Alignment changes after open-wedge high tibial osteotomy result in offloading in the patellofemoral joint: a SPECT/CT analysis.

PURPOSE: The patellofemoral (PF) joint may be adversely affected by medial open-wedge high tibial osteotomy (OWHTO). This study aimed to evaluate the PF compartmental changes using combined single-photon emission computed tomography (SPECT) and conventional computed tomography (CT) after OWHTO to provide clinical guidance regarding the PF joint pressure and force. METHODS: Patients with medial osteoarthritis and varus malalignment > 5° were treated using OWHTO. Patients with a minimum 2-year follow-up were included in the study. The patellar positions were evaluated based on the radiographic parameters. The changes in chondral lesions during second-look arthroscopic examination were evaluated, and the PF joint arthritis grade was recorded on patellar Merchant radiographs using Kellgren-Lawrence classification. The PF compartmental changes according to SPECT/CT analysis after OWHTO were evaluated in all patients. The scintigraphic uptake was graded on four scales. Patients were divided into improved and unimproved groups according to the PF compartmental grade using the SPECT/CT uptake grading system. RESULTS: At a mean follow-up period of 47.0 months (range 25-74 months), the mean mechanical femorotibial angle changed significantly from varus 6.3° (range 5-12°) to valgus 2.6° (range 0-8°); p < 0.001) postoperatively. The radiological parameters presenting patellar positions, including the tibial slope, patellar convergence angle, and lateral tilt angle, did not change significantly between the preoperative values and the 2-year follow-up values. The mean patellar height significantly decreased (0.07 ± 0.14, p = 0.001 according to the Blackburn-Peel index and 0.32 ± 0.23, p < 0.001 using the modified Insall-Salvati ratio). The average tibial tubercle to trochlear groove (TT-TG) distance significantly decreased from 14.1 to 12.2 mm (p < 0.001). The Q angle also significantly decreased from 9.8o to 7.7o (p = 0.008). Chondral lesions of the patella and trochlear groove revealed significant deterioration; at 2 years after OWHTO, the arthritic grades of the PF joints worsened significantly, as determined by radiography (p = 0.007). Scintigraphic uptake in the PF joint was significantly lower (from 2 to 1) at 2 years postoperatively compared to that immediately after the index operation (p < 0.001). Only 4 of 56 (7.1%) patients showed increased uptake. Comparison between the improved and unimproved groups according to scintigraphic uptake changes revealed that the changes in the cartilage status on the patellar undersurface and TT-TG distance were the most significant predictive factors of increased scintigraphic uptake in the PF joint after OWHTO. CONCLUSION: Alignment correction by OWHTO result in PF compartment offloading and should be considered when identifying the surgical indications for OWHTO. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy.

PURPOSE: The objectives of this study were (1) to evaluate the clinical and radiologic outcomes of open-wedge high tibial osteotomy focusing on patellofemoral alignment and (2) to search for correlation between variables and patellofemoral malalignment. METHODS: A total of 46 knees (46 patients) from 32 females and 14 males who underwent open-wedge high tibial osteotomy were included in this retrospective case series. Outcomes were evaluated using clinical scales and radiologic parameters at the last follow-up. Pre-operative and final follow-up values were compared for the outcome analysis. For the focused analysis of the patellofemoral joint, correlation analyses between patellofemoral variables and pre- and post-operative weight-bearing line (WBL), clinical score, posterior slope, Blackburn Peel ratio, lateral patellar tilt, lateral patellar shift, and congruence angle were performed. RESULTS: The minimum follow-up period was 2 years and median follow-up period was 44 months (range 24-88 months). The percentage of weight-bearing line was shifted from 17.2 ± 11.1 to 56.7 ± 12.7%, and it was statistically significant (p < 0.01). Regarding the clinical results, statistical significance was observed using all scores (p < 0.01). In the radiologic evaluation, patellar descent was observed with statistical significance (p < 0.01). Last follow-up lateral patellar tilt was decreased with statistical significance (p < 0.01). In correlation analysis between variables of patellofemoral malalignment, the pre-operative weight-bearing line showed an association with the change in lateral patellar tilt and lateral patellar shift (correlation coefficient: 0.3). CONCLUSION: After open-wedge high tibial osteotomy, clinical results showed improvement, compared to pre-operative values. The patellar tilt and lateral patellar shift were not changed; however, descent of the patella was observed. Therefore, mild patellofemoral problems should not be a contraindication of the open-wedge high tibial osteotomy. LEVEL OF EVIDENCE: Case series, Level IV.

Effect of Metabolic Syndrome on the Outcome of Corticosteroid Injection for Trigger Finger: Matched Case-Control Study.

PURPOSE: To compare the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome (MS). METHODS: Fifty-one patients with trigger finger and MS were matched for age and sex with 52 control patients without MS. All patients were treated with a single corticosteroid injection. The response to treatment, including objective triggering, tenderness at the A1 pulley, and Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH) were assessed at 6, 12, and 24 weeks' follow-up. Before the 24-week evaluation, 7 in the MS group and 10 in the control group were lost to follow-up. RESULTS: Prior to treatment, patients with MS had Quinnell grades and initial mean QuickDASH scores similar to those in the control group. The proportion of treatment failure for the MS group (49%) was significantly higher than that of control group (19%) after 6 months' follow-up. Unresolved triggering was more prevalent in patients in the MS group at the 12- and 24-week follow-ups. Local tenderness was more persistent in the MS group than in the control group throughout the 24 weeks of follow-up. After 24 weeks of follow-up, 14 patients (27%) in the MS group and 6 (12%) in the control group underwent surgical release. QuickDASH scores of the MS group were worse than those of the control group at the 12- and 24-week follow-ups. CONCLUSIONS: Trigger finger patients with MS are at risk of poorer functional outcomes and treatment failure after a single corticosteroid injection than age- and sex-matched controls. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Analysis of the Causes of Elevated C-Reactive Protein Level in the Early Postoperative Period After Primary Total Knee Arthroplasty.

BACKGROUND: Measurement of C-reactive protein (CRP) levels as a screening test for acute periprosthetic joint infection has high sensitivity and low specificity. We performed the present study to analyze the causes of elevated CRP levels in the early postoperative period after primary total knee arthroplasty (TKA). This study is intended to help the postoperative care of patients through understanding the factors associated with postoperative elevation of CRP. METHODS: The records for 627 patients who underwent primary TKA between January 2005 and May 2013 were examined. We excluded 50 patients for whom TKA with inflammatory arthritis or revision TKA was performed. We measured serial CRP levels during the 4-week early postoperative period in all included cases to find the cases that showed a CRP pattern of elevation-depression-elevation (a bimodal pattern). We analyzed the causes of re-elevated CRP levels in patients with a bimodal pattern of CRP change. RESULTS: Of the 577 included patients, 76 showed bimodal CRP elevation patterns. Eighteen elevations were caused by postoperative infections (periprosthetic infection), 10 by cardiovascular problems, 11 by gastrointestinal problems, 12 by urologic problems, 10 by respiratory problems, and 15 had unknown origins. CONCLUSION: Our study shows that elevated CRP levels after TKA can have various causes. Although there may be other causes for an elevated CRP, it is essential to perform a work-up for prosthetic joint infections. In addition, there seems to be a need to evaluate noninfectious causes and infection of other sites, in addition to periprosthetic infection.

Concomitant posterior cruciate ligament injuries with direct injury-related patellar fractures.

INTRODUCTION: Posterior cruciate ligament (PCL) injuries and direct injury-related patellar fractures have similar causative factors. However, the mechanisms underlying these injuries differ. We aimed to evaluate the incidence and relationship between PCL injuries and direct injury-related patellar fractures. MATERIALS AND METHODS: Of the 195 patients diagnosed with a patellar fracture at our clinic during 2007-2011, 104 required surgical treatment and underwent the posterior drawer test under general anesthesia and magnetic resonance imaging. We assessed whether the causes of trauma, fracture classification, compression of the fracture fragment, and fracture displacement were related to the incidence of PCL injuries. RESULTS: Of the 104 patients, 26 had concomitant PCL injuries with direct injury-related patellar fractures. Most of the PCL injuries were grades 1 and 2, observed in 14 and 9 patients, respectively. Among three patients with grade 3 PCL injury, only two required PCL reconstruction. No significant relationship was observed between the causes of trauma and the incidence of PCL injury. According to the fracture classification, lower pole and comminuted fractures were associated with higher incidence rates of PCL injury than transverse and vertical fractures. Compressed and displaced patellar fractures were also associated with higher incidence rates of PCL injury. CONCLUSION: Although a PCL injury requiring surgical intervention was extremely rare, 25 % patients who required surgery for patellar fractures presented with a PCL injury. The incidence of a PCL injury was higher in the lower pole, comminuted, displaced, and compressed patellar fractures.

Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Patient comprehension of their injury, its treatment, and health care provider's instructions plays an important role in health management and recovery from trauma. PURPOSE OF THE STUDY: This study investigates the effects of health literacy (the ability to obtain, process, and understand health information needed to make appropriate health decisions) on treatment outcomes and satisfaction in patients with mallet finger injuries. METHODS: A total of 72 patients who had been treated with an orthosis for an acute mallet finger injury were enrolled in this prospective study. Health literacy was measured according to the newest vital sign during the initial visit, and adherence according to the treatment protocol was rated at week 7 when orthotic intervention was ceased. At 6 months, a follow-up visit was conducted to assess the extensor lag, treatment satisfaction, and disability (through the Quick Disabilities of the Arm, Shoulder, and Hand score). Bivariate and multivariable analyses were performed to determine whether patient demographics, injury characteristics, and health literacy factors accounted for following outcomes: extensor lag, satisfaction, and disability. RESULTS: The newest vital sign scores were moderately correlated with patient adherence and age. Extensor lag was associated with an increase in age, poor adherence, and low health literacy, and these 3 factors accounted for 28% of the variation in the extensor lag. A greater disability was associated with poor adherence, which accounted for 12% of the variance in disability. Lower treatment satisfaction was associated with low health literacy and poor adherence, and these 2 factors accounted for 21% of the variation in treatment satisfaction. DISCUSSION AND CONCLUSIONS: Limited health literacy was associated with poor adherence in orthosis care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction. LEVEL OF EVIDENCE: 2B.

A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures.

PURPOSE: To compare surgical outcomes of volar locking plates (VP) and external fixation (EF) (with or without intra-focal fixation) for AO-type C2 and C3 fractures of the distal radius. METHODS: From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were enrolled in a prospective, randomized study comparing volar plate fixation with external fixation (with or without intra-focal fixation), 74 patients were studied. The researchers evaluated functional assessments (wrist range of motion, grip strength, and Michigan Hand Questionnaire) at each patient visit and measured radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity) at 12 months. RESULTS: The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6 months. The range of motion was significantly greater in the VP group than in the EF group at 3 months. There were no significant differences in the range of motion and grip strength between the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group than in the EF group at 3 months but was same at 12 months. There was no significant difference between groups with respect to volar tilt or radial inclination. The VP group showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group and 3 in the EF group had an intra-articular stepoff deformity greater than 2 mm. This difference did not reach statistical significance. CONCLUSIONS: These results for functional recovery after distal radius surgery offer insight into treatment decisions and interpretations of treatment outcomes for patients with comminuted intra-articular distal radius fractures.

Effects of Metabolic Syndrome on the Outcome of Carpal Tunnel Release: A Matched Case-Control Study.

PURPOSE: To compare outcomes of carpal tunnel release in patients with or without metabolic syndrome. METHODS: In a prospective consecutive series, 35 patients with metabolic syndrome and surgically treated carpal tunnel syndrome (CTS) were age- and sex- matched with 37 control patients without metabolic syndrome. Grip, pinch strength, perception of touch with Semmes-Weinstein monofilament, and Boston Carpal Tunnel Questionnaires (BCTQ) were assessed preoperatively and at 3, 6, and 12 months postoperatively. RESULTS: Patients with metabolic syndrome had more severe electrophysiologic grade of CTS than those without metabolic syndrome, but the 2 groups had similar preoperative grip/pinch strength and BCTQ scores. The BCTQ symptom score for the metabolic syndrome group was significantly greater than that of the control group at 3 months, and the BCTQ function score of the metabolic syndrome group was significantly greater than that of the control group at 3 and 6 months' follow-up. However, there was no significant difference in BCTQ symptom or functional scores between groups at 12 months' follow-up. There was no significant difference in grip strength between groups through 12 months' follow-up whereas the pinch strength of the control group was significantly greater than that of the metabolic syndrome group at 12 months' follow-up. Semmes-Weinstein monofilament test results were significantly greater in the control group than in the metabolic syndrome group at 3 and 6 months' follow-up but were similar at 12 months. CONCLUSIONS: Patients with CTS and metabolic syndrome have delayed functional recovery after carpal tunnel release, but noteworthy improvements in symptom severity and hand function are similar to those in patients without metabolic syndrome 1 year after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Restoration of the anatomic position during a meniscal allograft transplantation using pre-existing landmarks.

INTRODUCTION: Accurate sizing and positioning of a meniscal allograft is an important factor for successful outcomes of meniscal allograft transplantation. The objectives of this study were (1) to search a proper rotational landmark, (2) to determine the sagittal slope of meniscus, and, thus (3) to determine the meniscal positioning. MATERIALS AND METHODS: A total of 121 consecutive patients who underwent magnetic resonance imaging in the 3 months prior to the beginning of the study were selected. To assess the meniscal rotation, rotation 0° line of the meniscus was defined as a line connecting the center of the anterior and the posterior horn of the medial and lateral meniscus, respectively. At this level, four possible reference lines were compared: Akagi line, line perpendicular to the largest mediolateral dimension (LMLD), line between the medial border of the patellar tendon and the apex of the medial tibial spine (PTMS), and line between the lateral border of the patellar tendon and the apex of the lateral tibial spine. To assess the meniscal slope, the slope of the insertional area, meniscal and bony slopes at the mid-plateau area were compared. RESULTS: Akagi line was significantly different with a true meniscal rotation (line connecting between centers of the anterior and posterior horns) in both medial and lateral meniscus (p < 0.01 and p < 0.01). LMLD was significantly different in the lateral meniscus (p < 0.01), however, no statistical difference was observed in the medial meniscus (n.s.). PTMS was not different in the medial meniscus (n.s.), however, it was different in the lateral meniscus (p < 0.01). On the medial side, significant statistical difference was observed between insertional and bony slope (p < 0.01) and between meniscal and bony slope (p < 0.01). On the lateral side, comparison of three slopes showed significant statistical differences (p < 0.01-p = 0.03). CONCLUSION: Line between patellar tendon and tibial spine was a good reference line for a meniscal rotation in the medial meniscus. Among previously introduced reference lines, LMLD showed approximity with a true meniscal rotation. The slope between tibial insertion and mid-portion was significantly different in the lateral meniscus.

Serial assessment of weight-bearing lower extremity alignment radiographs after open-wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to perform a serial assessment of the radiologic parameters of the mechanical axis (MA) and the weight-bearing line (WBL) using a weight-bearing anteroposterior (AP) long-standing view of the lower extremity to determine whether the postoperative MA and WBL change with time. METHODS: A total of 90 consecutive lower limbs were examined retrospectively from a weight-bearing AP long-standing view of the lower extremity obtained from 120 patients who underwent open-wedge high tibial osteotomy (OWHTO). A total of 30 patients were excluded because of (1) complications (7 patients) such as bone graft collapse or broken screws, malunion, or nonunion arising after surgery and (2) no acquisition of a regular series of weight-bearing AP long-standing views of the lower extremity (23 patients). The AP long-standing view of the lower extremity was taken, and weight-bearing AP long-standing views of the lower extremity at 1 month, 6 months, 1 year, and 2 years postoperatively were used for assessment of serial change. The Picture Archiving Communication System (Marotech, Inc, St-Augustin-de-Desmaures, Quebec, Canada) was used for radiologic measurements of the WBL ratio and MA. Serial changes were compared between 1 month, 6 months, 1 year, and 2 years postoperatively. RESULTS: The WBL ratio progressively shifted medially, with significant changes at all time points until 1 year postoperatively (1 month to 6 months, P = .04; 6 months to 1 year, P = .04; 1 year to 2 years, P = .22). Even though the MA angle showed a similar decreasing trend, it showed no statistical difference (P > .05). CONCLUSIONS: This study showed that after OWHTO, the WBL shifts progressively medially until 1 year postoperatively. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Comparison of femoral tunnel widening between outside-in and trans-tibial double-bundle ACL reconstruction.

PURPOSE: The objectives of this study were to compare (1) the degree of widening by comparing the diameter at the most widened area and the site of widening by measuring the distance from the tunnel entrance to the most widened area in two femoral tunnels (anteromedial and posterolateral), and (2) the morphologic change at the tunnel entrance between outside-in and trans-tibial double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective study that included 17 trans-tibial and 19 outside-in double-bundle ACL reconstructed patients was conducted for evaluation of serial computed tomography (CT) scan (immediate post-operation and post-operative 1 year). Digital image communication in medicine (DICOM) data was extracted from the PiViewSTAR and imported into OsiriX, which was installed on a Macbook Pro laptop computer. Diameter of the most widened area and distance from the entrance to this point were measured from each of two perpendicular (sagittal and coronal) planes that were accurately realigned parallel to the tunnel direction. Change in the morphology of the tunnel entrance between immediate post-operation and 1-year post-operation was evaluated. RESULTS: Widening was observed in both planes of both tunnels in the two techniques. However, no statistical significances in the diameter of most widened area and distance from the tunnel entrance to the most widened point were observed between the both techniques (n.s.). Distances from the centre point to each four sections showed an increase in all four sections of all both tunnels in both techniques. However, no statistical significance was observed between the two techniques (n.s.). CONCLUSION: Widening was observed in all tunnels using both techniques and degrees, and sites of the widening did not differ between groups. Morphologic change at the tunnel entrance was not limited to the specific direction and occurred in all directions without significant difference between groups. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Comparison of anatomic ACL reconstruction between selective bundle reconstruction and double-bundle reconstruction.

PURPOSE: The objective of this study was to compare the clinical and radiologic results of preserved ligament remnants in the selective bundle anterior cruciate ligament (ACL) reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction in order to confirm the evidence of selective bundle reconstruction. METHODS: This retrospective comparative study was conducted for comparison between preserved ligament remnants in the selective bundle ACL reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction. From 2008 to 2010, 16 patients (group I) underwent selective bundle ACL reconstruction and 30 patients (group II) underwent double-bundle ACL reconstruction. Clinical, stability and radiologic results (tunnel locations of femoral tunnels using 3-D computed tomography and graft signal intensity using magnetic resonance imaging) were compared. RESULTS: In comparison with functional results, no statistical differences in the Lysholm, Tegner and International Knee Documentation Committee scores were observed between the two groups (n.s.). In comparison with stability results between the two groups, no statistical differences were observed in the Lachman, pivot shift and anterior drawer stress tests using a Telos device at 30° and 90° flexed positions (n.s.). In evaluation of the femoral tunnel location, no statistical significant differences in the tunnel position were observed between the groups (n.s.). No statistically significant differences in signal intensity were observed between the two groups (n.s.). CONCLUSIONS: Compared to the double-bundle ACL reconstruction, selective bundle ACL reconstruction produced comparable clinical and radiologic results. Selective bundle ACL reconstruction could be performed instead of double-bundle ACL reconstruction if some intact bundle exists. LEVEL OF EVIDENCE: Comparative study, Level III.

Lateral tibial bone mineral density around the level of the proximal tibiofibular joint.

PURPOSE: During open-wedge high tibial osteotomy, fracture occurring in the insufficient osteotomy before distraction of the osteotomy gap is an important complication. The objective of this study was to evaluate bone mineral density (BMD) around the proximal tibiofibular joint (PTFJ) and the osteotomy hinge. The hypotheses of this study were (1) BMD would be higher in the level of PTFJ, compared with that of above--or below--the level of PTFJ, (2) BMD of the posterolateral side of the hinge would be higher than that of the anterior or lateral side. METHODS: Computed tomography was used to determine the BMD of the lateral aspect of the proximal tibia around the PTFJ and the osteotomy hinge. The means and standard deviations of the regions of interest were measured. To verify the first hypothesis, a coronal reconstructed image showing the beginning of the fibula head was used and an axial reconstructed image showing the beginning of the fibula head was used for verification of the second hypothesis. RESULTS: BMD of the lateral aspect of the proximal tibia at the level of the PTFJ was significantly higher, compared with that of above (P = 0.04)-or below (P < 0.01)--the level of the PTFJ in male patients. In addition, it was also significantly higher, compared with that of below the level of the PTFJ (P < 0.01). BMD of the posterolateral area of the proximal tibia was significantly higher than that of the anterior or lateral area in both male and female patients (P < 0.01). CONCLUSION: BMD of the level of the PTFJ was higher, compared with that of above-or below-the level of the PTFJ and that of the posterolateral area of the proximal tibia was significantly higher, compared with that of the anterior or lateral area.

Sagittal and coronal plane location of the popliteal artery in the open-wedge high tibial osteotomy.

PURPOSE: The objectives of this study were (1) to evaluate the sagittal and coronal plane location of the popliteal artery during the advancement of open-wedge high tibial osteotomy and (2) to confirm the effect of osteoarthritis if it changes the relationship between the popliteal artery and posterior cortex. METHODS: Two hundred consecutive patients were enrolled, and we divided patients into two subgroups according to age and cartilage status in the radiologic report of magnetic resonance imaging (group I: 100 non-arthritic knees; group II: 100 arthritic knees). For prediction of the location of the popliteal artery during the operation, sagittal and coronal plane location along the osteotomy plane was evaluated. RESULTS: The distance between the posterior cortex of the osteotomy and popliteal artery was 13-14 mm on the sagittal plane, and the popliteal artery was located at an approximately 35 ± 5.5 mm portion from the starting point of the osteotomy on the coronal plane. The distance at the starting point of osteotomy was larger than at the end portion and prominent area. In comparison between groups I and II, group II showed a larger distance on the sagittal planes [osteotomy-vascular: 13.6 vs 14.4 (p = 0.01), fibula-vascular: 4.88 vs 6.5 (p < 0.01), and prominence-vascular: 4.3 vs 5.3 (p < 0.01)] compared to the group I. CONCLUSIONS: Special caution and some protection should be given until the approximately 35 mm portion from the starting point of the posteromedial cortex with consideration for the approximity on the sagittal plane. In comparison between the non-arthritic and arthritic knee, differences were observed on the sagittal plane. However, the value was minimal, and the clinical relevance was questionable. LEVEL OF EVIDENCE: Case series, Level IV.

Factors delaying recovery after volar plate fixation of distal radius fractures.

PURPOSE: To evaluate the factors influencing delayed functional recovery in patients with a distal radius fracture treated by volar plate fixation. METHODS: A total of 122 patients with a distal radius fracture treated by volar locking plate were enrolled. The wrist range of motion, grip strength, and functional outcome by the Michigan hand score were assessed 3, 6, and 12 months after surgery. The factors assessed for their influence on delayed functional recovery include age, sex, bone mineral density (BMD), hand dominance, the type of fracture, the energy of trauma, the time to surgery, and the duration of immobilization. A multivariate regression analysis was conducted to identify independent predictors of delayed functional recovery in terms of the Michigan hand score. RESULTS: There was a significant decrease in the wrist range of motion in patients with a high-energy trauma, severe type fracture, or increase in duration of immobilization at month 3, whereas only a severe fracture type was associated with a decreased range of motion after 6 and 12 months. An increase in age, a decrease in BMD, and high-energy trauma reduced grip strength at months 3 and 6, whereas only an increase in age and a decrease in BMD reduced grip strength at month 12. According to the multivariate regression analysis, severe type fracture and high-energy trauma reduced functional outcomes at months 3 and 6. Conversely, at month 12, an increase in age and a decrease in BMD reduced functional outcome. CONCLUSIONS: An increase in age and a decrease in BMD were important risk factors influencing delayed functional recovery up to 12 months after distal radius fracture surgery, whereas fracture severity and high-energy trauma were associated with decreased functional outcomes up to 6 months after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Effect of anxiety and catastrophic pain ideation on early recovery after surgery for distal radius fractures.

PURPOSE: To evaluate the effects of preoperative anxiety and catastrophic pain ideation on perceived disability and objective measures after distal radius fracture surgery. METHODS: A total of 121 patients with distal radius fractures treated with volar plate fixation were enrolled. The wrist range of motion (ROM), grip strength, and perceived disability as measured by the Michigan Hand Questionnaire (MHQ) score were assessed 4, 12, and 24 weeks after surgery. To evaluate psychological factors related to pain, catastrophic pain ideation was measured using the Pain Catastrophizing Scale (PCS) and pain anxiety was measured using the Pain Anxiety Symptom Scale (PASS). Then relative contributions of pain anxiety and catastrophic pain ideation and other clinical parameters to functional recovery in terms of grip strength, ROM, and MHQ score were assessed. RESULTS: An increase in the PCS score was associated with the wrist ROM and grip strength only at week 4, whereas an increase in the PASS score was associated with the wrist ROM at week 4 and grip strength at weeks 4 and 12. According to a multivariate regression analysis, an increase in the PCS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4; and an increase in the PASS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4 and grip strength and MHQ score at week 12. At week 24, only age and fracture severity were associated with the MHQ score. In addition, age was associated with grip strength and fracture type was associated with ROM. CONCLUSIONS: Preoperative PCS and PASS were significantly associated with delayed recovery as evidenced by scores on both objective and subjective measures of function. Given these relationships, it becomes important to assess preoperative PCS and PASS and address issues for patients at risk with brief psychosocial intervention early in the recovery process. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Tibial component coverage based on bone mineral density of the cut tibial surface during unicompartmental knee arthroplasty: clinical relevance of the prevention of tibial component subsidence.

INTRODUCTION: An optimally implanted tibial component during unicompartmental knee arthroplasty would be flush with all edges of the cut tibial surface. However, this is often not possible, partly because the tibial component may not be an ideal shape or because the ideal component size may not be available. In such situations, surgeons need to decide between component overhang and underhang and as to which sites must be covered and which sites could be undercovered. The objectives of this study were to evaluate the bone mineral density of the cut surface of the proximal tibia around the cortical rim and to compare the bone mineral density according to the inclusion of the cortex and the site-specific matched evaluation. MATERIALS AND METHODS: One hundred and fifty consecutive patients (100 men and 50 women) were enrolled in this study. A quantitative computed tomography was used to determine the bone density of the cut tibial surface. Medial and lateral compartments were divided into anterior, middle, and posterior regions, and these three regions were further subdivided into two regions according to containment of cortex. The site-specific matched comparison (medial vs. lateral) of bone mineral density was performed. RESULTS: In medial sides, the mid-region, including the cortex, showed the highest bone mineral density in male and female patients. The posterior region showed the lowest bone mineral density in male patients, and the anterior and posterior regions showed the lowest bone mineral density in female patients. Regions including cortex showed higher bone mineral density than pure cancellous regions in medial sides. In lateral sides, posterior regions including cortex showed highest bone mineral density with statistical significance in both male and female patients. The anterior region showed the lowest bone mineral density in both male and female patients. CONCLUSION: The mid-region of the medial side and the posterior region of the lateral side are relatively safe without cortical coverage when the component is not flush with all edges of the tibia. Cortical coverage is strongly recommended for the prevention of subsidence of the tibial component in the posterior region of the medial side, and in the anterior region of the lateral side.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture.

PURPOSE: Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF. METHODS: A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I. RESULTS: Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively). CONCLUSIONS: High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Reliability and validity of carpal alignment measurements in evaluating deformities of scaphoid fractures.

PURPOSE: Several radiographic carpal alignment indices are used to evaluate the deformities of scaphoid fractures. The purpose of this study was to determine the reliabilities and validities of radiographic carpal alignment indices commonly used to evaluate deformities of scaphoid fractures. METHODS: Thirty-six patients with a scaphoid fracture were evaluated. Five carpal alignment indices were assessed on lateral plain radiographs, namely, scapholunate angle, radioscaphoid angle, radiolunate angle, radiocapitate angle, and capitolunate angle. Three examiners measured these radiographic indices at two sessions, and intraobserver and interobserver reliabilities were determined and expressed as intraclass correlation coefficients. Discriminant validities of radiographic carpal alignment indicies between injured and uninjured wrists were evaluated. For convergent validity testing, the correlation between the radiographic carpal alignment indices and intrascaphoid angles (ISAs) or height-to-length (HL) ratios on CT longitudinal scans was assessed. Further, carpal alignment indices after surgical reconstruction were compared to the Mayo wrist score. RESULTS: Scapholunate and radiolunate angles had the highest reliabilities, and radiocapitate angle had the lowest. Radiolunate angle had the highest discriminant validity followed by scapholunate, and capitolunate angles. In convergent validity testing, scapholunate angles and radiolunate angles correlated with ISA angles, and radiolunate and capitolunate angles correlated with HL ratios. Only the radiolunate angles correlated with the Mayo wrist scores. CONCLUSIONS: Among radiographic carpal alignment measures, radiolunate angle is the most reliable and valid carpal alignment index for evaluating deformities of scaphoid fractures. Scapholunate and capitolunate angles could be used as an alternative, but have less validity.

Foot drop secondary to peroneal intraneural cyst arising from tibiofibular joint.

UNLABELLED: An 11-year-old boy presented to our outpatient clinic with a three-month history of pain over the fibular head area and gait difficulty. Surgical exploration revealed a mass arising from the superior tibiofibular joint invading the peroneal nerve along the articular branch of the common peroneal nerve. The pathogenesis of the intraneural ganglion of the peroneal nerve may be an articular origin and superior tibiofibular joint is the central point. LEVEL OF EVIDENCE: V.