Failure of the linkage mechanism in a semi-constrained total elbow arthroplasty is a rare and unpredictable event: a review of seven cases.

PURPOSE: Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries. METHODS: Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism. RESULTS: All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure. CONCLUSION: Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

Radiographic Analysis in Extra-Articular and Intra-Articular Distal Radius Fractures Treated with Variable-Angle Volar Locking Plate Fixation.

(1) Background: Different distal radial fracture types have different prognosis after fixation. Our study aim is to evaluate the differences in radiographic parameters by using variable-angle volar locking plate (VAVLP) fixation according to extra-articular and intra-articular distal radial fracture. (2) Methods: There are two groups: extra-articular group (21) and intra-articular group (25). Forearm radiographs immediately after surgery and at 3 months after operation were reviewed for analyzing radial height (RH), ulnar variance (UV), radial inclination (RI), volar tilt (VT), tear drop angle (TDA), distal dorsal cortical distance (DDD), and Soong classification (SC). (3) Results: There were no significant differences in the above parameters between two groups at either immediately post-operative or at 3-month follow-up, except for TDA (p = 0.048). Most patients in both groups were at low risk of flexor tendon rupture, except for two cases. We observed a positive correlation between post-operative DDD and 3-month change in the intra-articular group, but not the extra-articular group. (4) Conclusions: Our study demonstrates that VAVLP fixation is effective in maintaining the stability of most radiographic parameters and reduces the risk of tendon rupture in both extra-articular and intra-articular distal radial fractures. Post-operative DDD can be used to predict the degree of subsequent displacement in patients with intra-articular fractures fixed with VAVLP.

A Functional Polymorphism Downstream of Vitamin A Regulator Gene CYP26B1 Is Associated with Hand Osteoarthritis.

While genetic analyses have revealed ~100 risk loci associated with osteoarthritis (OA), only eight have been linked to hand OA. Besides, these studies were performed in predominantly European and Caucasian ancestries. Here, we conducted a genome-wide association study in the Han Chinese population to identify genetic variations associated with the disease. We recruited a total of 1136 individuals (n = 420 hand OA-affected; n = 716 unaffected control subjects) of Han Chinese ancestry. We carried out genotyping using Axiom Asia Precisi on Medicine Research Array, and we employed the RegulomeDB database and RoadMap DNase I Hypersensitivity Sites annotations to further narrow down our potential candidate variants. Genetic variants identified were tested in the Geisinger's hand OA cohort selected from the Geisinger MyCode community health initiative (MyCode®). We also performed a luciferase reporter assay to confirm the potential impact of top candidate single-nucleotide polymorphisms (SNPs) on hand OA. We identified six associated SNPs (p-value = 6.76 × 10-7-7.31 × 10-6) clustered at 2p13.2 downstream of the CYP26B1 gene. The strongest association signal identified was rs883313 (p-value = 6.76 × 10-7, odds ratio (OR) = 1.76), followed by rs12713768 (p-value = 1.36 × 10-6, OR = 1.74), near or within the enhancer region closest to the CYP26B1 gene. Our findings showed that the major risk-conferring CC haplotype of SNPs rs12713768 and rs10208040 [strong linkage disequilibrium (LD); D' = 1, r2 = 0.651] drives 18.9% of enhancer expression activity. Our findings highlight that the SNP rs12713768 is associated with susceptibility to and severity of hand OA in the Han Chinese population and that the suggested retinoic acid signaling pathway may play an important role in its pathogenesis.

Functional Outcomes Are Similar After Arthroscopic Capsular Repair of Triangular Fibrocartilage Complex Tears Between Outside-In Technique and All-Inside Technique Using Pre-Tied Suture Device.

PURPOSE: To compare outcomes of arthroscopic triangular fibrocartilage complex capsular repair at 2-year follow-up between outside-in and all-inside techniques. METHODS: In total, 58 consecutive patients (wrists) with a Palmer 1B triangular fibrocartilage complex tear without symptomatic distal radioulnar joint instability underwent arthroscopic suture repair from 2011 to 2019 including 31 patients via the outside-in technique (group A) and 27 via the all-inside technique using a pre-tied needle device (group B). Two-year follow-up included visual analog scale (VAS) pain score, motion range, grip strength, Mayo Modified Wrist Score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and complication rate. Correlation between functional result and patient satisfaction was analyzed. RESULTS: Score changes in VAS, wrist flexion-tension, supination-pronation, grip strength, MMWS, and QuickDASH at 2-year follow-up were not significantly different between group A (3.4 ± 0.8, 18.4 ± 17.5, 12.9 ± 13.3, 30.7 ± 11.2, 26.6 ± 7.9 and 19.4 ± 9.9 and group B (3.4 ± 1.0, 18.5 ± 18.3, 15.6 ± 13.7, 30.8 ± 11.4, 28.1 ± 8.6, and 7.6 ± 7.2) with P values of .400, .489, .223, .486, .240, and .223 respectively. Surgical time averaged 105 minutes (78 to 136) in group A and 94 minutes (61-126) in group B with significant difference (P = .012). Patient satisfaction averaged 1.1 (0-3.5) in group A and 1.0 (range 0-3.0) in group B. Satisfaction score was more strongly correlated with QuickDASH (coefficients: 0.863 in group A and 0.918 in group B) than with MMWS (-0.693 in group A and -0.465), grip strength (-0.619 in group A and -0.417 in group B) and VAS score (0.607 in group A and 0.222 in group B). CONCLUSIONS: Both techniques achieved comparable outcomes with shorter surgical time in all-inside repair using pre-tied needle device. Patient satisfaction was strongly correlated with QuickDASH score. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative investigation.

Long-Term Outcomes of Radial Head Arthroplasty in Complex Elbow Fracture Dislocation.

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was -0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.

All-arthroscopic repair of Atzei class II and III triangular fibrocartilage complex tears using the FasT-Fix suture device.

BACKGROUND: The study is aimed to propose an arthroscopic repair technique using a pre-tied suture device for peripheral TFCC (triangular fibrocartilage complex) tear with proximal component involvement. METHODS: Through a retrospective review in the medical records of patients who underwent unilateral arthroscopic repair for TFCC Palmer IB lesion between 2017 and 2019, 12 patients were arthroscopically diagnosed as proximal component tear and received more than 1 year follow-up postoperatively. The arthroscope was introduced from 6R portal to discriminate Atzei class II from III lesions by a "visualization test" and to supervise the repair procedure using pre-tied FasT-Fix suture device from 3-4 portal. Two poly-ether-ether-ketone (PEEK) blocks were further advanced along the device needle to finally seat outside the ulnar joint capsule, followed by gradually tightening the pre-tied suture loop until the TFCC periphery was securely repositioned and held stably. RESULTS: Operation time averaged 87 min. Hook test and DRUJ arthroscopy confirmed proximal component tear in all 12 wrists. Four patients were diagnosed to be Atzei class II lesion as full thickness tear of distal component was arthroscopically identified from 6R portal while the other 8 exhibited partial thickness tear and were categorized as class III lesion. Follow-up averaged 15 months with a range of 12 to 24 months. Mayo modified wrist score improved from an average of 61.3 preoperatively to 90.4 at the latest visit. CONCLUSIONS: A modified technique for diagnosis and all-arthroscopic repair in TFCC Atzei class II and III lesions using a pre-tied suture device is a feasible and safe option with promising results.

Retrospective cohort study on radial head arthroplasty comparing long-term outcomes between valgus type injury and fracture dislocation.

BACKGROUND: Radial head arthroplasty (RHA) has been commonly adopted for irreparable radial head fractures while little information is addressed on valgus type injury. The purpose of this study is to report long-term outcomes and radiographic analysis in RHA for valgus type injury with comparison to fracture dislocation injury. METHODS: A retrospective cohort study was conducted in patients receiving unilateral RHA with loose-fit, modular metal prosthesis for irreparable radial head fractures between 2004 and 2012. Totally, 33 patients with a mean follow up of 9 years (range, 7 to 15 years) were enrolled and divided into two groups including 14 valgus injuries and 19 fracture-dislocations. Demographics of the patients, injury details, clinical and radiographic outcomes, and correlation analysis were investigated and compared between two groups. RESULTS: In patient demographics, significant difference was noted in sex distribution (p = 0.001), lateral collateral ligament involvement (p = 0.000) and time from injury to RHA (p = 0.031) between two groups. No patient underwent subsequent removal or revision of prosthesis. Good to excellent results according to Mayo Elbow Performance Score (MEPS) was achieved in 13 and 14 patients in group A and B respectively. Final motion range and Disabilities of the Arm, Shoulder, and Hand score was significantly better in valgus injury group. Radiographic analysis demonstrated fewer patients in valgus injury group presented periprosthetic osteolysis with weak to moderate negative correlation between radiolucency score and MEPS. CONCLUSIONS: With an average of 9 years follow-up, RHA using loose-fit, modular metal prosthesis achieves encouraging outcomes for both valgus injury and fracture dislocation. In valgus type injury, better motion range, lower disability score and lower incidence of periprosthetic osteolysis is noted while correlation analysis of radiolucency score suggests extended, long-term investigation.

Surgical management of ulnar styloid fractures: comparison of fixation with anchor suture and tension band wire.

BACKGROUND: Limited reference is available regarding surgical management in symptomatic ulnar styloid fractures with small bony avulsion. The study goal is to report the surgical outcomes using anchor suture fixation with comparison to traditional tension band wire fixation. METHODS: We retrospectively reviewed the medical records in patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2017. A total of 31 patients were enrolled including two kinds of fixation methods. Anchor suture fixation plus distal radioulnar joint pinning was performed in ten patients with tiny avulsion bony fragments (group A); tension band wire fixation was performed in 21 patients with big styloid fracture fragments (group B). Patient characteristics and 2-year treatment outcomes were compared between two groups based on Mayo Modified Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); visual analog scale (VAS), and surgical complication. Descriptive statistics were used for calculation of key variables; a p value of < 0.05 was considered statistically significant. RESULTS: Based on Gaulke classification, there were five subtypes in group A and three subtypes in group B. Incidence of concomitant distal radius fractures was significantly higher in group B; other patient characteristics including age, sex, injury side, and time to surgery showed no significant difference. Outcome assessment regarding MMWS, QuickDASH, and VAS was comparable between two groups. Bone-related complications including nonunion, DRUJ subluxation, and styloid resorption were analyzed; the difference was not significant. Incidence of implant-related complications including migration and secondary removal surgery was significantly higher in group B (p = 0.021). CONCLUSION: Surgical fixation in symptomatic ulnar styloid fractures yields comparable treatment outcomes in both fracture patterns. Implant-related complication with secondary removal surgery is more common in tension band wire group. Anchor suture fixation is a feasible option for tiny styloid avulsion fragments with limited surgical complication.

Arthroscopy-Assisted Corrective Osteotomy, Reduction, Internal Fixation and Strut Allograft Augmentation for Tibial Plateau Malunion or Nonunion.

PURPOSE: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. METHODS: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion (n = 44) or nonunion (n = 14), were included in this study. There were 19 Schatzker type II fractures (32.7%), 2 type III fractures (3.4%), 7 type IV fractures (12%), 20 type V fractures (34.5%), and 10 type VI fractures (17.2%). The mean follow-up period was 46.2 ± 17.6 months. Clinical and radiologic outcomes were scored by the Rasmussen system. Articular depression was measured from computed tomography. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up. RESULTS: Mean clinical score improved from 15.4 ± 3.9 (pre-revision) to 23.2 ± 4.5 (post-revision). Mean radiologic score improved from 7.7 ± 2.5 (pre-revision) to 12.0 ± 3.9 (post-revision). Fifty-six fractures achieved successful union. The average union time was 19.6 ± 7.5 weeks. Post-revision, 81% had good or excellent clinical results and 62% had good or excellent radiological results. Secondary osteoarthritis (OA) was noted in 91% of all injured knees, where 25.8% were mild OA, 25.8 % were moderate OA, and 38% were severe OA. There were 6 cases of deep infection (10.3%) and 1 case of wound edge necrosis (1.7%). Five cases were converted to total knee replacement after the index surgery with an average period of 13.5 months (range 8-24 months). CONCLUSIONS: Arthroscopy-assisted corrective osteotomy, reduction, internal fixation, and strut allograft augmentation can restore tibial plateau malunion/nonunion with well-documented radiographic healing and good clinical outcomes.

Application of Bone Marrow-Derived Mesenchymal Stem Cells for Muscle Healing After Contusion Injury in Mice.

BACKGROUND: Skeletal muscle injuries are very common in sports medicine. Conventional therapies have limited clinical efficacy. New treatment methods should be developed to allow athletes to return to play with better function. PURPOSE: To evaluate the in vitro differentiation potential of bone marrow-derived mesenchymal stem cells and the in vivo histologic and physiologic effects of mesenchymal stem cell therapy on muscle healing after contusion injury. STUDY DESIGN: Controlled laboratory study. METHODS: Bone marrow cells were flushed from both femurs of 5-week-old C57BL/6 mice to establish immortalized mesenchymal stem cell lines. A total of 36 mice aged 8 to 10 weeks were used to develop a muscle contusion model and were divided into 6 groups (6 mice/group) on the basis of the different dosages of IM2 cells to be injected (0, 1.25 × 105, and 2.5 × 105 cells with/without F-127 in 100 µL of phosphate-buffered saline). Histological analysis of muscle regeneration was performed, and the fast-twitch and tetanus strength of the muscle contractions was measured 28 days after muscle contusion injury, after injections of different doses of mesenchymal stem cells with or without the F-127 scaffold beginning 14 days after contusion injury. RESULTS: The mesenchymal stem cell-treated muscles exhibited numerous regenerating myofibers. All the groups treated with mesenchymal stem cells (1.25 × 105 cells, 2.5 × 105 cells, 1.25 × 105 cells plus F-127, and 2.5 × 105 cells plus F-127) exhibited a significantly higher number of regenerating myofibers (mean ± SD: 111.6 ± 14.77, 133.4 ± 21.44, 221.89 ± 32.65, and 241.5 ± 25.95, respectively) as compared with the control group and the control with F-127 (69 ± 18.79 and 63.2 ± 18.98). The physiologic evaluation of fast-twitch and tetanus strength did not reveal differences between the age-matched uninjured group and the groups treated with various doses of mesenchymal stem cells 28 days after contusion. Significant differences were found between the control group and the groups treated with various doses of mesenchymal stem cells after muscle contusion. CONCLUSION: Mesenchymal stem cell therapy increased the number of regenerating myofibers and improved fast-twitch and tetanus muscle strength in a mouse model of muscle contusion. However, the rapid decay of transplanted mesenchymal stem cells suggests a paracrine effect of this action. Treatment with mesenchymal stem cells at various doses combined with the F-127 scaffold is a potential therapy for a muscle contusion. CLINICAL RELEVANCE: Mesenchymal stem cell therapy has an effect on sports medicine because of its effects on myofiber regeneration and muscle strength after contusion injury.

The Effect of Hyperbaric Oxygen Treatment on Myoblasts and Muscles After Contusion Injury.

The recommended treatment varies depending on the severity of muscle injuries. The aim of this study was to evaluate the in vitro myoblast proliferation and the in vivo histologic and physiologic effects of hyperbaric oxygen treatment on muscle healing after contusion. Cells from the C2C12 myoblast cell line were exposed to 100% O2 for 25 min then to air for 5 min at 2.5 atmospheres absolute in a hyperbaric chamber for a total treatment duration of 90 min per 48 h at intervals of 2, 4, 6 and 8 days. Cell growth measurements and western blot analysis of myogenin and actin were performed. Then, 18 mice aged 8-10 weeks were used in the muscle contusion model. The histologic and physiologic effects and muscle regeneration after hyperbaric oxygen treatment were evaluated. The myoblast growth rate was significantly higher (p < 0.05) after hyperbaric oxygen treatment. Densitometric evaluation demonstrated a 39% (p < 0.05) and 25% (p < 0.05) increase in myogenin and actin protein levels, respectively, in the cells treated with 1 dose of hyperbaric oxygen. Similarly, the myogenin and actin protein levels increased for samples receiving multiple hyperbaric oxygen treatments when compared with the control. Physiologic evaluation of fast twitch and tetanus strength revealed a significant difference between the control group and the 14-day hyperbaric oxygen group. In conclusion, hyperbaric oxygen treatment increases the myoblast growth rate and myogenin and actin production. Better histologic and physiologic performance were found after hyperbaric oxygen treatment in animal contusion model. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:329-335, 2020.

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study.

BACKGROUND: Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy. METHODS: We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups. RESULTS: All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms. CONCLUSIONS: Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.

Early and late fixation of ulnar styloid base fractures yields different outcomes.

BACKGROUND: The role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention. METHODS: We retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3 months of injury in 13 patients (group A) and beyond 3 months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of < 0.01 was considered statistically significant. RESULTS: Patient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1 months in group A and 12.3 months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4 ± 5.9 vs. 12.9 ± 9.9) and grip strength (37.4 ± 5.1 vs. 29.1 ± 5.9 kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9° ± 4.3° vs. 75° ± 8.5°), extension (84.6 ± 4.3 vs. 76.7 ± 6.5), and flexion (80.4° ± 3.8° vs. 72° ± 4.1°). The difference was not significant in case of pronation (78.8° ± 3° vs. 74.3° ± 5.9°) and with respect to pain scores (0.6 ± 0.7 vs. 1.3 ± 1). CONCLUSION: Both osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.

Anteromedial fractures of the ulnar coronoid process: correlation between surgical outcomes and radiographic findings.

BACKGROUND: This study aimed to report the radiographic findings and surgical outcomes of anteromedial facet (AMF) fracture of the ulnar coronoid process and to suggest an optimal approach. METHODS: In this retrospective study, 20 consecutive patients with unilateral AMF fracture of coronoid process were surgically treated and divided into two groups without (group A) and with (group B) additional proximal ulnar fractures in equal case number. Time from injury to surgery averaged 4.38 ± 2.56 weeks. Mayo Elbow Performance Score (MEPS) and Shortened Disability of the Arm and Shoulder and Hand (quickDASH) score were used for functional evaluation. Cohen kappa coefficient (kappa) analysis was used to determine interobserver reliability on a radiographic reading. RESULTS: All cases had a mean follow-up of 2.3 years. MEPS at 2 years averaged 87.75 ± 12.51; quickDASH, 7.05 ± 6.19. A significantly higher MEPS was found in subtype 3 than in subtype 2 (p = 0.036) and in group B than in group A (p = 0.020). Significantly lower quickDASH cores were found in group B than in group A (p = 0.011). Kappa analysis showed moderate agreement in the O'Driscoll classification (kappa = 0.56) and substantial agreement in categorization of the additional proximal ulnar fractures (kappa = 0.76). CONCLUSIONS: Additional proximal ulnar lesions were considered an integral part of varus posteromedial rotatory instability and required further categorization in the management of AMF fractures. Significantly better functional outcomes were achieved when those lesions were fully addressed.

Long-term outcomes of modular metal prosthesis replacement in patients with irreparable radial head fractures.

BACKGROUND: The purposes of this study were to investigate the long-term outcomes of radial head replacement and to analyze the relationship between functional outcomes and periprosthetic radiolucency. METHODS: We retrospectively reviewed 32 patients who underwent unilateral radial head replacement between 2004 and 2011. Data on patient characteristics including age, gender, injury complexity, associated trauma, injury chronicity, and number of surgeries were collected and analyzed. Of these patients, 14 had terrible triad injury, 14 valgus-type injuries, 3 Monteggia fracture, and 1 concomitant distal humerus fracture. Clinical survey was performed at 7 to 15 years after replacement surgery. The Mayo Elbow Performance Score (MEPS) and shortened Disabilities of the Arm, Shoulder, and Hand (quickDASH) score were used for functional evaluation. Residual elbow or forearm pain was evaluated using visual analog scale (VAS). Radiographs were reviewed by orthopedic and radiologic specialists, and periprosthetic radiolucency was measured based on the diameter of radial head prosthesis. RESULTS: The 32 patients returned for follow-up at an average of 8.94 years. None underwent prosthesis revision or removal. MEPS averaged 83.4; good or excellent results were achieved in 26 patients. QuickDASH scores averaged 11.7. Significantly better MEPS (p = 0.023) and quickDASH scores (p = 0.026) were noted when replacement surgery served as the primary surgery instead of late salvage. VAS scores averaged 1.25, with residual pain noted in 24 elbows (75%). Periprosthetic radiolucency was noted in 21 patients (66%) with a mean thickness of 3.53 mm. The difference in functional outcomes was not significant between patients with and without radiolucency, with p values of 0.127 for MEPS and 0.135 for quickDASH scores. Spearman correlation analysis showed low correlation between the measured width of radiolucency and VAS scores (r = 0.143). CONCLUSION: Sustained, encouraging clinical outcomes were reported in the present study. Although periprosthetic radiolucency did not correlate with functional or pain scores, surgical optimization and meticulous survey were warranted.

Results of Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex Tear With Exploration of Dorsal Sensory Branch of Ulnar Nerve.

BACKGROUND: Ulnar-sided approach in arthroscopic triangular fibrocartilage complex (TFCC) repair may jeopardize treatment success by exposing the dorsal sensory branch of ulnar nerve (DSBUN) in risk of injury. We aim to conduct a follow-up assessment of arthroscopic outside-in TFCC repair and efficacy of sensory nerve exploration. METHODS: We conducted a retrospective chart review of 58 patients (59 wrists) who received arthroscopic repair of the peripheral attachment of the TFCC. Ulnar-sided skin incision and exploration of DSBUN were performed before arthroscopy setting. Arthroscopic outside-in repair through pullout suture ligation was performed. Functional survey at 6 months and 1 year postoperatively was based on Mayo Modified Wrist Score (MMWS), and compared to the preoperative assessment. A p-value of less than 0.05 was considered significant as calculated using paired t-test. RESULTS: Postoperative MMWS averaged 74.32±11.50 at 6 months, and 84.41±9.52 at one year; both showed significant difference as compared to preoperative status. Significant improvement was noted in all 4 individual items except motion retrieval between 6 months and 1 year. Totally, 45 (76%) cases achieved good or excellent results at one year; however, less patients resumed pre-injury activity level when treatment delay was more than 6 months than those treated earlier (41% vs. 57%). Complication included 6 transient paresthesia; 1 anchor migration and 1 distal radioulnar arthrosis. No more nerve complication was found after modification of perineural dissection. CONCLUSION: Arthroscopy is effective in obtaining both correct diagnosis and treatment of peripheral TFCC tear. Modified perineural dissection can minimize sensory nerve complications.

A modified approach for elbow arthroscopy using an adjustable arm holder.

BACKGROUND: Position shifting from elbow arthroscopy to open surgery could complicate the surgical procedures; patient safety and risks of contamination are of concern. The aim of this study is to retrospectively assess the safety and efficacy of elbow arthroscopy in 32 elbows of 32 patients using a modified arm holder to facilitate subsequent open surgery in supine position. METHODS: We performed a retrospective study in arthroscopy of the elbow performed with patients in the supine position under general or regional anesthesia. Arthroscopic indications were intraarticular lesions with or without second disorders. The operated arm was securely supported using an adjustable arm holder, which allowed a second surgical procedure without repositioning the patient. We recorded arthroscopic findings, clinical outcome, and complications for all patients. The average duration of follow-up was 17.1 months. Functional assessment was based on the Mayo Elbow Performance Score. RESULTS: All patients had either good or excellent results with a mean Mayo Elbow Performance Score of 89.2 ± 7.2. Final motion arc averaged 113.3 ± 11.8; residual motion limitation was noted in 2 patients with preoperative ankylosis. No complications were observed immediately after surgery or during follow-up except transient paresthesia along medial cutaneous nerve in 2 patients. A total of 17 patients (53.1%) underwent other surgeries (19 procedures) after arthroscopy; 16 of these surgeries were open elbow procedures including ligament repair (7), ligament reconstruction (5), and ulnar nerve transposition (4). The average time for arthroscopy was 45.2 min; the time interval between the end of arthroscopy and the start of the second surgery procedure averaged 6.5 min. CONCLUSIONS: Arthroscopy of the elbow using an adjustable arm holder with the patients in the supine position was safe and efficacious. This procedure eliminates the need for repositioning the patient and thus may facilitate subsequent concomitant surgical procedures.

Distal radius fractures: Minimally invasive plate osteosynthesis with dorsal bicolumnar locking plates fixation.

BACKGROUND: Controversy still exists regarding the current treatment modalities for unstable distal radius fractures. There are yet few articles investigating the efficacy of bicolumnar dorsal plating technique, which is designed to minimize tissue dissection while providing sufficiently secure fixation. A clinical study was performed to evaluate the feasibility of the minimally invasive plate osteosynthesis (MIPO) technique using a modified dorsal approach for the treatment of distal radius fractures. MATERIALS AND METHODS: Thirty patients with unilateral distal radius fracture who underwent bicolumnar plate fixation with a minimally invasive dorsal approach between September 2008 and December 2010 were included in this retrospective study. Twenty four patients (8 men and 16 women) with a mean age of 53 years (range 18-85 years) were available for followup of at least 1 year or more were included in final study. Herein, we report the functional radiological outcomes of the study. There were three cases of AO Type A fracture, five cases of AO Type B fracture, and 16 cases of AO Type C fracture. RESULTS: The union was achieved in all the patients. The functional results at one-year followup, assessed using the modified Gartland and Werley scoring system, were excellent in 14 patients, good in seven patients, and fair in three patients. The average correction of deformity was 4.1 mm for radial height, 7.6° for radial inclination, and 20.7° for volar tilt. CONCLUSIONS: MIPO with a dorsal approach is a feasible option for the management of displaced distal radius fractures and can result in favorable surgical outcomes.

Intramedullary nailing for correction of post-traumatic deformity in late-diagnosed distal radius fractures.

BACKGROUND: Post-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius. MATERIALS AND METHODS: From July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months. RESULTS: All fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8. CONCLUSION: Surgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius. LEVEL OF EVIDENCE: IV.

Outcomes and Satisfaction with Endoscopic Carpal Tunnel Releases and the Predictors - A Retrospective Cohort Study.

BACKGROUND: Patient's final satisfaction with endoscopic carpal tunnel release (ECTR) is still unpredictable. The study aims to find the predictive factors for satisfaction in patients with carpal tunnel syndrome (CTS) treated by ECTR using the Boston CTS questionnaire. METHODS: We conducted a retrospective chart review of 37 patients (55 hands) who received ECTR and completed Boston carpal tunnel questionnaire at preoperative visit, 1 month and 6 months after operation while a telephone interview was conducted at 2 years after operation. Independent risk variables, including mean symptom severity scale, functional status scale, each item in questionnaire at all the time points, ASA physical status scale, age, gender, dominant site lesion, bilateral lesions, duration of symptoms and anesthesia method were recorded. Final outcome was determined by the patient's satisfaction at the interval of 2 years. Predictors to outcome were analyzed by stepwise multiple regression analysis and tested with Pearson correlation test. A p value of less than 0.05 was considered significant. RESULTS: The severity of hand or wrist numbness during the daytime (Q6, explained 6.5% variances), the severity of numbness or tingling at night (Q9, explained 16.2% variances), the functional status of writing (q1, explained 13.9% variances), carrying grocery bags (q7, explained 13.6% variances) had significant predictive value (p<0.001). Other factors were not significant in the analysis including ASA, gender, age, dominant site lesion, bilateral lesions, anesthesia method and duration of symptoms. CONCLUSIONS: Boston questionnaire is a simple and reliable tool with high predictive values to evaluate patient's outcome and satisfaction in ECTR.