Comparison of Locking Plate Fixation and Coracoclavicular Ligament Reconstruction for Neer Type 2B Distal Clavicle Fractures.

Background: There remains no consensus regarding which repair technique provides the most optimal results for unstable distal clavicle fractures. Purpose: To compare radiologic and clinical outcomes between locking plate fixation and anatomic coracoclavicular (CC) ligament reconstruction for patients with unstable distal clavicle fractures. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 41 patients with Neer type 2B distal clavicle fracture. In group A (n = 15), patients were treated using CC ligament reconstruction with autologous palmaris longus tendon, artificial tape, and Steinmann pin fixation; in group B (n = 26), patients were treated using anatomic locking plate fixation. All patients had a minimum 2 years of follow-up. CC distance and arthrosis of the acromioclavicular joint were assessed radiographically. Clinical outcomes-including range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons rating scale, and Constant score-were compared between the groups using the paired Student t test and Fisher exact test. Results: Bone union was attained in all patients. In both groups, the CC distance decreased significantly from presurgery to final follow-up: group A, from 16.25 ± 4.75 to 7.66 ± 2.61 mm (P < .001); group B, from 17.3 ± 4.07 to 9.33 ± 2.01 mm (P < .001). The final CC distance was significantly greater in group B (7.66 vs 9.33 mm in groups A and B, respectively; P = .028). Osteoarthritis of the acromioclavicular joint occurred in 13 of 41 patients (3 in group A and 10 in group B). At final follow-up, there was no statistical significance between the groups in range of motion, and clinical outcome scores were satisfactory in both groups, with no statistical difference between them. Conclusion: Anatomic locking plate and anatomic reconstruction of the CC ligament showed good clinical results, so both techniques can be considered reliable for restoring stability. However, CC ligament reconstruction had better CC distance on radiologic assessment and did not require removal surgery, so it may be the preferable surgical option to treat unstable distal clavicle fractures (Neer type 2B).

Reconstruction of large bone defect using autogenous fibular strut and iliac bone graft for revision total elbow arthroplasty.

ABSTRACT: The stability and longevity of the prosthesis after revision total elbow arthroplasty (TEA) are greatly influenced by the reconstruction of bone defects around the distal humerus and proximal ulna. This study evaluated the clinical and radiological results of reconstruction of a large bone defect using an autogenous fibular strut and iliac bone graft in revision TEA.This retrospective study reviewed 10 patients who underwent revision TEA with autogenous fibular strut and iliac corticocancellous bone graft between March 2007 and May 2016. Range of motion (ROM), Visual Analog Scale (VAS), and Mayo Elbow Performance Score were used to evaluate clinical outcomes at the final follow-up. Plain radiographs were reviewed for bone union and the presence of re-loosening or for the presence of peri-prosthetic fractures.At the final follow-up, the ROMs of the elbow was 102.5° (range, 90-120°) from extension to flexion, 60.0° (range, 40-80°) in pronation, and 58.5° (range, 35-80°) in supination. The mean preoperative VAS and Mayo Elbow Performance Score were 5.1 and 46.5, and theses scores were improved to 2.6 and 79.0, at the final follow-up (P < .05). Union of the grafted bone with the distal humerus was achieved at an average of 4.5 months (range, 3-6 months). Re-osteolysis recurred in 2 cases, and additional surgery for bone grafting was performed in 1 case.Autogenous fibular strut bone grafting is an effective technique when revision TEA has large bone defects around the prosthesis resulting in a relatively stable prosthesis fixation and good union rate with a satisfactory clinical outcome after TEA revision.

Anterior Interosseous Nerve Syndrome: Is it a Compressive Neuropathy?

BACKGROUND: Anterior interosseous nerve (AIN) syndrome is a rare disease whose pathophysiology is controversial. Despite efforts to elucidate the pathophysiology of AIN syndrome, it has not yet been resolved. We reinterpret electrodiagnostic studies, magnetic resonance imaging (MRI), and surgical findings to clarify the pathophysiology of AIN syndrome. MATERIALS AND METHODS: In this retrospective case series, we included surgically treated 20 cases of nontraumatic AIN syndrome. Surgery was performed after a minimum of 12 weeks of conservative treatment. The clinical data and operation records were extracted from the medical records for analysis. All electrodiagnostic tests were reinterpreted by physicians with an American Board Certification in electrodiagnostic medicine. Moreover, every contrast-enhanced MRI performed during the assessment was reviewed by a musculoskeletal radiologist. RESULTS: Of the twenty re-analyzed cases, nine AIN syndromes (45%) showed abnormal electromyography in non-AIN innervated muscles. Sensory nerve conduction studies were normal in all cases. Five magnetic resonance images (46%) showed signal changes in non-AIN-innervated muscles. Only four cases (20%) revealed definitive compression of the AIN during surgery. CONCLUSIONS: Electrodiagnostic study and MRI indicated that many patients with AIN syndrome exhibited a diffuse pathologic involvement of the motor component of the median nerve. We conclude that the main pathophysiology of AIN syndrome would be diffuse motor fascicle neuritis of the median nerve in the upper arm.

Low vitamin D levels in post-menopausal women are associated with complex regional pain syndrome type I in surgically treated distal radius fractures.

BACKGROUND: Complex regional pain syndrome type I (CRPS I) is a chronic devastating condition and a relatively common complication of distal radius fractures (DRF). The purpose of this study was to investigate the relationship of vitamin D levels in surgically treated post-menopausal women with CRPS I occurrence in DRF. METHODS: From February 2016 to March 2017, 158 surgically treated post-menopausal patients with DRF were enrolled. Exclusion criteria were (1) patients who had been taking vitamin D or osteoporosis medication at the time of injury; (2) patients with medical factors that may affect vitamin D levels; (3) patients who were reluctant to enroll in the study; and (4) patient with additional fractures, ligamentous injuries, or neuropathy. A total of 107 patients were available for final analysis. We compared the serum vitamin D levels in post-menopausal women with DRF with CRPS I (group 1) and without CRPS I (group 2). Bone mineral density (BMD) of the femur and spine, osteocalcin, alkaline phosphatase (ALP), body mass index (BMI) were also measured. RESULTS: The average age at the time of surgery was 66.5 years (range, 39-86 years). The mean follow-up period was 16.3 months after surgery. Among the 107 surgically treated DRF patients, 19 (18%) met the Budapest criteria for CRPS I during the follow-up period. The mean serum vitamin D level in group 1 (15.2 ng/ml) was significantly lower than that in group 2 (20.5 ng/ml, p = 0.027). The mean values of osteocalcin, ALP, BMI, and BMD were not significantly different between the groups. CONCLUSION: Lower vitamin D levels in post-menopausal women can increase CRPS I occurrence in distal radius fractures.

Small joint arthrodesis technique using a dowel bone graft in a rabbit model.

The dowel bone graft fusion technique for the ankle is a well-known and useful method. However, clinical results of dowel bone graft for small joint fusion are unknown. The objective of the present study is to evaluate the effects of dowel bone graft technique for small joint arthrodesis in an in vivo arthrodesis of rabbit elbow model compared with the conventional arthrodesis technique (open, joint surface debridement, and internal fixation method). We assigned 28 young adult New Zealand white rabbits to one of two groups: Group 1, the conventional fusion technique group; Group 2, the dowel bone graft fusion technique group. We performed arthrodesis surgery in two different ways for each group. Eight weeks after the operation, specimens were harvested, radiographed, mechanically tested for torque to failure and stiffness, and evaluated for histology. Fusion rates were 77% (10/13) in Group 1 and 93% (13/14) in Group 2 (p = 0.326). Torque to failure showed a mean of 0.86 Nm in Group 1 and 0.77 Nm in Group 2 (p = 0.464). The mean value of stiffness was 0.11 Nm/deg in Group 1 and 0.11 Nm/deg in Group 2 (p = 0.832). In Group 2, histological examination showed residual cartilage absorption and inflammatory response in all cases. In this model, we have been unable to show a difference in either the union rate or strength of fusion between the two methods. However, the dowel bone graft technique is an easy and less invasive method and has some advantages over the conventional method.

Entrapment of the extensor pollicis longus tendon in a pediatric Smith fracture: A case report.

RATIONALE: Most pediatric distal radius fractures are effectively treated nonoperatively; however, operative intervention is indicated in patients with open and highly unstable fractures, in those with concomitant neurovascular injuries and in patients whom soft tissue interposition between fracture fragments precludes anatomical reduction. Notably, soft tissue interposition between fracture fragments is diagnostically challenging. Surgeons must be mindful of this rare complication for early detection and prompt treatment. PATIENT CONCERNS: A 14-year-old boy presented to the emergency department with left wrist pain after falling from a bicycle. Plain radiography and computed tomography revealed a displaced Smith fracture, which was irreducible by closed reduction, necessitating open reduction and volar plate fixation. The patient reported inability to extend his thumb at his 6-week postoperative follow-up visit. DIAGNOSIS: Ultrasonography showed extensor pollicis longus (EPL) tendon entrapment near the fracture site. INTERVENTIONS: A second operation was performed 10 weeks after the first surgery, and intraoperative exploration revealed EPL tendon entrapment. The EPL tendon was torn to shreds; therefore, extensor indicis proprius tendon transfer was performed for EPL tendon reconstruction. OUTCOMES: The patient's thumb motion was completely restored after the second operation. LESSENS: EPL tendon entrapment in a pediatric Smith fracture is rare. Signs of EPL tendon entrapment include inability to perform active thumb extension, dorsal wrist pain radiating along the course of the EPL tendon, which is exacerbated by thumb flexion, a tenodesis effect elicited on thumb examination, and difficulty in anatomical fracture reduction. Surgical exploration of the EPL tendon is warranted in patients presenting with any of these signs following attempted reduction of a Smith fracture.

Modified triceps fascial tongue approach for primary total elbow arthroplasty.

BACKGROUND: Triceps weakness is a common complication of total elbow arthroplasty (TEA). Many posterior approaches for TEA have been introduced to maintain triceps function. The present study evaluated the clinical outcomes and extensor strengths of primary TEA with modified triceps fascial tongue approach. METHODS: Twenty-one primary TEAs performed in 20 patients by a single surgeon were reviewed with a mean of 64.2 months (range, 24-127 months) of follow-up. Every TEA was performed using the modified triceps fascial tongue approach, with the Coonrad-Morrey prosthesis. Patient demographics, range of motion, pain visual analog scale, and triceps strength (Medical Research Council [MRC] scale) were compared before and after the operation. The Mayo Elbow Performance Score was evaluated at the latest follow-up. RESULTS: Triceps strength was normal (MRC grade V) in 10 elbows (48%) and good (MRC grade IV) in 11 (52%). Triceps strength after arthroplasty was significantly improved compared with the preoperative strength (P < .001). Mean flexion arc was improved from 78° to 100° after arthroplasty (P = .004). However, mean flexion contracture (preoperative; 29°, postoperative; 26°) was not improved after surgery (P = .377). The mean visual analog scale pain score improved from 7.7 preoperatively to 2.4 postoperatively (P < .001). Postoperative Mayo Elbow Performance Scores were excellent in 13 elbows, good in 6, and fair in 2. The only complications were 3 intraoperative condylar fractures. CONCLUSIONS: Modified triceps fascial tongue approach is an easy and effective approach for primary TEA.

Multiple etiologies of trigger wrist.

BACKGROUND: Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. The clinical manifestations and surgical results of trigger wrist with multiple etiologies were evaluated. METHODS: From October 2008 to December 2012, this study retrospectively reviewed 15 patients diagnosed with trigger wrist. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29-86 years). The mean follow-up period was 16.2 months (range, 11-30 months). RESULTS: The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n = 5), severe tenosynovitis of the flexor tendon (n = 4), fibroma around the flexor tendon sheath (n = 2), a rheumatoid nodule (n = 1), both anomalous muscle belly and tenosynovitis (n = 1), a ganglion (n = 1), and pigmented villonodular synovitis (n = 1). Mild-to-moderate symptoms of median neuropathy without thenar muscle atrophy were present in all patients. Postoperatively, all patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent. CONCLUSIONS: Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

Trigger Wrist.

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.

Flexor carpi radialis brevis: an unusual anomalous muscle of the wrist.

During imaging studies or surgical procedures, anomalous forearm and wrist muscles are occasionally encountered. Among them, the flexor carpi radialis brevis is very rare. Because the trend is growing toward treating distal radius fractures with volar plating, the flexor carpi radialis brevis is worth knowing. Here, we report two cases with a review of the literature.

Vertebral compression fracture in the middle of fused segments without a history of injury: a case report.

STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To report a rare case of a vertebral compression fracture in the middle of fused segments in the absence of a history of trauma, and to investigate the contributory factors. SUMMARY OF BACKGROUND DATA: Few articles have been published on vertebral fractures among fused segments. However, several articles have addressed fractures at juxtafused segments after implant removal. To the best of the authors' knowledge, only one case of compression fracture within fused segments has been previously reported. METHODS: This study involved the case of a 62-year-old woman with vertebral compression fracture of L4 within a solid fused segment region after implant removal. An investigation was conducted to identify the factors that contributed to this compression fracture. RESULTS: Plain radiographs and bone scanning showed a compression fracture of L4 within a region of fused segments (L3-S1) after implant removal without the history of injury. BMD revealed osteopenia of -2.3 SD on the neck of the femur. The patient's symptoms were relieved by conservative treatment. The contributory factors may have been persistent anterior motion, osteopenia and/or osteoporosis, and a subcortical substance defect associated with screw tracks after implant removal. CONCLUSION: Vertebral compression fractures in solid fused segments may occur as a complication of implant removal. Accordingly, if spinal implant removal is needed for revision surgery, surgeons should be aware of this significant complication.