Tatsuya Masuko

Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes

BACKGROUND Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. METHODS From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. RESULTS Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112 degrees +/- 17 degrees preoperatively to 128 degrees +/- 12 degrees postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 +/- 23 points preoperatively to 191 +/- 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. CONCLUSIONS The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions.

Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes: surgical technique.

BACKGROUND Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. METHODS From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. RESULTS Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112° ± 17° preoperatively to 128° ± 12° postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 ± 23 points preoperatively to 191 ± 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. CONCLUSIONS The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions.

Rupture of the flexor digitorum profundus tendon after injections of insoluble steroid for a trigger finger

Dear Sir, A 37-year-old right-handed woman presented with a 2 week history of loss of flexion, pain and swelling of her right little finger. She had been diagnosed with trigger finger at another hospital and had been given seven flexor sheath injections of 20mg of triamcinolone acetonide and 1% lignocaine around the A1 pulley over a 14 month period. About 2 months after the last injection, while trying to move the headrest of her car seat, the woman experienced painful snapping in her right little finger and lost flexion of the distal interphalangeal (DIP) joint. A rupture of the flexor digitorum profundus (FDP) was suspected and the patient was referred to our hospital. The patient was in good health and did not suffer from rheumatoid arthritis, diabetes mellitus, collagen disorder or wrist trauma and was not on systemic steroid treatment. She had tenderness on the palmar aspect of the metacarpophalangeal (MP) joint of the right little finger and was unable to flex the DIP joint, but could flex the proximal interphalangeal joint. On a magnetic resonance scan the FDP could not be seen at the MP joint. At operation, the FDP tendon was found to be ruptured, and its ends were identified (Fig 1). As the distance between the tendon ends was approximately 2 cm and direct suturing was not possible, tendon grafting from the palm to the fingertip was carried out using the palmaris longus (PL) tendon. The day after surgery passive flexion of the right little finger was started using the modified Kleinert method. After 3 weeks, active flexion was permitted. By 8 weeks the motion of the finger was smooth, and the active range of motion of the DIP joint was 0 –50 . However, 14 weeks after surgery, the patient was suddenly again unable to flex the injured finger during light active rehabilitation. As a re-rupture of the grafted FDP tendon was suspected, the tendon was explored. The grafted tendon was torn at the distal end. Forearm-to-fingertip grafting using the PL tendon from the opposite forearm was done. The course of postoperative rehabilitation was similar to that after the first operation. At 27 weeks, the active range of motion of the DIP joint was 15 to 45 . Local corticosteroid injection is widely used for the treatment of trigger finger despite the risk of tendon rupture. There have been only two reports on rupture of the flexor tendon after local corticosteroid injection for the treatment of a triggering digit (Fitzgerald et al., 2005; Taras et al., 1995). Taras et al. reported a case of rupture of the right flexor pollicis longus tendon in a patient with trigger thumb: the patient had received two local corticosteroid injections 4 years earlier. Fitzgerald et al. reported a case of rupture of the right middle FDP and FDS tendons in a patient with trigger finger: the patient was treated with two local injections of triamcinolone, each of 20mg, with a 3 month interval between injections. There have been a few other reports of rupture of the flexor digitorum tendon after corticosteroid injection

Surgical treatment of acute elbow flexion contracture in patients with congenital proximal radioulnar synostosis. A report of two cases.

Congenital proximal radioulnar synostosis is a rare congenital upper-extremity disorder in which the proximal aspects of the radius and ulna are fused and the rotational motion of the forearm is restricted. It has been estimated that 26% of all patients who have congenital radioulnar synostosis have a 10° to 30° limitation of elbow extension1. The Japanese-language literature includes reports on three patients with congenital proximal radioulnar synostosis who had an acute development of elbow flexion contracture2-4. However, to our knowledge, there have been no published reports in the English-language literature regarding patients with this disorder. We describe the cases of two boys with congenital proximal radioulnar synostosis in whom an elbow flexion contracture developed in a relatively acute manner. After removal of a hypoplastic lateral soft-tissue structure analogous to the annular ligament, both patients were able to achieve full extension of the elbow without recurrence of the elbow flexion contracture. Our patients and their families were informed that data from the cases would be submitted for publication. CASE 1. A thirteen-year-old boy had a restriction in elbow extension after having slept with the elbow held in a hyperflexed position. Three days after this first episode, which had resolved spontaneously, the same elbow flexion contracture appeared without any inducement and continued for seven days, at which point the patient was seen in our clinic. There was no history of trauma, and physical examination demonstrated neither swelling nor ecchymosis of the elbow. The patient had pain in the elbow and was noted to have some tenderness over the right radial head and the anterior aspect of the elbow joint. The active range of motion was from 75° to 135° (Fig. 1-A). The right forearm was fixed in 10° of pronation. The patient had been aware of …

Transplantation of tissue-engineered cartilage for the treatment of osteochondritis dissecans in the elbow: Outcomes over a four-year follow-up in two patients

The ideal goal of treatment for osteochondral lesions is to resurface the lesions with hyaline cartilage and to prevent the occurrence of secondary osteoarthritis. To achieve this goal, autologous chondrocyte implantations (ACI) have been developed and clinically applied to osteochondral lesions of the knee and ankle joints. Osteochondral lesions such as osteochondral dissecans (OCD) or osteochondral fractures are frequently involved in the elbow. Although the implementation of ACI in the elbow has been reported, postoperative follow-up is limited. Consequently, the surgical efficacy of this procedure remains unclear. We present 2 patients with OCD in the elbow who underwent ACI, with favorable clinical and radiographic outcomes over a 4-year follow-up.

RADIOLUNATE FUSION WITH DISTRACTION USING CORTICOCANCELLOUS BONE GRAFT FOR MINIMIZING DECREASE OF WRIST MOTION IN RHEUMATOID WRISTS

Radiolunate fusion is a limited carpal fusion procedure used for patients with rheumatoid arthritis. However, this procedure inevitably causes decreases in range of motion, especially wrist flexion. Linscheid and Dobyns described the possibility of minimizing the decrease in motion at the radiocarpal joint by slight distraction of the joint. We hypothesized for our modified procedure that a corticocancellous bone graft was inserted between the radius and the lunate with a small amount of over-correction could provide slight distraction of radioscaphoid joint and protect the joint from decreased range of motion after arthrodesis. Twelve wrists in ten patients with rheumatoid arthritis underwent radiolunate fusion. Mean age at operation was 53 years old and mean follow-up period was 5.7 years. Clinical evaluation and radiological assessment showed that decrease in range of motion was minimized compared with other procedures. Because our modified procedure can minimize decrease in motion, it is recommended.

Forearm fascial hernia after harvesting the palmaris longus tendon

Dear Sir, A 32-year-old male carpenter presented with a painful swelling in the left forearm. The pain was exacerbated by active wrist flexion and prevented him from working. Thirty-three months before visiting our clinic he had undergone ligament reconstruction surgery for lateral collateral ligament insufficiency in the left elbow, using the palmaris longus tendon, which was harvested with a tendon stripper. Approximately 9 months after the operation, he noticed a painful swelling in the left forearm. Physical examination revealed a palpable fascial defect over the flexor-pronator compartment of the mid-forearm. On active wrist flexion, a 3 3 cm firm mass became apparent, corresponding to the fascial defect. A dynamic ultrasound examination demonstrated flexor muscles protruding through the fascial defect. Magnetic resonance images revealed a herniation of the flexor carpi ulnaris (FCU) muscle that became more prominent with muscle contraction. Because the symptoms had persisted for 4 months, surgical exploration was undertaken. Under general anaesthesia, a palmar zig-zag skin incision was made over the fascial defect in the forearm. A 3 4 cm fascial defect overlying the belly of FCU was found. Passive wrist flexion caused the muscle belly to protrude through the fascial defect (Fig 1). The defect could not be closed directly and extending the fasciotomy from the proximal edge of the defect proximally was also ineffective in reducing the volume of the herniated muscle belly. The ultimate size of the defect was 6 4 cm. Therefore, we repaired the fascial defect with an onlay graft of fascia lata harvested from the right thigh. The fascia was attached to the adjacent fascia with appropriate tension using 3-0 nylon sutures (Fig 2). There was no protrusion of the muscle belly on passive wrist flexion after the graft. Five months postoperatively, the patient was asymptomatic without evidence of recurrent herniation in the forearm. Postoperative MRI showed no muscle protrusion at the repaired site. Although a large number of symptomatic fascial hernias have been reported in the lower extremities, fascial hernias are extremely rare in the forearm (Golshani et al., 1999; Olch and Watson, 1996; Roberts et al., 1989). As a result there is a possibility of misdiagnosing this lesion in the forearm. The current case resulted from a fascial tear caused by harvesting the palmaris longus tendon using a tendon stripper. Although no other case has been reported, care should be taken to prevent forearm hernia in similar circumstances. In treating fascial hernias, extended fasciotomy has been the most effective operation in the lower extremities. However, in upper extremities, the best operative procedure is still not established. As loss of anatomical integrity may impair the function of herniated muscles, we carried out repair of the defect with a fascia lata onlay graft to restore more normal anatomy and achieved a satisfactory clinical result.

ELDERLY KENDO (JAPANESE FENCING) PLAYER WITH KIENBÖCK'S DISEASE IN ONE WRIST AND PREISER'S DISEASE IN THE OTHER WRIST: A CASE REPORT

Elderly patients suffering from avascular necrosis of a carpal bone in both wrists are extremely rare. We report a case of an elderly kendo (Japanese fencing) competitor who sustained Preisers disease in the left hand following the occurrence of Kienböcks disease in the right hand. The current case demonstrates the importance of raising awareness of these diseases as potential sports-related problems in the elderly.

491 NEW ALGORITHM FOR CRPS TYPE I AND II USING NEUROTROPIN® AND ELCATONIN

painful points relieved the suffering. In all, diffuse pain and signs of sympathetic activity disappeared and mobility significantly improved leaving only sequelae of initial injury. Conclusion:Many patients suffering of the sequelae of initial injury are misdiagnosed as CRPS and overtreated. Once such “CRPS-label” has been attached to the patient it has been rarely reevaluated, changed and properly treated. Majority of CRPS like patients have overlooked but well known and treatable pathology.