Moon Sang Chung

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

BACKGROUNDnAlthough 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.nnnMETHODSnA 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnDespite 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.

Metatarsal lengthening in congenital brachymetatarsia: one-stage lengthening versus lengthening by callotasis.

We retrospectively reviewed and compared the outcomes of 15 one-stage metatarsal lengthenings with intercalary bone graftings in 10 patients with those of nine metatarsal lengthenings by callotasis in five patients younger than 15 years. In the one-stage lengthening group, the diaphyseal osteotomy site was gradually distracted intraoperatively for 20-30 min to relax the surrounding soft tissues. In the callotasis group, lengthening was achieved with mini-Orthofix M-100. There was little difference in the outcomes between the two groups in terms of length gain, percentage increase, and complications. However, the period to achieve bony consolidation was longer in the callotasis group (2.7 months/cm) than in the one-stage lengthening group (1.5 months/cm). No case of neurovascular impairment was found in both groups.

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.

Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children.

Background: To evaluate the efficacy of lateral or parallel pin fixation using 3 smooth Kirschner wires (K-wires) or smooth Steinmann pins for the operative management of displaced supracondylar humeral fracture in a consecutive series of children. Methods: Sixty-one consecutive displaced or angled supracondylar humeral fractures (Gartland type II or III) in children (mean age, 5 years 6 months) treated by 2 orthopaedic surgeons between 2001 and 2004 according to the following protocol: close reduction under general anesthesia with fluoroscopic guidance and only lateral percutaneous pinning using 3 divergent or parallel Kirschner wires or Steinmann pins. Minimum 2 years follow-up was done in all 61 patients (range, 2.0-3.3 years). Clinical assessment was obtained at final follow-up using Flynn criteria, and radiologic assessment was obtained using the Baumann and lateral humerocapitellar angles of both arms. Statistical analysis was performed by means of the Student t test (P < 0.05). Results: The study group consisted of 61 patients, of whom 24 (39%) presented with Gartland type II fractures, and the remaining 37 (61%) presented with a type III fracture. A comparison of perioperative and final radiographs shows no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. Eight patients had preoperative nerve palsy. Five of these nerve injuries resolved immediately after surgery, and the other 3 resolved completely within 12 weeks of surgery. After an average of 28 months postoperation, 56 (91.8%) patients had achieved an excellent clinical result, and 5 (8.2%) achieved a good result. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a minor pin-track infection. Conclusions: Our series demonstrates that only 3 lateral divergent or parallel pin fixations are effective and safe for avoiding iatrogenic ulnar nerve injury and are appropriate treatment options for displaced or angled supracondylar humeral fractures in children. Level of Evidence: Therapeutic study, level III.

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

PURPOSEnWe analyzed several clinical features of carpal tunnel syndrome to identify potential prognostic factors influencing a patient-based outcome assessment after carpal tunnel release.nnnMETHODSnWe 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnThis information may be used in preoperative consultation regarding the outcome of surgery from the patients perspective.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnPrognostic 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.nnMelorheostosis 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.nnA 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 …

Oblique Closing Wedge Osteotomy and Lateral Plating for Cubitus Varus in Adults

Corrective osteotomy around the elbow can require longer recovery time in adults than in children because of the longer healing period and the propensity for stiffness. We hypothesized a lateral oblique closing wedge osteotomy with a larger contact area and fixation with a lag screw plus early motion would provide stable fixation and early motion recovery in adults with cubitus varus deformity. Twelve consecutive patients who needed surgery were treated using this procedure. They were allowed active motion exercises 1xa0week postoperatively. The age of the patients at the time of surgery averaged 39xa0years (range, 31–48xa0years). The minimum followup was 15xa0months. All patients achieved healing of the osteotomy, and regained preoperative arcs of elbow motion at a mean of 7.3xa0weeks (range, 2–12xa0weeks) postoperatively. The average humerus-elbow-wrist angle improved from −23.3° to 8° (pxa0<xa00.002) by a mean gain of 29.6°. The mean lateral prominence index did not increase postoperatively. The final MEPI and DASH score averaged 95.4 points and 5.5 points. No patient experienced nerve palsy. Oblique osteotomy and fixation with a lag screw and lateral plating is a reasonable alternative technique for cubitus varus in adults, with early recovery of elbow motion and satisfactory deformity correction.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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

INTRODUCTIONnThe 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.nnnMATERIALS AND METHODSnThe 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.nnnRESULTSnThe 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).nnnCONCLUSIONSnPost-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.

Patients' Preferred and Retrospectively Perceived Levels of Involvement During Decision-Making Regarding Carpal Tunnel Release

BACKGROUNDnPatient-centered care requires physicians to respond to patients preferences, including their preferences regarding treatment decision-making. The authors surveyed patients to determine their preoperative preferences and their retrospectively perceived levels of involvement in decision-making for carpal tunnel release, and they attempted to identify factors that affect patient preferences and experiences.nnnMETHODSnSeventy-eight patients who underwent carpal tunnel release for carpal tunnel syndrome were requested to indicate their preferred level of involvement preoperatively and to assess their actual levels of involvement postoperatively, using a Control Preferences Scale containing five levels that range from fully active to fully passive. Clinical and demographic factors that potentially affected patients preoperative preferences and postoperative assessments of levels of involvement were analyzed.nnnRESULTSnFifty-nine patients (76%) indicated preoperatively that they preferred shared decision-making, and sixty-six (85%) thought postoperatively that they had experienced this type of decision-making. The correlation between preoperative and postoperative Control Preferences Scale assessments was significant (r = 0.525, p < 0.001). A history of a surgical procedure was independently associated with a preoperative preference for a more active role (odds ratio = 4.2), and patients with a caregiver (odds ratio = 4.0) or private insurance (odds ratio = 2.6) were more likely to experience an active role. Patients who preferred a collaborative role had lower scores on the Disabilities of the Arm, Shoulder and Hand questionnaire than those who preferred a fully active role (p = 0.002) or a fully passive role (p = 0.009).nnnCONCLUSIONSnThe majority of patients with carpal tunnel syndrome preferred to share surgical decision-making with the surgeon, and those who preferred a collaborative role had less severe symptoms than those who preferred a fully active or a fully passive role. A history of a surgical procedure, having a caregiver, and having private insurance were associated with a more active role. This information may assist the establishment of patient-centered consultation in patients with carpal tunnel syndrome.

Failure of the Interosseous Membrane to Heal With Immobilization, Pinning of the Distal Radioulnar Joint, and Bipolar Radial Head Replacement in a Case of Essex-Lopresti Injury: Case Report

The authors report a case of a patient with complex radial head and ulnar shaft fractures with an associated tear of the interosseous membrane, which failed to heal despite open reduction internal fixation of the ulna, a bipolar radial head replacement, and cross pinning of the distal radioulnar joint. This case demonstrates that failure of the interosseous membrane can occur even in a properly replaced bipolar radial head with adequate immobilization of the forearm and pinning of the distal radioulnar joint.