Alvin Chao-Yu Chen

Arthroscopy-Assisted Surgery for Tibial Plateau Fractures : 2-to 10-Year Follow-up Results

PURPOSEnThis study evaluated the outcome of arthroscopy-assisted reduction with internal fixation for treating tibial plateau fractures at 2- to 10-year follow-up.nnnMETHODSnFifty-four patients with tibial plateau fractures treated by arthroscopy-assisted reduction with internal fixation were enrolled in this prospective study. According to the Schatzker classification, the fractures types were as follows: type I, 1 (2%); type II, 21 (39%); type III, 4 (7%); type IV, 10 (19%); type V, 8 (15%); and type VI, 10 (19%). The mean age at operation was 48 years (range, 22 to 68 years). The mean follow-up period was 87 months (range, 28 to 128 months). Clinical and radiologic outcomes were scored by the Rasmussen system.nnnRESULTSnThe mean postoperative Rasmussen clinical score was 28.4 (range, 19 to 30), and the mean radiologic score was 16.1 (range, 12 to 18). Good or excellent clinical and radiologic results were achieved in 96% of patients. The 6 fracture types did not significantly differ with regard to Rasmussen score or rate of satisfactory results (P > .05). Secondary osteoarthritis was noted in 10 injured knees (19%). All 54 fractures were successfully united. The mean preoperative fracture depression was 13.7 mm (range, 6 to 25 mm). Fracture depression at the final follow-up averaged 0.3 mm (range, 0 to 4 mm). No complications directly associated with arthroscopy were noted in any of the 54 patients.nnnCONCLUSIONSnArthroscopic surgery for tibial plateau fractures with associated soft-tissue injuries is a safe, reproducible, and effective procedure that provides precise diagnosis and effective treatment in a 1-stage procedure.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Arthroscopic Ganglionectomy Through an Intrafocal Cystic Portal for Wrist Ganglia

PURPOSEnA retrospective study was conducted on arthroscopic ganglionectomy in wrists using a novel intrafocal cystic portal. The safety and efficacy of this technique were assessed by treatment of 15 wrists in 15 patients.nnnMETHODSnArthroscopic ganglionectomy was performed by the same surgeon with the patient under general anesthesia or regional block. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were reported. The mean follow-up was 15.3 months. Functional assessment by use of modified Mayo wrist scores, patient satisfaction, and recurrence were included in the follow-up evaluation.nnnRESULTSnTwo thirds of the patients acquired good to excellent results, whereas the results for the remaining third were fair. Complications included 1 recurrence and 1 case of transient paresthesia sensation. The most common arthroscopic findings were capsular and ligament lesions, rather than ganglionic stalks.nnnCONCLUSIONSnArthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Dorsal and volar 2.4-mm titanium locking plate fixation for AO type C3 dorsally comminuted distal radius fractures.

PURPOSEnIn this retrospective, nonrandomized, single-surgeon study, we evaluated the clinical outcomes of dorsal and volar locking plate fixation for AO type C3 dorsally comminuted distal radius fractures.nnnMETHODSnWe treated 41 consecutive patients who had sustained AO C3 dorsally comminuted fractures of the distal radius with 2.4-mm titanium locking plates between 2006 and 2008. Patients in group 1 (n = 22) were treated with dorsal locking plates, and those in group 2 (n = 19) with volar locking plates. We evaluated clinical outcomes at an average of 37 months and performed statistical analysis using the Mann-Whitney U test and Fishers exact test.nnnRESULTSnNo significant difference was noted between the 2 groups in terms of radial inclination, volar tilt, and ulnar variance. At the 3- and 6-month follow-up, group 1 showed better clinical results with respect to wrist extension, grip strength, and Gartland and Werley score, whereas group 2 showed better wrist flexion during this period. The range of motion and grip strength progressively leveled out between the 2 groups, and no significant differences were observed at the 9- and 12-month assessments. One patient in group 1 had short-term complex regional pain syndrome, and 4 patients in group 2 had temporary median nerve numbness.nnnCONCLUSIONSnTreatment with dorsal or volar locking plates can provide satisfactory radiographic and functional outcomes for AO type C3 dorsal comminuted distal radius fractures. The dorsal plate group showed an earlier recovery of wrist extension, grip strength, and functional score at the 3- and 6-month follow-up owing to direct reduction as well as fragmental-specific fixation of the dorsal fracture fragments.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Arthroscopy-Assisted Reduction of Posteromedial Tibial Plateau Fractures With Buttress Plate and Cannulated Screw Construct

PURPOSEnTo present the radiologic and clinical results of posteromedial fractures treated with arthroscopy-assisted reduction and buttress plate and cannulated screw fixation.nnnMETHODSnTwenty-five patients with posteromedial tibial plateau fractures treated by the described technique were included in this study. According to the Schatzker classification, there were 5 type IV fractures (20%), 2 type V fractures (8%), and 18 type VI fractures (72%). The mean age at operation was 46 years (range, 21 to 79 years). The mean follow-up period was 86 months (range, 60 to 108 months). Clinical and radiologic outcomes were scored by the Rasmussen system. Subjective data were collected to assess swelling, difficulty climbing stairs, joint stability, ability to work and participate in sports, and overall patient satisfaction with recovery. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up in comparison with the films taken at the time of injury.nnnRESULTSnThe mean postoperative Rasmussen clinical score was 25.9 (range, 18 to 29), and the mean radiologic score was 15.8 (range, 10 to 18). All 25 fractures achieved successful union, and 92% had good or excellent clinical and radiologic results. The 3 fracture types did not significantly differ in Rasmussen scores or rates of satisfactory results (P > .05). Secondary osteoarthritis was noted in 6 injured knees (24%).nnnCONCLUSIONSnArthroscopy-assisted reduction with buttress plate and cannulated screw fixation can restore posteromedial tibial plateau fractures of the knee with well-documented radiographic healing, good clinical outcomes, and low complication rates.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Arthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament

PURPOSEnThe purpose of the study was to highlight our surgical technique of arthroscopic suture fixation for acute tibial eminence posterior cruciate ligament (PCL) avulsion fractures, clinical and radiographic outcomes, and complication rates.nnnMETHODSnThis prospective study enrolled patients who had undergone arthroscopic reduction and suture fixation by use of 4 No. 5 Ethibond sutures (Ethicon, Somerville, NJ) for image-proven displaced PCL attachment fractures of the tibial eminence with posterior knee instability of grade II or higher. The mean follow-up period was 36 months (range, 24 to 45 months). Follow-up assessment included 3 different functional scores, KT-1000 arthrometry (MEDmetric, San Diego, CA), and radiographic evaluation.nnnRESULTSnThe mean preoperative Lysholm score in the 36 patients was 35 (range, 26 to 55); the mean postoperative Lysholm score was 95 (range, 80 to 100). The mean preinjury and preoperative Tegner scores in the 36 patients were 7.4 ± 1.6 (range, 5 to 9) and 3.2 ± 1.5 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.0 ± 1.8 (range, 5 to 9). At the final follow-up, the International Knee Documentation Committee scores were observed to be normal (grade A) or nearly normal (grade B) in 33 patients (91.7%) and abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved union within 3 months. No significant complications such as arthrofibrosis, loss of initial fixation, or wound infection were noted.nnnCONCLUSIONSnTreatment of tibial PCL avulsion fractures by arthroscopic suture fixation is a successful technique to restore tibial avulsion injuries of the PCL with well-documented radiographic healing, good clinical outcomes, and low complication rates.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Buttressing angle of the double-plating fixation of a distal radius fracture: a finite element study

Treatment of a distal radius fracture should consider principles including stable fixation and early motion. The aim of this study was to investigate the biomechanical interactions of plate-fixation angles in the internal double-plating method coupled with various load conditions using non-linear finite element analysis (FEA). A 3D finite element distal radius fracture model with three separation angles (50, 70, and 90°) between the buttressed L- and straight plates was generated based on computed tomography data. After model verification and validation, frictional (contact) elements were used to simulate the interface condition between the fixation plates and the bony surface. The stress/strain distributions and displacements at the radius end were observed under axial, bending, and torsion load conditions. The simulated results indicated that the bending and torsion increased the stress values more than the axial load. The radius and straight plate stress values decreased significantly with increasing fixation angles for all load conditions. However, the L-plate stress values increased slightly under the bending buckling effect. The displacements at the radius end and strains at the fracture healing interface decreased with increasing fixation angles for axial and torsion conditions but displayed a slight difference for the bending condition. The findings using FEA provide quantitative evidence to identify that much larger plate fixation angles could provide better mechanical strength to establish favorable stress-transmission and prevent distal fragment dislocation.

Augmentation of osteochondral repair with hyperbaric oxygenation: a rabbit study

BackgroundCurrent treatments for osteochondral injuries often result in suboptimal healing. We hypothesized that the combination of hyperbaric oxygen (HBO) and fibrin would be superior to either method alone in treating full-thickness osteochondral defects.MethodsOsteochondral repair was evaluated in 4 treatment groups (control, fibrin, HBO, and HBO+fibrin groups) at 2-12 weeks after surgical injury. Forty adult male New Zealand white rabbits underwent arthrotomy and osteochondral surgery on both knees. Two osteochondral defects were created in each femoral condyle, one in a weight-bearing area and the other in a non-weight-bearing area. An exogenous fibrin clot was placed in each defect in the right knee. Left knee defects were left empty. Half of the rabbits then underwent hyperbaric oxygen therapy. The defects in the 4 treatment groups were then examined histologically at 2, 4, 6, 8, and 12 weeks after surgery.ResultsThe HBO+fibrin group showed more rapid and more uniform repair than the control and fibrin only groups, but was not significantly different from the group receiving HBO alone. In the 2 HBO groups, organized repair and good integration with adjacent cartilage were seen at 8 weeks; complete regeneration was observed at 12 weeks.ConclusionsHBO significantly accelerated the repair of osteochondral defects in this rabbit model; however, the addition of fibrin produced no further improvement.

Assessment in Orthopedic Training—An Analysis of Rating Consistency by Using an Objective Structured Examination Video

OBJECTIVESnThis study describes a fast and efficient method that uses a prevalidated videotape of an objective structured clinical examination (OSCE) in a fracture scenario to evaluate raters and to measure the consistency of raters from different subspecialties and with varying levels of seniority.nnnSTUDY DESIGNnWe videotaped clinical scenarios for the purpose of evaluating residents communication and clinical assessment skills. All orthopedic staff used prevalidated checklists to assess residents performance in the videotape at 3 different time points. Cronbachs α was calculated to evaluate the internal consistency of the OSCE checklist construct. Kendalls W and KR-20 were used to investigate rater agreement. Expert validity was calculated to compare OSCE experts with the present raters.nnnRESULTSnA high Cronbachs α for the 23-item scale regarding global assessment in all 3 tests confirmed construct validity. Kendalls W showed only moderate interrater reliability. KR-20 was 0.96 for the pretest, 0.968 for the posttest, and 0.892 for the long-term test, indicating high internal consistency. The p-value for expert validity was 0.626 (independent t-test, n.s.).nnnCONCLUSIONSnThis efficient and fast video-based assessment of raters was reliable and yielded satisfactory rater consistency and some evidence for validity.

Medical record review for faculty promotion: A cohort analysis

Background: A medical record is an important source of information regarding medical care and medical record review plays an important role in the evaluation of the teaching proficiency. The study analyzed the difference between internal and external auditing when conducting medical record review for faculty promotion in a study institute. Methods: We analyzed the scores related to the medical records maintained by applicants for the faculty promotion of attending physicians during the period between 2008 and 2010 at the Chang Gung Memorial Hospital. The scores were obtained from one internal reviewer of the study institute and two external reviewers from other medical centers, and routine scores were obtained from the Committee of Medical Record 1 year before application. Pearson′s correlation coefficient was used to analyze the correlation and statistical significance. Results: There were 259 applicants for faculty promotion enrolled in this study [professors (n = 33, 13%), associate professors (n = 63, 24%), assistant professors (n = 90, 35%), lecturers (n = 73, 28%)]. The scores of the external reviewers 1 and 2 were correlated with routine scores (r = 0.187, p = 0.002; r = 0.198, p = 0.001; N= 259), respectively. The correlation between external reviewers′ average and ordinary scores was significant for assistant professor (r = 0.334, p = 0.001, n = 90) and professor grades (r = 0.469, p = 0.006, n = 33). However, the internal reviewer scores did not correlate with the routine scores (r = 0.073, p = 0.241, N = 259). Conclusions: The scores from external reviewers correlated more with routine scores than the scores from internal reviewers, suggesting that utilizing an external auditing system of medical records for the faculty promotion of attending physicians is quite feasible and balanced.

Early and late fixation of ulnar styloid base fractures yields different outcomes

BackgroundThe role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention.MethodsWe retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3xa0months of injury in 13 patients (group A) and beyond 3xa0months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of <u20090.01 was considered statistically significant.ResultsPatient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1xa0months in group A and 12.3xa0months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4u2009±u20095.9 vs. 12.9u2009±u20099.9) and grip strength (37.4u2009±u20095.1 vs. 29.1u2009±u20095.9xa0kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9°u2009±u20094.3° vs. 75°u2009±u20098.5°), extension (84.6u2009±u20094.3 vs. 76.7u2009±u20096.5), and flexion (80.4°u2009±u20093.8° vs. 72°u2009±u20094.1°). The difference was not significant in case of pronation (78.8°u2009±u20093° vs. 74.3°u2009±u20095.9°) and with respect to pain scores (0.6u2009±u20090.7 vs. 1.3u2009±u20091).ConclusionBoth osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.