Simple curettage and allogeneic cancellous bone chip impaction grafting in solitary enchondroma of the short tubular bones of the hand.

Enchondroma is the most common bone tumor in the hand. While standard surgical procedure is intra-lesional excision and bone grafting, there is a dispute between allogeneic bone, autogenous bone, and synthetic bone substitute grafting. Diverse adjuvant treatments have been introduced to reduce recurrence, but results are mixed with controversies. Meanwhile, whether existing descriptive classification could predict treatment outcome remains unclear. Thus, we reviewed patients with solitary enchondroma of the hand who underwent simple curettage followed by allogeneic cancellous bone chip impaction grafting. Eighty-eight patients with more than 5 years of follow-up were enrolled. Demographic data, local recurrence, and complications were reviewed. Duration of consolidation and the difference according to Takigawa classification were assessed. Range of motion (ROM), and functional scores were also evaluated. There were 51 women and 37 men, with a mean age of 37.9 years. Mean follow-up was 10.2 years. Recurrence occurred only in one patient. There was no complication. Mean postoperative total active motions of fingers and thumb were 239° and 132.9°. Mean modified Disabilities of the Arm, Shoulder, Hand score, and Musculoskeletal Tumor Society Score were 1.63, and 99.2 at the last follow-up. Consolidation, ROM, and functional scores according to Takigawa classification showed no significant differences. This study suggests that simple curettage with impaction grafting of allogeneic cancellous bone chip is a feasible method for treating solitary enchondromas involving short tubular bone of the hand with good long-term outcomes. Postoperative recurrence and complication rates were very low. Radiographic and clinical results were good regardless of the previous radiological classification.

Pancarpal dissociation, a very rare type of injury: A case report.

RATIONALE: Pan-carpal dissociation is very rare injury and there is little information as to diagnosis, treatment, and prognosis of this injury. PATIENT CONCERNS: A 35-year-man presented to our hospital with severe pain and swelling of the left wrist and forearm after slipping and falling while riding a motorcycle. DIAGNOSIS: The wrist simple radiographs demonstrated unrecognizable severe fracture-dislocation of the carpal bones concomitant with fractures of the radioulnar shaft. Three-dimensional computed tomography revealed a capitate fracture-dislocation, as well as hamate dislocation, lunotriquetral (LT), and scapholunate (SL) dissociation. These findings suggested pan-carpal dissociation. INTERVENTIONS: To prevent compartment syndrome, fasciotomy, carpal tunnel release, and open reduction and plate fixation for both bone fracture were performed first. Then, for pan-carpal dissociation, the capitate, carpometacarpal joint (CMCJ), and hamate were reduced and fixed first. Then, the SL, LT, and other intercarpal ligaments were repaired. Finally, additional trans-carpal pins to reinforce the ligament repair and 2.0 mm plate to buttress the third CMCJ were fixed. The patient was instructed to begin gentle range of motion exercises of the wrist with pins from four weeks after surgery and all pins were removed at six weeks postoperatively. OUTCOMES: 12 months after the operation, the patient exhibited almost full range of motion with mild pain with VAS (Visual analogue scale) 1-2 at rest and VAS 3-4 with effort. Quick DASH (the disabilities of the arm, shoulder and hand) score was 25 and modified Mayo score was 70. The radiographs demonstrated union of the radioulnar shaft, and the carpal bone alignment was successfully maintained. LESSONS: Pan-carpal dissociation can be diagnosed in patients with capitate fracture-dislocation, hamate dislocation, LT, and SL dissociation. This pattern of injury is very rare and the authors recommend reduction and fixation of the distal carpal row, followed by the proximal row to facilitate an easy approach to the distal carpal row. Although it is very severe injury, rigid anatomical fixation and an early rehabilitation can lead to favorable functional outcomes.

Primary radial nerve palsy associated with humeral shaft fractures according to injury mechanism: is early exploration needed?

BACKGROUND: Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were (1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, (2) to estimate the risk factors of primary RNP, and (3) to evaluate whether early exploration is helpful for radial nerve recovery. METHODS: This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low-energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated. RESULTS: There were 31 cases of radial nerve palsy among 162 patients: 27 in the high-energy humeral shaft fracture group and 4 in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases recovered (88.9%). The other 9 radial nerves were not explored, and only 5 cases recovered (55.6%). CONCLUSIONS: This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in high-energy humeral shaft fracture. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury.

The risk of hip fractures in individuals over 50 years old with prediabetes and type 2 diabetes - A longitudinal nationwide population-based study.

BACKGROUND: The present study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and hip fractures using a large-scale nationwide population-based cohort that is representative of the Republic of Korea. We determined the risks of hip fractures in individuals with prediabetes and T2DM with different diabetes durations, and compared them with the risks of hip fractures in individuals without T2DM. METHODS: A total of 5,761,785 subjects over 50 years old who underwent the National Health Insurance Service medical checkup in 2009-2010 were included. Subjects were classified into 5 groups based on the diabetes status; Normal, Prediabetes, Newly-diagnosed T2DM, T2DM less than 5 years, and T2DM more than 5 years. They were followed from the date of the medical checkup to the end of 2016. The endpoint was a new development of hip fracture during follow-up. The hazard ratios (HRs) and 95% confidence intervals (CIs) of hip fractures for each group were analyzed using Cox proportional hazard regression models after adjusting for age, sex, smoking, alcohol drinking, regular exercise, body mass index, hypertension, dyslipidemia, and chronic kidney disease. RESULTS: The HRs of hip fractures were 1 in the Normal group, 1.032 (95% CI: 1.009, 1.056) in the Prediabetes group, 1.168 (95% CI: 1.113, 1.225) in the Newly-diagnosed T2DM2, 1.543 (95% CI: 1.495, 1.592) in the T2DM less than 5 years and 2.105 (95% CI: 2.054, 2.157) in the T2DM more than 5 years. The secular trend of the HRs of hip fractures according to the duration of T2DM was statistically significant (P < .001). Subgroup analyses also showed the same increasing pattern of the HRs of hip fractures according to the duration of T2DM in both sexes and all age groups (50-64 years, 65-74 years, over 75 years). CONCLUSIONS: In summary, this large-scale, retrospective, longitudinal, nationwide population-based cohort study of 5,761,785 subjects demonstrated that the risks of hip fractures started to increase in prediabetes and was associated linearly with the duration of T2DM. The secular trend of risks of hip fractures according to the duration of T2DM was consistent in both sexes and all age groups.

Hemovac blood after total knee arthroplasty as a source of stem cells.

BACKGROUND: With increasing life expectancy, stem cell therapy is receiving increasing attention. However, its application is restricted by ethical concerns. Hence a need exists for design of safe procedures for stem cell procurement. Here, we investigated whether hemovac blood (HVB) is an appropriate stem cell source. METHODS: HVB concentrates (HVBCs) from 20 total knee arthroplasty (TKA) patients and bone marrow aspirate (BMA) concentrates (BMACs) from 15 patients who underwent knee cartilage repair were comparatively evaluated. A bone marrow aspiration needle was inserted into the anterior superior iliac spine. Aspiration was performed using a 50-mL syringe, including 4 mL of anticoagulant, followed by centrifugation to obtain BMACs. To obtain HVBCs, blood was aspirated from the hemovac immediately after TKA surgery. Different cell types were enumerated. Isolation of BMA and HVB mononuclear cells was performed using density gradient centrifugation. Non-hematopoietic fibroblast colonies were quantified by colony forming unit-fibroblast assay surface marker analysis of HVB, HVBC, BMA, and BMAC was performed via flow cytometry. Mesenchymal stem cells (MSCs) isolated from HVBCs and BMACs were examined for osteogenic, adipogenic, and chondrogenic differentiation potential. Gene expression analysis was performed by quantitative real-time polymerase chain reaction (qRT-PCR). RESULTS: The number of cells from HVB and HVBC was significantly lower than from BMA and BMAC; however, the number of colonies in HVBC and BMAC did not differ significantly (P>0.05). Isolated cells from both sources had a fibroblast-like appearance, adhered to culture flasks, and formed colonies. Under different culture conditions, MSC-specific surface markers (CD29, CD44, CD90, CD105), osteogenic markers [RUNX2, osteopontin, osteocalcin, and alkaline phosphatase (ALP)] and adipogenic markers (PPARγ and C/EBPα) were expressed. Moreover, SOX9, type II collagen, and aggrecan were significantly upregulated upon chondrogenic differentiation. CONCLUSIONS: HVB from TKA patients is a useful source of stem cells for research.

Comparison of the demographic and wound characteristics of non-suicidal and suicidal self-wrist cutting injuries.

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

Two-dimensional Morphological Characteristics of the Distal Radius on Axial Magnetic Resonance Image and the Effects on Distal Screw Length.

BACKGROUND: Detection of dorsal cortical penetration of distal locking screws is difficult owing to the irregular shape of the dorsal surface of the distal radius. This study was designed to analyze two-dimensional morphological characteristics of the distal radius on axial magnetic resonance image, and to suggest a guideline for evaluation of screw length in distal radius fractures on the fluoroscopic or plain X-ray true lateral image. METHODS: Anteroposterior length and lateral width of the distal radius, distance between the highest and the lowest point of the dorsal cortex (deceptive length), and widths of the first to second (hazard zone) and the third to fifth extensor compartments (safe zone) at the Lister tubercle level were measured on 104 axial magnetic resonance images by two hand surgeons. RESULTS: The mean length and width of the distal radius at the Lister tubercle level were 22.96 mm and 30.42 mm, respectively. The mean hazard zone and safe zone widths were 8.72 mm and 19.43 mm, respectively. The mean deceptive length was 4.07 mm and the deceptive length did not have a relationship with height, sex, and age of subjects. CONCLUSIONS: We suggest that 4 mm be used as a reference value for the evaluation screw length at the safe zone. If the vertical distance between a distal screw tip and the peak of the Lister tubercle is lesser than 4 mm on a fluoroscopic or plain X-ray true lateral image, dorsal cortical penetration should be suspected. When dorsal cortical penetration at the hazard zone is suspected, both oblique or pro-supination views should be checked.

Survey of Preferences in Patients Scheduled for Carpal Tunnel Release Using Conjoint Analysis.

BACKGROUND: This study aimed to investigate the preferences of patients scheduled for carpal tunnel release using conjoint analysis and also introduce an example of how to apply a conjoint analysis to the medical field. The use of conjoint analysis in this study is new to the field of orthopedic surgery. METHODS: A total of 97 patients scheduled for carpal tunnel release completed the survey. The following four attributes were predefined: board certification status, distance from the patient's residency, medical costs, and waiting time for surgery. Two plausible levels for each attribute were assigned. Based on these attributes and levels, 16 scenarios were generated (2 × 2 × 2 × 2). We employed 8 scenarios using a fractional factorial design (orthogonal plan). Preferences for scenarios were then evaluated by ranking: patients were asked to list the 8 scenarios in their order of preference. Outcomes consisted of two results: the average importance of each attribute and the utility score. RESULTS: The most important attribute was the physician's board certificate, followed by distance from the patient's residency to the hospital, waiting time, and costs. Utility estimate findings revealed that patients had a greater preference for a hand specialist than a general orthopedic surgeon. CONCLUSIONS: Patients considered the physician's expertise as the most important factor when choosing a hospital for carpal tunnel release. This suggests that patients are increasingly seeking safety without complications as interest in medical malpractice has increased.

Enhancement of Healing of Long Tubular Bone Defects in Rabbits Using a Mixture of Atelocollagen Gel and Bone Marrow Aspirate Concentrate.

We evaluated the bone-forming potential of a mixture of atelocollagen and bone marrow aspirate concentrate which was transplanted into bone defects. Radial shaft defects of about 10 mm in size were created in 30 New Zealand white rabbits. Ten rabbits in the control group were not treated further, 10 rabbits in the first experimental group (E1) received an atelocollagen injection, and 10 rabbits in the second experimental group (E2) received an injection of a mixture of atelocollagen and bone marrow aspirate concentrate. The groups were compared radiologically at 8 weeks. Osteogenesis in group E2 progressed more rapidly than that in the other groups, and osteogenesis in group E1 progressed faster than that in the control group. Thus, the administration of a mixture of atelocollagen and bone marrow aspirate concentrate in bone defects was found to enhance bone defect healing.

The Effect of Distal Location of the Volar Short Arm Splint on the Metacarpophalangeal Joint Motion.

BACKGROUND: The goals of this study were to compare maximal metacarpophalangeal joint (MCPJ) flexion angles after application of a volar short arm splint at 3 different locations and verify the relations between the three different physical and radiological locations. METHODS: Forty dominant hands of healthy subjects were analyzed in the study. We defined a transverse skin folding line as a line drawn from the radial aspect of the thenar crease to the ulnar aspect of the distal transverse palmar crease. The distal end of the volar short arm splint was applied on 3 parallel locations to this line. Location A was on this transverse skin folding line; location B was 1 cm proximal to location A; and location C was 1 cm distal to location A. Two orthopedic surgeons measured the maximal MCPJ flexion angles of each finger except the thumb with the application of a volar short arm splint at 3 different locations as well as without a splint as a control. Radiological locations of the 3 different distal ends of the volar short arm splint were also assessed by anteroposterior radiographs of the wrist. RESULTS: When the splint was applied at location A and C, the maximal MCPJ flexion angle decreased to a mean of 83° (91% of control value) and 56° (62% of control value), respectively (compared to the control, p < 0.001). At location B, the maximal MCPJ flexion angle was a mean of 90° (99% of control value); no significant difference was observed compared to the control or without the splint (p = 0.103). On radiography, the average length from the metacarpal head to the distal end of the splint at all fingers decreased in the order of location B, A, and C (29 mm, 19 mm, and 10 mm, respectively; p < 0.001). CONCLUSIONS: We recommend applying the distal end of a volar short arm splint at proximal 1 cm to the transverse skin folding line to preserve MCPJ motion perfectly, which is located at distal 44% of the whole metacarpal bone length radiologically.

Reliability of semi-pronated ulnar deviation PA view (billiard view) of the wrist in evaluating the scaphoid.

Various methods assessing the scaphoid have been reported because of its unique position. In our hospital, pre- and postoperative evaluation of the scaphoid alignment has been carried out in the billiard view, a combination of 45° pronated oblique with ulnar deviation posteroanterior (PA) view, in addition to 3DCT scan and PA and lateral view. This study compared the intra- and inter-observer reliabilities of the lateral intrascaphoid angle and scaphoid length (SL) and scaphoid height (SH) on the billiard view. A total of 60 patients who underwent surgery for scaphoid nonunion were identified and the preoperative and the final follow-up postoperative plain radiographs were used for measurement. Three observers assessed each image. Intra- and inter-observer reliability was determined using intra-class correlation (ICC) coefficients. Intra-observer reliability was all excellent ranging between 0.855 and 0.992. Inter-observer reliability ranged between 0.292 and 0.983. SL and SH demonstrated excellent agreement, while ISA demonstrated poor to moderate agreement. The best method for assessing the scaphoid in simple radiograph remains debatable, but our current data suggest that measuring SL and SH on the billiard view is reproducible and can be used for evaluating restoration of scaphoid alignment.

Epidermal Inclusion Cyst after Carpal Tunnel Release: A Case Report.

Background Carpal tunnel release is one of most commonly performed procedures in upper extremity surgery, with low complication rates. Case Description We report a case of epidermal inclusion cyst that occurred in a 44-year old man after carpal tunnel release. The epidermal inclusion cyst formed beneath the previous operation scar and induced recurrent carpal tunnel syndrome. Symptoms resolved completely after excision of the cyst. Literature Review Epidermal inclusion cysts are the third most common type of hand tumors. Although repeated minor trauma is the most frequent cause, surgical procedures can induce an epidermal inclusion cyst. One case report of epidermal inclusion cyst after carpal tunnel release was found in literature. Etiology, treatment, and prevention methods are reviewed. Clinical Relevance We hope this case report alerts physicians to the possibility of development of epidermal inclusion cyst after carpal tunnel release and the importance of basic surgical skills, such as gentle handling of a surgical wound, profuse saline irrigation, and careful wound closure with precise approximation of skin edges.

Redisplacement of Distal Radius Fracture after Initial Closed Reduction: Analysis of Prognostic Factors.

BACKGROUND: To evaluate risk factors of redisplacement and remind surgeons of key factors regarding conservative treatment of distal radius fracture. METHODS: A total of 132 patients who received conservative treatment for distal radius fractures between March 2008 and February 2011 were included in this study. Radial inclination, radial length, volar tilting angle, ulnar variance, fragment translation, and presence of dorsal metaphyseal comminution were measured on the X-rays taken immediately after reduction, one week after injury during the first follow-up outpatient clinic visit, and after the gain of radiological union. Secondary displacement was defined as a loss of reduction during the follow-up period, and was divided into 'early' and 'late' categories. We analyzed the influence of initial displacement radiologic variables, dorsal cortex comminution, and patient age on the development of secondary displacement. RESULTS: Development of secondary displacement was significantly associated only with initial displacement radiologic variables (p < 0.001), development of the late secondary displacement was significantly associated with age (p = 0.005), and initial displacement radiologic variables were associated significantly with a serial increase in ulnar variance (p = 0.003). CONCLUSIONS: Greater displacement on the initial radiographs indicates a higher possibility of development for secondary displacement, and older patients had a higher probability of late secondary displacement development. Furthermore, dorsal comminutions did not affect secondary displacement directly.

Double tension band wiring for treatment of olecranon fractures.

PURPOSE: Although tension band wiring (TBW) is generally accepted as standard treatment for olecranon fractures, it has several shortcomings such as loss of reduction, skin irritation, and migration of the K-wires. To overcome these problems and increase fixation stability, we used a rigid fixation technique with double tension band wiring (DTBW). Here, we describe the technique and outcomes of the treatment. METHODS: We retrospectively reviewed 21patients with olecranon fractures who were treated by DTBW. We evaluated clinical and radiological outcomes by checking the range of motion, loss of reduction, functional scoring, skin complications, and pin migration. There were 15 cases of Mayo type IIA fractures (71%) and 6 of type IIB fractures (29%). The mean follow-up period was 37 months (range, 12-58 mo). We also compared the mechanical stability of DTBW and TBW in a sawbone model using a single cycle load to failure protocol. RESULTS: All fractures united without displacement, and no migration of the K-wires was observed during the period of follow-up. Mean loss of elbow extension was 2° (range, 0°-15°) and mean elbow flexion was 134° (range, 125°-140°). The mean Mayo Elbow Performance Score was 94 (range, 70-100). Biomechanical testing revealed greater mechanical strength in the DTBW technique than in the TBW when measured by mean maximum failure load and mean bending moment at failure. CONCLUSIONS: DTBW produced good clinical and radiological outcomes and could be an effective option for the treatment of olecranon fractures by providing additional stability through a second TBW. Biomechanical comparison with a control group (TBW) supported the mechanical benefits of DTBW. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Musicians' medicine: musculoskeletal problems in string players.

There is increasing attention to medical problems of musicians. Many studies find a high prevalence of work-related musculoskeletal disorders in musicians, ranging from 73.4% to 87.7%, and string players have the highest prevalence of musculoskeletal problems. This paper examines the various positions and movements of the upper extremities in string players: 1) basic postures for holding instruments, 2) movements of left upper extremity: fingering, forearm posture, high position and vibrato, 3) movements of right upper extremity: bowing, bow angles, pizzicato and other bowing techniques. These isotonic and isometric movements can lead to musculoskeletal problems in musicians. We reviewed orthopedic disorders that are specific to string players: overuse syndrome, muscle-tendon syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Symptoms, interrelationships with musical performances, diagnosis and treatment of these problems were then discussed.