Sticky and Strain-Gradient Artificial Epineurium for Sutureless Nerve Repair in Rodents and Nonhuman Primates.

The need for the development of soft materials capable of stably adhering to nerve tissues without any suturing followed by additional damages is at the fore at a time when success in postoperative recovery depends largely on the surgical experience and/or specialized microsuturing skills of the surgeon. Despite fully recognizing such prerequisite conditions, designing the materials with robust adhesion to wet nerves as well as acute/chronic anti-inflammation remains to be resolved. Herein, a sticky and strain-gradient artificial epineurium (SSGAE) that overcomes the most critically challenging aspect for realizing sutureless repair of severely injured nerves is presented. In this regard, the SSGAE with a skin-inspired hierarchical structure entailing strain-gradient layers, anisotropic Janus layers including hydrophobic top and hydrophilic bottom surfaces, and synergistic self-healing capabilities enables immediate and stable neurorrhaphy in both rodent and nonhuman primate models, indicating that the bioinspired materials strategy significantly contributes to translational medicine for effective peripheral nerve repair.

Clinical Validation of an Artificial Intelligence Model for Detecting Distal Radius, Ulnar Styloid, and Scaphoid Fractures on Conventional Wrist Radiographs.

This study aimed to assess the feasibility and performance of an artificial intelligence (AI) model for detecting three common wrist fractures: distal radius, ulnar styloid process, and scaphoid. The AI model was trained with a dataset of 4432 images containing both fractured and non-fractured wrist images. In total, 593 subjects were included in the clinical test. Two human experts independently diagnosed and labeled the fracture sites using bounding boxes to build the ground truth. Two novice radiologists also performed the same task, both with and without model assistance. The sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated for each wrist location. The AUC for detecting distal radius, ulnar styloid, and scaphoid fractures per wrist were 0.903 (95% C.I. 0.887-0.918), 0.925 (95% C.I. 0.911-0.939), and 0.808 (95% C.I. 0.748-0.967), respectively. When assisted by the AI model, the scaphoid fracture AUC of the two novice radiologists significantly increased from 0.75 (95% C.I. 0.66-0.83) to 0.85 (95% C.I. 0.77-0.93) and from 0.71 (95% C.I. 0.62-0.80) to 0.80 (95% C.I. 0.71-0.88), respectively. Overall, the developed AI model was found to be reliable for detecting wrist fractures, particularly for scaphoid fractures, which are commonly missed.

Ulnar positive variance associated with TFCC foveal tear.

OBJECTIVE: The ulnar positive variance (UPV) can be observed on simple radiography due to a triangular fibrocartilage complex (TFCC) foveal tear. This study investigated to identify how much radiographic UPV occurs due to a TFCC foveal tear, which may be misdiagnosed as an ulnar impaction syndrome (UIS). MATERIALS AND METHODS: One hundred forty patients who underwent arthroscopic transosseus TFCC foveal repair from March 2013 to March 2019 in our institution were enrolled in this study. Ulnar variances were measured in preoperative, postoperative 6 weeks, 1-year follow-up wrist posteroanterior (PA) radiograph, and power grip PA radiograph of the affected wrist and were compared with those of the same patient's unaffected wrist. RESULTS: In the neutral wrist PA radiograph, ulnar variance increased by 0.56 mm (p < 0.001) after TFCC foveal tear compared to the unaffected side. In the power grip view, ulnar variance also increased by 0.39 mm (p < 0.001) in the affected wrist. The preoperative ulnar positive variance was reduced after an arthroscopic transosseous TFCC foveal repair from 0.56 to 0 mm (p < 0.001). No significant statistical difference was observed between an Atzei class 2 and 3 TFCC tear (0.56 mm vs. 0.41 mm, p = 0.263). CONCLUSION: This study revealed that TFCC foveal tear induces 0.56 mm of radiologic UPV, which was successfully corrected after arthroscopic transosseous TFCC foveal repair. Therefore, UPV associated with TFCC foveal tear should not be misdiagnosed as an UIS. Also, when ulnar shortening osteotomy is planned in case of UIS combined with TFCC foveal tear, the amount of UPV induced by TFCC foveal tear should be considered to prevent over-shortening.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion.

PURPOSE: To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN). METHODS: Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation. RESULTS: This study consisted of 66 patients: group I (n = 22) and group II (n = 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .94, Quick-DASH: P = .23, grip strength: P = .69, VAS: P = .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .59, Quick DASH: P = .82, grip strength: P = .15, VAS: P = .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups. CONCLUSIONS: Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Risk Factors of Flexor Tendon Rupture After ORIF of Distal Radius Fracture.

OBJECTIVES: To analyze the risk factors associated with postoperative flexor tendon rupture, after a volar plate fixation of distal radius fractures. DESIGN: Retrospective observational case-control study. SETTING: Tertiary Care University Hospital in the Republic of Korea (2009-2020). PATIENTS: Sixteen referred patients were treated for flexor tendon rupture, following previously performed volar plating of distal radius fractures at other institutions. 16 patients were randomly selected from our database as controls, and were matched based on the Soong grade of the case group. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Radial tilt and radial height were measured on anteroposterior radiographs. The volar tilt, tear drop angle, carpal translation, and Soong grade were measured in a lateral view. RESULTS: Quantitative measurements of the volar tilt, carpal translation, and tear drop angle were positively correlated with the flexor tendon rupture. The mean volar tilt and tear drop angle in the tendon rupture group were significantly smaller than those in the control group. The mean carpal translation in the tendon rupture group was significantly greater than that in the control group. CONCLUSIONS: This study demonstrated that volar tilt, carpal translation, and tear drop angle are significant risk factors for flexor tendon rupture, especially for plates placed at Soong grade 1 or 2. We suggest that the potential for tendon rupture because of incomplete reduction of the distal radius fracture along with implant prominence volar to the watershed line aggravates flexor tendon irritation at the distal edge of the plate because of distorted flexor tendon paths. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Arthroscopic Capsular Repair of Wrist Triangular Fibrocartilage Complex Tears: Beware That Apparent Isolated Atzei Class 1 (Isolated Distal Component) Tears May Include a Proximal Component.

Accumulating knowledge about the anatomy of the triangular fibrocartilage complex (TFCC) and its function has revealed that the foveal insertion of the TFCC plays a key role in distal radioulnar joint stability rather than the superficial fibers that insert into the ulnar styloid. Recently, the interest in torn peripheral TFCC repair has been shifting from capsular repair for Atzei class 1 to foveal repair for Atzei class 2 or 3. Most acute Atzei class 1 tears spontaneously heal without surgical repair; in contrast, in cases of sustained pain and distal radioulnar joint instability even after successful Atzei class 1 repair, the unrecognized proximal component TFCC tear concomitant with a distal component TFCC tear may exist and appropriate treatment for the proximal component TFCC tear should be combined. Although overall successful results have been reported using various repair techniques, the most important consideration is re-establishing biologic regeneration potential at the insertion site of torn TFCC.

Development of a regenerative porous PLCL nerve guidance conduit with swellable hydrogel-based microgrooved surface pattern via 3D printing.

Peripheral nerve injury causes severe loss of motor and sensory functions, consequently increasing morbidity in affected patients. An autogenous nerve graft is considered the current gold standard for reconstructing nerve defects and recovering lost neurological functions; however, there are certain limitations to this method, such as limited donor nerve supply. With advances in regenerative medicine, recent research has focused on the fabrication of tissue-engineered nerve grafts as promising alternatives to the autogenous nerve grafts. In this study, we designed a nerve guidance conduit using an electrospun poly(lactide-co-ε-caprolactone) (PLCL) membrane with a visible light-crosslinked gelatin hydrogel. The PLCL nanoporous membrane with permeability served as a flexible and non-collapsible epineurium for the nerve conduit; the inner-aligned gelatin hydrogel paths were fabricated via 3D printing and a photocrosslinking system. The resultant gelatin hydrogel with microgrooved surface pattern was established as a conducting guidance path for the effective regeneration of axons and served as a reservoir that can incorporate and release bioactive molecules. From in vivo performance tests using a rat sciatic nerve defect model, our PLCL/gelatin conduit demonstrated successful axonal regeneration, remyelination capacities and facilitated functional recovery. Hence, the PLCL/gelatin conduit developed in this study is a promising substitute for autogenous nerve grafts. STATEMENT OF SIGNIFICANCE: Nerve guidance conduits (NGCs) are developed as promising recovery techniques for bridging peripheral nerve defects. However, there are still technological limitations including differences in the structures and components between natural peripheral nerve and NGCs. In this study, we designed a NGC composed of an electrospun poly(lactide-co-ε-caprolactone) (PLCL) membrane and 3D printed inner gelatin hydrogel to serve as a flexible and non-collapsible epineurium and a conducting guidance path, respectively, to mimic the fascicular structure of the peripheral nerve. In particular, in vitro cell tests clearly showed that gelatin hydrogel could guide the cells and function as a reservoir that incorporate and release nerve growth factor. From in vivo performance tests, our regenerative conduit successfully led to axonal regeneration with effective functional recovery.

Revisional triangular fibrocartilage complex (TFCC) repair using arthroscopic one-tunnel transosseous suture: preliminary results.

PURPOSE: The purpose of this study was to report the clinical outcome of revision arthroscopic triangular fibrocartilage complex (TFCC) foveal repair using a one-tunnel transosseous suture technique after failed primary TFCC repair. METHODS: Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique after failed TFCC repair from 2014 to 2018 were retrospectively reviewed. The clinical outcome was evaluated using the Modified Mayo Wrist Score (MMWS) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. The Visual Analog Scale (VAS) for pain, stability of the distal radioulnar joint (DRUJ), grip strength, and active range of motion (ROM) of the wrist joint also were assessed. RESULTS: This study cohort consisted of eight patients, and their mean time to revision after initial surgery was 15.1 months. Previous surgeries were performed using an arthroscopy-assisted mini-open TFCC repair in six cases, an arthroscopic all-inside repair in one case, and an arthroscopic transosseous suture technique in the remaining case. After revisional TFCC foveal repair, all patients demonstrated improved pain and a stable DRUJ. Participants showed improvement in grip strength and mean active wrist ROM. There was improvement in MMWS (from 58.6 to 87.5) and Quick-DASH score (from 46.9 to 12.2) during the mean follow-up of 15.6 months (range: 8-36 months). CONCLUSION: Based on the results of this study, remaining ulnar TFCC remnants may be appropriate for sufficient stable repair using an arthroscopic one-tunnel transosseous suture technique after failed primary repair. However, only a small number of patients was examined. A larger number has to be investigated to confirm the promising preliminary results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Influence of carpal-ulnar translation on clinical outcome after scaphocapitate arthrodesis for the treatment of late-stage Kienböck disease.

BACKGROUND: This study sought to compare postoperative outcomes after scaphocapitate arthrodesis (SCA) for the treatment of late-stage Kienböck disease according to the amount of ulnar translation of the carpus and to identify surgical factors associated with carpal-ulnar translation. METHODS: Thirty-nine patients diagnosed with Kienböck disease (Lichtman stages III-IV) and treated with SCA were retrospectively reviewed. They were divided into the translated group (n=28) and untranslated group (n=11) according to the presence of carpal-ulnar translation. The following surgical factors in the patients were assessed: excision of the lunate, postoperative carpal height ratio, and radioscaphoid angle (RSA). Pain Visual Analog scale (VAS) score, wrist range of motion, grip strength, modified Mayo wrist score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and progression of radioscaphoid osteoarthritis were also assessed. RESULTS: All patients showed functional improvement after a mean postoperative follow-up period of 40 months (VAS: 4.1 vs. 1.1, p <0.001; grip strength, 42.3 vs. 51.2 lb., p = 0.002; MMWS, 52.6 vs. 69.5, p <0.001; QuickDASH, 33.7 vs. 21.5, p <0.001). No statistically significant differences were found between the two groups in terms of outcome measures. Among the assessed surgical factors, the mean postoperative RSA was significantly smaller in the translated group than in the untranslated group (34.8° vs. 46.8°, p = 0.008). The proportion of patients with postoperative RSA <30° was significantly higher in the translated group than in the untranslated group (54.5% vs. 0%, p<0.001). CONCLUSION: These results suggest that sufficient pain relief and functional improvement can be achieved after SCA for the treatment of late-stage Kienböck disease disregarding the occurrence of carpal-ulnar translation. In this study, overcorrection to RSA <30° induced more frequent carpal-ulnar translation after SCA.

Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps.

BACKGROUND: The reverse sural artery flap (RSAF) is widely used to reconstruct foot and ankle defects. Although it is commonly used in a nonsensate type, there has been controversy as to whether it provides sufficient stability and durability when applied to weight-bearing heels. The aim of this study was to evaluate patient outcomes after weight-bearing heel coverage using a nonsensate RSAF. METHODS: Twenty-three patients who underwent reconstruction surgery of the weight-bearing heel with RSAF from 2004 to 2018 in a tertiary hospital were retrospectively reviewed. All surgeries were performed without a sensate procedure. The patients' experience of pressure sore on the flap area and the ability to use normal footwear were investigated. Light touch, Semmes-Weinstein test (SWT), and two-point discrimination tests were assessed, along with postoperative wound complications. RESULTS: Heel damage etiologies included malignant tumors in 14 (61%), trauma-related in 7 (30%) and diabetic ulcers in 2 (9%) patients. Patient mean age was 58 years (range, 18-93 years) and the mean follow-up period was 57 months (range, 12-185 months). The mean size of the flap was 64.1 cm2 (range, 20-169 cm2). All flaps healed without major complications. All returned to daily living activities and 20 (86%) patients were able to use normal footwear. Of the 11 patients who had available measurement records, 8 (73%) showed a light touch sense. The mean SWT value was 4.31 (range, 3.61- 4.56). Two-point discrimination was not observed in any of the patients. Two patients had experienced superficial ulcers on the flap within a one-year postoperative period, which spontaneously healed and did not recur. No full-thickness ulcers were observed during the follow-up period. CONCLUSIONS: The results of this study suggest that patients who underwent nonsensate RSAF for the reconstruction of the heel could expect to maintain the property for stable weight-bearing without pressure sore.

Influence of TFCC foveal tear on the location of lunate chondromalacia in ulnar impaction syndrome.

OBJECTIVE: The purpose of this study was to identify the location of lunate chondromalacia and to compare the difference in location according to presence or absence of triangular fibrocartilage complex (TFCC) foveal tear, which induces distal radioulnar joint (DRUJ) instability. METHODS: We performed a retrospective study of 97 patients (102 wrists) who were diagnosed with and treated for idiopathic ulnar impaction syndrome (UIS) between 2014 and 2018. Subjects were divided into two groups according to presence or absence of TFCC foveal tear with DRUJ instability. Group I had UIS without a TFCC foveal tear (52 wrists, mean age of 43.2 years), while Group II had UIS with a TFCC foveal tear (50 wrists, mean age of 45.3 years). There was no significant difference in age, sex, or duration of symptoms between the two groups. All patients underwent wrist MR Arthrography (MRA) in the same gantry, and all scanned coronal sections of the lunate were standardized into 10 slices, including the whole anteroposterior width of the lunate. Each slice was sequentially numbered from dorsal to volar side, and the location of chondromalacia was marked in each numbered section. Radiological parameters including ulnar variance and ulnolunate distance (ULD), which indicated the distance between the ulnar head and lunate, were measured in the wrist series. RESULTS: The most frequent location of lunate chondromalacia was slightly to the volar side of the lunate in both groups. Group I showed a higher frequency of chondromalacia in the volar side of the lunate. In Group II, chondromalacia was identified with high frequency not only on the volar side of the lunate but also on the dorsal side. In other words, Group II showed broader chondromalacia in the lunate. There was no significant difference in ulnar variance (Group I, 3.19 ± 1.42 mm; Group II, 2.76 mm ± 1.67 mm) or ulnolunate distance (Group I, 1.66 ± 0.94 mm; Group II, 2.05 mm ± 0.87 mm). The average ULD decreased during radial deviation but increased during ulnar deviation. CONCLUSION: This study showed that lunate chondromalacia associated with idiopathic ulnar impaction syndrome occurs more frequently on the volar side of the lunate. Also, TFCC foveal tear, which causes DRUJ instability, leads to broader lunate chondromalacia in idiopathic ulnar impaction syndrome. Therefore, further analysis of the pattern of lunate chondromalacia can provide a clue for DRUJ instability.

Tips and tricks to achieve osteotomy healing and prevent refracture after ulnar shortening osteotomy.

BACKGROUND: Parallel osteotomy is essential for favorable osteotomy reduction and healing and technically challenging during diaphyseal ulnar shortening osteotomy (USO). This study aimed to evaluate the advantages of guided osteotomy for parallel osteotomy and reduction osteotomies, healing over freehand osteotomy. It also aimed to identify surgical factors affecting healing after diaphyseal USO. METHODS: Between June 2005 and March 2016, 136 wrists that had undergone diaphyseal USO for ulnar impaction syndrome (UIS) were evaluated. The wrists were divided into two groups according to the osteotomy technique (group 1: freehand osteotomy, 74 wrists; group 2: guided osteotomy, 62 wrists). The osteotomy reduction gap and time to osteotomy healing (union and consolidation) were compared between the groups. A multiple regression test was performed to identify the surgical factors affecting healing. The cut-off length of the reduction gap to achieve osteotomy union on time and the cut-off period to decide the failure of complete consolidation were statistically calculated. RESULTS: The baseline characteristics did not differ between the two groups. The osteotomy reduction gap and time to osteotomy union, and complete consolidation were shorter in group 2 than in group 1 (p = 0.002, < 0.001, 0.002). The osteotomy reduction gap was a critical surgical factor affecting both time to osteotomy union and complete consolidation (p < 0.001, < 0.001). The use of a dynamic compression plate affected only the time to complete consolidation (p < 0.001). The cut-off length of the osteotomy reduction gap to achieve osteotomy union on time was 0.85 mm. The cut-off period to decide the failure of complete consolidation was 23.5 months after osteotomy. CONCLUSIONS: The minimal osteotomy reduction gap was the most important for timely osteotomy healing in the healthy ulna, and guided osteotomy was beneficial for reducing the osteotomy reduction gap.

Augmented peripheral nerve regeneration through elastic nerve guidance conduits prepared using a porous PLCL membrane with a 3D printed collagen hydrogel.

Peripheral nerve injury results in significant sensory and motor functional deficits. Although direct neurorrhaphy in the early phase may reduce its devastating effects, direct end-to-end neurorrhaphy is sometimes impossible owing to a defect at the injured site of the nerve. Autogenous nerve graft is a primary consideration for peripheral nerve defects; however, significant morbidity of the donor site is inevitable. Recently, the treatment using engineered synthetic nerve conduits has been regarded as a promising strategy to promote the regeneration of peripheral nerve defects. In this study, we developed longitudinally oriented collagen hydrogel-grafted elastic nerve guidance conduits (NGC) to reconstruct sciatic nerve defects. An elastic NGC was prepared by using poly(lactide-co-caprolactone) (PLCL), and electrospun PLCL was adopted to fabricate nanoporous structures with appropriate permeability for nerve regeneration. Oriented collagen hydrogels were prepared by the 3D printing method to achieve a microscale hydrogel pattern. Based on sciatic nerve injury models in rats, we confirmed the beneficial effects of the NGC with 3D printed collagen hydrogel on axonal regeneration and remyelination along with superior functional recovery in comparison with the NGC filled with the bulk collagen hydrogel. It is believed that the aligned collagen hydrogels provide a preferable environment for nerve regeneration, functioning as an oriented guidance path. In conclusion, the PLCL nerve guide conduit containing a 3D printed aligned collagen hydrogel can be useful for peripheral nerve regeneration.

Ultrasound diagnosis and follow-up of a locked thumb metacarpophalangeal joint caused by radial sesamoid entrapment: a case report.

BACKGROUND: A locked thumb metacarpophalangeal joint is a rare condition that presents as restricted joint motions with mild hyperextension deformity, usually after a relatively minor hyperextension injury. Owing to the limitations of radiographs, computed tomography is a useful diagnostic imaging modality for assessing sesamoid displacement. However, despite its convenience, ultrasound findings of the locked thumb have rarely been reported. Here, we report a case of a locked thumb metacarpophalangeal joint diagnosed and followed-up using ultrasound. CASE PRESENTATION: A 15-year-old boy with a locked thumb metacarpophalangeal joint presented to our hospital. On physical examination, the 1st metacarpophalangeal joint was found to be hyperextended, and active and passive flexions were not possible. While radiographs were inconclusive, ultrasound revealed radial sesamoid entrapment at the 1st metacarpophalangeal joint causing locking. After closed manual reduction, metacarpophalangeal motions recovered. Success of the reduction was also confirmable by ultrasound. CONCLUSIONS: Ultrasound can be a feasible modality to diagnose a locked thumb metacarpophalangeal joint and immediately judge the success or failure of the reduction.

Functional Outcomes Are Similar After Early and Late Arthroscopic One-Tunnel Transosseous Repair of Triangular Fibrocartilage Complex Foveal Tears.

PURPOSE: To compare outcomes at different time periods following arthroscopic triangular fibrocartilage complex (TFCC) transosseous foveal repair within 6 months, between 6 and 12 months, and more than 12 months from injury. METHODS: Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique by a surgeon from 2014 to 2017 were retrospectively reviewed. The patients were assigned to 1 of 3 groups according to time between injury and surgery. Pain visual analog scale (VAS); grip strength; modified Mayo wrist score (MMWS); Quick disabilities of the arm, shoulder, and hand (QuickDASH) score; and distal radioulnar joint stability were assessed at minimum 2 years postoperatively, along with minimal clinically important difference, and overall patient satisfaction. RESULTS: This study cohort consisted of 80 patients: group A (<6 months, n = 38), group B (6-12 months, n = 20), and group C (>12 months, n = 22). No differences were found among groups in VAS, grip strength, and MMWS and QuickDASH. Overall, patients exhibited significant functional improvement at 2 years (VAS: 3-0, P < .001; grip strength: 77.1%-95.6%, P < .001; MMWS: 65-90, P < .001, QuickDASH: 20.5-4.5, P < .001). Median changes in outcome variables and the proportion of patients achieving minimal clinically important difference for the QuickDASH were similar among groups. Seventy-eight patients (97%) achieved distal radioulnar joint stability, and 70 patients (87%) were satisfied with treatment. CONCLUSIONS: Although this current study has insufficient statistical power, the available data suggest that patients with a TFCC foveal tear who underwent arthroscopic transosseous repair surgery more than 12 months after injury could expect to experience similar functional improvement compared with patients who underwent surgery within 6 months or between 6 and 12 months following injury. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Changes in the morphology of the triangular fibrocartilage complex (TFCC) on magnetic resonance arthrography related to disruption of ulnar foveal attachment.

OBJECTIVE: To assess whether a proximal ligamentous component (PLC) of the triangular fibrocartilage complex (TFCC) with a distally prolapsing morphology is associated with the presence of a TFCC foveal tear on arthroscopy. METHODS: One-hundred thirty-two patients (134 wrists) who underwent MR arthrography and subsequent wrist arthroscopy between September 2014 and March 2018 were retrospectively evaluated. The degree of distal PLC prolapse was measured on coronal MR arthrography using the height-to-length ratio (HLR). Subjects' demographics, ulnar variance, presence of a degenerative TFCC tear, and ulnar styloid nonunion were assessed. The association between specific variables and the presence of a foveal tear was investigated. RESULTS: A TFCC foveal tear was identified in a total of 101 of 134 wrists examined by arthroscopy. Univariable analysis showed that the HLR of the PLC was significantly greater in the foveal tear group compared with the intact fovea group (44.6 vs. 38.9%, respectively, p < 0.001). Multivariable analysis showed that HLR was positively associated with a foveal tear (odds ratio [OR], 1.211; p < 0.001). The estimated cut-off value of the HLR was 41% (area under the curve [AUC] 0.77). CONCLUSIONS: PLCs with a distal prolapse pattern and large HLR are associated with TFCC foveal tears. The HLR of the PLC measured on coronal MR images can therefore be used as an additional predictor of tears of the foveal attachment of the TFCC.

Dorsal transosseous reduction and locking plate fixation for articular depressed middle phalangeal base fracture.

PURPOSE: An articular depressed fragment at the base of the middle phalanx can be an obstacle to congruent reduction and stable fixation. This study assessed the outcomes of a transosseous reduction technique combined with locking plate fixation for the treatment of articular depressed middle phalangeal base fracture. METHODS: Between 2015 and 2017, seven patients (eight fingers) with intraarticular comminuted middle phalangeal base fracture were included in this study. Mean follow-up was 19 months (range 12-30 months). All patients showed depression of the articular fragment on sagittal computed tomography (CT) scan and were treated with a transosseous reduction technique and dorsal locking plate fixation. Radiographic evaluation was performed to ensure restoration of a concentric articular surface postoperatively. Total active range of motion (TAM) of the finger, grip strength, and the quick Disabilities of the Arm, Shoulder and Hand (quick DASH) score were evaluated at the last follow-up. Complications were also assessed. RESULTS: All fractures obtained bony union with a concentric joint. There was no significant loss of reduction during the follow-up period. The mean active proximal interphalangeal (PIP) joint and distal interphalangeal joint motion arcs at follow-up were 89° and 61°, respectively. Mean TAM of the affected finger and mean grip strength were 94% (range 80-100%) and 94% (range 86-100%) of the contralateral side, respectively. Mean quick DASH score was 2.3 (range 0-9.1). All patients returned to work. No surgery-related complications occurred. CONCLUSIONS: This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, level IV.

Distraction Arthroplasty in an Osteochondral Defect of the Middle Finger in a Juvenile Patient.

A 13-year-old female patient visited our hospital with a painful distal interphalangeal joint and deformity on her right middle finger. Initial plain radiographs uncovered ulnar-sided subluxation of the distal interphalangeal joint of the right middle finger, and an osteochondral defect was also noted at the articular surface of the distal and middle phalanges. We decided to attempt distraction arthroplasty with an external fixator. Finally postoperative 12-month follow-up plain radiographs showed complete osteochondral regeneration and phalangeal alignment. To our knowledge, this is the first report to assess the use of a distraction arthroplasty concept for treating an osteochondral defect in the finger.

Severe Destructive Tendinopathy in the Wrist Due to Dialysis-Related Amyloidosis.

Dialysis-related amyloidosis (DRA) is a specific subtype of amyloidosis with several clinical presentations. Herein we report a case of severe destructive tendinopathy around the wrist associated with long-standing hemodialysis (HD). A 63-year-old female patient who had been on regular HD for 23 years suffered from symptoms of pain and a palpable mass around the wrist. Magnetic resonance imaging showed an ill-defined soft tissue mass around the extensor tendons that partially invaded the wrist joint. We performed surgical excision and tenolysis for the mass. The operative finding revealed an ill-defined yellowish soft tissue mass extensively invading the extensor tendons and wrist joint. The tendon fibers were severely fibrillated and showed impending rupture due to the infiltrated mass. Histological examination showed DRA. Amyloidosis-induced tendinopathy should be considered when a patient on long-term HD complains of an unusual mass-like lesion in the extremity and/or nonspecific joint stiffness. Early surgical intervention improves patient's disability and decreases the risk of spontaneous tendon rupture.