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Objective: This study aimed to introduce a new wound management method combining negative pressure wound therapy and polymethylmethacrylate sealant for Gustilo type III open tibia fractures and to evaluate its clinical outcomes., Methods: Among 186 patients who visited our institution for the treatment of open tibia fractures between January 2016 and December 2019, 20 male patients who sustained Gustilo type III open tibia fractures and were compelled to undergo delayed flap coverage using negative pressure wound therapy combined with polymethylmethacrylate sealant due to initial critical condition were enrolled in this study. We retrospectively investigated patients' demographics, interval between the injury and flap coverage, number of negative pressure wound therapy changes, flap survival, bone union time, and infection-induced complications., Results: The mean interval from injury until flap coverage was 27.8 (range, 8-63) days. Most soft-tissue defects were reconstructed using free flaps (14/20, 70%); the anterolateral thigh flap was the most frequently used flap (12/20, 60%) in this study. Among 20 flaps trans- ferred, 16 flaps (80%) survived uneventfully, 1 flap (5%) developed partial necrosis, and 3 flaps (15%) failed. The mean follow-up period was 22.7 (range, 12- 43) months. A total of 17 patients (85%) achieved tibia fracture union. The mean bone union time was 31 (range, 12-81) weeks. With regard to infection-induced complications, 3 patients (15%) developed osteomyelitis and no patient showed superficial surgical site infection., Conclusion: Combination therapy using negative pressure wound therapy and polymethylmethacrylate sealant serves as a useful and reliable therapeutic strategy for wound management of Gustilo type III open tibia fractures, especially when delayed soft-tissue recon- struction is unavoidable. Corresponding author: Yoo Joon Sur yoojoon@catholic.ac.kr Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License., Level of Evidence: Level IV, Therapeutic Study.

Background: Acromioclavicular (AC) joint dislocation is common among shoulder injuries, and various surgical methods have been introduced for effective ligament reconstruction. Reconstruction of the coracoclavicular (CC) ligament in the anatomical position using autologous tendons is a recent surgical trend. This study is to report clinical and radiologic results of reconstruction of the CC ligament using an autologous palmaris longus tendon interweaved with Mersilene tape (PLMT) with a minimum 2-year follow-up., Methods: This retrospective study analyzed 76 patients (mean age, 43.4 ± 11.2 years) with AC joint dislocation treated by reconstruction of the CC ligament with PLMT, from March 2004 to February 2017. The mean follow-up period was 28 ± 6.7 months (range, 24-66 months). The Visual Analog Scale (VAS) for pain assessment, American Shoulder and Elbow Surgeons rating scale (ASES), and Constant Score (CS) were used to evaluate clinical outcomes at the preoperative and the final follow-ups. CC and AC distances were measured using anteroposterior (AP) X-ray preoperatively and at the final follow-up for radiologic outcomes. Complications were also assessed., Results: The mean preoperative VAS for pain, ASES, CS were 5.7 ± 0.7, 77.1 ± 6.2, and 61.5 ± 5.2, respectively. These scores at the final follow-up improved to 2.1 ± 0.5, 90.9 ± 4.3, and 94 ± 7.0, respectively (p = 0.043, p <  0.001, p <  0.001). The mean preoperative CC and AC distances were 16.49 ± 3.73 mm and 13.84 ± 3.98 mm, respectively. The final follow-up CC and AC distances were 9.29 ± 2.72 mm and 5.30 ± 2.09 mm, respectively (p <  0.001, p <  0.001). Although a slight re-widening of the CC distance occurred in 10 patients (13.1%), most patients regained full range of motion of the affected shoulder at the final follow-up., Conclusion: The CC ligament reconstruction with PLMT for the treatment of AC joint dislocation showed good clinical and radiological results. This technique could be a good alternative treatment for AC dislocations., (© 2022. The Author(s).)

Rationale: Pan-carpal dissociation is very rare injury and there is little information as to diagnosis, treatment, and prognosis of this injury., Patient Concerns: A 35-year-man presented to our hospital with severe pain and swelling of the left wrist and forearm after slipping and falling while riding a motorcycle., Diagnosis: The wrist simple radiographs demonstrated unrecognizable severe fracture-dislocation of the carpal bones concomitant with fractures of the radioulnar shaft. Three-dimensional computed tomography revealed a capitate fracture-dislocation, as well as hamate dislocation, lunotriquetral (LT), and scapholunate (SL) dissociation. These findings suggested pan-carpal dissociation., Interventions: To prevent compartment syndrome, fasciotomy, carpal tunnel release, and open reduction and plate fixation for both bone fracture were performed first. Then, for pan-carpal dissociation, the capitate, carpometacarpal joint (CMCJ), and hamate were reduced and fixed first. Then, the SL, LT, and other intercarpal ligaments were repaired. Finally, additional trans-carpal pins to reinforce the ligament repair and 2.0 mm plate to buttress the third CMCJ were fixed. The patient was instructed to begin gentle range of motion exercises of the wrist with pins from four weeks after surgery and all pins were removed at six weeks postoperatively., Outcomes: 12 months after the operation, the patient exhibited almost full range of motion with mild pain with VAS (Visual analogue scale) 1-2 at rest and VAS 3-4 with effort. Quick DASH (the disabilities of the arm, shoulder and hand) score was 25 and modified Mayo score was 70. The radiographs demonstrated union of the radioulnar shaft, and the carpal bone alignment was successfully maintained., Lessons: Pan-carpal dissociation can be diagnosed in patients with capitate fracture-dislocation, hamate dislocation, LT, and SL dissociation. This pattern of injury is very rare and the authors recommend reduction and fixation of the distal carpal row, followed by the proximal row to facilitate an easy approach to the distal carpal row. Although it is very severe injury, rigid anatomical fixation and an early rehabilitation can lead to favorable functional outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: There remains no consensus regarding which repair technique provides the most optimal results for unstable distal clavicle fractures., Purpose: To compare radiologic and clinical outcomes between locking plate fixation and anatomic coracoclavicular (CC) ligament reconstruction for patients with unstable distal clavicle fractures., Study Design: Cohort study; Level of evidence, 3., Methods: The study included 41 patients with Neer type 2B distal clavicle fracture. In group A (n = 15), patients were treated using CC ligament reconstruction with autologous palmaris longus tendon, artificial tape, and Steinmann pin fixation; in group B (n = 26), patients were treated using anatomic locking plate fixation. All patients had a minimum 2 years of follow-up. CC distance and arthrosis of the acromioclavicular joint were assessed radiographically. Clinical outcomes-including range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons rating scale, and Constant score-were compared between the groups using the paired Student t test and Fisher exact test., Results: Bone union was attained in all patients. In both groups, the CC distance decreased significantly from presurgery to final follow-up: group A, from 16.25 ± 4.75 to 7.66 ± 2.61 mm ( P < .001); group B, from 17.3 ± 4.07 to 9.33 ± 2.01 mm ( P < .001). The final CC distance was significantly greater in group B (7.66 vs 9.33 mm in groups A and B, respectively; P = .028). Osteoarthritis of the acromioclavicular joint occurred in 13 of 41 patients (3 in group A and 10 in group B). At final follow-up, there was no statistical significance between the groups in range of motion, and clinical outcome scores were satisfactory in both groups, with no statistical difference between them., Conclusion: Anatomic locking plate and anatomic reconstruction of the CC ligament showed good clinical results, so both techniques can be considered reliable for restoring stability. However, CC ligament reconstruction had better CC distance on radiologic assessment and did not require removal surgery, so it may be the preferable surgical option to treat unstable distal clavicle fractures (Neer type 2B)., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Abstract: The stability and longevity of the prosthesis after revision total elbow arthroplasty (TEA) are greatly influenced by the reconstruction of bone defects around the distal humerus and proximal ulna. This study evaluated the clinical and radiological results of reconstruction of a large bone defect using an autogenous fibular strut and iliac bone graft in revision TEA.This retrospective study reviewed 10 patients who underwent revision TEA with autogenous fibular strut and iliac corticocancellous bone graft between March 2007 and May 2016. Range of motion (ROM), Visual Analog Scale (VAS), and Mayo Elbow Performance Score were used to evaluate clinical outcomes at the final follow-up. Plain radiographs were reviewed for bone union and the presence of re-loosening or for the presence of peri-prosthetic fractures.At the final follow-up, the ROMs of the elbow was 102.5° (range, 90-120°) from extension to flexion, 60.0° (range, 40-80°) in pronation, and 58.5° (range, 35-80°) in supination. The mean preoperative VAS and Mayo Elbow Performance Score were 5.1 and 46.5, and theses scores were improved to 2.6 and 79.0, at the final follow-up (P < .05). Union of the grafted bone with the distal humerus was achieved at an average of 4.5 months (range, 3-6 months). Re-osteolysis recurred in 2 cases, and additional surgery for bone grafting was performed in 1 case.Autogenous fibular strut bone grafting is an effective technique when revision TEA has large bone defects around the prosthesis resulting in a relatively stable prosthesis fixation and good union rate with a satisfactory clinical outcome after TEA revision., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were (1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, (2) to estimate the risk factors of primary RNP, and (3) to evaluate whether early exploration is helpful for radial nerve recovery., Methods: This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low-energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated., Results: There were 31 cases of radial nerve palsy among 162 patients: 27 in the high-energy humeral shaft fracture group and 4 in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases recovered (88.9%). The other 9 radial nerves were not explored, and only 5 cases recovered (55.6%)., Conclusions: This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in high-energy humeral shaft fracture. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures., Methods: We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group., Results: There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6-210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups., Conclusions: This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.

Rationale: Distal radius fracture with simultaneous ipsilateral radial head fracture is a very rare pattern of injury. This type of injury is referred to as 'radius bipolar fracture'. Treatments for this injury pattern can be challenging because both the wrist and elbow need to be considered. There are currently no guidelines for the treatment of this specific type of injury. We report two cases of this unusual pattern of injury treated in our hospital., Patient Concerns: Case 1 was a 78-year-old female patient and case 2 was a 19-year-old female patient who visited our emergency department with left elbow and wrist pain after slipping and falling., Diagnosis: Plain radiography and computed tomography revealed radius bipolar fracture. Case 1 had an AO type C3 distal radius fracture, a Mason type III radial head fracture. Case 2 had an AO type B2 undisplaced distal radius fracture and a Mason type III radial head fracture., Interventions: In case 1, open reduction and internal fixation (ORIF) was performed for the distal radius fracture and radial head replacement arthroplasty for the radial head fracture. In case 2, distal radius fracture was treated conservatively and ORIF was performed for the radial head fracture., Outcomes: Bony union as achieved in both cases. At 1-year follow-up, case 1 showed slight limited range of motion of the wrist. Case 2 showed no radius shortening and full range of motion of the wrist and elbow. The Quick disabilities of the arm, shoulder and hand score was 18 and 16, respectively., Lessons: After this type of injury, the radius length can be changed, and as a result, ulnar variance can be affected. When radial head replaced is considered, it would be better to operate on the wrist first, and then perform radial head replacement. In this way, radiocapitellar overstuffing or instability can be prevented. However, if ORIF is planned for proximal radius fracture, either the proximal or distal radius can be fixed first. Surgeons should try to preserve radial length during treatment to optimize patient outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The present study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and hip fractures using a large-scale nationwide population-based cohort that is representative of the Republic of Korea. We determined the risks of hip fractures in individuals with prediabetes and T2DM with different diabetes durations, and compared them with the risks of hip fractures in individuals without T2DM., Methods: A total of 5,761,785 subjects over 50 years old who underwent the National Health Insurance Service medical checkup in 2009-2010 were included. Subjects were classified into 5 groups based on the diabetes status; Normal, Prediabetes, Newly-diagnosed T2DM, T2DM less than 5 years, and T2DM more than 5 years. They were followed from the date of the medical checkup to the end of 2016. The endpoint was a new development of hip fracture during follow-up. The hazard ratios (HRs) and 95% confidence intervals (CIs) of hip fractures for each group were analyzed using Cox proportional hazard regression models after adjusting for age, sex, smoking, alcohol drinking, regular exercise, body mass index, hypertension, dyslipidemia, and chronic kidney disease., Results: The HRs of hip fractures were 1 in the Normal group, 1.032 (95% CI: 1.009, 1.056) in the Prediabetes group, 1.168 (95% CI: 1.113, 1.225) in the Newly-diagnosed T2DM2, 1.543 (95% CI: 1.495, 1.592) in the T2DM less than 5 years and 2.105 (95% CI: 2.054, 2.157) in the T2DM more than 5 years. The secular trend of the HRs of hip fractures according to the duration of T2DM was statistically significant (P < .001). Subgroup analyses also showed the same increasing pattern of the HRs of hip fractures according to the duration of T2DM in both sexes and all age groups (50-64 years, 65-74 years, over 75 years)., Conclusions: In summary, this large-scale, retrospective, longitudinal, nationwide population-based cohort study of 5,761,785 subjects demonstrated that the risks of hip fractures started to increase in prediabetes and was associated linearly with the duration of T2DM. The secular trend of risks of hip fractures according to the duration of T2DM was consistent in both sexes and all age groups., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Locked posterior fracture-dislocation of the shoulder (LPFDS) is a very rare injury that occurs predominantly in young patients following high-energy trauma. The long-term outcome of the treatment of this injury is often poor. This study sought to present the characteristics of injury, discuss the pathological anatomy, and to report the treatment outcomes of our case series., Methods: Between January 2012 and May 2018, a total of 234 patients who underwent surgical treatment for proximal humerus fractures were reviewed. Among them, six patients (mean age, 54.7 years; range, 35-76 years) with LPFDS were included in this study. Four patients were treated with open reduction and internal fixation (ORIF) with locking plates, one with hemiarthroplasty, and one with reverse total shoulder arthroplasty. Clinical results were evaluated by Constant, American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores and radiologic evaluation was conducted using follow-up radiographs., Results: The mean length of follow-up was 26.2 months (range, 12-54). The mean Constant, ASES, and VAS scores were 66.7, 65.5, and 2.2, respectively. Four patients who underwent ORIF achieved bony union, but avascular necrosis (AVN) of the humeral head was observed in two patients. No complications were observed in the patients who underwent arthroplasty surgery until final follow-up., Conclusions: In the treatment of LPFDS, replacement arthroplasty can produce predictable results. The approach of ORIF may be considered as a first choice of treatment in young patients but is sometimes correlated with postoperative complications such as AVN and the functional outcomes may be unpredictable. Therefore, patients should undergo careful diagnosis and treatment of this type of injury., Competing Interests: Conflict of interest None., (Copyright © 2020 Korean Shoulder and Elbow Society.)

In scaphoid nonunion, pseudarthrosis and sclerotic change occur at the nonunion site. These changes make a distal fragment look like a trapezium on plain radiographs and we called this phenomenon the double trapezia sign. The purpose of this study was to estimate the diagnostic reliability of the double trapezia sign and its clinical and prognostic implications for the scaphoid nonunion.A retrospective review of 124 patients who underwent surgical treatment because of scaphoid nonunion between January 2007 and December 2017 was performed. Two hand surgeons and 1 musculoskeletal radiologist reviewed preoperative plain radiographs independently. Each observer evaluated the plain radiographs in 2 separate sessions at least 3 weeks apart to assess intraobserver and interobserver reliabilities of the double trapezia sign. To assess clinical and prognostic implications of the double trapezia sign, the patients were divided into the positive and nonpositive groups, and several variables such as age, sex, duration of nonunion, size of the distal fragment, avascular necrosis (AVN) of the proximal fragment, type of bone graft, healing time, and failure rate were compared between the 2 groups.The kappa values of intraobserver and interobserver reliabilities were >0.8, corresponding to almost perfect agreement. There were 58 patients in the positive group and 66 patients in the nonpositive group. The mean duration of nonunion was 38.5 months in the positive group and 12.2 months in the nonpositive group (P < .001). The size of distal fragment was 49.6% and 60.9%, respectively (P < .001). The AVN of proximal fragment was 24.1% and 54.5%, respectively (P = .001). The mean healing time was 4.1 and 6.4 months, respectively (P < .001). The failure rate was 13.8% and 27.3%, respectively (P = .066).In conclusion, the double trapezia sign is a valuable radiographic sign of scaphoid nonunion. The double trapezia sign is easily identifiable on plain radiographs and has excellent intra- and interobserver reliabilities. The positive double trapezia sign implies mid-waist nonunion, long duration of nonunion, less possibility of AVN, and favorable postoperative prognosis.

Effective engineering approaches for cartilage regeneration involve a combination of cells and biomaterial scaffolds. Multipotent mesenchymal stem cells (MSCs) are important sources for cartilage regeneration. Atelocollagen provides a suitable substrate for MSC attachment and enhancing chondrogenic differentiation. Here, we assessed the chondrogenic potential of adipose tissue derived human MSCs (hMSCs) mixed with atelocollagen gel. We observed cell attachment, viability, and microstructures by electron microscopy over 21 days. The levels of Sox9, type II collagen, aggrecan, type I collagen, Runx2, type X collagen, ALP, Osterix, and MMP13 were measured by RT-qPCR. Cartilage matrix-related proteins were assessed by enzyme-linked immunosorbent assay (ELISA), histology, and immunohistochemistry. hMSCs of all groups exhibited well-maintained cell survival, distribution and morphology. Abundant type II collagen fibers developed on day 21; while Sox9, type II collagen, and aggrecan expression increased over time in the atelocollagen group. However, type I collagen, RUNX2, type X collagen (CoL10A1), Osterix, and ALP were not expressed. These results corroborated the protein expression detected by ELISA. Further, histological analysis revealed lacunae-like structures, while staining demonstrated glycosaminoglycan accumulation. Cumulatively, these results indicate that atelocollagen scaffolds improve hMSC chondrogenic differentiation and are a potential approach for cartilage regeneration.

Background: The pattern of transcondylar fracture of the humerus is unique and the incidence rate is very low. Stable internal fixation may be difficult to achieve, and complications have been reported at a higher rate. The purpose was to report the outcomes of open reduction and internal fixation (ORIF) for transcondylar fractures of the humerus., Methods: Seventeen patients were included between January 2014 and December 2017. ORIF was performed using anatomic distal humerus plates. Results were evaluated by range of motion, Mayo Elbow Performance Score (MEPS), and complications. We analyzed the results according to ulnar nerve transposition status and fixation pattern., Results: The mean range of elbow motion was 117° flexion and 20° extension. The MEPS was excellent in 12, good in 3, fair in 1, and poor in 1. There were in total 5 cases of complications among 17 patients: 1 with nonunion, 1 with ulnar neuropathy, 2 with delayed union, and 1 with heterotopic ossification. The results according to ulna nerve transposition and fixation pattern showed no difference., Conclusions: For reliable and good results, rigid fixation using anatomic plates and appropriate immobilization of the fracture site are key factors in the treatment. In our case series, the overall outcome was good and there were 2 major complications. The ORIF using anatomic plates can be a reliable treatment option for transcondylar humeral fractures., (© 2020 The Authors.)

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

Rationale: Most pediatric distal radius fractures are effectively treated nonoperatively; however, operative intervention is indicated in patients with open and highly unstable fractures, in those with concomitant neurovascular injuries and in patients whom soft tissue interposition between fracture fragments precludes anatomical reduction. Notably, soft tissue interposition between fracture fragments is diagnostically challenging. Surgeons must be mindful of this rare complication for early detection and prompt treatment., Patient Concerns: A 14-year-old boy presented to the emergency department with left wrist pain after falling from a bicycle. Plain radiography and computed tomography revealed a displaced Smith fracture, which was irreducible by closed reduction, necessitating open reduction and volar plate fixation. The patient reported inability to extend his thumb at his 6-week postoperative follow-up visit., Diagnosis: Ultrasonography showed extensor pollicis longus (EPL) tendon entrapment near the fracture site., Interventions: A second operation was performed 10 weeks after the first surgery, and intraoperative exploration revealed EPL tendon entrapment. The EPL tendon was torn to shreds; therefore, extensor indicis proprius tendon transfer was performed for EPL tendon reconstruction., Outcomes: The patient's thumb motion was completely restored after the second operation., Lessens: EPL tendon entrapment in a pediatric Smith fracture is rare. Signs of EPL tendon entrapment include inability to perform active thumb extension, dorsal wrist pain radiating along the course of the EPL tendon, which is exacerbated by thumb flexion, a tenodesis effect elicited on thumb examination, and difficulty in anatomical fracture reduction. Surgical exploration of the EPL tendon is warranted in patients presenting with any of these signs following attempted reduction of a Smith fracture.

Background: The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction., Methods: Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015)., Results: One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction., Conclusions: The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.

Background: Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle., Methods: Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted., Results: An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it., Conclusions: The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

Rationale: Large soft tissue defects on the lower back represent a treatment challenge. Among a variety of reconstructive procedures, the latissimus dorsi (LD) muscle or musculocutaneous flap is one of most frequently used pedicled flaps. However, the pedicled LD flap carries a bulky pivot point and a short arc of rotation. If a pedicled LD muscle flap is transferred using a reverse turnover pattern, theses drawbacks can be avoided., Patient Concerns: The first patient was a 56-year-old man with hepatocellular carcinoma and multiple bone metastases involving D11-L4 vertebral bodies. A chronic ulcer was developed on his lower back area after palliative radiation therapy for bone metastases. The second patient was a 41-year-old man with a soft tissue mass on his lower back, which was diagnosed as dermatofibrosarcoma protuberans via previous incisional biopsy. A large soft tissue defect was developed on his lower back as a result of a wide resection., Diagnosis: Both patients were referred to our department for the treatment of a large soft tissue defect on lower back., Interventions: They underwent the reverse turnover pedicled LD muscle flap and split-thickness skin graft., Outcomes: At postoperative 6-month follow-up, both patients remained free of wound problem., Lessons: The reverse turnover pedicled LD muscle flap is quite straightforward. Even if a soft tissue defect in the lower back is large or complicated by infection or radiation therapy, perfusion of LD by posterior intercostal arteries is likely to be preserved. We recommend the reverse turnover pedicled LD muscle flap as an effective alternative for reconstruction of soft tissue defects involving the lower back.

Background: The lateral femoral condyle (LFC) flap is a vascularized bone flap based on the superior lateral genicular artery (SLGA). Harvest technique for this flap has not yet been demonstrated. The purpose of this study was to better delineate the blood supply to the bone and skin of this flap to allow for a safe and effective harvest., Materials and Methods: Twenty-three lower extremities were injected with latex or a mixture of latex and barium sulfate. The SLGA was identified and dissected, documenting the course, diameter, anatomical relations, length, and branches. In the mixture group, high-resolution CT scanning was performed prior to dissection. Two additional specimens were dissected to illustrate the harvest technique., Results: The SLGA originated from the popliteal artery at an average of 44.3 mm proximal to the knee joint line. The SLGA had an average diameter of 1.9 mm at origin and length of 56 mm. It coursed posterior to the femur, reaching the lateral intermuscular septum (IMS), dividing into superficial (patellar) and deep (condylar) branches, which coursed toward and gave branches to the patella and the LFC, respectively. At least one (average 1.4) septocutaneous skin perforator >5 mm emerged and ran posterior to the IMS. 3D reconstructions of the CT scans were used to confirm anatomic findings and describe a standard harvest technique., Conclusions: The SLGA has consistent anatomy, adequate length, suitable diameter at origin for microvascular anastomosis, and constant perforators to bone and skin. The LFC flap provides a useful alternative to flaps from the medial knee or iliac crest., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

A 10-year-old patient presented to the emergency room after a motor vehicle accident. The patient was diagnosed with left scapular body fracture and concomitant inferior angle apophyseal separation with intrathoracic displacement causing hemopneumothorax. The displaced scapular body was reduced surgically and separated apophysis of the inferior angle was fixed to the scapular body with absorbable suture. Postoperative 2-year follow-up showed a good result. A literature search found two pediatric cases of intrathoracic displacement of scapular body fracture. There was no previous report of apophyseal separation of the inferior angle of the scapula.

Background: Detection of dorsal cortical penetration of distal locking screws is difficult owing to the irregular shape of the dorsal surface of the distal radius. This study was designed to analyze two-dimensional morphological characteristics of the distal radius on axial magnetic resonance image, and to suggest a guideline for evaluation of screw length in distal radius fractures on the fluoroscopic or plain X-ray true lateral image., Methods: Anteroposterior length and lateral width of the distal radius, distance between the highest and the lowest point of the dorsal cortex (deceptive length), and widths of the first to second (hazard zone) and the third to fifth extensor compartments (safe zone) at the Lister tubercle level were measured on 104 axial magnetic resonance images by two hand surgeons., Results: The mean length and width of the distal radius at the Lister tubercle level were 22.96 mm and 30.42 mm, respectively. The mean hazard zone and safe zone widths were 8.72 mm and 19.43 mm, respectively. The mean deceptive length was 4.07 mm and the deceptive length did not have a relationship with height, sex, and age of subjects., Conclusions: We suggest that 4 mm be used as a reference value for the evaluation screw length at the safe zone. If the vertical distance between a distal screw tip and the peak of the Lister tubercle is lesser than 4 mm on a fluoroscopic or plain X-ray true lateral image, dorsal cortical penetration should be suspected. When dorsal cortical penetration at the hazard zone is suspected, both oblique or pro-supination views should be checked.

Background: This study aimed to delineate and compare the hot spots and three-dimensional vascular territories of dominant profunda artery perforators in the posterior thigh region, and modifications in flap design are discussed., Methods: Twenty-nine posterior thigh flaps were raised in fresh cadaveric specimens, and profunda artery perforators were documented. Dominant perforators were injected with iodinated contrast to assess perforasomes using computed tomographic angiography. Analysis with three-dimensional rendering and volume calculations of perfusion patterns was performed., Results: In total, 316 perforators were mapped and 33 perforators were injected for analysis. The hot spot for dominant perforators was the proximal medial quadrant, 5 to 10 cm from the inferior gluteal crease, with two smaller hot spots in the upper lateral and distal posterior midline. Although 69 percent were musculocutaneous, distal perforators were predominantly septocutaneous in the posterior midline, 5 to 8 cm from the popliteal crease. Proximal perforators were classified into first (most proximal) and second perforators, and their median perforasome was 233 and 286.4 cm, respectively (p = 0.86). There were no significant differences between proximal and distal perforators in perforasome surface areas, percentage areas perfused, and perforasome volumes. Large linking vessel networks were attributed to a broader perforasome and greater overlap between adjacent or distal perforators., Conclusions: Dominant linking vessels and recurrent flow through the subdermal plexus contribute to the robust vascular supply of profunda artery perforator flaps. Posterior thigh region perforator hot spots and their perfusion characteristics can inform the potential limits, orientation, and modifications of flap or skin paddle designs.

Purpose: To study the intraosseous 3-dimensional microvasculature of the capitate bone using a novel high-resolution micro-computed tomography (μCT) imaging technology, and to examine the blood supply as it relates to the most common fracture types., Methods: Ten cadaveric wrists were injected with a lead-based contrast agent. The capitates were harvested and imaged using a μCT scanner. The intraosseous vascularity was incorporated into a 3-dimensional image. We measured the vascular pattern as well as the vessels' cross-sectional area, number, and distribution. An average capitate fracture line was calculated using clinical data from 22 patients with capitate fractures. The fracture line was projected on the representative capitate to assess its relation with the nutrient vessels' entry points., Results: The capitate is a well-vascularized carpal supplied by dorsal and volar vascular systems that anastomose in 30% of cases. There was no predominance of one vascular system over the other. Most vessels enter the capitate at the distal half and supply the proximal pole in a retrograde fashion. In addition, most specimens (70%) also had at least one vessel entering the proximal pole through the volar capitate ligaments and supplying the proximal pole directly. The average fracture line had an oblique orientation, and 90% of the specimens had a blood vessel entering proximal to that line., Conclusions: This μCT vascular study further verifies that the capitate receives most of its vasculature in a retrograde fashion, but the study also shows that most capitates have vessels supplying the proximal pole directly. These findings might explain why most capitate waist fractures do not progress to proximal pole avascular necrosis., Clinical Relevance: This study characterizes the microvasculature of the capitate and might shed light on processes involved in bone healing and the etiology of capitate avascular necrosis., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the demographics, diagnosis, management, and outcomes of capitate fractures in the adult and pediatric population treated in our institution., Methods: We performed a retrospective chart and radiographic review of 53 patients with capitate fractures treated in our institution between 2002 and 2015. Patients' demographic characteristics, mechanism of injury, management including surgery-related data, and outcomes, including complications, were recorded. A radiographic evaluation of the location and pattern of the fracture was performed., Results: Capitate fractures were prevalent in young males and older females. Fracture location was variable with 9 different locations; in addition 80% of patients had an associated fracture in the wrist or hand. The most common fracture pattern was the transscaphoid, transcapitate perilunate dislocation. Most diagnoses were made with the aid of advanced imaging. Within this series, there was only 1 case (4%) of fracture nonunion and there were no cases of avascular necrosis of the proximal pole in limited follow-up. Isolated capitate fractures were significantly more common in children. In addition, children had better functional outcomes than adults., Conclusions: This series provides updated information on this rare injury. Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the history and physiology of perforator flaps. 2. Understand the concept of "free-style" perforator flaps and principles in design and harvest. 3. Understand the uses of perforator flaps in reconstruction and applications in new settings. 4. Understand new principles in single and multiple perforator flap harvest and adjunct techniques that can be used in perforator flaps. 5. Highlight pertinent anatomy and techniques for selected perforator flaps described., Summary: Extended knowledge of vascular anatomy has propagated the development of perforator flaps, which preserve muscle function and reduce morbidity. This has been achieved through the exemplary works of Manchot, Salmon, Milton, Taylor, and many others. With over 350 clinically relevant perforators in the body, this has created new flap options and a sense of creative freedom for reconstruction tailored toward a specific defect, without constraints of specific landmarks and using a "free-style" approach. Dominant perforators may be found in zones of high perforator density or "hot spots," which can help to conceptualize local flap options and aid flap design. This article aims to outline the history, physiology, and principles of flap design and harvest, and highlight traditional and evolving concepts and modifications of contemporary and traditional flaps that are changing reconstructive practice. This is a broad overview focusing on clinical applications, highlighting key concepts in a selection of new or evolving flaps being used in clinical practice and providing source references to acquire detailed flap descriptions.

Background: The area perfused by a single perforator depends on its perforasome and its unique interperforator flow pattern. The purpose of this study was to clarify the interperforator flow patterns of the peroneal and posterior tibial artery perforators using three-dimensional computed tomographic angiography., Methods: Thirteen whole-leg skin flaps were harvested in the subfascial plane from fresh cadavers. Peroneal, posterior tibial, anterior tibial, and sural artery perforators with a diameter greater than 0.5 mm were documented. Three-dimensional computed tomographic angiography with an injection of iodinated contrast medium into the peroneal or posterior tibial artery perforator was used to investigate the percentages of the area and the perforators that were perfused., Results: The mean percentage of the total area perfused was as follows: peroneal artery perforator, 42.0 percent; posterior tibial artery perforator, 38.0 percent (p = 0.084). The mean percentage of the total perforators perfused was as follows: peroneal artery perforator, 55.0 percent; posterior tibial artery perforator, 44.2 percent (p = 0.004). Although the mean percentages of same-source artery perforators perfused by a peroneal artery perforator (73.6 percent) and by a posterior tibial artery perforator (77.2 percent) did not differ (p = 0.513), the mean percentages of other-source artery perforators perfused by a peroneal artery perforator (49.9 percent) and by a posterior tibial artery perforator (32.3 percent) were significantly different (p < 0.001)., Conclusions: This study demonstrated that a single peroneal or posterior tibial artery perforator perfused approximately 40 percent of the whole leg surface and that peroneal and posterior tibial artery perforators had different interperforator flow patterns. The results of this study may improve preoperative planning for pedicled perforator flap surgery., Clinical Question/level of Evidence: Therapeutic, V.

Introduction: Although the perforating branches of the deep femoral artery have been introduced as recipient vessels for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head, comprehensive knowledge of the related anatomy is deficient. The aims of this study were to provide detailed anatomical data for the perforating branches of the deep femoral artery and validate their usefulness as recipient vessels for vascularized fibular grafts., Materials and Methods: Anatomical dissection was performed on 11 fresh human cadaveric lower extremities. The number, locations, and diameters of the perforating branches were documented. The topographic relationships with the vastus ridge and the tendinous insertion of the gluteus maximus were clarified. The diameters of the perforating branches were compared with those of the ascending branch of the lateral circumflex femoral and the peroneal arteries., Results: The mean number of perforating branches was 3.5. The mean distances from the vastus ridge to the first, second, and third perforating branches were 8.1, 13.7, and 20.4 cm, respectively. The first perforating branch was always located medial to the tendinous insertion of the gluteus maximus, whereas the second perforating branch was always located distal to the gluteus maximus. The mean diameters of the first, second, third, and fourth perforating branches were 3.1, 2.3, 1.6, and 1.2 mm, respectively. The mean diameters of the ascending branch of the lateral circumflex femoral and the peroneal arteries were 2.0 and 3.6 mm, respectively., Conclusion: The first perforating branch of the deep femoral artery is an appropriate alternative recipient vessel for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head. It has a very consistent anatomy with a suitable location and diameter for anastomosis of the peroneal artery., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background Carpal tunnel release is one of most commonly performed procedures in upper extremity surgery, with low complication rates. Case Description We report a case of epidermal inclusion cyst that occurred in a 44-year old man after carpal tunnel release. The epidermal inclusion cyst formed beneath the previous operation scar and induced recurrent carpal tunnel syndrome. Symptoms resolved completely after excision of the cyst. Literature Review Epidermal inclusion cysts are the third most common type of hand tumors. Although repeated minor trauma is the most frequent cause, surgical procedures can induce an epidermal inclusion cyst. One case report of epidermal inclusion cyst after carpal tunnel release was found in literature. Etiology, treatment, and prevention methods are reviewed. Clinical Relevance We hope this case report alerts physicians to the possibility of development of epidermal inclusion cyst after carpal tunnel release and the importance of basic surgical skills, such as gentle handling of a surgical wound, profuse saline irrigation, and careful wound closure with precise approximation of skin edges.

Background: The pedicled latissimus dorsi (LD) flap serves an important function in breast reconstruction, but its utility is limited by its inability to provide sufficient breast volume., Objectives: The purpose of this preliminary report was to review the techniques and outcomes of utilizing fat-grafted, volume-enhanced LD flap transfer with fat grafting recipient sites in autologous breast reconstruction., Methods: A retrospective study was performed of 10 patients (14 breasts) who underwent autologous breast reconstruction utilizing the LD flap transfer technique and simultaneous fat grafting between August 2012 and September 2014. Multilayer, multisite fat grafting was performed to the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles simultaneously with the LD flap transfer., Results: Three patients underwent an immediate breast reconstruction, four underwent a delayed breast reconstruction, and four underwent a tertiary breast reconstruction following previously failed breast reconstructions (one patient underwent each of the first two procedures, one on each breast). The average age of the patients was 55 years (range, 39-76 years), the average body mass index of the patients was 29.3 (range, 19.6-39.9), and the average fat grafting volume for the patients was 176 mL (range, 50-300 mL). There was 100% flap survival and complete wound healing. No seroma or fat grafting-related complications were clinically detected. Three patients required additional fat grafting., Conclusions: The fat-grafted, volume-enhanced LD flap procedure with fat grafting recipient sites offers a simple and safe technique for autologous breast reconstruction, with low morbidity and fast recovery. It can be a useful alternative to utilizing abdomen-based flaps in autologous breast reconstruction or could be performed to salvage both implant-based and free-flap breast reconstructions. LEVEL OF EVIDENCE 4: Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

The Triathlon condylar-stabilizing (CS) lipped insert is designed to provide anteroposterior (AP) stability of the posterior-stabilized (PS) insert, without a post. The purpose of this study was to compare the AP stability of the knee in patients with Triathlon CS and PS total knee arthroplasty (TKA) with midterm follow-up. Thirty-one patients received a Triathlon PS TKA in one knee and a Triathlon CS TKA in the contralateral knee, and 28 patients were followed up with a minimum duration of 5years. Although there was no difference in functional outcomes, the posterior displacement was significantly greater in the CS TKA group than in the PS TKA group (P<0.001). The Triathlon CS lipped insert could not restore posterior stability with PCL sacrifice., (Copyright © 2014 Elsevier Inc. All rights reserved.)

During imaging studies or surgical procedures, anomalous forearm and wrist muscles are occasionally encountered. Among them, the flexor carpi radialis brevis is very rare. Because the trend is growing toward treating distal radius fractures with volar plating, the flexor carpi radialis brevis is worth knowing. Here, we report two cases with a review of the literature.

This study reports a rare case of complete dislocation of the thumb metacarpal with extreme displacement. Although there are several reported cases of similar injury in earlier published reports, metacarpals of all the cases remained in situ. In this case, the metacarpal was totally displaced out of the hand. Although open reduction and internal fixation were performed, the clinical outcome was unsatisfactory because of severe soft tissue damage.

Purpose: Although anterior transposition of the ulnar nerve is a commonly performed procedure for treatment of cubital tunnel syndrome, there are concerns that surgical mobilization puts blood supply to the nerve at risk. The purpose of this study was to compare the effects of subcutaneous anterior transposition (SAT) and in situ decompression (ISD) on the ulnar nerve's histologic and electrophysiologic properties in a rabbit model., Methods: We assigned 30 male, young adult New Zealand white rabbits to 1 of 3 groups (each group, n = 10). The extensive dissection-SAT group underwent complete neurolysis of the right ulnar nerve from brachial plexus to wrist and a subsequent SAT, the ISD group underwent ISD with 4-cm-long exposure of the ulnar nerve, and the SAT group underwent SAT with 4-cm-long circumferential neurolysis of the ulnar nerve. We killed the animals 7 days after the operation. We assessed electrophysiologic changes by finding the percentage of compound motor action potential of the surgical limb compared with the contralateral limb, and histologic changes by ischemic fiber degeneration., Results: The extensive dissection-SAT group showed a significantly lower percentage of compound motor action potential and higher grade of ischemic fiber degeneration than the ISD and SAT groups. On the other hand, the percentage of compound motor action potential and the grade of ischemic fiber degeneration were similar between the latter 2 groups without a statistically significant difference., Conclusions: This study demonstrated that surgical mobilization of the ulnar nerve during SAT has an effect similar to ISD on the nerve's histologic and electrophysiologic properties at the 7th postoperative day in a rabbit model., Clinical Relevance: In a rabbit model, ISD and SAT appear to affect histologic and electrophysiologic findings of the ulnar nerve equally at postoperative day 7, which suggests that they would have the same relative safety in a clinical setting., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We report here on an unusual case of recurrent dissociation of a polyethylene tibial insert from its metal baseplate after high-flex posterior-stabilized (PS) Genesis II total knee arthroplasty with using the mini-subvastus approach. After the 1st episode of dissociation, which had happened 1 month after the primary surgery, we changed the tibial insert and found damages on the dovetails and the post of the retrieved insert. Unfortunately, the patient suffered the same dissociation 1 month after the tibial insert was changed. This case illustrates that incomplete seating of the insert due to limited surgical exposure and anterior impingement of the high-flex PS post may contribute to the risk of dissociation., (Copyright © 2010 Elsevier B.V. All rights reserved.)

We report a case involving an avulsion fracture of the iliac crest apophysis in a 16-year-old boy. Occasionally, apophyseal avulsion fractures of the pelvis occur; however, those that occur at the iliac crest are rare. As a result of the large size of the fracture fragment and marked displacement (more than 3 cm), the fracture was managed operatively with open reduction and internal fixation. The patient returned to preinjury physical activity levels 2 months after surgery without complication.

Skeletal metastasis is a common event during the advanced stage of a malignant tumour, but metastasis to the hand is rare (about 0.1% incidence). We have seen seven cases of metastatic malignant tumour of the hand since 1983, and report them here.

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

The purpose of this study was to evaluate the effect of changing activity after total knee arthroplasty (TKA) on metabolic syndrome with a follow-up period of 2 years. Two hundred consecutive patients who were to undergo TKA were prospectively enrolled. The patients' blood pressure, fasting plasma glucose level, the lipid profile, the waist circumference, the Knee Society score, and the Lower Extremity Activity Scale were measured preoperatively and at the 2-year follow-up visit. The data from 169 patients were finally collected and reviewed. Two years after primary TKA, there was no change in the prevalence of metabolic syndrome, despite that the patients had a significant increase of their physical activity., (Copyright © 2010 Elsevier Inc. All rights reserved.)

We report a case of posterior Monteggia lesion in a 12-year-old girl consisting of a greenstick fracture of the proximal ulnar metaphysis and a radial neck fracture with a proximal and posterior 90-degree rotational displacement of the radial head. Closed reduction of the radial head resulted in complete reversal of the radial head, which was corrected by open reduction and internal fixation. Cast immobilization without correction of the plastic deformation of the proximal ulna caused posterior bowing of the ulna and posterior displacement of the fractured radial neck. Corrective osteotomy of the ulna and third operation of radius resulted in bony union and acceptable alignment.

Permanent post-traumatic patellar dislocation is a rare condition, and total knee arthroplasty (TKA) can be performed for osteoarthritic knees with this condition. There have been only a few reports about using the standard medial parapatellar approach and extensive lateral release or extensor mechanism realignment for patients with permanent post-traumatic patellar dislocation. We performed two TKAs with using a subvastus approach and lateral release for osteoarthritic knees with permanent post-traumatic patellar dislocation. The patients were well satisfied with their results. The patellae tracked very well in the femoral trochlear groove throughout the full range of motion after the operations. Bone scans were done 1 year postoperatively on both patients, and the scans showed normal vascularity for the patella.