The clinical outcomes of scaphoid nonunion treated with a precisely processed autologous bone screw: a case series.

INTRODUCTION: Metal implants and bioabsorbable implants are frequently used in orthopaedic surgery, but they have some disadvantages. The usefulness of autologous bone has been described, and a method to precisely process autologous bone into implants such as screws and apply the implants clinically has been desired. We created a new system for manufacturing autologous bone screws during surgery and report five cases of scaphoid nonunion treated with precise autologous bone screws made from the tibial cortex using the new system. PATIENTS AND METHODS: From 2012 through 2017, seven patients were diagnosed with scaphoid nonunion at our hospital and based on the inclusion/exclusion criteria, five of them were analyzed herein. The surgery was performed according to Zaidemberg's technique. The bone screw in each case was made from autologous tibial cortex using a numerically controlled lathe (model MTS4, Nano Co., Yokohama, Japan) under sterile conditions. The change in each patient's modified Mayo wrist score between the preoperative examination and at the final survey was determined, as were complications. RESULTS: The median modified Mayo wrist score improved significantly from 65 to 95 points. All patients who were followed for > 2 years fused at a median duration of 3.5 months. Bone regeneration was confirmed at the donor sites in all cases. One fracture at the donor site occurred as a severe complication. CONCLUSIONS: Precisely shaped autologous bone screws manufactured by a computer-assisted machine, together with a vascularized bone graft, may be a useful technique for treating scaphoid nonunions; these screws had good stability and bone replacement. Careful observation of the donor site is required. LEVEL OF EVIDENCE: IV.

Outcomes of surgical treatment for osteochondritis dissecans of the elbow: evaluation by lesion location.

BACKGROUND: For treatment of advanced elbow osteochondritis dissecans (OCD), we have used surgical treatment. Although favorable treatment outcomes have been reported for centrally located OCD, treatment outcomes are generally questionable and the choice of surgical method is controversial for laterally located OCD. Our purpose was to evaluate the treatment outcomes based on lesion location. METHODS: The patients were 30 young (mean age, 14 years) male athletes who underwent surgical treatment of elbow OCD and were monitored for more than 1 year. Osteochondral autografts harvested from the knee were transplanted to centralized (13 patients) or lateral localized (9 patients) OCD lesions. For lateral widespread (8 patients) OCD lesions, a detached osteochondral fragment was fixed using small osteochondral plugs. When the remaining cartilage defect was large after fragment fixation, a large-sized osteochondral plug was transplanted to the defect. Treatment outcomes were evaluated by the Japanese Orthopaedic Association score, elbow range of motion (ROM), and radiographic findings. RESULTS: The Japanese Orthopaedic Association score significantly improved in patients with centralized, lateral localized, and lateral widespread types of OCD. ROM significantly improved in patients with centralized and lateral localized, and they returned to playing sports within 6 months. However, patients with lateral widespread OCD exhibited no significant ROM improvement, and returning to sports was difficult for 3 patients because of poor osseous integration of the fixed osteochondral fragment. CONCLUSIONS: Osteochondral autograft transplantation provided favorable outcomes for centralized and lateral localized elbow OCD lesions. However, for lateral widespread OCD lesions, reconstruction of the entire capitellar lesion area may be necessary.

Osteochondral autograft transplantation for malunited intra-articular fracture of the proximal interphalangeal joint: a case report.

INTRODUCTION: Malunited intra-articular fracture of the proximal inter-phalangeal (PIP) joint sometimes causes problems, such as range of motion (ROM) limitation in the joint or lack of digital dexterity; however, the treatment method has not yet been established. We report a juvenile case of osteochondral autograft tranplantation to treat a malunited intra-articular fracture of the middle finger. CASE REPORT: A 14-year-old boy was injured at the right middle finger by a baseball impact and underwent conservative treatment. At 5 months after the injury, he complained of continuing pain and restricted ROM. Plain X-ray and CT images showed a bony defect in the articular surface of the PIP joint of the right middle finger. He was diagnosed with malunited intra-articular fracture of the PIP joint and underwent surgical treatment. First, through a palmar incision, a columnar-shaped drill hole was made at the recipient site of osteochondral defect. Then a cylindrical osteochondral plug, 4.5 mm in diameter, harvested from the knee, was inserted into the recipient hole and press-fitted. One year after surgery, the patient has neither pain nor ROM limitation of the finger and the knee joint. MRI showed smooth articular surface of the PIP joint. DISCUSSION: The benefits of our method include use of articular cartilage as a reconstruction material, availability for a relatively large cartilage defect, and stability of the autograft for the press-fitting method, which enable early mobilization exercise after surgery.

Tenosynovial Giant Cell Tumor, Localized Type With Extensive Chondroid Metaplasia: A Case Report With Immunohistochemical and Molecular Genetic Analysis.

Tenosynovial giant cell tumor (TSGCT) of localized type is a common disease occurring mostly in the hands. Diagnosis of this tumor is relatively easy to render with hematoxylin-eosin-stained sections as compared with that of TSGCT of diffuse type. However, very rare cases with chondroid metaplasia that have recently been reported mainly in diffuse type can make pathological differentiation from soft tissue cartilaginous tumors extremely difficult. In this article, the authors present the second reported case of TSGCT of localized type showing extensive chondroid metaplasia. Pathological interpretation was difficult without utilizing immunohistochemistry and fluorescence in situ hybridization. One must be careful not to misdiagnose this lesion as cartilaginous tumors of soft tissue, and we suspect at least some chondroblastoma-like chondroma could be reclassified as TSGCT of localized type with extensive chondroid metaplasia. Morphological, immunohistochemical, and molecular genetic characteristics are presented and discussed.

Elbow Brace Promotes Postoperative Rehabilitation of Osteochondral Graft in Young Athletes with Osteochondritis Dissecans of the Humeral Capitellum.

OBJECTIVE: Treatment of large advanced osteochondritis dissecans (OCD) of the elbow in young athletes is challenging. METHODS: We retrospectively reviewed the results in 9 baseball players (mean age, 13.7 years; range, 12-15 years) who were followed up for a mean 21.1 months (range, 12-36 months) after osteochondral autograft. In this operation, cylindrical osteochondral plugs were harvested from a lateral femoral condyle and transferred to the lesion in humeral capitellum. After immobilizing the elbow by a splint for 2 weeks, the patients were encouraged to do range of motion exercises using an elbow brace with a hinge for 2 months. The elbow brace was applied to avoid excess stress to the implants on the capitellum and to the lateral collateral ligament. Patients were clinically assessed by the Japanese Orthopaedic Association elbow score (JOA score) and morphologically by radiographs as well as by magnetic resonance imaging (MRI). RESULTS: Patients started playing catch at 3 months and returned to baseball at competitive level at around 6 months postoperatively. The average JOA score was 68.0 points before operation and improved to 98.7 points at follow-up. Bony fusion between the implants and host bone was observed radiographically at 3 months. MRI confirmed a durable load-bearing articular surface of the capitellum at 1 year. CONCLUSIONS: Osteochondral autograft with postoperative rehabilitation using an elbow brace is a reasonable treatment for young athletes with an advanced lesion of OCD of the elbow who desire a relatively quick return to their pre-injury sports activity level.

Delineation of extensor tendon of the hand by MRI: usefulness of "soap-bubble" mip processing technique.

To evaluate the capability of the "Soap-Bubble" maximum intensity projection (MIP) processing technique in visualisation of extensor tendons of the hand, 36 intact subjects and seven patients with surgically confirmed extensor tendon rupture were examined. Three-dimensional T1-weighted turbo spin echo (3DT1TFE) MRI was performed using a sensitivity encoding flex coil, followed by Soap-Bubble MIP processing. For patients with extensor tendon ruptures, MRI findings and intraoperative findings were compared. As results, with only 3DT1TFE sequence, the entire extensor tendons that run along the arch of the hand were not shown on one image, but were visualised with addition of Soap-Bubble MIP. Although delineation of the extensor pollicis longus was poor in 27/43 subjects, it was much improved by the combination of water-suppression technique. MRI findings and intraoperative findings agreed in all patients. Soap-Bubble MIP processing with addition of water-suppression technique is considered useful for visualising the extensor tendons of the hand.

A new surgical technique for treating bilateral Freiberg disease.

Freiberg disease is relatively rare and difficult to treat satisfactorily. We describe a new surgical technique of osteochondral plug transplantation for late-stage Freiberg disease that may restore normal function to the metatarsophalangeal joint. In the present series, we performed osteochondral plug transplantation to treat a stage IV lesion, according to Smillie's classification, by harvesting an osteochondral plug from the non-weight-bearing site on the upper lateral femoral condyle of the ipsilateral knee. We also treated a stage II lesion using retrograde drilling. One year after surgery, the patient had no pain when running and returned to full athletic activity. The clinical and morphologic results were excellent. Arthroscopic intervention produced good results in the early stages and osteochondral plug transplantation may be an excellent surgical procedure to restore normal function to the metatarsophalangeal joint in the later stages of Freiberg disease.

Usefulness of braided polyblend polyethylene suture material for flexor tendon repair in zone II by the side-locking loop technique.

Flexor tendon injuries in zone II were treated in 14 fingers of 13 patients with our method. Firstly, a 2-strand core suture was made by the side-locking loop technique using a USP 2-0-sized braided polyblend polyethylene suture, then 7-strand peripheral cross-stitches were added using a USP 5-0-sized monofilament nylon suture. Post-operative exercises included passive flexion and extension without external fixation on the next day of surgery. Average follow-up observation period was 18 months. As results, the Strickland method of assessment for surgical outcome showed excellent in eight digits and good in five digits, though there was a poor outcome in one digit. Our suture method enabled early post-operative mobilisation exercise without using a splint, while preventing adhesion between the repaired tendon and peripheral tissues, which is considered to provide far greater ultimate tensile strength and a smaller gap at the sutured site than by the conventional method.

Optimum suture material for locking technique in tendon repair: effects of suture friction in mobilization.

BACKGROUND: The 2-strand side-locking loop technique allows secure locking formation easily, yielding maximum tensile force. However, not all suture materials are suitable for this technique. METHODS: The bovine gastrocnemius tendons were transected and repaired end-to-end by the side-locking loop technique using USP2 braided polyblend, braided polyester, monofilament nylon, braided nylon, or monofilament absorbable polydioxanone sutures. A repetitive loading protocol from 10N to 100N was used, and the loading was repeated 10,000 times. In ruptured samples during the repetitive loading test, the number of loading was recorded. In samples which did not rupture, the ultimate tensile strength was measured after repetitive loading. After testing, ruptured sutures were examined microscopically. For comparison of ultimate tensile strength before and after repetitive loading, we performed a one-time loading test on samples which did not undergo the repetitive loading. FINDINGS: With monofilament nylon, braided nylon, or monofilament absorbable polydioxanone, suture rupture occurred during repetitive loading. In contrast, no suture rupture occurred with braided polyblend or braided polyester. Microscopic observation showed abrasion of the surface in braided polyester, though the friction effects were not seen with braided polyblend. The mean ultimate tensile strength before and after repetitive loading was 395N and 399N, respectively, for braided polyblend. For braided polyester, they were 208N and 174N, respectively. INTERPRETATION: Braided polyblend suture material has an excellent resistivity to friction and is suitable for the side-locking loop technique.

Biomechanical differences resulting from the combination of suture materials and repair techniques.

BACKGROUND: Many suture materials and repair techniques have been applied in clinical tendon surgery. However, no recommendation is available concerning the choice of suture materials and repair techniques except in a few experimental studies. The purpose of the current study is to show the biomechanical difference resulting from the combination of suture materials and repair techniques. METHODS: The gastrocnemius tendons of 24-week-old cattle (diameter 14-16x9-11 mm) were repaired with application of a single locking, multiple locking, single grasping, or multiple grasping technique using a USP2 suture thread of either braided polyblend polyethylene, polyester, polydioxanone, or nylon. Therefore, a total of 16 combinations were made, with eight specimens for each combination. The specimen was set in an Instron tensiometer to measure the gap length after repetitive tensile loading 500 times (10-100 N). RESULTS: The single locking technique using braided polyblend polyethylene provided the smallest gap (4.5+/-0.5 mm). Other techniques using the same material resulted in a large gap (10.0-11.8 mm). The polyester provided a relatively smaller gap length, irrespective of the repair technique (7.4-8.8 mm). Polydioxanone and nylon tended to result in a large gap (9.3-12.3 mm and 8.4-10.6 mm, respectively). CONCLUSIONS: Mechanical properties of each tendon suture depended on the particular combination of suture materials and repair techniques. The combination of braided polyblend polyethylene and single locking technique provided the highest antigap strength.