Proximal row carpectomy with interposition arthroplasty using both capsular flap and acellular human dermal matrix.

BACKGROUND: In cases of wrist arthritis, proximal row carpectomy (PRC) has been widely utilized and shown favorable long-term outcomes. However, its applicability is limited in cases where arthritis extends to the lunate fossa or capitate. Recently, surgical approaches combining various methods of interposition arthroplasty have been introduced to overcome these drawbacks. The purpose of this study was to perform PRC and interposition arthroplasty with dorsal capsule and acellular dermal matrix(ADM),and analyze the clinical outcomes of these procedures. METHODS: Fourteen cases who underwent PRC and interposition arthroplasty using both dorsal capsular flap and ADM were retrospectively recruited. The researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), retear, and radiocarpal distance (RCD). RESULTS: One year post-surgery, both the VAS pain scores, DASH scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the postoperative mean RCD was 4.8 ± 0.8 mm and one year follow up mean RCD was 3.6 ± 0.5 mm at one year post-surgery. Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases. CONCLUSION: The PRC and interposition arthroplasty with ADM demonstrated significantly improved clinical outcomes after surgery, showing a maintain of RCD without graft failure effectively.

Arthroscopic Medialization Partial Repair with Biologic Interposition Tuberoplasty for Large to Massive Irreparable Rotator Cuff Tear.

An irreparable rotator cuff tear is a challenging condition to treat, and various treatment modalities are being introduced. Medialization in the partial repair method has the limitation of exposing the tuberosity, while tension-free biologic interposition tuberoplasty using acellular dermal matrix has the limitation of exposing the humeral head. The authors believe that by combining these two techniques, it is possible to complement each other's limitations. Therefore, they propose a surgical method that combines medialization and biologic interposition tuberoplasty for addressing these constraints.

Combination of arthroscopic biologic tuberoplasty and bursal acromial reconstruction.

Background: Recently, among the various method for irreparable rotator cuff tears, the "tension-free allodermis graft technique" has been introduced as a method for arthroscopic biologic tuberoplasty(ABT) and bursal acromial reconstruction(BAR).The objective was to analyze the outcomes of ABT and BAR combination surgical technique. Methods: Eighteen cases who underwent simultaneous ABT and BAR procedures were retrospectively recruited. Before the surgery and at one year post-surgery, the researchers assessed the patients' Visual Analog Scale(VAS), American Shoulder and Elbow Surgeons(ASES) scores, pain scores, range of motion(ROM), retear, and acromiohumeral distance (AHD). Results: One year post-surgery, both the VAS pain scores, ASES scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the AHD significantly improved from 4.3 ± 4.1 mm before surgery to 9.2 ± 1.9 mm at one year post-surgery (p < 0.001). Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases. Conclusion: The combination of ABT and BAR demonstrated significantly improved clinical outcomes after surgery, showing a substantial increase in AHD and preventing graft failure effectively.

Assessment of the efficacy of the far cortical locking technique in proximal humeral fractures: a comparison with the conventional bi-cortical locking technique.

BACKGROUND: Locking plate fixation is one of the treatment strategies for the management of proximal humeral fractures. However, stiffness after locking plate fixation is a clinical concern. The mechanical stiffness of the standard locking plate system may suppress the interfragmentary motion necessary to promote secondary bone healing by callus formation. The far cortical locking (FCL) technique was developed to address this limitation in 2005. FCL increases construct flexibility and promotes callus formation. Our study aimed to evaluate the clinical and radiological outcomes of the FCL technique when implemented in proximal humeral fracture management. Furthermore, we compared the surgical outcomes of FCL with those of the conventional bicortical locking (BCL) screw fixation technique. METHODS: Forty-five consecutive patients who had undergone locking fixation for proximal humeral fractures were included in this study. A proximal humeral locking plate (PHILOS) system with BCL screw fixation was used in the first 27 cases, and the periarticular proximal humeral locking plate with FCL screw fixation was used in the final 18 consecutive cases. Functional capacity was assessed using the constant score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion. Radiographic outcomes were evaluated using the Paavolainen method of measuring the neck-shaft angle (NSA). RESULTS: No significant differences in clinical outcomes (ASES score, constant score, and range of motion) were found between the two groups. The union rate at 12 weeks was significantly higher in the FCL group (94.4%) than in the BCL group (66.7%, p = 0.006). No significant differences in NSA were found between the two treatment strategies. The complication rate was not significantly different between the two groups. CONCLUSIONS: When implemented in proximal humeral fractures, the FCL technique showed satisfactory clinical and radiological outcomes as compared with the conventional BCL technique. The bone union rate at 12 weeks after surgery was significantly higher in the FCL group than in the BCL group. However, no significant difference in the final bone union rate was found between the two groups.

Comparative analysis of a locking plate with an all-suture anchor versus hook plate fixation of Neer IIb distal clavicle fractures.

BACKGROUND: The coracoclavicular fixation with suture anchors adds stability to type IIb distal clavicle fractures fixed with a plate and screws when loaded to failure. The purpose of this study was to compare the clinical and radiological outcomes between the use of a locking compression plate (LCP) with all-suture anchor fixation and hook LCP fixation of Neer IIb distal clavicle fractures. METHODS: A total of 82 consecutive patients who underwent plate fixation for Neer IIb distal clavicle fractures were included. The subjects were divided into two groups: an LCP with all-suture anchor fixation group and hook LCP fixation group. For clinical assessments, the American Shoulder and Elbow Surgeons score, Korean shoulder score (KSS), and Constant score were recorded. A percentage of the coracoclavicular distance (CCD%) was used to evaluate fracture reduction. Typical reported complications, such as secondary dislocation, implant failure or loosening, peri-implant fracture, acromion osteolysis, stiffness, peri-anchor osteolysis, postoperative acromioclavicular joint arthrosis, nonunion, or delayed union, were also analyzed. RESULTS: There were no differences in the clinical and radiological outcomes at the final follow-up between the two groups. The period for bone union and CCD% showed no significant differences between groups. Stiffness at 3 months after surgery of LCP with all-suture anchor fixation (n = 3, 10.7%) was less than that of hook LCP fixation (n = 17, 31.5%). The complication rate also showed no significant differences between groups. However, LCP with all-suture anchor fixation had anchor-related complications, although it can reduce hook-related complications. CONCLUSION: LCP with all-suture anchor fixation showed satisfactory outcomes in comparison with hook LCP fixation. In Neer IIb distal clavicle fractures, LCP with all-suture anchor fixation is a useful method for the maintenance of reduction, avoiding implant removal, and hook-related complications. However, anchor fixation should be carefully used, especially in osteoporotic patients or patients with underlying diseases. LEVEL OF EVIDENCE: Level III, retrospective study.

Comparison between hook plate fixation with and without coracoclavicular ligament suture for acute acromioclavicular joint dislocations.

BACKGROUND: Hook plates are widely used for repair of acromioclavicular joint (ACJ) dislocations. However, it is unclear whether repair of torn coracoclavicular (CC) ligament is necessary. The purpose of this study was to evaluate the outcomes of the hook plate fixation with direct CC ligament repair for acute ACJ dislocation in comparison with the hook plate fixation without direct CC ligament repair. METHODS: The study included 120 patients with acute ACJ dislocations who underwent surgery. The patients were divided into 73 patient groups with Arbeitsgemeinschaft für Osteosynthesefragen (AO) hook plate fixation and direct CC ligament repair and 47 patient groups without direct CC ligament repair. For clinical assessments, the American Shoulder and Elbow Surgeons score, constant score, and time for implant removal were recorded. The corcoclavicular distance (CCD) and the CCD ratio were used for the evaluation of reduction. Typical reported complications, such as secondary dislocation, implant failure or loosening, peri-implant fracture, acromion osteolysis, and postoperative ACJ arthrosis, were also analyzed. RESULTS: There were no differences in the clinical outcomes between the two groups. There was no difference in the timing of implant removal between the two groups. The last follow-up CCD was not statistically significant between group with direct CC ligament repair and without repair (9.1 ± 3.3 vs. 9.0 ± 2.8, respectively, p > 0.05). The last follow-up CCD ratio showed significant differences between the two groups (12.6 ± 25.5% vs. 26.3 ± 39.7, respectively, p < 0.05). There was no statistically significant difference in the complication rate between the two groups. CONCLUSION: The hook plate fixation with direct CC ligament repair group was better for maintenance of reduction than that of the hook plate fixation without direct CC ligament repair group. Although, there were no differences of clinical outcomes and complications between two groups. LEVEL OF EVIDENCE: Level III, Retrospective Study.

Clinical outcomes of arthroscopic lateral ulnar collateral ligament repair with or without intra-articular fracture.

BACKGROUND: The pathoanatomy and biomechanics of elbow instability have been previously reported; however, few researchers have dealt with the operative management and clinical consequence of recurrent elbow instability. Recent studies on arthroscopic lateral collateral ligament (LCL) complex repair have reported successful outcomes similar to those achieved by open repair. We aimed to determine the validity of arthroscopic repair of the LCL complex in elbows with unstable dislocation with or without intra-articular fracture. METHODS: Eighteen consecutive patients who had undergone arthroscopic repair of the LCL complex for unstable dislocation of the elbow with or without intra-articular fracture and who were followed for at least 12 months were included in the study. Ligament injury combined with coronoid and/or radial head fractures were treated with arthroscopic technique. Pain, range of motion, clinical outcomes based on the Mayo Elbow Performance Score (MEPS), and surgical complications were evaluated. RESULTS: At 12 months follow-up, all 18 patients demonstrated complete settlement of the instability and mean (and standard deviation) extension of 1.7 ± 3.8°, flexion of 138.3 ± 3.8°, supination of 88.6 ± 5.3°, and pronation of 88.2 ± 5.6°. The average MEPS was 97.7 ± 3.9 points and according to this validated outcome score. However, slight widening (2 mm) of the radiocapitellar joint space was accompanied in one patient, although the varus stress test and pivot shift test were not observed. One patient showed delayed union of the anteromedial facet fracture, and two patients showed pin site irritation, which was a complication of arthroscopic coronoid fracture fixation and was fully resolved after pin removal. CONCLUSION: In patients with unstable elbow dislocation, with or without an intra-articular fracture, arthroscopic repair of the LCL complex is an effective and alternative treatment option that can restore elbow stability and have satisfactory clinical and radiographic results.

New predictors for subscapularis tear: Coraco-lesser tuberosity angle, lesser tuberosity angle, and lesser tuberosity height.

BACKGROUND: The pathogenesis of degenerative subscapularis (SC) tear is not clear, several mechanisms are involved: intrinsic tendon degeneration or subcoracoid impingement. The aim of this study was to propose new radiographic markers, the coraco-lesser tuberosity angle (CLA), lesser tuberosity angle (LTA) and lesser tuberosity height (LTH). The hypothesis was that higher values of CLA, LTA, and LTH would be associated with a higher likelihood in detecting a SC tear. METHOD: A total of 114 patients who classified as SC tears through arthroscopic evaluation were retrospectively enrolled in the study from 2016 to 2018. Fifty-seven patients with impingement syndrome were also enrolled as the control group for normal-population comparison. The CLA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation, the LTA and LTH were measured on magnetic resonance imaging. Multivariable analyses were used to clarify the potential risks for SC tears. All measurements were calculated by two shoulder surgeons independently measured at 2 different times, 1 month apart. RESULTS: The intra- and inter-observer reliabilities for radiologic measurements and the interobserver reliability of SC tear classification were almost perfect. The mean CLA value of SC tear group (41.4±4.2°) was significantly larger than that of the control group (38.7±4.0°, p<0.001). The mean LTA value of SC tear group (33.4±4.3°) was significantly larger than that of the control group (31.0±3.9°, p=0.001). Mean LTH value was 9.5±1.9mm in patients and 8.9±1.5mm for controls, there was no statistically significant difference (p=0.054). Multivariable analysis showed that larger CLAs significantly increased the risk of SC tears, with odds ratios of 1.17 per degree. Moreover, larger LTAs also significantly increased the risk of SC tears, with odds ratios of 1.14 per degree. CONCLUSION: Our findings confirmed associations between new predictors (CLA and LTA) and SC tears. CLA and LTA values were greater in patients with SC tears than in controls, suggesting that they may be independent risk factors for SC tear onset. LEVEL OF EVIDENCE: IV, retrospective study.

Coracoid clavicular tunnel angle is related with loss of reduction in a single-tunnel coracoclavicular fixation using a dog bone button in acute acromioclavicular joint dislocation.

PURPOSE: Despite the high failure rates of techniques used to maintain the reduction of single-tunnel coracoclavicular (CC) fixation, analyses of the etiology of loss of reduction related to surgical techniques are limited. Therefore, it was hypothesized that the initial coracoclavicular tunnel angle was related to loss of reduction in the single-tunnel technique for AC joint dislocation. This study aimed to evaluate the clinical and radiological outcomes of arthroscopic single-tunnel CC suture button fixation according to the initial coracoclavicular tunnel angle. METHODS: Thirty-two consecutive patients who underwent arthroscopic single-tunnel CC suture button fixation for AC joint dislocation from 2014 to 2018 were enrolled. The tunneling-first technique was used in the first 11 patients, while the reduction-first technique was used in the remaining 22 consecutive patients. For clinical assessments, the American Shoulder and Elbow Surgeons (ASES) score and Korean Shoulder Score (KSS) were recorded. For radiological evaluation, coracoclavicular distance ratio, coracoclavicular tunnel angle, coracoid, and clavicular tunnel widths were measured. RESULTS: The ASES score did not differ significantly between the two groups (n.s.). However, the KSS was significantly better in the reduction-first group (p = 0.031). No significant intergroup differences were observed in the pre- and postoperative coracoclavicular distance ratio. However, at the last follow-up, loss of coracoclavicular distance ratio was significantly smaller in the reduction-first group (p < 0.001). At the final follow-up, loss of the coracoclavicular distance ratio was positively correlated with the postoperative coracoclavicular tunnel angle (p < 0.001, Spearman's rho correlation coefficient = 0.602). The final follow-up clavicular tunnel width was also significantly smaller in the reduction-first group (p = 0.002). Finally, the last follow-up clavicular tunnel width was positively correlated with the postoperative coracoclavicular tunnel angle (p = 0.008, Spearman's rho correlation coefficient = 0.459). CONCLUSION: The reduction-first technique showed better clinical and radiological outcomes than the tunneling-first technique in single-tunnel CC fixation for AC joint dislocation. A large postoperative coracoclavicular tunnel angle was associated with loss of reduction and clavicular tunnel widening. Therefore, obtaining a straight coracoclavicular tunnel angle is crucial for achieving better outcomes and minimizing loss of reduction. LEVEL OF EVIDENCE: III.

Clinical outcomes of dual 3.5-mm locking compression plate fixation for humeral shaft fractures: Comparison with single 4.5-mm locking compression plate fixation.

BACKGROUND: Recently, several in vitro biomechanical studies that used dual small locking plate fixation for humeral shaft fractures have investigated. However, in vivo studies about dual plate fixation for humeral shaft fractures are limited. The purpose of our study was to report the outcomes of dual small plating for humeral shaft fractures in comparison with those of single large fragment plating. METHODS: Sixty consecutive patients who underwent an open reduction internal fixation for humeral shaft fractures at our institution from September 2014 to December 2017 were included. Single 4.5-mm locking compression plate (LCP) fixation was used in the first 40 cases, and dual 3.5-mm LCP fixation was used in the final 20 consecutive cases. Data were collected to define patient characteristics, injury mechanism, clinical outcomes, time to surgery, operative time, estimated blood loss, and complications. Using simple radiography during the follow-up period (6, 12, 24, and 52 weeks after surgery), the shoulder and elbow joint ranges of motion (ROM) were also evaluated. RESULTS: Demographic data, time to surgery, surgical time, and estimated blood loss had no significant differences between the two groups. No significant differences were observed in nonunion rate and union rate 3 months after surgery. However, two patients (5%) in the single 4.5-mm LCP fixation group showed metal failure and breakage. No significant differences were found in postoperative shoulder and elbow ROM. Three patients (7.5%) in the single plating group and one patient (5%) in the dual plating group developed radial nerve palsy after surgery. No vascular injury and deep infection were observed in either group. CONCLUSION: For diaphyseal humeral fractures, dual 3.5-mm LCP fixation to the humerus is a possible treatment choice. This method showed satisfactory union rate, ROM, and complication rate, without increasing surgical time, in comparison with the conventional single 4.5-mm LCP fixation. Level of evidence: III.

The supraspinatus occupation ratios of both the ≥ 50% articular- and bursal-side partial-thickness rotator cuff tears were low and the infraspinatus occupation ratio of the ≥ 50% bursal-side partial-thickness rotator cuff tears was low.

PURPOSE: The purpose of this study was to analyze the relationship between the occupation ratio and partial-thickness rotator cuff tears. METHODS: The study included and retrospectively investigated 683 patients with partial-thickness rotator cuff tears between 2013 and 2017. Fifty patients with impingement syndrome were also enrolled as the control group for normal-population comparison. The participants were divided into five groups: Group A, control group; Group B, < 50% articular-side tears; Group C, ≥ 50% articular-side tears; Group D, < 50% bursal-side tears; and Group E, ≥ 50% bursal-side tears. Muscle volume was evaluated by measurement of each occupation ratio of the supraspinatus and infraspinatus tendons on the most lateral view of the T1-weighted oblique-sagittal images in which the scapular spine remained in contact with the scapular body. RESULTS: Fifty patients were enrolled in Group A. A total of 683 patients with Partial thickness rotator cuff tear were divided and classified into the following groups: 272 into Group B, 153 into Group C, 161 into Group D, and 97 into Group E. The supraspinatus occupation ratios of all partial-thickness rotator cuff tear groups were significantly lower than those of the control group. Furthermore, the supraspinatus occupation ratios of Groups C and E (≥ 50% partial-thickness rotator cuff tears) were significantly lower than those of Groups B and D (< 50% partial-thickness rotator cuff tears). However, the infraspinatus occupation ratio of only Group E was significantly lower than that of the other groups. CONCLUSION: The supraspinatus occupation ratios of both the ≥ 50% articular- and bursal-side partial-thickness rotator cuff tears were lower than those of the other partial-thickness rotator cuff tears. Conversely, the infraspinatus occupation ratio of only the ≥ 50% bursal-side partial-thickness rotator cuff tears was low. LEVEL OF EVIDENCE: IV.

Effect of Surgical-Site, Multimodal Drug Injection on Pain and Stress Biomarkers in Patients Undergoing Plate Fixation for Clavicular Fractures.

BACKGROUND: Surgical-site, multimodal drug injection has recently evolved to be a safe and useful method for multimodal pain management even in patients with musculoskeletal trauma. METHODS: Fifty consecutive patients who underwent plating for mid-shaft and distal clavicular fractures were included in the study. To evaluate whether surgical-site injections (SIs) have pain management benefits, the patients were divided into two groups (SI and no-SI groups). The injection was administered between the deep and superficial tissues prior to wound closure. The mixture of anesthetics consisted of epinephrine hydrochloride (HCL), morphine sulfate, ropivacaine HCL, and normal saline. The visual analogue scale (VAS) pain scores were measured at 6-hour intervals until postoperative hour (POH) 72; stress biomarkers (dehydroepiandrosterone sulfate [DHEA-S], insulin, and fibrinogen) were measured preoperatively and at POH 24, 48, and 72. In patients who wanted further pain control or had a VAS pain score of 7 points until POH 72, 75 mg of intravenous tramadol was administered, and the intravenous tramadol requirements were also recorded. Other medications were not used for pain management. RESULTS: The SI group showed significantly lower VAS pain scores until POH 24, except for POH 18. Tramadol requirement was significantly lower in the SI group until POH 24, except for POH 12 and 18. The mean DHEA-S level significantly decreased in the no-SI group (74.2 ± 47.0 µg/dL) at POH 72 compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). There was no significant difference in the insulin and fibrinogen levels between the groups. The correlation values between all the biomarkers and VAS pain scores were not significantly different between the two groups (p > 0.05). CONCLUSIONS: After internal fixation of the clavicular fracture, the surgical-site, multimodal drug injection effectively relieved pain on the day of the surgery without any complications. Therefore, we believe that SI is a safe and effective method for pain management after internal fixation of a clavicular fracture.

Editorial Commentary: The Practical Goal of Arthroscopic Osteosynthesis for the Treatment of Unstable Scaphoid Nonunion.

Arthroscopic reduction with osteosynthesis using bone grafting has become a successful alternative to open techniques for the treatment of chronically unstable scaphoid nonunions. Several studies have demonstrated that arthroscopic techniques are safe and reproducible in addition to causing less soft tissue damage and providing promising short- and mid-term results. However, these techniques have limitations in restoring normal carpal alignment, especially in patients with unstable scaphoid nonunion and carpal collapse deformities, although this does not affect the recovery of clinical function. Therefore, the practical goal of arthroscopic technique should be kept in mind when treating unstable scaphoid nonunions.

What Is the Most Effective Eccentric Stretching Position in Lateral Elbow Tendinopathy?

BACKGROUND: A variety of treatment options suggest that the optimal treatment strategy for lateral elbow tendinopathy (LET) is not known, and further research is needed to discover the most effective treatment for LET. The purpose of the present study was to verify the most effective position of eccentric stretching for the extensor carpi radialis brevis (ECRB) in vivo using ultrasonic shear wave elastography. METHODS: A total of 20 healthy males participated in this study. Resting position was defined as 90° elbow flexion and neutral position of the forearm and wrist. Elongation of the ECRB was measured for four stretching maneuvers (forearm supination/pronation and wrist extension/flexion) at two elbow angles (90° flexion and full extension). The shear elastic modulus, used as the index of muscle elongation, was computed using ultrasonic shear wave elastography for the eight aforementioned stretching maneuverangle combinations. RESULTS: The shear elastic modulus was the highest in elbow extension, forearm pronation, and wrist flexion. The shear elastic moduli of wrist flexion with any forearm and elbow position were significantly higher than the resting position. There was no significant difference associated with elbow and forearm positions except for elbow extension, forearm pronation, and wrist flexion positions. CONCLUSIONS: This study determined that elbow extension, forearm pronation, and wrist flexion was the most effective eccentric stretching for the ECRB in vivo.

Posterior Shoulder Instability in the Patients with Bilateral Congenital Absence of Long Head of Biceps Tendon: A Case Report.

Rare cases of a congenital absence of the long head of the biceps tendon (LHBT) have been reported, and its incidence is unknown. In a literature review of the congenital absence of the LHBT, only 1 case was associated with posterior shoulder instability and severe posterior glenoid dysplasia. This paper reports the first case of a patient with a bilateral congenital absence of the LHBT with posterior shoulder instability without glenoid dysplasia or posterior glenoid tilt. The patient experienced a traffic accident while holding the gear stick with his right hand. After the accident, a posteroinferior labral tear with paralabral cysts was detected on the magnetic resonance images. The congenital absence of the LHBT was assumed to have affected the posterior instability that possibly increased the susceptibility to a subsequent traumatic posterior inferior labral tear. This case was identified as a posterior inferior tear caused by a traumatic 'gear stick injury'.

What are the anatomical predictive factors of degenerative superior labrum anterior to posterior lesion in rotator cuff tear?

The purpose of this study was to evaluate the influence of anatomical factors degenerative superior labrum anterior to posterior lesion in rotator cuff tear. The study included 421 middle-aged patients treated using arthroscopic surgery for rotator cuff tears. Patients were divided into two groups based on the superior labrum anterior-to-posterior (SLAP). Glenoid inclination, glenoid length, humeral head diameter, acromio-humeral distance (AHD) head-glenoid difference (HGD), head glenoid angle (HGA), size and retraction of rotator cuff tears were evaluated in both groups. In conclusion, a HGD exceeding 10 mm could be anatomically predictive of degenerative SLAP. LEVEL OF EVIDENCE: Case series, Level IV.

Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures.

BACKGROUND: Bisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate. METHODS: Between August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery. RESULTS: No significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67). CONCLUSIONS: This study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation.

The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy.

PURPOSE: The aim of this study was to compare the results of arthroscopic peripheral repair (AR) and arthroscopic debridement (AD) for the treatment of chronic unstable triangular fibrocartilage complex (TFCC) tears in ulnar-positive patients undergoing ulnar-shortening osteotomy (USO). METHODS: A total of 31 patients who underwent arthroscopic treatments combined with USO for unstable TFCC tears and were followed-up at a minimum of 24 months were included in this retrospective cohort study. Fifteen patients were treated with AR, and 16 patients were treated with AD while at the same time undergoing a USO. Outcome measures included wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, and overall outcomes according to the modified Mayo wrist scoring system. In addition, a stress test to assess distal radioulnar joint (DRUJ) stability was performed before and after surgery to compare the 2 cohorts. RESULTS: Both respective cohorts showed significant improvements in grip strength and subjective scores at the final follow-up. Grip strength, DASH, and PRWE scores were better in the AR group than in the AD group. The recovery rate from DRUJ instability observed during the preoperative examination was superior in the AR group. CONCLUSIONS: Both AD and AR of the TFCC combined with USO are reliable procedures with satisfactory clinical outcomes for unstable TFCC tears in ulnar-positive patients. However, AR of the TFCC is suggested if DRUJ stability is concomitantly compromised. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic management of chronic unstable scaphoid nonunions: effects on restoration of carpal alignment and recovery of wrist function.

PURPOSE: The purpose of this study was to assess the effects of arthroscopically assisted reduction and osteosynthesis on restoration of carpal alignment and recovery of clinical wrist function in patients with unstable scaphoid nonunion. METHODS: Thirty-six patients who underwent arthroscopically assisted osteosynthesis with or without bone grafting for unstable scaphoid nonunion between July 2006 and January 2012 were enrolled. The average time from injury to surgery was 51 ± 78.3 months. Radiographic and clinical evaluations were assessed on preoperative and postoperative days, and follow-up evaluation took place at a minimum of 24 months. RESULTS: Union was achieved in 86% (31 of 36) of patients at a mean of 11 ± 2.7 weeks. Scaphoid axial length (SAL), lateral intrascaphoid angle (ISA), scapholunate angle (SLA), and reversed carpal height ratio (CHR) was significantly improved after surgery, and those correction ratios averaged 66% ± 46.8%, 74% ± 58.2%, 81% ± 59.8%%, and 94% ± 46%, respectively. The range of wrist motion was unchanged after surgery, but the grip strength improved from 74% ± 22.1% preoperatively to 89% ± 13.7% postoperatively compared with the contralateral side (P = .042). Mean Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores improved significantly (P < .001) from 44 and 51 preoperatively to 13 and 23 postoperatively, respectively. The radiological parameters of the scaphoid and carpal alignment in patients who achieved bony union did not correlate with clinical wrist function. CONCLUSIONS: Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion is limited for restoration of normal carpal alignment but has positive effects on the recovery of clinical wrist function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.