Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

Open reduction and internal fixation of modified Mason type III/IV radial head fractures with more than three fragments: an analysis of the clinical outcome and reoperation rate.

PURPOSE: It is generally accepted that a radial head fracture (RHF) with more than three parts is not suitable for repair; therefore, most authors suggest straightforward radial head arthroplasty (RHA). With up to 20% risk for reoperation after RHA, improvement in reduction and fixation techniques may represent a valuable alternative before further extending the indications for arthroplasty. To determine the functional results and radiological failure rate after osteosynthesis of multi-fragmentary RHF with more than three articular fragments. We specifically determined (1) the one-year Broberg and Morrey functional elbow score, (2) duration of fracture healing, (3) complication rate, and (4) number of patients converted to RHA. METHODS: This study is a retrospective single-center case series. All patients who underwent primary osteosynthesis for RHF between 2012 and 2019 were included. Nine patients with an average age of 52 years had an average clinical and/or radiological follow-up of 49 months. RESULTS: The preoperative imaging identified nine fractures with four fragments. Three patients underwent osteosynthesis with plates and screws, whereas six patients underwent osteosynthesis with only screws. The mean Broberg and Morrey score was 95 points. Overall, eight of the nine patients had satisfactory results. All patients retained their radial heads and showed radiological fracture healing. Only two patients presented with low-grade complications requiring no further surgery. CONCLUSION: Our study showed that osteosynthesis of RHF with up to four fragments can achieve good functional results with a low complication rate and seems to be a valid alternative to RHA.

Comparisons of the morbidities of a double gastrocnemius flap and a medial gastrocnemius flap in the orthoplastic reconstruction around the knee.

BACKGROUND: The pedicled gastrocnemius flap is commonly used to treat lower limb defects. Either the medial, lateral, or both heads can be used. When extended soft tissue defects are present, a double gastrocnemius (DG) flap may be used. However, no data of the additional donor site morbidity compared to a medial gastrocnemius (MG) flap are available. The aim of this study was to compare the donor site morbidity of a DG with that of a MG. METHODS: Patients with a soft tissue defect around the knee, treated with a gastrocnemius flap between 2018 and 2021 at the University Hospital of Lausanne and Bari, with a minimum follow-up of 12 months, were included. According to the size and the position of the defect, it was decided whether one (10 patients) or two (9 patients) heads of the gastrocnemius were necessary for the coverage. The mean age was 61 years (range 42-82) in DG, and 63 years (range 45-78) in MG. The average defect size was 89.8 cm2 in the DG group and 53.4 cm2 in the MG group. The etiologies were trauma (n = 10), infection (n = 7) and sarcoma (n = 2). A medial approach or a posterior midline approach was used for the harvesting of the gastrocnemius muscle. Once the flap was harvested, it was rotated and transposed anteriorly over the defect, either through a subcutaneous tunnel or by dividing the intervening skin bridge, depending on the soft tissue defect. A split-thickness skin graft was used to close the skin over the remaining exposed muscle flap. The active range of motion of the ankle and knee joints was measured. Muscle strength was assessed with a hand-held dynamometer and by the ability to stand on tiptoe. Physical function was evaluated through the Lower Extremity Functional Scale (LEFS). RESULTS: The two groups were homogeneous, with no significant difference in age, sex, and BMI. All flaps survived in both groups. Both groups showed lower values in strength and range of motion of the operated leg, when compared to contralateral side. In plantar flexion, this accounted for a reduction in MG by 3.8 ± 1.0 kg of strength and 8 ± 3° of ROM, and in DG by 4.7 ± 1.7 kg and 16 ± 4°, respectively. For knee flexion, the reduction in MG was 4.4 ± 0.6 kg and 16 ± 7°, while in DG 5.6 ± 1.0 kg and 28 ± 6°. In the MG group, 60% were able to stand on the tiptoe of the operated leg, as opposed to 0% in DG. The average LEFS score in DG was lower by 10.9 points (p < .05). Questions concerning running and jumping had a lower score in DG (p < .01). CONCLUSIONS: The harvesting of both gastrocnemii led to significant additional donor site morbidity compared to the harvesting of the medial gastrocnemius alone. However, the additional morbidity did not have an impact on activities of daily living and walking, even though it limited the ability to perform more demanding tasks such as running and jumping. Therefore, based on our study, the choice of a DG flap should be critically assessed in younger, more demanding patients.

Coverage of Palmar Mini Plates with Flexor Pulleys in the Treatment of Dorsal Fracture-Subluxation of the Proximal Interphalangeal Joint.

Introduction: Dorsal fracture dislocations (DFD) of the proximal interphalangeal joint (PIPJ) are challenging fractures. A palmar surgical approach and plate fixation has a high complication rate, including flexor contractions, reduction of range of motion (ROM) and secondary need for plate removal. Methods: We use the flexor tendon pulleys to cover the mini plate with the assumption that it may reduce the adhesion between the mini plates and the tendons and reduce postoperative complications. We present the outcomes of using this technique in eight patients. Results: All patients had an excellent outcome at a mean follow-up of 17 months, and none required removal of the implants. Conclusions: This study presents a surgical technique that may potentially reduce the high complication rate found after ORIF for treatment of DFD of the PIPJ. Therefore, improving the clinical outcomes after this type of surgery. Level of Evidence: Level IV (Therapeutic).

Is increased trapezial slope a cause of early trapeziometacarpal osteoarthritis?

OBJECTIVES: Thumb carpometacarpal joint osteoarthritis is one of the most common forms of osteoarthritis in the hand. The underlying causes are multifactorial. We investigated whether increased trapezial slope could be a causal factor. MATERIAL AND METHODS: We measured trapezial slope and 1st metacarpal slope in 37 patients with early thumb carpometacarpal joint osteoarthritis and compared results with 41 patients without osteoarthritis, using computer-supported 3D-analysis based on CT scans. RESULTS: There was a significant intergroup difference in trapezial slope (111° in patients with osteoarthritis, and 107° in patients without) and in 1st metacarpal slope (17° versus 14°). CONCLUSION: Steeper trapezial slope seemed to be a risk factor for thumb carpometacarpal joint osteoarthritis. Therefore, correction of trapezial slope by trapezium osteotomy could be a valuable surgical approach in early thumb carpometacarpal joint osteoarthritis.

Residual stability of the distal radioulnar joint following ulnar styloid fracture: influence of the remnant distal radioulnar ligaments.

Clinical studies suggest that even untreated basal ulnar styloid fractures may not affect patient outcomes. This may be due to the remaining parts of the distal radioulnar ligament still attached providing sufficient residual stability of the distal radioulnar joint. We tested this hypothesis in a biomechanical cadaveric model. Dorsopalmar translation of the distal radioulnar joint and forearm rotation were measured. Seventeen specimens were tested after a simulated ulnar styloid fracture including the fovea, followed by transection of the remaining palmar (n = 9) or dorsal (n = 8) portions of the distal radioulnar ligament and finally with all remnants transected. Rotation and translation both increased significantly after the final transection compared with the foveal fracture. The increase in translation was larger after transection of the dorsal remnants. We conclude that in an ulnar styloid fracture including the fovea, some ligament components are still attached to the ulnar head, giving residual stability to the distal radioulnar joint.

Does Age Affect the Outcomes of Core Decompression for the Treatment of Kienböck Disease?

Background: Core decompression of the distal radius is a minimally invasive technique that has demonstrated good clinical outcomes in the treatment of Kienböck disease. However, the effectiveness of core decompression has not been compared in different age groups. The aim of this study is to compare the outcomes of core decompression in patients <45 years of age to those ≥45 years of age. Methods: This retrospective study included 36 patients with Kienböck disease who were treated with core decompression over a 20-year period. The mean follow-up was 7 years. Outcome measures included visual analogue scale pain score (VAS), active range of flexion/extension at the wrist, grip strength, and modified Mayo wrist score. The patients were divided into two age groups namely <45 years (younger group; n = 22) and ≥45 years (older group; n = 12) and the outcome measures were compared between the two age groups. Results: There were no statistically significant differences between the outcomes of the two age groups. Conclusion: The outcomes of core decompression of the distal radius for Kienböck disease in older patients (≥45 years) are favorable and similar to those seen in younger patients (<45 years). Level of Evidence: Level III (Therapeutic).

The anatomy of the anconeus nerve redefined.

The anconeus nerve is the longest branch of the radial nerve and suitable as a donor for the neurotization of the axillary nerve. The aim of this study was to map its topographical course with reference to palpable, anatomical landmarks. The anconeus nerve was followed in 15 cadaveric specimens from its origin to its entry to the anconeus. It runs between the lateral and the medial head of the triceps before entering the medial head and running intramuscularly further distal. Exiting the muscle, it lies on the periosteum and the articular capsule of the elbow, before entering the anconeus muscle. Two types of anconeus nerve in relation to branches innervating triceps were found: nine nerves also innervated the lateral triceps head, while the other six only contributed two branches to its innervation. The course of the anconeus nerve is important for harvesting as a donor nerve and to protect the nerve in surgical elbow approaches.

The Critical Size of Ulnar Styloid Fragment for the DRUJ Stability.

Background Ulnar styloid fractures can be associated with clinically significant instability of the distal radioulnar joint (DRUJ). However, the exact fragment size that results in DRUJ instability is unknown. Purpose The objective of this study was to determine the critical size of an ulnar styloid fracture that would result in a significant increase in DRUJ translation and forearm rotation. Methods Eight cadaveric specimens were used to investigate the effects of three different ulnar styloid fracture sizes on DRUJ instability: tip fracture, base fracture, and a fracture including the fovea. Forearm rotation and dorsopalmar DRUJ translation were measured after each sequential increase in fracture size. Results Relative to the uninjured state, a significant increase in forearm rotation and dorsopalmar translation was found for all three fractures. However, the fovea fracture showed a statistically significant increase in forearm rotation compared with all other fracture types and a statistically significant increase in total dorsopalmar translation compared with the tip fracture. Conclusion In this study, ulnar styloid fractures involving the fovea resulted in significantly greater DRUJ instability comparted to tip and base fractures alone. This study provides important biomechanical data regarding the critical size of ulnar styloid fractures that result in DRUJ instability and may aid in the surgical decision-making algorithm in these patients.

Should We Repair the Pronator Quadratus in a Distal Radius Fracture with an Ulnar Styloid Base Fracture? A Biomechanical Study.

Background Merits of repairing the pronator quadratus (PQ) to restore distal radioulnar joint (DRUJ) stability after a volar approach remain controversial. Distal radius fractures are often associated with ulnar styloid fractures (USF). When involving the fovea, this USF can lead to a DRUJ instability. The PQ repair may be key in reducing this DRUJ instability. Methods This study aims to assess the biomechanical role of PQ repair in a cadaveric model of USF. In 17 forearm specimens, a USF including the fovea was executed. Positional changes of the DRUJ in forearm rotation and dorso-palmar (DP) translation were measured with variable loads (0, 2.5, and 5N) applied to the PQ origin. Results Forearm rotation and DP-translation decreased significantly with PQ loading of 5N, changing on average by 5 degrees and 0.6 mm, respectively. Conclusion We found a significant decrease in forearm rotation and DP-translation comparing a fully loaded PQ to an unloaded PQ in our cadaveric model.

Volar Plate Capsulodesis With Internal Brace Augmentation for the Claw Hand.

Claw hand deformity is characterized by hyperextension of the metacarpophalangeal joints and flexion of the proximal interphalangeal joints. Surgical treatment of claw hand deformities often involves soft tissue procedures such as tendon transfers or volar plate capsulodesis. However, tissue attenuation over time can lead to recurrence of the deformity. Augmentation with an internal brace may help to address this problem. This report presents a novel technique for the treatment of claw hand deformity involving augmentation of the traditional volar plate capsulodesis with internal brace. Two illustrative cases utilizing the described technique are presented.

Ulnar footprints of the distal radioulnar ligaments: a detailed topographical study in 21 cadaveric wrists.

Understanding of the exact topography of the distal radioulnar ligaments insertions remains limited. An anatomical study was performed in 21 fresh frozen cadaveric wrists, where the superficial and deep ligaments were sequentially transected sharply at their ulnar insertions. The relationships between the distal radioulnar ligament footprints relative to the bony landmarks of the ulnar styloid were digitized. Our study demonstrated that in the coronal plane, the superficial distal radioulnar ligaments inserted at an average of 87% of the styloid height proximally to the styloid tip distally. The deep distal radioulnar ligaments inserted at an average of 81% of the styloid height distally to the fovea proximally. The superficial footprint had an area of 10.6 mm2 on the ulnar styloid. The deep distal radioulnar ligaments attachment was asymmetric and generally had two separate footprints. This study adds important topographical knowledge about the footprint of the distal radioulnar ligaments and may contribute to understanding the consequences of ulnar styloid fractures and distal radioulnar ligaments lesions.

Internal Bracing Augmentation for Scapholunate Interosseous Ligament Repair: A Cadaveric Biomechanical Study.

PURPOSE: Internal bracing (IB) is an augmentation method using high-strength nonabsorbable tape. This study compared scapholunate interosseous ligament (SLIL) repair alone, SLIL repair with IB augmentation (RIBA), and native intact SLIL (NIS) in a biomechanical cadaveric model. METHODS: We used 21 specimens of fresh-frozen wrists in this study (7 matched pairs, SLIL repair-only and SLIL RIBA groups; and 7 independent fresh-frozen wrists, NIS group). In the SLIL RIBA group, augmentation using IB was performed after the repair. The specimens were preloaded and cyclically loaded in tension. Maximum extension and hysteresis were measured in all specimens. The specimens were subsequently tested for load to failure. Failure load (yield point load, mean ultimate load, and load at clinical failure) and linear stiffness were calculated. RESULTS: In cyclic tensile testing, RIBA showed lower maximum extension and lower hysteresis than repair alone. In load to failure testing, the yield point load was statistically higher in the RIBA (59.3 N) group than in the repair-only (30.4 N) group but showed no significant difference compared with the NIS (90.7 N) groups. Moreover, the RIBA (98.5 N) group showed higher and lower mean ultimate loads than the repair-only (37.7 N) and NIS (211.8 N) groups, respectively. Load at clinical failure was higher with RIBA than with repair alone (3-mm extension: 70.0 vs 26.4 N; 4-mm extension: 84.1 vs 33.4 N). Repair alone and RIBA had comparable linear stiffness (38.2 vs 44.1 N/mm). CONCLUSIONS: Although SLIL RIBA did not recreate biomechanical properties equivalent to those of NIS, it demonstrated a significantly higher strength than repair alone. CLINICAL RELEVANCE: Repair with IB augmentation could serve as a novel surgical technique that enhances SLIL direct repair through biomechanical support.

Carpal Instability Nondissociative Following Acute Wrist Fractures.

PURPOSE: Carpal malalignment following intra-articular fractures has been reported in the literature, with no clear description of possible ligamentous injury leading to the radiological appearance. This study presents a series of patients that developed carpal instability nondissociative (CIND) following acute wrist fractures. The mechanism of injury is postulated by using a cadaveric laboratory investigation. METHOD: Twelve patients with average age of 32 years were identified with CIND, between 2013 and 2018. Ten patients with a normal carpal alignment in the initial postoperative radiographs exhibited CIND-palmar radiographically at different postoperative periods, and 2 patients showed CIND-dorsal in the initial postoperative x-rays. Four cadaveric specimens were used to validate this injury pattern. RESULTS: In cadaveric dissections, CIND-palmar could be reproduced by applying an axial loading and dorsal shearing force on a wrist with sequential sectioning of dorsal and palmar extrinsic wrist ligaments. For the intra-articular fractures with CIND-dorsal, the cause is likely a result of volar radiocarpal extrinsic ligament injury combined with intra-articular incongruity of the scaphoid fossa. Eight out of the 12 patients had severe wrist pain and underwent additional surgery. Three patients with reducible CIND-palmar had open capsular repair, and 5 patients with fixed nonreducible malalignment were treated with radioscapholunate arthrodesis. At an average follow-up of 2.3 years, pain relief was noted, together with an improvement in grip strength and range of movement. Radiographically, the wrist alignment was corrected and maintained. CONCLUSIONS: This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity, associated with acute intra-articular fractures and radiocarpal fracture-dislocations, that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. Early detection of this condition may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Kinematically aligned total knee arthroplasty reproduces more native rollback and laxity than mechanically aligned total knee arthroplasty: A matched pair cadaveric study.

BACKGROUND: A growing body of evidence supports that kinematically aligned (KA) total knee arthroplasty (TKA) provides superior clinical outcomes and satisfaction than mechanically aligned (MA) TKA. In theory, KA TKA would restore knee kinematics closer to the native condition than MA TKA, but the current biomechanical evidence is lacking. HYPOTHESIS: KA TKA would restore knee biomechanics to the native condition better than MA TKA. METHODS: Seven pairs of cadavers were tested. For each pair, one knee was randomly assigned to KA TKA and the other to MA TKA. During KA TKA, the sizes of femur and tibia resections were equivalent to implant thickness to align with the patient-specific joint line. MA TKA was performed using conventional measured resection techniques. All specimens were mounted on a customized knee-testing system and digitized. Knee motions measured during flexion included rollback, axial tibiofemoral rotation, and laxities, specifically varus-valgus laxity, anterior-posterior translation, and internal-external rotation. RESULTS: The pattern of knee motion following KA TKA was similar to the native knee. However, following MA TKA, both medial and lateral rollback and tibiofemoral axial rotation were decreased relative to those of the native knee. Valgus laxity was restored only after KA TKA, whereas varus laxity was restored only after MA TKA. Anterior translation was increased regardless of the alignment strategy. In addition, rotational laxities were restored after KA TKA, but external rotation laxity increased after MA TKA. CONCLUSION: KA TKA restores femoral rollback and laxity to the native condition better than MA TKA. KA TKA may enhance functional performance and provide a more normal knee sensation. LEVEL OF EVIDENCE: II, Controlled laboratory study.

Surgical Treatment of Mild to Severe Hallux Valgus Deformities With a Percutaneous Subcapital Osteotomy Combined With a Lateral Soft Tissue Procedure.

Distal metatarsal (MT) osteotomies have been used in mild or moderate cases of hallux valgus (HV) and proximal MT osteotomy has been considered the treatment of choice for severe deformities. A distal osteotomy could achieve a greater degree of correction by the addition of a distal soft-tissue procedure and be used to treat also severe deformity. Limited evidence about the use of the percutaneous subcapital osteotomy (SCOT); a type of MT osteotomy, in combination of a soft tissue procedure, is available. We evaluated this procedure routinely used in our clinic. A total of 30 consecutive patients treated in our hospital from September 2012 to April 2015 with SCOT combined with lateral soft tissue release were included in this retrospective review. Outcomes assessed included radiological parameters: HV angle (HVA) and intermetatarsal angle (IMA), clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. In 12 of the 30 patients included, the pathology was bilateral, comprising a total of 42 cases. The overall correction of the angles was statistically significant (P < .001), changing from a HVA of 28.2° and IMA of 13.5° preoperatively to 8.0° and 6.0° postoperatively, respectively. The cases were divided into mild-moderate (34/42) and severe (8/42). Both groups showed a statistically significant correction in the angles, 3 months after surgery (P < .001). The AOFAS score showed a median of 49 points (n = 24) preoperatively and of 95 points (n = 40) at the end of follow-up. The complication rate at end of follow-up was 19% (8/42). After a minimum follow-up of 1 year, our technique for HV correction results in a clinically relevant improvement of the radiological parameters and AOFAS score in mild to severe deformities. Combination with lateral release could be a meaningful surgical alternative for the treatment of severe cases to help decrease the risk of recurrence. Levels of Evidence: Level IV.

Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion.

PURPOSE: The implant positioning for kinematically aligned total knee arthroplasty (TKA) differs fundamentally from conventional mechanically aligned TKA. This difference may affect patellofemoral (PF) biomechanics after TKA. This cadaveric study tested the hypothesis that kinematically aligned TKA would restore PF biomechanics to the native condition better than mechanically aligned TKA. METHODS: Seven pairs (14 knees) of fresh-frozen cadavers were tested. All specimens were mounted on a customized knee-testing system and digitized using a Microscribe 3DLX instrument (Revware Inc., Raleigh, NC, USA) to measure patellar kinematics in terms of patellar varus/valgus rotation, medial/lateral position, flexion/extension rotation and proximal/distal position at knee flexion angles of 0°, 30°, 60°, 90°, and 120°. The medial and lateral PF joint contact pressure distributions at 120° of knee flexion were measured using a K-scan system (Tekscan Inc., Boston, MA, USA). All patellae remained unresurfaced. For each pair, one knee was randomly assigned to kinematically aligned TKA and the other to mechanically aligned TKA performed using the conventional measured resection technique. During kinematically aligned TKA, the amount of femur and tibia resected was equivalent to implant thickness to maintain the patient-specific joint line. All patellar kinematics were measured and compared between the native condition and after surgery. RESULTS: The patellae of mechanically aligned TKA rotated more valgus and was positioned more laterally compared with those of kinematically aligned TKA at knee flexion angles ≥ 90°. Neither the patellar flexion/extension rotation nor the proximal/distal position differed between either prosthetic knee design and the native knee at all flexion angles. The contact pressure distribution between the medial and lateral PF joint after kinematically aligned TKA were similar to those of the native knee, while the lateral PF joint contact pressure after mechanically aligned TKA was higher than that of the native knee (p = 0.038). CONCLUSIONS: Kinematically aligned TKA better restores patellar kinematics and PF contact pressure distribution to the native condition than mechanically aligned TKA during deep knee flexion. These findings provide clues to understand why kinematically aligned TKA is associated with less anterior knee pain and better PF functional performance compared to mechanically aligned TKA. Patients undergoing kinematically aligned TKA may experience a more normal feeling during deep knee flexion activities.

Review and Long-Term Outcomes of Cruciate Ligament Reconstruction versus Conservative Treatment in Siblings with Congenital Anterior Cruciate Ligament Aplasia.

There is no consensus on the best treatment for anterior cruciate ligament hypoplasia or aplasia. To our knowledge, no comparative study between operative and conservative treatment of this condition has ever been performed. Conservative treatment is a viable alternative to surgery for ACL aplasia. Two siblings were examined at our outpatient clinic. The male patient underwent bilateral ACL reconstruction, while his sister was treated conservatively. Our results show a worse long-term outcome for the operative patient. At her last follow-up, the female patient treated conservatively showed subjective improvement in stability and gait. A review of the literature shows inconsistent outcomes after reconstruction in contrast to reports with cruciate ligament agenesis that did not undergo reconstruction with acceptable to good outcomes. Cruciate reconstruction should be reserved for cases of impaired articular instability, objectively manifest in the frequency of giving-way episodes. Treatment depends on the patient's condition and expectations. Surgery should therefore only be suggested after proper patient counseling.