Publications by authors named "Erica Kholinne"

79 Publications

The Surgical Procedure in Managing Peroneal Tendon Injury: A Case Series.

Orthop Res Rev 2022 27;14:255-262. Epub 2022 Jul 27.

St. Carolus Bone & Joint Center, St. Carolus Hospital, Jakarta, Indonesia.

Introduction: Peroneal tendon injury is one of the pathological ankle conditions which causes pain and is frequently misdiagnosed as ankle sprain. There is a variety of peroneal tendon injuries, depending on the mechanism of injury. We report a series of three peroneal injuries in our institution.

Case Presentation: All three of the patients presented with ankle pain and instability following injuries. There was a presence of peroneus quartus in one of the patients. Retromalleolar pain was revealed in all of the patients, in addition to instability. All of the three patients received open peroneal tendon repair with groove tubular deepening for the 1 patient. Following the surgery, the patients could partially weight-bear after 3-4 weeks. Full range of motion was restored 6 weeks after surgery.

Discussion: The peroneal muscle functions as a dynamic stabilizer of the ankle, which is vital to control the dynamic stability of the lateral ankle. There is a variety of peroneal injuries ranging from split tear to chronic dislocation. The treatment for peroneal tendon subluxation can be conservative or surgical. There are several surgical techniques for peroneal tendon subluxation repair, such as: 1) direct repair of retinaculum; 2) retromalleolar groove deepening; 3) tendon graft reconstruction; 4) bone block procedure; 5) tendon rerouting procedure.

Conclusion: Peroneal tendon injury should always be considered following inversion ankle trauma, especially in case of chronic lateral retromalleolar pain. Surgeries are often required after failure of conservative treatment which can cause impaired walking, decreased sports performance, or chronic pain and muscle strain.
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http://dx.doi.org/10.2147/ORR.S351356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9342706PMC
July 2022

The Role of Virtual Clinics in Postoperative Total Knee Replacement Surgery Follow-Up during COVID-19 Pandemic.

Adv Orthop 2022 16;2022:9558511. Epub 2022 Jun 16.

St. Carolus Bone & Joint Center, St. Carolus Hospital, Jakarta, Indonesia.

Background: The purpose of this study was to evaluate the feasibility of the virtual clinic for outpatient follow-up care after TKR surgery.

Methods: A total of 546 TKR surgeries were performed from January 2017 to December 2019. 30 patients were not able to go the hospital for routine follow-up. The data collections were taken for age, gender, year of surgery, functional score (Oxford Knee Score (OKS)), and active range of motion (ROM). The virtual clinic was conducted with the physician assistant and the operating surgeon via WhatsApp video call (WhatsApp Inc., Mountain View, California, USA) or Zoom (Zoom Video Communications, Inc., San Jose, California, USA).

Result: The average follow-up period was 39.1 months. The earliest follow-up was 20 months, while the longest follow-up was 97 months. The average OKS score was 45. The average consultation time for the virtual clinic is 9 minutes 21 seconds. Most of the patients were satisfied with the online consultation, with only two patients having a satisfaction score below 80%.

Conclusion: The virtual clinic for TKR surgery showed a high satisfaction rate during the COVID-19 pandemic, which has the potential to extend to the postpandemic era.
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http://dx.doi.org/10.1155/2022/9558511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9225886PMC
June 2022

Ulnar nerve decompression with osteocapsular arthroplasty for primary elbow osteoarthritis.

J Orthop Surg (Hong Kong) 2022 May-Aug;30(2):10225536221109914

Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, 587171Eulji University School of Medicine, Uijeongbu, Korea.

Purpose: The aim of this study was to suggest treatment guidline for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness by evaluating the effect of ulnar nerve decompression on the outcome of osteocapsular arthroplasty.

Methods: A total of 30 patients who underwent primary osteocapsular arthroplasty for elbow OA were retrospectively reviewed. The surgical outcomes were evaluated for pain score (visual analog scale; VAS), range of motion (ROM), and Mayo Elbow Performance Score (MEPS). The ulnar nerve decompression was performed for (1) ulnar nerve neuropathy, and (2) high-grade stiffness of flexion, defined as the flexion angle, is <90°. Patients were categorized into the two groups: ulnar nerve decompression group (UD group, = 11) and the non-decompression group (Non-UD group, = 19). The surgical outcome was compared between the groups.

Results: Primary elbow OA with cubital tunnel syndrome or high-grade stiffness showed comparable improvement in MEPS, VAS, and ROM arc at final follow-up in the UD group compared with the non-UD group (UD group vs. non-UD group: MEPS 85.91 vs 86.84, -value = 0.824, VAS 1.46 vs 1.16, -value = 0.588, ROM arc 108 vs 109, -value = 0.949). Improvement in ROM arc at 2 years follow-up was significantly higher in UD group (UD group vs. non-UD group: ROM arc difference, 42 vs 14, = 0.002).

Conclusion: Osteocapsular arthroplasty with ulnar nerve decompression for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness provided improved motion arc and compatible clinical results.

Level Of Evidence: Level III, Retrospective comparative study.
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http://dx.doi.org/10.1177/10225536221109914DOI Listing
June 2022

Serial magnetic resonance imaging evaluation of the early reaction of all-suture anchors in arthroscopic rotator cuff repair.

Acta Orthop Traumatol Turc 2022 Mar;56(2):111-115

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Korea.

Objective: The aim of this study was to evaluate the early reaction of all-suture anchors (ASAs) in arthroscopic rotator cuff repair.

Methods: This retrospective case series comprised 23 patients (8 women, 15 men; mean age = 59.9 years, age range = 36-73 years) with medium-size rotator cuff tear who underwent arthroscopic rotator cuff repair. All patients underwent postoperative serial magnetic resonance imaging (MRI) evaluation 3 and 6 months postoperatively. Demographic and operative characteristics were recorded. MRIs were evaluated for osseous cyst formation, and tunnel volume was measured. Statistical analyses were performed to detect differences in the serial MRI follow-up observation.

Results: A total of 39 ASAs were evaluated. Osseous cyst formation was found in two ASAs (5.1%) at the 6-month follow-up. Tunnel expansion was significantly observed in both 3- and 6-month postoperative MRI evaluations (P < 0.001). The mean tunnel volume significantly increased 1.95 times at the 3-month follow-up and 2.84 times at the 6-month follow-up (P < 0.001).

Conclusion: Evidence from this study has revealed low rates of cyst formation but significant increases in tunnel volume at the early follow-up following arthroscopic rotator cuff repair with ASAs.

Level Of Evidence: Level IV, Therapeutic Study.
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http://dx.doi.org/10.5152/j.aott.2022.20167DOI Listing
March 2022

The dynamic rotation axis of ulnohumeral joint during active flexion-extension: an in vivo 4-dimensional computed tomography analysis.

BMC Musculoskelet Disord 2022 Feb 16;23(1):152. Epub 2022 Feb 16.

Department of Hand Surgery, Hand Surgery Research Center, Affiliated Hospital of Nantong University, College of Medicine, University of Nantong, 20 West Temple Road, Nantong, 226001, Jiangsu, China.

Background: As the collateral ligament reconstruction becomes more common to perform, the knowledge between the collateral ligament reconstruction and the elbow rotation axis is still ambiguous. The purpose of this study was to investigate the location of the intersections between the elbow rotation axis and medial and lateral aspect of the humerus.

Methods: Four-dimensional computed tomography (4D CT) scan was designed to obtain the images from 8 participants. The instantaneous rotation axis was created according to the trochlea notch of the ulna in the Rapidform XO software. Then the intersections between the instantaneous rotation axis and the medial and lateral aspect of the humerus were identified in the Geomagic Wrap software. Landmark coordinate systems of the distal humerus was created.

Result: The intersections in the medial aspect of the humerus were mostly located in the superior and posterior quadrant and showed the trend from anterior-superior to posterior-superior with the increment of the elbow flexion. The intersections in the lateral aspect of the humerus were mostly located in the middle half of the anterior quadrant and showed the trend from posterior-inferior to anterior-superior with the increment of the elbow flexion.

Conclusion: There's no isometric point for medial collateral ligament (MCL) and lateral ulnar collateral ligament (LUCL) reconstruction. The isometric area for MCL reconstruction should be considered at the superior and posterior quadrant of the medial aspect of the humerus. The isometric area for LUCL reconstruction should be considered at the middle half of the anterior quadrant of the lateral aspect of the humerus.

Trial Registration: This work was supported by the National Natural Science Foundation of China [ No.81911540488 ] in 07/01/2019.
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http://dx.doi.org/10.1186/s12891-022-05102-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8848841PMC
February 2022

High-Grade Bursal Side Rotator-Cuff Repair: A Surgical Outcome Review.

Orthop Res Rev 2021 11;13:179-186. Epub 2021 Oct 11.

Department of Anatomy, Physiology and Biology Cell, Universitas Padjadjaran, Bandung, Indonesia.

Purpose: We aimed to evaluate surgical outcomes of high-grade bursal rotator cuff-tear repairs.

Methods: This systematic review was performed in May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed. Inclusion criteria were English-language studies reporting the results of pain improvement, functional outcome scores, and radiographic examinations after repair of bursal side partial rotator-cuff tears at any time point in patients of any age and with all levels of evidence. Exclusion criteria were articles not in English, in vitro or animal studies, epidemiological studies, and such article types as technical notes or narrative reviews.

Results: Of 58 articles, five were included in this study, of which three and two had level III and IV evidence, respectively, four were comparative studies, and one was a case series. Visual analogue scales were used in four of the five studies, all showing improvement in pain assessment from 5.87 preoperatively to 1.02 postoperatively. All five studies showed significant improvement on each functional outcome score at the final follow-up. The retear rate for all studies was 10.97% (27 of 246).

Conclusion: High-grade bursal side partial-thickness rotator cuff-tear repair gave satisfactory results in terms of pain scores, range of motion, and functional outcomes. The retear rate was still considerably high (10.9%), necessitating better understanding of the basic science, such as molecular mechanisms during adaptation, to improve the surgical technique.
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http://dx.doi.org/10.2147/ORR.S323092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524261PMC
October 2021

Outcomes and Return to Sport and Work After Open Bankart Repair for Recurrent Shoulder Instability: A Systematic Review.

Orthop J Sports Med 2021 Oct 7;9(10):23259671211026907. Epub 2021 Oct 7.

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea.

Background: Open Bankart repair provides surgeons and patients with an alternative solution for managing recurrent instability in young athletes with or without minimal bone loss. Despite many studies that have reported low recurrence rates and good functional outcomes after open Bankart repair, we have limited knowledge about the return to sport and work for high-demand populations.

Purpose: To assess the return to sport and work for high-demand populations after open Bankart repair for recurrent anterior shoulder instability, outcomes of open Bankart repair with regard to recurrence, and development of osteoarthritic (OA) changes.

Study Design: Systematic review; Level of evidence, 4.

Methods: We searched PubMed, EMBASE, Cochrane Library, Scopus, and Google Scholar databases using keywords as well as Medical Subject Headings terms and Emtree using "(Open Bankart OR Bankart surgery) (NOT arthroscopy NOT revision)" for English-language studies. We conducted a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results: In total, 11 articles (10 with level 4 and 1 with level 3 evidence) including 563 patients (566 shoulders) were identified. The majority of patients were male (82%), the average age at the time of surgery was 27.4 years, and the mean follow-up was 11.5 years (range, 2.5-29 years). The most common functional score used was the Rowe score (95%) for the reported outcome measures, which showed good to excellent results (mean, 88.5 points). The overall recurrent instability rate, including dislocation and subluxation as a postoperative complication, was 8.5%. A total of 87% of patients were able to return to sport and work postoperatively. Overall, OA changes were reported in 33% of the patients, and the overall revision rate was 1%.

Conclusion: Open Bankart repair exhibited favorable results, with a low postoperative instability rate. It is a reliable surgical procedure that allows high-demand patients to return to sport and work.
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http://dx.doi.org/10.1177/23259671211026907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511924PMC
October 2021

Current concepts in anterior glenohumeral instability: diagnosis and treatment.

SICOT J 2021 14;7:48. Epub 2021 Sep 14.

Department of Orthopaedics, University of Ulsan, College of Medicine, Asan Medical Center, 05505 Seoul, Korea.

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.
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http://dx.doi.org/10.1051/sicotj/2021048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8439181PMC
September 2021

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair.

J Shoulder Elbow Surg 2022 Feb 16;31(2):310-317. Epub 2021 Aug 16.

Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR).

Methods: We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair.

Results: Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005).

Conclusion: Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.
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http://dx.doi.org/10.1016/j.jse.2021.07.012DOI Listing
February 2022

Arthroscopic Superior Capsular Reconstruction for Older Patients With Irreparable Rotator Cuff Tears: A Comparative Study With Younger Patients.

Am J Sports Med 2021 08 15;49(10):2751-2759. Epub 2021 Jul 15.

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea.

Background: Arthroscopic superior capsular reconstruction (ASCR) is a method for treating irreparable chronic rotator cuff tears. However, the extent to which ASCR can be performed with regard to the patient's age has yet to be determined.

Purpose: To compare the surgical outcomes of ASCR for the treatment of irreparable rotator cuff tears (IRCTs) in patients aged <65 years versus patients aged ≥65 years.

Study Design: Cohort study; Level of evidence, 3.

Methods: Of 105 patients with IRCTs who underwent ASCR between March 2013 and June 2020, 73 patients were enrolled in this study based on the selection criteria. Polypropylene mesh augmentation to the graft was used in 18 of 36 patients in the younger adults group (age, <65 years) and 20 of 37 patients in the older adults group (age, ≥65 years). The clinical and radiological outcomes were evaluated preoperatively and at the final clinical follow-up. The graft integrity status was evaluated using serial magnetic resonance imaging and set as the primary endpoint. Furthermore, subgroup analysis was performed based on age group and graft type.

Results: The mean age of the patients was 59.2 ± 3.8 years in the younger adults group and 70.5 ± 4.1 years in the older adults group. Both groups showed improvement based on the clinical and radiological outcomes at the final follow-up. The mean American Shoulder and Elbow Surgeons scores improved from 52.3 ± 15.4 to 77.3 ± 13.5 in the younger adults group ( < .001) and from 45.7 ± 16.1 to 76.6 ± 11.4 in the older adults group ( < .001). The mean visual analog scale for pain scores improved from 5.5 ± 1.2 to 2.1 ± 0.9 in the younger adults group ( < .001) and from 5.5 ± 1.4 to 2.1 ± 1.2 in the older adults group ( < .001). The graft healing rate was significantly higher in the younger adults group (81%) than in the older adults group (65%) ( = .049). Subgroup analysis showed that after mesh augmentation, the healing rate in the younger adults group (84%) was similar to that in the older adults group (85%) ( = .299).

Conclusion: ASCR resulted in a favorable surgical outcome for both younger and older adult patients with IRCT. The younger patients had lower graft failure rates and superior surgical outcomes. In older patients, ASCR using polypropylene mesh augmentation may reduce graft failure and result in surgical outcomes similar to those in younger patients.
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http://dx.doi.org/10.1177/03635465211024652DOI Listing
August 2021

Complications of modern design total elbow replacement.

J Clin Orthop Trauma 2021 Aug 15;19:42-49. Epub 2021 May 15.

Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea.

Total elbow arthroplasty is an important surgical option for advanced arthritis of the elbow. Semi-constrained linked prosthesis is still a popular choice, however, complications and revisions after TER remain high. Aseptic loosening and infection are two most common mode of failure. Periprosthetic fracture, implant failure, and triceps insufficiency have also been reported. Revision arthroplasty needs careful preoperative planning to tackle deficiency in soft tissue and osseous structure. Impaction, strut allograft or allograft prosthesis composite graft should be considered for failed TER.
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http://dx.doi.org/10.1016/j.jcot.2021.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176365PMC
August 2021

Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?: A Propensity-Score-Matched Study.

J Bone Joint Surg Am 2021 08;103(15):1402-1410

Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: The effects of nonsteroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase (COX)-2 inhibitors on postoperative fracture-healing are controversial. Thus, we investigated the association between NSAID/COX-2 inhibitor administration and postoperative nonunion or delayed union of fractures. We aimed to determine the effects of NSAID/COX-2 inhibitor administration on postoperative fracture-healing with use of a common data model.

Methods: Patients who underwent operative treatment of a fracture between 1998 and 2018 were included. To determine the effects of NSAID/COX-2 inhibitor administration on fracture-healing, postoperative NSAID/COX-2 inhibitor users were compared and 1:1 matched to nonusers, with 3,264 patients matched. The effect of each agent on bone-healing was determined on the basis of the primary outcome (nonunion/delayed union), defined as having a diagnosis code for nonunion or delayed union ≥6 months after surgery. The secondary outcome was reoperation for nonunion/delayed union. To examine the effect of NSAIDs/COX-2 inhibitors on bone union according to medication duration, a Kaplan-Meier survival analysis was performed.

Results: Of the 8,693 patients who were included in the analysis, 208 had nonunion (178 patients; 2.05%) or delayed union (30 patients; 0.35%). Sixty-four (30.8%) of those 208 patients had a reoperation for nonunion or delayed union. NSAID users showed a significantly lower hazard of nonunion compared with the matched cohort of nonusers (hazard ratio, 0.69 [95% confidence interval, 0.48 to 0.98]; p = 0.040) but did not show a significant difference in the other matched comparison for any other outcomes. Kaplan-Meier survival analysis revealed significantly lower and higher nonunion/delayed union rates when the medication durations were ≤3 and >3 weeks, respectively (p = 0.001). For COX-2 inhibitors, the survival curve according to the medication duration showed no significant difference among the groups (p = 0.9).

Conclusions: Our study demonstrated no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture-healing. However, continued use of these medications for a period of >3 weeks may be associated with higher rates of nonunion or delayed union.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01663DOI Listing
August 2021

Failure Rate After Superior Capsular Reconstruction With Achilles Tendon-Bone Allograft for Irreparable Rotator Cuff Tears.

Orthop J Sports Med 2021 May 5;9(5):23259671211002280. Epub 2021 May 5.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea.

Background: Superior capsular reconstruction (SCR) is an alternative to reverse shoulder arthroplasty for irreparable rotator cuff tears (IRCTs). The reconstructed capsule acts as a static restraint to prevent superior migration of the humeral head. Traditional SCR uses a fascia lata autograft, which has shown failure at the greater tuberosity. An Achilles tendon-bone allograft has been proposed to improve the failure rate.

Purpose: To evaluate the surgical outcomes of SCR using an Achilles tendon-bone allograft for the treatment of IRCTs.

Study Design: Case series; Level of evidence, 4.

Methods: We retrospectively evaluated 6 patients with massive IRCTs who underwent SCR using an Achilles tendon-bone allograft between January 2017 and January 2018. Clinical outcomes were assessed using range of motion, the American Shoulder and Elbow Surgeons score, and the visual analog scale for pain. The acromiohumeral distance and the status of graft integrity were evaluated using serial magnetic resonance imaging. Second-look arthroscopy surgery was performed to evaluate graft integrity at the mean of 7.5 months postoperative.

Results: The mean ± SD clinical follow-up period was 14.5 months (range, 12-17 months). The American Shoulder and Elbow Surgeons and visual analog scale scores improved from 42.8 ± 11.9 and 4.0 ± 1.2 to 62.1 ± 14.7 and 2.8 ± 1.4, respectively. Forward flexion and external rotation improved from 98° ± 36° and 58° ± 4° to 123° ± 20° and 39° ± 8°, respectively. The acromiohumeral distance improved from 3.9 ± 0.8 mm to 6.4 ± 2.2 mm at final follow-up. However, second-look arthroscopy at a mean of 7.6 months postoperatively confirmed a graft failure rate of 83.3%.

Conclusion: SCR using an Achilles tendon-bone allograft for the treatment of IRCTs had a high graft failure rate among patients in this case series.
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http://dx.doi.org/10.1177/23259671211002280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113925PMC
May 2021

Technique for Arthroscopic-Assisted Reduction and Cannulated Screw Fixation for Coronal Shear Fractures of the Distal Humerus.

Arthrosc Tech 2021 Apr 22;10(4):e949-e955. Epub 2021 Mar 22.

Department of Orthopedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea.

Several articles have described arthroscopic fixation of coronal shear fractures of the distal humerus. However, not all of them have used purely arthroscopic techniques. In this Technical Note we describe another technique for intra-articular distal humeral fracture fixation using arthroscopy alone. Standard proximal anteromedial, proximal anterolateral, and posterolateral viewing portals are established with soft spot portal for reduction. During intra-articular examination, the fragment involving the capitellum and the trochlea as 1 piece is detected. Closed manipulative reduction under anesthesia is conducted with distraction, varus force, and gradual elbow extension. After closed reduction, reduction of the fragment more precisely under arthroscopic visualization using probe and elevator is performed. The fragment is temporarily fixed using 2 Kirschner wires from posterior direction. Anatomic reduction is confirmed with an image intensifier. Screw guide pin is inserted posteroanteriorly under image intensification, and a headless compression screw is placed over each wire. We describe a safe, reproducible, and minimal invasive technique for the arthroscopic treatment of coronal shear fractures of the distal humerus.
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http://dx.doi.org/10.1016/j.eats.2020.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084756PMC
April 2021

Forearm Interosseous Ligaments: Anatomical and Histological Analysis of the Proximal, Central, and Distal Bands.

J Hand Surg Am 2021 11 21;46(11):1029.e1-1029.e8. Epub 2021 Apr 21.

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Korea. Electronic address:

Purpose: To characterize and compare the histological structure of the proximal, central, and distal bands of the interosseous membrane (IOM) of the human forearm in fresh-frozen specimens.

Methods: The IOMs from 16 fresh-frozen left forearm specimens were carefully dissected and examined. The footprint areas of the proximal, central, and distal IOM bands were measured in 6 specimens. The histological characteristics of the IOM bands were evaluated using hematoxylin-eosin and Masson trichrome staining protocols in 10 specimens as histological analysis necessitated an intact footprint. The footprint areas of the IOM were measured using an image processing program. The insertion complex was assessed using a light microscope.

Results: Histological assessment revealed that the IOM structure demonstrated similarities with ligament structure. The average footprint areas of the proximal, central, and distal bands at the radial site were 11.1 ± 0.8, 180.4 ± 30.4, and 10.7 ± 1.3 mm, respectively. At the ulnar site, they were 11.0 ± 1.1, 171.8 ± 30.1, and 10.7 ± 1.2 mm, respectively. The insertion complex of the IOM into the bone comprised 4 layers: (1) interwoven collagen, (2) oblique collagen, (3) mineralized fibrocartilage (tidemark), and (4) lamellar bone. The average tidemark zone thicknesses of the proximal, central, and distal bands were 20.1 ± 6.3, 107.8 ± 22.9, and 20.6 ± 4.7 μm, respectively at the radial site and 12.0 ± 4.5, 85.7 ± 23.2, and 13.5 ± 6.9 μm, respectively at the ulnar site.

Conclusions: In this study, we confirm that the histological characteristics of the IOM are similar to those of ligaments. Compared with the proximal and distal bands, the central band has a greater footprint area and thicker tidemark zone.

Clinical Relevance: If surgical reconstruction is performed, the size and histological characteristics of the graft should be similar to those of the native ligaments.
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http://dx.doi.org/10.1016/j.jhsa.2021.03.002DOI Listing
November 2021

Poor Prognostic Factors in Patients With Rotator Cuff Retear.

Orthop J Sports Med 2021 Apr 2;9(4):2325967121992154. Epub 2021 Apr 2.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: The treatment for retears after arthroscopic rotator cuff repair (ARCR) has long been a challenge.

Purpose: This study aimed to (1) summarize the characteristics of patients with a retear after primary ARCR and (2) determine the risk factors for poor clinical outcomes after a retear.

Study Design: Case-control study; Level of evidence, 3.

Methods: We collected the data of patients with a retear after primary ARCR between January 2011 and December 2016. There were 45 patients with retears included (19 men [42.2%] and 26 women [57.8%]; mean ± SD age, 63.11 ± 8.87 years). Initially, the demographic and outcome data of patients with a retear were analyzed. Patients were classified into good and poor outcome groups according to their overall satisfaction at final follow-up. Univariable and multivariable logistic regression analyses were performed to determine the factors for poor clinical outcomes after a retear.

Results: A total of 31 patients were classified into the good outcome group, and 14 patients were classified into the poor outcome group. Both the good and the poor outcome groups showed that clinical scores significantly improved at the time of the retear diagnosis, but the final scores were maintained or worse compared with scores at the time of the retear diagnosis. Final range of motion (ROM), except external rotation in the good outcome group, was worse or had no significant change compared with ROM at the time of the retear diagnosis. On multivariable logistic regression analysis, current smoking (odds ratio [OR], 45.580 [95% CI, 3.014-689.274]; = .006), female sex (OR, 32.774 [95% CI, 2.433-441.575]; = .009), and retears of the same or larger size than the initial tear (OR, 10.261 [95% CI, 1.544-68.202]; = .016) showed a higher OR for poor clinical outcomes after a retear.

Conclusion: Smoking, female sex, and retears of the same or larger size than the initial tear were independent risk factors for poor clinical outcomes after a rotator cuff retear. Final clinical scores and ROM were similar or worse compared with the scores and ROM at the time of the retear diagnosis. Therefore, revision surgery should be actively considered in female patients or those who smoke with poor clinical outcomes and a larger retear size than the preoperative tear size at the time of the retear diagnosis.
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http://dx.doi.org/10.1177/2325967121992154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020255PMC
April 2021

The relationship between rotator cuff integrity and acromiohumeral distance following open and arthroscopic rotator cuff repair.

SICOT J 2021 26;7:23. Epub 2021 Mar 26.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, 05505 Seoul, Republic of Korea.

Background: Acromiohumeral distance (AHD) has become both a diagnostic and prognostic parameter related to rotator cuff pathology which is always measured in a 2-dimensional plane. The purposes of this study were (1) to evaluate the regional AHD with MRI following open and arthroscopic rotator cuff repair and, (2) to investigate its association to the rotator cuff integrity following medium to large size rotator cuff repair with open and arthroscopic manner.

Methods: A retrospective review of 112 patients who were treated for full-thickness medium to large size rotator cuff tears either by open repair (open group) or arthroscopic repair (arthroscopic group) was done. All patients included in the study are those with at least 12 and 18 months for the post-operative MRI and clinical follow-up. Propensity score matching was used to select controls matched for age, sex, body mass index, tear size, and affected site. There were 56 patients in each group with a mean age of 63.3 years (range, 50 to 77 years). The post-operative functional and radiologic outcomes for both groups were compared. AHD was measured at three regions of interest (ROI) with MRI and compared pre-and post-operatively.

Results: AHD was significantly greater in the open group when measured at the anterior third of the lateral acromion border compare to the arthroscopic group (p = 0.005). The re-tear rate was affected by AHD at the anterior third of the lateral border of the acromion for the arthroscopic and open group (p = 0.021, p = 0.029). The AHD measured at the anterior and middle third of lateral acromion border were significantly greater in healed compared to the re-tear rotator cuff group (p = 0.019, p = 0.022).

Conclusions: Open rotator cuff repair showed greater AHD at the anterior third of the lateral border of the acromion. Regional AHD measured at anterior third of the lateral border of acromion significantly associated with rotator cuff integrity following repair.

Level Of Evidence: propensity-matched case-control (Level II).
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http://dx.doi.org/10.1051/sicotj/2021012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019552PMC
March 2021

Arthroscopic superior capsular reconstruction of the shoulder: a narrative review.

Ann Transl Med 2021 Feb;9(3):268

Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea.

Irreparable rotator cuff tears (IRCTs) in young and considerably active patients are difficult to treat because it is mostly associated with poor outcome which may lead to a painful and dysfunctional shoulder. Most of the IRCTs are encountered in massive size rotator cuff tears which associated with high failure rate following surgical repair. Thus, the IRCTs was considered challenging for its poor healing rate following repair which may induce the arthritic changes. Since the advent of arthroscopic superior capsular reconstruction (ASCR) of the shoulder in 2013, it has gained its popularity. The procedure has become the most popular option for joint-preserving shoulder surgery for patients with IRCTs. It works by providing a static restraint to the superior humeral head migration to optimize the rotator cuff force couples, hence improving joint kinematics. The acceptance of superior capsular reconstruction has made it rapidly evolving in terms of a wider variety of procedures and broader surgical indications. Despite the enthusiasm and widely acceptance towards the procedure, there are still many queries that exist regarding the best indications, surgical technique particularly graft of choice, the long-term outcome, and the complication and risk of the superior capsular reconstruction (SCR). This narrative review provide the current evidence of SCR in an attempt to provide a state-of-the-art knowledge.
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http://dx.doi.org/10.21037/atm-20-5925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940888PMC
February 2021

How Many Proximal Screws Are Needed for a Stable Proximal Humerus Fracture Fixation?

Geriatr Orthop Surg Rehabil 2021 9;12:2151459321992744. Epub 2021 Feb 9.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.

Purpose: This biomechanical study investigates the optimal number of proximal screws for stable fixation of a 2-part proximal humerus fracture model with a locking plate.

Methods: Twenty-four proximal humerus fracture models were included in the study. An unstable 2-part fracture was created and fixed by a locking plate. Cyclic loading and load-to-failure tests were used for the following 4 groups based on the number of screws used: 4-screw, 6-screw, 7-screw, and 9-screw groups. Interfragmentary gaps were measured following cyclic loading and compared. Consequently, the load to failure, maximum displacement, stiffness, and mode of failure at failure point were compared.

Results: The interfragmentary gaps for the 4-screw, 6-screw, 7-screw, and 9-screw groups were significantly reduced by 0.24 ± 0.09 mm, 0.08 ± 0.06 mm, 0.05 ± 0.01 mm, and 0.03 ± 0.01 mm following 1000 cyclic loading, respectively. The loads to failure were significantly different between the groups with the 7-screw group showing the highest load to failure. The stiffness of the 7-screw group was superior compared with the 6-screw, 9-screw, and 4-screw groups. The maximum displacement before failure showed a significant difference between the comparative groups with the 4-screw group having the lowest value. The 7-screw group had the least structural failure rate (33.3%).

Conclusion: At least 7 screws would be optimal for proximal fragment fixation of proximal humerus fractures with medial comminution to minimize secondary varus collapse or fixation failure.

Level Of Evidence: Basic science study.
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http://dx.doi.org/10.1177/2151459321992744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876747PMC
February 2021

Determination of the patient acceptable symptomatic state after osteocapsular arthroplasty for primary elbow osteoarthritis.

J Shoulder Elbow Surg 2021 Sep 30;30(9):2127-2133. Epub 2021 Jan 30.

Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: The study aimed (1) to determine patient acceptable symptomatic state (PASS) values for the pain visual analog scale (PVAS), range-of-motion (ROM) scale difference, Mayo Elbow Performance Score (MEPS), and Self-evaluation Elbow (SEE) following osteocapsular arthroplasty for primary elbow osteoarthritis and (2) to determine factors for achieving the PASS.

Methods: The study analyzed retrospectively collected osteocapsular arthroplasty registry data from January 2010 to April 2019. Fifty patients were evaluated, and anchor questions for deriving PASS values were administered at a 1-year follow-up. PASS values for the PVAS score, ROM difference, MEPS, and SEE score were derived using a sensitivity- and specificity-based approach. Univariate and multivariate logistic regression analyses were performed to determine factors for achieving the PASS. A subgroup comparison analysis based on age was also conducted.

Results: The PASS value was 1.0 for the PVAS score, 15° for ROM difference, 75 for the MEPS, and 60 for the SEE score. Older age (≥65 years) showed significantly lower odds ratios for achieving the PASS for the PVAS score (0.888; 95% confidence interval, 0.804-0.981; P = .032) and ROM (0.861; 95% confidence interval, 0.760-0.976; P = .020).

Conclusion: Reliable PASS values were derived for the PVAS score, ROM difference, MEPS, and SEE score after osteocapsular arthroplasty. The PASS values defined in this study can be implemented as clinically relevant targets in patients undergoing osteocapsular arthroplasty. An analysis of factors that affect clinical symptom improvement showed that older age (≥65 years) was significantly correlated with lower PASS values for the PVAS score and ROM.
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http://dx.doi.org/10.1016/j.jse.2020.12.013DOI Listing
September 2021

Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?

Am J Sports Med 2021 07 12;49(9):2542-2550. Epub 2021 Jan 12.

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea.

Background: Elbow instability, particularly posterolateral rotatory instability (PLRI), has been reported in patients with refractory lateral epicondylitis (LE). However, evidence of diagnostic approach and surgical outcomes is lacking.

Purpose: To identify (1) the risk factors, clinical and radiologic-diagnostic characteristics, and (2) the treatment options and clinical outcome of LE with PLRI.

Study Design: Systematic review.

Methods: We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, Scopus, and EMBASE databases using keywords as well as Medical Subject Headings terms and Emtree using "(lateral epicondylitis OR tennis elbow) AND (instability OR posterolateral rotatory instability)" for English-language studies. We conducted a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results: In total, 8 articles comprising 6 level 4 and 2 level 3 studies were identified, including 249 patients (254 elbows). The main triggering factor was heavy labor activity (74/172; 43%). A total of 184 patients (73.9%) received either single (4/184; 2.2%) or multiple (180/184; 97.8%) steroid injections. Clinically, instability was always accompanied by pain in 9% of study individuals. Magnetic resonance imaging (MRI) revealed that radial collateral ligament (RCL) and lateral ulnar collateral ligament (LUCL) lesions were most common (18/79; 23%). The most common surgical procedure performed was arthroscopic RCL plication (62/120; 52%) followed by LUCL reconstruction (30/120; 25%). A ligament patholaxity sign was shown intraoperatively for 64% (44/69). Clinical outcomes ranged from good to excellent in all studies. The most common residual symptom was limited range of motion (11/18; 61%).

Conclusion: Instability can coexist and may be associated with refractory LE. The risk factors of instability associated with refractory LE are heavy labor and multiple steroid injections. A systematic approach to identify the clinical and MRI presentation of the condition followed by examination under anesthesia are necessary for affirmative diagnosis, as independent presentations may be misleading.
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http://dx.doi.org/10.1177/0363546520980133DOI Listing
July 2021

Arthroscopic Excision of Heterotopic Ossification in the Supraspinatus Muscle.

Clin Shoulder Elb 2020 Mar 1;23(1):37-40. Epub 2020 Mar 1.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Heterotopic ossification is formation of bone in atypical extra-skeletal tissues and usually occurs spontaneously or following neurologic injury with unknown cause. We report a 46-year-old female with right shoulder pain and restricted range of motion (ROM) for 3 months without history of trauma. Magnetic resonance imaging (MRI) showed a lesion within the rotator cuff supraglenoid. Excisional biopsy from a previous institution revealed a heterotopic ossificans (HO ). Following repeat MRI and bone scan, histopathology from arthroscopic resection confirmed an HO. The patient demonstrated improved pain and ROM at follow-up. Idiopathic HO rarely occurs in the shoulder joint, and resection of HO should be delayed until maturation of the lesion to avoid recurrence. The current case showed that arthroscopic HO resection provides an excellent surgical view to ensure complete lesion removal and minimize soft tissue damage at the supraglenoid area. Furthermore, the minimally invasive procedure of arthroscopy may reduce rehabilitation time and facilitate early return to work.
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http://dx.doi.org/10.5397/cise.2020.00024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714324PMC
March 2020

Evaluation of Deltoid Origin Status Following Open and Arthroscopic Repair of Large Rotator Cuff Tears: A Propensity-Matched Case-Control Study.

Clin Shoulder Elb 2020 Mar 1;23(1):11-19. Epub 2020 Mar 1.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: The purpose of this study was to evaluate and compare deltoid origin status following large rotator cuff repair carried out using either an open or an arthroscopic method with a propensity score matching technique.

Methods: A retrospective review of 112 patients treated for full-thickness, large rotator cuff tear via either a classic open repair (open group) or an arthroscopic repair (arthroscopic group) was conducted. All patients included in the study had undergone postoperative magnetic resonance imaging (MRI) and clinical follow-up for at least 12 and 18 months after surgery, respectively. Propensity score matching was used to select controls matched for age, sex, body mass index, and affected site. There were 56 patients in each group, with a mean age of 63.3 years (range, 50-77 years). The postoperative functional and radiologic outcomes for both groups were compared. Radiologic evaluation for postoperative rotator cuff integrity and deltoid origin status was performed with 3-Tesla MRI.

Results: The deltoid origin thickness was significantly greater in the arthroscopic group when measured at the anterior acromion (P=0.006), anterior third (P=0.005), and middle third of the lateral border of the acromion level (P=0.005). The deltoid origin thickness at the posterior third of the lateral acromion was not significantly different between the arthroscopic and open groups. The arthroscopic group had significantly higher intact deltoid integrity with less scarring (P=0.04). There were no full-thickness deltoid tears in either the open or arthroscopic group.

Conclusions: Open rotator cuff repair resulted in a thinner deltoid origin, especially from the anterior acromion to the middle third of the lateral border of the acromion, at the 1-year postoperative MRI evaluation. Meticulous reattachment of the deltoid origin is as essential as rotator cuff repair when an open approach is selected.
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http://dx.doi.org/10.5397/cise.2020.00017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714323PMC
March 2020

The role of the interosseous ligament in forearm rotation: A bio-mechanical study.

J Orthop Surg (Hong Kong) 2020 Sep-Dec;28(3):2309499020973481

Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea.

Background: Management of longitudinal forearm instability remains challenging. Chronic forearm stability may be overcome by reconstruction of the interosseous ligament (IOL). Despite the bands of the IOL being inseparable, studies of the IOL have focused on the central band (CB), but have neglected the proximal (PB) and distal (DB) bands. The purpose of this study was to characterize the bio-mechanical properties of the IOL.

Materials And Methods: Twelve frozen specimens from individuals of both sexes were bio-mechanically analyzed using a custom-designed jig operated at constant angular speed to simulate forearm rotation. Strain was measured during dynamic forearm simulation using a motion tracking system.

Results: The average strain of the CB, PB, and DB during forearm simulation were 0.08 ± 0.04, 0.83 ± 0.47, and 0.65 ± 0.23 mm (p < 0.001). The IOL was generally shortest during maximal pronation and increased as the forearm was rotated to a neutral position. The strain of the CB remain constant during forearm rotation and was the lowest at full pronation to 20° pronation position. Throughout forearm rotation, the strain of the CB remained constant, whereas the strain of the PB and DB fluctuated.

Conclusions: The PB, CB, and DB of the forearm IOL have different bio-mechanical properties. CB maintained a constant rotational strain throughout forearm rotation. Strain on the CB was significantly lower than strains on the PB and DB. By contrast, strains on the PB and DB varied, suggesting that their roles differ from those of the CB. When CB reconstruction is needed, graft should be tensioned at 20° forearm pronation to gain optimum tension.
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http://dx.doi.org/10.1177/2309499020973481DOI Listing
June 2021

Navigation-assisted anchor insertion in shoulder arthroscopy: a validity study.

BMC Musculoskelet Disord 2020 Dec 5;21(1):812. Epub 2020 Dec 5.

Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

Background: This study aimed to compare conventional and navigation-assisted arthroscopic rotator cuff repair in terms of anchor screw insertion.

Methods: The surgical performance of five operators while using the conventional and proposed navigation-assisted systems in a phantom surgical model and cadaveric shoulders were compared. The participating operators were divided into two groups, the expert group (n = 3) and the novice group (n = 2). In the phantom model, the experimental tasks included anchor insertion in the rotator cuff footprint and sutures retrieval. A motion analysis camera system was used to track the surgeons' hand movements. The surgical performance metric included the total path length, number of movements, and surgical duration. In cadaveric experiments, the repeatability and reproducibility of the anchor insertion angle were compared among the three experts, and the feasibility of the navigation-assisted anchor insertion was validated.

Results: No significant differences in the total path length, number of movements, and time taken were found between the conventional and proposed systems in the phantom model. In cadaveric experiments, however, the clustering of the anchor insertion angle indicated that the proposed system enabled both novice and expert operators to reproducibly insert the anchor with an angle close to the predetermined target angle, resulting in an angle error of < 2° (P = 0.0002).

Conclusion: The proposed navigation-assisted system improved the surgical performance from a novice level to an expert level. All the experts achieved high repeatability and reproducibility for anchor insertion. The navigation-assisted system may help surgeons, including those who are inexperienced, easily familiarize themselves to of suture anchors insertion in the right direction by providing better guidance for anchor orientation.

Level Of Evidence: A retrospective study (level 2).
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http://dx.doi.org/10.1186/s12891-020-03808-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719245PMC
December 2020

Primary Linked Total Elbow Arthroplasty for Acute Distal Humerus Fracture Management: A Systematic Review of Clinical Outcome.

Clin Orthop Surg 2020 Dec 21;12(4):503-513. Epub 2020 Jul 21.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Backgroud: The treatment of distal humerus fractures is often challenging in osteoporotic elderly patients. Total elbow arthroplasty (TEA) is a salvage option for non-reconstructable fractures. The aim of this systematic review was to evaluate the clinical evidence for primary TEA in patients with acute distal humeral fractures.

Methods: Literatures were searched through PubMed, Ovid/Medline, Cochrane, Google Scholar, and Embase databases with the keywords, "distal humerus fracture," "total elbow arthroplasty," and "outcome" according to the MeSH (Medical Subject Headings) index for English-language studies published from April 2009 to April 2019. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Results: Ten articles with a total of 269 patients were included in the review. The Bryan-Morrey approach was the most common surgical approach (33.7%) with triceps reflecting (42%) for triceps tendon management. The most common implant design used was the Coonrad-Morrey system (83%). The mean postoperative motion arc was 102.3° for flexion-extension and 145.8° for pronation-supination. The average functional outcome score was 89.5 with Mayo Elbow Performance Score (MEPS). An excellent MEPS was found in studies with less than 7 days of average time from injury to surgery. The overall complication rate was 21.5%.

Conclusions: The current review showed favorable outcome of primary linked TEA for acute distal humerus fractures. Despite the promising functional outcomes, the complication rate was still considerably high. This systematic review will give surgeons help in explaining to patients regarding the expected outcome after primary TEA for acute distal humerus fractures.
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http://dx.doi.org/10.4055/cios20012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683186PMC
December 2020

Role of Additional Inferomedial Supporting Screws in Osteoporotic 3-Part Proximal Humerus Fracture: Finite Element Analysis.

Geriatr Orthop Surg Rehabil 2020 4;11:2151459320956958. Epub 2020 Nov 4.

Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Introduction: Importance of inferomedial supporting screws in preventing varus collapse has been investigated for the proximal humerus fracture. However, few studies reported the results of osteoporotic complex fracture. This study aimed to demonstrate the stress distribution pattern, particularly in osteoporotic 3-part proximal humerus fractures involving greater tuberosity (GT) with different screw configurations.

Materials And Methods: Using the computed tomography (CT) images of 2 patients, who had osteoporosis and the other had normal bone density, 3-part fractures involving the GT, without medial support were reconstructed. To reflect the osteoporosis or real bone density, Hounsfield unit of CT scans were utilized. A force of 200 N was applied in 30° varus direction. The proximal screws were set in 2 ways: 6 screws without inferomedial supporting screws and 9 screws with inferomedial supporting screws. Qualitative and quantitative analysis of internal stress distribution were performed.

Results: The most proximal part area near humeral head vertex and near the 1st screw's passage and tip had more stress concentrated in osteoporotic 3-part fractures. The stress distribution around the proximal screws was found near the GT fracture line and its lateral side, where the local max values located. Inferomedial supporting screws decreased these effects by changing the points to medial side from the GT. The ratio in osteoporotic bone model decreased to that in normal bone model when inferomedial supporting screws were applied (normal bone, 2.97%-1.30%; osteoporosis bone, 4.76%-1.71%).

Conclusions: In osteoporotic 3-part proximal humerus fracture, the stress distribution was concentrated on the area near the humeral vertex, 1st row screw tips, and lateral side region from the GT fracture line. Moreover, inferomedial supporting screws ensured that the stress distribution is similar to that in normal bone setting, particularly in osteoporotic condition.
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http://dx.doi.org/10.1177/2151459320956958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649924PMC
November 2020

Systematic Review of the Surgical Outcomes of Elbow Plicae.

Orthop J Sports Med 2020 Oct 30;8(10):2325967120955162. Epub 2020 Oct 30.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea.

Background: Surgical resection is usually required for symptomatic elbow plicae that have failed nonoperative therapy. However, evidence of surgical outcomes has not been presented.

Purpose: To review the surgical outcomes for the treatment of synovial plicae in the radiocapitellar joint.

Study Design: Systematic review; Level of evidence, 4.

Methods: We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, and Embase databases using keywords as well as Medical Subject Headings terms and Emtree ([(elbow OR humeroradial joint OR radiohumeral joint) AND (meniscus OR plica)] OR snapping elbow OR snapping triceps OR synovial fold syndrome OR synovial fringe) for English-language studies. We conducted a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results: A total of 14 articles comprising four level 5 and ten level 4 studies were identified, including 279 patients (284 elbows). The triggering factors reported for 58 patients were heavy labor (29 patients; 50.0%), sporting activities (17 patients; 29.3%), and nonspecific trauma (12 patients; 20.7%). Overall, 92 patients (33.0%) were administered a steroid injection before surgery. Arthroscopic plica resection was performed in 266 patients (95.3%). Intraoperatively, plicae were mostly found in the posterior (44.0%) and posterolateral (28.6%) sites, and chondromalacia of the radial head was observed in 25 patients (9.2%). Of the reported surgical outcomes, 67.7% showed a resolution of symptoms. However, 9.3% of patients had residual symptoms, which were likely associated with pre-existing radial head chondromalacia. The complication rate was reported as 1.8%.

Conclusion: Symptomatic elbow plicae were mostly treated arthroscopically, with most of the results being favorable. Pre-existing chondromalacia and the underestimation of concomitant intra-articular abnormalities may yield an inferior outcome.
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http://dx.doi.org/10.1177/2325967120955162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607772PMC
October 2020

Osteochondral reconstruction for post-traumatic coronoid deficiency.

J Orthop Surg (Hong Kong) 2020 Sep-Dec;28(3):2309499020968606

Department of Orthopedic Surgery, 65526Asan Medical Center, University of Ulsan, Seoul, Korea.

Purpose: This study aimed to evaluate the clinical outcome and graft survival following coronoid reconstruction with osteochondral bone grafts for post-traumatic coronoid deficiency treatment. We hypothesized that coronoid reconstruction using an osteochondral bone graft will provide favorable results in treating post-traumatic coronoid deficiency.

Methods: A retrospective review was performed on eight patients (mean age = 45.8 years) who underwent osteochondral bone graft reconstruction indicated for post-traumatic coronoid deficiency. The osteochondral bone grafts were obtained from the radial head remnant (four patients), olecranon tip (two patients), and iliac crest (two patients). All the injuries were terrible triad. The mean duration from injury to surgery was 79.3 weeks. The visual analog scale (VAS) for pain, motion arc, and Mayo elbow performance score (MEPS) were used to evaluate the clinical outcome. Radiologic evaluation of graft healing and integrity was performed using computed tomography at 19 months and plain elbow radiography at 24.1 months after reconstruction. The immediate graft height was measured.

Results: VAS and MEPS values improved from 4.1 ± 1.2 to 1.1 ± 0.3 and 34.2 ± 16.9 to 85.0 ± 7.1, respectively ( = 0.018, = 0.018) after reconstruction. The motion arc significantly improved from 84.2° ± 16.1° to 102.1° ± 18.2° at the final follow-up of 39.1 ± 18.8 months ( = 0.048). All the osteochondral grafts survived, with nonunion in two patients (25%). The mean immediate graft height was 15.4 ± 2.6 mm. Among the eight patients, three (37.5%) developed secondary osteoarthritis of the ulnohumeral joint.

Conclusions: Coronoid reconstruction with osteochondral bone graft may serve as an option to salvage post-traumatic coronoid deficiency. Sufficient graft height was required for graft survival. Secondary osteoarthritis of the ulnohumeral joint should not be underestimated during follow-up.
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http://dx.doi.org/10.1177/2309499020968606DOI Listing
June 2021

Engineered Cell Sheets for the Effective Delivery of Adipose-Derived Stem Cells for Tendon-to-Bone Healing.

Am J Sports Med 2020 11 14;48(13):3347-3358. Epub 2020 Oct 14.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Efforts are being made to treat rotator cuff tears (RCTs) that exhibit poor healing and high retear rates. Tendon-to-bone healing using mesenchymal stem cells is being explored, but research is needed to establish effective delivery options.

Purpose: To evaluate the effects of an adipose-derived stem cell (ADSC) sheet on mesenchymal stem cell delivery for tendon-to-bone healing of a chronic RCT in rats and to demonstrate that ADSC sheets enhance tendon-to-bone healing.

Study Design: Controlled laboratory study.

Methods: Mesenchymal stem cells were obtained from rat adipose tissue, and a cell sheet was prepared using a temperature-responsive dish. To evaluate the efficacy of stem cells produced in a sheet for the lesion, the experiment was conducted with 3 groups: repair group, cell sheet transplantation after repair group, and cell sheet-only group. Histological, biomechanical, and micro-computed tomography (micro-CT) results were compared among the groups.

Results: Hematoxylin and eosin staining for histomorphological analysis revealed that the cell sheet transplantation after repair group (5.75 ± 0.95) showed statistically significant higher scores than the repair (2.75 ± 0.50) and cell sheet-only (3.25 ± 0.50) groups ( < .001). On safranin O staining, the cell sheet transplantation after repair group (0.51 ± 0.04 mm) had a larger fibrocartilage area than the repair (0.31 ± 0.06 mm) and cell sheet-only (0.32 ± 0.03 mm) groups ( = .001). On micro-CT, bone volume/total volume values were significantly higher in the cell sheet transplantation after repair group (23.98% ± 1.75%) than in the other groups ( < .039); there was no significant difference in the other values. On the biomechanical test, the cell sheet transplantation after repair group (4 weeks after repair) showed significantly higher results than the other groups ( < .005).

Conclusion: Our study shows that engineered stem cells are a clinically feasible stem cell delivery tool for rotator cuff repair.

Clinical Relevance: This laboratory study provides evidence that ADSCs are effective in repairing RCTs, which are common sports injuries.
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http://dx.doi.org/10.1177/0363546520964445DOI Listing
November 2020
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