Won Sik Choy

Subtalar Arthroscopic Procedures for the Treatment of Subtalar Pathologic Conditions: 115 Consecutive Cases

Arthroscopic procedures of subtalar pathology has shown promising results in previous studies, but the number of patients was relatively small. This article describes our experience and evaluated the clinical outcomes of 115 patients treated with subtalar arthroscopy for a range of subtalar pathologies. One hundred fifteen patients were followed up for >1 year after undergoing a subtalar arthroscopic procedure. Mean patient age was 40 years, and mean follow-up period was 42 months. Preoperative diagnosis included sinus tarsi syndrome in 31 patients, degenerative arthritis in 30, calcaneal fracture in 15, arthrofibrosis in 10, os trigonum syndrome in 8, talar fracture in 5, talocalcaneal coalition in 7, and calcaneal tumor in 1. The clinically modified American Orthopaedic Foot and Ankle Society (AOFAS) and AOFAS ankle-hindfoot scales and patient satisfaction were evaluated. Thirty-one patients had subtalar synovitis and underwent synovectomy; 9 had mild degenerative disease and underwent debridement and chondroplasty; 6 had chondromalacia and underwent intra-articular shaving; 11 had a loose body removed; 10 underwent arthroscopic resection for arthrofibrosis; 8 had symptomatic os trigonum and underwent arthroscopic excision; 6 underwent excision and multiple drilling for an osteochondral lesion of the talus; and 26 had severe degenerative joint disease and underwent arthroscopic subtalar arthrodesis. The mean modified AOFAS ankle-hindfoot scale in the subtalar fusion group was increased from 33 points preoperatively to 84 points postoperatively (P< .005), and the mean AOFAS ankle-hindfoot scale in the other-than-fusion group increased from 69 points preoperatively to 89 points postoperatively (P<.005). Ninety-seven percent of patients were satisfied with the procedure, and there were no serious complications.

Precontoured locking plate fixation for displaced lateral clavicle fractures.

Displaced fractures of the lateral end of the clavicle are associated with an increased risk of nonunion with conservative treatment; therefore, operative treatment is recommended. Various operative treatments have been suggested, but no consensus exists regarding a gold standard for the surgical treatment of this type of fracture. The purpose of this study was to evaluate clinical and radiological outcomes using a precontoured locking compressive distal clavicular plate for Neer type II distal clavicle fractures. Thirty-five patients with Neer type II distal clavicle fractures underwent surgery between March 2009 and January 2012. All patients were evaluated for function using the Constant-Murley Shoulder Outcome Score and University of California, Los Angeles shoulder rating scale, active shoulder range of motion, time to bone union, and coracoclavicular distance. Mean follow-up was 24.2 months (range, 12-35 months). No significant difference existed between the injured and contralateral sides in mean Constant-Murley scores (P=.13) or mean University of California, Los Angeles shoulder rating (P=.27). All patients obtained bony union over a mean of 4.1 months (range, 3.5-6.0 months).The coracoclavicular distance was not significantly different between the injured and contralateral shoulders in the immediate postoperative period (P=.28) or at final follow-up (P=.35). One superficial wound infection occurred, but no major complications, such as nonunion, plate failure, secondary fracture, or deep infection, occurred. Precontoured locking compressive distal clavicular plate fixation for the treatment of displaced fractures of the lateral end of the clavicle is an acceptable surgical method with good results.

Modified Hemihamate Arthroplasty Technique for Treatment of Acute Proximal Interphalangeal Joint Fracture-dislocations

AbstractWe retrospectively reviewed 11 patients who underwent modified hemihamate arthroplasty for the treatment of comminuted dorsal fracture-dislocation of the proximal interphalangeal (PIP) joint. This technique was used to minimize the potential risk of complications at the recipient site by volarly oblique osteotomy in the coronal plane at graft harvesting and anatomical repair of the detached flexor sheath. The average joint involvement of the fracture was 58.4%, and the mean duration of follow-up was 38 months. The active range of motion of the distal interphalangeal, PIP, and metacarpophalangeal joint was 80.4, 85.4, and 91.8 degrees, respectively. The mean disabilities of the arm, shoulder, and hand score was 4.8, and all patients achieved bony union at final follow-up. One patient showed radiographic signs of graft absorption, but this did not limit their daily activities. The modified hemihamate arthroplasty technique is safe and reliable and reduces the risk of iatrogenic damage when used to treat comminuted dorsal fracture-dislocations of the PIP joint.

Modified pull-out wire suture technique for the treatment of chronic bony mallet finger.

Twenty-three patients with a chronic bony mallet finger deformity (more than 3 months after the injury) and fracture fragment involving more than one-third of the articular surface underwent surgical treatment. The fracture fragment was fixed, and the mallet finger deformity was corrected in all patients using a modified pull-out wire (wire passed through the dorsal fragment directly) with a transarticular Kirschner wire fixation technique. Active motion of the proximal interphalangeal and metacarpophalangeal joints was not restricted. According to Crawfords evaluation criteria, there were 17 excellent, 4 good, and 2 fair results. Four patients showed radiologic signs of mild degenerative changes, which did not limit their daily activities. The modified pull-out wire suture with the transarticular Kirschner wire fixation technique provides an alternative and acceptable treatment modality for the treatment of chronic bony mallet finger deformities with or without subluxation of the distal phalanx.

Four Treatment Strategies for Complex Regional Pain Syndrome Type 1

Complex regional pain syndrome (CRPS) poses a dilemma for many clinicians due to its unknown etiology and largely unsuccessful treatment modalities. The purpose of this study was to compare the clinical results of 4 treatment modalities for CRPS type 1. A total of 59 patients were divided into 4 groups based on treatment modality: group A, an oral nonsteroidal anti-inflammatory drug (NSAID) (n=10); group B, oral gabapentin (n=12); group C, intravenous (IV) 10% mannitol and steroid (n=11); group D, a combination of IV 20% mannitol and steroid with oral gabapentin (n=26). The patients remained under medical supervision after discharge and were evaluated either once a month or once every 2 months until final follow-up at a mean of 8 months. Patients in group A showed improvement in pain level, finger range of motion, swelling, and grip strength, without statistical significance (P=.076, P=.062, P=.312, and P=.804, respectively). Patients in group B showed significant improvement in pain level (P<.001), and patients in group C showed improvement in pain, finger range of motion, and swelling (P=.127), which rendered functional impairment unchanged. In comparison, patients in group D showed recovery of grip strength and improvement in pain level, finger range of motion, and (P<.001, P=.016, P=.031, and P=.047, respectively). Based on these results, a protocol including a combination of IV 20% mannitol and steroid with oral gabapentin is an acceptable and effective treatment for CRPS type 1.

Modified Extension-Block K-wire Fixation Technique for the Treatment of Bony Mallet Finger

This article describes the treatment of a bony mallet finger deformity using 2 extension-block Kirschner wires (K-wires) with a transarticular K-wire fixation technique for precise alignment of the terminal extensor tendon-bone relationship and effective immobilization of the distal interphalangeal joint. Twenty-nine patients (33 fingers) with a bony mallet finger deformity and fracture fragment involving more than one-third of the articular surface were treated surgically. The fracture fragment was fixed and the mallet finger deformity was corrected in all patients using modified extension-block K-wires (2 dorsal extension-block pins) with a transarticular K-wire (volar side pin) fixation technique. Active motion of the proximal interphalangeal and metacarpophalangeal joints was not restricted. The wires are removed in the clinic 6 weeks postoperatively when the bridging trabeculae were observed in the radiographs, and immobilization in a stock splint was continued for an additional 2 weeks. According to Crawfords evaluation criteria, there were 24 (73%) excellent, 7 (21%) good, and 2 (6%) fair results. Three patients showed radiological signs of mild degenerative changes, which did not limit their daily activities. Nail ridging occurred in 3 cases (9%), which disappeared after an average of 6 months with normal growth, and mild scarring at the dorsal pin site occurred in 2 cases (6%). Modified extension-block K-wires with a transarticular K-wire fixation technique is an acceptable alternative treatment modality for the management of bony mallet finger deformities with or without subluxation of the distal phalanx.

Solitary pelvic osteochondroma causing L5 nerve root compression.

Osteochondroma is the most common benign bone tumor, accounting for more than one-third of all benign bone tumors. It usually develops at the metaphysis of the long bones, especially the distal femur and proximal tibia. Approximately 40% of osteochondromas are found around the knee. Osteochondroma commonly presents as a painless mass and is incidentally identified via plain radiographs. Thus, surgical excision is not routinely recommended unless the tumor causes clinical symptoms or cosmetic distress. Osteochondroma located in the pelvis is unusual. Spinal nerve root compressions due to pelvic osteochondroma are also rarely reported. We assessed the solitary pelvic osteochondroma of a 33-year-old man mimicking spinal disease. An exostotic bony projection composed of dense calcification of the cartilaginous cap arose from the iliac crest, which was located just lateral to the right sacroiliac joint in the paravertebral area, L5 level. Magnetic resonance imaging showed an irregular, exophytic outgrowing calcified mass with cartilage cap and exostotic mass compressed to the proximal part of the right L5 nerve root lateral to the nerve root foramen. The L5 nerve root was focally compressed and thinned.En bloc excision, the treatment of choice of symptomatic osteochondroma, was performed. The patient had complete resolution of symptoms postoperatively, and other neurologic symptoms may be expected to improve over time.

Synovial Chondromatosis of the Radiocarpal Joint

Synovial chondromatosis is an uncommon lesion of unknown etiology, characterized by progressive metaplasia associated with the formation of cartilage in the synovial membranes of joints, tendon sheaths, or bursae. Synovial chondromatosis is typically monoarticular and affects large joints such as the knee and hip, although it has also been described in the ankle, elbow, and shoulder. However, it rarely occurs in the wrist. Our literature review showed only 28 cases with wrist involvement, 13 cases with distal radioulnar joint involvement, 12 cases with midcarpal joint involvement, and 3 cases with radiocarpal joint involvement. This article presents a case of synovial chondromatosis of the radiocarpal joint. A 45-year-old right-handed woman presented with a 4-year history of a palpable mass and pain in her right wrist. On physical examination, 2 masses were palpable on the volar and radial aspect of the joint. Plain radiographs of the right wrist demonstrated well-defined radiopaque calcified mass lesions. Cortex and subcortical bone on the radial aspects of the radius and scaphoid were eroded. T1-weighted magnetic resonance imaging (MRI) showed a low-signal-intensity lesion, and T2-weighted MRI showed a heterogeneous high-signal-intensity lesion in the radiocarpal joint, which was consistent with synovial chondromatosis. Operatively, 2 glistening white lobulated masses were removed together with attached synovia. A histologic examination confirmed synovial chondromatosis with dystrophic calcification. At the time of the most recent examination (3 years postoperatively), the patient was pain-free, had no residual motion deficit, and showed no radiographic evidence of recurrent disease.

Dislocated Double-layered Lateral Meniscus Mimicking the Bucket-handle Tear

Various shapes of congenital abnormalities of the meniscus have been reported. Among them, the double-layered meniscus is rare. This article describes a 22-year-old man with a double-layered lateral meniscus who reported right knee pain with no history of trauma. The double-layered lateral meniscus included both the upper and lower meniscus. The anterior and posterior edge of the upper meniscus was attached to the lower lateral meniscus, and its periphery was not connected to the capsule and the lower meniscus. In addition, the upper meniscus was dislocated into the intercondylar notch, mimicking a bucket-handle tear. However, the lower meniscus was normal in appearance, so a bucket-handle or horizontal tear of the meniscus was ruled out of the differential diagnosis. Although this is a rare case, clinicians should be aware of this anomaly due to the potential for a double-layered meniscus to contribute to a bucket-handle or horizontal tear of the lower meniscus. Therefore, early diagnosis and proper treatment of a double-layered meniscus are needed before an additional injury occurs to a normal meniscus.

Conservative Treatment Is Sufficient for Acute Distal Radioulnar Joint Instability With Distal Radius Fracture.

AbstractTreatments for acute distal radioulnar joint (DRUJ) instability with distal radius fracture vary from conservative to operative treatment, although it seems to be no consensus regarding which treatment is optimal. This prospective randomized study was designed to compare the clinical outcomes for operative and conservative treatment of acute DRUJ instability with distal radius fracture, according to the presence or absence and type of ulnar styloid process fracture and the degree of its displacement. Between July 2008 and February 2013, we enrolled 157 patients who exhibited an unstable DRUJ during intraoperative manual stress testing (via the ballottement test) after fixation of the distal radius. Patients were classified according to the type of the ulnar styloid process fracture, using preoperative wrist radiography, and each group was divided into subgroups, according to their treatment method. We then compared the clinical outcomes between the conservative and operative treatments, using their range of motion; Disabilities of the Arm, Shoulder, and Hand score; modified Mayo wrist score; and grip strength. At 3 months after surgery, among patients without ulnar styloid process fracture, the flexion-extension range was 79 ± 15° after supination sugar-tong splinting (group A-1), 91 ± 14° after DRUJ transfixation (group A-2), and 89 ± 10° after arthroscopic triangular fibrocartilage complex repair (group A-3); the operative treatments provided greater joint motion ranges than conservative treatment. The groups with ulnar styloid process fractures at the tip (group B) or base (group C) also exhibited better clinical outcomes after the operative treatments, compared with after the conservative treatment. However, at the final follow-up, groups A-1, A-2, and A-3 exhibited similar flexion-extension ranges (122 ± 25°, 119° ± 18°, and 120° ± 16°, respectively) and modified Mayo wrist scores (87 ± 7, 89 ± 8, and 85 ± 9). Thus, the conservative and operative treatments provided similar long-term outcomes, and similar results were observed for patients with ulnar styloid process fracture at the tip or base. The average splint application period for patients who underwent conservative treatment was 6.6 weeks (range, 4-9 weeks). In our practice, conservative treatment (supination sugar-tong splinting) and surgical treatments provided similar long-term outcomes for acute DRUJ instability with distal radius fracture.