Jihyeung Kim

Multiple congenital brachymetatarsia: A ONE-STAGE COMBINED SHORTENING AND LENGTHENING PROCEDURE WITHOUT ILIAC BONE GRAFT

We performed nine metatarsal and three proximal phalangeal lengthenings in five patients with congenital brachymetatarsia of the first and one or two other metatarsal bones, by a one-stage combined shortening and lengthening procedure using intercalcary autogenous bone grafts from adjacent shortened metatarsal bones. Instead of the isolated lengthening of the first and the other metatarsal bones, we shortened the adjacent normal metatarsal and used the excised bone to lengthen the short toes, except for the great toe, to restore the normal parabola. One skin incision was used. All the operations were performed bilaterally and the patients were followed up for a mean period of 69.5 months (29 to 107). They all regained a nearly normal parabola and were satisfied with the cosmetic results. Our technique is straightforward and produces good cosmetic results. Satisfactory, bony union is achieved, morbidity is low, and no additional surgery is required for the removal of metal implants.

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.

Radial polydactyly: proposal for a new classification system based on the 159 duplicated thumbs.

Background: Polydactyly is one of the most common congenital differences that affect the hand. It has various anatomic and morphologic features. Although the Wassel classification has been used widely for radial polydactyly, it is based on the anatomic level of duplication and has some limitations in describing the concrete morphology of the duplication. The authors devised a new classification system based on the anatomic pattern of duplication to facilitate surgical correction of the deformity and evaluated surgical outcomes. Methods: A total of 159 duplicated thumbs in 142 patients who were treated surgically from 1990 to 2007 and followed for >12 months were included in this series. The authors categorized all cases of radial polydactyly into the following: type I (joint type), where the extra digit has its own joint at its origin; type II (single epiphyseal type), where the origin of the extra digit is derived directly from the common epiphysis; type III (osteochondroma-like type), where the origin of the extra digit resembles an osteochondroma; and type IV (hypoplastic type), where the extra digit is connected to the main digit by soft tissue alone. All patients underwent surgical treatment based on this classification. The surgical outcomes were assessed using the Tada score. Results: Of the 159 radial polydactyly cases, 84 (50%) were classified as the joint type—37 (22%) as the osteochondroma-like type, 33 (19%) as the single epiphyseal type, and 15 (9%) as the hypoplastic type. All the cases were classified with the proposed classification system. In the evaluation of the surgical outcomes, 134 (84%), 17 (11%), and 8 (5%) were rated as good, fair, and poor, respectively. Conclusions: This new classification system for radial polydactyly is practical and closely related to the surgical strategies. Level of Evidence: Diagnostic IV.

Non-vascularized iliac bone grafting for scaphoid nonunion with avascular necrosis:

We present the surgical outcomes of non-vascularized bone grafting taken from the iliac crest in 24 patients with scaphoid nonunion and avascular necrosis. The Fisk-Fernandez technique was used in 11 patients, and cancellous bone grafting was used in 13 patients. Bony union was achieved in 22 of the 24 patients. Non-vascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis. Although revascularization of the proximal fragment after surgery was not evaluated, bony union was confirmed in nearly all patients. Level of evidence: IV

The Effect of Psychological Factors on the Outcomes of Carpal Tunnel Release: A Systematic Review

BACKGROUND Several studies report that psychological factors are associated with outcomes of carpal tunnel release. However, interpretation of the association is difficult as there are diverse outcome parameters and patient expectations are different. We performed a systematic review to assess the relationships between psychological factors and the various outcome parameters. METHODS We identified 611 papers and selected 8 papers that fit the inclusion criteria. Psychological factors assessed were anxiety, depression, pain catastrophizing, coping, and mental health status. Outcomes of interest included satisfaction and measures of perceived level of function, pain, and physical measures of recovery. RESULTS For satisfaction and perceived level of function as the outcome, three studies reported a significant association, one study found an association approaching a value of significance, and one study reported no association. For pain as the outcome, two studies reported a significant association. For physical measures, one study reported no association. CONCLUSIONS This systematic review found that depression correlates with postoperative pain, but that the association is less clear between psychological factors and outcomes such as satisfaction, perceived level of symptom and function, and physical measures of recovery. As pain may not be a primary symptom or outcome of CTS, we consider that the current literature does not strongly support the association between psychological factors and outcomes of CTR. This review could be of benefit during preoperative counseling in patients with psychological disturbances.

Clinical Outcome of Lateral Wedge Osteotomy of the Radius in Advanced Stages of Kienböck's Disease

Background Radius osteotomies showed favorable clinical outcome in Kienböcks disease. However, few articles have been published on the long-term outcome of lateral wedge osteotomy of the radius in patients with advanced stage Kienböcks disease. Methods Eleven patients with Lichtman stage IIIB/IV Kienböcks disease (group A; mean follow-up period, 86.1 months; range, 48 to 163 months) and 14 patients with Lichtman stage IIIA Kienböcks disease (group B; mean follow-up period, 85.1 months; range, 49 to 144 months) underwent radial wedge osteotomy between August 2004 and August 2012. Radiological changes of the lunate and radiocarpal joint were compared between two groups after osteotomy. The wrist flexion/extension angle, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were evaluated preoperatively and at the final follow-up. The Nakamura Scoring System (NSSK) was used for comprehensive understanding of radiological and clinical outcomes. Results Nine patients of group A and 11 patients of group B showed radiological improvement in the lunate regarding sclerosis, cystic changes, or fragmentation. No patients showed progression of arthritic changes in radiocarpal and midcarpal joints. The wrist flexion/extension angle, grip strength, and DASH score were significantly improved in both groups after operation, but intergroup difference was not statistically significant at the final follow-up (p = 0.149, p = 0.267, and p = 0.536, respectively). The mean NSSK was 21.6 (range, 15 to 27) in group A and 21.8 (range, 15 to 26) in group B. Conclusions Radial wedge osteotomy yielded excellent radiological and functional outcomes in advanced stages of Kienböcks disease and these results were comparable to those of Lichtman stage IIIA disease. This technique could be a useful alternative to salvage procedures in the treatment of Lichtman stage IIIB/IV Kienböcks disease without severe radiocarpal arthritis.

Innervated Reverse Digital Artery Island Flap through Bilateral Neurorrhaphy using Direct Small Branches of the Proper Digital Nerve.

Background: The reverse digital artery flap uses the radial or ulnar surface of the proximal phalanx of the involved digit and has been applied to sensate flaps using the superficial sensory nerve branch and the dorsal branch of the proper digital nerve. As these nerve branches innervate the dorsal surface of the finger, however, hypesthesia of the dorsal side of the middle phalanx is inevitable. Methods: Thirty fingers of 25 patients who had the innervated reverse digital artery flap using direct small branches of the proper digital nerve were included in this study. The minimum follow-up duration was 24 months, and the average defect size was 2.8 cm2. Results: In all cases, the pulp defects were successfully reconstructed with this flap. The average size of the donor flap was 3.9 cm2. At 6 months after surgery, the average static two-point discrimination value was 5.9 mm, the average moving two-point discrimination value was 5.0 mm, and the average Semmes-Weinstein monofilament score was 3.79. At 1 year postoperatively, the average Cold Intolerance Severity Score was 20. The percentage total active motion was measured at 99 percent 2 years after surgery. Conclusions: Because this flap does not sacrifice the proper digital nerve or dorsal branch of the nerve, the sensibility of the dorsal aspect of the proximal and middle phalanx can be preserved. This flap is cosmetically excellent, as it uses a donor flap similar to the injured fingertip and the donor scar can be hidden by adjacent fingers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Expression of vitamin D receptor in the subsynovial connective tissue in women with carpal tunnel syndrome

Studies suggest that low vitamin D levels are associated with carpal tunnel syndrome. We aimed to evaluate whether level of vitamin D receptor expression in the endothelial cells of the subsynovial connective tissue is associated with clinical features of carpal tunnel syndrome. We obtained the subsynovial connective tissue from 52 women with carpal tunnel syndrome during surgery and performed immunohistochemical analysis of vitamin D receptors in the endothelial cells of the subsynovial connective tissue. We explored correlation of vitamin D receptor expression with clinical features of carpal tunnel syndrome, such as age, symptom duration, symptom severity and electrophysiological severity. Diverse range of vitamin D receptor expression was observed. Vitamin D receptor expression was independently associated with distal motor latency. This suggests that vitamin D receptor expression may be associated with disease progression, as prolonged distal motor latency reflects severity of the disease. Further studies are necessary to explore the role of vitamin D and vitamin D receptors in patients with carpal tunnel syndrome. Level of evidence: IV

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint.

Repeatability of a multi-segment foot model with 15-marker set in normal adults

Several 3D multi-segment foot models (MFMs) have been introduced for the in vivo analysis of dynamic foot kinematics [1,2]. However, there is scanty evidence available to support their clinical use. Considering the potential of MFM to assess the function in foot pathology, there is a need for simple, reproducible and reliable multi-segment foot models. The purpose of this study was to assess the reliability of a simple MFM with 15-marker set. Twenty healthy adults mean aged 28.9 years (10 males and 10 females) were tested. Eight markers of 15-marker set were placed in foot to evaluate segmental foot motion. Three representative strides from five separate trials were used for analysis from each session. Kinematic data of foot segmental motion was collected and tracked using the Foot3D Multi-Segment Software (Motion Analysis Co., Santa Rosa. CA). Retests were performed in the same manner with an interval of 4 weeks. Coefficients of multiple correlation (CMC) and intra-class correlation (ICC) were calculated in order to assess the inter-trial and inter-session repeatability. Inter-segment foot angles from healthy adults from a MFM with 15-marker set showed a narrow range of variability during the whole gait cycle. The mean inter-trial ICC (± Standard deviation) was 0.981 (± 0.010), which was interpreted as excellent. The mean inter-trial CMC (± Standard deviation ) was 0.948 (± 0.027), which was interpreted as excellent or very good repeatability. The mean inter-session ICC (±SD) was 0.886 (± 0.047) and the mean inter-session CMC (±SD) was 0.801 (± 0.077), which were interpreted as excellent or very good repeatability. The lowest repeatability was in the transverse plane at the forefoot and the most consistent finding was observed at the sagittal plane of the hallux and hindfoot (Table ​(Table1,1, Figure ​Figure11). Table 1 Repeatability of foot kinematics Figure 1 Walking kinematics for the 1st and 2nd visit (average with a range representing 2 standard deviations). Each row shows the motion of each segment: hallux, hindfoot, arch, forefoot, medial forefoot, lateral forefoot motion. Each column represents motion ... We demonstrated a MFM with 15-marker set had high inter-trial and inter-session repeatability, especially in sagittal plane motion. We thought this MFM would be applicable to evaluation of the motion of the foot segment during gait.