Hyun Sik Gong

Factors Affecting Rotator Cuff Healing After Arthroscopic Repair Osteoporosis as One of the Independent Risk Factors

Background: The prognostic factors associated with structural outcome after arthroscopic rotator cuff repair have not yet been fully determined. Hypothesis: The hypothesis of this study was that bone mineral density (BMD) is an important prognostic factor affecting rotator cuff healing after arthroscopic cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: Among 408 patients who underwent arthroscopic repair for full-thickness rotator cuff tear between January 2004 and July 2008, 272 patients were included whose postoperative cuff integrity was verified by computed tomography arthrography (CTA) or ultrasonography (USG) and simultaneously who were evaluated by various functional outcome instruments. The mean age at the time of operation was 59.5 ± 7.9 years. Postoperative CTA or USG was performed at a mean 13.0 ± 5.1 months after surgery, and the mean follow-up period was 37.2 ± 10.0 months (range, 24-65 months). The clinical, structural, and surgery-related factors affecting cuff integrity including BMD were analyzed using both univariate and multivariate analysis. Evaluation of postoperative cuff integrity was performed by musculoskeletal radiologists who were unaware of the present study. Results: The failure rate of rotator cuff healing was 22.8% (62 of 272). The failure rate was significantly higher in patients with lower BMD (P < .001); older age (P < .001); female gender (P = .03); larger tear size (P < .001); higher grade of fatty infiltration (FI) of the supraspinatus, infraspinatus, and subscapularis (all P < .001); diabetes mellitus (P = .02); shorter acromiohumeral distance (P < .001); and associated biceps procedure (P < .001). However, in the multivariate analysis, only BMD (P = .001), FI of the infraspinatus (P = .01), and the amount of retraction (P = .03) showed a significant relationship with cuff healing failure following arthroscopic rotator cuff repair. Conclusion: Bone mineral density, as well as FI of the infraspinatus and amount of retraction, was an independent determining factor affecting postoperative rotator cuff healing. Further studies with prospective, randomized, and controlled design are needed to confirm the relationship between BMD and postoperative rotator cuff healing.

Patients with wrist fractures are less likely to be evaluated and managed for osteoporosis.

BACKGROUND Although osteoporosis is being evaluated and treated increasingly in elderly patients with fragility fractures, some studies have suggested that physicians may be missing important opportunities, especially in patients with nonvertebral fractures. The purpose of the present study was to determine whether specialists responsible for treating fractures at various locations have different propensities for evaluating and treating osteoporosis after a fracture in female patients over the age of fifty years. METHODS A retrospective nationwide cohort study was performed with use of data collected during 2007 by the Korean Health Insurance Review Agency, which covers 97% of the population. The incidences of fractures around the hip, spine, and wrist in female patients more than fifty years of age and the frequencies of bone density scans for osteoporosis and the use of medications for its treatment were analyzed and compared. RESULTS The database identified 31,540 hip fractures, 58,291 spine fractures, and 61,234 wrist fractures in female patients who were more than fifty years of age in Korea during 2007. Of these patients, 7095 (22.5%) with a hip fracture, 16,779 (28.8%) with a spine fracture, and 5348 (8.7%) with a wrist fracture underwent diagnostic bone density scans. Furthermore, 7060 patients (22.4%) with a hip fracture, 17,551 (30.1%) with a spine fracture, and 4594 (7.5%) with a wrist fracture were managed with at least one medication approved for the treatment of osteoporosis. CONCLUSIONS Despite a recent increase in the recognition of osteoporosis in patients with fragility fractures, our review of this national cohort indicates that patients with a wrist fracture are less likely to be evaluated and managed for osteoporosis than those with a hip or spine fracture by physicians who are responsible for treating symptomatic fractures. Additional studies and intervention programs are necessary to improve this care gap, beginning with physicians who are responsible for fracture treatment.

Treatment of Freiberg Disease with Intra-articular Dorsal Wedge Osteotomy and Absorbable Pin Fixation:

Background: The purpose of this study was to evaluate the outcome of intra-articular dorsal wedge osteotomy and absorbable pin fixation for the treatment of Freiberg disease. Methods: From January of 1997, to July of 2003, 12 patients with symptomatic Freiberg disease had intra-articular dorsal wedge osteotomy through the affected metatarsal head fixed with absorbable polyglycolide pins. All 12 patients were women with an average age of 36 (range 16 to 59) years. The Smillie stage of necrosis ranged from II to V. Active range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed after radiographic union was achieved. The mean followup was 45 (range 22 to 84) months. Results: Radiographically, solid healing of all osteotomies was observed at an average of 10 (range 8 to 16) weeks. There was no evidence of displacement, osteolysis, sinus formation, or progression of osteonecrosis at final followup. Pain measurement on a visual analog scale had improved significantly from an average of 8.0 to 2.3 (p < 0.05). The range of motion of the metatarsophalangeal joint increased by a mean of 26 (range 5 to 60) degrees. All patients were satisfied with the results and would have the surgery again. Conclusions: In patients with Freiberg disease, intra-articular dorsal wedge osteotomy restores congruity of the metatarsophalangeal joint, and fixation with absorbable pins provides adequate fixation and avoids a second procedure for implant removal.

Early Initiation of Bisphosphonate Does Not Affect Healing and Outcomes of Volar Plate Fixation of Osteoporotic Distal Radial Fractures

BACKGROUND Bisphosphonates can adversely affect fracture-healing because they inhibit osteoclastic bone resorption. It is unclear whether bisphosphonates can be initiated safely for patients who have sustained an acute distal radial fracture. The purpose of this randomized study was to determine whether the early use of bisphosphonate affects healing and outcomes of osteoporotic distal radial fractures treated with volar locking plate fixation. METHODS Fifty women older than fifty years of age who had undergone volar locking plate fixation of a distal radial fracture and had been diagnosed with osteoporosis were randomized to Group I (n = 24, initiation of bisphosphonate treatment at two weeks after the operation) or Group II (n = 26, initiation of bisphosphonate treatment at three months). Patients were assessed for radiographic union and other radiographic parameters (radial inclination, radial length, and volar tilt) at two, six, ten, sixteen, and twenty-four weeks, and for clinical outcomes that included Disabilities of the Arm, Shoulder and Hand (DASH) scores, wrist motion, and grip strength at twenty-four weeks. The two groups were compared with regard to the time to radiographic union, the radiographic parameters, and the clinical outcomes. RESULTS No significant differences were observed between the two groups with respect to radiographic or clinical outcomes after volar locking plate fixation. All patients obtained fracture union, and the mean times to radiographic union in Groups I and II were similar (6.7 and 6.8 weeks, respectively; p = 0.65). Furthermore, the time to radiographic union was not related to osteoporosis severity or fracture type. CONCLUSIONS In patients with an osteoporotic distal radial fracture treated with volar locking plate fixation, the early initiation of bisphosphonate treatment did not affect fracture-healing or clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Radiologic Outcomes of Arthroscopic Glenoid Labrum Repair With the BioKnotless Suture Anchor

Background Although arthroscopic glenoid labrum repair using the BioKnotless anchor is common, the benefits and efficacy have not been fully evaluated. Hypothesis BioKnotless suture anchor is a clinically and radiologically suitable material for arthroscopic labral repair. Study Design Case series; Level of evidence, 4. Methods Ninety-seven patients underwent arthroscopic glenoid labrum repair with BioKnotless anchor between July 2004 and December 2005. Thirty-seven patients had traumatic anterior instability and 60 patients had an isolated superior labrum, anterior-posterior (SLAP) lesion. The mean age at surgery was 36.0 years (range, 15–66); the average follow-up was 34.1 months (range, 24–54). Clinical outcomes were evaluated using range of motion and various functional evaluation scores including sports activity. Pain and patient satisfaction were measured using a visual analog scale (VAS). Computed tomography arthrography was conducted in 73 patients at least 1 year after surgery for radiologic evaluation. Results In patients with instability, the Western Ontario Shoulder Instability index and Rowe score improved from 53.2 to 85.9 and from 68.7 to 92.7, respectively. Return to normal recreation and sports were possible in 30 patients (81.1%); the mean satisfaction VAS was 9.2. There was 1 postoperative dislocation, and the apprehension test was positive in 1 case. Postoperative range of motion including external rotation was not different. In patients with a SLAP lesion, the American Shoulder and Elbow Surgeons score and Constant score improved from 67.3 to 96.0 and 79.1 to 96.8, respectively. Pain VAS decreased from 6.0 to 0.4, and the mean satisfaction VAS was 9.4. Return to normal recreation and sports were possible in 50 patients (83.3%). All labra were found to have firmly healed to bony glenoid rim without anchor-related osteolysis in postoperative CT arthrography. Conclusion Clinically and radiologically, the BioKnotless anchor appears to be an acceptable alternative for arthroscopic labrum repair, and a suitable material allowing the avoidance of certain troublesome drawbacks of the conventional knot-tying suture anchor.

Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft

OBJECTIVES The study aims to evaluate outcomes of autologous iliac bone impaction grafts (AIBIGs) with locking-compression plates (LCPs) in four-part proximal humeral fracture. METHODS Between October 2004 and October 2008, 21 AIBIG with LCP osteosyntheses were done for four-part proximal humeral fractures. Patients included seven males and 14 females. Their mean age at the time of the operation was 66.3±16.9 years (range: 24-87 years). Five patients had high-energy fractures other than fall from standing height. There were two fracture-dislocation cases, and three valgus-impacted fractures. The length of the calcar segment attached to the articular segment was 7.04±6.10mm; 13 of the 21 cases had lengths less than 8mm. Medial-hinge displacement was 16.77±15.84mm; 19 of the 21 cases had displacements more than 2mm. RESULTS There was no avascular necrosis of the humeral head and union was achieved in all cases. Varus collapse and hardware-related complications were not observed. Postoperative neck-shaft angles were found to be 129±9° (range: 109-146°). Neer scores were 92.0±6.3 (range: 81-100). CONCLUSION The results of using AIBIG with LCP for four-part proximal humeral fractures are excellent. There are significant bone defects in osteoporotic or comminuted fractures and LCP alone does not always provide reliable fixation. Therefore, meticulous technique and use of AIBIG in this complicated type of fracture can ensure a favourable outcome.

Results of concomitant rotator cuff and SLAP repair are not affected by unhealed SLAP lesion

HYPOTHESIS To verify the anatomic results of combined repair of a full-thickness rotator cuff tear and superior labral anterior and posterior (SLAP) lesion. In addition, we compared the anatomic and functional outcomes according to the status of the repaired SLAP lesion. METHODS We enrolled 61 patients who underwent cuff repair with concomitant SLAP repair and were available for both functional and radiologic outcome evaluation at least 1 year after the operation. There were 40 male and 21 female patients with a mean age of 57.4 years (range, 39-70 years). We measured various clinical outcomes and evaluated the structural outcomes of the rotator cuff and the superior labrum and rotator cuff using computed tomography arthrography at the final follow-up visit. We also evaluated the functional outcome according to anatomic healing of the superior labrum. RESULTS Labral healing to the bony glenoid was achieved in 49 patients (80.3%), and anatomic healing of the rotator cuff was observed in 44 patients (72.1%). The retear rate of the rotator cuff was not statistically different with respect to labral healing status. All functional outcomes improved significantly (P < .001), and there were no statistical differences in functional outcome with respect to postoperative healing of the superior labrum. CONCLUSIONS An unhealed SLAP lesion did not preclude the successful outcome of concomitant rotator cuff repair. Therefore, repair of a concomitant SLAP lesion may not be an essential procedure for a successful outcome of a rotator cuff repair.

Clinical Features Influencing the Patient-Based Outcome After Carpal Tunnel Release

PURPOSE We analyzed several clinical features of carpal tunnel syndrome to identify potential prognostic factors influencing a patient-based outcome assessment after carpal tunnel release. METHODS We evaluated 102 hands of 64 patients with carpal tunnel syndrome using the Boston self-assessment questionnaire preoperatively and 3, 6, 9, and 12 months postoperatively. The clinical findings evaluated as prognostic indicators were paresthesia, cold intolerance, subjective weakness, nocturnal pain, thenar atrophy, Tinel sign, Phalen test, and electrophysiologic grades. All assessments of outcome were subjective based on the reports of patients, and no objective measurements were obtained to establish improvement after surgery. RESULTS The overall symptom and functional scales of the self-assessment questionnaire demonstrated a significant improvement at 3 months after surgery, but no significant further improvement was observed thereafter. Patients with nocturnal pain, patients without subjective weakness, and patients without cold intolerance demonstrated more improvement of the scores in the bivariate analysis. CONCLUSIONS This information may be used in preoperative consultation regarding the outcome of surgery from the patients perspective. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Successful elbow contracture release secondary to melorheostosis. A case report.

Melorheostosis is a rare, noninheritable developmental dysplasia of cortical bone that is often characterized by a classic radiographic pattern of flowing hyperostosis along the cortex of long bones1. Patients with this condition may have joint pain, stiffness, deformity, and restricted range of motion due to soft-tissue contracture2. Involvement usually follows a sclerotomal distribution3 and usually affects only one extremity4,5. Joint contracture occurs when the abnormal ossification in the cortex of the long bone involves the soft tissues and extends into the joint, resulting in soft-tissue fibrosis and contracture2,5,6. There is no specific treatment for this condition; options range from nonsurgical management (e.g., splinting and early training in making optimal use of the unaffected extremity) to various types of surgical management (e.g., tendon lengthening, sympathectomy, implant arthroplasty, or even amputation2. The literature indicates that surgical release of a joint contracture may be difficult and that recurrence of the deformity is frequent2,4-6. Melorheostosis of the elbow is rare compared with that of the lower extremity, and a thorough search of the literature revealed no reports on surgical release of a stiff elbow caused by this condition. We report the case of a thirty-seven-year-old man who had a fixed flexion contracture of the elbow as a result of isolated melorheostotic involvement of the proximal part of the ulna and who obtained a functional range of motion after open release of the elbow. The patient was informed that data concerning the case would be submitted for publication, and he consented. A thirty-seven-year-old man presented with limitation of motion of the left, nondominant elbow. He reported that pain and limited elbow motion had developed after he played a game of squash five …

Vitamin D levels in post-menopausal Korean women with a distal radius fracture

INTRODUCTION The purpose of this study was to investigate serum levels of vitamin D in post-menopausal Korean women with a distal radius fracture (DRF) and to determine if there is any association between vitamin D levels and bone-related variables such as bone mineral densities (BMDs), serum parathyroid hormone (PTH) levels and several bone turnover markers. MATERIALS AND METHODS The data of 104 postmenopausal women surgically treated for a distal radius fracture (DRF group) and 107 age-matched control patients without a fracture (control group) were compared. Serum vitamin D levels (25-hydroxycholecalciferol, 25(OH)D(3)) were compared between the groups with consideration of age and seasonal variations. BMDs, serum PTH and several bone turnover markers, including serum osteocalcin, C-telopeptide and urine N-telopeptide, were measured and analysed to find any association with vitamin D levels. RESULTS The mean 25(OH)D(3) level was significantly lower in the DRF group compared to the control group (p < 0.001). In particular, patients in their sixth and seventh deciles in the DRF group had significantly lower 25(OH)D(3) levels than patients in the control group (p = 0.001 and 0.013, respectively). When seasonal variation was considered, significant differences of 25(OH)D(3) levels were found between the groups in autumn and winter. Hip BMDs were significantly lower in the DRF group than in the control group, and there was a positive correlation between serum 25(OH)D(3) levels and hip BMDs. Bone turnover markers were not significantly different between the two groups, although serum PTH levels were marginally higher in the DRF group (p = 0.08). CONCLUSIONS Post-menopausal Korean women with a DRF were found to have significantly lower serum vitamin D levels than the control group, and vitamin D levels were particularly lower in women in their sixth and seventh deciles who may be a good target group for prevention of future fractures. Future investigation should focus on determining whether vitamin D supplementation can be helpful in preventing future fractures in patients with a DRF.