Publications by authors named "Jae-Man Kwak"

54 Publications

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

Staged revision still works for chronic and deep infection of total elbow arthroplasty?

SICOT J 2022 26;8:21. Epub 2022 May 26.

Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Seoul 05505, South Korea.

Purpose: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery.

Methods: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34-83 years). The mean follow-up was 62 (range, 24-108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated.

Results: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0-70), which improved to 75.5 (range, 35-85). The mean disease duration was 8.4 months (range, 5-20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up.

Conclusion: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue.

Level Of Evidence: Level IV, Case series, Treatment study.
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http://dx.doi.org/10.1051/sicotj/2022019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9135019PMC
May 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

Patient-specific instrumentation improves the reproducibility of preoperative planning for the positioning of baseplate components with reverse total shoulder arthroplasty: a comparative clinical study in 39 patients.

J Shoulder Elbow Surg 2022 Jul 15;31(7):1488-1498. Epub 2022 Jan 15.

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

Background: The application of patient-specific instrumentation (PSI) for reverse total shoulder replacement has been rapidly increasing, which could reduce errors in implant positioning. Although PSI theoretically holds promise, evidence of the accuracy and reliability of PSI in shoulder replacement surgery is limited.

Methods: Thirty-nine shoulders that underwent reverse total shoulder arthroplasty were included in this study and categorized into two groups: the conventional (n = 20) and PSI (n = 19) groups. Screw (length and angle) and baseplate (version, inclination, translation, and rotation) positioning were calculated based on postoperative computed tomography images using a three-dimensional measurement tool. The difference between the values of the preoperative target and postoperative measurement was calculated to evaluate the reproducibility of preoperative planning. Screw involvement in the suprascapular and spinoglenoid notches was assessed. Thus, the correlation between the position of the baseplate and the screws was assessed.

Results: The mean differences between the planned length and angle (anteroposterior and superoinferior angles) and postoperative measurement in the PSI group were significantly smaller than those in the conventional group. Similarly, the mean difference in baseplate rotation between the planned and postoperative measurements in the PSI group was significantly lower than that in the conventional group (4.5° vs 10.6°; P < .001). The spinoglenoid notch was involved in 10 cases in the conventional group and 2 cases in the PSI group, and this difference was significant (P = .014). Overall, the mean difference between the preoperative and postoperative version, inferior inclination, and rotation values for the baseplate position was significantly correlated with the values for screw position (length and angle).

Conclusions: PSI improves the reproducibility of preoperative planning for baseplate and screw positioning and reduces the risk of neurovascular injury in reverse total shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jse.2021.12.012DOI Listing
July 2022

Radial Head Prosthetic Replacement in Adolescents: A Report of 5 Cases.

J Pediatr Orthop 2022 Feb;42(2):109-115

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: The management of severe radiocapitellar joint pathologies in young patients is challenging. Radial head arthroplasty (RHA) is a treatment option in the adult population, but most surgeons avoid implementing it in younger patients, and there are no published results for patients younger than 16 years.

Methods: Our retrospective cohort describes 5 patients (4 male 1 female) who underwent cementless modular RHA at an average age of 14 years (range: 13 to 15). The preoperative diagnoses were post-traumatic radiocapitellar incongruity and arthrosis because of previous Salter-Harris type 3 or 4 fractures of the radial head in 3 cases; and axial instability of the forearm following failed radial head excision in 2 cases. Because of the complexity of the elbow pathology in these cases, all underwent concomitant procedures including: contracture release (5 cases), corrective ulnar osteotomy (2 cases), distal ulnar shortening osteotomy, excision of radioulnar synostosis, microfracture of the capitellum, and partial excision of the medial triceps (1 case each). Collected data included patient-reported outcomes, visual analog scale pain score at rest and during physical activity and radiographic assessment of arthritis and prosthesis loosening.

Results: Average clinical follow-up was 8 years (range: 3 to 13). All 5 patients were pain-free at rest, and 3 reported moderate elbow pain (visual analog scale: 5 to 6) with physical activity. At an average radiographic follow-up of 3 years (range: 0.5 to 5), 3 patients showed mild progression of elbow arthrosis, but there were no signs of progressive capitellar erosion or implant loosening. Only 1 complication was noted-development of heterotopic ossification in 1 patient, which required open heterotopic ossification excision and contracture release 2 years following the RHA. None of the patients required prosthesis revision or removal.

Conclusion: RHA was successful in improving pain and axial forearm stability in this very small series of adolescent patients. Concerns regarding long-term longevity and complications still exist. Considering the lack of other reliable treatment options, RHA may be indicated in this challenging patient population.

Level Of Evidence: Level IV: therapeutic study-case series.
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http://dx.doi.org/10.1097/BPO.0000000000002030DOI Listing
February 2022

Ultrasonographic Measurement of Elbow Varus Laxity With a Sequential Injury Model of the Lateral Collateral Ligament-Capsular Complex.

Orthop J Sports Med 2021 Nov 10;9(11):23259671211048941. Epub 2021 Nov 10.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established.

Hypothesis: Increased elbow varus laxity due to lateral collateral ligament-capsular complex (LCL-cc) injury could be assessed reliably via ultrasound.

Study Design: Descriptive laboratory study.

Methods: Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion.

Results: At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; < .01).

Conclusion: Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space.

Clinical Relevance: Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.
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http://dx.doi.org/10.1177/23259671211048941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8586189PMC
November 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

Radial Head Lag: A Possible Biomechanical Mechanism for Osteochondritis Dissecans of the Capitellum in Baseball Pitchers.

Am J Sports Med 2021 10 15;49(12):3226-3233. Epub 2021 Sep 15.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Osteochondritis dissecans (OCD) of the capitellum is common in throwing athletes and is believed to result from repetitive overloading on the radiocapitellar (RC) joint, although the cause and mechanism remain unclear. The torsional forces (moments) generated by the triceps during elbow extension pull only on the ulna; therefore, the radial head moves passively across the capitellum and is effectively "dragged along" by the ulna. Any laxity in the proximal radioulnar joint could lead to asynchronous motion between the radius and ulna, resulting in the radial head lagging behind the coronoid and possibly malarticulating with the capitellum during such motion.

Hypothesis: Radial head motion on the capitellum lags behind ulnohumeral joint motion during simulated throwing.

Study Design: Controlled laboratory study.

Methods: A total of 8 cadaveric elbows were tested under simulated throwing, including active extension of the elbow generated by pulling of the triceps under valgus stress, as well as during passive extension under valgus stress to serve as a reference. Ulnohumeral motion was tracked using a video camera. Radial head motion was tracked using an intra-articular, thin-film pressure sensor mounted on the capitellum, and the longitudinal movement of the center of force (COF) of the radial head was measured. Radial head motion was compared between passive and active motion for each 10° of elbow extension from 90° to 20°.

Results: Elbow motion during simulated active extension reached an angular velocity of 366 deg/s. Radial head motion during simulated active extension significantly lagged compared with its motion during passive extension at every elbow extension angle examined between 70° and 20° ( < .001). The maximal lag reached a mean of 4 mm (range, 2-7 mm). In other words, RC and ulnohumeral motion were asynchronous during simulated throwing.

Conclusion: This study describes a novel phenomenon: motion of the radial head across the capitellum during rapid extension, such as in baseball pitching, lags behind that seen during passive elbow motion. According to a new proposed theory of OCD lesion development, this lag should result in RC incongruency and elevated shear forces on the capitellum due to edge loading.

Clinical Relevance: We propose a new biomechanical explanation for OCD of the capitellum in baseball pitchers: radial head lag. Understanding this process is the first step in efforts to prevent this common injury.
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http://dx.doi.org/10.1177/03635465211033971DOI Listing
October 2021

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

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

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

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

Surgical management for primary osteoarthritis of the elbow.

J Orthop Surg (Hong Kong) 2021 Jan-Apr;29(1):2309499020988174

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

The objective of this review is to summarize the surgical options for primary osteoarthritis of the elbow, reported clinical outcomes, and suggested indications in previous literatures. The surgical management of primary elbow arthritis has evolved because of an improved understanding of pathologic mechanisms and manifestations as well as the development of novel surgical techniques and devices. Osteocapsular arthroplasty (OCA), elbow debridement, distraction arthroplasty, and total elbow arthroplasty (TEA) have been employed for managing elbow osteoarthritis. Elbow debridement and OCA can be helpful in most cases of symptomatic elbow arthritis. TEA is usually recommended for end-stage arthritis in elderly patients after prosthetic implants have been in place for long periods or after complications. Distraction arthroplasty might find a place in the treatment of younger, active patients with end-stage arthritis.
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http://dx.doi.org/10.1177/2309499020988174DOI Listing
June 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

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

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

Reconstruction of large chronic rotator cuff tear can benefit from the bone-tendon composite autograft to restore the native bone-tendon interface.

J Orthop Translat 2020 Sep 30;24:175-182. Epub 2020 Jan 30.

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

Purpose: We designed a paired controlled study to investigate the advantages of using bone-tendon composite autograft to reconstruct chronic rotator cuff tear compared with primary repair and provide some evidence to use the bone-tendon composite autograft.

Method: Thirty-eight Sprague-Dawley rats were used. The native bone-tendon junctions of supraspinatus and Achilles tendon insertion from two rats were harvested for gross and histological observation. Another thirty-six rats had bilateral supraspinatus tenotomy from the great tuberosity. Three weeks later, primary repair (simple tendon pullout direct repair to bone) was performed on one side and the other side was reconstructed using an Achilles-calcaneus composite autograft from the ipsilateral leg. Nine rats were sacrificed for biomechanical testing and another three were sacrificed for histological evaluation at 3, 6, and 9 weeks after surgery, respectively.

Results: The Achilles-calcaneus composite autograft group showed significantly better biomechanical characteristics at 3 and 6 weeks in terms of maximum load and stiffness. Tissue histology demonstrated an organised extracellular matrix, a clear tidemark, and distinct fibrocartilage layers in the composite graft group, similar to those of the native bone-tendon interface. Additionally, clear bone-to-bone healing and tendon-to-tendon healing were observed. By contrast, the conventional primary repair could not regenerate the structure of the native bone-tendon interface.

Conclusions: Bone-tendon autograft for chronic rotator cuff reconstruction is superior to the primary repair regarding biomechanical property and histological structure. Our study may provide some evidence in support of the reconstruction of a chronic rotator cuff tear using bone-tendon composite autografts in clinical practice.

The Translational Potential Of This Article: The current study finds the bone-tendon autograft can restore the normal bone-tendon interface, which can not regenerate after repair and is the key factor affecting re-tear. The bone-tendon autografts from our body can be the candidates for rotator cuff tear reconstruction especially the large to massive rotator cuff tear in the future to reduce the re-tear after rotator cuff tear.
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http://dx.doi.org/10.1016/j.jot.2020.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548344PMC
September 2020

The elbow plica: a systematic review of terminology and characteristics.

J Shoulder Elbow Surg 2021 May 7;30(5):e185-e198. Epub 2020 Oct 7.

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

Background: There has been a lack of evidence regarding the structure of the elbow plica, or synovial fold. Inconsistency remains regarding the correct terminology, prevalence, and investigation used to understand this anatomic structure.

Methods: For this systematic review, we searched the PubMed, Ovid-MEDLINE, Cochrane, Google Scholar, and Embase databases using keywords as well as medical subject headings for English-language studies. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results: We included 27 articles in this review. "Plica" was the most commonly used terminology (33%). The prevalence of plicae in asymptomatic and symptomatic patients was 77% and 97%, respectively. Provocative factors were sporting activities (57%), including those performed by professional athletes, and heavy labor (43%). Lateral elbow pain represented the most common symptom (49%). Magnetic resonance imaging was the most commonly used diagnostic modality (64%). On the magnetic resonance imaging scans of symptomatic patients, the most common location of the plica was the posterolateral region (54%) and its thickness was a minimum of 3 mm. In 2 studies that included symptomatic patients, the plica was found to cover more than one-third of the radial head.

Conclusion: Plicae are prevalent in both asymptomatic and symptomatic patients. Consideration of the pathologies associated with an elbow plica helped identify the following: (1) its thickness is >3 mm and (2) its location is in the posterolateral aspect and/or it covers more than one-third of the radial head quadrant.
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http://dx.doi.org/10.1016/j.jse.2020.09.011DOI Listing
May 2021

Arthroscopic Superior Capsular Reconstruction With Mesh Augmentation for the Treatment of Irreparable Rotator Cuff Tears: A Comparative Study of Surgical Outcomes.

Am J Sports Med 2020 11 24;48(13):3328-3338. Epub 2020 Sep 24.

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

Background: Arthroscopic superior capsular reconstruction (ASCR) is an alternative to open surgery for irreparable chronic rotator cuff tears (RCTs). This approach can provide static restraint while avoiding upward migration of the humeral head. However, graft tears and their effect on clinical outcomes after ASCR remain a debated topic.

Purpose: To evaluate the clinical outcomes of ASCR with mesh augmentation for the treatment of irreparable RCTs.

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

Methods: The data of 72 patients with irreparable RCTs who underwent ASCR between 2013 and 2018 were retrospectively evaluated. Among them, 64 patients who met the inclusion and exclusion criteria were enrolled in this study. Fascia lata grafts augmented with a polypropylene mesh were used for 30 patients (mesh group), and grafts without mesh augmentation were used for 34 patients (control group). Clinical outcomes were evaluated using range of motion, the American Shoulder and Elbow Surgeons (ASES) questionnaire, and visual analog scale for pain. Radiological outcomes were evaluated according to acromiohumeral distance and stage of rotator cuff arthropathy. The status of fatty infiltration and graft integrity was evaluated using magnetic resonance imaging. Outcomes were assessed preoperatively and at the final follow-up.

Results: Both groups showed improvement in clinical and radiological outcomes at the final follow-up. The mesh group demonstrated a larger improvement in ASES score (mean ± SD, 29.1 ± 15.8) than the control group (18.1 ± 15.9) ( = .006). The mean improvement in active forward flexion was significantly higher in mesh group (40°± 26°) than in control group (28°± 23°) ( = .003). The mean improvement in active external rotation was also significantly higher in the mesh group (11°± 5°) than in the control group (6°± 3°) ( = .004). Graft healing rate was significantly higher in the mesh group (83.3%) than in the control group (58.8%) ( = .039), and acromiohumeral distance was significantly greater in the mesh group (9.1 ± 2.4 mm) than in the control group (6.3 ± 1.8 mm) at the final follow-up ( = .001). Subgroup analysis revealed that patients with graft failure generally showed progression of fatty infiltration without improvement in the stage of rotator cuff arthropathy. Patients with intact grafts demonstrated a more substantial improvement in functional outcomes (ASES score and forward flexion motion).

Conclusion: ASCR with mesh augmentation reduced graft failure rate to restore superior shoulder joint stability.
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http://dx.doi.org/10.1177/0363546520958708DOI Listing
November 2020

The contact area of the radiocapitellar joint under pronation and supination with axial load using a 3-dimensional computed tomography: an in vivo study.

J Shoulder Elbow Surg 2021 Jun 17;30(6):1238-1244. Epub 2020 Sep 17.

Department of Hand Surgery, Affiliated Hospital of Nantong University, College of Medicine, University of Nantong, Nantong, China. Electronic address:

Objective: To evaluate the contact area of the radiocapitellar joint with forearm pronation and supination under axial loading.

Materials And Methods: Six healthy volunteers (2 males and 4 females, mean age: 44.6 years) were included in the study. A computed tomography scan of the extended elbow joints was obtained at 4 positions of forearm: full pronation with or without load and full supination with or without load. Mimics, 3-matic Medical, Geomagic, and Photoshop were used to reconstruct 3-dimensional models. The contact area of the radiocapitellar joint was measured. Shifting of the center of the contact area of the radiocapitellar joint was measured.

Results: The axial load added 8.6% and 10.5% contact area to pronation and supination without load, respectively. From pronation without load, the center of contact area significantly shifted 2.4 ± 1.1 mm anteromedially to supination without load and shifted by 1.0 ± 0.5 mm to the center of the radial head compared with the pronation with load. The center of the contact area significantly shifted 2.4 ± 1.5 mm anteromedially from the pronation to the supination under loading. The contact area of the tuberosity anterior in the radial head significantly increased by 14% (without load) and 8% (with load) from pronation to supination.

Conclusion: Axial loading increases the contact area of the radiocapitellar joint. The center of the contact area of the radiocapitellar joint changed according to loading and shifted to the anterior tuberosity of the radial head from forearm pronation to supination.
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http://dx.doi.org/10.1016/j.jse.2020.08.042DOI Listing
June 2021

Distribution of Osteochondral Lesions in Patients With Simple Elbow Dislocations Based on MRI Analysis.

Orthop J Sports Med 2020 Aug 28;8(8):2325967120946269. Epub 2020 Aug 28.

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

Background: The clinical relationship between osteochondral lesions and long-term outcomes and patterns in the elbow joint has not yet been established. A sole evaluation from plain standard radiography may underestimate the severity of bony lesions in patients with simple dislocations. It has been suggested that the mechanism of a posterior elbow dislocation could be inferred from the pattern of bony contusions and osteochondral lesions visible on magnetic resonance imaging (MRI) in patients with simple elbow dislocations.

Purpose/hypothesis: The purpose of this study was to describe the incidence and distribution of osteochondral lesions based on MRI findings in patients with simple elbow dislocations. We hypothesized that (1) osteochondral lesions are consistently found in patients with simple elbow dislocations and (2) the distribution and severity of osteochondral lesions may explain the mechanism of the simple elbow dislocation.

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

Methods: A retrospective review of 43 patients with simple elbow dislocations was performed in tertiary-level hospitals from January 2010 to August 2019. Two orthopaedic surgeons separately assessed the initial plain radiographs and MRI scans. Osteochondral lesions were evaluated and categorized based on whether they were located (1) on the lateral side (posterolateral capitellum and radial head; type 1) or (2) on the medial side (posterior trochlea and anteromedial facet of the coronoid; type 2). The severity of the osteochondral lesions was assessed according to the Anderson classification.

Results: Of the 43 patients, 21 (48.8%) presented with osteochondral lesions on MRI. The type 1 pattern of osteochondral lesions was the most frequently observed on MRI in patients with simple elbow dislocations (69.8% of cases), and these were confirmed by simple radiography. Posterolateral capitellum osteochondral lesions were found in 13 patients. Among them, 10 (76.9%) were advanced-stage lesions (stages III and IV according to the Anderson classification).

Conclusion: Osteochondral lesions were found on MRI after simple elbow dislocations at a rate of 48.8%. Osteochondral lesions in the posterolateral capitellum were associated with an advanced stage. Clinically, these findings may help surgeons in the diagnosis of osteochondral lesions and in determining how to manage patients with the progression of arthritic changes.
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http://dx.doi.org/10.1177/2325967120946269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457416PMC
August 2020

Topography of sensory receptors within the human glenohumeral joint capsule.

J Shoulder Elbow Surg 2021 Apr 21;30(4):779-786. Epub 2020 Jul 21.

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

Background And Hypotheses: Sensory receptors in the joint capsule are critical for maintaining joint stability. However, the distribution of sensory receptors in the glenohumeral joint of the shoulder, including mechanoreceptors and free nerve endings, has not been described yet. This study aimed to describe the distributions of different sensory receptor subtypes in the glenohumeral joint capsule. Our hypotheses were as follows: (1) Sensory receptor subtypes would differ in density but follow a similar distribution pattern, and (2) the anterior capsule would have the highest density of sensory receptors.

Methods: Six glenohumeral joint capsules were harvested from the glenoid to the humeral attachment. The capsule was divided into 4 regions of interest (anterior, posterior, superior, and inferior) and analyzed using modified gold chloride stain. Sensory receptors as well as free nerve endings were identified and counted under a light microscope from sections of each region of interest. The density of each sensory receptor subtype was calculated relative to capsule volume.

Results: Sensory receptors were distributed in the glenohumeral joint capsule with free nerve endings. The anterior capsule exhibited the highest median density of all 4 sensory receptors examined, followed by the superior, inferior, and posterior capsules. The median densities of these sensory receptor subtypes also significantly differed (P = .007), with type I (Ruffini corpuscles) receptors having the highest density (2.97 U/cm), followed by type IV (free nerve endings, 2.25 U/cm), type II (Pacinian corpuscles, 1.40 U/cm), and type III (Golgi corpuscles, 0.24 U/cm) receptors.

Conclusion: Sensory receptor subtypes are differentially expressed in the glenohumeral joint capsule, primarily type I and IV sensory receptors. The expression of sensory receptors was dominant in the anterior capsule, stressing the important role of proprioception feedback for joint stability. The surgical procedure for shoulder instability should consider the topography of sensory receptors to preserve or restore the proprioception of the shoulder joint.
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http://dx.doi.org/10.1016/j.jse.2020.07.006DOI Listing
April 2021

The forearm interosseous ligament: comparative mechanical properties of the proximal, central, and distal bands.

J Hand Surg Eur Vol 2021 Feb 17;46(2):184-187. Epub 2020 Jul 17.

Department of Orthopedic Surgery, University of Ulsan, Seoul, Korea.

We compared the mechanical properties of the three parts of interosseous membranes in 12 fresh-frozen specimens. The proximal, central and distal bands of interosseous membranes were tested in a universal testing machine. Tensile strength, ultimate strain, ultimate load and elastic modulus were measured and compared. The stress-strain relationship curves of these bands were similar to those of ligaments. Tensile strength, ultimate load and elastic modulus were significantly higher in the central band than in the proximal and distal bands. Ultimate strain was significantly lower in the central band than in proximal and distal bands. We conclude that the interosseous membrane is similar to ligaments in structure with each band having distinct characteristics. The findings may aid in clinical choice of proper grafts used for interosseous membrane reconstruction.
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http://dx.doi.org/10.1177/1753193420939497DOI Listing
February 2021

Arthroscopic Modified Bosworth Procedure for Refractory Lateral Elbow Pain With Radiocapitellar Joint Snapping.

Orthop J Sports Med 2020 Jun 29;8(6):2325967120929929. Epub 2020 Jun 29.

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

Background: Radiocapitellar joint snapping due to the presence of synovial plica has been described as a contributory intra-articular pathology of lateral epicondylitis (LE).

Hypothesis: The arthroscopic modified Bosworth technique can provide a safe and favorable outcome for refractory LE with radiocapitellar snapping.

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

Methods: Patients treated with the arthroscopic modified Bosworth procedure for refractory LE with radiocapitellar joint snapping were included in this study. The sequential surgical procedures included excision of the upper portion of the anterolateral annular ligament, removal of the synovial plicae, and release of the extensor carpi radialis brevis for all patients. Clinical outcomes were measured at a minimum 1-year follow-up.

Results: A total of 22 patients with a mean ± SD age of 51.2 ± 10.4 years were included in this study. The mean follow-up was 29.4 ± 7.7 months (range, 21-42 months). The overall visual analog scale score (from preoperative to final follow-up) was 7.5 ± 1.2 vs 2.5 ± 1.8 ( < .001); flexion-extension motion arc was 133.8° ± 11.2° vs 146.4° ± 7.1° ( = .001); pronation-supination motion arc was 101.8° ± 9.2° vs 141.7° ± 10.2° ( = .001); Disabilities of the Arm, Shoulder and Hand score was 54.5 ± 13.2 vs 3.6 ± 4.1 ( < .001); and Mayo Elbow Performance Score was 51.9 ± 12.2 vs 84.3 ± 10.3 ( < .001).

Conclusion: Radiocapitellar joint snapping may coexist with LE as a disease spectrum. The arthroscopic modified Bosworth technique provides safe and favorable outcomes for patients with refractory LE associated with radiocapitellar joint snapping.
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http://dx.doi.org/10.1177/2325967120929929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325455PMC
June 2020

Subacromial bursal preservation can enhance rotator cuff tendon regeneration: a comparative rat supraspinatus tendon defect model study.

J Shoulder Elbow Surg 2021 Feb 12;30(2):401-407. Epub 2020 Jun 12.

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

Background: The role of subacromial bursa in rotator cuff surgery is unknown. This study aimed to assess the subacromial bursa's role in the healing of supraspinatus tendon injury in a rat model.

Methods: Twenty-three male Sprague-Dawley rats (9 weeks old; weight, approximately 296 g) were used in this study. Three rats used as biomechanical study controls were killed at 12 weeks of age. A supraspinatus tendon defect was made bilaterally in 20 rats, whereas an additional subacromial bursa sectioning was performed on the left side. Six rats were killed for biomechanical testing and 4 were killed for histologic observation at 3 and 9 weeks, respectively.

Results: The regenerated tendon in the bursal preservation group showed significantly superior biomechanical properties in maximum load to failure at 3 and 9 weeks and stiffness at 9 weeks after surgery compared with the bursal removal group. The modified Bonar scale scores showed better regenerated supraspinatus tendons in the bursal preservation group.

Conclusion: The present study found that the subacromial bursa plays an important role in rotator cuff regeneration in this rat supraspinatus injury model. Extensive bursectomy of the subacromial bursa may not be recommended in rotator cuff repair surgery, though future in vivo human studies are needed to confirm these observations.
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http://dx.doi.org/10.1016/j.jse.2020.05.025DOI Listing
February 2021

Remnant Tendon Preservation Enhances Rotator Cuff Healing: Remnant Preserving Versus Removal in a Rabbit Model.

Arthroscopy 2020 07 6;36(7):1834-1842. Epub 2020 Apr 6.

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

Purpose: To assess whether anatomic repair preserving remnant tendon tissue can enhance tendon-to-bone healing biomechanically and histologically in a rabbit rotator cuff tear model.

Methods: In this controlled laboratory study, bilateral infraspinatus tenotomy from the greater tuberosity, with remnant tendon on the footprint, was performed in 26 New Zealand white rabbits. An open transosseous technique was used to perform bilateral infraspinatus tendon repair 1 week later. Preservation and removal of the remaining tendon were performed on the left and right sides, respectively. Seven rabbits each were killed humanely for biomechanical testing and 6 rabbits each were killed humanely for histologic evaluation at 4 and 12 weeks.

Results: Significantly superior biomechanical properties were shown in the remnant tissue-preservation group at 4 and 12 weeks in terms of maximum load (89.6 ± 24.3 N vs 68.2 ± 20.7 N at 4 weeks, P = .048; 120.8 ± 27.5 N vs 93.3 ± 25.1 N at 12 weeks, P = .035) and stiffness (25.3 ± 3.4 N/mm vs 17.7 ± 5.2 N/mm at 4 weeks, P = .009; 26.7 ± 5.2 N/mm vs 19.4 ± 5.2 N/mm at 12 weeks, P < .001). Improved bone-tendon interface histologic maturity scores (14.8 ± 0.9 vs 8.2 ± 1.5 at 4 weeks, P = .027; 16.8 ± 0.7 vs 10.5 ± 1.4 at 12 weeks, P = .027) and large metachromasia areas (0.117 ± 0.053 mm vs 0.032 ± 0.017 mm at 4 weeks, P = .022; 0.14 ± 0.046 mm vs 0.037 ± 0.016 mm at 12 weeks, P = .007) were obtained in the preservation group compared with the removal group at 4 and 12 weeks.

Conclusions: This study showed that preserving remnant tissue in anatomic repair can significantly improve rotator cuff healing compared with remnant tissue removal on the footprint in terms of biomechanical properties, bone-tendon interface histologic maturity scores, and metachromasia at 4 and 12 weeks after repair in a rabbit rotator cuff tear model.

Clinical Relevance: The results suggest that preservation of remnant tissue on the footprint containing the native bone-tendon interface, when present, may be a better option for rotator cuff healing in rotator cuff repair surgery.
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http://dx.doi.org/10.1016/j.arthro.2020.03.012DOI Listing
July 2020

Suprascapular nerve injury affects rotator cuff healing: A paired controlled study in a rat model.

J Orthop Translat 2021 Mar 5;27:153-160. Epub 2020 Mar 5.

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

Purpose: We designed a paired controlled study to investigate the role of the suprascapular nerve (SSN) in rotator cuff healing using a rat tear model, and we hypothesised that rotator cuff healing is impaired in the absence of a healthy SSN.

Methods: Bilateral supraspinatus tenotomy from the great tuberosity was performed for 36 Wistar rats, which was then repaired immediately. A defect on the SSN was made on the right side, and a sham surgery was performed on the SSN at the left side. Twelve rats were sacrificed for biomechanical (six rats) and histological (six rats) testing, evaluated at 3, 6, and 9 weeks after surgery.

Results: The bone-tendon junction on the nerve-intact side showed significantly better biomechanical characteristics than the nerve-injured side in terms of maximum load, maximum stress over time, stiffness at 9 weeks, and Young's modulus at 3 and 9 weeks. On the nerve-injured side, significantly smaller fibrocartilage layers and muscle fibres could be obtained over time. In addition, on the nerve-injured side, inferior bone-tendon interface formation was obtained in terms of cell maturity, cell alignment, collagen orientation, and the occurrence of tidemark and Sharpey's fibres through 9 weeks. In addition, neuropeptide Y was secreted in the nerve-intact group at 6 and 9 weeks.

Conclusion: This study showed the inferior healing of the bone-tendon junction on the nerve-injured side compared with the nerve-intact side, which indicates that the SSN plays an important role in rotator cuff healing. Surgeons should pay more attention to SSN injury when treating patients with rotator cuff tear.
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http://dx.doi.org/10.1016/j.jot.2020.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071639PMC
March 2021

Small Subchondral Drill Holes Improve Marrow Stimulation of Rotator Cuff Repair in a Rabbit Model of Chronic Rotator Cuff Tear.

Am J Sports Med 2020 03 13;48(3):706-714. Epub 2020 Jan 13.

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

Background: Microfracture of the greater tuberosity has been proved effective for enhancing tendon-to-bone healing after rotator cuff repair. However, no standard diameter for the microfracture has been established.

Purpose/hypothesis: This study aimed to assess treatment with large- and small-diameter microfractures to enhance healing during rotator cuff repair surgery in a rabbit model of chronic rotator cuff tear. It was hypothesized that a small-diameter microfracture had advantages in terms of tendon-to-bone integration, bone-tendon interface maturity, microfracture healing, and biomechanical properties compared with a large-diameter microfracture.

Study Design: Controlled laboratory study.

Methods: Bilateral supraspinatus tenotomy from the greater tuberosity was performed on 21 New Zealand White rabbits. Bilateral supraspinatus repair was performed 6 weeks later. Small-diameter (0.5 mm) microfracture and large-diameter microfracture (1 mm) were performed on the left side and right side, respectively, in 14 rabbits as a study group, and simple repair without microfracture was performed in 7 rabbits as a control group. At 12 weeks later, 7 of 14 rabbits in the study group were sacrificed for micro-computed tomography evaluation and biomechanical testing. Another 6 rabbits were sacrificed for histological evaluation. In the control group, 3 of the 7 rabbits were sacrificed for histological evaluation and the remaining rabbits were sacrificed for biomechanical testing.

Results: Significantly better bone-to-tendon integration was observed in the small-diameter microfracture group. Better histological formation and maturity of the bone-tendon interface corresponding to better biomechanical results (maximum load to failure and stiffness) were obtained on the small-diameter microfracture side compared with the large-diameter side and the control group. The large-diameter microfracture showed worse radiographic and histological properties for healing of the microfracture holes on the greater tuberosity. Additionally, the large-diameter microfracture showed inferior biomechanical properties but similar histological results compared with the control group.

Conclusion: Small-diameter microfracture showed advantages with enhanced rotator cuff healing for biomechanical, histological, and radiographic outcomes compared with large-diameter microfracture, and large-diameter microfracture may worsen the rotator cuff healing.

Clinical Relevance: This animal study suggested that a smaller diameter microfracture may be a better choice to enhance healing in clinical rotator cuff repair surgery in humans.
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http://dx.doi.org/10.1177/0363546519896350DOI Listing
March 2020
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