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The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

Background Peripheral triangular fibrocartilage complex (TFCC) tears may induce instability of the distal radioulnar joint (DRUJ). In this biomechanical study, simulated peripheral tears of the TFCC were examined on the stability of the DRUJ. Restabilization effect of the DRUJ by ulnar shortening and direct repair of those injuries were sequentially examined. Method The DRUJ stiffness was measured in intact, simulated two types of peripheral tears (ulnar and extended ulnodorsal) at three forearm positions: neutral, 60° pronation and 60° supination in 8 fresh frozen cadaver specimens. After the tears were sutured with stitches or after simulated ulnar shortening of 3 mm, the DRUJ stiffness was again measured. Results The ulnar and ulnodorsal TFCC tears decreased the DRUJ stiffness significantly compared with the intact in all forearm positions. When ulnar shortening was done for the ulnar tear, the DRUJ stiffness increased significantly in the neutral and 60° pronated positions. When the ulnar TFCC tear was repaired, the DRUJ stiffness increased significantly in all forearm positions. DRUJ stiffness did not increase either with ulnar shortening or repair in ulnodorsal tear of the TFCC, however. Conclusion The simulated TFCC tears indicated significant loss of DRUJ stiffness. Direct repair or ulnar shortening was effective only on treatment of the ulnar tear of the TFCC in this study.

We studied the characteristics of acute blocking of supination of the distal radioulnar joint caused by triangular fibrocartilage complex injuries. Twenty-four patients who were treated for acute blocking of supination were retrospectively assessed. Supination was suddenly blocked after minor trauma to the wrist. Active and passive supination was severely restricted with a mean preoperative range of motion (11°), whereas pronation was almost normal. The cause was identified arthroscopically or at open operation. It was found to be a result of avulsion of the dorsal or palmar portion of the radioulnar ligament, which blocked movement of the ulnar head. Blocking was reduced manually in four cases, by arthroscopic surgery in eight cases and by open surgery in 12 cases. After treatment, forearm supination improved to 84° of the mean range of motion. Distal radioulnar joint blocking from a ruptured triangular fibrocartilage complex should be considered in the differential diagnosis of loss of forearm supination. Level of evidence: IV

The purpose of this study was to evaluate the mid- to long-term clinical outcomes of total finger joint arthroplasty using a costal osteochondral autograft for joint ankylosis. Twenty-three joints (three metacarpophalangeal joints, 20 proximal interphalangeal joints) in 23 patients (19 men and four women) were treated with a costal osteochondral autograft and were evaluated after a mean follow-up of 77 months (60–138). Mean age was 33 years (18 to 55). Significant improvement in active finger extension/flexion was seen from a preoperative mean of −24°/26° (arc: 2°) to −13°/75° (arc: 63°) at latest follow-up. Mean preoperative Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand score was initially 24 and improved significantly to 5 at latest follow-up. Conclusion: total finger arthroplasty using a costal osteochondral autograft gave an anatomical and biological reconstruction and provided stable improvement at a mean follow-up of 77 months. Level of evidence: IV

Introduction The safety and efficacy of using artificial collagen nerve conduits filled with collagen filaments to treat nerve defects has not been fully studied in humans. We conducted a multicenter, controlled, open-label study to compare the safety and efficacy of artificial nerve conduit grafts with those of autologous nerve grafts. Methods We included patients with a sensory nerve defect of ≤30 mm, at the level of the wrist or a more distal location, with the first-line surgical methods selected according to a patient’s preference. We compared sensory recovery using static two-point discrimination and adverse events between the artificial collagen nerve conduit and autologous nerve grafting. Results The artificial nerve conduit group included 49 patients, with a mean age of 42 years and nerve defect of 12.6 mm. The autologous nerve graft group included 7 patients, with historical data of an additional 31 patients, with a mean age of 36 years and nerve defect of 18.7 mm. The rate of recovery of sensory function at 12 months was 75% (36/49) for the artificial nerve conduit group and 73.7% (28/38) in the autologous nerve group. No serious adverse events directly associated with use of the artificial nerve conduit were identified. Conclusions The treatment of nerve defects ≤30 mm using artificial collagen nerve conduits was not inferior to treatment using autologous nerve grafts. Based on our data, the new artificial collagen nerve conduit can provide an alternative to autologous nerve for the treatment of peripheral nerve defects.

We investigated the relationship between the radial inclination of the distal radius and distal radioulnar joint stability. Six fresh-frozen upper extremities were used. Radial inclination was decreased by 10° and 20° and increased by 10° from the original radial inclination. Distal radioulnar joint stiffness was assessed with an intact radioulnar ligament and after partial and then complete sectioning of the radioulnar ligament. Radial angulation deformities significantly increased distal radioulnar joint stiffness when the radioulnar ligament is totally or partially attached to the ulnar fovea. After complete sectioning of the radioulnar ligament, distal radioulnar joint stiffness decreased significantly; additional radial angulation deformity slightly increased distal radioulnar joint stiffness, but the distal radioulnar joint never recovered to the original stiffness. Based on the results, radial angulation deformities of the distal radius should be corrected within 10° when the radioulnar ligament is intact, to reduce the risk of symptomatic distal radioulnar joint instability.

Costal osteochondral grafting is a technique to achieve anatomical and biological repair of articular defects. Some small series of clinical applications of this procedure for advanced osteochondritis dissecans of the humeral capitellum, with short-term follow-up, have been reported; however, longer-term outcomes remain unclear. The purpose of this study was to clarify longer-term clinical outcomes of costal osteochondral autografts in the treatment of advanced osteochondritis dissecans of the humeral capitellum.Seventy-two patients with an osteochondral defect of the humeral capitellum were treated with costal osteochondral autograft and followed for a minimum of 3 years (mean follow-up, 57 months; range, 36 to 147 months). The mean patient age was 14.3 years. Clinical outcomes, including elbow range of motion, Timmerman and Andrews clinical rating score, donor-site morbidity, responses to a questionnaire regarding a return to sporting activities, and radiographic findings, were evaluated.The mean elbow range of extension/flexion increased significantly, from -21°/122° preoperatively to -4°/136° postoperatively (p0.001). The mean clinical rating score improved significantly, from 101 to 190 by the latest follow-up (p0.001). The overall clinical score-based assessment was excellent for 60 patients, good for 9, and fair for 3. Seventy of the 72 patients returned to their original sport. The remaining 2 patients had changed sporting activities before surgery and did not return to baseball, despite satisfactory clinical results.Costal osteochondral autograft successfully achieved anatomical and biological reconstruction in the treatment of advanced osteochondritis dissecans of the humeral capitellum.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Trapeziometacarpal (TMC) arthrodesis provides stability and strength of the thumb, whereas fixation of the TMC joint restricts motion of the thumb, which may consequently impair the activity of daily living. The objective of our study was to investigate how length and area of the thumb-tip trajectory were reduced after the TMC joint fusion. Methods Six fresh, frozen cadavers were used for this study. Tension was applied to the distal tendons of 4 extrinsic thumb muscles (extensor pollicis longus, flexor pollicis longus, abductor pollicis longus, and extensor pollicis brevis) by servomotor, whereas tension was applied to 4 intrinsic muscles (abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis) using static weights. The thumb-tip trajectory was examined using a motion capture system without tension and with 5 different weights to induce intrinsic muscle tension before and after the TMC joint fusion. Findings When tension was applied to the intrinsic muscles, the length of the thumb-tip trajectory decreased in all conditions compared with that before the TMC joint fusion, whereas the trajectory decreased only when the abductor pollicis longus was pulled. The overall thumb-tip trajectory area was reduced to approximately 30% compared with that before the TMC joint fusion. Interpretation Thumb-tip trajectory was restricted by the TMC joint fusion to approximately 30%. However, the reduced area was found tolerable for performing daily activities. Thus, arthrodesis can be the first-line treatment in patients who wish to engage in activities of daily living without difficulties.

Background Recently, arthroscopic Bankart repairs have become much more popular than open repairs for the treatment of recurrent anterior shoulder instability. However, it is unclear whether the modern arthroscopic Bankart repairs using suture anchors could restore equivalent stability to open repairs. We conducted a meta-analysis to compare arthroscopic Bankart repairs using suture anchors and open repairs in regard to clinical outcomes. Methods A literature review was performed according to the PRISMA guidelines. PubMed was searched from January 1966 to January 2017. Studies were identified using the terms ‘anterior shoulder dislocation’ or ‘recurrent anterior shoulder dislocation’ and ‘Bankart repair’. The search yielded 36 publications. After reading the full-text articles, we included four randomized controlled trials and five retrospective studies that compared arthroscopic and open repairs using suture anchors. Results No significant differences were found between the two procedures in frank re-dislocation and revision surgery due to recurrence. However, the overall recurrent instability including not only re-dislocation but also subluxation and apprehension was significantly higher in arthroscopic repairs than in open repairs, while a significantly higher Rowe score and lower loss of external rotation at 90° of abduction were observed following arthroscopic repairs compared to open repairs. Conclusions Modern arthroscopic Bankart repairs using suture anchors provide an equivalent outcome compared to open repairs in terms of apparent re-dislocation, but overall recurrent instability including subluxation or apprehension was still significantly higher in arthroscopic repairs than in open repairs.

Wrist arthroscopy is now widely indicated for diagnosis and treatment of acute or chronic wrist pain, especially for triangular fibrocartilage complex (TFCC) lesions, as a gold standard. In most cases radiocarpal and midcarpal arthroscopy was performed, while DRUJ arthroscopy has been rarely performed because of its difficulties. Recent anatomic and biomechanical studies demonstrated that the radioulnar ligament (RUL), which is the proximal component of the TFCC facing to the DRUJ, is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the fovea area, where it is the main attaching portion to the ulna and is the isometric point during forearm rotation as the rotation axis passes, is responsible for DRUJ instability. Although physical examination and imaging diagnosis may indicate a foveal detachment of the TFCC, DRUJ arthroscopy is potential for visualizing the RUL at the fovea. Role of DRUJ arthroscopy should be more important not only for diagnosis of rupture of the RUL but also for decision making of treatment option for RUL tear. DRUJ arthroscopy also demonstrates the joint surface of both the sigmoid notch and ulnar head, and the proximal surface of the TFCC.

Purpose To assess the outcomes of our technique involving oblique headless compression screw for arthrodesis of the thumb interphalangeal joint and the distal interphalangeal joints of the other digits. Methods A total of 28 joints (19 thumb interphalangeal and 9 distal interphalangeal) in 23 patients with a mean age of 65 years (range, 58–74 y) were retrospectively analyzed. All operations were performed with the Acutrak2 micro-screw. After the resection of synovium and joint cartilage by a dorsal approach, a 0.88-mm diameter guide wire was inserted at the ulnar side of the proximal phalanx in the thumb and radial side of the middle phalanx in the other digits from proximal to distal to fix the joint obliquely. We verified its position under fluoroscopic control and placed the cannulated screw from proximal to distal over the guide wire. Results Intraoperative rigid fixation was obtained except for 1 case, which required additional K-wire fixation. The overall union rate was 96%. Average time to fusion was 11 weeks (range, 8–30 wk), with 76% achieving union within 3 months. There were 2 complications, 1 nonunion and 1 late infection. Other complications such as dorsal skin necrosis, nail deformity, and paresthesia did not occur. Conclusions Efforts to avoid invasion of the nailbed can be technically demanding. We believe that our proximal to distal technique with oblique placement of the headless compression screw is a straightforward and effective method with a relatively low risk of complication. Type of study/level of evidence Therapeutic IV.

We examined the medium- to long-term outcome of the original reconstruction technique of the radioulnar ligament using a half-slip of the extensor carpi ulnaris tendon for chronic foveal avulsion of the triangular fibrocartilage complex. We treated 37 wrists in 36 patients with a minimum follow-up of 5 years. Of 36 patients, 12 had more than 10 years follow-up. At final follow-up, 30 patients (31 wrists) reported no pain, five patients (five wrists) reported mild occasional pain and one patient reported severe persistent pain. Two patients had lost 30° of supination. Complete stability of the distal radio-ulnar joint was achieved in 31 wrists, moderate instability was noted in five and severe distal radio-ulnar joint instability remained in one. The size of the bone tunnel was assessed radiologically: in two it had enlarged; in 23 it was unchanged; and in 12 it appeared to have closed over the tendon graft. The overall clinical outcomes were 28 excellent, four good, four fair and one poor. The 12 wrists with more than 10 years follow-up had seven excellent, three good and two fair clinical results. This reattachment technique appears to work and last over the medium- to long-term. Level of evidence: IV

The aim of this study was to validate the potential association between cigarette smoking and cubital tunnel syndrome (CubTS).One hundred patients with CubTS were compared with 100 controls with ulnar abutment syndrome matched for age, gender, and body mass index. The smoking status was compared between patients and controls using the sign test and the Wilcoxon signed rank test. Conditional logistic regression was used to calculate the association between CubTS and pack-years smoked.A significant association was found between increased pack-years smoked and CubTS. A significant difference in the number of never smokers and ever smokers was observed between the patients with CubTS and controls. The difference in mean pack-years in the patients and controls was highly significant. A dose-dependent association with pack-years was found between patients and controls.High cumulative cigarette smoking is associated with CubTS. Muscle Nerve 54: 1136-1138, 2016.

Background: The Michigan Hand Outcomes Questionnaire (MHQ) has shown reliability, validity and responsiveness and has been used to assess surgical outcomes mainly in North America. We established a Japanese version of the MHQ and evaluated its reliability and validity compared with both the short-form 36 (SF-36) questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in a Japanese-speaking population. Methods: The MHQ was cross-culturally adapted to a Japanese version according to guidelines. Sixty-eight patients with hand conditions were enrolled in this study and answered the MHQ, DASH questionnaire and SF-36 questionnaire. The MHQ was completed again with an interval of one or two weeks. Reproducibility and internal consistency were statistically assessed by the test-retest method and calculating Cronbach's alpha. Spearman's rank correlation was calculated to assess associations between the MHQ and the SF-36 questionnaire as well as the DASH questionnaire. Results: The intraclass correlation coefficients of MHQ subscales ranged from 0.68 to 0.93. Aesthetics subscale of the left hand showed the lowest intraclass correlation but still a good correlation. Cronbach's alpha values of the MHQ ranged from 0.81 to 0.96 for all subscales. The absolute values of Spearman's rank correlation coefficient between MHQ subscales and DASH function/symptoms scores ranged from 0.49 to 0.82. Spearman's correlation coefficients of the MHQ total score to subscales of the SF-36 questionnaire ranged from 0.42 to 0.68. The strongest correlations were found between work performance of the MHQ and rolephysical of the SF-36 questionnaire. Conclusions: The Japanese version of the MHQ has adequate instrument properties for assessing hand outcomes compared with the SF-36 questionnaire as well as the DASH questionnaire.

A case of radial and volar perilunate trans-scaphoid fracture dislocation in which the proximal fragment of the scaphoid was dislocated dorsally is presented.

We report the case of a 43-year-old man with steroid-induced osteonecrosis of the distal humerus in both arms. Costal osteochondral autografts were used to restore both joints with satisfactory outcomes.

We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients < 50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases > 50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p < 0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is < 50 years of age, and the pre-operative delay is < seven months. If the patient is > 50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure.

Background: A variety of osteotomies has been proposed to correct posttraumatic cubitus varus deformity as well as any associated hyperextension and/or rotational deformities. However, lateral closing-wedge osteotomy and step-cut osteotomy, both of which have been used extensively with satisfactory outcomes, correct only in the coronal plane. To date, no direct comparison has been made between three-dimensional and simple coronal plane osteotomies. Methods: Between 1983 and 2007, we treated eighty-six elbows with a posttraumatic varus deformity. We classified patients who underwent three-dimensional osteotomies as Group I and those who underwent simple coronal plane osteotomies as Group II, and we compared the outcomes between the groups. Clinical evaluation included an assessment of the carrying angle and measurement of the passive range of motion before surgery and at the time of the final follow-up. To evaluate the remodeling capacity of the bone to recover elbow flexion in Group II, we assessed the range of motion before surgery and at the time of the final follow-up in patients who were less than ten years old and those who were more than ten years old. Results: There was no significant difference between the groups with regard to the carrying angle or the elbow range of motion, either before surgery or at the time of the final follow-up. However, Group I had more significant loss of correction (p = 0.018). In Group II, elbow motion reached the physiological range by the time of the final follow-up in patients who were less than ten years old. Conclusions: For osteotomies to correct cubitus varus deformity, correction of internal rotation is not needed. With a three-dimensional osteotomy, it is difficult to maintain correction and to acquire the planned carrying angle because of the small area of bone contact. It is necessary to correct hyperextension in patients older than ten years of age, as after that age bone remodeling is not expected to increase elbow flexion. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

We retrospectively defined the rate and clinical features of tendon entrapment in 693 consecutive patients with 701 distal radius fractures treated in a single hospital. Eight extensor tendons and one flexor tendon were entrapped. All fractures with extensor tendon entrapment were palmarly displaced (Smith type) or epiphyseal. Flexor tendon entrapment was seen in dorsally angulated (Colles type) epiphyseal fracture. The rate of tendon entrapment in acute distal radius fractures was 1.3%. Extensor tendon entrapment in palmarly displaced fractures is more common.

Cartilage disorders of the finger joint may influence hand function. Loss of integrity of the finger joint may severely compromise its stability and may lead to degenerative arthritis. Anatomical reduction of the finger cartilage should be as precise as possible in treating cartilage defects due to trauma and other causes. We have repaired cartilage defects in finger joints by arthroplasty with costal osteochondral grafting in 29 patients (30 joints) since 1997. Three patients underwent total joint reconstruction using costal osteochondral grafting for complete bony ankylosis (1 metacarpophalangeal joint and 2 proximal interphalangeal joints). The purpose of this study was to describe the history, indications, and surgical techniques of the costal osteochondral graft for cartilage disorders or defects in the metacarpophalangeal and proximal interphalangeal joints.

Purpose For the purpose of achieving anatomical reduction as precisely as possible, we performed osteochondral grafting from the costo-osteochondral junction in 16 patients (17 joints) with posttraumatic articular cartilage injury or avascular necrosis in finger joints. The purpose of this study was to review our series of costal osteochondral grafts in order to determine the practicality, effectiveness, and functionality of this grafting technique in a clinical setting. Methods Patients were followed for at least 18 months postoperatively (18–57 months; average, 28 months). The injured joints included 3 metacarpophalangeal, 9 proximal interphalangeal, 3 distal interphalangeal, and 2 thumb interphalangeal joints. The defect accounted for 50% to 100% of the articular surface (average, 63%). Results The average time until bone union of the graft was 58 days. The mean arc of motion was 13° before surgery versus 58° after surgery, with a mean increase of 45°. In 7 patients (8 joints), an extremely small portion (approximately 1 × 1 mm in size and thinner than 0.1 mm) of the implanted cartilage was obtained via biopsy using a scalpel with the consent of the patient at the time of screw removal and was used to prepare histologic specimens, which revealed scattered chondrocytes within the matrix without differences from normal hyaline cartilage in any. The chondrocytes in the grafts appeared viable, and the reconstruction of the joint surface could be confirmed histologically. Conclusions Osteochondral grafting from the costo-osteochondral junction achieves excellent reconstruction of the injured joint without affecting other joints. This technique is particularly beneficial in cases where it is difficult to obtain allograft donors, as is often the case in Japan. Despite these encouraging findings in this small series, we believe that it is necessary to conduct further studies of this method over a longer period. Type of study/level of evidence Therapeutic IV.

Purpose The ulnar-shortening procedure has been successfully used to relieve ulnar impaction syndrome and may help in stabilizing the distal radioulnar joint (DRUJ) by increasing the tension within the triangular fibrocartilage complex. This procedure, however, may increase pressure at the DRUJ and possibly induce degenerative changes in the joint. This study aimed to examine the changes in pressure at the DRUJ by simulating the ulnar-shortening procedure in intact and torn states of the triangular fibrocartilage complex. Methods Seven fresh-frozen cadaver arms amputated at the midportion of the humerus were used. The ulna and humerus were affixed firmly to a custom mount that allowed 60° forearm rotation. An external fixator was attached to the distal ulna, leaving a 10-mm space to allow progressive shortening. Pressure sensors were inserted in the DRUJ, and pressure distribution in the joint was recorded after every 1-mm shortening that was performed up to a maximum of 6 mm with or without the application of muscle load. These data were then compared with those obtained with the original length of the ulna in 3 joint positions: neutral, 60° pronation, and 60° supination. The tests were repeated after sectioning either the dorsal or the palmar portion of the radioulnar ligament (RUL) and finally after complete sectioning of the RUL. Results The peak pressure at the DRUJ increased notably in the intact specimens during progressive ulnar shortening. Compared with the intact specimens, those with partial RUL sectioning exhibited a smaller increase in the peak pressure with ulnar shortening. Complete sectioning of the RUL at its attachment to the ulnar fovea resulted in even smaller increases. Conclusions The greater the amount of ulnar shortening, the higher is the peak pressure at the DRUJ. The amount of ulnar shortening should be carefully planned to avoid excessive pressure at the DRUJ.

We report two extremely rare cases of dorsal radial avulsion injury of the triangular fibrocartilage complex accompanied by an avulsion fracture of the sigmoid notch of the radius. Anatomical reduction of the bone fragment in conjunction with reattachment of the dorsal portion of the radioulnar ligament to the radial sigmoid notch were necessary to restore stability of the distal radioulnar joint and tension of the triangular fibrocartilage proper.

An 8-year-old boy with a history of the inability to extend the middle finger at the proximal interphalangeal and distal interphalangeal joints with the wrist and metacarpophalangeal joints in the neutral position since the age of 5 months had surgery. The flexor digitorum profundus muscle of the middle finger had a short muscle belly and was replaced in part with mature fat tissue. Histologic examination of the resected tissue showed replacement of a part of the muscle with mature fat tissue. It was speculated that some myosatellite cells, which typically differentiate into skeletal muscle cells, may have erroneously differentiated into adipocytes in the first postnatal year, during which complete development of skeletal muscles occurs.

Congruity of the ulnohumeral joint, especially its anterior portion, is an important stabilizer of the elbow joint. We report on 3 patients in whom the insufficiency of the coronoid process, such as nonunion or a flattened trochlear notch, was associated with posterolateral rotatory instability of the elbow. In our opinion, addressing the anterior bony integrity of the ulnohumeral joint, in addition to the ligamentous stabilizer and mechanical axis, is essential to achieve stability in these circumstances. This issue is discussed with a review of the literature.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up. In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05). The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation. There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head. Cite this article: Bone Joint J 2015;97-B:1582–7.

We developed an original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw for chronic foveal avulsion of the TFCC. The clinical outcome of 66 wrists with foveal detachment of the TFCC treated by this procedure was examined. A distally based ECU half-slip was harvested, inserted into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the centre of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw. We evaluated 66 wrists of 65 patients with a minimum follow-up of 1 year. Ulnar variance was neutral in 47 wrists, negative in 5 and positive in 14 wrists. Causes of injury were falls in 34 patients, traffic accidents in 12, sports activities in 9, labour in 2 and unknown in 8 patients. In the positive variance wrists, ulnar shortening was performed before the reattachment. The clinical outcome was evaluated using our original DRUJ evaluating system. Preoperatively, severe wrist pain was reported in 50 wrists and moderate pain in 16 wrists. Severe no-endpoint DRUJ instability was noted in 65 wrists, while 1 wrist demonstrated moderate DRUJ instability. Only 2 wrists had supination loss by 20 degrees. At the final follow-up, no pain was felt in 55 wrists, mild pain in 3 wrists, and 8 patients had moderate pain. One wrist exhibited a 30-degree loss of supination. The DRUJ was stable in 55 wrists, mildly unstable in 3, moderately unstable in 4 and severely unstable in 4 wrists. There were 50 excellent, 9 good, 3 fair and 4 poor results. The technique of anatomical reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is effective for chronic foveal avulsion of the TFCC with severe DRUJ instability.

A case of successful treatment of pronation contracture of the forearm due to iatrogenic scar formation in the distal membranous part of the interosseous membrane of the forearm is presented and the management of this problem is discussed.

Purpose Laboratory studies evaluating the importance of the stabilizing structures of the distal radioulnar joint (DRUJ) largely have been limited to static design. Clinically, dynamic loading seems to be an important component of DRUJ instability. This study was designed to evaluate the influence of dynamic loading on the stability of the DRUJ with foveal versus styloid triangular fibrocartilage complex (TFCC) disruptions in a laboratory setting. Methods Twelve fresh-frozen cadaveric upper-extremity specimens were tested using a dynamic simulator to study the contributions of the 2 ulnar insertions of the TFCC to the dynamic stability of the DRUJ. The specimens were tested in 3 loading conditions (no load, agonist loading, antagonist loading) in 3 different states of the TFCC (intact, foveal disruption, styloid disruption). Results Without load no significant differences were found for the different conditions of the TFCC. Under loaded conditions the foveal insertion had a greater effect on stability than did the styloid insertion. Under agonist loading significant differences were found during supinating and pronating motions. With antagonist loading a significant difference was found only during supination. Conclusions The study results support the clinical impression that dynamic loading is an important component of DRUJ instability and that disruption of the foveal TFCC insertion into the foveal region of the distal ulna can produce instability.

We studied the changes in the shape of the triangular fibrocatilage (TFC: disc proper) which occur during forearm rotation in disarticulated and articulated wrists. The influence of artificial 3 mm ulnar lengthening on distortion of the disc was also examined. In the disarticulated wrists, slight distortion of the central and radial portions of the TFC was observed in the ulnar neutral variance specimens. More distortion was noted in the radial and central portions of the TFC in specimens with positive ulnar variance or with the ulna lengthened. However, in the articulated wrist, the TFC demonstrated little change in shape during pronosupination even in the ulnar positive variance wrists or with the ulna lengthened. There was no significant change in palmar and dorsal peripheral lengths of the TFC in ulnar neutral, ulnar positive or ulna-lengthened specimens at three rotatory positions of the forearm. These findings suggest that changes in ulnar variance which occur during forearm rotation can produce distortion on the TFC, but the carpus helps to maintain the shape of the TFC during pronation–supination, even with positive ulnar variance.

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC.The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score.Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24-210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed.Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2=0.21; β=-0.33; 95% CI, -0.11 to 0.01; p=0.01) and between the magnitude of change in the TFC angle and the extent of ulnar shortening (R2=0.18; β=-0.29; 95% CI, -5.8 to 0.29; p=0.03). The Mayo wrist score was not correlated with the percent change in TFC thickness or the magnitude of change in the TFC angle.These results suggest that, in patients with TFCC injury with a smaller preoperative ulnar variance, a high residual potential for regeneration in the disc proper was seen after ulnar shortening osteotomy, and correlated with the extent of ulnar shortening and the suspension effect on TFC. However, there was no correlation between disc regeneration or the suspension effect on TFC and the Mayo wrist score.Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

The relationship between increased volar tilt of the distal radius and distal radioulnar joint stability was examined. Distal radioulnar joint stiffness was recorded at 10° intervals from 10° dorsal angulation to 20° of volar angulation from the anatomical position of the radius. Tests were performed with the intact radioulnar ligament and repeated after partial and then complete sectioning of the radioulnar ligament at the ulnar fovea. With the intact radioulnar ligament, distal radioulnar joint stiffness increased significantly at 10° and 20° of volar angulation. Partial sectioning of the radioulnar ligament resulted in an approximate 10% decrease of distal radioulnar joint stiffness compared with the intact state, but distal radioulnar joint stiffness still increased significantly with greater volar tilt. Complete sectioning of the radioulnar ligament significantly decreased distal radioulnar joint stiffness, and increasing the volar tilt did not result in increased distal radioulnar joint stiffness. These results suggest that volar angulation deformities of the distal radius should be corrected to 10° of volar tilt when the triangular fibrocartilage complex is intact. Level of Evidence: N/A

Three-dimensional fingertip trajectory was examined under different force levels of the lumbrical muscle to clarify the function of the lumbrical muscle in free index finger motion. The metacarpophalangeal joint balancing effect of the lumbrical muscle in the thumb-up position was also examined. The motions of the finger bones were recorded during simulated contraction of flexor digitorum profundus when different forces (0.000–1.960 N) were applied to the lumbrical muscle in cadaveric specimens. The greater the force with which the lumbrical muscle was pulled, the larger the arc formed by the fingertip, and the greater the rebalancing influence on the metacarpophalangeal joint. This result indicates that the lumbrical muscle functions simultaneously to enlarge the fingertip trajectory and to balance the metacarpophalangeal joint against gravity in the axial plane. A 0.980 N force was ideal for maximal finger movement. The lumbrical muscle rebalanced the metacarpophalangeal joint against gravity in the thumb-up position with a force ⩾0.980 N.

Ulnar deviation is a common complication in patients with rheumatoid arthritis (RA). We report a case of an unusual radial deviation of the middle finger caused by an occult intramuscular ganglion of the second interosseous muscle (IOM) in a patient with RA. The resection of the ganglion did not resolve the problem, and the full range of motion of the metacarpophalangeal (MP) joint was achieved through dissection of the tendon of the second dorsal IOM.

We investigated the influence of radial styloidectomy on carpal alignment and examined translation of the wrist after sequentially increased styloidectomy of 8 cadaver wrists. The radial aspect of the scaphoid fossa of the distal radius was cut obliquely at 3, 6, and 10 mm from the radial styloid guided by real-time fluoroscopy. Radiographic analysis of the changes of carpal alignment was performed with the wrist in neutral position. Force-displacement curves from the neutral to the radioulnar and palmar-dorsal directions were obtained using a multi-axis testing machine. Results demonstrated no significant malalignment of the carpal bones after radial styloidectomy. Significantly increased radial translation (>40% reduction in stiffness), however, was observed due to the loss of radial articular contact after 6- and 10-mm radial styloidectomies. Significant ulnar and palmar carpal displacement also was noted after 6- and 10-mm radial styloidectomies, with 6 specimens demonstrating moderate ulnar and palmar translation and 2 demonstrating notable increased palmar and ulnar translations. We conclude that there is a definite risk of increased carpal instability with radial styloidectomy procedures. A styloidectomy of no more than 3 to 4 mm is recommended.

Objective. To analyse in vivo normal forearm rotation utilizing the image processing method on axial magnetic resonance imaging. Design. Rotatory motion and translation of the radius and rotation of the ulna were analysed in vivo, utilizing features of the bone image; axial centre of gravity and axis of the bone. Methods. Axial magnetic resonance images at the proximal, middle and distal portion of the right forearms of 20 healthy volunteers were examined in five rotational positions, maximum pronation, 45° pronation, neutral, 45° supination and maximum supination. The axis of forearm rotation, the rotation angle of the radius, the rotation of the radius around its axial centre of gravity, and the rotation of the ulna around its axial centre of gravity were calculated on these axial MR images. Results. The radius rotates in a near-circular ellipse around its rotational centre located on a line through the radial head and the ulnar head from maximum supination to 45° pronation. There was discrepancy between the calculated maximum rotational angle of the radius and the pronation–supination angle showed on the goniometer. This discrepancy was due to motion at the radiocarpal, midcarpal and carpometacarpal joints. The rotation of the ulna ranges within 6°. At maximum pronation, there was palmar translation of the radius. Conclusions. The forearm rotation is not a simple rotatory motion but a complex motion with rotation and translation. The palmar translation of the radius at maximum pronation may be caused by incongruity of the distal radioulnar joint and contraction of the pronator quadratus muscle. Relevance To date there exist few methods for the accurate and non-invasive assessment for motion analysis of the forearm rotation. Such a technique utilizing magnetic resonance image characteristics is, however, helpful to reveal accurate self- and relative-rotatory motion of both radius and ulna as well as the translation movement on forearm rotation in normal forearm.

We now report newly developed three-dimensional magnetic resonance imaging (3D-MRI) system which is based on semiautomatic tissue extraction from the axial MR images utilizing the fuzzy reasoning calculation method and 3D-image reconstruction with surface rendering. We also studied normal in vivo dynamic changes of the interosseous membrane (IOM) of forearm during rotation using this 3D-MRI. Serial axial MRI of right forearms of five healthy volunteers was obtained in five rotational positions, and extraction and 3D-reconstruction of the radius, ulna, and IOM was made using the system. Extraction results were well with the fuzzy reasoning method. 3D-MRI of the radius and ulna, IOM were reconstructed from these images respectively, and their 3D-shapes were almost identical to the anatomic shape. 3D-MRI showed there were wavy deformities on the IOM in pronation position in the all five subjects and dorsiflexion on the most dorsal portion of the IOM at maximum supination in three forearms. In neutral position, the IOM of all five volunteers was almost flat. From anatomic orientation, these dynamic changes of the IOM mainly occurred at the membranous portion, which is soft, thin, and elastic. Otherwise, the tendinous portion which is a thick and strong complex of 5 to 10 bundles run from proximal one third of the radius to distal one fourth of the ulna, demonstrated minimal dynamic changes on the 3D-MRI. Therefore, the tendinous portion is considered to be taut during rotation to provide stability between the radius and the ulna, while the membranous portion is easy to deform and allowing smooth rotation. Furthermore, because of wide-use, our 3D-MRI system is useful for in vivo analysis of soft tissue kinesiology in normal and abnormal musculoskeletal systems.

We used magnetic resonance (MR) myelography in ten patients with injuries to the brachial plexus and compared the findings with those obtained by conventional myelography and postmyelographic CT (CTM). In the presence of complete nerve-root avulsion (seven cases), a post-traumatic meningocele was detected by MR myelography. In injuries to the upper roots (three cases) MR myelography showed abnormal findings with a high signal intensity in the nerve root, obliteration of the damaged nerve root, or enlargement and obliteration of the root sleeve. No pseudomeningoceles were detected in these upper-root injuries by MR myelography and CTM. The overall accuracy of detection of damaged nerve roots or root sleeves was better with MR myelography than with conventional myelography and was similar to that of CTM. MR myelography is non-invasive, relatively quick, requires no contrast medium, provides imaging in multiple projections, and is comparable in diagnostic ability to the more invasive, time-consuming techniques of conventional myelography and CTM.

To demonstrate the clinical feasibility of high-resolution three-dimensional (3D) isotropic FSE MRI of the wrist by comparing it to high-resolution conventional 2D FSE (2D) MRI.Eleven healthy volunteers were enrolled. All images were obtained at 3 Tesla (T). Delineation of anatomic structures of the wrist, amount of artifact, quality of fat suppression, image blur, and overall quality were qualitatively evaluated. Relative signal intensity (SI) of each structure and relative signal contrast between structures of the wrist were quantitatively measured.The 2D MRI demonstrated significantly higher scores than 3D in anatomic delineation of the SL ligament (P = 0.013), fat suppression (P = 0.013), and image blur (P = 0.003). The remaining quantitative analyses, including overall quality, revealed no statistical significances between 2D and 3D MRI. There were no statistical differences in relative SI of each structure between 2D and 3D imaging, except for bone marrow with fat suppression. There were no significant differences in relative fluid to TFCC and fluid to bone marrow contrast between 2D and 3D imaging, suggesting that both sequences have similar rates of detection for TFCC pathology and bone marrow lesions.With regard to clinical applications, 3D MRI of the wrist has almost equal potential to 2D MRI.

Relationship between dorsal tilt of the distal radius and distal radioulnar joint stability was examined. Stiffness in dorsopalmar displacement of the radius (distal radioulnar joint stiffness) was recorded at 10° intervals until 30° of dorsal angulation from 10° of palmar tilt. Tests were repeated after partial sectioning of the radioulnar ligament, then after complete sectioning of the radioulnar ligament. All data were compared with control (intact triangular fibrocartilage complex, 10° of palmar tilt). The distal radioulnar joint stiffness in dorsal translation decreased significantly with dorsal tilt 10° and 20° in pronation. Partial sectioning of the radioulnar ligament indicated a decrease of the distal radioulnar joint stiffness in the dorsal translation at neutral tilt to 20° of dorsal tilt in the neutral position and in pronation. Distal radioulnar joint stiffness decreased significantly in both dorsal and palmar translations in all forearm positions at 10° and 20° of dorsal tilt. From these findings, the dorsal angulation of the radius should be corrected to less than 10° of dorsal tilt.

Simple decompression of the ulnar nerve at the elbow has not been shown to reduce nerve strain in cadavers. In this study, ulnar nerve strain at the elbow was measured intraoperatively in 11 patients with cubital tunnel syndrome, before and after simple decompression. Statistical analysis was performed using a paired Student’s t-test. Mean ulnar nerve strain before and after simple decompression was 30.5% (range 9% to 69%) and 5.5% (range −2% to 11%), respectively; this difference was statistically significant ( p < 0.01) with a statistical power of 96%. Simple decompression reduced ulnar nerve strain in all patients by an average of 24.5%. Our results suggest that the pathophysiology of cubital tunnel syndrome may be multifactorial, being neither a simple compression neuropathy nor a simple traction neuropathy, and simple decompression may be a favourable surgical procedure for cubital tunnel syndrome in terms of decompression and reduction of strain in the ulnar nerve.

Hypothesis We hypothesized that the clavicle overrides the acromion during certain shoulder motions for individuals with acromioclavicular (AC) joint separation producing clinical symptoms. We measured 3-dimensional clavicular and scapular motions in AC joint separation models during humerothoracic motions, which should be impacted by the loss of AC joint continuity. Materials and methods Ten shoulders from 6 whole cadavers were used. The scapular and clavicular motions were measured in intact and AC joint separation models using an electromagnetic tracking device. The measurement was performed during shoulder abduction with humerothoracic neutral rotation. It was also measured during shoulder abduction with humerothoracic internal rotation, which could cause clavicular overriding. The kinematic changes caused by ligament sectioning were evaluated in these 2 arm motions. Results The clavicle completely overrode the acromion in all AC separation models during abduction with internal rotation, but not in any shoulders during abduction with neutral rotation. Upward clavicular rotation increased, posterior clavicular rotation decreased, and external scapular rotation decreased with ligament sectioning. These kinematic changes were common for both of the measured arm motions. Scapular upward rotation and posterior tilt did not change because of ligament sectioning during abduction with neutral rotation. However, these scapular rotations significantly decreased with ligament sectioning during shoulder abduction with internal rotation. Conclusion Scapular and clavicular kinematics were affected in AC separation models. Abduction with humeral internal rotation resulted in a decrease in scapular posterior tilt and upward rotation in AC separation models, and thereby could lead to AC joint articulation dysfunction.

Background: Scapulothoracic dyskinesis is an important consequence of acromioclavicular joint dislocations. However, no reports have described changes in 3-dimensional motions of the scapula and clavicle with respect to the thorax caused by acromioclavicular joint dislocation. Hypothesis: Sectioning of the acromioclavicular (AC) and coracoclavicular (CC) ligaments affects scapular and clavicular motion in a whole-cadaver model. Study Design: Controlled laboratory study. Methods: We evaluated shoulder girdle motion (scapula, clavicle, and humerus) relative to the thorax of 14 shoulders from 8 whole cadavers after sequential sectioning of the AC and CC ligaments (trapezoid and conoid ligaments). An electromagnetic tracking device measured 3-dimensional kinematics of the scapula and clavicle during humerothoracic elevation in the coronal and sagittal planes and adduction in the horizontal plane. Results: Sectioning of the AC ligament increased clavicular retraction during sagittal plane elevation and horizontal plane adduction. Sectioning of the trapezoid ligament decreased scapular external rotation during sagittal plane elevation and horizontal plane adduction. Sectioning of the conoid ligament decreased scapular posterior tilting during sagittal plane elevation and horizontal plane adduction. Acromioclavicular and CC ligament sectioning also delayed clavicular posterior rotation and increased clavicular upward rotation during coronal plane elevation. Conclusion: Our study revealed that AC and CC ligament disruption affected in vitro shoulder girdle kinematics in the whole-cadaver model. Clinical Relevance: The results of this cadaveric study revealed that AC and CC ligament disruption could cause dyskinesis of the scapula and clavicle. The kinematic changes could be a potential source of pain and dysfunction in the shoulder with AC joint dislocation, and therefore surgical reconstruction may be indicated in certain patients.

Background: The mechanical properties of the foot are controlled by many structures including muscles, tendons, ligaments, tarsal joints and bones. Among them, muscles make the dynamic changes of foot alignment, especially the posterior tibial (PT) and peroneal longus (PL) which contribute to maintaining the foot arch. The purpose of this study was to quantify the effect of PT and PL on the foot mechanical properties. Methods The mechanical properties with a longitudinal load to the tibia was measured in eight cadaveric feet. The measurement was carried out with absence of tendon traction (control), the presence of isolated traction of each tendon of the PT or PL, and finally after simultaneous traction of both tendons. Results The bone displacement significantly decreased with tendon traction. The stiffness significantly increased with PT traction compared to control, and significantly decreased with PL traction and with traction of both tendons. Among the four testing conditions, the energy during loading was least with isolated PT traction. The energy dissipation rate was significantly increased with PL traction and with traction on both tendons, whereas no significant difference existed with PT traction compared to control. Conclusions The PT increased the stiffness and reduces the energy stored in the foot. The PT acted to improve the energy efficiency of the load transmission. The PL decreased the stiffness and increased the energy stored. Clinical Relevance: PT and PL muscles affect the foot arch. Excessive or insufficient traction may cause some foot disorders.

Because the radioulnar ligament attaches to the ulnar fovea and base of the ulnar styloid, foveal detachment of the triangular fibrocartilage complex (TFCC) induces severe distal radioulnar joint instability. This article describes both an arthroscopic and open repair technique to reattach the TFCC to the fovea. Both techniques reanchor the detached TFCC to the fovea. Both techniques are reliable and promising techniques in the repair of a foveal detachment of the TFCC.

Diagnosis of injuries to the ligamentous structures of the wrist can be a challenge, particularly when there is involvement of the small, complex structures of the proximal wrist. Recent advances in magnetic resonance (MR) imaging, especially in spatial and contrast resolution, have facilitated more precise visualization of these structures. However, there are a number of pitfalls that may cause difficulty in diagnosis of injuries to the triangular fibrocartilage complex (TFCC), lunotriquetral ligament, and scapholunate ligament. Use of inappropriate MR imaging sequences and MR imaging artifacts may decrease the accuracy of diagnosis of injuries to the TFCC and wrist ligaments, whereas variant anatomy of the proximal wrist structures may mimic disease of the TFCC and wrist ligaments. Knowledge of the detailed anatomy of the wrist, as well as variant patterns of structure morphology and signal intensity, can help differentiate actual disease from normal or variant appearances at assessment with MR imaging.

We present a case of post-traumatic osteonecrosis of the radial head in a 13-year-old boy which was treated with costo-osteochondral grafts. A satisfactory outcome was seen at a follow-up of two years and ten months. Although costo-osteochondral grafting has been used in the treatment of defects in articular cartilage, especially in the hand and the elbow, the extension of the technique to manage post-traumatic osteonecrosis of the radial head in a child has not previously been reported in the English language literature. Complete relief of pain was obtained and an improvement in the range of movement was observed. The long-term results remain uncertain.