Hyuk Jin Lee

Long-term outcomes of ulnar shortening osteotomy for idiopathic ulnar impaction syndrome: at least 5-years follow-up.

Background There have been few outcomes studies with follow-up after performing ulnar shortening osteotomy for ulnar impaction syndrome. We investigated the long-term clinical and radiological outcomes of ulnar shortening osteotomy for the treatment of idiopathic ulnar impaction syndrome. Methods We retrospectively reviewed 36 patients who had undergone ulnar shortening osteotomy for idiopathic ulnar impaction syndrome for a mean follow-up of 79.1 months (range, 62 to 132 months). The modified Gartland and Werley scores were measured pre- and postoperatively. The radiographic parameters for the assessment of the distal radioulnar joint (DRUJ) as well as the relationship between these radiographic parameters and the clinical and radiological outcomes were determined. Results The average modified Gartland and Werley wrist score improved from 65.5 ± 8.1 preoperatively to 93.4 ± 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 ± 2.0 mm was reduced to an average of -0.6 ± 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 ± 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ. Conclusions The clinical outcomes are satisfactory for even more than 5 years after ulnar shortening osteotomy for treating idiopathic ulnar impaction syndrome despite the osteoarthritic changes of the DRUJ. The patients who need a larger degree of ulnar shortening may develop DRUJ arthritis.

The effect of buffered lidocaine in local anesthesia: a prospective, randomized, double-blind study.

PURPOSEnOpen carpal tunnel decompression under local anesthesia is routinely done by many surgeons. However, patients complain of pain during the injection of local anesthesia. This prospective, double-blind, randomized study was to compare the pain visual analog scale (VAS) scores of local anesthesia using lidocaine with and without sodium bicarbonate in patients with bilateral carpal tunnel syndrome.nnnMETHODSnTwenty-five patients underwent bilateral simultaneous carpal tunnel decompression. All had topical anesthetic cream applied on the palm and wrist before the lidocaine block. In a randomized manner, half of the hands were blocked with nonbuffered lidocaine and half were blocked with buffered lidocaine. Pain was evaluated on a VAS score.nnnRESULTSnThe mean pain VAS score in the hand with buffered lidocaine was 4.6 ± 1.5 and 6.5 ± 1.5 for the hand with nonbuffered lidocaine. After adjustment for individual threshold of the pain, the mean pain VAS score changed into 4.6 ± 1.3 with buffered lidocaine and 6.6 ± 1.7 without buffered lidocaine.nnnCONCLUSIONSnIn open carpal tunnel surgery, the use of buffered lidocaine for local anesthesia reduces the anesthetic pain effectively.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic I.

The Natural History of Pediatric Trigger Thumb: A Study with a Minimum of Five Years Follow-up

Background Pediatric trigger thumb is due to deformed flexion of the interphalangeal joint. We previously reported that pediatric trigger thumb can spontaneously resolve in > 60% of patients at the median follow-up of 48 months. The purpose of this study was to determine whether there were any more cases of resolution with a follow-up of more than 5 years and whether any residual deformities remain, and so to confirm the natural history of pediatric trigger thumb. Methods We prospectively followed 87 thumbs in 67 patients with pediatric trigger thumb and these patients didnt receive any treatment such as passive stretching, splinting or surgery. The date of the first visit ranged from April 1994 to March 2005. The patients were evaluated every six-months prior to resolution and annually after resolution. The median duration of follow-up was 87.3 months (range, 60 to 156 months). Results Of the 87 trigger thumbs, 66 (75.9%) resolved spontaneously. The median time from the initial visit to resolution was 49.0 months (95% confidence interval, 41.1 to 56.9). There were no residual deformities that resolved beyond 48 months. Although complete resolution did not occur in the remaining 21 thumbs, the flexion deformities did improve in all 21 thumbs. There were no other differences between the two groups besides the average duration of follow-up. There was no difference in resolution based on gender. Conclusions Pediatric trigger thumb can spontaneously resolve in > 75% of the cases after a follow-up period of at least 5 years. An operation may be delayed or avoided in the majority of cases. This may help both the families and the surgeons make decisions regarding the proper treatment of pediatric trigger thumb.

Classification and Surgical Treatment of Symphalangism in Interphalangeal Joints of the Hand

Background Symphalangism is a rare congenital difference characterized by ankylosis of interphalangeal (IP) joints of the fingers and toes. In adults, there were several attempts to restore the stiff joints into mobile ones, but these treatment options resulted in poor outcomes and could not be applied to growing children. Here, we report our experiences on surgical treatment for children who had symphalangism of the hand. Methods We treated 36 joints in 17 children with symphalangism of the hand using dorsal capsulotomy and collateral ligament release. The diagnoses were based on history, physical examination, and simple radiographs. Affected fingers were classified according to our grading system. Simple compressive dressing was applied using Coban after surgery. Passive range of motion (ROM) exercise was started on day one or 2 postoperative, with the help of a hand therapist and patients parents. The patients were prescribed passive ROM exercises for at least 2 hours a day over a period of 6 months. Results A single surgeon operated on 30 proximal IP joints, 3 distal IP joints, and 3 IP joints of the thumb. Twenty six joints were classified as grade I, and 10 as grade II. The ROM of affected joints, which was 7.8 ± 8.1 (mean ± SD) degrees preoperatively, increased to 46.8 ± 18.6 degrees at final follow-up. The final ROM was significantly better in grade I joints, especially when the children had operations at ages 24 months or younger. Conclusions Symphalangism of the hand in children, can be restored into a mobile joint by release of the collateral ligament, a dorsal capsulotomy, and postoperative physical therapy.

Compartment syndrome due to extravasation of peripheral parenteral nutrition: extravasation injury of parenteral nutrition

Compartment syndrome is a rare but devastating condition that can result in permanent neuromuscular or soft tissue injuries. Extravasation injuries, among the iatrogenic causes of compartment syndrome, occur under a wide variety of circumstances in the inpatient setting. Total parenteral nutrition via a peripheral route is an effective alternative for the management of critically ill children who do not obtain adequate nutrition via the oral route. However, there is an inherent risk of extravasation, which can cause compartment syndrome, especially when detected at a later stage. Herein, we report a rare case of compartment syndrome and skin necrosis due to extravasation, requiring emergency fasciotomy and skin graft in a 7-month-old boy who was treated with peripheral parenteral nutrition via a pressurized infusion pump. Although we cannot estimate the exact time at which extravasation occurred, the extent and degree of the wound suggest that the ischemic insult was prolonged, lasting for several hours. Pediatric clinicians and medical teams should carefully examine the site of insertion of the intravenous catheter, especially in patients receiving parenteral nutrition via a peripheral intravenous catheter with a pressurized infusion pump.

Ulnar Neuropathy After Extracorporeal Shockwave Therapy: A Case Report

Currently, extracorporeal shockwave therapy (ESWT) is widely used for treatment of various musculoskeletal disorders. We report a case of ulnar neuropathy secondary to the application of ESWT. A 48‐year‐old man was diagnosed with medial epicondylitis and underwent 2 sessions of ESWT. Immediately after the second session, he experienced paresthesia and weakness in the right hand. On physical examination, atrophy of the first dorsal interosseus and weakness of the abductor digiti minimi were observed. Electrophysiologic study demonstrated ulnar neuropathy at the elbow with severe partial axonotmesis. Our case report demonstrates that ESWT might cause or contribute to peripheral nerve injury at the site of application.

Characteristic radiographic features of the central ray in Apert syndrome

We reviewed retrospectively seven patients with Apert acrosyndactyly and measured the size of the capitate ossification centre relative to that of the hamate and determined the relative position of the middle finger metacarpal relative to the ring finger metacarpal. We then compared those parameters in 197 normal children. In all patients, the middle finger metacarpal bone had migrated proximally relative to the ring finger metacarpal and the size of the capitate ossification centre was smaller than that of the hamate. After surgical release of the middle finger, relative proximal migration of the middle finger metacarpal was partially relieved and catch-up growth of the capitate was observed within several months. As fusion of the distal phalanges creates a diamond-shaped configuration, bone growth is markedly impaired in the middle finger ray. Therefore, early separation of the middle finger may be as important as early separation of the border digits.

Limitation of elbow flexion in a patient with congenital radioulnar synostosis.

A 12-year-old boy presented with a restriction in left elbow flexion. He had difficulties in sporting activities and washing his hair. There was no history of injury. He had been diagnosed with a left congenital proximal radioulnar synostosis at the age of 2 years, without any other abnormalities. He had no pain of the left elbow and active motion was from 5–95°. The forearm was fixed in a position of 30° pronation position with 25° of cubitus valgus. Radiographs showed an anterior displacement of the radial head and a unilateral synostosis of the proximal aspects of the radius and ulna that could be classified as a type IV synostosis according to the system of Cleary and Omer (1985). Three-dimensional (3D) CT reconstruction scans showed the radial head to be about 15 mm longer than the tip of the coronoid process of the ulna (Figure 1). Surgery was carried out through an anterior approach under general anaesthesia. About 15 mm of the radial head was excised. The excised radial head had a small dimple, a bluish contusion and cartilage denudation on the articular surface. There was no enlarged soft tissue that could cause impingement within the range of motion. The joint capsule was securely closed. After resection, the elbow could be flexed fully without any impingement. Postoperatively the elbow was immobilized for 3 days followed by a range of motion exercises. Six months later there was full flexion of the elbow and no tenderness around the joint (Figure 2). Most patients with congenital radioulnar synostosis have a fixed position of the forearm ranging from neutral rotation to maximum pronation. Although the extent of clinical disability is variable, many patients are asymptomatic and do not have any perception of a handicap, with the exception of those who have a bilateral involvement or a severe degree of fixed pronation (Cleary and Omer, 1985). Generally speaking, patients with congenital radioulnar synostosis do not have problems with elbow flexion and extension, although some authors have reported that an acute flexion contracture of the elbow can develop after forced hyperflexion (Masuko et al., 2004). Limitation of elbow flexion causes considerable difficulty in activities of daily living as more than 130° of flexion are required for everyday tasks. In this case, the limitation of elbow flexion and associated difficulties were unusual findings in congenital radioulnar synostosis. The cause of the limitation was diagnosed by physical examination and a lateral radiograph of the elbow in a position of maximum flexion.

Sequelae of the Hip Joint Infection Treated with a Modern Alumina-on-Alumina THA

Total hip arthroplasty (THA) in patients with sequelae of the hip joint infection is a technically challenging procedure. In addition, the majority of such patients are less than fifty years old, so it has been reported that they have higher prevalence of complication and failure of component fixation. Alumina-on-alumina couplings are an attractive alternative and may offer a promising option for such young active patients. We analyzed 33 primary cementless alumina-onalumina THAs (PLASMACUP®SC-BiCONTACT® system incorporating BIOLOX® forte) that had been performed in patients who had sequelae of the hip joint infection. The average age of the patients was 37.8 years (range, 19-68 years) and 26 patients were younger than 50 years old. They were followed-up for more than 5 years (average, 74 months; range, 60-93 months). All hips had no recurrence of hip joint infection. The mean Harris hip score improved from 59.8 points to 93.5 points. All of the implants had radiographic evidence of a bone ingrowth and no radiological loosening was found. During the follow-up period, no cup or stem was revised and no periprosthetic osteolysis was observed. Nonunion of the osteotomized greater trochanter occurred in one hip, but no postoperative infection or ceramic failure was observed. The 5-year minimum follow-up clinical results of modern alumina-on-alumina THAs performed in patients with sequelae of the hip joint infection were encouraging with regard to osteolysis and implant stability. Our findings show that this alternative articulation offers a reliable solution for these young patients with long-standing anatomic abnormalities of the bone and soft tissues.

Intra-articular osteoid osteoma in the proximal ulna combined with radial head subluxation: a case report.

Osteoid osteoma is a relatively common benign bone tumor that was first described by Jaffe in 1935. Its typical clinical feature is pain, which is worse at night and relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). Typical radiologic findings are a nidus with a small radiolucent area within an extensive reactive cortical thickening. This tumor has a predilection for the diaphysis or metaphysis of long bones, with 50-60% occurring in the femur or tibia. However, localization in the elbow is a very rare presentation, and shows an atypical picture that causes both diagnostic delay and therapeutic problems. We herein report a case of a 19-year-old man who had pain and limited motion of the left elbow as a result of osteoid osteoma at the sigmoid notch of the proximal ulna. Anterior subluxation of the radial head was also observed by simple radiographs. En bloc resection and synovectomy resulted in pain relief, motion recovery, and reduction of the subluxated radial head. The patient consented when asked if data concerning his case could be submitted for publication.