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Complications and failures after carpal tunnel release have been reported from 3% to 25%. And the revision surgeries usually show poorer outcomes than the primary surgeries. There are diverse etiologies causing neuropathic symptoms after the carpal tunnel release, which became a clinical challenge. Potential causes of the symptoms are categorized into three by those natures; persistent symptom, recurrent symptom, and new symptom. The decision of proper management should be based on the etiologies of reproduced symptoms. This article described an overview of the clinical presentation, etiologies, diagnosis, and treatments of the recalcitrant carpal tunnel syndrome.

The aims of the study were (1) to compare outcomes in terms of malunited distal radius bone union in open-wedge corrective osteotomy using autogenous or allogenic bone and (2) to introduce a new parameter that quantifies the rate of the bone union.This retrospective study included 22 patients (14 males, 8 females) who underwent open-wedge corrective osteotomy with bone grafting for a malunited distal radius fracture between January 2006 and December 2018 were enrolled. The mean follow-up duration was 57.2 weeks (SD 46.1, range 12-206). All the patients were then divided into 1 of the 2 groups based on the graft material used: autog- enous bone graft group (n=10, 5 males and 5 females) and allogenic bone graft group (n=12, 9 males and 3 females). We introduced the "duration of union/correction gap ratio" to represent the healing potential of each graft materials. Radiologic parameters including initial correction gap, radial inclination, radial length, palmar tilt, and ulnar variance were also measured pre- and postoperatively. Functional outcomes were assessed by grip strength, range of motion, and the disability of the Arm, Shoulder, and Hand score.Of the 22 patients, 16 (72.7%) achieved complete union within 12 weeks, 3 (13.6%) in over 12 weeks, and the other 3 (13.6%) showed nonunion. Excluding the 3 nonunion cases, the mean union duration was 10.6 weeks, and the mean correction gap was 10 mm. The mean correction gap was wider in the autogenous bone graft group, and the mean union duration was longer in the allogenic bone graft group. Autogenous bone grafts had a significantly lower duration of bone union/correction gap ratio than allogenic bone grafts (0.76 vs. 1.61, P0.001). According to the correction method (simple open-wedge corrective osteotomy vs. open-wedge corrective oste- otomy OWCO), only duration of bone union/correction gap ratio reflected the actual difference between values.Despite autogenous bone graft donor site morbidities, in our study, autogenous bone showed better bone healing potential than allogenic bone. In terms of bone union, autogenous bone has the benefit of better union in larger gaps than allogenic bone. Surgeons can take advantage of the newly introduced "duration of bone union/correction gap ratio" to compare the bone healing potential by graft materials or surgical options.Level IV, Therapeutic Study.

Surgical treatment can be considered for patients with undifferentiated arthritis (UA) limited to the elbow joint. The purpose of this study was to analyze the clinical outcomes of arthroscopic synovectomy.Nineteen patients who underwent arthroscopic synovectomy for chronic UA of the elbow between 2006 and 2019 were enrolled in this study. One patient was excluded because of evidence of tuberculosis in the biopsy. Chronic UA of the elbow was defined as (1) localized synovitis diagnosed by magnetic resonance imaging, (2) no specific cause, and (3) no response to conservative treatment for3 months. We compared baseline characteristics and clinical outcomes between the remission and disease progression groups.Postoperatively, synovitis was controlled in 13 patients. In 5 patients, the symptoms disappeared after surgery without any medical treatment. Four patients discontinued disease-modifying antirheumatic drugs. Nine patients were classified as in remission. The disease progression group had a longer symptom duration, elevated rheumatoid markers, and higher Larsen grading. However, the difference was not statistically significant.Arthroscopic synovectomy achieved remission in approximately 47% of patients with chronic UA of the elbow. Although arthroscopic synovectomy did not prevent RA, it can be considered for rapid resolution of synovitis and diagnostic purposes.

This study presents our technique of arthroscopic scaphoid excision and four-corner arthrodesis and compares the clinical and radiological outcomes with those achieved with the open method. Twenty-seven patients (14 in arthroscopy group and 13 in open group) were included. Bone union was achieved in 13 of 14 patients in the arthroscopy group and in all 13 patients in the open group. In the open group, severe stiffness (flexion–extension arc was 10°) occurred in one patient after surgery. The mean postoperative flexion–extension arc was 75° and 51° in the arthroscopy group and open group, respectively. The pain, clinical scores, and radiological indices were improved in both arthroscopy and open groups. Arthroscopic and open scaphoid excision and four-corner arthrodesis did not show significant differences in clinical outcomes and bone union rates. The arthroscopic method provided a superior range of motion. Level of evidence: III

Purpose: The purpose of this study was to evaluate the relationship between the progression of arthritis and the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) through the treatment-resistant mono joint rheumatoid arthritis treated with arthroscopic synovectomy.Methods: We retrospectively reviewed 65 patients who underwent arthroscopic synovectomy for rheumatoid wrist or elbow which had not responded to systemic treatment for at least 6 months. The main treatment response evaluation methods of rheumatologists were the American College of Rheumatology (ACR) response criteria, and the ACR/EULAR (European League Against Rheumatism) remission criteria. The medical records, results of laboratory tests and radiographs of wrist or elbow that had been performed by rheumatologists before arthroscopic synovectomy were investigated. We examined whether the results of laboratory tests and arthritic change of radiograph had statistically significant correlation. Results: The mean duration of joint symptom until referral to orthopedic department was 23 months (range, 1 month to 9.2 years). During this period, rheumatologists had took average one X-ray (range, 0–3). Forty-seven patients (72.3%) had CRP of 1 mg/dL or less as included in the ACR/EULAR remission criteria. Seventeen out of 65 patients who had two or more X-ray were able to evaluate the progression of arthritis. The change of arthritis and mean ESR (p=0.787) or CRP (p=0.303) the same period didn’t have statistically significant relationship (Spearman correlation analysis).Conclusion: Since the method of evaluating the treatment response of rheumatologists is to assess the systemic condition, arthritis of one joint that is resistant to treatment is considered to require periodic radiographs as method to assess itself.

This study aimed to identify the rates and risk factors for failure of percutaneous A1 pulley release. We retrospectively analysed patients who underwent percutaneous A1 pulley release between 2015 and 2019. We defined failure as (1) pain or discomfort at the final follow-up, (2) when open release or revision percutaneous release was performed, or (3) when steroid injections were administered three or more times for symptom control. A total of 331 digits from 251 patients were included. The mean follow-up duration was 47 months (minimum 24 months). Complete resolution was achieved in 287 cases (87%), but 21% required steroid injection before symptoms settled. There was failure in 44 cases (13%). Involvement of the index, middle and ring fingers was significantly different between the successful and failure groups. Percutaneous A1 pulley release has a long-term success rate of 87%. The failure rate was higher when the procedure was performed on the index, middle or ring fingers. Level of evidence: III

Background: The intracompartmental septum isolating the extensor pollicis brevis (EPB) has been reported to affect the patient’s response to nonsurgical treatment in de Quervain’s disease. A simple physical test called the modified staged Finkelstein test was developed to evaluate the septum; the result of this test was compared with those of the pre-existing physical test (EPB entrapment test) and ultrasonographic (US) examination of the septum. Methods: We retrospectively analyzed 52 patients who underwent two clinical tests, including the modified staged Finkelstein test and the EPB entrapment test, and US examination for de Quervain’s disease. The correlation between the clinical test results and US findings was evaluated; sensitivity, specificity, and positive and negative predictive values were calculated. Results: The proportion of wrists with a separate septum was 50% (26 patients) in the US examination. The sensitivity and specificity of the modified staged Finkelstein test were 88.5% and 73.1%, respectively; those of EPB entrapment test were 71.4% and 84.2%, respectively. The positive and negative predictive values of the modified staged Finkelstein test were 76.7% and 86.4%, respectively. Conclusions: The modified staged Finkelstein test showed acceptable diagnostic values for the diagnosis of septum compared with pre-existing physical tests. Knowledge about the existence of septum could be helpful in treating patients and expecting prognosis.

To analyze postoperative outcomes after arthroscopic transosseous triangular fibrocartilage complex (TFCC) foveal repair and identify factors affecting the clinical outcomes.This study retrospectively enrolled patients who were treated for TFCC foveal tears by arthroscopic transosseous TFCC foveal repair. The diagnosis of TFCC foveal tear was made based on medical history, physical examination, and magnetic resonance imaging, with confirmation via arthroscopic examination. Outcome evaluation was completed at a minimum of 2 years postoperatively, and patients were classified into 2 groups according to the minimal clinically important difference of the Patient-Rated Wrist Evaluation. Various factors including age, sex, trauma history, body mass index, symptom duration, hand dominance, ulnar variance, subluxation of the distal radioulnar joint, preoperative pain score, and functional status, as well as the cross-sectional area (CSA) of the pronator quadratus (PQ) muscle, were retrospectively analyzed using both univariate and multivariate analyses.During the study period, 42 patients were treated for TFCC foveal tears. The functional status significantly improved after surgery. Overall, 27 and 15 patients showed good and poor functional outcomes, respectively, which were assessed according to the minimal clinically important difference of the Patient-Rated Wrist Evaluation. On univariate analysis, clinical outcomes were better in male patients (P = .035), younger patients (P = .022), and those with higher CSAs of the PQ muscles (P.001). However, on multivariable logistic regression analysis, only a higher CSA of the PQ muscle was identified as an independent prognostic factor affecting clinical outcome after TFCC foveal repair (P = .004).Arthroscopic transosseous TFCC complex foveal repair led to satisfactory results. However, lower PQ muscle CSA on magnetic resonance imaging was the most independent prognostic factor negatively affecting clinical outcomes.Level III, retrospective comparative study.

Although reconstruction of the lateral ulnar collateral ligament (LUCL) has been considered the procedure of choice for posterolateral rotatory instability (PLRI), recent studies have reported that the entire lateral collateral ligament complex (LCLC), rather than its posterior part only, contributes to preventing PLRI. Thus, it was hypothesized that dual reconstruction of the radial collateral ligament (RCL) and LUCL for the treatment of elbow PLRI could provide favourable clinical results regardless of the mechanism of injury. This retrospective study reviewed the clinical results of 21 patients who underwent dual reconstruction of the RCL and LUCL between 2011 and 2016. Functional outcomes were assessed using the numeric rating scale (NRS) score, Mayo Elbow Performance Score (MEPS), quick Disabilities of the Arm, Shoulder, and Hand (quick DASH) score, and manual varus instability. To identify any difference in outcomes according to the aetiologies for LCLC insufficiency, our patients were divided into LCLC insufficiency associated with elbow dislocation and that with lateral epicondylitis. At a median follow-up of 27 months (range 13–65 months), all patients showed resolved instability and achieved a functional arc of motion. In addition, lateral pivot shift tests were negative in all patients. The median MEPS significantly improved after surgery from 70 (range 60–75) to 85 (range 75–100) (p

Malunion after distal radius fracture is common in older patients; however, whether patient-perceived outcomes are influenced by radiologic outcome is controversial. This study evaluated patient-perceived outcomes according to radiologic parameters in older patients who underwent nonoperative treatment. The records of 167 patients older than 55 years who had a distal radius fracture were reviewed. All fractures were treated nonoperatively, and average length of follow-up was 7 years. Outcomes were evaluated using numeric rating scales for pain and satisfaction, as well as Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Radiographs were evaluated for dorsal tilt, radial inclination, and ulnar variance. Fifty-one patients (30%) developed malunion. The pain numeric rating scale score was 0.8 for patients with malunion and 0.4 for patients with acceptable alignment; this difference was not statistically significant. The QuickDASH score was higher for patients with malunion (14.9 vs 11.1 for patients with acceptable alignment); however, this difference was not clinically meaningful. Satisfaction scores were lower for patients with malunion than for patients with acceptable alignment (80.8 vs 92.3). Patients with malunion stated they would choose surgery rather than a cast (13.3% vs 7.2%) if they developed another fracture; this difference was not statistically significant. The subanalysis according to radiologic parameters showed dorsal tilt and ulnar variance affected patient satisfaction but not other outcomes. This study indicated nonoperative treatment in older adults obtained acceptable patient-perceived outcomes despite residual deformity. However, patients whose radiologic parameter exceeded the tolerable range were less satisfied. [ Orthopedics . 2021;44(2):e190–e196.]

PURPOSE: The current study aimed to demonstrate the outcomes of patients with Lichtman stage II and IIIA Kienböck’s disease with mild pain and good range of motion (ROM) after conservative management. We hypothesized that we can conservatively manage patients with early-stage Kienböck’s disease including those with stage IIIA. PATIENTS AND METHODS: This study is a retrospective case series. Between January 2012 and December 2017, 38 patients were enrolled in this study. The mean follow-up period of conservatively managed group was 49.1 months. The flexion–extension (FE) arc, grip strength, Pain Visual Analog Scale (pVAS), Modified Mayo Wrist Score (MMWS), and disabilities of the arm, shoulder, and hand (DASH) score were determined for functional evaluation. The radiographic parameters were assessed using the Stahl’s index and carpal height ratio. The morphological changes in the lunate were also evaluated with plain radiographs. RESULTS: A total of 31 of 38 patients (81.6%) showed favorable outcomes after conservative treatment. The mean pVAS score, MMWS, and DASH score showed statistically significant improvement, as well as the morphology of lunates on the plain radiograph. The mean FE arc was slightly decreased without statistical significance. The grip strength showed improvement with statistical significance. One patient showed the same radiographic morphology, but did not manifest any pain. A total of five (13.2%) patients who experienced aggravated pain and decreased ROM underwent surgical treatment. The other patient required surgical intervention but was provided conservative treatment due to her circumstances. CONCLUSION: Favorable outcomes can be expected in patients with Lichtman stages II and IIIA avascular necrosis of the lunate (Kienböck’s disease) with mild pain and good ROM who undergo conservative management. LEVEL OF EVIDENCE: IV.

The perfusion index (PI) is an objective tool used to assess a successful nerve block. Epinephrine is a widely used adjuvant to local anesthetics, and it may affect PI values because of the vasoconstrictive property. The aim of this study was to investigate the influence of epinephrine on PI as an indicator of a successful block in ultrasound-guided supraclavicular brachial plexus block (SCBPB). In this randomized controlled trial, 82 adult patients underwent upper limb surgery under SCBPB were recruited between July 2018 and March 2019 in a single tertiary care center. Participants were randomly assigned to one of two groups: non-epinephrine group (n = 41) or epinephrine group (5 mcg ml−1, n = 41). The primary outcome was the comparison of the “PI ratio 10,” which was defined as the ratio of the PI 10 to the baseline. Receiver operating characteristic (ROC) curves were constructed to determine the accuracy of the PI in predicting the block success at each time interval. The PI ratio 10 was 2.7 (1.9–4.0) in non-epinephrine group and 3.3 (2.2–4.4) in epinephrine group (median difference: 0.4; 95% confidence interval [CI] − 1.1 to 0.2; P = 0.207). The ROC curves compared without group identification were not significantly different over time. The cut-off value for the PI and PI ratio at 5 min (PI ratio 5) were 7.7 (area under the ROC [AUROC]: 0.89, 95% CI 0.83–0.94) and 1.6 (AUROC: 0.94, 95% CI 0.90–0.98), respectively. The perineural epinephrine did not affect the PI following a SCBPB. The PI ratio 5 > 1.6 might be considered as a relatively accurate predictor of a successful SCBPB.Trial registration: This study was registered at the Clinical Trial Registry of Korea (https://cris.nih.go.kr. CriS No. KCT0003006).

Background: Although there have been many studies of the vascularized bone graft (VBG) or unloading procedures alone for the treatment of Kienböck disease, little information has been reported about patients treated with VBG combined with unloading procedures. The purpose of this study is to 1) describe the outcomes in patients treated with VBG combined with unloading procedures, 2) compare the outcomes according to the unloading procedures and 3) find any radiologic parameters affecting revascularization in Kienböck disease. Methods: A retrospective review was performed involving in 20 patients undergoing 4th and 5th extensor compartmental VBG with unloading procedures for Kienböck disease from 2010–2015. After VBG in all patients, unloading procedures were additionally performed depending on the ulnar variance. These additional operations included joint leveling procedures (radial and capitate shortening osteotomy) or temporary scaphocapitate pinning. Radiologic outcome was evaluated according to Lichtman stage and presence of revascularization evidence. Clinical evaluations included wrist range of motion, grip strength, visual analogue scale (VAS), and Mayo wrist score. Results: VBG with joint leveling procedures was performed in 11 patients (5 radial shortening and 6 capitate shortening) and VBG with temporary scaphocapitate pinning was performed in 9 patients. Although clinical outcomes were not significantly different according to the unloading procedures, there were significantly more patients with evidence of healing of osteonecrosis on radiographs in joint leveling procedure group than temporary scaphocapitate pinning group. Overall, evidence of healing of osteonecrosis was found on plain radiographs in 11 patients and was not found in 9 patients. However, there were no significant preoperative radiological parameters affecting revascularization on radiographs. Conclusions: Not all patients had evidence of revascularization on radiography after VBG combined with unloading procedures for Kienböck disease. However, among the unloading procedures, joint-leveling procedures positively influenced the revascularization process.

The aim is to report the long-term clinical results after pisiform excision in patients with refractory flexor carpi ulnaris (FCU) tendinopathy. We performed pisiform excision in 14 patients with recalcitrant FCU tendinopathy, who had failed conservative treatment. Nine patients were followed-up for more than 2 years. Pre-operative pain visual analog scale (VAS) was extracted from the electronic medical records. Post-operative symptoms and function were assessed with pain VAS, quick disabilities of arm, shoulder and hand (DASH) score, patient rated wrist evaluation (PRWE) score, and satisfaction VAS for surgery at the final follow-up. After the mean follow-up period of 6 years, all patients showed improvement in pain VAS (from 5.9 to 1.2). The post-operative scores of quick DASH and PRWE were 3.5 and 13.1, respectively. Satisfaction VAS score was 8.8 and all patients returned to their work. Excision of the pisiform bone improved symptoms in patients with refractory FCU tendinopathy.

Background: Disruption of the triangular fibrocartilage complex (TFCC) foveal insertion can lead to distal radioulnar joint (DRUJ) instability accompanied by ulnar-sided pain, weakness, snapping, and limited forearm rotation. We investigated the clinical outcomes of patients with TFCC foveal tears treated with arthroscopic-assisted repair. Materials and Methods: Twelve patients underwent foveal repair of avulsed TFCC with the assistance of arthroscopy between 2011 and 2013. These patients were followed up for an average of 19 months (range 14–25 months). The avulsed TFCC were reattached to the fovea using a transosseous pull-out suture or a knotless suture anchor. At the final followup, the range of motion, grip strength and DRUJ stability were measured as objective outcomes. Subjective outcomes were assessed using the Visual Analog Scale (VAS) for pain, patient rated wrist evaluation (PRWE), Disabilities of the Arm, Shoulder and Hand questionnaire (DASH score) and return to work. Results: Based on the DRUJ stress test, 5 patients had normal stability and 7 patients showed mild laxity as compared with the contralateral side. Postoperatively, the mean range of pronation supination increased from 141° to 166°, and the mean VAS score for pain decreased from 5.3 to 1.7 significantly. The PRWE and DASH questionnaires also showed significant functional improvement. All patients were able to return to their jobs. However, two patients complained of persistent pain. Conclusions: Arthroscopically assisted repair of TFCC foveal injury can provide significant pain relief, functional improvement and restoration of DRUJ stability.

The purpose of this study was to test the hypothesis that an improved outcome can be achieved by employing simultaneous steroid injection after percutaneous A1 pulley release. One hundred and twelve digits were randomized to either percutaneous A1 pulley release alone or release of the A1 pulley with a steroid injection. The visual analogue scale score for pain, modified patient global impression of improvement and modified Quinnell grade were assessed at 3 weeks and 3 months after surgery. At 3 weeks, subjective improvement in the group with simultaneous steroid injection was significantly superior. At 3 months, pain score in the patients without a steroid injection was significantly better. No significant differences were found in the modified Quinnell grade. We conclude from this study that the simultaneous steroid injection at the time of surgical release decreases pain and improves subjective outcomes during the early postoperative period after percutaneous trigger finger release. Level of evidence: I

Dorsal wrist ganglion can be removed through open or arthroscopic excision. The better method for relieving pain remains unknown. In this study, we addressed the following questions: (1) does open excision provide better pain relief than arthroscopic? (2) is there any difference in patient satisfaction, functional outcome, and re-operation rate? Forty-five patients with painful dorsal wrist ganglions underwent open or arthroscopic excision. Posterior interosseous neurectomy was performed during open excision. Clinical outcomes were assessed with a focus on pain relief. Patient satisfaction, recurrence, and reoperation due to residual pain were also assessed. The average pain scores improved significantly after both, open and arthroscopic excision. However, five patients who underwent arthroscopic excision reported the same or worse pain, whereas all patients who underwent open excision reported postoperative alleviation of pain. The recurrence rate was comparable. Patient satisfaction was better in those who underwent open excision. Reoperation was performed in four patients who had residual pain after arthroscopic excision. Both, open and arthroscopic methods can alleviate pain in patients with painful dorsal wrist ganglion. However, 20% of the patients who underwent arthroscopic excision reported residual or persistent pain.

Background Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. Methods We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone debridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. Results The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. Conclusions Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open debridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.

Background Thickened synovial plicae in the radiocapitellar joint have been reported as a cause of lateral elbow pain. However, few reports regarding diagnosis based on detailed physical examination and magnetic resonance imaging (MRI) findings are available. The aims of this study were to characterize the clinical manifestations of this syndrome and to investigate the clinical outcomes of arthroscopic surgery. Methods We analyzed 20 patients who received a diagnosis of plica syndrome and underwent arthroscopic debridement between 2006 and 2011. The diagnosis was based on physical examination and MRI findings. Elbow symptoms were assessed using a visual analog scale for pain; the Mayo Elbow Performance Index; and the Disabilities of the Arm, Shoulder and Hand score at a minimum of 2 years after surgery. The thickness of plicae on MRI was compared with the normal data in the literature. Results Plicae were located on the anterior side in 1 patient, on the posterior side in 15, and on both sides in 4. Radiocapitellar joint tenderness and pain with terminal extension were observed in 65% of patients. MRI showed enlarged plicae consistent with intraoperative findings. The mean plica thickness on MRI was 3.7 ± 1.0 mm, which was significantly thicker than the normal value. The mean lengths (mediolateral length, 9.4 ± 1.6 mm; anteroposterior length, 8.2 ± 1.7 mm) were also greater than the normal values. The visual analog scale score for pain decreased from 6.3 to 1.0 after surgery. The Mayo Elbow Performance Index and Disabilities of the Arm, Shoulder and Hand scores improved from 66 to 89 and from 26 to 14, respectively. Conclusions Specific findings of the physical examination and MRI provide clues for the diagnosis of plica syndrome. Painful symptoms were successfully relieved after arthroscopic debridement.

Purpose To compare mechanical properties of a multistrand suture technique for flexor tendon repair with those of conventional suture methods through biomechanical and clinical studies. Methods We describe a multistrand suture technique that is readily expandable from 6 to 10 strands of core suture. For biomechanical evaluation, 60 porcine flexor tendons were repaired using 1 of the following 6 suture techniques: Kessler (2-strand), locking cruciate (4-strand), Lim/Tsai's 6-strand, and our modified techniques (6-, 8-, or 10-strand). Structural properties of each tenorrhaphy were determined through tensile testing (ultimate failure load and force at 2-mm gap formation). Clinically we repaired 25 flexor tendons using the described 10-strand technique in zones I and II. Final follow-up results were evaluated according to the criteria of Strickland and Glogovac. Results In the biomechanical study, tensile properties were strongly affected by repair technique; tendons in the 10-strand group had approximately 106%, 66%, and 39% increased ultimate load to failure (average, 87 N) compared with those in the 4-, 6-, and 8-strand groups, respectively. Tendons in the 10-strand group withstood higher 2-mm gap formation forces (average, 41 N) than those with other suture methods (4-strand, 26 N; 6-strand, 27 N; and 8-strand, 33 N). Clinically, we obtained 21 excellent, 2 good, and 2 fair outcomes after a mean of 16 months (range, 6–53 mo) of follow-up. No patients experienced poor results or rupture. Conclusions The 10-strand suture repair technique not only increased ultimate strength and force at the 2-mm gap formation compared with conventional suture methods, it also showed good clinical outcomes. This multistrand suture technique can greatly increase the gap resistance of surgical repair, facilitating early mobilization of the affected digit. Type of study/level of evidence Therapeutic IV.

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting multiple joints. Wrist involvement is common. Patients with persistent symptoms despite medical management are candidates for surgery. Synovectomy can provide pain relief and functional improvement for rheumatoid wrist. Arthroscopic synovectomy is a safe and reliable method, with minimal postoperative morbidity. This article reviews the role, technique, and results of arthroscopic synovectomy in the rheumatoid wrist.

This study proposed a user-tracking control algorithm for a powered wheeled walker and examined how it improves the tracking performance of a user. Our newly developed powered wheeled walker based on the mechanism of infant walker and powered wheelchair has enhanced walking stability and needs less physical power to be moved. The walker is able to smoothly track user’s various movements (i.e. forward, backward translation, and rotation) using pelvis motion sensors determining walking direction and stereo cameras analyzing lower extremity motion. In particular, weighting factors of controllers using pelvis motion sensor and stereo cameras can be suitably adjustable online. The experimental testing was conducted to examine walker’s tracking performance, and the results from electromyography testing showed that the walker based on user-tracking control algorithm significantly decreased the magnitude of exerted muscle strength in both upper and lower extremity compared to conventional passive wheeled walker. Thus, we were able to successfully verify that the proposed walker can automatically track a user with gait impairment for safe walking without a helper.

Introduction The prevalence of sesamoid bone in hand is known to be variable among populations of various geographic origins. Since counting with radiographs might be inaccurate due to superimposition of adjacent digits, we tried to overcome this obstacle using 3D-reconstructed CT in Korean patients. The purpose was to provide an accurate incidence of sesamoid bones using 3D-CT. Methods Sesamoid bones were examined in 427-CT images. 3D-CT images were analyzed by one observer and parts of hands (411-hands) were evaluated with radiograph to compare with CT results. Statistical analysis between the CT and radiograph results was performed. Results Sesamoids of metacarpo-phalangeal (MP) joint of the thumb were always present on both radial and ulnar sides, except for 9-cases (2.1%) where they were not present on radial side and 6-cases (1.5%) where they were not present on ulnar side. MP joint of the little finger was the second most prevalent location (62.8%). The sesamoid of the index finger MP joint and thumb interphalangeal joint was observed in 44% and 42.4%, respectively. There was a rare incidence in the MP joints of middle and ring finger (0.7%). The incidence of sesamoid bone was statistically different between the two counting methods for the MP joints of index and little finger and thumb interphalangeal joint ( P Discussion We could observe five frequent sesamoid bones in the MP joints of the thumb, index, and little finger, and the interphalangeal joint of the thumb in Korean individuals. 3D-CT images revealed the accurate incidences of hand sesamoid bones.

The purposes of this study were to evaluate the clinical results of arthroscopic débridement and to identify preoperative factors that influence the outcome.Forty-three elbows with primary osteoarthritis in 43 patients treated with arthroscopic débridement were retrospectively evaluated. At a mean follow-up of 38 months (range, 18-77 months), the visual analog scale (VAS) score for pain, the arc of elbow motion, and the Mayo Elbow Performance Index (MEPI) score were assessed. The relationships between postoperative MEPI score and postoperative motion arc and preoperative factors including age, sex, involvement of the dominant arm, duration of symptoms, demand of elbow activity, VAS score, previous history of failed surgery, and arc of elbow motion were statistically evaluated.The mean VAS score for pain, the mean arc of flexion-extension, and the mean MEPI score significantly improved after the operation (all P values .001). Multivariate regression analysis revealed that among preoperative variables, arc of motion was found to be the only independent prognostic factor that affected both postoperative elbow function (P = .024) and final arc of motion (P .001). The cutoff value of preoperative arc of motion for the final arc of motion was determined to be 80° (P .001). Involvement of the dominant arm was found to be another independent factor that affected postoperative MEPI scores (P = .016).Arthroscopic débridement for elbow osteoarthritis provides satisfactory pain relief, improvement of elbow motion, and good functional outcome. Based on the fact that preoperative motion arc is the independent factor that can predict clinical outcome, arthroscopic treatment is highly recommended for patients who have a motion arc of 80° or more as it yields reliable results.

용자 보행 추종 성능을 실험적으로 검증하였다. Abstract: This paper describes the development of a walking assistive robot for effective self-rehabilitation for elderly people facing an inconvenience in walking. The main features of the developed robot are enhanced safety and mobility using the baby walker and electric wheelchair mechanisms and an accurate walking tracking control algorithm using potentiometers and stereo cameras. Specifically, a pelvis supporter is designed to prevent the user from falling down and reduce the burden on their legs, and electric motors are used for easy locomotion with low effort. Next, the walking intention and direction of the user are automatically recognized by using potentiometers attached at the pelvis supporter so that the robot can track the user, and the rapidity and accuracy of the tracking were increased by applying a lower-body motion analysis algorithm with stereo cameras. Finally, the user-tracking performance of the developed robot was experimentally verified through stepwise walking assistance experiments.

Purpose To investigate the effects of arthroscopic wrist synovectomy on the clinical course of rheumatoid arthritis in a large series with long-term follow-up. Methods We performed arthroscopic synovectomy on 56 wrists in 49 patients with rheumatoid arthritis. At a mean follow-up of 7.9 years (range, 5–12 y), we evaluated pain and patient satisfaction using a visual analog scale and assessed overall function using the Mayo wrist score. Radiographic stage was graded according to Larsen stage. We determined clinical outcomes on the recurrence of wrist synovitis, which we evaluated by symptoms of pain and swelling and physical examination. Preoperative variables were statistically analyzed to find factors that could influence the results. Results The mean visual analog scale score for wrist pain decreased from 6.3 to 1.7, and the mean Mayo wrist score (evaluated in 39 wrists) improved from 48 (range, 5–70) to 76 (range, 55–100). The mean visual analog scale score for patient satisfaction was 7.9. At final follow-up, synovitis was controlled in 42 wrists (75%) and recurred in the others. The mean Larsen stage progressed from 2.2 to 3.3. Analysis of preoperative variables revealed no factors that significantly affected clinical outcomes in terms of sex, age, duration of wrist symptom, preoperative serologic inflammatory markers, or Larsen stage. Conclusions Arthroscopic synovectomy of the wrist can provide pain relief and functional improvement with control of synovitis in 75% of rheumatoid wrists that have not responded to medication. Type of study/level of evidence Therapeutic IV.

Background Heterotopic ossification (HO) is considered as a common extrinsic cause of elbow stiffness. The purpose of this study was to show the results of surgical treatment for post-traumatic elbow stiffness caused by HO in a large, consecutive series of patients in a single unit. Methods We retrospectively reviewed 77 surgically treated patients with post-traumatic elbow stiffness caused by HO. Final motion arc and Mayo Elbow Performance Index (MEPI) were assessed as final results. Univariable and multivariable analyses were done to determine which factors had an effect on the final motion arc. Results The average arc of elbow motion increased from 45° preoperatively to 112°, with an improvement of 67° at the final follow-up evaluation. The mean MEPI score was 91.9. At the final evaluation, 65 patients (84.4%) obtained a total motion arc of ≥100°. Recurrent HO was observed in 16 patients postoperatively, and 6 underwent repeated surgical release. The time from the initial injury to surgical release with a cutoff value of 19 months was the only independent factor affecting the final range of motion (ROM) in multivariable median regression analysis. With the numbers studied, no significant association was found between the final ROM and other clinical variables except for the recurrence of HO (93° vs 117°). Conclusions From the results of our study, we can support the surgical treatment of elbow stiffness caused by post-traumatic HO regardless of preoperative ROM. However, recurrence of heterotopic bone and delay in surgery of more than 19 months are associated with less favorable results.

The purpose of this study was to find out whether the carpal indices measured on lateral radiographs with a slightly malpositioned wrist are the same as those measured in the true neutral position. Lateral radiographic views of 25 wrists were taken with 5° intervals from 20° of flexion to 20° of extension. Most carpal indices measured in the flexed or extended position were significantly different from the wrist in zero flexion-extension, except scapholunate angle at 5° of extension and scaphocapitate angle at 5° and 10° of flexion. Starting from the flexed position, there was an average of −4.0° change in radioscaphoid angle, −1.0° in scapholunate angle, −1.0° in scaphocapitate angle, +3.0° in radiolunate angle, and +2.0° in lunocapitate angle for each 5° of extension with linear trends. The results from this study suggest that even minimal degrees of flexion-extension can affect the measurements of carpal indices on lateral radiographs.

ObjectivesTo determine which ultrasonographic [US] features of epicondylitic lesions are more treatable using extracorporeal shock wave therapy [ESWT].MethodsThirty patients [9 men and 21 women; mean age 47.8 years] with chronic lateral epicondylitis lasting at least 12 months were included. They were diagnosed and classified by US into three groups: simple tendinosis, tendinosis with calcification, and tendinosis with tear. Each patient was treated with low-energy ESWT for three to four sessions of 2000 shocks. Clinical evaluations [the 100-point scoring system and the Nirschl score] to evaluate symptomatic or functional improvement were performed before, three, and six months after treatment. Success rates were measured three and six months after treatment using the Roles and Maudsley score. Follow-up US was performed three months after treatment.ResultsLesions with calcifications showed only 33.3 percent [4 of 12 patients] of improvement after treatment on follow-up US, which was much lower than other ...

Purpose: To describe the recent clinical results and complications of total elbow arthroplasty based on the literature review. Materials and Methods: The indications of total elbow arthroplasty include rheumatoid or inflammatory arthritis, posttraumatic arthritis, anklylosed elbow, tumor resection which cannot recover elbow function by other reconstructive procedures, and comminuted distal humerus fracture in elderly patients. Complications are aspetic loosening, infection, prosthesis fracture, periprosthetic fracture, ulnar neuropathy, ectopic ossification, triceps insufficiency, dislocation, and bushing wear. Results and Conclusion: Mean 10 year survival rate following total elbow arthroplasty has been reported 85% on the basis of revision. The prognosis in patients with an inflammatory arthritis is reported to be best, and loosening rate in patients with a posttraumatic arthritis tends to be high. Complication rate is known to be higher than that of other joint arthroplasty. In particular, deep infection occurs in 3~5% of the patients. Total elbow arthroplasty provide satisfactory results when it is performed properly in selected patients who have an elbow joint with irreversible dysfunction and low level activities.

[Introduction][1] We describe a surgical release for patients who have a lack of elbow flexion limiting the ability to perform activities of daily living after trauma. ![Figure][2] ![Figure][2] [Step 1: Mobilize the Ulnar Nerve][3] Mobilize the ulnar nerve through the cubital tunnel with the accompanying superior ulnar collateral vessels. ![Figure][2] [Step 2: Dissect the Triceps and Resect the Posterior Aspect of the Capsule][4] Dissect the triceps from the distal part of the humerus and resect the posterior aspect of the capsule to expose the olecranon tip and fossa. ![Figure][2] [Step 3: Resect the Posterior Band of the Medial Collateral Ligament][5] Release the posterior band of the medial collateral ligament while continually checking the flexion arc until >130° of flexion can be achieved. ![Figure][2] [Step 4: Resect the Anterior Aspect of the Capsule][6] Perform an anterior approach if there is persistent flexion contracture or any impingement restricting full flexion. [Step 5: Lengthen the Triceps If Indicated][7] Consider triceps lengthening if you cannot achieve >130° of passive flexion with two fingers. ![Figure][2] [Step 6: Transpose the Ulnar Nerve Anteriorly][8] Locate the released ulnar nerve over the medial humeral epicondyle on the fascia overlying the common flexor-pronator muscles. [Step 7: Postoperative Management][9] Physical therapy consists of active-assisted and gentle passive flexion and extension exercises of the elbow, usually for two to six months. [Results][10] Forty-two patients with 130° of flexion can be achieved. ![Figure][2] [Step 4: Resect the Anterior Aspect of the Capsule][6] Perform an anterior approach if there is persistent flexion contracture or any impingement restricting full flexion. [Step 5: Lengthen the Triceps If Indicated][7] Consider triceps lengthening if you cannot achieve >130° of passive flexion with two fingers. ![Figure][2] [Step 6: Transpose the Ulnar Nerve Anteriorly][8] Locate the released ulnar nerve over the medial humeral epicondyle on the fascia overlying the common flexor-pronator muscles. [Step 7: Postoperative Management][9] Physical therapy consists of active-assisted and gentle passive flexion and extension exercises of the elbow, usually for two to six months. [Results][10] Forty-two patients with

We investigated the relationship between stress applied in several positions of the wrist and pain intensity in triangular fibrocartilage lesions in sixty-one patients who were diagnosed as having triangular fibrocartilage lesions and had a wrist arthroscopy. Before arthroscopy, we stressed the wrist with an axial load applied in four different wrist positions, and the evoked pain was graded into four levels. The patients who had a triangular fibrocartilage lesion on arthroscopy were divided into those with a traumatic tear and those with degenerative changes. While hypersupination and extension of wrist position evoked the most severe pain in patients with a traumatic tear, the intensity of pain did not relate to wrist rotation in patients with degenerative changes.

Purpose To describe an arthroscopic technique for complete removal of the synovium from the elbow joint and to investigate the clinical outcomes of arthroscopic synovectomy in patients with rheumatoid elbow. Methods Arthroscopic synovectomy was performed on 26 rheumatoid elbows in 25 patients with radiographic changes of Larsen grade 3 or less. We performed total synovectomy of the elbow using multiple portals and by dividing the elbow into the anterior, posterior, and radiocapitellar compartments. At a mean follow-up of 33.9 months (range, 13 to 68 months), pain was evaluated with a visual analog scale and range of motion was measured. The Mayo Elbow Performance Score was used to assess total elbow function. Radiologic changes were determined according to the Larsen grading system. Results The mean visual analog scale score for pain decreased from 6.5 to 3.1, and the mean flexion arc increased from 98.1° to 113.3° after the operation. The mean Mayo Elbow Performance Score improved from 58.5 to 77.4 points. There were 2 excellent, 17 good, 4 fair, and 3 poor results. Radiologic assessment showed no change in 13 elbows, improvement in 6, and progression in 7. Clinically apparent synovitis recurred in 4 elbows, in which the result was considered unsuccessful. Conclusions Arthroscopic synovectomy of the elbow by use of multiple portals is a technically feasible procedure. It can effectively relieve pain, increase range of motion, improve Mayo Elbow Performance Score, and delay radiologic progression in rheumatoid elbows, resulting in a high satisfaction rate, although recurrent synovitis occurs in some patients. Level of Evidence Level IV, therapeutic case series.

Background The purpose of the current study is to investigate anatomical relationships between the muscle overlying the distal transverse carpal ligament (TCL) and the thenar motor branch of the median nerve. Methods Of the 192 wrists that underwent open carpal tunnel release, a muscle belly overlying the TCL was observed on the distal margin of TCL in 25 wrists and ligament exposure could not be achieved without transection of it. We recorded surgical findings of these 25 wrists. The origin of the recurrent motor branch arising from the major median nerve was marked on the axial and coronal section diagrams of the wrist. Results The presence of muscle overlying the TCL was seen in 25 wrists (21 patients, 13%). The locations of origin were distributed not only on the radial side but anterior or ulnar side of the major median nerve. Abnormal branches originated from the unusual side in 14 cases (56% of those with a muscle overlying the TCL): central-anterior side in eight cases, ulnar-anterior side in five cases, and ulnar side in one case. These anomalous branches were frequently associated with the muscle belly overlying the TCL in our study regardless of the origin site. The branches were prone to cut if careless midline incision along the third web space was performed. Unusual origin and aberrant pathway of the recurrent thenar motor branch were associated with the presence of a muscle overlying the TCL. Conclusions A thorough knowledge of the standard and variant anatomy of the muscle belly and recurrent motor branch in the carpal tunnel is fundamental to prevention of complications such as muscle wasting or atrophy by iatrogenic motor branch injury during carpal tunnel release.

Stability of the distal radioulnar joint (DRUJ) is provided by bony architecture and by soft tissues such as the triangular fibrocartilage complex (TFCC), the joint capsule, and surrounding muscles.1) Cadaver studies have demonstrated that the volar and dorsal distal radioulnar ligaments, which are components of the TFCC, play a major role in stabilizing the joint.2-5) Many authors have made various attempts to restore DRUJ stability surgically following trauma. Some have employed indirect methods such as tenodesis using the flexor carpi ulnaris tendon or the extensor carpi ulnaris tendon.6-8) However, these nonanatomic procedures are not reliable in that the normal stability of the joint is not restored and the joint motion may be restricted. Anatomic reconstruction of the major structures responsible for joint stability is the most important principle for the treatment of instability of an injured joint with an intact articular surface. In this sense, some authors have tried to achieve anatomic reconstruction of the volar and dorsal distal radioulnar ligaments for DRUJ stability. Scheker et al.9) reconstructed the ligaments in 15 patients by using a tendon graft whose ends were anchored in pre-drilled holes in the radius and the ulna. Adams and Berger10) reported the clinical results of a procedure in which a tendon graft was passed through near the normal anatomic attachment site of the volar and dorsal distal radioulnar ligaments to attempt the best possible anatomic reconstruction. The objective of this study was to analyze clinical outcomes after anatomic reconstruction of the distal radioulnar ligaments in patients with posttraumatic chronic instability of the DRUJ. The study was based on the idea that the best outcomes can be obtained with anatomic reconstruction of the soft tissue stabilizers and realignment of the DRUJ.

Indole-3-carbinol, a natural compound found in cruciferous vegetables, is known to have anticancer activity. In the present study, the antiplatelet and antithrombotic activities of indole-3-carbinol were investigated in vitro and in vivo. Indole-3-carbinol significantly inhibited collagen-induced platelet aggregation in human platelet rich plasma (PRP) in a concentration-dependent manner. Indole-3-carbinol significantly inhibited fibrinogen binding to the platelet surface glycoprotein IIb/IIIa (GP IIb/IIIa) receptor by flow cytometric analysis. In addition, the levels of thromboxane B2 (TXB2) and prostaglandin E2 (PGE2) in collagen stimulated PRP were significantly inhibited in a concentration-dependent manner by indole-3-carbinol. Furthermore, indole-3-carbinol dose-dependently suppressed the death of mice with pulmonary thrombosis induced by intravenous injection of collagen and epinephrine. These results suggest that indole-3-carbinol can be a potent antithrombotic agent with antiplatelet activity through the inhibition of GP IIb/IIIa receptor and thromboxane B2 formation. Copyright © 2007 John Wiley & Sons, Ltd.

A cadaver model was used in a biomechanical study of dorsally angulated distal radius fractures to evaluate alterations in carpal kinematics. Distal radius fractures were simulated by dorsal closing-wedge osteotomy and fixed with a custom-designed external fixator. A magnetic tracking device measured the carpal bone motions in several positions of dorsal angulation from neutral tilt to 30 degrees dorsal tilt. Changes in carpal alignment showed different patterns between each specimen consisting of a spectrum from dorsal subluxation of the entire carpus to adaptive dorsal carpal instability (DISI deformity). Components of carpal bone motion were altered markedly at all positions of dorsal angulation of the distal radius. The severity of the DISI deformity and related carpal instability correlated well with the alterations of carpal kinematics during wrist flexion and extension, whereas dorsal subluxation alone had a poor relationship with changes in carpal kinematics. The amount of DISI deformity and the degree of dorsal angulation of the radius may be prognostic factors when considering whether to perform a corrective osteotomy of the distal radius.

Background Magnetic resonance imaging (MRI) may be useful to diagnose a posterolateral plica syndrome of the elbow joint because this syndrome has less clear clinical features. The purposes of this study were to document mediolateral and sagittal dimensions of a posterolateral synovial fold and to determine the proportion of subjects with the posterolateral plica in asymptomatic elbows. We also aimed to determine whether the dimensions of the posterolateral synovial fold and the prevalence of the plica differ between symptomatic and asymptomatic subjects. Materials and methods This retrospective review of prospectively collected data included 50 asymptomatic elbows (asymptomatic group) and 14 elbows with arthroscopically confirmed posterolateral plicae (plica group). The mediolateral and sagittal dimensions of the posterolateral synovial fold were measured. In addition, the criteria for the prevalence of posterolateral plica was determined with conventional MRI as synovial fold dimension ≥ 3 mm and coverage of radial head by synovial fold ≥ 30%. Results The plica group showed larger posterolateral synovial fold dimensions compared to the asymptomatic group. The median mediolateral and sagittal dimensions of the synovial fold in the asymptomatic group were 3.8 mm and 4.7 mm, respectively. Dimensions in the plica group were 7.0 mm and 7.4 mm, respectively. When the presence of posterolateral plica was determined using the dimension criteria, there was no difference in the prevalence of the plica between the asymptomatic and the plica group. However, using the coverage criteria, the prevalence of posterolateral elbow plica was significantly greater in the plica group than the asymptomatic group (64% vs. 18%; p < 0.001). Conclusions The patients who underwent arthroscopic surgery for posterolateral plica syndrome had larger dimensions of the posterolateral synovial fold and higher prevalence of the posterolateral plica on conventional MRI compared to the asymptomatic subjects.

The distally based sural flap is an efficient flap for reconstruction of soft tissues defects of lower limb. The unstable vascular pedicle, however, is prone to compression by the subcutaneous tunnel, especially when a long pedicle covers the distal area of the foot. The aim of the present study was to introduce a modified surgical technique that leaves the skin extension over the pedicle and to report the clinical results of this modification. A total of 25 consecutive patients with a mean age of 51.7 ± 14.7 years underwent surgery. We modified the conventional sural flap technique by leaving a skin extension over the entire length of the pedicle, creating a fasciocutaneous vascular pedicle. The postoperative flap survival rates, complications, and the characteristics of the flaps such as flap size, pedicle length, and the most distal area that could be covered with this modification, were reviewed. At the last clinical follow-up examination, all the flaps survived, although partial necrosis was observed in 2 (8%) cases. Four cases of venous congestion developed but healed without additional complications. The mean flap size was 5.9 ± 1.8 × 9.2 ± 2.7 cm. With this modification, the sural flap could cover the defect located in extreme distal areas, such as the medial forefoot and dorsum of the first metatarsophalangeal joint, with a longer pedicle (≤27 cm) in 7 patients (28%). A skin extension along the pedicle achieved the favorable survival rate of the sural flap and successfully extended the surgical indications to more distal areas.