Small volar fragment in the lunate fossa leads to volar tilt loss after volar plate fixation for AO/OTA type-C distal radius fracture.

OBJECTIVES: The relationship between volar fragment size and postoperative volar tilt loss in complete articular distal radius fracture is not well known. In this study, we measured precise radiological parameters to help identify other factors that might contribute to volar tilt loss. MATERIAL AND METHODS: We retrospectively reviewed the radiological examinations and charts of 256 patients with distal radial fracture who underwent volar locking plate fixation between March 2014 and July 2022. Radiological parameters were measured based on preoperative CT and immediate postoperative radiographs. Univariate and multivariate linear regression analysis was performed to identify relevant factors associated with volar tilt loss following volar locking plate fixation. The receiver operating characteristic curve was used to identify the cutoff value of the independent parameters. RESULTS: On univariate analysis, 2 radiologic parameters on preoperative CT (volar fragment length at the lunate fossa, and teardrop angle) and 4 on immediate postoperative X-ray (radial inclination, radial length, capitate shift, and volar tilt) were significantly associated with postoperative volar tilt loss. On multivariate linear regression analysis, the risk of volar tilt loss increased as the capitate moved toward the back of the radial shaft. The cut-off for anteroposterior length in the lunate fossa was 6.5 mm. CONCLUSIONS: AO/OTA type-C distal radius fractures with <6.5 mm anteroposterior length in the lunate fossa had significantly higher rates of malunion with dorsal deformity. In addition, preoperative teardrop angle <37.2 ° and immediate postoperative volar tilt <3.7º are also predictors of postoperative volar tilt loss.

Radiologic and clinical outcomes of an arthroscopic bridging graft for irreparable rotator cuff tears with a modified MasonAllen stitch using a plantaris tendon autograft: a case series with minimum 2-year outcomes.

BACKGROUND: Surgical management of a massive rotator cuff tear (RCT) is always challenging. This study describes the clinical and radiological outcomes of patients who underwent bridging grafts using a plantaris tendon for an irreparable RCT. METHODS: Thirteen patients with a massive RCT were treated with arthroscopic interposition of a folded plantaris tendon autograft between June 2017 and January 2020. For clinical evaluation, a visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score, and range of motion values were collected. For radiographic evaluation, standardized magnetic resonance imaging and ultrasonography were performed to check the integrity of the interposed tendon. RESULTS: A statistically significant improvement at the final follow-up was evident in scores for the VAS (-3.0, P=0.003), ASES (24.9, P=0.002), D ASH (-20.6, P=0.001), and Constant-Murley values (14.2, P=0.010). In addition, significant improvement was shown in postoperative flexion (17.3°, P=0.026) and external rotation (27.7°, P<0.001). In postoperative radiologic evaluations, the interposed tendons were intact at the last examination in 12 of the 13 patients. No complications related to donor sites were reported. CONCLUSIONS: An arthroscopic bridging graft for irreparable RCTs using a modified Mason-Allen stitch and a plantaris autograft resulted in improved short-term radiological and clinical outcomes. Graft integrity was maintained for up to 2 years in most patients. Level of evidence: IV.

Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis.

OBJECTIVES: To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis. DESIGN: Retrospective. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type. INTERVENTION: Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP. MAIN OUTCOME MEASUREMENTS: Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores. RESULTS: The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group. CONCLUSION: Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal Humerus Fractures Treated Using Locking Plate: A Comparison Between Anatomical Reduction and Valgus Bent Locking Plate Fixation After Valgus Reduction.

Introduction: Plate osteosynthesis is preferred for the treatment of proximal humerus fractures (PHFs). However, applying the locking plate flush against the bone may lead to varus malreduction and medial displacement of the humeral head. We hypothesized that slight valgus reduction and valgus bent locking plate fixation against potential varus deformation would yield better results than the traditional plate fixation. Methods: We retrospectively reviewed patients with PHFs treated with locking plate fixation between March 2014 and July 2019. We evaluated changes in the neck-shaft angle (NSA) and humeral head height, as well as the development of complications postoperatively. Clinical outcomes were measured at 1-year post-surgery and at the last follow-up using the American Shoulder and Elbow Surgeons, the Disabilities of the Arm, Shoulder and Hand, and the Constant-Murley scores. Results: A total of 58 patients with PHFs were enrolled in this study. They were divided into the valgus-aligned group (n = 28) and the anatomical group (n = 30). According to radiographic evaluation, immediate postoperative NSA was significantly greater in the valgus-aligned group. Moreover, the NSA measured at the last follow-up was significantly greater the valgus-aligned group. In contrast, the NSA became considerably more varus-aligned in the anatomical group. Conclusion: The appropriate valgus reduction and valgus bending plate fixation could lead to better short-term results and improve the ability of proximal humerus locking plates to prevent varus collapse and fixation failure. Level of Evidence: Level III, retrospective cohort design.

Anterosuperior approach versus deltopectoral approach for reverse total shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Surgical approach is an important factor that may affect the outcomes of reverse total shoulder arthroplasty (RTSA). The most common approaches for RTSA are anterosuperior (AS) and deltopectoral (DP). However, controversy exists on which surgical approach is better. This meta-analysis aimed to compare both approaches in terms of radiological and clinical outcomes and complications. METHODS: We searched PubMed, Embase, and Cochrane Library databases for studies that compared the postoperative outcomes of the AS and DP approaches for RTSA. After screening and quality assessment of the articles, we obtained two randomized controlled trials and four retrospective comparative studies. We analyzed the radiologic outcomes, functional outcomes, and complications between the two approaches. The standardized mean difference and odds ratio were used to analyze the differences in outcomes between the two surgical approaches. Statistical significance was set at P < 0.05. RESULTS: The incidence rate of glenoid implant loosening was significantly (P = 0.04) lower in the AS group than that in the DP group. In terms of forward flexion after surgery, the DP approach produced significantly (P = 0.03) better outcomes compared with the AS approach. There were no significant differences in radiological outcomes or other complication rates between the two approaches. CONCLUSION: As a result of this meta-analysis, one of the two approaches did not bring a better result than the other. One has strength for better forward flexion and the other for a lower glenoid loosening rate. With this in mind, it is recommended to use the approach that the surgeon is most familiar with.

Comparison of the Complications, Reoperations, and Clinical Outcomes between Open Reduction and Internal Fixation and Total Elbow Arthroplasty for Distal Humeral Fractures in the Elderly: A Systematic Review and Meta-Analysis.

Distal humeral fractures are challenging injuries seen in the elderly. Open reduction and internal fixation (ORIF) are the gold standard treatments. Total elbow arthroplasty (TEA) is an alternative to ORIF. This study aimed to pool and analyze the outcomes and complications in elderly patients with distal humeral fractures treated with either ORIF or TEA by performing a meta-analysis. We searched the PubMed, Embase, Google Scholar, and Cochrane Library databases for studies that compared the clinical and functional outcomes of ORIF and TEA in patients aged 60 years or older. After screening and performing a quality assessment of the articles, we obtained one randomized control study and nine retrospective comparative studies. The odds ratio and standardized mean difference were used to analyze the differences in outcomes between the two surgical options. In terms of the flexion/extension arc, TEA produced significantly better outcomes than ORIF (p = 0.02). The rates of reoperation and elbow stiffness were significantly lower in the TEA group than in the ORIF group (p = 0.003 and p = 0.04, respectively). However, the functional scores and other ranges of motion (flexion, loss of extension, pronation, supination) after surgery were similar between the two groups. The outcomes from the present meta-analysis can provide guidance when selecting a surgical option for distal humeral fractures in the elderly.

Arthroscopic Reduction and Fixation of Coronoid Fractures with Bending K-Wire: A New Technique.

The ulnar coronoid process plays a key role in maintaining elbow stability; however, there is no gold standard treatment for ulnar coronoid process fractures. We present a novel surgical technique, arthroscopic reduction and bent K-wire fixation, for type II and III coronoid process fractures according to the O'Driscoll classification. Five patients were treated and retrospectively reviewed between January 2016 and December 2019. All the surgeries were performed by a single surgeon. We evaluated clinical outcomes by evaluating a range of motion, disability of arm, shoulder, and hand (DASH) score, Mayo Elbow Performance score (MEPS), and radiographic images. Intraoperative and postoperative radiographs showed that the fractures healed well and were satisfactorily fixed. The average elbow extension/flexion was -3/130, with an average DASH score of 2.42 and MEPS of 97. Coronoid process fractures can be treated successfully with arthroscopic reduction and fixation of bent K-wire, which allows more rigid fixation and early functional exercise, resulting in good outcomes without special tools.

Bi-columnar locking plate fixation through a combined medial and lateral approach for the treatment of low transcondylar fractures of the distal humerus in the elderly.

BACKGROUND: Low transcondylar fractures (LTFs) of the distal humerus are relatively uncommon elbow injuries in elderly patients after low-energy injuries. Although there is still debate regarding the method of fixation, several surgeons prefer bi-columnar fixation using pre-contoured locking plates. However, posterior approaches, which are usually used to perform the above procedure, have disadvantages, such as ulnar nerve neuropathy, damage to the extensor mechanism, and the need for general anesthesia. To solve these problems, the authors designed a combined medial and lateral approach. The purpose of this study was to present the outcomes of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of LTFs of the distal humerus in the elderly.  METHODS: A total of 46 patients diagnosed with distal humeral fractures between May 2017 and April 2020 were included. Thirty patients were excluded, and 16 patients who underwent open reduction and internal fixation by the medial and lateral approach were selected. We carried out all the surgeries under brachial plexus anesthesia. The clinical outcomes were assessed based on the visual analog scale (VAS) score, Mayo elbow performance score (MEPS), disabilities of the arm, shoulder, and hand (DASH) score, and range of motion (ROM) of the elbow joint. Standardized radiographs were obtained at 3, 6, and 12 months after surgery and at the last follow-up visit to evaluate for bony union and to check for complications, such as ulnar nerve neuropathy and heterotopic ossification. RESULTS: The mean age was 81 years (range, 65-91 years). Bony union was achieved in 15 out of 16 patients. The mean VAS score was 2.1 (range, 0-6), the mean MEPS was 84.4 (range, 70-100), and the mean DASH score was 20.6 (range, 9.5-33.6). There were three complications including reduction loss, skin necrosis, and stiffness of the elbow. There was no ulnar nerve neuropathy. The post-operative ROM was 100 degrees or higher in all cases, which did not cause any impairment in daily life. CONCLUSION: LTFs of the distal humerus in the elderly can yield satisfactory results with bi-columnar internal fixation through a combined medial and lateral approach.

Risk Factors for Periprosthetic Joint Infection after Shoulder Arthroplasty: Systematic Review and Meta-Analysis.

Periprosthetic joint infection (PJI) after shoulder arthroplasty is a devastating complication that requires several additional surgeries. The purpose of this study was to assess the evidence regarding risk factors for PJI and identify those that contribute to infection by performing a meta-analysis. We searched the PubMed, Embase, and Cochrane Library databases for studies that assessed the risk factors for infection after shoulder arthroplasty. After performing screening and quality assessment on the articles, we obtained two case-control studies and six retrospective cohort studies (total of 420 infected cases and 28,464 controls). Review Manager 5.4 was used to assess the heterogeneity and odds ratio for 20 different factors that broadly included demographic factors, perioperative factors, and comorbidities. Factors that are markedly associated with PJI after shoulder arthroplasty were male sex, operation history, revision arthroplasty, acute trauma, and non-osteoarthritis as a preoperative diagnosis. Statistical analysis revealed that diabetes mellitus, liver disease, alcohol overuse, iron-deficiency anemia, and rheumatoid arthritis were risk factors for PJI after shoulder arthroplasty. The result of analysis shows that several specific factors can be targeted to prevent infections after shoulder arthroplasty. Surgeons should consider the risk factors and perform the appropriate management for patients.

Use of an Arthroscopic Bridging Graft for Irreparable Rotator Cuff Tears With the Modified Mason-Allen Stitch Using a Tendon Autograft.

We describe a technique for treating irreparable rotator cuff tears (RCTs) by bridging grafts with a long tendon autograft. In this technique, the plantaris tendon is harvested and prepared in a Y-shaped graft. The folded end of the graft is anchored to the greater tubercle and the other 2 limbs are fixed to rotator cuff tissue using modified Mason-Allen stitches. The autograft can decrease the tension on the repair of irreparable RCTs and has biological superiority. Our clinical experience indicates this technique will bring superior integrity to irreparable RCT repairs.

Characteristics of Elbow Dislocation in Patients with Preexisting Cubitus Varus.

BACKGROUND: The aim of this study was to investigate the clinical presentations, patterns of soft-tissue injuries, and outcomes of treatment of elbow dislocations in patients with preexisting cubitus varus. METHODS: Four cases of elbow dislocation in patients with preexisting cubitus varus, which were treated at 3 residency training hospitals, were retrospectively reviewed. Soft-tissue injury patterns were investigated using magnetic resonance imaging (MRI). Clinical outcomes were assessed at an average of 50.8 months (range, 34-82 months) after treatment using the Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. RESULTS: The mean patient age was 49.5 years (range, 33-57 years). All patients had a posteromedial elbow dislocation, which was an indirect injury caused by a fall onto an outstretched hand. One patient had failed closed reduction; 3 others had redislocation or gross instability after closed reduction. Significant tears of the lateral collateral ligament complex and common extensor group were shown in MRI. All patients had surgical treatment including lateral complex repair only (n = 2), repair of both sides' complexes (n = 1), and corrective osteotomy with lateral complex repair (n = 1). At the final follow-up, the mean MEPS was 92.5 ± 8.7 and the mean QuickDASH score was 4.5 ± 6.4. CONCLUSIONS: Elbow dislocation in patients with preexisting cubitus varus may present as posteromedial dislocation with acute instability. Surgical treatment of this injury led to acceptable clinical outcomes.

Myositis ossificans causing ulnar neuropathy: a case report.

Myositis ossificans (MO) can compress peripheral nerves and cause neuropathy. We herein describe a patient with ulnar neuropathy caused by MO at the medial elbow. A 28-year-old man with a drowsy mentality and multiple organ damage following a traffic accident was admitted to our hospital. After 3 weeks of postoperative care, the patient's mental status recovered. However, he complained of severe sharp pain in his left medial forearm and fourth and fifth fingers. He exhibited weak fifth finger abduction and wrist adduction. Severe elbow joint pain was elicited during range-of-motion testing of his left elbow. Ultrasound also showed an edematous, enlarged, hypoechoic ulnar nerve lying above the MO, and the MO outwardly displaced the ulnar nerve. Elbow radiographic examination, computed tomography, and magnetic resonance imaging revealed MO development and compression of the left ulnar nerve. The patient underwent surgery; the following day, his left medial forearm pain completely disappeared with slight improvement in the motor weakness of fifth finger abduction. Ultrasound is a useful tool to easily evaluate the presence of MO and compression of peripheral nerves caused by MO.

Patterns of injury mechanism observed in terrible triad.

INTRODUCTION: The purpose of this study was to classify the injury mechanism of terrible triad (TT) and suggest a treatment method according to the mechanism. MATERIALS AND METHODS: Forty TTs with magnetic resonance imaging (MRI) scans and 3-dimensional computed tomography (3D CT) were enrolled. 3D CT scans of coronoid fractures were used for classifying into O'Driscoll type representing injury mechanisms and measuring sizes. In MRI scans, lateral collateral ligament complex (LCLC) injuries were classified into distraction (D) type caused by varus force and stripping (S) type caused by forearm external rotation force. Using these findings, possible injury mechanisms were speculated and classified into groups. Characteristic soft tissue injury patterns of collateral ligaments and overlying muscles, direction of dislocation in simple radiographs, and the amount of involvement of radial head fracture were investigated. Ulnar- and radial-side instabilities of soft tissues were newly defined and investigated. RESULTS: There were 29 (73%) cases by posterolateral external rotation (PLER), 5 (13%) cases by posteromedial external rotation (PMER), and 6 (14%) cases by posteromedial internal rotation (PMIR). Simple radiographs showed all posterolateral dislocations in PLER TT compared to posteromedial or pure posterior dislocations in PMER or PMIR TT. Regarding LCLC and overlying extensor muscle, they were all completely torn with D type in all PLER compared to D type in PMER or PMIR. The ulnar collateral ligament was spared in 5 (17%) cases among 29 PLER in contrast to complete rupture in all PMER and PMIR. In PLER, PMER, and PMIR, involvement ratios of radial head fracture were 82% (range, 27%-100%), 61% (range, 25%-100%), and 61% (range, 25%-100%), respectively, and sizes of coronoid fractures were 7 mm (range, 1-14 mm), 6 mm (range, 2-11 mm), and 10 mm (range, 2-16 mm), respectively. In PLER, PMER, and PMIR, percentages of ulnar-side instabilities were 17%, 20%, and 17%, respectively, and those of radial-side instabilities were 59%, 60%, and 83%, respectively. CONCLUSIONS: TT is caused by at least 3 mechanisms (PLER, PMER, and PMIR) with characteristic soft tissue injuries and fracture patterns. PLER is the main mechanism of injury. It is always observed in the form of posterolateral dislocation on simple radiographs compared with pure posterior or posteromedial dislocation of PMER or PMIR. It should be managed individually based on injury mechanisms presenting different instability patterns.

How Much Will High Tension Adversely Affect Rotator Cuff Repair Integrity?

PURPOSE: To suggest a cutoff value of tension related to retear of a repaired chronically contracted rotator cuff and to analyze the correlation between predictive factors and integrity of repair in large to massive contracted rotator cuff tears (RCTs). METHODS: We analyzed arthroscopic rotator cuff repairs for large to massive (>3 cm) contracted RCTs, not amenable to complete repair by standard means with meticulous release, with a minimum of 1 year follow-up. An intraoperative procedure was designed for the estimation of repair tension using a tensiometer. Clinical and radiological findings were compared between the healed group and the retear group, and magnetic resonance imaging was performed ∼1 year postoperatively for the evaluation of integrity of the repair site. The receiver operating characteristic curve was used to identify the cutoff value of the independent factors. Factors affecting postoperative retear were examined with multivariate analysis. RESULTS: Fifty patients were enrolled in this study and divided into the healed group (31 patients) and the retear group (19 patients) according to the follow-up magnetic resonance imaging findings. Significant results showed that tension (5.13 < 95% confidence interval [CI] < 58.15, P < .001) and acromiohumeral interval (AHI) (1.13 < 95% CI < 33.10, P = .013) were important factors for the integrity of rotator cuff repair. The cutoff value of tension was 35 N, and an AHI <6.6 mm may also be considered a predictor of retear. An occupation ratio of the tension >35 N was the strongest predictor of retear, with an area under the curve of 0.799, sensitivity of 84.2%, and specificity of 67.7% (accuracy = 76.0%). CONCLUSIONS: The integrity of a large to massive rotator cuff repair is strongly related to the tension to reach the articular margin of the footprint and AHI. We found that the possibility of retear increases when tension ≥35 N is required. AHI <6.6 mm may also be considered a predictor of retear. LEVEL OF EVIDENCE: Level III, retrospective cohort design.

Medial Buttress Plating for Humerus Fractures With Unstable Medial Column.

The purpose of this study was to report surgical tips and techniques on the use of additional medial buttress plate fixation in proximal humeral fractures with unstable medial column restoration after lateral locking compression plate fixation. Between April 2011 and January 2017, 17 patients with medial cortical deficiency were treated using this technique. The average follow-up period was 30 (range, 12-81) months. Successful fracture healing was achieved in all 17 cases. The mean neck-shaft angle change was 1.33 degree (range, 0-7.4 degree). Anterior glenoid rim erosion occurred in 1 patient. No avascular necrosis of the humeral head or significant loss of reduction, and no implant failure or screw perforation occurred. In the first part of this study, we described in detail the indications and surgical technique applied to these fractures. In the second part, we reviewed the clinical and radiographic outcomes of these patients. Supplemental medial buttress plate fixation after lateral locking compression plate fixation was effective in preventing varus collapse and implant failure for proximal humeral fractures with an unstable medial column.

Causes and treatment outcomes of revision surgery after open reduction and internal fixation of tibial plateau fractures.

PURPOSE: Treatment of a tibial plateau fracture (TPF) remains controversial and is generally challenging. Many authors report good results after conventional open reduction and internal fixation in TPF, but complications still occur. This study analyzed causes and outcomes of revision surgery for TPF. The usefulness of a flow chart for revision surgery in TPF was also evaluated. METHODS: We reviewed all patients who underwent more than two operations for a TPF between 2008 and 2015. Finally, 24 cases were selected and retrospectively investigated. The medial tibial plateau angle and proximal posterior tibial angle were radiologically evaluated. The American Knee Society Score (AKSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), and bone union time were investigated after surgery. RESULTS: Revision surgery for infection was performed in eight cases, for nonunion in six cases, for posttraumatic arthritis (with total knee arthroplasty) in six cases, and for other reasons in four cases. The mean clinical AKSS at final follow-up was 87.3 ± 5.3 (range, 75-95), the functional AKSS was 81.9 ± 5.5 (range, 70-90), the WOMAC score was 9.9 ± 3.1 (range, 5-16), the flexion ROM was 119.8 ± 16.5° (range, 100-150°), and the extension ROM was 2.5 ± 3.3° (range, 0-10°). CONCLUSIONS: Although complications cannot be avoided in some cases, good clinical outcomes are possible when patients are divided according to the presence or absence of infection, with selection of appropriate revision surgery as shown in the flow chart. If an infection is present, treatment should be based on the presence or absence of bone union. If there is no infection, treatment should be based on the presence or absence of nonunion, post-traumatic arthritis, malunion, or immediate post-operative malreduction.