Usefulness of multiple bioabsorbable Mg screws/K­wires for comminuted radial head fractures.

PURPOSE: We hypothesized that multiple absorbable screws/K-wires would be effective for native head preservation in comminuted radial head fracture fixation (com-RHFs). METHODS: Seventeen patients who met the inclusion criteria between 2018 and 2020 were included. Radiologic findings indicating proper union and clinical outcomes such as the range of elbow motion, visual analog scale score, and Mayo Elbow Performance Score were assessed prospectively after surgery and at least three years of follow-up. RESULTS: The mean follow-up period was 4.6 years. Eleven, one, three, and two patients presented with isolated com-RHFs, type 2 (accompanied injury of medial collateral ligament), type 4 ("terrible triad") fractures, and type 5 posterior olecranon fracture-dislocations, respectively. Union was achieved after a mean of nine weeks postoperatively. The head and shaft angles did not differ significantly from the contralateral normal values (p = 0.778 and 0.872, coronal and sagittal, respectively). At the final follow-up, the mean flexion-extension/pronation-supination arcs were 126.47 ± 4.92°/135.59 ± 10.13°, and thus were significantly different from those on the contralateral side (p < 0.001, both), however the arcs were functional ranges for ordinary daily life. Also, functional status was satisfactory in all individuals. The arthritis grade and extent of heterotrophic ossification were satisfactory in all cases, and there were no serious complications requiring revision surgery. CONCLUSIONS: Absorbable screw/K-wire fixation for com-RHFs is an option before radial head arthroplasty associated with a low complication rate and no need for revision.

Free Fibula Flap for Congenital Pseudarthrosis of the Tibia: Indications and Challenges.

Background: Congenital pseudoarthrosis of the tibia (CPT) is a rare pathological disease associated with neurofibromatosis type 1 (NF1). It presents with tibial bowing and can progress into a nonhealing fracture. Treatment options include conservative approaches such as serial bracing or various surgical options.Surgically, the aims are to achieve long-term bone union, prevent limb length discrepancies (LLDs), and avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture.The purpose of our study is to highlight our experience with both the conservative approach and the use of vascularized free fibula reconstruction of these deformities, including the challenges encountered with a long-term follow-up until skeletal maturity. Methods: We present a retrospective analysis of a total of nine (9) patients consisting of three (3) girls and six (6) boys. Six (6) children were treated with a vascularized fibula flap, and the other three (3) were treated conservatively. Outcomes measured included fractures, LLD, ankle valgus deformity, donor site morbidity, and number of surgical corrections. Results: All patients had flap survival. Three (3) of six children had a previous failed surgery with intramedullary nail and bone graft prior to performing a vascularized free fibula reconstruction. The follow-up period ranged from 8 months to 200 months. The complications included stress fractures (50%), LLD (66.6%), and ankle valgus (33.3%). During growth phases, these children required multiple corrective surgeries. Conclusions: Fibula free flap is a good treatment option for CPT even in patients with prior surgical failures with variable results.Level of Evidence - Level 4 - Case series Therapeutic Studies-Investigating the Results of Treatment.

Subchondral Radial and Ulnar K-Wire Positioning With Cancellous Bone Graft Shortens Union Time in Scaphoid Waist Nonunion.

BACKGROUND: Bone grafting in patients with scaphoid waist nonunion can present several technical challenges. In this study, we aimed to present a modified surgical technique for scaphoid waist nonunion, which consisted of subchondral radial and ulnar K-wires positions with cancellous bone graft, and to compare the clinical outcome of this modified technique with the conventional method. METHODS: We retrospectively reviewed 72 patients with scaphoid waist nonunion who had been surgically treated between January 2011 and December 2020. Of these, 34 patients were treated with the modified method and 38 with the conventional method. Debridement of the nonunion site was performed using a curette, rongeur, and microburr. Two or 3 K-wires were inserted along the cancellous portion of the scaphoid in the conventional method. In the modified method, 2 K-wires were inserted along the ulnar and radial subchondral portion of the scaphoid to increase the space for bone grafting in the cancellous portion of the scaphoid. The autologous cancellous bone grafted in both the methods. Demographic, radiological, and clinical outcomes were reviewed and compared between the groups. RESULTS: There were no significant differences in demographics and characteristics of nonunion between the 2 groups of patients. The modified method group showed significantly shorter union time than the conventional method group (conventional group: 13.0 ± 1.3 weeks, modified group: 11.4 ± 1.1 weeks; P < 0.001). The bony union rate was 97.1% for the modified method and 89.5% for the conventional method. Satisfactory clinical outcomes (excellent and good Mayo wrist scores) were achieved in 27 cases (81.8%) using the modified method and 22 cases (64.7%) using the conventional method. CONCLUSION: Subchondral radial and ulnar K-wire positioning with cancellous bone graft (modified method) can improve the union time with satisfactory clinical outcomes in the treatment of scaphoid waist nonunion.

Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment.

PURPOSE: We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series. METHODS: We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated. RESULTS: The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone. CONCLUSIONS: If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Volar Locking Plate Fixation for Distal Radius Fractures Distal to the Watershed Line with an Intact Lunate Volar Rim.

Background: We treated distal radius fractures (DRFs) beyond the watershed line without fracture of the lunate volar rim using a volar locking plate (VLP) and report the radiological and clinical outcomes at least 3 years after surgery. Methods: In 41 consecutive patients between January 2012 and August 2017, the fragment was composed of the radial styloid process (distal to the watershed line) and the lunate volar rim was intact. We evaluated demographic factors, radiological features and radiological/clinical outcomes at the final follow-up. Results: Twenty-nine patients were followed and evaluated. The mean follow-up period was 5.7 years. The mean patient age was 52.7 years and 24 patients had intracapsular intra-articular fractures. The fracture line was present in the lunate fossa in all patients. Twenty patients were classified as Soong grade 2, and five and four patients were grades 1 and 0, respectively. No radiological parameter (volar tilt, radial inclination, step-off and ulnar variance) was significantly different between the affected and contralateral normal sides. The mean visual analogue scale pain score and Disabilities of the Arm, Shoulder and Hand score, as well as the range of movement of the wrist, were not different between the affected and contralateral normal wrists. Finally, the grip strength on the affected side was 92% of the contralateral value. Major complications, such as nonunion, malunion and tendon rupture, were absent. Conclusions: DRFs distal to the watershed line with an intact lunate volar rim are rare and easy to miss. Careful inspection of 3D-CT images is necessary to determine these injuries, and the optimal choice for proper fixation of the fragment amongst the commercial VLPs would result in satisfactory radiological and clinical outcomes. Level of Evidence: Level IV (Therapeutic).

Importance of Whole-Body Scintigraphy or Positron Emission Tomography for Early Detection of Femoral Lesions in Breast Cancer Patients Treated with Bisphosphonates.

Background: We hypothesized that most of the atypical femoral fractures (AFFs) associated with bisphosphonate treatment for breast cancer (BC) could be found before the fracture event in another radiological examination already performed by breast surgeons, rather than on simple radiographs (SRs). Methods: We thoroughly inspected the clinical charts of BC patients treated at our institute between 2008 and 2017. In total, 228 patients were categorized into three groups based on SRs: complete AFF on at least one side (group 1); incomplete fracture on at least one side, but not any complete fracture (group 2); and no suspicious lesion (group X) on either femur. Then, we inspected whole-body scintigraphy (WBS) and positron emission tomography (PET)-computed tomography (CT) images in all groups. For group X, patients with radiological clues from at least one femur were categorized, ultimately, into final group 3 and the rest made up the normal group. Results: About 35% of the patients showed AFFs (complete or incomplete) or suspicious lesions as AFFs, associated with the side effect of Bisphosphonate. In group 1, bilateral lesions (complete or incomplete fractures) were more frequently seen on SRs than unilateral lesions (p = 0.008). The initially identified findings in WBS and PET-CT for the respective complete and incomplete fractures on SRs of groups 1 and 2 were seen at a mean of 7 months previously. SRs did not reveal the lesions in group 3 until 5 months after the initial identification of the lesions in WBS and PET-CT. Conclusions: Even before incomplete AFFs were detectable on SRs, they could be found at check-ups using WBS and PET-CT that had been previously examined by breast surgeons and radiologists for metastasis surveillance. Awareness of the lesions creates an opportunity for prophylactic surgery before complete fractures occur.

How long does it to achieve sagittal realignment of the displaced epiphysis in Salter-Harris type II distal radial fracture when treated by manual reduction?

This study aimed to investigate how long it takes for the dorsally displaced distal radial epiphysis to achieve realignment. We retrospectively reviewed 56 patients with dorsally displaced Salter-Harris type II distal radial epiphyseal fractures who were aged ≤15 years at the time of injury. All fractures were treated with closed reduction and immobilised using a sugar tong splint for 6 weeks. We evaluated the change in the displaced epiphysis position (%) until 12 weeks and the long-term clinical and radiological outcomes. We analysed significant differences in demographic factors and epiphyseal displacement according to the required period for epiphyseal realignment. The estimated area of the receiver operating characteristics (ROC) curve was calculated, and cut-off values were suggested to predict the required period for epiphyseal realignment. Sixteen (28.6%) and 42 (75%) patients achieved realignment of the epiphysis within 8 and 12 weeks, respectively. The cut-off values of 13.1 and 22.9% displacement at the 1-week follow-up were the best predictors of epiphyseal realignment within 8 and 12 weeks, respectively. Patients with a residual displacement of up to 51.3% in the sagittal plane at the 1-week follow-up achieved complete realignment of the epiphysis at the 6-month follow-up. From this study, we could predict the timing of epiphyseal realignment, and expect epiphyseal realignment even if re-displacement occurred up to 51.3% at the 1-week follow-up.

Outcomes of Flexor Tendon Repair in Patients With Concurrent Neurovascular Injuries of Multiple Digits in Zone 1.

PURPOSE: We treated several patients with multiple flexor (flexor digitorum profundus; FDP) injuries accompanied by injuries to the digital nerve or vessels around the distal interphalangeal crease (zone 1). Here, we retrospectively report the outcomes and review the literature. MATERIALS AND METHODS: Between January 2010 and December 2018, 16 patients who met the study inclusion criteria were investigated. Tendons were repaired using the cross-locked cruciate (Adelaide) technique (6-strand) or modified Becker method (4-strand). The neurovascular structures were repaired under a microscope. RESULTS: Sixteen patients (47 digits) were treated. According to the criteria of Moiemen and Elliot, the lacerated areas were in zones IA and IB in 7 and 40 digits, respectively. The mean ranges of motion were 149.27 ± 7.78 and 66.43 ± 2.04 degrees according to the Strickland and modified Strickland assessments, respectively. The mean 2-point discrimination was 5.00 ± 0.63 mm. Four patients (group 1) presented with injuries to 2 digits, and 9 (group 2) and 3 (group 3) patients had 3 and 4 injured digits, respectively. The outcomes were satisfactory in terms of the mean range of motion; 2-point discrimination; cold tolerance; visual analog scale pain score; Disabilities of the Arm, Shoulder, and Hand score; and grip strength. There were no differences among the groups. CONCLUSIONS: Open multiple-finger injuries involving flexor digitorum profundus rupture with concurrent neurovascular injuries on one or both sides occasionally occur in industrial environments. Fortunately, each digit exhibits a consistent injury type in a particular anatomical location; appropriate repair yields satisfactory outcomes despite the presence of multiple injuries.

Treatment Strategies for Acute Seymour Fractures in Children and Adolescents: Including Crushed Open Fractures.

PURPOSE: We aimed to suggest treatment strategies for Seymour fractures (SFs) with varying clinical manifestations, based on the retrospective outcomes of patients seen at our institute. METHODS: Between March 2000 and December 2019, a total of 26 SF patients were categorized into 3 groups: acute typical SF (category 1; open fracture/exposed germinal matrix and physis), acute injuries but delayed presentation (category 2; presented to our institute more than 24 hours after the injury with misdiagnosis as simple nail injuries), and direct crush injuries (category 3; the most severe injury type, characterized by nail loss, nail bed lacerations, or maceration of the germinal matrix). In category 1, reduction was maintained using K-wire fixation without nail plate sutures. In 2, massive irrigation/debridement was followed by reduction and nail plate suturing without K-wire fixation. Finally, in 3, nail bed repair, reinsertion of the extracted nail plate after creating a penetration hole for drainage, K-wire fixation, and nail plate suturing were sequentially performed. RESULTS: The mean age of the patients was 8.92 years. At the final follow-up, the mean dorsal angulation was 1.73 degrees, and the length ratio was 97.88%; no significant differences were observed compared with the contralateral normal side ( P = 0.498 and P = 0.341, respectively). The final visual analog scale pain score; the Disabilities of the Arm, Shoulder, and Hand score; and the active range of motion ratio were 0.50, 1.52, and 96.92%, respectively. There were no significant complications requiring revision surgery. Although the overall outcomes were satisfactory, category 3 patients had slightly worse visual analog scale pain scores; Disabilities of the Arm, Shoulder, and Hand scores; and range of motion compared with those in the other categories ( P = 0.003, P = 0.002, and P < 0.001, respectively). CONCLUSIONS: Satisfactory clinical outcomes were obtained by applying different surgical treatments to the different SF categories. We have suggested appropriate treatment strategies for acute SF varying in severity.

Repair integrity and functional outcomes of arthroscopic repair in chronic anterior shoulder instability: single-loaded versus double-loaded single-row repair.

INTRODUCTION: This study compared the clinical outcome and repair integrity of single-loaded and double-loaded single-row arthroscopic repair of chronic anterior shoulder instability. MATERIALS AND METHODS: Fifty consecutive chronic anterior shoulder instability cases treated by arthroscopic labral repair were included. A single-loaded single-row technique was used in the first 25 consecutive shoulders, and a double-loaded single-row technique was used in the next 25 consecutive shoulders. The number of suture anchors was 4 in the shoulders that underwent single-loaded repair and 3 in the shoulders that underwent double-loaded repair. 42 shoulders (84.0%) followed up clinical outcomes were evaluated a minimum 2 years (mean 28.5 months; range 24-46) postoperatively. The postoperative labral repair integrity was evaluated by MDCT-arthrogram at a minimum 6 months postoperatively. RESULTS: At the final follow-up, the average UCLA, ASES, Constant, Rowe score, VAS pain score, and VAS for instability scores improved significantly, to 33.05, 92.33, 89.05, 94.86, 0.90 and 0.52, respectively, in the single-loaded group and to 32.19, 90.10, 89.05, 94.52, 0.90, and 0.86, respectively, in the double-loaded group. The clinical scores improved in both groups postoperatively (all P < 0.05); however, there was no significant difference between the two groups at final follow-up (P = 0.414, 0.508, 1.000, 0.917, 1.000, and 0.470, respectively). The re-tear rate was 2 (9.5%) in the shoulders that underwent single-loaded repair and 3 (14.3%) in the shoulders that underwent double-loaded repair; this difference was statistically not significant (P = 0.634). CONCLUSION: The double-loaded single-row technique resulted in comparable clinical outcomes, and re-tear rate compared with the single-loaded single-row technique in chronic anterior shoulder instability at short-term follow-up. Number of used suture anchor in double-loaded single-row technique was fewer than that of single-loaded single-row technique. LEVEL OF EVIDENCE: Comparative retrospective study, level III.

Elimination of irreducible intercalary fragment and fixation using locking plate for Mayo type IIB olecranon fracture-outcomes compared with type IIA.

BACKGROUND: We hypothesized that the outcomes of articular reduction with elimination of irreducible articular intercalary fragments for Mayo type IIB fractures fixed using olecranon locking plates would be as satisfactory as those of noncomminuted fractures. METHODS: A total of 65 patients were enrolled from among 92 who had undergone operative treatment for olecranon fractures between March 2008 and February 2015. Patients with fragments that were eliminated because they were too comminuted to be fixed during surgery (type IIB) were included in group 1. Patients without intraarticular comminuted fragments (type IIA) or with very few fragments were assigned to group 2. In group 1, articular congruency and reduction status were confirmed by direct visualization. The fracture was then fixed with a locking plate and irreducible intercalary fragments were eliminated. RESULTS: There were no significant differences in demographic characteristics, such as age and gender, between the two groups. Both groups achieved bony union within the approximately 6-year follow-up period and there were no serious complications in either group. The grades of heterotrophic ossification and ulnohumeral arthritis were not significantly different between the groups. The mean flexion-extension and pronation-supination arcs were similarly satisfactory in both groups (127.35° and 134.39° vs. 129.69° and 133.75° in groups 1 and 2°, respectively). Clinical outcomes including visual analog scale pain scores, as well as the Mayo Elbow Performance scores (87.73 vs. 88.28 in groups 1 and 2, respectively), were also similarly satisfactory in both groups. CONCLUSIONS: Locking plate fixation under direct visualization (to reduce the articular surface in Mayo type IIB fractures) and elimination of articular intercalary fragments resulted in satisfactory radiologic and clinical outcomes, similar to those of noncomminuted fractures also treated using a locking plate. LEVEL OF EVIDENCE: Level IV, Retrospective therapeutic study.

Diagnostic Criteria and Treatment of Atypical Ulnar Fractures Associated With Prolonged Bisphosphonate Therapy: Multicenter Case Analysis.

PURPOSE: Atypical ulnar fracture (AUF) related to prolonged bisphosphonate therapy is a rare complication. We propose diagnostic criteria of AUFs and present a treatment algorithm. METHODS: Twelve AUFs in 10 patients were studied. The diagnosis of AUF was based on the case definition of atypical femoral fracture (AFF). We investigated clinical and radiographic characteristics of AUFs according to major and minor features of AFFs, and modified the case definition of an AFF to fit the characteristics of AUFs. All AUFs were treated surgically. The radiographic union of fractures was investigated, and delayed fracture healing was defined as a delay of 6 months or more. RESULTS: The average point at which AUFs occurred was at a point 35.1% along the proximal diaphysis of the total ulnar length. All major features of AFFs were identified in the 12 AUFs. Among the minor features, generalized cortical thickening was observed in 6 AUFs, prodromal symptoms in 2 AUFs, bilateral involvement in 2 patients, and delayed fracture healing in 10 AUFs (5 delayed union, 5 nonunion). Initially, 11 of 12 AUFs were treated with plating, and 1 was treated with intramedullary nailing. Two nonunions were revised with sclerotic bone resections, bone grafts, and plate fixation. Finally, union was achieved in 9 AUFs. CONCLUSIONS: The case definition of AFFs can be used for the diagnosis of AUFs, although some modifications must be included in the case definition. Plating is useful in managing AUFs, although sclerotic bone resections and bone grafts may be required. Atypical ulnar fractures occurred in patients who took bisphosphonates longer than AFFs or those whose bisphosphonates were discontinued a few years earlier. Therefore, physicians should be aware of AUFs in those patients and, if necessary, perform a screening test to look for atypical fractures in other bones. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic V.

Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method.

BACKGROUD: The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications. METHODS: We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion. RESULTS: Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12-20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and Constant-Murley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable. Therefore, second surgery for implant removal is necessary after bone union is achieved.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

BACKGROUD: The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model. METHODS: Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination. RESULTS: On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage. CONCLUSIONS: The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

Effectiveness of Percutaneous Pinning of Acute Partial Scapholunate Injury during Volar Locking Plating for Distal Radius Fractures: A Comparative Study of Pinning and Conservative Treatment.

BACKGROUD: We hypothesized that concurrent temporary fixation of scapholunate ligament (SL) injury during volar locking plate (VLP) fixation of distal radius fractures (DRFs) would improve restoration outcomes based on both radiological and clinical results. Here, we performed a prospective, comparative study investigating the effectiveness of temporary percutaneous reduction/pinning during VLP fixation in DRFs. METHODS: The first 43 consecutive SL injuries were treated concurrently after VLP fixation by closed pinning (group 1); the next 36 consecutive injuries were treated nonoperatively (group 2). Patients were followed up for at least 5 years after treatment. Basic demographic data, radiological measurements, arthroscopic findings of SL injury, and other clinical outcomes were evaluated. RESULTS: The mean follow-up period was 7.2 years. No significant differences in basic demographic data were evident between groups. Fracture patterns were not distinctively different between groups. The initial scapholunate angle measured immediately after surgery was 23° ± 3° in group 1 and 38° ± 13° in group 2, indicating a significantly hyperextended scaphoid position in group 1. The final scapholunate angles were also significantly different between groups although the final angle in group 2 (58° ± 11°) was within normal limits. Final visual analog scale scores, Disabilities of the Arm, Shoulder and Hand scores, Gartland and Werley system scores, and wrist motions were not different between groups; however, grip strength at the time of final follow-up was closer to that of the contralateral uninjured wrist in group 1. Arthrosis was less advanced in group 1. CONCLUSIONS: Temporary fixation for SL injury with a DRF can be an effective option for the maintenance of scapholunate angle. The non-fixed group exhibited a more pronounced collapse of the scapholunate angle although the angle was still within normal limits, and clinical outcomes were similar between groups regardless of the fixation status.

Antegrade intramedullary nailing in comminuted, open metacarpal bone fracture: maintenance of the length.

PURPOSE: The purpose of this study was to evaluate the radiological and clinical outcomes of treatment of comminuted open fractures of the metacarpal bone (MCB) with associated injuries to soft tissues, tendons, and neurovascular structures using antegrade intramedullary nailing (AIN) at least 2 years postoperatively. METHODS: Between January 2008 and December 2017, a total of 27 patients who met the inclusion/exclusion criteria were included in this study. The inclusion criterion was open and comminuted fracture (with/without segmental bone defects). We evaluated simple radiograph and computed tomography (CT) findings and clinical conditions (visual analog scale [VAS] pain score and Disabilities of the Arm, Shoulder, and Hand [DASH] score), including active range of motion (ROM) at metacarpophalangeal joint (MP) and grip strength at final follow-up. RESULTS: The mean preoperative angulation was 29.63° ± 7.59° and the mean shortening was 9.30 ± 2.38 mm. Union was achieved at mean 12.3 weeks postoperatively, without any complications due to operative treatment. The dorsal angulation measured on the CT scans, shortening on simple radiographs was significantly improved (10.26 °± 3.19°, 0.52 ± 1.05 mm, respectively). The final VAS and DASH scores were 0.41 ± 0.64 and 3.6 ± 2.47, respectively, indicating satisfactory outcomes. The final ROM was 85.0° ± 3.67°. The mean final grip strength was 89.56 ± 5.69% relative to the normal side. A mean extension lag at the MP joint of 12° was noted in three patients; however, it was resolved by additional tenolysis. CONCLUSIONS: AIN is a simple method for fixation of open comminuted metacarpal fractures accompanied by soft tissue injury. The simplicity of the method is beneficial for repairing associated injured structures and healing soft tissue. Minimized additional damage around the MCB during surgery and good stability resulted in satisfactory bony union with minimal angulation, shortening, and rotation. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Tips and tricks to achieve osteotomy healing and prevent refracture after ulnar shortening osteotomy.

BACKGROUND: Parallel osteotomy is essential for favorable osteotomy reduction and healing and technically challenging during diaphyseal ulnar shortening osteotomy (USO). This study aimed to evaluate the advantages of guided osteotomy for parallel osteotomy and reduction osteotomies, healing over freehand osteotomy. It also aimed to identify surgical factors affecting healing after diaphyseal USO. METHODS: Between June 2005 and March 2016, 136 wrists that had undergone diaphyseal USO for ulnar impaction syndrome (UIS) were evaluated. The wrists were divided into two groups according to the osteotomy technique (group 1: freehand osteotomy, 74 wrists; group 2: guided osteotomy, 62 wrists). The osteotomy reduction gap and time to osteotomy healing (union and consolidation) were compared between the groups. A multiple regression test was performed to identify the surgical factors affecting healing. The cut-off length of the reduction gap to achieve osteotomy union on time and the cut-off period to decide the failure of complete consolidation were statistically calculated. RESULTS: The baseline characteristics did not differ between the two groups. The osteotomy reduction gap and time to osteotomy union, and complete consolidation were shorter in group 2 than in group 1 (p = 0.002, < 0.001, 0.002). The osteotomy reduction gap was a critical surgical factor affecting both time to osteotomy union and complete consolidation (p < 0.001, < 0.001). The use of a dynamic compression plate affected only the time to complete consolidation (p < 0.001). The cut-off length of the osteotomy reduction gap to achieve osteotomy union on time was 0.85 mm. The cut-off period to decide the failure of complete consolidation was 23.5 months after osteotomy. CONCLUSIONS: The minimal osteotomy reduction gap was the most important for timely osteotomy healing in the healthy ulna, and guided osteotomy was beneficial for reducing the osteotomy reduction gap.

Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome - a retrospective case-control study.

LEVEL OF EVIDENCE: Level III, case-control study.

Risk factors for atypical forearm fractures associated with bisphosphonate usage.

BACKGROUND: The purpose of this study was to find the diagnostic factors for atypical forearm fractures additional to atypical femur fractures, via a retrospective case-control study. Thus, our authors performed a complete enumeration survey for patients under the treatment of bisphosphonate (BP). METHODS: We identified 53 patients that met the following inclusion criteria between March 2009 and February 2019: a BP therapy history or ongoing administration of at least 1 year, presence of simple radiographs of bilateral femurs and forearms, and availability of complete medical records and radiological data. The patients were divided into two groups: those with any lesion of atypical fractures of ulna or radius, regardless of the displacement of at least one side extremity in simple radiographs (group 1, 20 patients); and those without any lesions of pathognomonic finding or fractures in either forearm in simple radiographs (group 2, 33 patients). RESULTS: Univariate analyses of basic demographic characteristic such as age, smoking, comorbidity of diabetes mellitus or any connective tissue disease needing steroid treatment, and BMD showed no significant differences between the groups (P > 0.05). The co-morbidity of malignant cancer inevitably needing BP usage was not different between the two groups. Multivariate analyses of the several variables that differed significantly between the two groups in univariate analyses demonstrated that total period and single prescribing physician/surgeon were significantly associated with forearm fractures. A cut-off value of 65 months for the total period predicted the presence atypical forearm fractures. CONCLUSIONS: Atypical forearm fractures are probably more common than reported in the literature to date, and all forearm lesions were accompanied by preceding atypical femur fractures. The period of BP administration had the main effect on the occurrence of atypical forearm fractures, particularly if more than 65 months. Also, the prescription by multiple physician was predicting factor for forearms lesion additionally to AFFs, however, more evidence-based study is needed to understand the effects of cancer-related BP usage on the forearm. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Revision osteosynthesis after primary treatment of atypical ulnar fractures associated with bisphosphonate usage - Nonunion after ordinary open reduction and internal fixation.

BACKGROUND: We performed revision surgeries to treat nonunion of bisphosphonate-associated ulnar fractures that had originally been treated, after misdiagnosis, using the typical open reduction/internal fixation (ORIF). METHODS: Of nine cases of ulnar nonunion initially treated at other institutions, we performed revision surgeries on four that met our inclusion/exclusion criteria. All previous implants were removed; the areas of nonunion were resected, and strut bone grafts were inserted and fixed with locking plates. Radiological assessments were performed monthly for 3 months after surgery and then every 3 months for 1 year. RESULTS: All patients were female, with a mean age of 71.8 years. All patients had been taking bisphosphonate for a mean of 7.2 years. The primary fixation methods used at other institutions were intra-medullary nailing (n = 1) and placement of 3.5-mm locking plates (n = 3). In one patient (patient 1), the contralateral (right) ulna developed a new fracture at 1 month after revision surgery on the left ulna. Another patient (patient 3) exhibited an incomplete fracture in the contralateral (right) ulna. All four patients exhibited hip fractures (bilateral in three). All revisions resulted in final union at a mean of 4.8 months postoperatively. CONCLUSION: Atypical ulnar fractures should be suspected in elderly women on long-term bisphosphonate treatment. Union will fail with standard ORIF for atypical ulnar fractures, because the fracture occurred due to compromised normal bone metabolism as reflected in the bone resorption, remodeling, and healing processes. Revision osteosynthesis using a locking plate with callus resection and strut/cancellous bone graft provided satisfactory results. LEVEL OF EVIDENCE: Therapeutic level IV.