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Deep vein thrombosis (DVT) is a common clinical problem affecting the lower extremities. Prompt imaging of suspected DVT is helpful for rapid diagnosis and proper treatment. However, patients without clear predisposing factors for DVT may be directed to alternative diagnoses of a musculoskeletal disorder. The few case reports and studies of magnetic resonance (MR) imaging of unsuspected DVT are limited to the calf and knee. Here, we report two cases with a rare presentation of thigh MR imaging of unsuspected DVT. Identifying branching, abnormal intraluminal signals on fluid-sensitive imaging, or rim-enhancing tubular structures within the edema of the thigh muscle is important for differentiating intramuscular DVT from other thigh pathologies.

Background: Charcot joint or neurogenic arthropathy in diabetes is a late complication invading the foot and ankle that results in dislocation, instability, and deformity of the affected area. Sensory neuropathy leads to numbness and malalignment of the foot and ankle or inadequate post-traumatic response, which results in progressive fractures, multiple joint dislocations, ulcerations, osteomyelitis, and amputation. Because of such serious consequences, understanding of pathophysiology is important in determining treatment strategies. Early diagnosis and appropriate treatment can prevent this destructive process.Current Concepts: The number of adults diabetic patients continuously increases. Health care and life expectancy will continue to improve with the development of medicine. As a result, the incidence of diabetes-related complications will increase. Diabetic Charcot joint will have a serious negative impact on the quality of life and financial burden on the diabetic patients. The goal of treatment for Charcot joint is not to build a normal foot, but to make a stable plantigrade foot that can be worn shoes. Therefore, it would be most important to understand the progress and characteristics of the disease and to develop an appropriate plan in order to select the appropriate treatment method.Discussion and Conclusion: Understanding Charcot joint and familiarization with its appropriate treatment should reduce the number of the cases of diabetic Charcot joint patients with disabilities or amputations.

The purpose of this study was to evaluate the radiographic and clinical outcomes of patients with hallux valgus (HV) with concomitant metatarsus adductus (MA) treated with distal chevron metatarsal osteotomy (DCMO), without any procedure for the second or third metatarsal.A multicentre retrospective study involving four hospitals was conducted. A total of 45 feet from 38 patients who had received DCMO for HV with MA with at least one year post-operative follow-up were analysed. HV angle (HVâ), inter-metatarsal angle (IMâ), MA angle (MAâ), and the lateral sesamoid grade were measured. Foot function index (FFI) and visual analogue scale (VAS) were recorded. Patients were divided into mild (18° ≤ MAâ 20°) and moderate (20° ≤ MAâ) MA groups, and results were compared.The mean HVâ and IMâ improved significantly from 35.1° and 14.4° pre-operatively to 10.6° and 7.1° one year post-operatively (p 0.001). There were no differences in pre-operative HVâ, IMâ, or the sesamoid grade, and also no difference in post-operative HVâ or the sesamoid grade between mild and moderate MA groups. Only the mean post-operative IMâ showed a difference between the two groups (8.3° vs. 6.3°; p = 0.019). All clauses of FFI and VAS improved significantly (p 0.001). When the extent of improvement was compared between the two groups, there were no significant differences in any category (p 0.05). The total rate of recurrence (HVâ ≥ 20°) was 11.1% (5/45), and although the moderate group (4/29, 13.8%) had a higher proportion than the mild group (1/16, 6.3%), this was not statistically significant (p = 0.641).DCMO for patients with HV with MA had satisfactory radiographic and clinical outcomes with minimal recurrence. Except in cases of severe combined deformity, we recommend performing DCMO alone without any additional procedure or manipulation of the other metatarsals as a viable treatment option.

To evaluate clinical and radiological outcomes of medial row anchor insertion between 90° or 45° (deadman) angle in the suture-bridge rotator cuff repair of medium-to-large rotator cuff tears. This retrospective analysis included 113 consecutive patients undergoing arthroscopic suture-bridge repair for medium-to-large rotator cuff tears (mean tear size: 2.8 × 2.3 cm) between 2010 and 2013. The patients were divided into two groups: group I (53 patients) and group II (60 patients) involving 90° and 45° medial row anchors, respectively. The conventional lateral row anchors were inserted in the suture-bridge repair. The clinical outcomes at 2 years and radiological outcomes including re-tear or footprint coverage (anteroposterior length and mediolateral width) of the repaired tendon using postoperative MRI were evaluated. Clinical outcome scores were significantly improved in both groups. However, Group I (90° anchor insertion group) showed better clinical scores without the difference of range of motion. The postoperative MRI revealed enlarged footprint coverage with 90° medial row anchor. The repaired footprint cuff size (mediolateral width) in the coronal plane MRI showed a statistically significant difference (45°: 19 mm vs. 90°: 24 mm) (p

Fracture stem of the reverse total shoulder arthroplasty (RTSA) was designed for better tuberosity bone healing for the proximal bone defect of complex proximal humeral fractures (PHF). Our purpose was to compare the clinical and radiological outcomes of patients using fracture stem vs non-fracture (conventional) stem of RTSA in complex PHF of elderly patients. Between 2008 March and 2017 June, 48 patients who had undergone an RTSA with non-fracture or fracture stem for complex PHF with a minimum 18 months of follow-up were evaluated. Finally, total 45 patients with a mean age of 80 ± 7 years (65–92 years) were enrolled because three patients were excluded due to age related mortality. We divided them into two groups: 25 patients using non-fracture stem (non-fracture stem group) in the early period of this study, and consecutive 20 patients using fracture stem (fracture stem group) in the later period. Between two groups, we compared clinical and radiologic outcomes such as tuberosity failure, heterotopic ossification (HO), dislocation, acromion fracture, notching, loosening and periprosthetic fracture. In all patients, clinical outcomes were improved significantly and tuberosity failure was found in 62% (28/45). Between two groups, there were no statistically significant differences on clinical outcomes and radiologic outcomes except UCLA score. As complications, two humeral stem revision was performed due to tuberosity failure related HO and stem loosening with subsequent periprosthetic fracture in non-fracture stem group. Compared to non-fracture stem, fracture stem usage of RTSA in complex PHF of elderly patients has no significant different impact on clinical and radiological outcomes. However, tuberosity failure related secondary HO of non-fracture stem might be responsible for stem loosening and periprosthetic fracture in the RTSA for complex PHF of elderly patients. Level IV, case series study.

Compared to single row repair, use of lateral row anchors in suture bridge rotator cuff repair enhances repair strength and increases footprint contact area. If a lateral knotless anchor (push-in design) is inserted into osteoporotic bone, pull-out of the lateral row anchor can developed. However, failures of lateral row anchors have been reported at several months after surgery. In our cases, even though complete cuff healing occurred, delayed pull-out of the lateral row anchor in the suture bridge repair occurred. In comparison to a conventional medial anchor, further biomechanical evaluation of the pull-out force, design, and insertion angle of the lateral anchor is needed in future studies. We report three cases with delayed pull-out of lateral row anchor in suture bridge rotator cuff repair with a literature review.

Background Our hypothesis was that minimally invasive plate osteosynthesis (MIPO) using long philos plate (LPP) would show better clinical and radiological outcomes and less complications than narrow locking compression plate (NLCP) for spiral humerus shaft fractures with or without metaphyseal fracture extension. Methods From January 2009 to May 2016, we retrospectively studied 35 patients who underwent MIPO for spiral humerus shaft fractures with or without metaphyseal fracture extension (AO classification 12 A, B, C except A3). Eighteen patients underwent MIPO with a 4.5 mm NLCP (group I) in the early period of this study, while 17 patients underwent MIPO with LPP (group II) in the later period. Range of motion (ROM), pre- and post-operative anteroposterior (AP) and lateral angulation of the fracture, operation time, amount of bleeding, and functional outcomes including American Shoulder and Elbow Surgeons score, University of California at Los Angeles score, and Simple Shoulder Test score were analyzed at the final follow up. Results All patients had complete bony union and achieved satisfactory functional outcomes except 2 patients. In LPP group, better outcomes in postoperative fracture angulation on X-ray and operation time (p

The purpose of this study was to evaluate whether trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation improves mid-term clinical outcomes for high-grade partial articular-sided supraspinatus tendon avulsion (PASTA) lesions or not. A retrospective review of a consecutive series of arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation was conducted. Total 115 patients (44 men and 71 women) with minimum 2 years follow-up were enrolled in our study. Their mean age was 59.7 ± 7.6 (38–77) years and mean follow-up were 6.9 ± 2.5 (2 ~ 10) years. Clinical assessment and radiological outcomes using post-operative MRI were evaluated at last follow-up. All these tears were high-grade PASTA lesions in which mean cuff tear size (exposed footprint) was anteroposterior length 15.7 ± 6.3 mm (5–25 mm) and mediolateral width 10.1 ± 3.6 mm 6.4 mm (5–16 mm). At last follow-up, mean pain VAS, ASES, UCLA, and SST scores were improved from pre-operative values of 5, 59, 21, and 7 to post-operative values of 1, 84.4, 29.5, and 9.4, respectively (p value < 0.001). ROM such as forward flexion, abduction, and internal rotation to the back were improved from a pre-operative mean of 148° (±24), 144° (±24), L2 (Buttock-T7) to a post-operative mean of 161° (±10), 160.0° (±12), and T12 (L3–T5), respectively (p value < 0.001). Follow-up MRI showed Sugaya classification type I in 24 patients (20.9%), type II in 78 patients (67.8%), type III in 11 patients (9.6%) and type 4 in 2 patients (1.7%) were found. As complications, shoulder stiffness was found in five patients, Popeye deformity in two patients and retear in two patients. Revision surgery of the retear was performed in 2 patients. At the last follow-up, 17% (20/115 patients) reported occasional discomfort at the extremes of range of motion during a heavy work or sports activities. In high-grade PASTA lesions, arthroscopic trans-tendon suture bridge repair with tenotomized pathologic biceps tendon augmentation could be a useful treatment modality capable of preserving rotator cuff footprint, providing simultaneous biceps tenodesis, inducing better tendon healing and possibly preventing tendon buckling and residual pain of the conventional trans-tendon repair methods. These specific methods showed satisfactory outcomes and decreased residual shoulder discomfort (17%) at mid-term follow-up. Level IV, Retrospective case study.

Forefoot injuries are commonly caused by sport-related activities and are often around the metatarsophalangeal joints. The hallux interphalangeal (IP) joint is anatomically stable; therefore, injuries to this joint are considered to be rare compared with those to the metatarsophalangeal joint. Instability of the hallux IP joint has rarely been reported in barefoot contact sports, and its treatment has not been sufficiently explored.This study investigated chronic varus instability of the hallux IP joint. We performed a surgical reconstruction owing to conservative treatment failure. A good surgical outcome was achieved by reconstruction of the collateral ligament using the 4(th) extensor tendon-a promising alternative treatment option for this type of injury. This method indicated no morbidity outside the site of surgery and was more cost-effective than reconstruction using an allograft.

Purpose The purpose of this study was to report clinical results of open excision of extra-articular ganglion cysts around the knee joint combined with arthroscopic management of intra-articular pathologies if present. Materials and Methods Of the total 107 cases of cystic lesions around the knee, 23 cases of extra-articular ganglion cysts were reviewed between January 2006 and July 2011. There were 13 males and 10 females with a mean age of 48 years (range, 30 to 73 years). The mean follow-up duration was 40 months (range, 30 to 60 months). Preoperative magnetic resonance imaging (MRI) scan was done in all cases. Open surgical excision of the cyst was performed after arthroscopic management of intra-articular pathologies in all but 1 case. At the last follow-up, Lysholm and International Knee Documentation Committee (IKDC) scores were evaluated and MRI was conducted to detect recurrence. Results The mean Lysholm and IKDC scores showed significant improvement (p=0.005 and 0.013, respectively).The location of the cysts was anterior in 9, lateral in 7, medial in 6, and posterosuperior in 1. Intra-articular pathologies were found in 16/23 cases (69.6%). In 10/23 cases (43%), the cyst was connected to the knee joint. Three months postoperative MRI did not show any recurrence of ganglion cysts except for 1 case. Conclusions In the treatment of extra-articular ganglion cysts, MRI can be useful for detecting intra-articular lesions and connecting orifices, and arthroscopic management of intra-articular pathologies with open excision of the cyst should be considered as a viable treatment option.

The purpose of the present study was to describe the use of a novel hybrid surgical technique—arthroscopic-assisted plate fixation—and evaluate its clinical and anatomical outcomes in the management of large, displaced greater tuberosity (GT) fractures with comminution. From 2009 to 2011, this novel technique was performed in 11 patients [2 men and 9 women; median age, 64 years (range 41–83 years)] with large, comminuted GT fractures, with fragment displacements of >5 mm. The preoperative mean posterior and superior migration of the fractured fragment, as measured on computed tomography (CT), was 19.5 and 5.5 mm, respectively. Two patients had shoulder fracture-dislocation, and three had associated undisplaced surgical neck fracture. The mean duration between injury and surgery was 4 days. The mean follow-up duration was 26 months. At the final follow-up, the mean postoperative ASES, UCLA and SST scores were 84, 29, and 8, respectively. The mean range of motion was as follows: forward flexion, 138°; abduction, 135°; external rotation at the side, 19°; and internal rotation, up to the L2 level. The mean posterior and superior displacements of fracture fragments on postoperative CT scan [0.7 ± 0.8 mm (range 0–2.1 mm) and 2.8 ± 0.5 mm (range 3.4–5.3 mm), respectively] were significantly improved (p

To evaluate the clinical and radiological outcomes of unstable proximal humeral fractures (PHFs) treated with a locking plate and fibular strut allograft. This study included 36 patients [7 men, 29 women; mean age, 68 years (range, 22–94 years)] with unstable PHFs with medial column disruption. All patients were treated with open reduction and internal fixation using a locking plate and fibular strut allograft. Post-operative assessment included clinical outcomes, shoulder range of motion, radiographic examination, and any complications. Post-operative radiological assessment including the humerus neck-shaft angle (NSA) and the humeral head height was performed. At the mean two year follow-up visit, the mean American Shoulder and Elbow Society (ASES) and University of California, Los Angeles (UCLA) scores were 77 and 28, respectively. According to the UCLA rating scale, the result was excellent in six, good in 20, fair in six, and poor in four cases. According to the Paavolainen method, 31 patients had good results with an NSA of 130 ± 10°; three patients showed fair results with an NSA of 100–120°, and two patients experienced a poor result with an NSA of

Background:Intratendinous tears of the rotator cuff are rare, and little has been written about them.Purpose:To investigate the prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair.Study Design:Case series; Level of evidence, 4.Methods:Included in the study were 33 patients (16 male, 17 female; mean age, 53.4 years) with arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair from March 2006 to July 2012. A history of trauma was found in 10 cases (30.3%). The dominant arm was involved in 26 cases (78.8%). The mean follow-up duration was 56 months. Preoperatively, a thorough physical examination was performed; at final follow-up, shoulder range of motion (ROM) in forward flexion, abduction, external rotation (ER) at the side, and internal rotation (IR) at the back was noted, and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analog scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded and compared with the preoperative data. Postoperative magnetic resonance imaging (MRI) was performed at 6 months to investigate rotator cuff healing status and repair integrity.Results:The prevalence of arthroscopically confirmed intratendinous tears was 4.7% among all arthroscopically treated partial-thickness rotator cuff tears. Impingement signs were positive in most of the patients (positive Hawkins-Kennedy test result in 78.8%, positive Neer sign in 66.7%, and either positive Hawkins-Kennedy test result or Neer sign in 84.8%). At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from a preoperative mean of 51.4, 18.9, 6.0, and 5.4, respectively, to a postoperative mean of 90.6, 32.9, 1.4, and 10.8, respectively ( P < .001). According to the UCLA rating scale, outcomes were excellent in 17, good in 13, and fair in 3 cases. Shoulder ROM in forward flexion, abduction, ER at the side, and IR at the back improved from a preoperative mean of 135°, 129°, 25°, and L2, respectively, to a postoperative mean of 161°, 160°, 29°, and T10, respectively ( P < .001 for all except ER). As per the Sugaya classification, on postoperative MRI, type I healing status was found in 10 (30.3%), type II in 18 (54.5%), and type III in 2 (6.1%) cases. None of the patients showed any evidence of retears.Conclusion:Transtendon suture bridge repair yielded satisfactory clinical and radiological outcomes in patients with intratendinous rotator cuff tears.

To evaluate the effectiveness of immediate arthroscopy and clinical outcomes following open reduction and internal fixation (ORIF) of tibial plateau fractures. Sixty patients (36 men and 24 women, median age 56 (20–78) years) were divided into Group I (ORIF only: 26 patients, median age 58 (25–78) years) or Group II (ORIF with immediate arthroscopy: 34 patients, median age 55 (20–75) years) in tibial plateau fractures (Schatzker Type II–VI fractures). In the first part of this study, ORIF only was performed without arthroscopic treatment. In the second part, ORIF with immediate arthroscopic examination and treatment was performed. Clinical outcomes, utilizing range of motion (ROM), International Knee Documentation Committee (IKDC) score and hospital for special knee score (HSS) were assessed. At the final follow-up, HSS score was 81 ± 11 points in Group I and 83 ± 9 points in Group II. The IKDC score was 85 ± 8 points in Group I and 86 ± 6 points in Group II. In Group II, concomitant intra-articular lesions in 10 patients (29%) were found and treated simultaneously. However, there were no significant differences in clinical scores or ROM between the two groups. Immediate arthroscopy following ORIF for tibial plateau fracture is an effective procedure that provides accurate information for fracture reduction, leading to immediate treatment of concomitant intra-articular lesions without complications. III.

Tumoral calcinosis is an uncommon disorder and characterized by development of calcified masses within the soft tissues near the large joints such as the hip, elbow, and shoulder and rarely occurs in the foot. We report a case of tumoral calcinosis at the first meta-tarso-phalangeal (MTP) joint of foot with hallux valgus deformity associated with bunion which required resection. Surgical excision of the calcific mass alone, without surgery to the minimal hallux valgus, resulted in resolution of symptoms, without recurrence of the lesion. Subsequently, speculative etiology, differential diagnostic considerations as well as the therapeutic interventions for tumoral calcinosis are discussed taking into consideration the current literature. We conclude that tumoral calcinosis should be considered in the differential diagnosis of a painful mass that develops in the small joints of the foot.

Background: Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis. Methods: We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups. Results: Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33. Conclusion: Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture. Level of Evidence: Level III, retrospective comparative study.

An adult with ulcerative colitis and diabetes presented with a painful, swollen, edematous left foot. Diagnostic images and laboratory tests were inconclusive. Antibiotics were started immediately but aggravated his symptoms, and the laboratory results worsened. His foot was debrided twice per protocol for treating diabetic foot ulcers or cellulitis. After debridement, his condition worsened rapidly. Pyoderma gangrenosum was correctly diagnosed on the basis of massive neutrophilic infiltration detected in the biopsy tissue and because the lesion was well-defined and colored deep red to violet, unlike the bullosis diabeticorum blisters observed in the diabetic foot. His foot improved with systemic corticosteroids and topical wound care, and a skin defect was treated with a skin graft. After 9 months, his foot was well healed. Pyoderma gangrenosum can be diagnosed by careful examination and must be distinguished from an ulcerated diabetic foot lesion.

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.

Extensor tendon triggering is a rare disease entity. Even less common is a case of extensor digiti minimi (EDM) double triggering caused by impingement on the extensor retinaculum. Herein, we describe one patient with EDM double triggering developed at the extensor retinaculum and over the metacarpal head caused by its impingement on the extensor retinaculum.

To report the clinical and radiological outcomes of arthroscopic suture bridge repair for the GT fractures of the shoulder joint.From March 2008 to July 2013, we performed arthroscopic suture bridge repair of the GT fractures displaced more than 5 mm superiorly or posteriorly, but less than 2 cm in 40 cases [20 men, 20 women; mean age, 56 (27-80) years] with the average 32 (24-48) months follow-up. At the final follow-up, clinical (ASES, UCLA, SST, KSS score and range of motions) and radiological outcomes using post-operative MRI or CT scan were evaluated. Associated injuries occurred in 21 cases (52.5%): 8 rotator cuff tears; 7 SLAP lesions; 3 glenoid rim fractures; 3 Bankart lesions; 5 biceps tendon tears; 1 partial subscapularis tear; 1 combined subscapularis and biceps tendon tear, and 1 brachial plexus injury.At the final follow-up, the mean VAS score improved from 7 to 1; ASES, to 92; UCLA, to 32; KSS, to 90; and SST, to 10. Mean forward flexion, abduction, external rotation at the side, and internal rotation at the back were improved to 157°, 157°, 37° and T11, respectively. Mean residual superior and posterior displacement of the fracture was 0 (range -5 to 3.3) mm and 0.1 (-5.5 to 3.2) mm, respectively, compared to pre-operative displacement of 4.9 (0-14) mm and 4.5 (0-20) mm, respectively (p 0.001). Complications included anchor protrusion in five cases.Arthroscopic suture bridge repair was useful for the treatment of displaced GT fractures with or without comminution and the management of the combined lesions. At the final follow-up, meaningful remodeling of the GT fracture and satisfactory clinical outcomes could be achieved.

Almost all traumatic injuries can be classified using established criteria, but foot trauma can result in various combinations of injuries. Leibner et al. first described concomitant Lisfranc fracture-dislocation and complex dislocation of the metatarsophalangeal (MTP) joint, and coined the term ‘floating metatarsal.’ Since then several variants of floating metatarsal have been reported.2,4–7,9,10 Isolated floating metatarsal involving dislocation alone without fracture of the metatarsal is even more uncommon. We describe a case of an isolated locked floating metatarsal without fracture caused by minor trauma. In this case, the metatarsal head was button-holed and locked. The patient was treated by open reduction without fixation.

Hypothesis The combination of suprascapular nerve block (SSNB) and axillary nerve block (ANB) has been reported to provide safe and effective analgesia for arthroscopic shoulder surgery. This study was designed to identify anatomic landmarks of the suprascapular nerve (SSN) and axillary nerve (AN) and to evaluate the effects of SSNB and ANB using the identified landmarks. Materials and Methods This study included 52 cadaveric shoulders and 30 patients in the anatomic and clinical studies, respectively. After the exact location of the SSN and AN was identified from the cadavers, the clinical study at the end of the operation and at 8, 16, 24, 32, 40, and 48 hours postoperatively was performed in 2 groups: without both SSNB and ANB (group I) and with both SSNB and ANB (group II). Results The SSN was located at a length of one-half (2/5-3/5, 88%) from the anterior tip of the acromion to the superior angle of the scapula and at a length of two-fifths (1/3-1/2, 100%) from the anterior tip of the acromion to the medial border of the spine. The AN was located at a length of three-fifths (2/5-4/5, 98%) from the acromial angle to the inferior insertion of the teres major muscle. The depth from the skin was 3.20 ± 0.58 cm for the SSN and 2.07 ± 0.45 cm for the AN. The clinical study showed that the total amount of analgesic for patient-controlled anesthesia was markedly decreased at the end of the operation and at 8 hours postoperatively in group II compared with group I. Conclusions The SSNB and ANB were considered to provide safe and effective analgesia in terms of early postoperative pain in arthroscopic shoulder surgery.

We present two patients with open pilon fractures with large bone defects treated successfully with fibular strut allografts. The patients were initially treated by massive irrigation, wound debridement, and temporary external fixation. After complete wound healing, the bone defects were managed. Because autologous iliac crest or fibular bone grafts were impossible to be harvested due to multiple fractures, the bone defects were reconstructed with fibular strut allografts. Fixation was performed with a periarticular distal tibia locking plate. At 2 months postoperatively, the patients ambulated with partial weight-bearing; at 6 months, they had full range of motion of the ankle joint and full weight-bearing.

We reviewed 19 patients over 50 years of age who had rotator cuff tears com-bined with shoulder dislocation between October 2004 and October 2008. There were 7 males and 12females with a mean age 64.7 years (range, 50 to 78 years). The average follow-up duration was 22months (range, 8 to 56 months). We investigated the number of dislocations, the size of the cuff tear, thepresence of Bankart lesions and the time interval from dislocation to surgery. We also investigated theASES score, UCLA score, SST score, and shoulder range of motion before and after surgery. We ana-lyzed clinical outcomes and contributing factors.

Chronic proximal interphalangeal joint (PIPJ) instability of the finger is rare, and when it occurs usually requires surgical reconstruction. Complications arising from failed ligament reconstruction may result in a situation more difficult to address than the initial reconstruction. This situation is more likely for the finger than other orthopaedic reconstructions because the phalangeal bones are so small. We present a case of chronic radial PIPJ instability of the finger and severe bony defect caused by multiple failed ligament reconstructions that was treated successfully using a modification of the bone-ligament-bone graft technique.

Chronic proximal interphalangeal joint (PIPJ) instability of the finger is rare, and when it occurs usually requires surgical reconstruction. Complications arising from failed ligament reconstruction may result in a situation more difficult to address than the initial reconstruction. This situation is more likely for the finger than other orthopaedic reconstructions because the phalangeal bones are so small. We present a case of chronic radial PIPJ instability of the finger and severe bony defect caused by multiple failed ligament reconstructions that was treated successfully using a modification of the bone-ligament-bone graft technique.

Scapular fractures are uncommon and among them acromial fractures are even more uncommon. Because the vast majority of acromial fractures are either non-displaced or minimally displaced, symptomatic and nonoperative management was performed. We describe a case of avulsion fracture of the acromial physis displaced by acromioclavicular ligament treated with open reduction and internal fixation, and include a review of the literature.

To analyze the clinical and radiologic outcomes of arthroscopic cyst decompression and labral repair in patients with inferior paralabral cysts with chronic shoulder pain.Between March 2006 and September 2012, 16 patients who were identified as having inferior paralabral cysts presented with chronic shoulder pain. All patients underwent a thorough physical examination and preoperative magnetic resonance arthrographic evaluation. The mean age was 30 years (range, 17 to 50 years). The mean follow-up period was 38 months (range, 16 to 60 months). Clinical outcome scores (American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test) and passive shoulder range of motion were evaluated at last follow-up. Follow-up magnetic resonance imaging was performed at a mean of 8 months to determine the labral healing status and assess for cyst recurrence.The incidence of isolated inferior paralabral cysts was 0.6% (16 of 2,656 cases). Of the patients, 8 had multiple cysts and 8 had a single cyst. The mean length and width of the cysts were 1.0 cm and 0.4 cm, respectively. Eight cases had a history of trauma, and 13 patients were involved in sports activities. Seventy-five percent of cases showed a positive relocation test. The mean American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test scores improved from 64, 22, and 8.7, respectively, preoperatively to 83, 31, and 10, respectively (P.001), at final follow-up. Shoulder range of motion did not show any significant improvement. The location of the labral tear was as follows: anteroinferior tear in 5 cases, posteroinferior tear in 8 cases, and combined anteroinferior and posteroinferior tear in 3 cases. All cysts were found to be in association with a labral tear. A mean of 2.7 anchors were used for inferior labral repair. These cysts were found only in male patients. None of the patients showed any evidence of cyst recurrence on follow-up magnetic resonance imaging.Inferior labral tears treated with cyst decompression and labral repair showed satisfactory clinical results without any recurrence. Inferior paralabral cysts should be considered in the differential diagnosis in patients presenting with chronic shoulder pain, particularly active male patients.Level IV, therapeutic case series.

Shoulder arthroscopy has become a common procedure in today’s orthopedic practice. The safety of this procedure has been well established, but there are some complications associated with every surgical procedure both minor and major. In the present era, with advanced arthroscopic instruments, it is rare to encounter the problem of instrument breakage during arthroscopic surgery. Here, we report an unusual case in which we found a detached arthroscopic lens within the shoulder joint. A 58-year-old male patient who was previously operated for shoulder arthroscopy for the treatment of impingement syndrome combined with shoulder stiffness. We performed shoulder arthroscopy again and removed the detached lens arthroscopically. This case warrants the need for the surgeon and the operating room staff to be well acquainted with the arthroscopic instruments and to check the instruments properly before and after the completion of the procedure. If the operating room staff would have identified the damage to the scope, encountered during the primary operation, we could have avoided the second procedure to remove the lens.

The purpose of this study was to determine the anatomical and clinical outcomes of a biceps-incorporating rotator cuff repair without detaching the biceps origin from the glenoid in a large or massive rotator cuff tear, in which the biceps tendon could be incorporated into the cuff defect and help to provide tendon healing and prevent upward migration of the humeral head.Thirty-five consecutive patients with a mean age of 62 years (41-81 years) had primary arthroscopic repair of their large or massive rotator cuff in which biceps tendon incorporated into the cuff defect without detaching the biceps tendon from the glenoid was performed. Functional outcome was determined by the visual analog scale (VAS) for pain during motions, simple shoulder test (SST), the University of California, Los Angeles (UCLA) score, and the American Shoulder and Elbow Surgeons scores (ASES) (mean follow-up, 24 months). The continuity of rotator cuff mechanism was evaluated using the magnetic resonance imaging (MRI) among all the patients after 2 years.At the final follow-up, mean VAS scores increased significantly from 7.1 to 2.0 points, ASES scores from 35 to 83, UCLA scores from 14 to 30, and SST scores from 4 to 9, respectively (p0.05). Moreover, the range of motion was significantly increased except the external rotation from preoperative 27° to postoperative 33° (p = 0.183). MRI evaluation showed that 22 of 35 patients (63%) had heeled tendons and 7 patients (20%) had partial re-tear. Of 35 patients, 6 (17%) had a complete re-tear. Only 3 of these 6 patients were not satisfied with the result.Using this simple biceps-incorporating rotator cuff repair technique, we achieved good clinical and moderate anatomical results, and prevent superior migration of the humeral head in a large or massive rotator cuff tear.Level IV retrospective review.

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis

Transarticular lateral release through a medial incision can avoid a dorsal incision. This study investigated outcomes following hallux valgus correction using transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision.Between June 2004 and May 2009, a single surgeon performed a transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision for hallux valgus on a total of 103 feet of 68 patients. The average patient age at the time of surgery was 51 years, and the average followup was 27 months.The average preoperative and final followup results were: 1) hallux valgus angle improvement from 29 degrees to 5 degrees, 2) intermetatarsal angle from 13 degrees to 5 degrees and 3) medial sesamoid bone position from 3 to 1 (p0.05 for each variable). The average AOFAS scores were improved from 49 to 92, and the VAS pain scores were improved from 7 to 1 (p0.05 for both variables). No patient had a serious complication such as infection, avascular necrosis, nonunion, transfer-metatarsalgia, or first metatarsophalangeal joint arthritis.Hallux valgus correction using transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision was found to be effective and safe. The advantages include that the procedure is simple, early ambulation is possible, and there is no dorsal scarring.

Background: We evaluated the clinical characteristics and treatment outcomes of patients with chronic osteomyelitis in the foot and ankle in patients without diabetes. Methods: We reviewed 15 patients treated for chronic osteomyelitis involving the foot and ankle between September 2004 and March 2007. Patients with diabetes mellitus or who were immunocompromised were excluded. The cause of osteomyelitis, sites of occurrence, causative pathogens, and invasion of the adjacent joint(s) were reviewed, then the clinical characteristics were analyzed. Magnetic resonance imaging was performed to clarify the extent of infection and invasion of the adjacent joint. Surgical management included wide debridement, dead space control, and arthrodesis if there was invasion of the adjacent joint. The mean postoperative followup period was 3.3 years, during which recurrences and complications were evaluated. Results: Extrinsic causes accounted for 86.7% of the chronic osteomyelitis involving the foot and ankle. The most common cause of osteomyelitis was trauma with ten cases due to complications following fractures or dislocation. Methicillin-resistant Staphylococcus aureus and Pseudomonas were the most common causative pathogens. In 46.7% of the patients, the adjacent joint was involved and an arthrodesis was performed. The mean length of the hospital stay was 39.1 days. The average of number of surgeries was two. Fourteen of 15 patients had no recurrence. Conclusion: For the successful treatment of chronic osteomyelitis involving the foot and ankle, an arthrodesis based on invasion of the adjacent joint as well as wide debridement and dead space control was successful in this series. Level of Evidence: IV, Retrospective Case Series

Glomus tumors are rare benign neoplasms. They typically present with a triad of severe pain, point tenderness, and cold sensitivity. Most glomus tumors will form well-circumscribed nodules, and excisional biopsy of masses detected by ultrasonography or magnetic resonance imaging of the lesion can relieve the symptoms. We describe a 30-year-old female patient with nontumorous glomus cell proliferation with clinical symptoms similar to those of glomus tumors. The lesion was treated by exploration and excision, with a satisfactory clinical outcome.

Background The location and degree of bony defects that can affect clinical outcomes remains controversial in recurrent shoulder dislocation. The purpose of this study was to define the most common location of glenoid bony defects in patients with recurrent shoulder dislocation. Materials and methods We analyzed the shape and aspect ratio of 44 glenoids from deceased donors. Glenoid size was analyzed using a 3-dimensional (3D) computed tomography (CT) scan in 24 patients with recurrent shoulder dislocation who underwent arthroscopic Bankart repair. We measured the distances from the center of the longitudinal axis of the glenoid to the anterior glenoid rim at 9 positions, 10° apart, from 3:00 to 6:00 o'clock positions in the cadaver and patient groups. We compared the quantification of glenoid defects in the 24 patients using the 3D CT scan. A predictive model based on a discriminant analysis was developed. Results The largest length differences of the glenoid were at the 3:20 o'clock position. When percentage of bone antidefect of the 3:20 o'clock position was used, the model predicted the existence of a defect with 89.7% hit ratio. Conclusions The major direction of the glenoid defect was in a more anterior position rather than the anteroinferior glenoid in patients with recurrent shoulder dislocation. The 3:20 o'clock position was most common location of glenoid defect in shoulder instability. This pattern of bone loss should be considered by the surgeon when operating on these patients, especially when performing arthroscopic procedures for Bankart repair or bone block operations to the glenoid.

Partial articular surface of the rotator cuff tendon tears has been recognized as a source of treatable shoulder pain and a precursory pathology for full-thickness tendon tears. Arthroscopic rotator cuff repair is a possible surgical method of treatment. Recent data have shown that the treating partial-thickness rotator cuff repairs with transtendon technique shows good clinical outcome. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact bursal part. In cases of high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff, subsequently revision surgery in these patients will be demanding. To mitigate these problems, we describe here a new arthroscopic transtendon repair technique with tenotomized long head biceps tendon augmentation for high grade partial articular rotator cuff tear with the goal of providing increase tendon healing, as well as to minimize the probability of failure of the construct and to improve the clinical outcomes. The clinical results of the first 39 consecutive patients are reported showing significant decrease in pain and improved shoulder scores, as well as the post-operative range of motion and with no cases of re-tear of the rotator cuff tendon.

Study design a retrospective study of surgically managed patients. Objective to evaluate the results of posterior stabilization of thoracolumbar fracture using nonfusion method followed by the removal of metal implants within an appropriate period. Changes in the sagittal alignment and the restoration of segmental motion were also investigated. Summary of background data posterior fusion using a transpedicular screw system remains the treatment of choice for the management of thoracolumbar and lumbar fractures. However, fusion methods result in the permanent loss of segmental motion. If both stability and motion could be achieved, functional results would improve considerably. Methods twenty-three patients under 40 years of age (mean, 28.0 years) with thoracolumbar or lumbar spine fractures were managed by this nonfusion method. Implants were removed at a mean 9.7 months after initial fracture fixation, and patients were observed for more than 18 months. Sagittal alignments of metal fixed segments, heights of vertebral bodies, recovered motion ranges in flexion/extension, right-left bending view were measured radiologically. Clinical aspects, such as gross deformities and functional abilities, were also investigated. Results heights of fractured bodies were well maintained at final follow-up. Initial mean sagittal angle was 17.2° kyphosis, which became 2.8° lordosis after fixation of fractures. This angle was 1.7° kyphosis just before implant removal, 2.4° kyphosis just after implant removal, and showed 5.9° kyphosis at final follow-up. Mean segmental motion was 14.2° in the sagittal plane and 13.1° in the coronal plane at final follow-up. Most patients were satisfied with final gross appearance and functional outcome. Conclusion the described nonfusion method appears to be effective in achieving favorable sagittal alignment and regaining motions of fixed segments. The present study suggests that the nonfusion method is one of the most effective methods for managing thoracolumbar fractures, especially in young active people.

Purpose: The purpose of this study was to analyze complications after reverse total shoulder arthroplasty and report the clinical outcomes with review of previously reported studies. Materials and Methods: Complications after reverse total shoulder arthroplasty were analyzed for 98 patients who underwent reverse total shoulder arthroplasty and were followed-up for at least 6 months. Of 98 patients, 22 were men and 76 were women. The mean age was 75.0±6.5 years (range, 59-92 years) with a mean follow-up period of 22±19 months (range, 6-74 months). The types and time of occurrence of complications, methods of treatment, and clinical outcomes at the final follow-up were analyzed. Results: Complications occurred in 18 of 98 patients (18.4%). Seven of them received operative treatment and 11 were treated conservatively. Two cases had postoperative dislocations and were addressed with open reduction. In 2 cases, periprosthetic fractures occurred and were treated with open reduction and plate fixation. Two acromial stress fractures and 8 cases of heterotopic ossification were managed conservatively. Infection and humeral component loosening occurred in one case, respectively, and were treated with revision arthroplasty. Glenoid component loosening occurred in 2 cases, one of which was treated with revision arthroplasty and the other was managed conservatively. At the final follow-up, clinical outcomes showed a statistically significant improvement. Compared to groups with no complications, there were no significant differences in final clinical outcomes. Scapular notching occurred in 43.9% (43/98 cases). No statistically significant differences of clinical outcomes were observed between the scapular notching group and the no notching group (p＞0.05). Conclusion: In our study, 18% of complications occurred after reverse total shoulder arthroplasty and final clinical outcomes of these complications showed significant improvement. Scapular notching developed in 44% and did not provide a significant clinical effect at short term follow-up.

대퇴골 전자간 골절, 특히 불안정성 분쇄 골절은 점차 그 발생 빈도가 증가하고 있으며, 대퇴골 근위부 골절의 약 50% 정도를 차지하고 있다. 전자간 골절은 대퇴 경부 골절보다 발생 빈도가 4배 정도 많고 노령층에서 주로 발생된다. 따 라서 고령 환자의 불안정성 분쇄 골절에 있어서 골 유합술 대신 인공 고관절 반치환술을 일차적으로 사용하는 것에 대한 관심이 늘고 있으며, 여러 연구에서 골 유합술에 비해 조기 체중 부하 가능으로 인한 여러 전신적인 합병증의 발 생을 감소시키고, 골절부 불유합 및 대퇴 골두 무혈성 괴사 등의 위험성을 제거할 수 있는 장점을 가진다. 전자간 골절 시에 인공 고관절 반치환술을 시행하는 경우 EvansFixation of Greater Trochanter Using an AO Trochanteric Reattachment Device (AO TRD) in Arthroplasty for Intertrochanteric Femur Fracture of Elderly Patients

Purpose: In cases of patients who underwent bipolar hemiarthroplasty (BPHA) for treatment of a pertrochanteric fracture, we compared and analyzed the amount of blood loss and complications between a group using the cemented stem and a group using the cementless stem. Materials and Methods: A total of 104 patients who underwent BPHA for treatment of a pertrochanteric fracture in our hospital for three years and 10 months (From January 2008 to October 2011) were included in this study. Among the 104 patients, 64 patients with a cemented stem were categorized into group 1, and the other 40 patients with an uncemented stem were categorized into group 2. Before surgery, the type of stem was determined by the bone quality of the proximal femur, which had been evaluated with a simple X-ray. Then, after surgery, the amount of blood loss and complications were compared between the two groups. Results: Expected blood loss during the operation was 389.8 cc in group 1, and 395.3 cc in group 2(P=0.88). Postoperatively, average drained blood loss was 219.6 cc in group 1, and 338.1 cc in group 2. Cemented stem was associated with significantly less blood loss (P=0.004). The average operation time in group 1 and in group 2 was 96 minutes and 72 minutes. There was no significant difference in operating time (P=0.85). In addition, there was no difference in INR (International Normalized Ratio) and BMI (Body Mass Index) (P=0.28 and 0.08) regarding total amount of postoperatively drained blood loss. There was no occurrence of hypotensive shock or fatal pulmonary embolism in either group. Three cases of periprosthetic fracture occurred in group 2. Conclusion: Fewer occurrences of postoperative blood loss and fewer complications were observed in the cemented stem group than in the cementless stem group. Preoperative evaluation of bone quality and use of the cement stem for patients with poor bone quality may be a good treatment method that can help to reduce complications.

A completely extruded talus without any remaining soft tissue attachments is extremely rare. The present report describes treatment of a 45-year-old man who sustained a completely extruded talus injury following a rockclimbing fall. Upon admission, the extruded talus was deep-frozen in our bone bank. The open ankle joint underwent massive wound debridement and irrigation for 3 days. Four days later we performed a primary subtalar fusion between the extruded talus and the calcaneus, anticipating revascularization from the calcaneus. However, aseptic loosening and osteolysis developed around the screw and talus. At 12 months post-trauma we performed a tibiocalcaneal ankle fusion with a femoral head allograft to fill the talar defect. Follow-up at 24 months post-trauma showed the patient had midfoot motion, tibio-talar-calcaneal fusion, and was able partake in 4-hour physical activity twice per week.

From February, 2007 to September, 50 patients who underwent minimal invasive unicompartmental knee arthroplasty for treating medial compartment osteoarthritis of the knee were enrolled. The conventional Oxford unicompartmental knee arthroplasty with a 1-peg design was performed in 26 patients, and these patients were 5 males and 21 females with a mean age of 65.1 (±6.9). New 2-peg design unicompartmental knee arthroplasty was performed in 24 patients and these patients were 5 males and 19 females with a mean age of 62.5 (±8.8). The clinical results, the range of motion and the radiologic results were compared between the preoperative period and postoperative 1 year.

Compartment syndrome usually develops as a result of traumatic musculoskeletal injury or vascular injury. Early diagnosis and emergency fasciotomy are mandatory for the decompression of compartment pressure in the acute stage. Minor trauma or a non traumatic event can cause compartment syndrome. No report was available of the folk remedy. We report upon two cases of neglected compartment syndrome caused by a folk remedy.

Compared to other lateral soft tissue release methods during hallux valgus surgery, the medial transarticular approach has the advantages of being reproducible, safe, and simple. However, a few reports have described the disadvantages of medial transarticular lateral soft tissue release, including only inadequate lateral soft tissue release. Herein, we report a case of intermetatarsal neuroma in the first web space after hallux valgus correction using distal chevron metatarsal osteotomy and medial transarticular lateral soft tissue release. This case report aimed to highlight the possibility of nerve damage due to medial transarticular lateral soft tissue release during hallux valgus correction surgery.