Measurement of Radiological Parameters of Distal Radius Fracture Using the Ulnar Axis Compared with the Radial Axis.

Background: The long axis of the radius is a standard reference for measuring radiological parameters in distal radius fractures. However, in patients with severe comminution and anatomical variation with distal radius bowing, it is challenging to assess using the long axis of the radius. The long axis of the ulna can be used as an alternative reference. The aim of this study is to assess the reliability and level of agreement using the long axis of the ulna as an alternative reference in comparison to the long axis of the radius. Methods: Posteroanterior (PA) radiography of the wrist in patients with acute distal radius fractures was evaluated in two rounds by four observers. Radial height, radial inclination and ulnar variance were measured using radial and ulnar long axis as references. The intraobserver and interobserver reliability of the measurements with two reference axes was assessed using intraclass correlation coefficient (ICC). The level of agreement was determined using the Bland-Altman plot. Results: In total, 59 patients who underwent PA radiography of the wrist were included in this study. All parameters exhibited good agreement between the two methods, with a mean difference of nearly zero (radial height = -0.03 mm, radial inclination = -0.14° and ulnar variance = 0.03 mm). The limits of agreement in radial height (-2.87, 2.82 mm) and ulnar variance (-0.81, 0.87 mm) were narrow. However, for the radial inclination, it was wider (-6.21, 5.94°). Intraobserver reliability between the long axis of radius and ulna (ICC = 0.85-0.99 and 0.84-0.98, respectively) was good to excellent. The interobserver reliability of each parameter was excellent (ICC = 0.94-0.97). Conclusions: The ulnar long axis can be used as an alternative reference for measuring radial height, radial inclination and ulnar variance in PA radiography of the wrist in acute distal radius fracture, particularly if the radial long axis is distorted. Level of Evidence: Level III (Diagnostic).

Factors Influencing the Successful Treatment of Recurrent Trigger Finger With Repeated Corticosteroid Injections: A Prospective Cohort Study.

PURPOSE: The aim of this study was to determine the success rate, duration of disease control, and predictive factors of success of repeated corticosteroid injections for recurrent trigger finger. METHODS: This prospective cohort study involved patients who had recurrent trigger finger and a history of corticosteroid injections. A total 114 patients were treated with repeated corticosteroid injections and followed for 12 months. Data on demographic characteristics, comorbid conditions, and possible predictive factors for successful treatment from medical chart reviews and direct patient interviews were compared. Patients were classified into success or failure groups at one, three, six, and 12 months after the initial injection. The relationship between hypothesized predictors and success or failure after repeated corticosteroid injection was analyzed with multivariable logistic regression. RESULTS: The overall success rates from repeated cortisone injections after one, three, six, and 12 months were 97.4%, 84.2%, 68.4%, and 49.1%, respectively. Multivariable logistic regression modeling revealed that a high grade of disease (grade III or IV based on the Quinnell system), a body mass index (BMI) ≥ 25 kg/m2, and a short symptom-free period (< six months) after a previous injection were strong predictors of symptom recurrence (odds ratio = 3.6 [95% CI 1.5-8.4], odds ratio = 2.5 [95% CI 1.1-5.9], and odds ratio = 1.8 [95% CI 1.1-3.0], respectively). The average success rates for patients at 1-year according to the number of risk factors were as follows: none of the three risk factors, 73.3%; one risk factor, 54.2% to 63.6% (54.2% for grade III-IV triggering, 63.6% for BMI ≥ 25 kg/m2 and 63.6% for < 6-month symptom-free period); two risk factors, 30% to 75% (30% for a combination of grade III-IV and BMI ≥ 25 kg/m2, 45.5% with grade II-IV and < 6-month period, and 75% with a combination of < 6-month period and BMI ≥ 25 kg/m2); and all three risk factors, 11.8%. CONCLUSIONS: Repeated corticosteroid injections for recurrent trigger finger should be considered in patients who prefer nonsurgical treatment, especially in those without factors predictive of failure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Prebent Steinmann Pin to Remove the Broken Retrograde Intramedullary Nail After Tibiotalocalcaneal Arthrodesis.

A retrograde intramedullary nail is an implant option for tibiotalocalcaneal arthrodesis because it provides mechanical strength and compression at the fusion site, while being less invasive to soft tissue. However, some fusion failures result in implant overloading, resulting in implant failure. The accumulated stress at the level of the subtalar joint will most likely cause implant breakage. It is challenging to remove the broken tibiotalocalcaneal nail's proximal part. Several surgical procedures for removing the broken tibiotalocalcaneal nail have been reported. In this article, we present a surgical technique for removing a broken tibiotalocalcaneal nail by punching out the proximal part of the broken nail using a prebent Steinmann pin. It has the advantage of being less invasive and not requiring any specific tools to punch out the nail.

Cross-cultural translation, reliability and validity of the Thai version of the Patient­Reported Outcomes Measurement Information System (PROMIS) Parent Proxy Upper Extremity Short Form 8a in children with congenital upper extremity anomalies.

BACKGROUND: The PROMIS Parent Proxy Upper Extremity Short Form 8a version 2 (PROMIS Parent Proxy UE-SF) is one of the most commonly used self-assessment questionnaires for evaluating function in children with congenital upper extremity anomalies. However, this English questionnaire is difficult for Thai parents to complete. The purpose of this study is to translate the PROMIS Parent Proxy UE-SF into Thai and test its reliability and validity. METHODS: The PROMIS Parent Proxy UE-SF was translated into Thai using FACIT translation methodology. This version and the Thai version of the Michigan Hand Questionnaire (Thai-MHQ) were used to evaluate 30 Thai children with different types of congenital upper extremity anomalies. The reliability and validity of the Thai-PROMIS Parent Proxy UE-SF were evaluated by test-and-retest with the intraclass correlation coefficient (ICC) and Cronbach's alpha coefficient. Correlations between the Thai-PROMIS Parent Proxy UE-SF and Thai-MHQ were analysed by Pearson's correlation coefficients. RESULTS: The children's mean age was 4.47 ± 2.08 years (range 1-9 years). The main diagnoses included thumb duplication (11 children), syndactyly (4 children)4, congenital trigger thumb (3 children) and obstetric brachial plexus palsy (3 children). The children's parents completed the questionnaires, taking 164.23 ± 22.58 s for the Thai-PROMIS and 337.8 ± 49.37 s for the Thai-MHQ. The test-retest reliability of Thai-PROMIS evaluated by ICCs, was 0.9909 (good reliability), and the Cronbach's alpha of all items was 0.923. The Pearson's correlation coefficient between the Thai-PROMIS and Thai-MHQ showed a strong correlation with Domain 2 (activities of daily living, r = 0.7432) and a moderate correlation with the overall Thai-MHQ score (r = 0.699). CONCLUSIONS: The Thai-PROMIS Parent Proxy UE-SF is a valid, reliable and easy-to-use patient-reported outcome measure for assessing function in children with congenital upper extremity anomalies.

Effect of delayed distal radius fracture fixation on the difficulty of surgical operation.

Purpose: The effect of delayed distal radius fracture (DRF) fixation by volar locking plates (VLPs) on the operative time, rate of bone graft use and need for additional surgical incisions was analyzed. Short- and mid-term outcomes were compared between early and delayed DRF fixation. Methods: A retrospective cohort review of DRFs treated with VLPs was performed. The effects of delayed fixation were analyzed by 1) comparing intraoperative and radiographic parameters and follow-up outcomes between early fixation (EF, 1-10 days) and late fixation (LF, ≥11 days), 2) predicting the prolonged operative time using linear regression analysis, and 3) predicting the rate of bone graft use and additional incision using odds ratios. Results: Of 104 patients, 51 and 53 were in the EF and LF groups, respectively. EF showed a significantly shorter operative time, lower rate of bone grafting and fewer additional incisions (94.80 vs. 123 minutes, 3.92% vs. 26.18% and 2% vs. 20.45%, respectively). Radiographic parameters, immediate postoperative pain and wrist range of motion were significantly better in the EF group. However, the visual analog scale (VAS) pain and Patient-Rated Wrist Evaluation (PRWE) scores were not different at the 12-month follow-up. For every day of delay, the operation was prolonged by 2.17 min, the rate of bone grafting increased by 8%, and the chance of additional incisions increased by 8%. Conclusion: Delayed DRF fixation affects intraoperative and postoperative outcomes. We encourage internal fixation for DRFs as early as possible to reduce surgical complexity and improve postoperative outcomes.

Accuracy of the rotator cuff reparability score.

BACKGROUND: The reparability of large or massive rotator cuff tears is difficult to determine pre-operatively. We previously identified age ≥ 65 years, acromiohumeral interval ≤ 6 mm, and anteroposterior tear size ≥ 22 mm as risk factors for rotator cuff repair failure. We therefore developed a rotator cuff reparability score where each of the above risk factors is assigned a score of one point. AIM: To determine the accuracy of a rotator cuff reparability score. METHODS: This was a retrospective cohort study of recruited patients with large or massive rotator cuff tears treated at our institution between January 2013 and December 2019. Exclusion criteria were revision surgery and patients with contraindications for surgery. All patients underwent arthroscopic rotator cuff repair and were categorized into either complete or partial rotator cuff repair. Rotator cuff reparability scores were calculated for each patient. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were assessed. A receiver operating characteristic curve was plotted to determine the optimal cut-off rotator cuff reparability score. RESULTS: Eighty patients (mean age, 61 years; range, 25-84 years; 41 females and 39 males) were recruited. Intra- and inter-observer reliabilities were good to excellent. The number of patients with 0, 1, 2, and 3 risk factors for rotator cuff repair failure were 24, 33, 17, and 6, respectively. Complete repair was performed in all patients without risk factors. Two of the 33 patients with one risk factor and seven of the 17 patients with two risk factors underwent partial repair. One of the six patients with three risk factors underwent complete repair. The area under the curve was 0.894. The optimal cut-off score was two points with a sensitivity of 85.71% and a specificity of 83.33%. CONCLUSION: A rotator cuff reparability score of two was determined to be the optimal cut-off score for predicting the reparability of large or massive rotator cuff tears.

Grip strength after hamate hook excision and reconstruction surgery: A biomechanical cadaveric study.

Fractures of the hamate hook are common among professional athletes. The recommended treatment for this is hamate hook excision. The purpose of this study is to evaluate the hand grip strength after hamate hook resection at different levels. Six cadaver forearm flexor digitorum profundus tendons were loaded with 5- to 15-kilograms force and grip strength was subsequently measured. The same measurements were performed in five hamate hook conditions: normal, one-third, two-thirds, total hamate excision, and after perihamate ligament reconstruction. Multilevel mixed-effect models were used to calculate the scaling ratios after each surgical intervention and compared them to a normal hamate hook. A 25%, 36%, 47% reduction, and 7% increase (107% of baseline) in grip strength was found after one-third, two-thirds, total bone was resected, and after perihamate ligament reconstruction, respectively. The study shows an association between grip strength reduction and the level of hamate hook resection. Perihamate ligament reconstruction is recommended as it restores grip strength to normal.

Anatomic 3D-Printed Endoprosthetic With Multiligament Reconstruction After En Bloc Resection in Giant Cell Tumor of Distal Radius.

A 34-year-old woman was diagnosed with a giant cell tumor of the right distal radius with extensive articular invasion. After en-bloc resection of 5.5 cm of the distal radius, reconstruction was done with three-dimensional printing custom-made distal radius prosthesis. In addition, a multiligament reconstruction was done to prevent postoperative radiocarpal subluxation and imitate the native distal radius. At 18 months, the range of motion was 20° dorsiflexion, 10° palmar flexion, 10° supination, and 60° pronation. Her grip strength was 60% compared with the contralateral side. No complications were seen during this 2-year follow-up. We present the combined 3-dimensional printed custom-made prosthetic with multiligament reconstruction as an innovative method without postoperative complication at 2 years.

Arthroscopic Coracoclavicular Ligament Stabilization Using Coracoid Cortical Suspension in Acute Acromioclavicular Joint Injury; Precision of Drill Tunnel.

Acute acromioclavicular joint separation is a common injury of the shoulder. There are several methods for treating this condition; however, there is no gold standard established. Herein, we propose an arthroscopic method for the treatment of acute acromioclavicular joint separation using a simple cortical suspension device at the coracoid base via a transclavicular-transcoracoidal tunnel and tieing the suture at the clavicle. This method has the advantages of making a precision drilling tunnel using small implants and small stab incisions, with better cosmetic results and less implant irritation.

Arthroscopically Assisted Reduction in a Chronic Locked Posterior Shoulder Dislocation.

Neglected posterior shoulder dislocation is a difficult condition in terms of decision making and surgical technique. Not only the bony deformity but also the soft tissue and patient's underlying disease are of concern. Whether the poor results are associated with a time delay or the treatment method is not clear yet. To date, there is neither a consensus nor treatment guidelines. We describe an arthroscopically assisted reduction and open McLaughlin procedure. The advantage of this procedure is preservation of the soft tissue of the anterior part of the shoulder during the surgical reduction technique for chronic neglected posterior shoulder dislocation cases.

Pre-operative factors correlated with arthroscopic reparability of large-to-massive rotator cuff tears.

BACKGROUND: The purpose of this study is to determine the pre-operative factors that are associated with reparability of the large-sized and massive rotator cuff tears. METHODS: Sixty-six patients were included in this prognostic study. Demographic data, radiographic and MRI parameters were collected. Arthroscopic rotator cuff repair was performed for all included patient. Complete rotator cuff repair was achieved when the tendon covered up at least 50% of the anatomical footprint. The receiver operating characteristic (ROC) curve was analysed to define the cut-off level of each significant factor. RESULTS: Eleven large-sized rotator cuff tears and fifty-five massive rotator cuff tears were defined from MRI. Fifty-four patients were in the complete repair group, and twelve patients were in the partial repair group. The mean duration between MRI and surgery of 5.5 weeks. Reparability was correlated with age, mediolateral (ML) and anteroposterior (AP) tear size, rotator cuff arthropathy, superior migration of humeral head, fatty infiltration and atrophy of the supraspinatus muscle, and fatty infiltration of infraspinatus muscle (p < 0.05). The ROC curve defined a cut-off level of each predicting factor which included age of ≥65 years, mediolateral tear size of ≥36 mm, anteroposterior tear size of ≥22 mm, Hamada's rotator cuff arthropathy of ≥class2, acromiohumeral interval of ≥6 mm, ≥stage3 supraspinatus fatty infiltration, the presence of supraspinatus muscle atrophy, and ≥ stage1 infraspinatus fatty infiltration. In multivariated regression analysis, age, acromiohumeral interval, and anteroposterior tear size were statistically associated with the reparability. The intra- and inter-observer reliabilities were moderate to excellent. CONCLUSION: Age, ML tear size, AP tear size, rotator cuff arthropathy, superior migration of humeral head, fatty infiltration of supraspinatus and infraspinatus muscles and supraspinatus muscle atrophy all correlate with reparability of large to massive rotator cuff tear.

Arthroscopic Synthetic Augmentation in Acute Partial Injury of the Anterior Cruciate Ligament.

Acute partial injury of the anterior cruciate ligament (ACL) is a challenging condition without a standard treatment. Although ACL reconstruction provided a better outcome previously, recent studies have shown that preserving the ACL stump yields promising results in terms of better vascularization, proprioception, and ligamentization. ACL augmentation is becoming more popular. Therefore, we propose a technique to augment an acute partial ACL injury with synthetic suture material to stabilize the unstable cruciate ligament. The suture material acts as a structural tie for ACL healing without any need for external immobilization. This technique is beneficial in preserving the natural ACL stump and autograft, creating a narrow bone tunnel, and providing a good cosmetic outcome.

Arthroscopic Medial Meniscus Root Repair With Soft Suture Anchor Without Posterior Portal Technique.

Medial meniscal root injury is known to cause an increase in tibiofemoral contact pressure and results in early osteoarthritis. There have been many reports on meniscal root repairing techniques, which can be categorized into 2 groups. One is transosseous suture, and the other is anchor suture repair. Both techniques show improvement in not only clinical performance, but also radiographic finding. However, the meniscal root repair procedure must be performed by experienced physicians. Most techniques require a posteromedial portal, which takes time and may even complicate the procedure. The technique proposed in this study provides a simple procedure in which no posteromedial portal is required and a soft anchor suture, a commonly used suture in glenolabral repair, is used. The use of this suture, instead of the conventional anchor suture, is believed to lessen possible injury to the cartilage and results in easier revision surgery.

A survey of opinions regarding wishes toward the end-of-life among Thai elderly.

BACKGROUND: Knowledge of wishes toward the end-of-life is crucial for carrying out high quality palliative care. However, advance directive is not commonly available among Thais, particularly for non-cancerous older patients. OBJECTIVE: The present study aimed to explore Thai older person's wishes toward cares needed at the end-of-life. MATERIAL AND METHOD: A convenience sample of 100 older patients, who attended geriatric clinic at a university hospital in Thailand, was recruited. A 3-page questionnaire developed to suit Thai culture was utilized to elicit opinions concerning circumstances around end-of-life period. RESULTS: All participants were Buddhists with mean age of 75.9 (8.2). Toward the end-of-life, the majority wanted to know the truth about their illnesses and to be free from uncomfortable symptoms. Seventy-five percent did not want "prolong-life" treatments when chance of surviving is slim. Age less than 70 and having education of no more than 6 years were factors associated with being unwilling to prolong suffering with OR of 9.88 (1.20-81.57, p = 0.03) and 3.15 (1.11-8.95, p = 0.03), respectively. Interestingly, fifty-six percent of elderly did not want to die at home. Age less than 70 was the only factor significantly associated with being unwilling to die at home with OR of 2.80 (95% CI = 1.05-7.47, p = 0.04). CONCLUSION: The present study illustrated older persons' opinions in relation to cares at the end-of-life from a Thai perspective, which showed some similarities and differences when compared to western countries. These opinions should be crucial for carrying out optimal and qualitative end-of-life care for older people when advanced care planning is not in place for the individual.