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.

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.

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.

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.

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.

Subluxation of the extensor carpi ulnaris on magnetic resonance imaging on neutral wrist position: correlation with tenosynovitis of the extensor carpi ulnaris and translation of the distal radioulnar joint.

OBJECTIVE: To identify the subluxation degrees of extensor carpi ulnaris (ECU) tendon on neutral wrist MRI in patients with ulnar-sided wrist pain and to evaluate the relationships of ECU subluxation with accompanying imaging findings such as ECU tenosynovitis, distal radioulnar joint (DRUJ) stability, and triangular fibrocartilage complex (TFCC) pathology. MATERIALS AND METHODS: A total of 297 MRIs of 292 patients having ulnar side pain were reviewed retrospectively. Degrees of ECU subluxation was classified into four grades: grade 0, no subluxation; grade 1, tendon displacement < 50% of the tendon width; grade 2, tendon displacement 51 to 99% of the tendon width; and grade 3, tendon displacement of 100% of the tendon width. ECU tenosynovitis, ECU tendinosis, injuries of triangular fibrocartilage and distal radioulnar ligaments (DRUL), translation ratio of the DRUJ, rotation angle of the DRUJ, and the width, depth, and length of the ulnar groove were assessed on wrist MRI. The relationships between degree of ECU subluxation and these imaging findings were investigated. RESULTS: Women had higher subluxation degrees of the ECU tendon (p = 0.001). Tenosynovitis of the ECU, sprain of the dorsal DRUL, dorsovolar translation ratio and rotation angle of the DRUJ, and depth and length of the ulnar groove were statistically significantly related to the subluxation degree of the ECU tendon (p = 0.000). CONCLUSION: High-grade subluxation of the ECU tendon was strongly correlated with ECU tenosynovitis and DRUJ translation. Clinicians and radiologists should scrutinize imaging findings, particularly when patients with ulnar-sided wrist pain have high-grade subluxation of the ECU tendon.

Machine-learning algorithm that can improve the diagnostic accuracy of septic arthritis of the knee.

PURPOSE: Prompt diagnosis and treatment of septic arthritis of the knee is crucial. Nevertheless, the quality of evidence for the diagnosis of septic arthritis is low. In this study, the authors developed a machine learning-based diagnostic algorithm for septic arthritis of the native knee using clinical data in an emergency department and validated its diagnostic accuracy. METHODS: Patients (n = 326) who underwent synovial fluid analysis at the emergency department for suspected septic arthritis of the knee were enrolled. Septic arthritis was diagnosed in 164 of the patients (50.3%) using modified Newman criteria. Clinical characteristics of septic and inflammatory arthritis were compared. Area under the receiver-operating characteristic (ROC) curve (AUC) statistics was applied to evaluate the efficacy of each variable for the diagnosis of septic arthritis. The dataset was divided into independent training and test sets (comprising 80% and 20%, respectively, of the data). Supervised machine-learning techniques (random forest and eXtreme Gradient Boosting: XGBoost) were applied to develop a diagnostic model using the training dataset. The test dataset was subsequently used to validate the developed model. The ROC curves of the machine-learning model and each variable were compared. RESULTS: Synovial white blood cell (WBC) count was significantly higher in septic arthritis than in inflammatory arthritis in the multivariate analysis (P = 0.001). In the ROC comparison analysis, synovial WBC count yielded a significantly higher AUC than all other single variables (P = 0.002). The diagnostic model using the XGBoost algorithm yielded a higher AUC (0.831, 95% confidence interval 0.751-0.923) than synovial WBC count (0.740, 95% confidence interval 0.684-0.791; P = 0.033). The developed algorithm was deployed as a free access web-based application ( www.septicknee.com ). CONCLUSION: The diagnosis of septic arthritis of the knee might be improved using a machine learning-based prediction model. LEVEL OF EVIDENCE: Diagnostic study Level III (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.

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.

Features of the Ulnar Nerve Predicting Postoperative Prognosis in Idiopathic Cubital Tunnel Syndrome: Three Distinct Features of the Ulnar Nerve.

PURPOSE: This retrospective case-control study was performed to determine the relationships between features of the ulnar nerve and postoperative outcomes following in situ decompression in idiopathic cubital tunnel syndrome (CuTS). METHODS: The study population consisted of 86 patients who had undergone surgery for CuTS. We evaluated demographic factors, hand dominance, symptom onset time, time from diagnosis to surgery, findings of electrodiagnosis (nerve conduction velocity/electromyography), and preoperative clinical status. Intraoperatively, the ulnar nerve was defined as a definitively compressed, abnormally enlarged, or inflammatory lesion. Clinical improvements were evaluated at least 2 years after surgery. RESULTS: Fifty-four patients showed improvement after surgery in terms of the modified McGowan grade and were designated as group 1. Meanwhile, 32 patients with unchanged or aggravated status were classified as group 2. Preoperative status, as determined by the modified McGowan grade, Boston Symptom Severity Scale score, severity of electrodiagnosis, and predominant symptoms were similar between the groups (all, P > 0.05). On regression analysis, only the classification of nerve lesions and the time from diagnosis to surgery had an impact on postoperative outcome (all, P < 0.05). Especially, enlarged ulnar lesion predicted poor prognosis (P = 0.003). CONCLUSIONS: Ulnar nerve enlargement, grossly detected intraoperatively, and long interval between diagnosis and surgery were independently associated with poor prognosis of CuTS. Among the anatomic structures involved in the generation of CuTS, the medial epicondyle showed a strong association with enlarged nerve lesions.

Risk factors for failure of eradicating infection in a single arthroscopic surgical procedure for septic arthritis of the adult native shoulder with a focus on the volume of irrigation.

BACKGROUND: Septic arthritis of a native joint is relatively rare but is still a challenging and important orthopedic emergency. Most previous reports have focused on the clinical outcomes rather than the risk factors for failure in arthroscopic surgery. METHODS: We retrospectively reviewed the records of patients with septic monoarthritis of the shoulder who underwent arthroscopic irrigation and débridement between January 2007 and January 2019. All patients were divided into 2 groups according to recurrence after a single arthroscopic surgical procedure: eradicated group or recurred group. To identify risk factors affecting the recurrence of septic arthritis of the shoulder after arthroscopic surgery, the following parameters were considered: age; sex; involved side; presentation of rotator cuff tear; volume of irrigation; bacterial organism involved; preoperative erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count in blood and joint fluid; diabetes mellitus; and hypertension. We compared the eradicated and recurred groups regarding the presence of potential risk factors. RESULTS: The study included 97 patients with a mean age of 61 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgical procedure in 85 patients. However, a second arthroscopic surgical procedure was necessary in 12 patients (12.4%) because of infection recurrence. No significant differences were found between groups except in the volume of irrigation (P < .001). CONCLUSIONS: Most patients with septic arthritis (87.6%) of native shoulders were effectively treated with a single arthroscopic irrigation and débridement. The amount of irrigation may be the most important factor for preventing the need for additional surgical management.

Autogenous Bone Graft With Kirschner Wire Fixation Could Be a Reliable Treatment Option for Scaphoid Nonunion in Adolescents.

BACKGROUND: Scaphoid nonunion in adolescents is rare, and most treatments include prolonged immobilization and screw fixation. Many studies have shown that Kirschner wires (K-wires) show comparable outcomes in screw fixation in adult scaphoid nonunion. However, few studies have reported K-wire fixation results in the treatment of adolescent scaphoid nonunion. The purpose of this study was to evaluate the clinical and radiologic results after bone graft and K-wire fixation for scaphoid nonunion in adolescents. METHODS: We retrospectively reviewed 12 adolescent patients, mean age 15.4 (12 to 17) years, who underwent surgical treatment of scaphoid nonunion. Autogenous bone grafts with K-wire fixation were performed for all patients. Radiologic results, including bone union and degenerative changes, were evaluated with serial radiographs. Clinical results, including range of motion, grip strength, and a visual analogue scale for pain, were assessed. RESULTS: All patients received <3 years of postoperative follow-up assessments. Stable bony union was achieved in all patients. Radiologic bony unions were identified at an average of 11.4 weeks postoperatively (range, 9 to 15 wk). The mean active range of motion of the injured wrist at 3 years postoperatively was 215 degrees (range, 185 to 230 degrees). None of the patients were treated for wrist pain or needed medication during follow-up. Three patients experienced intermittent pain (visual analogue scale 1) after heavy work. The grip strength was reduced compared with the uninjured hand (31.8 and 32.8 kg, respectively), but there was no statistically significant difference (P=0.19). All patients had the K-wire removed at 12 weeks postoperatively. There was no degenerative change in the scaphoid at the final follow-up radiograph. CONCLUSION: Autogenous bone graft with K-wire fixation could be a reliable treatment option of scaphoid nonunion in adolescents. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Inevitable nonunion after ulnar shortening osteotomy in patients with ulnar impaction syndrome and breast cancer under bisphosphonate treatment.

BACKGROUND: Nonunion after ulnar shortening osteotomy (USO) was observed at a high rate in patients undergoing long-term bisphosphonate (BP) maintenance treatment after breast cancer surgery. Here, we report the unique features of these nonunions. METHODS: In total, 485 patients who had undergone USO between March 2008 and September 2017 were screened for inclusion based on the following criteria: (1) definitive nonunion after USO; (2) prior history of or ongoing BP therapy after the diagnosis of breast cancer; and (3) no evidence of metastasis in the ulna treated with USO, as determined based on the radiological evaluation. RESULTS: Five patients with histories of breast cancer and subsequent BP treatment were identified; all (100%) of these patients showed definitive nonunion after USO. The mean age was 56.2 years, and all ulnae were on the contralateral side to that of the original breast cancer. Intravenous Ibandronate® and Zolendronate® were administrated to one and four patients, respectively. The mean period of administration was 67.8 months. Three patients exhibited suspicious lesions impending atypical fracture on their femurs, and the other two patients were treated by intramedullary nailing after the occurrence of atypical fractures. Radiological evaluation revealed no evidence of a metastatic lesion, including in the musculoskeletal system, in any patient. Osteosynthesis was performed with cancellous iliac bone graft and mean of 4.3 months after osteosynthesis, union in all cases was achieved. CONCLUSIONS: Problems associated with BP treatment are well known. Even in cases in which the agent is essential for preventing bony metastasis of breast cancer, the normal bony physiology, including bone turnover and healing, is likely to be compromised. In addition to atypical fractures of the femur and ulna, procedures such as USO are likely to be affected by BP. Furthermore, not only a primary iliac bone graft but also other method (oblique osteotomy) should be needed to avoid nonunion during plating in USO. LEVEL OF EVIDENCE: IV, Retrospective case series.

Cross-sectional Area Just Proximal to the Carpal Tunnel According to the Ulnar Variances: Positive Ulnar Variance and Carpal Tunnel Syndrome.

PURPOSE: We evaluated the relationship between the area around the distal radioulnar joint according to the ulnar variances and the cross-sectional area using magnetic resonance imaging (MRI) scans in this prospective study of patients with carpal tunnel syndrome (CTS). METHODS: From among a total of 243 patients who had been diagnosed with CTS between March 2012 and February 2017 at our hospital, 41 patients with positive ulnar variance were enrolled in group 1. As control groups, 39 healthy volunteers who underwent MRI evaluations were included in group 2 (neutral ulnar variance) and group 3 (negative variance). Basic demographic data, including age, sex, and body mass index, were recorded for all 3 groups. An area encompassing the contents of carpal tunnel (nerves/tendons) was designated as area "A," and the area just beneath the subcutaneous fat was designated as area "B" at the levels of the lunate (L) and pisiform (P) on axial MRI. Ratios of these areas ("A/B at L" and "A/B at P") were evaluated in terms of their correlations with ulnar variance. RESULTS: Mean age, sex, and body mass index were not statistically different among the groups, respectively. Within each group, there was no difference between "A/B at L" and "A/B at P," respectively. When comparing the 3 groups, "A/B at L" and "A/B at P" were all significantly decreased in group 1 than in other groups. Regardless of the group, ulnar length negatively correlated with both "A/B at L" and "A/B at P" ratios. CONCLUSIONS: We found a positive relationship between decreased cross-sectional area around the distal radioulnar joint and positive ulnar variance on radiologic investigation. These findings show the importance of variance in the positive ulna variance to the development of CTS.

Histological Evidence of Intrinsic Muscle Degeneration in Compression Ulnar Neuropathy.

PURPOSE: We investigated the histological characteristics of the tissues in the intrinsic hand muscles of patients with compressive ulnar neuropathy (CUN) to determine how the compromised nerve influences the target muscle. METHODS: In total, 83 patients underwent surgery for CUN in our institution between March 2015 and August 2017. Of these, 45 patients who met our inclusion/exclusion criteria were initially included in this study. Basic demographic data including age, sex, hand dominance, duration of symptoms, bone mineral density, and clinical stage were evaluated. During the ulnar nerve decompression surgery, a biopsy of the ipsilateral adductor pollicis was performed. Using the biopsy samples, we analyzed the tissue composition and degree of degeneration, and investigated the association with demographic factors and clinical status. RESULTS: The ratio of muscle/connective tissue/fat was 62.62 ± 8.27%/23.44 ± 4.10%/14.16 ± 6.68% in the affected muscle. The ratio was different than that of samples taken from control groups. In samples containing muscle fibers, although the total fat content remained low, fat was consistently concentrated at the fascicular borders, between fascicles (perifascicular fat, 62.3 ± 18.2% of fascicles), and within fascicles (intrafascicular fat, 35.6 ± 11.8% of fascicles). The proportion of centrally nucleated muscle fibers was also significantly elevated (5.58 ± 4.25%; P < 0.001) compared with that of both controls (1.09 ± 1.26%) and the clinical threshold for abnormal central nuclei (3%). Preoperative scores assessed using Gabel and Amadio criteria were positively correlated with the muscle composition (r = 0.89, P < 0.001). In addition, the clinical status was negatively correlated with the degree of fat accumulation and the proportion of centrally nucleated muscle fibers (r = -0.94, P < 0.001, r = -0.82, P < 0.001). CONCLUSIONS: We demonstrated that target muscle in CUN underwent degeneration, which was potentially exacerbated by inflammation, and that the degree of degeneration was correlated with the patient's clinical status. Histologically, reversible recovery of the hand muscles may be possible if decompression of the ulnar nerve is performed at earlier stages.

Antegrade Intramedullary Pinning in Subacute Fifth Metacarpal Neck Fracture After Failed Conservative Treatment: A Prospective Comparative Study With Acute Fracture.

PURPOSE: The purposes of this study were to evaluate the efficacy of antegrade intramedullary pinning performed for neck fractures with angulations of over 30 degrees after failed conservative treatment during the subacute phase and to compare the radiologic and clinical results with those of acute fractures with angulations of over 30 degrees treated via the same procedure. METHODS: Seventy-three patients with a fifth metacarpal neck fracture were admitted to our institute between January 2010 and April 2015. Among them, 26 patients with an acute fracture (group 1) and 27 patients with a subacute fracture after failed conservative treatment who met the inclusion/exclusion criteria were investigated. After surgery, improvements in angulation and shortening, visual analog scale score for postoperative pain, Disabilities of the Arm, Shoulder, and Hand score, active range of motion, and grip strength were evaluated and compared. RESULTS: The mean durations of surgery from injury were 4.92 and 32.74 days in groups 1 and 2, respectively, with a significant difference (P < 0.001). The preoperative amounts of angulation were 44.91 and 45.89 degrees, and the amounts of preoperative shortening were 3.31 and 3.44 mm, respectively, with no significant difference (P > 0.05). At the final follow-up, the angulation had definitively improved compared with before surgery in both groups (P < 0.001, both). However, there was a slight significant difference in terms of the residual angulation of 3.35 and 5.56 degrees in groups 1 and 2, respectively (P = 0.02). Preoperative shortening was restored in both groups (P < 0.001, both) and the final state of residual shortening were similar (P = 0.06). The final visual analog scale scores, Disabilities of the Arm, Shoulder, and Hand scores, range of motion, and grip strength were all satisfactory in both groups without any significant difference. CONCLUSIONS: The failed treatment group, which had been predicted to obtain proper union through the initial use of conservative treatment, provided an adequate indication for noninvasive antegrade pinning. In addition, the current study suggested that closed reduction/immobilization remains a primary recommendation for angulated metacarpal neck fracture as long as careful observation is conducted if progression of the reduced fracture toward dorsal angulation is suspected.

Surgical Resection of Occult Subungual Glomus Tumors: Cold Sensitivity and Sonographic Findings.

PURPOSE: We surgically treated subungual masses that were suspected glomus tumors, although definitive clinical and radiological findings were lacking. We report the outcomes of a retrospective case series. METHODS: Of 42 patients treated by surgical resection between March 1996 and December 2015, 7 who met our inclusion/exclusion criteria were evaluated. At least 1 symptom of the typical triad (temperature sensitivity, severe pain, and localized tenderness) was absent, and computed tomography (CT) and magnetic resonance imaging (MRI) findings were normal. After ultrasonographic evaluation, we resected the masses using a transungual approach or a nail-preserving method. After pathological confirmation of the diagnosis, we followed all patients for at least 2 years to evaluate tumor recurrence and nail deformity. RESULTS: In 5 patients, cold sensitivity was the only symptom; no physical finding was suggestive of a glomus tumor. Tenderness was evidenced by the 2 patients who lacked cold sensitivity. None of the 7 patients exhibited CT or MRI abnormalities, but small acoustic shadows were evident in 4 patients, and blood-rich nodules were noted in 2 patients. The mean diameter of the 7 tumors was 2.1 mm, and pathological examination revealed typical glomus bodies. No major surgery-associated complication developed during follow-up. The final mean visual analog scale score (assessing pain) improved to 0.3 from the mean preoperative value of 3.6. CONCLUSIONS: Small glomus tumors exhibit few traditional symptoms and signs and no definitive radiological CT/MRI finding. However, cold sensitivity alone is a powerful surgical indication, and occasionally, ultrasonographic findings are useful even in the absence of CT/MRI findings.

Open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients 70 years and older.

HYPOTHESIS: The study purpose was to report the clinical and radiologic outcomes of osteosynthesis by open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients aged 70 years or older. MATERIALS AND METHODS: This retrospective study included 28 patients who received osteosynthesis treatment between March 2010 and December 2015. Primary conservative treatment had failed in all patients. All surgical procedures were performed via the posterior approach without olecranon osteotomy and with the use of double-locking plates for each column. RESULTS: The mean patient age was 72 years, and surgical procedures were performed a mean of 7.6 months after injury. Preoperatively, extension-flexion was 32° to 101° and forearm pronation-supination was 74° to 47°. The mean visual analog scale score was 4; the mean Mayo Elbow Performance Score was 50; and the mean Disabilities of the Arm, Shoulder and Hand score was 58. All cases showed proper union after a mean of 5.2 months. At the final follow-up examination, the extension-flexion and rotation arcs had improved significantly (to 20° to 124° and to 80° to 66°, respectively; both P < .001), and all clinical scores were satisfactory (visual analog scale score, 1; Mayo Elbow Performance Score, 65; and Disabilities of the Arm, Shoulder and Hand score, 24; all P < .001). Ulnar nerve transposition was performed in 7 patients, and no distinct ulnar nerve symptom was observed in any patient at the final follow-up examination. CONCLUSIONS: We consider osteosynthesis by open reduction and internal fixation as a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed.

Long-term results of closed reduction for developmental dislocation of the hip in children of walking age under eighteen months old.

BACKGROUND: Developmental dysplasia of the hip (DDH) diagnosed in older postnatal children can be effectively treated by closed reduction (CR) alone. However, no prospective or comparative trial to explore the differential effectiveness of CR between non-walking and walking postnatal children has yet been reported. This study investigated the clinical and radiologic outcomes of CR in the age range of interest (12-18 months old) via a prospective trial and compared these results with those of a younger age group who also underwent CR. PATIENTS AND METHODS: Between 1999 and 2009, 56 children diagnosed with DDH were enrolled. Of these, 45 were followed after CR for a period of at least seven years. The anatomical parameters of the hip/pelvis, including arthrograms, were evaluated and compared before and after CR. The final radiologic status, including the occurrence of avascular necrosis (AVN), and clinical outcomes were evaluated and compared. RESULTS: The mean ages at the start of treatment were 6.11 and 15.29 months old in group 1 and group 2, respectively. None of the children required surgical open reduction during the follow-up period. The final status of hips were classified according to the Bucholz-Ogden system. Two type II hips and one type I hip were found in group 1. In group 2, two type I hips and one type III hip were observed at the final follow-up. The overall clinical outcomes were satisfactory in both groups, according to McKay's criteria. No significant differences in clinical outcomes between the two groups were found (P = 0.382). Surgery was performed for just one patient in group 2 at seven years old. CONCLUSIONS: CR in DDH for postnatal children 12-18 months old may provide similar results to the non-walking age group if performed with preliminary traction, gentle CR under general anaesthesia, percutaneous adductor tenotomy, and the minimization of forceful abduction.

Temporary ipsilateral stiff shoulder after operative fixation of distal radial fractures.

BACKGROUND: This study was conducted to identify variables affecting the development of temporary stiff shoulder after operative fixation for distal radial fractures (DRF). MATERIALS AND METHODS: The study retrospectively analyzed 167 patients who had undergone internal fixation using volar locking plate for DRF between 2010 and 2013. Group 1 was denoted as the "normal group," and group 2 was denoted as the "stiff shoulder group." Basic demographic factors evaluated included age, sex, bone mineral density (BMD), and the dominancy. Also investigated were radiologic variables, including concurrent fractures of the styloid process, positive ulnar variances, classification of DRF, and morphologic type of the distal radioulnar joint. Finally, the type of plate, methods used for postoperative protection, and time of union were analyzed. RESULTS: Group 1 consisted of 114 patients, and group 2 consisted of 53 patients. On overall univariate analysis, BMD, hand dominancy, and the protective methods after plating were significantly different between the 2 groups. On multivariate analysis, a lower BMD and injury on the nondominant side were significant factors for shoulder stiffness. Stiffness was significantly higher in patients with a mean BMD < -2.6 than in patients with a mean BMD ≥ -2.6. At the final follow-up, all of the 53 patients in group 2 were relieved of the symptoms of a stiff shoulder. CONCLUSIONS: A lower BMD and injury on the nondominant distal radius were distinct factors for the development of a stiff shoulder after operative fixation in DRF. Fortunately, nonoperative treatments, such as stretching exercises/injections, were useful for the relief of these symptoms in the short-term follow-up.