Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex.

Aims: The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes. Methods: A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes. Results: A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations. Conclusion: Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment.

Prediction of an intracompartmental septum and its effect on outcomes of endoscopic release for de Quervain's syndrome.

LEVEL OF EVIDENCE: IV.

Robot-Assisted Retroauricular Anterior Scalenectomy for Neurogenic Thoracic Outlet Syndrome.

Background: This study described the surgical technique of a robot-assisted retroauricular anterior scalenectomy and assessed clinical outcomes and complications for patients with neurogenic thoracic outlet syndrome (nTOS). Methods: Between February 2014 and August 2016, 5 patients underwent robot-assisted retroauricular anterior scalenectomy using the da Vinci Xi system for nTOS. For clinical assessment, visual analog scale (VAS) symptom score, pinch and grip strength, and disabilities of arm, shoulder and hand (DASH) score were assessed to compare preoperative and postoperative outcomes. Postoperative complications were also reviewed. Results: The VAS symptom, pinch and grip strength, and DASH scores improved 1 year after the operation. All patients were satisfied with the surgical scars. Temporary postoperative complications, which spontaneously resolved within 3 months, were noticed in 2 patients: one with vocal cord palsy and the other with upper brachial plexus palsy. Conclusions: The robot-assisted retroauricular anterior scalenectomy for patients with nTOS seems feasible and safe, providing satisfactory cosmetic results.

Radial versus dorsal plating for trapeziometacarpal arthrodesis: a comparative biomechanical study.

Trapeziometacarpal arthrodesis is used for the treatment of advanced arthritis. Insufficient stabilization of the joint may lead to nonunion or hardware problems after arthrodesis. The purpose of this study was to compare the biomechanical properties of dorsal versus radial plate fixation of the trapeziometacarpal joint in ten pairs of fresh-frozen cadaveric hands. The biomechanical performance of each group was measured for stiffness in extension and flexion and load to failure using cantilever bending tests. The stiffness in extension was lower in the dorsally positioned group than in the radially positioned group (12.1 versus 15.2 N/mm, respectively). Load to failure was comparable between both groups (53.9 versus 50.9 N, respectively). A radially positioned locking plate for trapeziometacarpal arthrodesis may be biomechanically advantageous.

Outcomes of Arthroscopic Scaphoid Excision and Lunocapitate Fusion for Advanced Traumatic Arthritis of the Wrist.

Background: Arthroscopic lunocapitate (LC) fusion can be an alternative surgical treatment for scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist. We retrospectively reviewed patients who had arthroscopic LC fusion to estimate clinical and radiological outcomes. Methods: From January 2013 to February 2017, all patients with SLAC (stage II or III) or SNAC (stage II or III) wrists, who underwent arthroscopic LC fusion with scaphoidectomy and were followed up for a minimum of 2 years, were enrolled in this retrospective study. Clinical outcomes included visual analog scale (VAS) pain, grip strength, active range of wrist motion, Mayo wrist score (MWS), and the Disabilities of Arm, Shoulder and Hand (DASH) score. Radiologic outcomes included bony union, carpal height ratio, joint space height ratio, and loosening of screws. We also performed group analysis between patients with 1 and 2 headless compression screws to fix the LC interval. Results: Eleven patients were assessed for 32.6 ± 8.0 months. Union was achieved in 10 patients (union rate, 90.9%). There was improvmenet in mean VAS pain score (from 7.9 ± 1.0 to 1.6 ± 0.7, p = 0.003) and grip strength (from 67.5% ± 11.4% to 81.8% ± 8.0%, p = 0.003) postoperatively. The mean MWS and DASH score were 40.9 ± 13.8 and 38.3 ± 8.2, respectively, preoperatively and improved to 75.5 ± 8.2 and 11.3 ± 4.1, respectively, postoperatively (p < 0.001 for all). Radiolucent screw loosening occurred in 3 patients (27.3%), including 1 nonunion patient and 1 patient who underwent screw removal due to the screw migration encroaching the lunate fossa of radius. In group analysis, only the frequency of radiolucent loosening was higher in 1 screw (3 of 4) than 2 screw fixation (0 of 7) (p = 0.024). Conclusions: Arthroscopic scaphoid excision and LC fusion for patients with advanced SLAC or SNAC of the wrist was effective and safe only in cases fixed with 2 headless compression screws. We recommend arthroscopic LC fusion using 2 screws rather than 1 to decrease radiolucent loosening, which might affect complications such as nonunion, delayed union, or screw migration.

Comparison of arthroscopy-assisted vs. open reduction and fixation of coronoid fractures of the ulna.

PURPOSE: The purpose of this study was to compare clinical and radiographic outcomes and complications for arthroscopy-assisted vs. open reduction and fixation of coronoid fractures in patients with complex elbow fracture-dislocations. METHODS: This retrospective study analyzed patients with complex elbow fracture-dislocations who underwent surgical fixation for coronoid fractures of the ulna from March 2009 to January 2016. Subjects included those who received either arthroscopy-assisted (group A) or open surgery (group O) for coronoid fractures and concurrent reconstruction of the lateral column (radial head and/or lateral ulnar collateral ligament) with follow-up for at least 2 years. Clinical outcomes were assessed using the visual analog scale for pain, range of motion, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand score at 2 years after surgery. For radiographic assessment, union of the coronoid, development of heterotopic ossification, and arthritic changes were evaluated. We also reviewed surgery-related complications. RESULTS: Twenty-five patients (mean age, 40.0 ± 12.4 years) were enrolled in this study (group A, 15 patients; group O, 10 patients), and there were no statistical differences in baseline data between the 2 groups. Clinical outcomes did not differ between the 2 groups. All fractures were united and that the prevalence of heterotopic ossification and arthritic changes were similar between the 2 groups. However, operation-related complications were more common in group O than in group A (group A, 13.3%; group O, 40.0%), including 1 patient who underwent ulnar nerve neurolysis and anterior transposition at 3 months after the initial operation. CONCLUSIONS: Eliciting fewer complications, arthroscopy-assisted reduction and fixation of coronoid fractures shows union rates and clinical results comparable to open fixation in patients with complex elbow fracture-dislocation.

Accuracy of Conventional Triplane Measures Compared to 3-D Analysis for Assessment of Cubitus Varus Deformities in Adults.

PURPOSE: Cubitus varus is a common triplane deformity in adults associated with supracondylar humeral fractures experienced as a child and consists of varus, extension, and internal rotation components. When corrective osteotomy is indicated, these three components should be measured precisely. This study aimed to evaluate the accuracy of radiographic and physical measurements of cubitus varus deformities in adults compared to values measured on three-dimensional (3-D) bone surface models of the adult bilateral humerus. METHODS: Three-dimensional bilateral humerus models were developed using bilateral humerus CT images of 20 adult patients with cubitus varus. The varus, internal rotation, and extension components of the deformity were assessed by superimposing the 3-D bone model onto a mirror-image model of the contralateral normal humerus. Values obtained from the radiographic and physical measurements were compared with those from the 3D model. The reliability of each measurement was assessed by calculating correlation coefficients (CCs). RESULTS: Radiographic measurements of the varus and extension components showed good reliability (CC = 0.796 and 0.791, respectively). Physical measurement of the varus component, however, showed only moderate reliability (CC= 0.539), while physical measurement of the extension and internal rotation components exhibited poor reliability (CC = 0.164 and 0.466, respectively). CONCLUSION: Varus and extension components of cubitus varus in adults can be reliably measured using conventional methods, whereas the internal rotation component cannot. Thus, 3-D methods with which to quantify the rotational component preoperatively might be needed when the correction of a rotational deformity is considered.

Association between platelet count and osteoarthritis in women older than 50 years.

BACKGROUND: Osteoarthritis (OA) is a multifactorial disease involving inflammatory processes. Platelets play important roles in both hemostasis and the inflammatory response; however, the relationship between platelet count and OA is unclear. Our aim was to evaluate the association between platelet count and knee and hip OA in Korean women. METHODS: In this cross-sectional designed study, we included a total of 6011 women aged ⩾50 years from the 2010-2013 Korea National Health and Nutrition Examination Survey. Knee and hip OA were defined as Kellgren-Lawrence grade ⩾2 and presence of knee or hip pain, respectively. Platelet counts were divided into quartiles as follows: Q1, 150-212 (103/µl); Q2, 213-246 (103/µl); Q3, 247-283 (103/µl); and Q4, 284-450 (103/µl). Multiple logistic-regression analysis was conducted to calculate odds ratios and 95% confidence intervals. Receiver operating characteristic analysis was performed to determine the optimal platelet count cut-off with which to discriminate participants with knee and/hip OA versus those without OA. RESULTS: Of the 6011 participants, 1141 (18.1%) had knee or hip OA. The mean age of participants without OA was 60.6 years, and that of participants with OA was 68.0 years. Compared with the lowest quartile, odds ratios (95% confidence intervals) for OA were 1.08 (0.84-1.39) for Q2, 0.94 (0.73-1.23) for Q3, and 1.35 (1.08-1.69) for Q4 after adjusting for confounders. The prevalence of OA was significantly higher with platelet counts ⩾288 × 103/µl, compared with platelet counts <288 × 103/µl. CONCLUSION: High platelet counts within the normal range are significantly associated with knee and hip OA.

Headless screw fixation through the dorsal rough surface for proximal-pole scaphoid-nonunion: a report of 15 patients.

Clinical outcomes of the dorsal-retrograde headless screw-fixation technique in 15 patients with proximal scaphoid nonunion are presented. In this technique, screws are inserted from the dorsal rough surface of the scaphoid, located between the dorsal ridge and scaphoid-trapezium-trapezoid joint. Fifteen patients underwent osteosynthesis with this technique with iliac bone graft. Seven patients required primary surgery, and eight patients with a history of failed operation required revision surgery. Among 15 patients, 13 achieved union and two with persistent nonunion were asymptomatic with average follow-up of 24 months (range 14-57). Mean time to union was 20 weeks (range 12-40). Our experience with the dorsal-retrograde headless screw fixation technique has shown encouraging results for the treatment of proximal-scaphoid nonunion, especially in revision surgery wherein secure fixation of the small proximal fragments can be difficult using conventional anterograde techniques.Level of evidence: IV.

Platelet and white blood cell count are independently associated with sarcopenia: A nationwide population-based study.

INTRODUCTION: Sarcopenia is attracting increasing attention due to its harmful impacts on health. Chronic inflammation is proposed to be a major cause of sarcopenia. Here, we aimed to identify whether white blood cell (WBC) and platelet count have independent roles in sarcopenia occurrence. METHOD AND MATERIALS: This cross-sectional study analyzed 10,092 adults (4293 men and 5799 women) from the 2008-2011 Korea National Health and Nutrition Survey. Cut-off values for sarcopenia were defined as a skeletal muscle mass index <0.789 for men and <0.512 for women. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multiple logistic regression analysis after adjusting for confounding variables. ROC curve analysis was used to evaluate the ability of platelet count and white blood cell count to discriminate the presence of sarcopenia. RESULTS: After adjusting for possible confounders, the OR (95% CI) for sarcopenia occurrence according to platelet counts was 1.62 (1.20-2.19) for the T3 group in men and 1.72 (1.28-2.31) for the T3 group in women, relative to the lowest platelet count tertile. After adjusting for same confounders, the ORs (95% CI) for sarcopenia occurrence according to WBC counts was 1.86 (1.35-2.57) for the T3 group in men, and 2.36 (1.77-3.13) for the T3 group in women, relative to the lowest WBC count tertile. We also found independent significant associations between platelet count, WBC count, and sarcopenia. CONCLUSIONS: Higher platelet and WBC counts within the normal range are each independently associated with sarcopenia in Korean men and women. The inclusion of platelet, WBC, or combined platelet and WBC counts significantly improved the power to discriminate sarcopenia.

Tendon versus Pyrocarbon Interpositional Arthroplasty in the Treatment of Trapeziometacarpal Osteoarthritis.

BACKGROUND: Trapeziometacarpal (TMC) arthritis is treated with surgery when nonsurgical treatment fails. The best surgical option for improving pain relief, functional outcomes, and postoperative complications remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between trapezium excision with ligament reconstruction and tendon interposition (LRTI) and pyrolytic carbon interpositional arthroplasty. METHODS: From March 2009 to August 2014, 37 patients (39 wrists) with Eaton-Littler stage II or III TMC arthritis underwent complete trapezium excision with LRTI (Group L, n=19) or pyrolytic interpositional arthroplasty (Group P, n=20). Visual analog scale (VAS) pain scores; grip and pinch strength; Kapandji scores to quantify thumb opposition; and Disabilities of Arm, Shoulder, and Hand (DASH) scores were used to compare clinical outcomes between the two groups. Radiographic changes (metacarpal shortening, subluxation, and radiolucency) were evaluated on the radiographs of thumb basal joints. RESULTS: There were no differences in patient demographics, Eaton-Littler stage, preoperative outcome measures, or the duration of follow-up between the two groups. At the last follow-up, VAS pain scores, pinch and grip strengths, Kapandji scores, and DASH scores were significantly improved in both groups compared with preoperative scores. All follow-up measurements were similar between the two groups except pinch strength, which was 1.8 kg higher in Group P (p<0.001). Proximal metacarpal migration did not differ significantly between the groups. Periprosthetic lucency more than 1 mm was observed in 7 of 20 (35%) thumbs. Complication rates were similar between the two groups. CONCLUSIONS: All subjective and objective outcomes were similar following LRTI and pyrolytic interpositional arthroplasty in patients with TMC arthritis, except pinch strength, which was more improved following pyrolytic interpositional arthroplasty. Longer follow-up is required to test adverse effects of high rates of periprosthetic lucency and prosthetic subluxation on clinical outcomes after PyroDisk interpositional arthroplasty.

A comparative study of the effect of drilling depth on generation of compressive force by headless compression screws using conical and cylindrical type of drill bit.

BACKGROUND: This study was conducted to measure the effect of different drilling depths on compression forces generated by two commonly used headless compression screws using the two different types of drill bit, the Acutrak® mini (conical type drill bit) and the Synthes 3.0 HCS® (cylindrical type drill bit). METHODS: A load cell was placed between two Sawbone blocks, which were 12 mm and 40 mm in thickness, respectively. After placing the guide pin into the center of the block, the drilling depth of the Acutrak® mini and Synthes HCS® screws ranged from 16 to 28 mm and 22 to 28 mm, respectively. The 24-mm screws were inserted and the compression force was measured immediately and at 30 min post-insertion. RESULTS: The Acutrak® mini generated greater compression force compared to the Synthes 3.0 HCS® when drilled to a depth of less than 24 mm. The compression force of the Acutrak® mini showed a strong inverse correlation with the drilling depth. There was no significant inverse correlation observed between the compression force of the Synthes HCS® and the drilling depth. CONCLUSIONS: If the screw length and the drill depth are the same, the Synthes 3.0 HCS® (cylindrical type drill bit) is safer and easier to use as it has no change in the compression force even when over-drilling because the compression force of the two screws is similar. As for the Acutrak® mini (conical type drill bit), while it is technically demanding due to varying compression force according to the drill depth, it can be used in certain cases because it can give stronger compression force through under-drilling.

Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions.

PURPOSE: To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions. METHODS: Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10 weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared. RESULTS: Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P â‰’ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P = .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vs group O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P = .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P = .005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P = .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]). CONCLUSIONS: Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2 years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Idiopathic Ulnar Impaction Syndrome.

PURPOSE: To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS). METHODS: From May 2009 to June 2014, 42 patients who were aged 45 years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4 mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24 months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared. RESULTS: This study evaluated 19 patients after the AWP and 23 patients after USO. At 3 months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P < .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P = .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P = .001); clinical outcomes were similar at 6, 12, and 24 months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n = 4), implant irritation (n = 6), and refracture after implant removal (n = 2) in the USO group and secondary surgery (n = 1) and tendinopathy (n = 1) in the AWP group. CONCLUSIONS: The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2 years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3 months after surgery. LEVEL OF EVIDENCE: Level III, comparative trial.

Morphologic change of nerve and symptom relief are similar after mini-incision and endoscopic carpal tunnel release: a randomized trial.

BACKGROUND: The symptoms in carpal tunnel syndrome (CTS) can be ameliorated by open and endoscopic release of the transverse carpal ligament. It is unknown whether a mini-incision or endoscopic carpal tunnel release more effectively reverses the pathological changes that are observed in the median nerve in patients with CTS and these morphologic changes correlates with the subjective outcomes after carpal tunnel release. We hypothesized that (1) at 24 weeks after surgery, the subjective outcomes of mini-incision release and endoscopic release would not differ in patients with CTS; and (2) the ultrasonographic (US) morphology of the median nerve reverses similarly after mini-incision and endoscopic release; (3) the subjective outcomes correlates with these morphologic changes. METHODS: Between November 2011 and January 2013, 67 patients with CTS in their dominant wrist were randomized to either mini-incision (n = 32) or endoscopic (n = 35) release. Each patient was assessed by both the Boston Carpal Tunnel Questionnaire (BCTQ) and the Disabilities of the Arm, Shoulder, and Hand (DASH) pre-operatively and 24 weeks' post-operation. An US examination was conducted at both time points to measure the cross-sectional area (CSA) at the inlet, middle, and outlet (CSA-I, CSA-M and CSA-O) and the flattening ratio (FR) at the middle and outlet (FR-M and FR-O) of the median nerve. RESULTS: The post-operative mean BCTQ and DASH scores were improved significantly from the pre-operative scores in both groups (p < 0.001). The mean CSA-I decreased and CSA-M and CSA-O increased similarly in both groups (by 3.3, 3.0, and 3.8 mm2 in the mini-incision group and 2.9, 3.1. and 2.7 mm2 in the endoscopic group. The mean FR-M/FR-O decreased similarly from 3.6/4.2 to 3.2/3.0 in the mini-incision group and 3.8/4.3 to 3.2/2.9 in the endoscopic group. There were no significant differences in the subjective outcome scores or median nerve measures between the two groups. Improvement in the BCTQ-S only was significantly correlated with changes in the CSA at the inlet. CONCLUSIONS: Mini-incision and endoscopic release both similarly relieved subjective symptoms and functions along with the pathological changes in the median nerve morphology along the carpal tunnel in patients with idiopathic CTS. Symptom relief after surgical decompression seems to correlate with reduced nerve swelling at carpal inlet and reversed nerve flattening inside carpal tunnel. TRIAL REGISTRATION: This study was retrospectively registered in "ClinicalTrials.gov" at Oct 18th, 2013, and the registration number was NCT01972165 .

Correlation between change in muscle excursion and collagen content after tendon rupture and delayed repair.

BACKGROUND: The objectives of the present study were to compare changes in muscle excursion, total collagen, and collagen subtypes after tenotomy over time and after delayed tendon repair. METHODS: Tenotomy on the extensor digitorum tendon of the right second toes of 48 New Zealand White rabbits was performed; toes on the left leg were used as controls. Passive muscle excursion, total collagen content, and type I, III, and IV collagen contents were measured at 1, 2, 4, and 6 weeks after tenotomy. Next, passive muscle excursion and total collagen content were measured at 8 weeks after delayed tendon repair at 1, 2, 4, and 6 weeks after a tenotomy. RESULTS: Passive muscle excursion decreased sequentially over time after tenotomy. Meanwhile, total collagen increased over time. These changes were significant after 4 weeks of injury. Type I collagen significantly increased, type III collagen significantly decreased, and type IV collagen had no significant change over time. Passive muscle excursion was negatively correlated with total collagen and type I collagen after tenotomy at each time point after tenotomy (p < 0.05). After tendon repair, increases in total collagen content after tenotomy were not reversed, despite early repairs at 1 and 2 weeks after tenotomy. CONCLUSIONS: Increases in type I collagen were found to be associated with decreased excursion after tendon rupture. The increase in collagen that was observed after tenotomy was not reversed by repair within 8 weeks.

Comparative Outcome Analysis of Arthroscopic-Assisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations.

PURPOSE: To compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with trans-scaphoid perilunate fracture dislocations. METHODS: This retrospective study included consecutive patients with trans-scaphoid PLFDs who underwent arthroscopic-assisted reduction and fixation (group A) or open reduction and fixation (group O), and who were followed up for a minimum of 2 years between May 2005 and March 2013. We excluded initially missed patients. Each different surgeon who was on call had performed each experienced operation. These clinical outcomes were assessed: range of motion, grip strength, Mayo wrist score, and Disabilities of Arm, Shoulder, and Hand (DASH) score. For radiologic outcomes, the scapholunate angle, radiolunate angle, and lunotriquetral distance were measured. RESULTS: The total number of included patient was 20 (11 in group A and 9 in group O). Scaphoid union occurred in all patients except 1 individual (11 of 11 in group A, and 8 of 9 in group O). At the last follow-up, the mean flexion-extension arc was significantly greater in group A (125.0°) than in group O (105.6°) (P = .028). The mean grip strength was 81.1% that of the contralateral side in group A and 80.9% in group O (P = .594). The mean Mayo wrist score was 85.5 in group A and 79.4 in group O (P = .026), and the mean DASH score was 10.6 in group A and 20.8 in group O (P = .001); however, only the DASH score showed a minimum clinically important difference. The mean scapholunate angle, radiolunate angle, and lunotriquetral distance were similar between the 2 groups: 47.2°, 1.7°, and 2.0 mm in group A and 48.8°, 5.6°, and 2.1 mm in group O, respectively. CONCLUSIONS: Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with trans-scaphoid PLFDs, it is shown that the arthroscopic-assisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Effect of Debridement of Coexisting Partial Ligament Injuries on Outcomes Following Arthroscopic Osteosynthesis for Minimally Displaced Scaphoid Nonunions.

PURPOSE: Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided. METHODS: This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups. RESULTS: The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups. CONCLUSIONS: In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study.

PURPOSE: Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years. MATERIALS AND METHODS: Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale. RESULTS: Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination. CONCLUSION: An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years.

Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective?

BACKGROUND: Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions. QUESTIONS/PURPOSES: (1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions? METHODS: Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded. RESULTS: Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes. CONCLUSIONS: Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results. LEVEL OF EVIDENCE: Level IV, therapeutic study.