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INTRODUCTION: Scaphoid nonunion is a typical complication of scaphoid fractures, with the nonunion rate varying by the location of the scaphoid. The current widely used method for treating scaphoid nonunion, which is challenging for surgeons, is the headless compression screw (HCS). Various surgical approaches, such as the scaphoid plate, have been proposed to address the problem of screw fixation; however, no consensus exists regarding the optimal treatment method. This study focused on analyzing appropriate treatment methods based on the anatomical location of the scaphoid nonunion. METHODS: Ninety-seven patients with scaphoid nonunion were treated between 2008 and 2023. All patients underwent treatment using 1 HCS or scaphoid volar locking plate with nonvascularized bone graft from the distal radius depending on the scaphoid's location. The scaphoid angle and bone union were confirmed using radiological examinations. The clinical evaluations included range of motion, pain, grip strength, and functional wrist scores. RESULTS: Fifty-seven patients were included in the final analysis. In the screw group, 26 patients (26/42 [62%]) obtained a bone union, and all 15 patients (15/15 [100%]) in the plate group obtained a union (P = 0.005). In the waist group, 16 patients with screw (16/25 [64%]) and 8 using a plate (8/8 [100%]) showed bony healing. In the proximal group, 3 patients with HCS (3/9 [33%]) and 4 using plate (4/4 [100%]) showed bone union. In the distal group, 7 patients with a screw (7/8 [87%]) and 3 with the plate (3/3 [100%]) showed bone union. Significant differences were found in the waist (P = 0.047) and proximal groups (P = 0.026), but not in the distal group (P = 0.521). All groups showed improved radiological angles associated with the scaphoid and better clinical outcomes postoperatively. CONCLUSIONS: Plate fixation was overall superior to screw fixation for scaphoid nonunion, especially in the waist and proximal poles, providing better union rates and stability. For the distal group, both methods are effective, with the choice depending on the surgeon's expertise and patient factors. The results highlight the importance of the lesion's anatomical location in selecting the appropriate fixation method.

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INTRODUCTION: Various surgical techniques for ulnar styloid fractures (USFs) fixation have recently been developed, the actual clinical outcomes have not been discussed in detail. This study aimed to compare the outcomes of tension band wiring (TBW) and hook plate fixation in the treatment of USFs and to explore effective management strategies for these fractures. MATERIALS AND METHODS: We retrospectively reviewed 109 patients with styloid process fractures from March 2016 to July 2020. Among them, patients aged 21-75 years who required surgical intervention for USFs with distal radioulnar joint (DRUJ) instability, with or without accompanying distal radius fracturs (DRFs), were included. The patients were treated with either TBW (group T) or hook plate fixation (group P). The fractures were classified into four types based on their location and complexity. Postoperative assessments were conducted using radiographic analysis to monitor fracture healing. Clinical evaluations, including range of motion (ROM), grip strength, and patient-reported outcomes using the disabilities of the arm, shoulder, and hand scores and the visual analog scale for pain, were performed, at multiple time points up to a year after surgery. Statistical analyses were conducted to compare outcomes across fracture types and treatment methods. RESULTS: Osseous union was achieved in 96% of the patients. Specifically, the time to union in types 3 and 4 fractures was significantly shorter in group P than in group T. Functionally, ROM assessments showed similar flexion-extension in both groups but better pronation-supination in group T. Grip strength and patient-reported outcomes did not show significant differences between the groups. CONCLUSIONS: TBW offers slight ROM benefits for type 2 USFs, whereas hook plate fixation provides superior stability for complex types 3 and 4 USFs. Despite the minimal differences in ROM, the enhanced advantages of the hook plate fixation make it the preferred choice for severe fractures, ensuring faster healing.

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Background: The gait analysis method that has been used in clinical practice to date is an optical tracking system (OTS) using a marker, but a markerless gait analysis (MGA) system is being developed because of the expensive cost and complicated examination of the OTS. To apply this MGA clinically, a comparative study of the MGA and OTS methods is necessary. The purpose of this study was to evaluate the compatibility between the OTS and the MGA methods and to evaluate the usefulness of the MGA system in actual clinical settings. Methods: From March 2021 to August 2021, 14 patients underwent gait analysis using the OTS and MGA system, and the spatiotemporal parameters and kinematic results obtained by the 2 methods were compared. To evaluate the practicality of the MGA system in an actual clinical setting, MGA was performed on 14 symptomatic children with idiopathic toe walking, who had been treated with a corrective cast, and the pre-cast and post-cast results were compared. For the OTS, the Motion Analysis Eagle system was used, and for MGA, DH Walk was used. Results: The spatiotemporal parameters showed no significant difference between the OTS and MGA system. The joint angle graphs of the kinematics along the sagittal plane showed similar shapes as a whole, with particularly high correlations in the hip and knee (pelvis: 29.4%, hip joint: 96.7%, knee joint: 94.9%, and ankle joint: 68.5%). A quantified comparison using the CORrelation and Analysis (CORA) score also showed high similarity between the 2 methods. The MGA results of pre-cast application and post-cast removal for children with idiopathic toe walking showed a statistically significant improvement in ankle dorsiflexion after treatment (p < 0.001). Conclusions: MGA showed a good correlation with the conventional OTS in terms of spatiotemporal parameters and kinematics. We demonstrated that ankle sagittal kinematics improved after treatment by corrective cast in children with idiopathic toe walking using the MGA method. Thus, after the improvement of a few limitations, the MGA system may soon be able to be clinically applied.

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INTRODUCTION: The scapholunate ligament is the most important stabilizer of the scapholunate articulation. The management of chronic irreversible injuries of this ligament in the absence of preexisting arthritis of the wrist joint remains controversial. Recently, surgeons introduced a novel surgical technique using an internal brace (IB). Several biomechanical studies on this technique have been conducted using cadavers; however, very few studies have discussed the results in detail in actual clinical practice. Therefore, herein, we investigated the radiological and functional results of patients who underwent IB augmentation as a treatment for chronic scapholunate dissociation. METHODS: This retrospective study was conducted from April 2018 to May 2022. Twenty-two patients with chronic scapholunate dissociation were treated using the IB augmentation technique, of whom 17 were followed-up for at least 1 year. Radiological results, including scapholunate distance, scapholunate angle, and radioscaphoid angle, were collected. Furthermore, clinical parameters, such as the visual analog scale (preoperative and at final follow-up), the Disabilities of the Arm, Shoulder, and Hand scores (preoperatively and at 3, 6, and 12 months postoperatively), and Mayo wrist scores (preoperative and at final follow-up), were measured. RESULTS: The scapholunate distance increased significantly in the affected wrist compared to the unaffected wrist, which improved after reconstruction in all wrist positions ( P < 0.05). Compared to the unaffected wrist, the scapholunate angle increased significantly in all positions ( P < 0.05) except for extension ( P = 0.535) and improved after reconstruction in all wrist positions. The radioscaphoid angle significantly increased compared to the angle of the unaffected wrist in all positions ( P < 0.05) except for extension ( P = 0.602) and clenched fist ( P = 0.556). This angle improved after reconstruction in all wrist positions except for extension ( P = 0.900). The visual analog scale score (7-2, preoperatively and at final follow-up) and Mayo wrist score (53-82, preoperatively and at final follow-up) improved after surgery. The Disabilities of the Arm, Shoulder, and Hand scores also improved after surgery (68, 53, 30, 7, preoperatively and at 3, 6, and 12 months postoperatively). CONCLUSIONS: This study revealed that scapholunate ligament reconstruction using an autologous tendon and suture tape is a good reconstruction technique that can improve clinical symptoms and radiographic parameters with a shorter operation time and fewer complications than other reconstruction methods.

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PURPOSE: We hypothesized that increased friction between the flexor tendon and surrounding structures due to hand arthritis is an important risk factor for trigger finger (TF) after carpal tunnel release (CTR). Therefore, we compared TF development according to the presence or absence of arthritis in carpal tunnel syndrome (CTS) patients treated with CTR. METHODS: This retrospective study was based on data collected from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) in the Republic of Korea between January 1, 2002, and December 31, 2015. Patients diagnosed with TF between one month and one year after the CTR date or with a history of surgery were included in the study. During subsequent follow-up, the patients were divided into subgroups of those (1) with TF and (2) without TF. Sex, age, arthritis, and TF-related comorbidities were compared between the subgroups. RESULTS: The subgroup with TF had a higher proportion of women (9.43% vs 90.57%), the highest age range between 50 and 59 years, more cases of arthritis (32.55% vs 16.79%), and a higher proportion of patients with hypothyroidism (10.85% vs 4.60%) than the group without TF. The association between arthritis and TF after CTR was examined using a multivariate logistic regression model, showing arthritis to be a significant risk factor for TF after CTR (odds ratio, 1.35; P = 0.049). CONCLUSIONS: We identified arthritis as an important risk factor for the development of TF after CTR.

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BACKGROUND: Recent studies have demonstrated that the distal forearm dual-energy X-ray absorptiometry (DEXA) scan might be a better method for screening bone mineral density (BMD) and the risk of a distal forearm fracture, compared with a central DEXA scan. Therefore, the purpose of this study was to determine the effectiveness of a distal forearm DEXA scan for predicting the occurrence of a distal radius fracture (DRF) in elderly females who were not initially diagnosed with osteoporosis after a central DEXA scan. METHODS: Among the female patients who visited our institutes and who were over 50 years old and underwent DEXA scans at 3 sites (lumbar spine, proximal femur, and distal forearm), 228 patients with DRF (group 1) and 228 propensity score-matched patients without fractures (group 2) were included in this study. The patients' general characteristics, BMD, and T-scores were compared. The odds ratios (OR) of each measurement and correlation ratio among BMD values of the different sites were evaluated. RESULTS: The distal forearm T-score of the elderly females with DRF (group 1) was significantly lower than that of the control group (group 2) (p < 0.001 for the one-third radius and ultradistal radius measurements). BMD measured during the distal forearm DEXA scan was a better predictor of DRF risk than BMD measured during the central DEXA (OR = 2.33; p = 0.031 for the one-third radius, and OR = 3.98; p < 0.001 for the ultradistal radius). The distal one-third radius BMD was correlated with hip BMD, rather than lumbar BMD (p < 0.05 in each group). CONCLUSION: Performing a distal forearm DEXA scan in addition to a central DEXA scan appears to be clinically significant for detecting the low BMD in the distal radius, which is associated with osteoporotic DRF in elderly females. LEVEL OF EVIDENCE: III; case-control study.

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INTRODUCTION: Reconstruction of complex injuries of the extremities with full-thickness wounds is a challenging but important task. If primary closure is not feasible, more complex procedures are required, such as split-thickness skin graft or flap surgery. Recently, several studies have shown good results when combined with negative pressure wound therapy (NPWT) and artificial dermal replacement therapy after extensive surgical debridement and NPWT administration for severe complex wounds accompanied by tendon or bone exposure. However, flap surgery remains the only treatment for wounds in which the hardware is exposed after fracture fixation. Therefore, in this study, we attempted to prove the usefulness of the combined treatment using artificial dermal substitutes (MatriDerm) and NPWT by focusing on hardware-exposed wounds, which have not been studied before. METHODS: From 2019 to 2021, we treated with our wound management procedure 14 patients with hardware-exposing wounds after internal fixation using plates, out of 48 patients with full-thickness posttraumatic skin defect. Before skin grafting, after surgical debridement and thorough washouts, MatriDerm was placed and NPWT was applied over it. This staged approach aimed at conditioning even the most complex wounds so that closure with MatriDerm-augmented skin grafting would become possible in a one-step approach. RESULTS: We stratified the duration of treatment and number of replacements in NPWT according to the type of injury. Cases with open fractures required significantly longer NPWT than those with closed fractures (P = 0.01); however, there was no significant difference between the Gustilo-Anderson classification within open fractures (P > 0.05). Patients with open fractures underwent a mean of 6.6 changes while those with closed fractures underwent 2.5 (P = 0.002) until the final wound closure with MatriDerm-augmented skin grafting was performed. There was no significant difference in the treatment period based on the location and size of the wound, and there was no significant difference in the number of NPWT replacements. Skin grafting was successful in all 14 patients. CONCLUSIONS: This study revealed that NPWT and artificial dermis-augmented skin grafting after combined treatment with NPWT and artificial dermis were sufficiently useful for hardware-exposed wounds, where flap surgery has been considered the only treatment to date.

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INTRODUCTION: Ulnar fractures associated with long-term bisphosphonate (BPs) therapy are rare, and the nature and extent of this potential risk remains unknown. Although ulna is generally considered a "straight bone", it actually features a bow anatomically. For this reason, we speculated that ulnar bow may have a role in the development of atypical ulnar fractures (AUFs). Therefore, we compared the location and depth of ulnar bow between AUF patients and patients with atypical fractures other than the ulna. We aimed to answer: (1) whether a correlation exists between the location of the ulna bow and the location of AUFs, (2) whether the degree of ulnar bow affects the occurrence of AUFs. HYPOTHESIS: Ulnar bowing could play a critical role in the location and occurrence of AUFs. METHODS: We retrospectively reviewed the radiographs and medical records of 64 patients with atypical fractures admitted to our department between May 2010 to July 2020. The bow of the ulna was measured using anteroposterior (AP) and lateral radiographs. Bone angulation was described as apex of deformity, with apex lateral bow designated as AP plane bowing and apex posterior bow marked as lateral plane bowing. RESULTS: In all patients with atypical fractures, bow locations were measured at the proximal third level to the index line in 68% of AP plane and 72% of lateral plane. In patients with AUFs, fracture sites occurred in the range of 20% to<40%, except in one patient. Fracture site versus apex lateral bow location and fracture site versus apex posterior bow location showed a statistically significant correlation coefficient of 0.81 (p<0.001) and 0.69 (p=0.003), respectively. In lateral plane, there was a significant difference between AUF patients and patients with atypical fractures other than the ulna in ulnar bow depth (p=0.014). However, no statistically significant differences were found in AP plane (p=0.110). DISCUSSION: In AUFs, fracture site was highly correlated with ulnar bowing location, and, as the degree of apex posterior bow increased, occurrence of AUFs increased. These findings are helpful in understanding the role of bowing as the ulnar geometry in the development of AUF and early identification of the location of suspicious AUF. LEVEL OF EVIDENCE: IV.

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PURPOSE: The main cause of carpal tunnel syndrome (CTS) is pathological changes in the flexor synovium, which is a known cause of pressure elevation in the carpal tunnel. The importance of the transverse carpal ligament (TCL) in the pathogenesis of CTS has hitherto been overlooked. However, the TCL significantly affects carpal biomechanics; the TCL is known to affect the carpal bone to a greater extent when intra carpal tunnel pressure is high. In addition, the effect of TCL properties on the progression course of idiopathic CTS is unknown.Therefore, we hypothesized that TCL thickness, measured using ultrasonography, would influence the results of conservative treatment for CTS patients with mild to moderate symptoms. We aimed to investigate the relationship between the ultrasound-measured TCL thickness and idiopathic carpal tunnel conservative treatment surgery rate. MATERIALS AND METHODS: We analyzed the wrists of 127 patients with mild to moderate symptoms of CTS. The patients were diagnosed on the basis of electrophysiological assessment outcomes, median nerve cross-sectional area in the carpal tunnel, and clinical symptoms. The Boston carpal tunnel questionnaire score was also measured. Patients with a TCL thinner than 1.5 mm were classified into group A (n = 62), and those with a TCL thicker than 1.5 mm were classified into group B (n = 65). Patients with severe symptoms or other diseases were excluded. The patients were initially treated with night splinting after diagnosis. If symptoms were not ameliorated, steroid injection and surgical treatment were performed consecutively. The procedures were determined by a single surgeon. RESULTS: The mean TCL thickness was 1.51 mm: 0.98 mm in group A and 2.28 mm in group B. The percentages of patients who underwent surgery were 43.0% in group A and 67.7% in group B. Group B was 1.77 times more likely to have surgery, and the interval between diagnosis and surgery and/or steroid injection was shorter. The TCL thickness in group B was also related to cross-sectional area and symptom duration. CONCLUSIONS: Transverse carpal ligament thickness affects disease progression and may affect treatment efficacy, depending on the treatment method. Transverse carpal ligament thickness may be a criterion for deciding between surgical and conservative treatments based on a thickness threshold of 1.5 mm.

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