Intraobserver and interobserver reliability of the computed tomography-based radiographic classification of primary elbow osteoarthritis: comparison with plain radiograph-based classification and clinical assessment.

OBJECTIVES: To develop a staging system that could better reflect symptoms by the spurs quantification in the fossa and joint space narrowing using computed tomography (CT) for elbow arthritis and to evaluate its reproducibility with multiple readers. METHODS: This retrospective study evaluated 81 cases of primary elbow osteoarthritis using both plain radiography and CT. Qualitative and quantitative analyses were independently performed by four orthopedic surgeons using previous and newly proposed staging systems. The reproducibility of the new system was analyzed with intraclass correlation coefficients (ICC). Correlations between symptoms and radiologic classification were assessed using Pearson's correlation coefficient (PCC). RESULTS: The interobserver agreement (1) and intraobserver agreement (2) among the four evaluators was present by ICC. (1) The system of Hastings and Rettig [first observation, 0.544 (95% confidence interval (CI), 0.436-0.649); second observation, 0.582 (95% CI, 0.478-0.682)] and Broberg and Morrey's staging system [first observation, 0.620 (95% CI, 0.521-0.714); second observation, 0.656 (95% CI, 0.562-0.743)] showed substantial and moderate retrospective agreement, whereas the CT-based staging system showed almost perfect agreement [first observation, 0.867 (95% CI, 0.820-0.906); second observation, 0.909 (95% CI, 0.875-0.936)]. (2) The intraobserver agreement was almost perfect in the Brogerg and Morrey's and CT-based staging systems. CT-based staging showed high correlation with visual analogue scale (PCC 0.754, P < 0.001) and Mayo elbow performance score (PCC -0.614, P < 0.001) and moderate correlation with range of motion (PCC -0.458, P < 0.001). CONCLUSIONS: CT-based staging system was highly reproducible and clinically feasible than previous plain radiograph-based staging systems.

Mechanoreceptors distribution in the human medial collateral ligament of the elbow.

BACKGROUND: The human elbow maintains its stability mainly through its bony structure. Stability is enhanced by ligamentous structures. To allow the ligamento-muscular reflex, which protects against strain and stress, mechanoreceptors are embedded in the ligament. This report describes the existence and the distribution of the elbow medial collateral ligaments (MCLs) mechanoreceptors. HYPOTHESIS: The bony attachment site has the highest density of mechanoreceptors, and the anterior part has the highest density of mechanoreceptors. MATERIALS AND METHODS: Eight MCLs of elbow from fresh frozen cadavers were used. The MCLs were harvested deep to the periosteum from the medial epicondyle to the ulna. The fan-shaped ligaments were divided into six regions of interest (ROI) and stained with modified gold chloride stain. Specimens were evaluated under a light microscope. Golgi, Ruffini, and Pacinian corpuscles were found in every specimen. The number and the distribution of each mechanoreceptor in each ROI were recorded. The density of each mechanoreceptor was calculated in regards to its volume. RESULTS: Golgi, Ruffini, and Pacinian corpuscles were seen in the ligament with small nerve fibers. Ruffini corpuscles had the highest median density of all three corpuscles. The median corpuscle density was higher in the anterior than in the posterior part and higher in the bony attachment than in the mid-substance site except for Golgi corpuscle. CONCLUSION: The three typical types of mechanoreceptors were identified in human MCL with the anterior part and bony attachment as the dominant distribution site. LEVEL OF EVIDENCE: Basic Science Study.

Rotator cuff surgery in patients with rheumatoid arthritis: clinical outcome comparable to age, sex and tear size matched non-rheumatoid patients.

Aims This study aimed to compare the clinical outcomes of rotator cuff repair in patients with rheumatoid arthritis with those of patients who have no known history of the disease. We hypothesised that the functional outcomes are comparable between patients and without rheumatoid arthritis and may be affected by the level of disease activity, as assessed from C-reactive protein (CRP) level and history of systemic steroid intake. Patients and methods We conducted a retrospective review of the institutional surgical database from May 1995 to April 2012. Twenty-nine patients with rheumatoid arthritis who had rotator cuff repair were enrolled as the study group. Age, sex, and tear size matched patients with no disease who were selected as the control group. The mean duration of follow-up was 46 months (range 24-92 months). Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) questionnaire, Constant score and visual analogue scale (VAS). All data were recorded preoperatively and at regular postoperative follow-up visits. CRP was measured preoperatively as the disease activity marker for rheumatoid arthritis. Medication history was thoroughly reviewed in the study group. Results In patients with rheumatoid arthritis, all shoulder functional scores improved after surgery (ASES 56.1-78.1, Constant 50.8-70.5 and VAS 5.2-2.5; P < 0.001). The functional outcome of surgery in patients with rheumatoid arthritis was comparable to that of the control group (difference with control: ASES 78.1 vs. 85.5, P = 0.093; Constant 70.5 vs. 75.9, P = 0.366; VAS 2.5 vs. 1.8, P = 0.108). Patients with rheumatoid arthritis who had an elevated CRP level (> 1 mg/dl) showed inferior clinical outcomes than those with normal CRP levels. Patients with a history of systemic steroid intake showed inferior functional outcomes than those who had not taken steroids. Conclusions Surgical intervention for rotator cuff tear in patients with rheumatoid arthritis improved the shoulder functional outcome comparable to that in matched patients without rheumatoid arthritis. Elevated preoperative CRP level and history of systemic steroid intake portend inferior functional outcome in patients with rheumatoid arthritis.

Untethering physiolysis for delta phalanx (longitudinally bracketed diaphysis) combined with free fat interposition graft.

We report the results of physiolysis of the epiphyseal bracket combined with free fat grafting for the treatment of delta phalanx. Thirteen cases (five patients) were included. Mean patient age was 6.6years (range, 4-9). The patients underwent physiolysis in which the epiphyseal bracket was cut and replaced with a free fat graft. The angle between the long axis of the proximal and distal phalanges and the ratio between the width and length of the affected middle phalanx were evaluated on plain radiographs. The range of motion in the fingers was also evaluated. The mean follow-up period was 42.2months (range, 25-61). The mean correction angle was 17.1° (range; 13-23). The mean width-to-length ratio of the affected phalanx was improved from 0.6 to 0.47. The range of motion was maintained at the previous level. Physiolysis by untethering the bracketing epiphysis and free fat grafting can alleviate the angulation of clinodactyly, especially in growing children. It also allows catch-up growth in the middle phalanx.

Head-shaft angle changes during internal and external shoulder rotations: 2-D angulation in 3-D space.

INTRODUCTION: Restoration of native head-shaft angle (HSA) is critical for treatment of proximal humerus fracture. However, HSA has not been properly investigated according to the humeral rotation. This study was designed to analyze the relationship between the humeral rotation and the HSA at 1° increments, and clarify its serial changing pattern according to the humeral rotation. HYPOTHESIS: The angulation of HSA would be undervalued when the humerus is being rotated externally and it would be overvalued when it is being rotated internally. MATERIALS AND METHODS: Eight dried cadaveric normal humeri were CT scanned. They were analyzed using computer-aided design with a standardized neutral position. HSA was the angle between the humeral shaft axis (SA) and the humeral head axis (HA). SA and HA were the best-fit lines through center of all the best-fitting circles in every cross section along the humeral shaft and within the humeral head, respectively. Each 3D model was rotated 30° internally and 45° externally relatives to the SA at 1° increments with the camera was fixed at antero-posterior view of neutral position. Angulation of HSA in every rotational degree was documented as ratio relatives to the angulation of HSA in neutral position. RESULTS: The average HSA at neutral position was 133±1.93°. HSA was underestimated by 8±1.9% and it was overestimated by 20±5.1% at the maximum external rotation (ER) and internal rotation (IR), respectively. HSA was underestimated by 1% in every 5.8° of ER and overestimated by 1% in every 1.5° of IR. Rotational misalignments within 10° of IR and 18° of ER could be tolerated (P>.05). CONCLUSIONS: HSA was underestimated at ER and was overestimated at IR. This information could be useful for surgeons in restoring the native HSA for treatment of proximal humerus fracture. TYPE OF STUDY: Basic research study.

Long-term results of single-stage reduction surgery for the treatment of macrodactyly.

We report the long-term results of a single-stage reduction procedure for the treatment of macrodactyly. Six patients (eight cases) were included. These patients underwent a single-stage operation that included debulking with resection of the hypertrophied digital nerve and distal interphalangeal joint fusion or corrective osteotomy. Plain radiographs and functional parameters were assessed. Aesthetic improvement was achieved in all patients. The mean ratios of the lengths and circumference differences between the affected digit and the corresponding normal digit on the other hand were 1:1 and 1:1, respectively. The mean range of motion in the proximal interphalangeal joint was 76°. A sensory deficit in the lateral pulp of the distal phalangeal area was observed in three fingers. The Disabilities of the Arm, Shoulder and Hand score ranged from 0 to 9 (mean 4). The long-term results of the single-stage reduction procedure were satisfactory, as demonstrated by the excellent adjustment of the length and acceptable circumference of the affected digits. LEVEL OF EVIDENCE: IV.

The use of continuous negative pressure after open debridement for septic arthritis of the shoulder.

AIMS: The treatment of septic arthritis of the shoulder is challenging. The infection frequently recurs and the clinical outcome can be very poor. We aimed to review the outcomes following the use of continuous negative pressure after open debridement with a large diameter drain in patients with septic arthritis of the shoulder. PATIENTS AND METHODS: A total of 68 consecutive patients with septic arthritis of the shoulder underwent arthrotomy, irrigation and debridement. A small diameter suction drain was placed in the glenohumeral joint and a large diameter drain was placed in the subacromial space with continuous negative pressure of 15 cm H2O. All patients received a standardised protocol of antibiotics for a mean of 5.1 weeks (two to 11.1). RESULTS: Negative pressure was maintained for a mean of 24 days (14 to 32). A total of 67 patients (98.5%) were cured without further treatment being required. At a mean follow-up of 14 months (three to 72), the mean forward flexion was 123° (80° to 140°) and the mean external rotation was 28°(10° to 40°) in those with a rotator cuff tear, and 125° (85° to 145°) and 35° (15° to 45°) in those without a rotator cuff tear. CONCLUSION: Continuous negative pressure, following open arthrotomy, irrigation and debridement, was effective in treating septic arthritis of the shoulder. The rate of recurrence was significantly lower than with conventional treatment involving arthroscopic or open debridement reported in the literature. Functional outcomes, even in patients with rotator cuff tears, were excellent. TAKE HOME MESSAGE: Continuous negative pressure is effective in treating septic arthritis of the shoulder. Cite this article: Bone Joint J 2016;98-B:660-5.

Non-tuberculous mycobacterial infection of the musculoskeletal system: pattern of infection and efficacy of combined surgical/antimicrobial treatment.

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Osteophyte excision without cyst excision for a mucous cyst of the finger.

Osteophyte excision is a mainstay of treatment for mucous cyst combined with Heberden's node in a distal interphalangeal joint or in an interphalangeal joint of the thumb. The aim of this study was to evaluate the results of osteophyte excision without cyst excision for the treatment of a mucous cyst combined with Heberden's node. The medical records of 37 patients (42 cases) with a mucous cyst with Heberden's node were retrospectively reviewed. Thirty-eight of 40 cases with available pre-operative simple radiographs showed evidence of joint arthrosis. A T-shaped skin incision of the joint capsule between the extensor tendon and lateral collateral ligament was used. Osteophyte excision without cyst excision was performed. All cysts, except one, regressed without recurrence or a skin complication after osteophyte excision, but eight cases showed post-operative pain and loss of range of motion. Osteophyte excision without cyst excision may be a good treatment choice for mucous cyst of the finger.

A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion.

This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion.

Zona conoidea of the elbow: another articulation between the radial head and lateral trochlear of the elbow.

The zona conoidea comprises the area of the lateral trochlear ridge of the humerus. The purpose of this study is to reintroduce this term 'zona conoidea' to the discussion of the human elbow and to investigate its significance in the development of osteoarthritis of the elbow. The upper extremities of 12 cadavers were prepared. With the forearm in neutral, pronation and supination, the distance between the bevel of the radial head and zona conoidea was inspected. A total of 12 healthy volunteers had a CT scan. The distance between the zona conoidea and the bevelled rim of the radial head was measured in these positions. In the anatomical specimens, early osteo-arthritic changes were identified in the posteromedial bevelled rim of the radial head, and the corresponding zona conoidea in supination. Measurement in the CT study showed that in full supination, the distance between the bevel of the radial head and the zona conoidea was at a minimum. This study suggests that the significant contact between the bevel of the radial head and the zona conoidea in supination is associated with the initiation of osteoarthritis of the elbow in this area.

The contribution of the coronoid and radial head to the stability of the elbow.

We undertook this study to determine the minimum amount of coronoid necessary to stabilise an otherwise intact elbow joint. Regan-Morrey types II and III, plus medial and lateral oblique coronoid fractures, collectively termed type IV fractures, were simulated in nine fresh cadavers. An electromagnetic tracking system defined the three-dimensional stability of the ulna relative to the humerus. The coronoid surface area accounts for 59% of the anterior articulation. Alteration in valgus, internal and external rotation occurred only with a type III coronoid fracture, accounting for 68% of the coronoid and 40% of the entire articular surface. A type II fracture removed 42% of the coronoid articulation and 25% of the entire articular surface but was associated with valgus and external rotational changes only when the radial head was removed, thereby removing 67% of the articular surface. We conclude that all type III fractures, as defined here, are unstable, even with intact ligaments and a radial head. However, a type II deficiency is stable unless the radial head is removed. Our study suggests that isolated medial-oblique or lateral-oblique fractures, and even a type II fracture with intact ligaments and a functional radial head, can be clinically stable, which is consistent with clinical observation.

Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating.

PURPOSE: This study compared clinical outcomes and complications in patients with humeral shaft fractures treated using two methods of fixation by plating. METHODS: Minimally invasive plate osteosynthesis (MIPO, n=29) was prospectively performed from around the middle of the study period, while open reduction and plate osteosynthesis (ORPO, n=30) had been the original standard method. Locking compression plate was used in these two groups. Major characteristics of the two groups were similar in terms of fracture type, fracture location, age, associated injuries and numbers of open fractures. RESULTS: Primary union was achieved in 28 of 29 in the MIPO and in 27 of 30 in the ORPO. Mean time to union was similar in the two groups. Mean operation time in the MIPO (110min) was shorter than in the ORPO (169min) (P<0.05). Bone grafting was performed in five patients of in the ORPO, but in no patient in the MIPO (P<0.0001). There was one case of deep infection in the ORPO. Functional outcome was satisfactory in both groups. CONCLUSIONS: Minimally invasive plate osteosynthesis may achieve comparable results with the open plate osteosynthesis method in simple as well as complex fractures of humeral shaft. Although MIPO potentially has the radiation hazard, it may reduce the perioperative complications with a shortened operation time. LEVEL OF EVIDENCE: Level III. Case-control study.

Arthroscopically assisted percutaneous fixation for trans-scaphoid perilunate fracture dislocation.

Trans-scaphoid perilunate fracture dislocation is a complex carpal dislocation causing marked disruption of the carpal structures. Open treatment has been accepted as standard for this injury. We have used arthroscopically assisted percutaneous screw fixation and bone grafting to treat this injury in four patients. The functional outcome was good. All patients achieved solid union without nonunion or malunion. The complication and morbidity was relatively low; all patients had proper alignment and there was no evidence of instability or avascular necrosis or midcarpal arthritis.

Traumatic humeral articular cartilage shear (THACS) lesion in a professional rugby player: a case report.

A 20 year old male professional rugby player was seen at the clinic for evaluation of shoulder pain after rugby play. Magnetic resonance imaging showed extensive subchondral bone bruising of the humeral head with defect of the articular cartilage. Arthroscopy showed that the inferior half of the humeral head had extensive articular cartilage loss with nearly 70% of the inferior head having lost its cartilage. Sports medicine doctors should be aware that the shoulder joint in young competitive athletes playing contact sports may be exposed to greater risk of this kind of injury.

High bifurcation of median nerve at the wrist causing common digital nerve injury in endoscopic carpal tunnel release.

A 45-year-old right-handed woman was treated by endoscopic carpal tunnel release under local anaesthetic. When cutting the proximal half of the flexor retinaculum with the retrograde blade, she complained of an electric shock-like pain in her middle and ring fingers. Open exploration of the carpal tunnel was performed and a laceration of the middle/ring common digital nerve, which bifurcated at the unusually high level of the wrist crease, was found.