Treatment of Periprosthetic Fracture after Total Elbow Replacement Arthroplasty

The indications for total elbow replacement arthroplasty (TERA) include rheumatoid arthritis, degenerative arthritis, acute fracture, nonunion, malunion, posttraumatic arthritis, tumor, and chronic instability. With the development of designs and the increasing use of TERA, more periprosthetic fractures are occurring. On the other hand, there is less data on periprosthetic fractures after TERA because TERA is a relatively rare procedure. Thus, a careful review of the previous literature and appropriate selection of surgical indications are essential for achieving a satisfactory outcome, which should be accompanied by precise surgery as planned. This article presents the causes, risk factors, classification, and principles of treatment of periprosthetic fractures after TERA.

The Role of Thymic Stromal Lymphopoietin (TSLP) in Glomerulonephritis

Thymic stromal lymphopoietin (TSLP) is an interleukin-7-like cytokine that is an important trigger and initiator of many allergic diseases. TSLP promotes a T-helper type 2 (Th2) cytokine response that can be pathological. A relationship is formed both at the induction phase of the Th2 response through polarization of dendritic cells to drive Th2 cell differentiation and at the effector phase of the response, by promoting the expansion of activated T cells and their secretion of Th2 cytokines and TSLP. In transgenic mice with TSLP overexpression, it has been reported that TSLP leads to the development of mixed cryoglobulinemic membranoproliferative glomerulonephritis. In addition, TSLP can play an important role in the pathogenesis of IgA nephropathy and systemic lupus erythematosus-related nephritis. From our knowledge of the role of TSLP in the kidney, further studies including the discovery of new therapies need to be considered based on the relationship between TSLP and glomerulonephritis.

Brachial plexus injuries in adults

As the number of survivors of motor vehicle accidents and extreme sporting accidents increases, more people must live with brachial plexus injuries. Brachial plexus injuries also occur in multiple trauma patients and can be debilitating. Although the injured limb will never return to normal, an improved understanding of the pathophysiology of nerve injury and repair, as well as advances in microsurgical techniques, have provided the upper extremity reconstructive surgeons with opportunities to improve function in patients with these life-altering injuries. The purpose of this review is to present in detail some of the current concepts in the treatment of adult brachial plexus injuries and to give the reader an understanding of the nuances of the timing of treatment, the available treatment options, and the outcomes of treatment.

Free Functioning Muscle Transfer in Brachial Plexus Injury

The free functional muscle transfer (FFMT) is the surgical procedure aimed at reconstructing defective or deteriorated muscle function by grafting free muscles including blood vessels and nerves. Since the free gracilis transfer in the facial paralysis was introduced in 1976, there have been many studies and clinical applications of the FFMT in various donor and recipient sites in brachial plexus injury, muscle ischemic contracture, muscle defect after tumor resection, congenital muscular deficit, multiple trauma. When the reconstruction of the nerve is delayed for 9 months to 1 year after the brachial plexus injury, voluntary muscle contracture is impossible even after the nerve regeneration by the irreversible degeneration of the muscles. And it is difficult to obtain adequate function even if nerve transfer or nerve transplantation is performed because the distance to be regenerated is too long. In these cases, the FFMT has been improved the functions of the upper limb in flexion or extension of the elbow, fingers. Many good clinical results of the FFMT have been reported, so the FFMT gets much interests and attentions. The essential things for the successful outcome of the surgery are the anatomical knowledge, the skilled surgical technique and the choice of patients who can meet the indications and receive long-term rehabilitation. Recent advances in surgical techniques will result in improved results of the FFMT.

Diagnosis and Management of Ligament Injuries of the Wrist

The wrist joint is formed by the distal end of the radius and ulna proximally, and eight carpal bones distally. It has many ligaments to maintain stability of the complex bony structures. The incidence of ligament injuries of the wrist has increased due to sports activities. However, diagnosis and management of these injuries are sometimes difficult because of the anatomic complexity and variable injury patterns. Among them, scapholunate ligament injury and triangular fibrocartilage tears are the two most common injuries resulting in chronic disabling wrist pain. Thorough understanding of the wrist anatomy and physical and radiologic examination is mandatory for proper diagnosis and management of these conditions. This article will briefly discuss the wrist joint anatomy and biomechanics, and review the diagnosis and management of the scapholunate ligament injury and triangular fibrocartilage injury.

Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients

PURPOSE: Although the possibility of distal radius fractures is strong in hemodialysis patients, there are many difficult problems such as the bleeding tendency, hypervascularity and injury to arteriovenous fistula. We studied the outcomes of open reduction and volar locking plate fixation of the distal radius fractures in hemodyalisis patients with ipsilateral arteriovenous fistula. METHODS: From 2007 to 2009, a retrospective chart review was performed of eleven hemodialysis patients who underwent volar locking plate fixation for treatment of distal radius fractures. Eight of them were female and three were male and mean age was 68 years (range, 57-81 years). Mean follow-up period was 19 months (range, 12-28 months). All patients had osteoporosis with mean T-score of -2.7. All operations were performed on the next day of hemodialysis. Scheduled hemodialysis was possible on the next day of surgery without splint. We analyzed radiographic results, the wrist range of motion, Mayo wrist score and disabilities of the arm, shoulder and hand (DASH) score at the last follow-up. RESULTS: All fractures achieved anatomical reduction and united at final follow-up. Complications such as hematoma or occlusion of arteriovenous fistula were not observed. Mean Mayo wrist score was 78 and mean DASH score was 22. CONCLUSION: Volar locking plate fixation for distal radius fractures provides immediate support for continuing hemodialysis and exercise. Open reduction of the fractures and the use of tourniquet don't seem to increase the vascular complications like hematoma and fistula occlusion.

Radiologic Results in Accordance with the Number of Distal Locking Screws in Volar Plate Fixation for Distal Radius Fractures

PURPOSE: The purpose of this study was to determine whether the number of distal locking screws affected the final radiologic results after volar plate fixation for distal radius fractures. METHODS: We retrospectively identified 176 patients (male, 36; female, 140; average, 60 years) who had distal radius fractures treated with open reduction and volar plate fixation between 2011 and 2012. The number of screws used for distal fixation was determined according to the surgeon's preference and the type of plate used. Radiologic parameters and their displacements were measured postoperatively and at final follow-up. The results of using 4 or 5 distal locking screws were compared with those of using more than 6 distal locking screws. RESULTS: There was no significant displacement in fracture fragment when using 4 or 5 distal locking screws compared with using more than 6 distal locking screws. Mean displacement in ulnar variance was 0.6 mm in group with less than 5 screws, and the displacement was 0.4 mm in group with more than 6 screws (p=0.772). Secondary displacement was not correlated with fracture type or the number of distal locking screws. There was no fixation failure during the study period. CONCLUSION: It seems that 4 or 5 distal locking screws are strong enough to prevent a significant loss of fracture reduction. Filling every distal screw hole is not recommended to limit cost and avoid extensor tendon complications.

Melorheostosis of the Trapezium

We report a 56-year-old female with symptomatic protrusion of the bony lesion in the trapezium. Excision and biopsy of the bony lesion revealed thickened and sclerotic bony trabecula with adjacent zone of fibrocartilage, which is comparable with melorheostosis. This lesion with unique radiologic and histologic findings may be important to differentiate with other bony lesions such as myositis ossifications and osteosarcoma.

The Result of In Situ Pinning for Valgus Impacted Femoral Neck Fractures of Patients over 70 Years Old / 대한고관절학회지

PURPOSE: We aimed to evaluate the outcome of fixation with cannulated screws for valgus impacted femoral neck fractures in patients over 70 years of age. MATERIALS AND METHODS: We reviewed the outcome in 33 patients older than 70 years with valgus impacted femoral neck fractures who were treated with cannulated screws fixation from May 2007 to December 2010. These patients were followed for at least a year. We assessed the fixation failure rate, body mass index (BMI), bone mineral density (BMD) of proximal femur, distance between screw tip and joint, number of screws and time from fracture to operation. RESULTS: We identified six patients (18.2%) with failure. Two patients with subtrochanteric fractures through the screw insertion site and another patient with osteonecrosis were excluded from the fixation failure group. No difference was found in age, BMI, BMD of proximal femur, distance between screw tip and joint, number of screws and time from fracture to operation between failure and non-failure groups. CONCLUSION: The failure rate of cannualted screw fixation for valgus impacted femoral neck fractures in the elderly patients was not low. Risk of failure should be considered in the management of these patients and accurate assessment for fracture type should be performed using computed tomogram and clinical evaluation.

Implant Selection for Treatment of Distal Radius Fractures / 대한정형외과학회잡지

Anatomical reduction is essential for successful treatment of distal radius fractures. In-depth understanding of the implant is mandatory in order to obtain adequate fixation of the fracture fragments and to avoid implant-related complications. Selection of an improper implant and screw length may lead to rupture of flexor or extensor tendon as a complication. This article will briefly discuss the pros and cons of the traditional fixation methods such as percutaneous pin fixation and external fixation, and will focus on the recent development of the volar locking plate. Variable-angle locking plate, which was introduced in an effort to provide surgeons with more freedom for fixation, may have inadequate fixation strength if screw locking is repeated. From the biomechanical study, at least four distal locking screws are enough to have strength to maintain fracture fixation. Measuring screw length may be difficult; therefore, information about the ratio of the metaphysis and diaphysis will be helpful in deciding on the proper screw length. Locking screws are recommended as they are stronger than locking pegs. In order to avoid flexor tendon ruptures, the plate should not be placed too far distally.

Relationship between the Length of Distal Locking Screws and Diaphyseal Screws in Volar Plate Fixation of Distal Radius Fractures

PURPOSE: To determine the relationship between the length of distal locking screws and diaphyseal screws in volar plate fixation of distal radius fractures. METHODS: A retrospective review was performed of 169 patients who underwent volar locking plate fixation for treatment of distal radius fractures. All patients received 2.4 mm LCP volar extra-articular distal radius plate (DePuySynthes). The length of the diaphyseal screw which was placed in the elongated hole was correlated with the length of a distal locking screw from radial most (D1) to ulnar most (D4). We also evaluated distal screw penetration of the dorsal cortex and plate removal rate. RESULTS: The length of the diaphyseal screw which was placed in the elongated hole strongly correlated with the length of a distal locking screw. Average D1 screw length was 2 mm longer than the diaphyseal screw, and average D2 screw length was 4 mm longer than the diaphyseal screw. D3 and D4 screw were 6 mm longer than the diaphyseal screw. Plate removal was necessary in 13 patients (8%) due to screw irritation. These patients had significantly longer screws than average. Flexor or extensor tendon ruptures did not occur in this cohort. CONCLUSION: The length of the distal locking screws can be estimated with the length of the diaphyseal screw. This information may help surgeons to select the adequate length of distal locking screws during volar plating of distal radius fractures.

Perforator-Based Propeller Flap for Lower Extremity Reconstruction

PURPOSE: To report the clinical results of the perforated-based propeller flap for lower extremity soft tissue reconstruction. MATERIALS AND METHODS: Between January 2010 and June 2012, a total of 16 defects in the lower extremities were covered with perforator-based propeller flaps. Retrospective data for location and size of the defect, flap dimension, pedicle artery, pedicle rotation, complications were obtained. RESULTS: Peroneal artery-based perforator flap were used in eleven cases, posterior tibial artery-based perforator flap in two cases, anterior tibial artery-based perforator flap in one case and medial plantar artery-based perforator flap in two cases. The average size of the flaps was 63 cm2. The marginal skin necrosis of the flaps as a complication was developed in two cases, one of which was covered with split-thickness skin graft. There were no functional deficits from the donor site. CONCLUSION: For the reconstruction of lower extremities, the perforator-based propeller flap could be a reasonable alternative as it is a simple, safe and versatile technique.

Radial Artery Pseudoaneurysm after Arterial Blood Gas Analysis: A Case Report

Pseudoaneurysms might be caused by perforation of an artery with hematoma formation between the arterial wall and the surrounding tissue after penetrating injury, intervention or operation. The frequency of radial artery pseudoaneurysm as a complication of cannulation is known for 0.048%. We report one case of radial artery pseudoaneurysm after single arterial blood gas analysis at wrist, which was managed by excision followed by vein graft.

Cubital Tunnel Syndrome: Recent Trends of Treatment

Cubital tunnel syndrome is the second most common nerve entrapment syndrome affecting the upper extremity. Surgical treatment is indicated for those who have motor weakness or when conservative measures have failed. Several different surgical techniques have been introduced, however, the optimal treatment for cubital tunnel syndrome is still under debate. In the recent years, well-performed prospective randomized studies show that there is no difference in outcome among various surgical techniques regardless of the severity and presence of subluxation. It is advised that in situ decompression is the preferred technique because it is simpler and less time consuming procedure. Although in situ decompression is effective in uncomplicated ulnar nerve subluxation, anterior transposition should be considered when the subluxation is painful or when the ulnar nerve actually snaps back and forth over the medial epicondyle. Anterior transposition of the ulnar nerve is still indicated for revision surgery, previous trauma around the elbow, distal humerus fractures, severe osteoarthritis needing medial spur excision, and severe valgus deformity of the elbow.

Do You Need CAOS (Computer Assisted Orthopedic Surgery) in THA?: From a Negative Perspective

CAOS (Computer Assisted Orthopedic Surgery) has been introduced into the field of artificial joint replacement to increase the accuracy of implant placement. The advocates of CAOS insist that total hip replacement arthroplasty using CAOS will decrease dislocation, the wear rate, impingement and limb length discrepancy by increasing the accuracy and consistency of implant placement. However, we have to maximize the good results of total hip replacement arthroplasty by developing CAOS with understanding its disadvantages and limits, so we have reviewed CAOS using a critical eye for its negative aspects.

Comparison of Processed Nerve Allograft and Laminin Derived Peptide Incorporated Nerve Conduit for Peripheral Nerve Regeneration / 대한정형외과학회잡지

PURPOSE: To compare a processed nerve allograft, laminin derived peptide incorporated nerve conduit, and autograft in terms of electrodiagnostic testing and nerve histomorphometry for peripheral nerve regeneration in a rabbit sciatic nerve defect model. MATERIALS AND METHODS: Thirty New Zealand white rabbits were divided into three groups, and a unilateral 15 mm sciatic nerve defect was made. Group I, II and III was repaired with a reversed autograft, a processed acellular nerve allograft, and a laminin derived peptide incorporated nerve conduit, respectively. At twelve weeks, the animals were evaluated with the compound muscle action potential, wet muscle weight, and nerve histomorphometric parameters such as nerve area, number of axons, and myelin thickness. RESULTS: At twelve weeks, the compound muscle action potential for group I, II and III was 54.1%, 38.2% and 26.4%, respectively. Significant differences were found between the three groups (p<0.001, group I vs II; p<0.001, group I vs III; p<0.001, group II vs III). The wet muscle weight for group I, II and III was 57.8%, 54.4% and 43.9%, respectively. Group I had significantly more muscle weight than group III (p<0.001), but the difference was not significant with group II (p=0.256). Group II and III showed a significant difference (p=0.002). The number of axons in group III decreased and the shape of the axon was irregular, even though the nerve area and myelin thickness were similar in the three groups. CONCLUSION: An autograft remains the gold standard to repair a segmental nerve defect. Processed allograft demonstrated superior nerve recovery compared to the laminin derived peptide incorporated nerve conduit.

K-wire Fixation Supplemented with External Fixator Versus Volar Locked Plating for Unstable Fractures of the Distal Radius

PURPOSE: To campare the outcomes between K-wire fixation with supplementary external fixator and volar locking plate in the treatment of the unstable distal radius fracture. MATERIALS AND METHODS: We reviewed 26 unstable AO type C3 distal radius fracture retrospectively, treated from January 2004 to February 2009. They were divided into two groups; group I (14 cases of open reduction and K-wire fixation supplemented with a external fixator) and group II (12 cases of volar locked plating). Each group was statistically compared in terms of surgery time, the difference of radiologic reduction, and loss of reduction, range of motion (ROM) and Mayo wrist score. RESULTS: No statistical difference was found in terms of surgery time, radiologic reduction, and loss of reduction between two treatment groups. After 1 year of surgery, the Mayo wrist score of group I was 80.5 points, and group II was 80, which shows that both groups achieved fairly good score. Although group II gained a statistically significant improvement in the ROM of the wrist except pronation at postoperative three months, no statistical difference of ROM was found between two groups at postoperative 1 year. CONCLUSION: When it comes to the treatment for an unstable intra-articular distal radius fracture, clinical and radiological outcomes are comparable between the patients treated with K-wire fixation supplemented with a external fixator and those with a volar locking plate.

Extended Kocher Approach for Total Elbow Arthroplasty

PURPOSE: Total elbow arthroplasty is most commonly performed through a posterior approach by splitting or reflecting the triceps off the olecranon, but triceps avulsion, triceps weakness, and wound healing problems have been reported. We present the clinical results of total elbow arthroplasty using extended Kocher approach. MATERIALS AND METHODS: From September 2005 to October 2007, five patients who underwent total elbow arthroplasty using triceps preserving approach were evaluated. There were 4 women and 1 man. The mean age of the patients was 58 years (range, 36~68). The mean follow- up was 10 months. The patients were placed in the lateral decubitus position, and lateral Kocher interval is made through a straight posterior incision. Elbow joint is exposed by supinating the forearm and prosthesis was inserted. Postoperatively, the elbow was immobilized in extension for 1 week, and active range of motion exercise was begun. Range of motion, triceps strength, Mayo elbow performance score, Korean DASH questionnaire were evaluated at the last follow-up. RESULTS: Average operation time was 115 minutes (range, 97~138). Postoperative complications such infection, skin necrosis were not developed. Triceps strength was measured as grade IV in all patients except one who has triceps insufficiency preoperatively. Mean elbow range of motion was from 8 degrees to 124 degrees. Mean Mayo elbow performance score was 87 (range 75~95), and DASH score was 18 (range 9~34). CONCLUSIONS: Extended Kocher approach can be a reasonable alternative for total elbow arthroplasty. Linking the assembly can be difficult, so modification of the implant design is needed to solve this problem.

The Usefulness of Computed Tomography in Distal Radius Fractures Involving Articular Surface

PURPOSE: To evaluate the usefulness of computed tomography(CT) scanning in classification and selection of treatment method for distal radius fractures involving articular surfaces. MATERIALS AND METHODS: Plain radiographs and CT scans of 42 patients with intraarticular distal radius fractures was analysed for type of fractures and surgical indication and then the results were compared. RESULTS: Fracture types were changed in 15 of 42 patients. 10 patients with AO B1, B3, C1 or C2 type fractures were reclassified as C3 type, which suggested that CT scan revealed articular comminution more accurately. According to the assesment of plain radiographs, 16 patient needed surgical treatment. However additional 17(68%) patients were necessary operation on the bases CT scan evaluation. CONCLUSIONS: Evaluation of intraarticular fractures of distal radius using CT scan was useful for fracture classification and selection of treatment methods, which provided an accurate assessment of fracture patterns and reduction status.

Transposition Lateral Arm Flap for Coverage of the Elbow Defects

PURPOSE: Soft tissue defect can occur on the posterior aspect of the elbow after trauma or fracture fixation. To cover the defect and maintain elbow functions, various flap surgeries including latissimus dorsi muscle flap, lateral arm flap and radial forearm flap can be performed. We present the clinical results of transposition lateral arm flap for coverage of the elbow defect and discuss the cause of posterior soft tissue necrosis after fracture fixation. MATERIALS AND METHODS: Two patients who had posterior soft tissue defect of the elbow after open reduction of the fractures around the elbow were treated with transposition lateral arm flap. The mean size of skin defect was 20 cm2. The flap was elevated with posterior radial collateral artery pedicle and transposed to the defect area. Donor defect was covered with split thickness skin graft. The elbow was immobilized for 1 week in extended position and active range of motion was permitted. RESULTS: All two cases of transposition lateral arm flap survived without marginal necrosis. The average range of motion of the elbow was 10~115 degrees. Mayo elbow performance score was 72 and Korean DASH score was 23. CONCLUSION: When elbow fractures are fixed with three simultaneous plates and screws, skin necrosis can occur on the posterior aspect of the elbow around olecranon area. If the size of skin defect is relatively small, transposition lateral arm flap is very useful option for orthopaedic surgeons without microsurgical technique.