restore ACL length, stabilize fragments, promote early motion, and minimize morbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.