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1 ka a8;. ff, The Td$*$ournal '.,' of,';' Orthsll',nedic Su,r ger]r. -t o.- The Official Journal of the Royal College of Orthopaedic Surgeons of Thailand The tlfficial The Official The Official The Official The Official The Official The Sflicial The Official The Official Journal of Thai Hip & Knee Sociefy Jsurnal of Spine Soeiety af Thailand Jrurnal of Thai Orthopaedic Society for Sports Medieine Jnurnal rf Thai Musculoskeletal Tumor Society Journal nf Thniland Orthopaedic Trauma Journal of Thai Society for Hand Surgery of RCOST Journal af fediatrie Orthopaedic Society Journal af Thailand Orthopaedic Fcot and Ankle Society Journal of Metabalic Bone Disorder and Orthogeriatrics ISSN

2 The Thai Journal Of Orthopaedic Surgery The Official Journal of the Royal College of Orthopaedic Surgeons of Thailand The Official Journal of Thai Hip & Knee Society The Official Journal of Spine Society of Thailand The Official Journal of Thai Orthopaedic Society for Sports Medicine The Official Journal of Thai Musculoskeletal Tumor Society The Official Journal of Thailand Orthopaedic Trauma The Official Journal of Thai Society for Hand Surgery of RCOST The Official Journal of Pediatric Orthopaedic Society The Official Journal of Thailand Orthopaedic Foot and Ankle Society The Official Journal of Metabolic Bone Disorder and Orthogeriatrics ISSN Volume 38 / Number 3-4 July-October 2014

3 The Council Members of the Royal College of Orthopaedic Surgeons of Thailand (RCOST) President Thavat Prasartritha, MD Immediate Past President Adisorn Patradul, MD President Elect Sukit Saengnipanthkul, MD 1 st Vice-President Banchong Mahaisavariya, MD 2 nd Vice-President Aree Tanavalee, MD Registrar Chumroonkiet Leelasestaporn, MD Treasurer Thawee Songpatanasilp, MD Secretary General Keerati Chareancholvanich, MD Assistant Secretary General Charlee Sumettavanich, MD Promotion Thana Turajane, MD Council Members Sumroeng Neti, MD Pijaya Nagavajara, MD. Kanyika Chanmiprasas, MD Preecha Chalidapong, MD Warat Tassanawipas, MD Chiroj Sooraphanth, MD Thipachart Bunyaratabandhu, MD Advisory Board Samak Bukkanasen, MD Natee Rukpollamuang, MD Direk Israngkul, MD Suprija Mokkhavesa, MD Charoen Chotigavanich, MD Vinai Parkpian, MD Pongsak Vathana, MD Prasit Gonggetyai, MD Chaithavat Ngarmukos, MD Thamrongrat Keokarn, MD Suthorn Bavonratanavech, MD Wichien Laohacharoensombat, MD Saranatra Waikakul, MD

4 The Thai Journal of Orthopaedic Surgery Current Editorial Board ( ) Advisory Board Thamrongrat Keokarn, MD Charoen Chotigavanich, MD Vinai Parkpian, MD Pongsak Vathana, MD Suthorn Bavonratanavech, MD Thavat Prasartritha, MD Editor Pongsak Yuktanandana, MD Associate Editors Aree Tanavalee, MD Sittisak Honsawek, MD Managing Editor Supawinee Pattanasoon Editorial Board Chayanin Angthong, MD Theerachai Apivatthakakul, MD Apichart Asavamongkolkul, MD Sakda Chaikitpinyo, MD Pruk Chaiyakit, MD Sukrom Cheecharern, MD Thanainit Chotanaphuti, MD Bavornrit Chuckpaiwong, MD Thossart Harnroongroj, MD Pibul Itiraviwong, MD Polasak Jeeravipoolvarn, MD Kitti Jiraratanapochai, MD Weerachai kosuwon, MD Wichien Laohacharoensombat, MD Wiroon Laupattarakasem, MD Somsak Leechavengvongs, MD Supphamard Lewsirirat, MD Worawat Limthongkul, MD Sirichai Luevitoonvechkij, MD Banchong Mahaisavariya, MD Jakravoot Maneerit, MD Kittipon Naratikun, MD Adisorn Patradul, MD Vajara Phiphobmongkol, MD Chathchai Pookarnjanamorakot, MD Niti Prasathaporn, MD Sattaya Rojanasthien, MD Sukit Saengnipanthkul, MD Nadhaporn Saengpetch, MD Thananit Sangkomkamhang, MD Panupan Songcharoen, MD Thawee Songpatanasilp, MD, PhD Phutsapong Srisawat, MD Nattapol Tammachote, MD Boonsin Tangtrakulwanich, MD, PhD Parichart Thiabratana, MD Satit Thiengwittayaporn, MD Prakit Tienboon, MD Yingyong Torudom, MD Chairoj Uerpairojkit, MD Saranatra Waikakul, MD Thanapong Waitayawinyu, MD Wiwat Wajanavisit, MD Kiat Witoonchart, MD Patarawan Woratanarat, MD, PhD Editorial office address: The Royal College of Orthopaedic Surgeons of Thailand 4 th Floor, Royal Golden Jubilee Building, 2 Soi Soonvijai, New Petchburi Road, Bangkapi, Huay Khwang, Bangkok secretariat@rcost.or.th, supawineep@rcost.or.th Telephone: The Journal is free online at

5 The Thai Journal of Orthopaedic Surgery Volume 38 Number 3-4 July-October 2014 Contents Editorial 39 Pongsak Yuktanandana, MD Page Original Articles Complete Release of Superficial Medial Collateral Ligament in TKA: Surgical technique and 45 mid-term results Pongporn Prateeptongkum, MD, Aree Tanavalee, MD, Natdhadej Mekrungcharas, MD, Srihatach Ngarmukos, MD Long-term Results of Carpal Tunnel Release Using Agee s Single Portal Endoscopic Technique 51 Kawee Pataradool, MD, Tan SH, MD, Yong FC, MD, Teoh LC, MD Geriatric Hip Fracture Pathway in Private Hospital: Early results 57 Sombat Rojviroj, MD, Boonyarak Visutipol, MD, Sucheela Jisarojito, MD, Thawee Songpatanasilp, MD, Pannida Wattanapanom, MD, Wallob Samranvedhya, MD, Suthorn Bavonratanavech, MD, Anchalee Komkrit, RN, Kanokwan Nuntachaiyod, RN, Kanitta Siriwan, RN Serum CRP and ESR Values do not Correlate with Clinical and Radiographic Severity of Knee 63 Osteoarthritis Srihatach Ngarmukos, MD, Kolayuth Tunnitisupawong, MD, Aree Tanavalee, MD Case Reports Hip Arthroscopy in Traumatic Hip Dislocation: Literature review and two case reports 69 Trai Promsang, MD, Sittichoke Sukcharoenyingyong, MD, Kitiphong Kongrukgreatiyos, MD, Somsak Kuptniratsaikul, MD Non-tuberculous Mycobacterial Infection (Mycobacterium Abscessus) after Anterior Cruciate 77 Ligament Reconstruction: A case report Vantawat Umprai, MD, Pongsak Yuktanadana, MD Erratum 85 Instruction to Authors 87 Acknowledgements 95

6 วารสารราชว ทยาล ยแพทย ออร โธป ด กส แห งประเทศไทย ป ท ๓๘ ฉบ บท ๓-๔ กรกฎาคม-ต ลาคม ๒๕๕๗ สารบ ญ บทบรรณาธ การ 39 พงศ ศ กด ย กตะน นทน, พบ น พนธ ต นฉบ บ การทา complete release ของ superficial medial collateral ligament ในขณะผ าต ดเปล ยนข อเข าเท ยม: 45 เทคน คการผ าต ดและผลการร กษาในระยะ mid-term พงศ พร ประท ปทองคำ, พบ, อำร ตนำวล, พบ, ณ ฐเดช เมฆร งจร ส, พบ, ส หธ ช งำมอ โฆษ, พบ ผลการร กษาระยะยาวของการผ าต ดโรคพ งผ ดร ดเส นประสาทท ข อม อด วยว ธ ใช กล องชน ดแผลเด ยว 51 กว ภ ทรำด ลย, พบ, Tan SH, MD, Yong FC, MD, Teoh LC, MD แนวปฏ บ ต ในการด แลผ ป วยส งอาย ท กระด กสะโพกห กในโรงพยาบาลเอกชน: รายงานผลเบ องต น 57 สมบ ต โรจน ว โรจน, พบ, บ ณยร กษ ว ส ทธ ผล, พบ, ส ช ลำ จ ตสำโรจ ตโต, พบ, ทว ทรงพ ฒนำศ ลป, พบ, พ ณณ ดำ ว ฒนพนม, พบ, ว ลลภ สำรำญเวทย, พบ, ส ทร บวรร ตนเวช, พบ, อ จฉร คมกฤษ, พว, กนกวรรณ น นทช ยยอด, พว, ขน ษฐำ ศ ร วรรณ, พว การศ กษาความส มพ นธ ระหว างระด บ C-reactive protein ในเล อดและอ ตราการตกตะกอนของเม ดเล อดแดง 63 ก บความร นแรงของโรคข อเข าเส อมในทางคล น กและภาพถ ายร งส ส หธ ช งำมอ โฆษ, พบ, กลย ทธ ต ณน ต ศ ภวงษ, พบ, อำร ตนำวล,พบ รายงานผ ป วย การส องกล องในข อสะโพกเคล อนหล ดจากการบาดเจ บ: ทบทวนวรรณกรรมและรายงานผ ป วย 2 ราย 69 ไตร พรหมแสง, พบ, ส ทธ โชค ส ขเจร ญย งยง, พบ, ก ตต พงษ คงร กเก ยรต ยศ, พบ, สมศ กด ค ปต น ร ต ศ ยก ล, พบ การต ดเช อ Mycobacterium Abscessus หล งผ าต ดประกอบเอ นไขว หน าให ค นสภาพ: รายงานผ ป วย 1 ราย 77 ว นธว ช อ มพรำยน, พบ, พงศ ศ กด ย กตะน นทน, พบ หน า Erratum 85 คาแนะนาส าหร บผ ส งบทความเพ อลงต พ มพ 91 ก ตต กรรมประกาศ 95

7 39 Editorial During this year, the Royal College of Orthopaedic Surgeons of Thailand (RCOST) has the opportunity to host many international orthopaedics meetings in our country. One of the most important orthopaedics meetings in this region might be the Asia Pacific Orthopaedic Association (APOA) meeting which will be held in Pattaya, Thailand during the 23 rd -25 th October This is the 8th biennial APOA meeting along with the 36 th RCOST annual meeting. The Asia Pacific Orthopaedic Association (APOA) is a regional organization of orthopaedic surgeons mainly from the Asia Pacific region. It began in 1962 as the Western Pacific Orthopaedic Association, and in 2000, the name was changed to the Asia Pacific Orthopaedic Association. Today, APOA has 19 member chapters and more than 1,800 members from over 40 countries. The 19 member chapters are Australia, Bangladesh, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, New Zealand, Pakistan, the Philippines, Singapore, Sri Lanka, Taiwan, Thailand, Turkey, and Vietnam. APOA's core mission is to promote the education, research, and fellowship amongst orthopaedic surgeons in this region. Even the objective of this meeting is to exchange knowledge among orthopaedic surgeons in this region. However, friendship among orthopaedic surgeons is also very important. This volume of the Thai Journal of Orthopaedic Surgery consists of original articles, reviews, and case reports. The long-term results of carpal tunnel release using Agee s single portal endoscopic technique is very interesting. The complete release of the superficial medial collateral ligament in total knee arthroplasty showed the surgical technique and midterm results. The clinical pathway of geriatric hip fracture needs to be considered during the era of geriatric patients nowadays. Hip arthroscopy is becoming more practical and popular in Thailand and needs learning experience. The basic research in this volume is the study of serum C-reactive protein and erythrocyte sedimentation rate in knee osteoarthritis patients. There is also a case report of a rare infection after anterior cruciate ligament reconstruction. Last but not least, we would like to congratulate three of our RCOST members who are very honored to receive 2014 outstanding awards. Associate professor Kitiwam Vipurakorn receives the best service award. Police Major General Thana Turajane receives the best management award, and Professor Theerachai Apivathakakul receives the best academic award. Congratulations! Pongsak Yuktanandana, MD Editor in Chief The Thai Journal of Orthopaedic Surgery JRCOST VOL.38 NO.3-4 July-October 2014

8 40 สมาช กด เด น ราชว ทยาล ยแพทย ออร โธป ด กส แห งประเทศไทย สมาช กด เด น สาขาบร การ พญ. ก ต วรรณ ว ป ลากร Dr. Kitiwan Vipulakorn Higher Graduate Diploma in Clinical Science (Surgery) Diploma Thai Board of Orthopaedics Current Address: Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. Telephone: (043) Fax: (043) Education and Training 1983 M.D., Khon Kaen University. Thailand Certificate in Clinical Science (Surgery), Mahidol University, Thailand Diploma Thai Board of Orthopaedics, Thai Medical Council, Thailand Clinical attachment in Pediatric Orthopaedics, Children Memorial Hospital, Chicago, Illinois and Alfred I Dupont Institute, Delaware, USA 1990 F.I.M.S, International course, Khon Kaen 1993 Crotel-Doubusset Spinal Surgery Fellowship, Calot institute and Paris, France 1994 AO clinical fellowship in spinal surgery, Kantonsspital, St. Gallen, Switzerland Short course and fellowship in Ilizarov fixator, Lecco, Italy Clinical attachment in spinal surgery and microsurgery, Hiroshima School of Medicine, Hiroshima, Japan Training in Treatment of Thoracic depletion deformity (using VEPTER), Hamburg, Germany. Present positions Since 1997 Assist. Professor, Department of Orthopaedics, Faculty of Medicine, Khon Kaen University. Since 1997 Head of Pediatric Orthopaedic unit, Department of Orthopaedics, Faculty of Medicine, Khon Kaen University. Since 2004 Committee member, Spine section, Thai Orthopaedic Association Committee member, Pediatric Orthopaedic section, Thai Orthopaedic Association Since 2007 Vice Head of Department of Orthopaedics, Faculty of Medicine, Khon Kaen University President of Thai Pediatric Orthopaedic section of Royal College of Orthopaedic Surgeons of Thailand Academic appointments Lecturer, Department of Orthopaedic Surgery, Faculty of Medicine, Khon Kaen University. Since 1997 Assist. Professor, Department of Orthopaedics, Faculty of Medicine, Khon Kaen University Assist. Dean, Academic affair, Faculty of Medicine, Khon Kaen University Committee, Royal College of Orthopaedic Surgeons of Thailand Price/Award 2003 Award in ethical model for medical teaching, Medical council of Thailand Award in medical teacher model, Foundation of medical teacher, Faculty of Medicine, Khon Kaen University 2004 Award in excellent performance of government employee, Khon Kaen University 2005 Award in excellent performance of teaching staff, Khon Kaen University 2005 Award in excellent performance of health service, Faculty of Medicine, Khon Kaen University 2009 Award in excellent performance of health service, Faculty of Medicine, Khon Kaen University Scientific publications 1. Mahaisavariya B, Rojviroj S, Sirichatvapee W, Wipulakorn K. Free vascularized osteocutaneous graft. J Thai Orthop Assoc 1987; 12: Mahaisavariya B, Suibnugran C, Vipulakorn K, Reamsiri T. One more lead apron: An adjunct protection of radiation hazard during closed femoral nailing. J Thai Orthop Assoc 1987; 12: Wipulakorn K, Saengnipanthkul S, Kowsuwon W. Diagnostic values of serum calcium, phosphate and alkaline phosphatase in bone tumor patients. J Thai Orthop Assoc 1988; 13: Laupattarakasem W, Wipulakorn K, Saengnipanthkul S, Kowsuwon S. Intraosseous anchorage of iliotibial band graft. J Bone Joint Surg [Br] 1990; 72-B: Jirarattanaphochai K, Saengnipanthkul S, Wipulakorn K, Rojviroj S. Skeletal metastases distal to the elbow and knee. J Asean Orthop Assoc 1990; 4: Mahaisavariya B., Rojviroj S., Kosuwon W., Vipulakorn K. Free Vascularized Fibular Graft for the Treatment of Massive Long-Bone Defect. Bulletin of the Hosp. For Joint Dis. Orthop. Inst. 1990: 50(1): Suibnugarn C, Mahaisavariya B, Sirichativapee W, Wipulakorn K, Rojviroj S, Jirarattanaphochai K. Radiation exposure THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

9 41 during closed femoral nailing. J Asean Orthop Assoc 1990; 4: Saengnipanthkul S, Kowsuwon W, Wipulakorn K, Laupattarakasem W. Clinical diagnosis for metastatic adenocarcinoma of spine from unknown origin: a comparative study. Spine 1991; 16: Mahaisawariya B, Jeeravipoolvarn P, Vipulakorn K, Sirichativapee W. Shrinkage of the below-knee stump in leprosy. Br. J. Surg. 1992; 79(4): Mahaisavariya B, Songchareon P, Rojviroj S, Vipulakorn K. Reconstruction of bone and soft tissue defect using the osteocutaneous free fibular graft. J Med assoc Thai 1994;77: Mahaisavariya B, Laupattarakasem W, Wipulakorn K. Closed femoral nailing under ultrasound monitoring: feasibility of a new technique. J Thai Orthop Assoc 1995;20: Rojviroj S, Saengnipanthkul S, Sirichativapee W, Jirarattanaphochai K, Mahankanukrauh C, Vipulakorn K. Massive bone allograft: Experience at Srinagarind Hospital. J Asean Orthop Assoc 1995; 9: Nanagara R, Vipulakorn K, Chowakul V, Schumacher JR. Pathogenetic mechanism of Burkholderia Pseudomallei septic arthritis: ultrastructural findings of natural infected human synovial tissues. Srinagarind Med J. 1997; 12(suppl): Sanmahachai S, Mairaing E, Srinakarin J, Vipulakorn K, Jirarattanaphochai K, Boonpongsathein W. MRI of brachial plexus injury compared with intraoperative findings. The Asean J Radiology 1999; V(I): Nanagara R, Vipulakorn K, Suwannaroj S, Schumacher JR. Atypical morphological characteristics and surface antigen expression of Burkholderia Pseudomallei in natural infected human synovial tissues. Mod Rheumatol 2000; 10: Suwannaroj S, Mootsikapun P, Vipulakorn K, Nanagara R. Salmonella group D septic arthritis and necrotizing fasciitis in a patient with rheumatoid arthritis and diabetes mellitus. J Clin Rheumatol 2001; 7(2): Chanlalit C, Vipulakorn K, Jirarattanaphochai K, Mairaing E, Chowcheun P. Value of clinical findings, electrodiagnosis and magnetic resonance imaging in the diagnosis of root lesions in traumatic brachial plexus injuries. J Med Assoc Thai 2005; 88(1): Jianmongkol S, Thammaroj T, Vipulakorn K. Congenital metacarpal synostosis treated by double bone blocks technique: A case report from Thailand. Hand Surgery 2005; 10(1): สมาช กด เด น สาขาบร หาร นพ. ธนา ธ ระเจน Pol. Maj. Gen. Thana Turajane, MD (Hons) Current Address: Department of Orthopedic Surgery, Police General Hospital, Bangkok, Thailand Telephone: Thanaturajane@yahoo.com Education and Training Internship Prince of Songkhla University M.D. (Hons.) Haadyai, Songkhla, Thailand General Surgery Police General Hospital, 492/1 Rama Rd., Bangkok, Thailand, General Surgery Pramongkutklao Medical School Rajavithi Rd., Bangkok Thai Board of Orthopedic Surgery Pramongkutklao Medical School Rajavithi Rd., Bangkok, Thailand, Appointments General Practice Public Health Center Department of Health, Bangkok Attending Staff Department of Orthopedic Surgery, Police General Hospital, Bangkok Research Spine Fellow (with clinical participation) Div. of Orthopedic Surgery, Cleveland Spine & Arthritis Center,, 2700, 5 th floor, Franklin Blvd., Cleveland, Ohio 44113, USA Research Pediatric Fellow (with clinical participation) Department of Orthopedic Surgery, The Hospital for Special Surgery, Affiliated with the New York Hospital and Cornell University Medical School, 535 East 70th Street, New York, NY 10021, USA Attending Staff Department of Orthopedic Surgery, Police General Hospital, Bangkok JRCOST VOL.38 NO.3-4 July-October 2014

10 Clinical Fellow Department of Orthopedic Surgery, The Hospital for Special Surgery, Affiliated with the New York Hospital and Cornell University Medical School 535 East 70th Street, New York, NY 10021, USA Clinical Fellow Department of Orthopedic Surgery, The Hospital for Special Surgery, Affiliated with the New York Hospital and Cornell University Medical School 535 East 70th Street, New York, NY 10021, USA 1999 AO Fellowship Department of Orthopedic Surgery, (Arthroplasty) Spital Ziegler, Bern, Switzerland Attending Staff Department of Orthopedic Surgery, Police General Hospital, Bangkok Administrative Board Surgeon General office, Police General Hospital Work Experience Position Appointment Duration General Practice Physician Public Health Center, Metropolitan Department Internship in General and Department of Orthopedics, Police General Hospital Orthopedic Surgery Resident Department of Orthopedics, Pramongkutklao Medical School. Research Fellow (with clinical CSAS (Cleveland Spine and Arthritis Center, Ohio, participation) A.S.A. Research Fellow (with clinical HSS (Hospital For Special Surgery affiliated with participation) Cornell Medical School, New, York, NY) Clinical fellowship HSS (Hospital For Special Surgery affiliated with Cornell Medical Center) Chairman of Fellowship Training Department of Orthopedics, Police General Hospital now affiliated with Srinakarin Viroj Medical School Board Committee and Treasure Arthritis Foundation Thailand under Royal Patronage of HRH Princess Mahachakri Sirindhorn General Secretary Thai Osteoporosis Foundation Thailand under Royal Patronage of HRH Princess Kalayaniwatana Khomaluang Narathivasrajnakarin Vice General Secretary and Thai Osteoporosis Foundation Thailand under Royal Scientific Chairman Patronage of HRH Princess Kalayaniwatana Khomaluang Narathivasrajnakarin Scientific Chairman Thai Hip and Knee Section, Royal College of Orthopedic Surgeons, Thailand President Thai Hip and Knee Section, Royal College of Orthopedic Surgeons, Thailand Vice President Thai Hip and Knee Society, Thailand President Thai Hip and Knee Society, Thailand General Secretary Thai Orthopedic Surgery Foundation under Royal Patronage of HRH Princess Kalayaniwatana Khomaluang Narathivasrajnakarin Council Member Royal College of Orthopedic Surgeon, Thailand now Chairman Department of Orthopedic Surgery, Police General Hospital. Director STEP: Stem Cell Treatment and Research Excellence now Center, Police General Hospital affiliated with Chulalongkorn Medical School Director International Patients Service, Police General Hospital now affiliated with Chulalongkorn Medical School Director Orthopedics and Anesthesiology Department now Director Semi-privatization Project Police General Hospital now Chairman Hip Section Asia Pacific Orthopedic Association THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

11 43 สมาช กด เด น สาขาว ชาการ นพ. ธ รช ย อภ วรรธกก ล Dr. Theerachai Apivatthakakul Current Address: Department of Orthopaedic Surgery Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Telephone: Education and Training March 1987 Doctor of Medicine Faculty of Medicine, Chiang Mai University April March 1990 Orthopaedic residency training at Faculty of Medicine, Chiang Mai University April 1988 June 1992 Graduate diploma in clinical sciences (Orthopaedic Surgery) Faculty of Medicine, Chiang Mai University Certificate of Proficiency in Orthopaedics, Thailand October March 1993 AO fellowship BG Trauma Hospital Tubingen, Kartharinen Hospital Stuttgart, Germany Present positions - Professor, Orthopaedic Trauma - Chief of Trauma Unit Department of Orthopaedics, Faculty of Medicine, Chiang Mai University - AO Trauma Asia Pacific educational committee 2009-Present - AO Trauma Technical Commission member 2011-Present - Assistant Dean, Faculty of Medicine, Chiang Mai University, Scientific publications 1. ธ รช ย อภ วรรธกก ล. Minimally Invasive Plate Osteosynthesis (MIPO). กร งเทพ: พ.บ. ฟอเรน บ คส เซนเตอร ; Apivatthakakul T. Complications and solutions. In AO manual of fracture management. Minimally invasive plate osteosynthesis (MIPO) concepts and cases presented by AO East Asia. Tong G, Bavonratanavech S, editors. Stuttgart New York: Georg Thieme Verlag; 2006, page Apivatthakakul T. Humerus, shaft. In AO manual of fracture management. Minimally invasive plate osteosynthesis (MIPO) concepts and cases presented by AO East Asia. Tong G, Bavonratanavech S, editors. Stuttgart New York: Georg Thieme Verlag; 2006, page Apivatthakakul T, KS Khong. Tibia shaft. In AO manual of fracture management. Minimally invasive plate osteosynthesis (MIPO) concepts and cases presented by AO East Asia. Tong G, Bavonratanavech S, editors. Stuttgart New York: Georg Thieme Verlag; 2006 page, Apivatthakakul T. Minimally invasive techniques. In Techniques and Principles for the operating room. Porteous M, Bauerle S, editors. Stuttgart New York: Georg Thieme Verlag; 2010, page Apivatthakakul T., Miranda M. Complications and solutions. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page Apivatthakakul T., Babst R, Bavonratanavech S, Hontzsch D. Instruments. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page Apivatthakakul T., Miranda M. Complications and solutions. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page Babst R, Apivatthakakul T. Education in minimally invasive plate osteosynthesis (MIPO) - how to become a better MIPO surgeon. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page Apivatthakakul T, Belangero W, Liviani B. Humerus shaft. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page Oh CW, Apivatthakakul T., Bavonratanavech, Ma CH,Concha JM, Streubel P, Sandoval A. Special indications. In Minimally invasive plate osteosynthesis (MIPO) second expanded edition. Babst R, Bavonratanavech S, Persantez R, editors. Stuttgart New York: Georg Thieme Verlag; 2012, page JRCOST VOL.38 NO.3-4 July-October 2014

12 Complete Release of Superficial Medial Collateral Ligament in TKA: Surgical technique and mid-term results Pongporn Prateeptongkum, MD 1, Aree Tanavalee, MD 2, Natdhadej Mekrungcharas, MD 3, Srihatach Ngarmukos, MD 2 1 Department of Orthopedic Surgery, Srisangworn sukhothai Hospital, Srisamrong, Sukhothai, Thailand 2 Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok, Thailand 3 Department of Orthopedic Surgery, Wetchakarunrasm Hospital, Nongjok, Bangkok, Thailand Purpose: Intraoperative medial collateral ligament (MCL) injury or attenuation during total knee arthroplasty (TKA) has been reported with satisfactory clinical knee function and stability. However, there was no report on clinical outcomes and knee stability following intentionally complete release of intact superficial MCL (smcl) during TKA. We demonstrated the surgical technique of smcl release and reported mid-term clinical outcomes. Methods: A consecutive series of 35 patients, who underwent TKA and had intraoperatively complete release of smcl using the subperiosteal technique previously described by Insall, was evaluated for clinical outcomes and knee stability. The surgical technique for smcl release, the prosthesis and the postoperative rehabilitation protocols were uniform without additional external knee support. A digital dynamometer was used for the quantitative measurement of knee stability in the mediolateral plane at a static 20-lb force. Laxity of the MCL was graded as 0, 1+ and 2+ if the gap was 0 mm, > 0 mm and 5 mm, and > 5 mm, respectively. Weightbearing radiographs of patients at the latest follow up (FU) were evaluated. Results: Preoperatively, the mean tibiofemoral varus angle of the studied group was 14.3 (±6.4 ). The mean age and body mass index (BMI) were 70 years, 26.4 kg/m 2, respectively. The 10- to 12-mm polyethylene inserts were used in 5% of patients, whilst 14- to 17-mm inserts were used in 95% of patients. At the mean 6-year FU (range: 2-8 years), the mean Knee Society (KS) clinical and function scores were 94.3 and 84.2 points, respectively. The mean maximum range of motion (ROM) was Regarding the knee stability test, knees with grade 0, 1+ and 2+ were found in 84.4%, 15.6% and 0%, respectively. One patient in the studied group had revision due to infection. The 6-year survivorship for reoperation related to MCL instability was 100%. Conclusion: During ligament balancing for varus knees in TKA, some surgeons tend to avoid performing complete release of the smcl due to concerns on postoperative knee instability. The subperiosteal release of the smcl made a full-thickness layer of medial soft tissue attaching with the smcl, which provided adequate strength to withstand the valgus stress force from daily function. According to the present study, it confirmed a satisfactory mid-term result of TKA with subperiosteally complete release of smcl in terms of clinical outcomes, knee stability, range of motion, and survivorship. However, it was found that a thicker polyethylene insert related to the release was more common. In conclusion, subperiosteally complete release of the smcl during TKA provided reliable postoperative medial soft tissue tension and clinical results at mid-term. Keywords: Medial collateral ligament, Release, Outcomes, Total knee arthroplasty The Thai Journal of Orthopaedic Surgery: 38 No.3-4: Full text. e journal: Introduction During total knee arthroplasty (TKA) in fixed varus deformity, several bone and soft tissue Correspondence to: Tanavalee A, Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand areetana@hotmail.com procedures for proper gap balancing have been reported in the literature (1-6). Regarding the bony procedure, removal of medial osteophytes provides a relaxation of the medial soft tissue structure (3). However, bony procedure alone may provide a partial correction of varus deformity. Thus, further soft tissue procedures, such as a complete release of the medial collateral ligament (MCL), may be necessary for the correction of a deformity in order JRCOST VOL.38 NO.3-4 July-October 2014

13 46 to achieve a balanced medial gap and lateral gap in the coronal plane (5). Concerning soft tissue procedures of medial gap balancing, several investigators proposed different release techniques (1,4-6), as well as a release in sequential steps (2,5). In fact, to routinely visualize the medial proximal tibia in the standard medial knee arthrotomy, the deep part of MCL is subperiosteally released without an effect on the laxity of the medial soft tissue sleeve, while the release of superficial MCL (smcl) increases the medial soft tissue laxity (4). Thus, the so-called MCL release usually refers to a release of the smcl. Classical MCL release to correct medial soft tissue tension was described by Insall et al (1). Later on, Clayton et al (2) proposed the sequential MCL release beginning from the tibial attachment to the femoral attachment. Recently, Bellemans et al (6) proposed a new technique of MCL release with multiple needle punctures. Although some investigators reported clinical outcomes following iatrogenic injury or attenuated smcl during TKA (7,8), there has been no study addressing the clinical outcomes of TKA following intentionally complete release of the smcl at the time of surgery. The purpose of the present study was to evaluate the mid-term outcomes and knee stability in patients who underwent TKA with intentionally complete release of the smcl at the time of surgery. Materials and Methods From March 2004 to March 2007, a series of 35 patients (35 knees), who had late-stage knee osteoarthritis with a varus deformity and underwent TKA with intentionally complete release of the intact smcl at the time of surgery, were evaluated for clinical outcomes and knee stability. Selection criteria included patient age of 45 to 85 years, advanced primary knee osteoarthritis, no previous major knee surgery, body mass index (BMI) of less than 30 kg/m 2, a varus deformity which required complete release of smcl for gap balancing at the time of surgery, and no contralateral TKA within 1 year at the latest follow-up (FU). All surgeries were performed by a single surgeon (AT) using a single surgical approach (mini-midvastus approach), a single total knee system (NexGen Legacy Posterior Stabilized (LPS)-Flex, Warsaw, IN, USA) with routine patellar resurfacing. A single 3-day rehabilitation protocol 9 was used in all patients in the studied group. Surgical exposure, bone cuts, and gap evaluation Following the less invasive-midvastus approach, the femoral exposure was made with a 2- to 3-cm split along the fiber of the vastus medialis obliquus in order to gain complete visualization of the whole anterodistal femur with 60 of knee flexion. Medial osteophytes were removed from both the femoral and tibial sides. Standard subperiosteal exposure of the medial tibia towards the posteromedial corner was made using a curve osteotome. The medial tibial exposure towards the distal direction was limited to 1 cm at the midmedial plateau, and was limited to 0.5 cm at the posteromedial tibial corner. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were resected. Sequential bone cuts were made, including a distal femoral cut, proximal tibial cut and femoral anteroposterior cuts according to the proper femoral sizing with a 3-degree external rotation. The menisci were totally resected following distal femoral and proximal tibial bone cuts in a onepiece technique under direct visualization. The provisional gap evaluation in flexion and extension was made. The fine-tuning of the gap balancing was evaluated and made after femoral chamfer cuts, final tibial preparation with trial components in place. In all knees, the anterior referencing system for the femoral component was used. If an in-between size was measured, the smaller size was chosen. The patella was resurfaced in all patients and all components were cemented. Determining of superficial MCL release and technique With trial components in place and the knee in full extension, knees which had a tight medial gap and > 2-mm lateral gap of varus stress test were indicated for complete smcl release. The technique was as described by Insall et al (1,10), including the subperiosteal release of smcl using a slim osteotome (Fig. 1A). The release was made on the tibial attachment along the anteromedial part of the tibia until free of soft tissue resistance without pes anserinus insertion violation (Fig. 1B and 1C). In contrary, smcl release was not indicated if there was no medial gap tightness with negative valgus stress test and 2-mm lateral gap of varus stress test. (A) (B) (C) Fig. 1 Demonstrating the technique of subperiosteal smcl release. (A) With the knee in slight flexion, the release was made from the tibial attachment along the anteromedial part of the tibia cortex using a slim osteotome. (B) The osteotome was tilted to accommodate the curvature of the anteromedial tibia and was gently dived to 5-8 cm from the tibial joint line along the anteromedial part of the tibial shaft. (C) When the release was complete, it was free of distal soft tissue resistance. THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

14 47 Patient care and ambulation Following the actual insertion of components, the tourniquet was not deflated for hemostasis. The vacuum drainage was removed at hours after surgery. No additional external knee support was used during the postoperative period in any patient. Early postoperative ambulation 9 was started on the morning of the next day, including voluntary upright sitting, knee straightening, feet dangling, and full-weight walking with a walker under the supervision of orthopaedic fellows. The discharge criteria included ability to flex the operated knee to 90 and to walk independently with a walking aid. Outcome evaluation Follow-up was done at 2 weeks, 6 weeks, 12 weeks, and 6 months, and every year postoperatively. Patients were evaluated for clinical and functional outcomes using the Knee Society (KS) clinical and functional scores (11), range of motion (ROM), and quantitative measurements of knee stability in the mediolateral plane using a digital dynamometer (MicroFET2TM, Hoggan Health Industries, Salt Lake City, UT, USA) at a static 20-lb force for the valgus stress test where the knee is flexed to 30 as described by Koo and Choi (7). Laxity of the MCL was graded as 0, 1+ and 2+ if the gap measured from the valgus stress radiography was 0 mm, > 0 mm but < 5 mm, and between 5-10 mm, respectively. Weight-bearing radiographic evaluations of individual patient at the latest FU were compared with that at the 3-month FU which was determined as the baseline. Results The mean FU time was 71 months (range: months). Patient s demographic data and perioperative data are shown in Table 1. There was a high incidence in the thickness of polyethylene insert used in the studied group. Ninety-five percent of knees had 14-mm and 17-mm polyethylene inserts, of which, postoperative radiographs showed a relative elevated joint line ranging from 2 to 5 mm (Fig. 2). KS clinical and function scores, maximum passive knee ROM, and radiographic tibiofemoral angle at the latest FU are shown in Table 2. Regarding knee stability, more than 80% of knees in the studied group were defined as stable (grade 0 for valgus stress test) as shown in Table 2. At the latest FU, all patients had later contralateral TKA at an average time of 4 months after the first TKA. The primary reason for contralateral TKA was sciatica related to leg-length inequality. One patient underwent reoperation due to deep infection and was successfully managed with a 2-stage revision surgery. The 6-year survivorship for reoperation for any reason and for reoperation related to MCL instability was 97.2% and 100%, respectively. Fig. 2 Examples of pre- and 5-year postoperative radiographs of a patient whose TKA was performed with complete smcl release. The single-limb standing anteroposterior radiograph showed that the limb was in accepted alignment without medial gap opening; however, the joint line was elevated due to the 17-mm polyethylene insert. Table 1 Demographic data and intraoperative parameters Parameters Studied group (n=35) Complete smcl release Value Range Age* (year) Gender (number) Male 2 Female 33 Side (number) Right 22 Left 13 BMI* (kg/m 2 ) 26.4± Preop anatomical varus deformity* (degree) Polyethylene Thickness (number and %) 10 mm 0 12 mm 2 (5%) 14 mm 24 (69 %) 17 mm 9 (26 %) * presented in mean ±SD JRCOST VOL.38 NO.3-4 July-October 2014

15 48 Table 2 Clinical parameters Parameters Studied group (n=35) Complete smcl release Value Range KS clinical score* 94.3± KS function score* 84.2± Maximum passive ROM* (degree) 131.1± Valgus stress test (number and %) 0 27 (84.4 %) 1+ 5 (15.6 %) 2+ 0 Latest postoperative TFA* (degree) 5.6± * presented in mean±sd Discussion In performing primary TKA, a neutral mechanical axis, of which the tibiofemoral angle is approximately 4 to 6 degrees of anatomical valgus, is the target alignment. To do so, a proper soft tissue balance in both flexion and extension is mandatory (12). As the postoperative MCL tension and integrity play very important roles to stabilize the knee following TKA against the valgus force in the frontal plane, improper soft tissue release in moderate to severe varus knee in this plane usually results in an unsatisfactory outcome related to knee instability (13,14). In Asia, arthritic knees with moderate to severe fixed varus deformities are very common (15,16). Thus, at TKA surgery, contracture of MCL in varus knee osteoarthritis is usually a problematic issue to address. Although there have been reports on satisfactory clinical outcomes following intraoperative tears of MCL (7,8), some surgeons tend to avoid performing complete release of the MCL for ligament balancing, due to concerns of postoperative knee instability and impaired mid- to long-term clinical outcomes. The smcl has its origin on the medial epicondyle and its tibial insertion on the medial aspect of the upper tibia (4). It consists of anterior and posterior fibers along the anteromedial to posteromedial parts of the knee joint which provide an important role as the primary medial stabilizers of the knee joint in flexion and extension, respectively. According to the literature related to complete release of the MCL, most studies focused on surgical techniques rather than clinical outcomes (1-6). The subperiosteal technique of smcl release for varus knees during TKA was originally described by Insall et al (1). Technically, this release peels the smcl off together with the periosteum from its tibial insertion just medial to the pes anserine tendon insertion to the medial aspect of the upper tibia. When the release is complete, a 6- to 8-cm distance of dissection from the joint line along the medial aspect of the proximal tibia is usually obtained. Thus, this technique provides a full-thickness layer of medial soft tissue attaching to the smcl. When the subperiosteal sleeve heals to bone, it provides an indirect solid attachment of the smcl to the bone via the periosteum. However; Mihalko and associates (4) suggested that the posterior oblique ligament and the posterior capsule should not be released when the subperiosteal smcl release technique is used because of the possibility of destabilizing the medial soft-tissue sleeve. In the present study, we found that the quantitative measurement of the valgus stress test demonstrated no MCL laxity in more than 84% of patients, which agreed with the concept that subperiosteal release provides no further attenuation of the smcl. Although MCL laxity of < 5 mm was found in 16% of patients, patients had satisfactory clinical results. At the mean 6-year FU, there were similar outcomes including KS clinical and function scores, knee stability, and radiographic evaluation. Thus, we assume that this procedure is safe to perform in indicated patients. The major effect of TKA with complete smcl release in the present series was the necessity to use a thicker polyethylene insert in order to balance the tight medial gap to the lax lateral gap. In the present study, 96% of knees had a 14-mm or 17-mm polyethylene insert, while the knees with no release usually required a 10-mm or 12-mm polyethylene insert. Therefore, an elevated joint line related to thicker polyethylene following complete MCL release occurred in most knees in the present study. Although an elevated joint line after TKA might somewhat relate to limited postoperative ROM (17), the study by Selvarajah and Hooper demonstrated no limitation of postoperative ROM after TKA which had elevated joint lines of 10 mm (18). The postoperative knee ROM in the present study was in agreement with their study. It could be implied that a 2-mm to 5-mm elevated joint line following well-balanced gaps in TKA still facilitated satisfactory outcomes. A weakness of the present study was the small number of participants in the studied group due to a limited number of patients who were THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

16 49 indicated for complete release of smcl. Additionally, there was no quantitative measurement of the valgus-varus stress test at the intraoperative period. Thus, the intraoperative test could be biased by the surgeon s judgment for proper soft tissue tension. The strengths of the present study were that it was a mid-term FU of a series of patients with few variations of confounding factors, including surgeon, prosthesis, perioperative protocol, and postoperative soft tissue tension measurement. Conclusion At 6-year FU, complete subperiosteal release of smcl during TKA in osteoarthritic knees with varus deformities provides satisfactory mid-term outcomes. It provided stable and reliable postoperative tension of the medial soft tissue sleeve of the knee; however, a thicker polyethylene insert was the common effect following the release. References 1. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res 1985; 192: Clayton ML, Thompson TR, Mack RP. Correction of alignment deformities during total knee arthroplasties: staged soft-tissue releases. Clin Orthop Relat Res 1986; 202: Dixon MC, Parsch D, Brown RR, Scott RD. The correction of severe varus deformity in total knee arthroplasty by tibial component downsizing and resection of uncapped proximal medial bone. J Arthroplasty 2004; 19: Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA. Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 2009; 17: Mullaji A, Sharma A, Marawar S, Kanna R. Quantification of effect of sequential posteromedial release on flexion and extension gaps: a computer-assisted study in cadaveric knees. J Arthroplasty 2009; 24: Bellemans J, Vandenneucker H, Van Lauwe J, Victor J. A new surgical technique for medial collateral ligament balancing: multiple needle puncturing. J Arthroplasty 2010; 25: Koo MH, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty 2009; 24: Stephens S, Politi J, Backes J, Czaplicki T. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics 2012; 35: e Nophakhun P, Yindee A, Amornpiyakij P, Hlekmon N, Tanavalee A. The efficiency of the patient care team on 3-day protocol for early ambulation after MIS-TKA. J Med Assoc Thai 2012; 95: Yasgur DJ, Scuderi GR, Insall JN. Medial release for fixed-varus deformity. In: Scuderi GR, Tria AJ Jr, eds. Surgical techniques in total knee arthroplasty. New York: Springer-Verlag; 2002: Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; 248: Hood RW, Vanni M, Insall JN. The correction of knee alignment in 225 consecutive total condylar knee replacements. Clin Orthop Relat Res 1981; 160: Whiteside LA, Saeki K, Mihalko WM. Functional medical ligament balancing in total knee arthroplasty. Clin Orthop Relat Res 2000; 380: Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. The influence of preoperative deformity on intraoperative soft tissue balance in posterior-stabilized total knee arthroplasty. J Arthroplasty 2011; 26: Mullaji AB, Shetty GM, Lingaraju AP, Bhayde S. Which factors increase risk of malalignment of the hip-knee-ankle axis in TKA?. Clin Orthop Relat Res 2013; 471: Zhang Y, Hunter DJ, Nevitt MC, Xu L, Niu J, Lui LY, et al. Association of squatting with increased prevalence of radiographic tibiofemoral knee osteoarthritis: the Beijing Osteoarthritis Study. Arthritis Rheum 2004; 50: Ryu J, Saito S, Yamamoto K, Sano S. Factors influencing the postoperative range of motion in total knee arthroplasty. Bull Hosp Jt Dis 1993; 53: Selvarajah E, Hooper G. Restoration of the joint line in total knee arthroplasty. J Arthroplasty 2009; 24: JRCOST VOL.38 NO.3-4 July-October 2014

17 50 การทา complete release ของ superficial medial collateral ligament ในขณะผ าต ดเปล ยนข อเข าเท ยม: เทคน คการผ าต ดและผลการร กษาในระยะ mid-term พงศ พร ประท ปทองคา, พบ, อาร ตนาวล, พบ, ณ ฐเดช เมฆร งจร ส, พบ, ส หธ ช งามอ โฆษ, พบ ว ตถ ประสงค : ม งานว จ ยท แสดงว าการร กษาของการฉ กขาดหร อการย ดต วของ medial collateral ligament (MCL) ในขณะ ผ าต ดเปล ยนข อเข าเท ยมได ผลด ท งเร องอาการทางคล น กและความม นคงของข อเข า อย างไรก ตาม ม รายงานจานวนน อยมาก ท แสดงผลการร กษาของการต งใจทา complete release ของ MCL ขณะผ าต ดเปล ยนข อเข าเท ยม คณะผ ว จ ยแสดงเทคน คการ ผ าต ดห ตถการน และผลการร กษาระยะ mid-term ว ธ การศ กษา: กล มผ ป วยจานวน 35 ราย ซ งได ร บการทา complete release ของ superficial MCL (smcl) ในขณะผ าต ด เปล ยนข อเข าเท ยมตามเทคน คของนายแพทย Insall ซ งเป นการ release ล กต อช นใต เย อห มกระด ก และไม ใช อ ปกรณ พย งข อ เข าหล งการผ าต ด ท งน กล มผ ได ร บการประเม นผลทางคล น กและความม นคงของข อเข าหล งจากการผ าต ด โดยการตรวจ ความม นคงของข อเข าทาโดยใช มาตรกาล งกล ามเน อด จ ท ล ด วยแรงชน ด static ขนาด 20 ปอนด การตรวจความหย อนต ว ของ MCL แบ งเป น 3 ระด บ ค อ 0, 1+ และ 2+ แปลผลเม อตรวจพบการหย อนต วเป นระยะ 0 มม. การหย อนต วมากกว า 0 มม. แต ไม เก น 5 มม. และการหย อนต วมากกว า 5 มม. ตามลาด บ ผลการศ กษา: ก อนการผ าต ด กล มผ ป วยม ค าเฉล ยม ม tibiofemoral เป นม มเบ เข า 14.3 (±6.4 ) ม ค าเฉล ยอาย และด ชน มวล กาย 70 ป และ 26.4 กก./ม. 2 ตามลาด บ ร อยละ 5 และ 95 ของผ ป วย ม อ ตราการใช หมอนรองข อเข าเท ยมขนาด 10 ถ ง 12 มม. และ 14 ถ ง 17 มม. ตามลาด บ ท ค าเฉล ยการต ดตามผ ป วย 6 ป (พ ส ย, 2-8 ป ) ค าเฉล ย Knee Society (KS) clinical, function scores และม มงอข อเข ามากส ด เท าก บ 94.3 คะแนน 84.2 คะแนน และ ตามลาด บ ร อยละ 84.4 ร อยละ 15.6 และร อย ละ 0 ม ความม นคงของข อเข าเกรด 0, 1+ และ 2+ ตามลาด บ พบการต ดเช อในผ ป วย 1 ราย ซ งร กษาหายด ในเวลาต อมา อ ตรา การรอดช พ 6 ป สาหร บการถ กผ าต ดซ าจากความไม ม นคงของ MCL เท าก บร อยละ 100 สร ป: ศ ลยแพทย จานวนมากหล กเล ยงการทา complete release ของ smcl ในขณะผ าต ดเปล ยนข อเข าเท ยม เน องจากก งวล ว าอาจเก ดความไม ม นคงของข อเข าหล งการผ าต ด การ release smcl ด วยว ธ เลาะให ล กต อช นเย อห มกระด ก ในกล มผ ป วย ของงานว จ ยน ทาให เก ด full-thickness layer ของ medial soft tissue sleeve จ งทาให เก ดความแข งแรงพอต อการต านแรง valgus stress ท เก ดข นจากการใช งานข อเข าในช ว ตประจาว นได ทาให ได ผลการร กษาระยะ mid-term เป นท พอใจในเร อง ผลการร กษาทางคล น ก ความม นคงของข อเข า พ ส ยการเคล อนไหวของข อเข า และอ ตราการรอดช พ อย างไรก ตาม ผ ป วย กล มน ม การใช หมอนรองข อเข าเท ยมท หนาข นในอ ตราส ง โดยสร ป การทา complete release ของ smcl ด วยว ธ เลาะให ล ก ต อช นเย อห มกระด ก ย งคงทาให ระด บความแข งแรงของ medial soft tissue sleeve ท ต ดตามผลถ งระยะ mid-term เช อถ อได THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

18 Long-term Results of Carpal Tunnel Release Using Agee s Single Portal Endoscopic Technique Kawee Pataradool, MD 1, Tan SH, MD 2, Yong FC, MD 2, Teoh LC, MD 2 1 Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok, Thailand 2 Hand Surgery Department, Singapore General Hospital, Singapore Purpose: Open carpal tunnel release (OCTR) is the standard treatment after failed conservative management for carpal tunnel syndrome. Endoscopic carpal tunnel release (ECTR) has been developed and has been used increasingly over the last few years. According to several studies, ECTR results in a more rapid return to work and less scar tenderness than OCTR. Most studies have had short-term follow-ups and it is important to assess its long-term results. This study presents long-term results of ECTR by using a standard questionnaire. Methods: There were 76 patients (94 hands) who underwent endoscopic carpal tunnel release (ECTR), using Agee s single portal technique since July 1992 till October The Boston questionnaire was used to evaluate the long term results and patient satisfaction of this procedure, 28 patients (36 hands) responded with a mean age of 55 years at the time of operation and the mean follow-up period was 120 months. No complications developed in any patient. The Boston questionnaire is a self-administered questionnaire for the assessment of the severity of symptoms and functional status in patients who have carpal tunnel syndrome. There are 11 questions for symptom severity scoring, and 8 questions for functional severity scoring. The score varies from 1 (no problem) to 5 (very severe problem). The mean scores and standard deviations for symptom severity and functional status scores were recorded and classified into a range, with a score of 1-2 representing satisfactory, 2-3 as acceptable, 3-4 as fair, and 4-5 as unacceptable. Results: Mean symptom severity scores were 1.41 and mean functional status scores were % had no scar discomfort, and only 3.57 % had mild symptoms. All patients were satisfied with the results of the operation. Conclusion: The subjective assessment of the long-term results of ECTR in our patients, using the Boston questionnaire was rated as satisfactory, and the results were comparable, if not better, than prior studies, which used the same questionnaire to assess conventional open carpal tunnel release. Keywords: Open carpal tunnel release, Endoscopic carpal tunnel release, Agee s single portal technique, Boston carpal tunnel questionnaire The Thai Journal of Orthopaedic Surgery: 38 No.3-4: Full text. e journal: Introduction Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity, and surgical decompression of the carpal tunnel is the most commonly performed operation on the hand in the USA (1). Carpal tunnel release is the treatment of choice after failed conservative management (2). Conventional open carpal tunnel release (OCTR) has been widely accepted as an effective method for treating CTS. However, complications reported include failure to relieve Correspondence to: Pataradool K, Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV, Pathumwan, Bangkok 10330, Thailand kawee154@gmail.com symptoms, hypertrophic or painful scars, pillar pain, persistent symptoms, and infection (3-5). Endoscopic carpal tunnel release (ECTR) has since been developed for surgical decompression of the carpal tunnel. According to several studies, ECTR results in a more rapid return to work and less scar tenderness than OCTR (6,7). However, some studies referred to the major neurovascular complications reported in ECTR (8-10). Incomplete release of the carpal ligament is a potential complication of this method as suggested by other studies (11,12). But ECTR has been used increasingly over the last few years and it is important to assess its long-term results. Most studies have had short-term followups, and there was one study which talked about results at 4 years follow-up of carpal tunnel release by Agee endoscopic technique (13). To our JRCOST VOL.38 NO.3-4 July-October 2014

19 52 knowledge, there is no study that mentions longterm results for ECTR. The purpose of this study was to assess the subjective results in patients who underwent single portal ECTR at a long-term follow-up by using the Boston questionnaire established by Lanvine in 1993 (15) as the self-administered questionnaire for the assessment of severity of symptoms and functional status. The questionnaire is excellently reproducible, and widely used for subjective assessment for the results of CTS management. Materials and Methods This is the retrospective review of all patients who had undergone single portal ECTR in our department between September 1991 to December All procedures were performed by our senior consultants (TLC, YFC). There were 135 patients (22 males, 113 females) with a mean age of 52 years (range 25 to 88 years). One hundred and three patients had unilateral carpal tunnel release performed, and 32 had bilateral carpal tunnel release. All patients had pre-operative electrophysiological studies that confirmed the presence of carpal tunnel syndrome. Single portal ECTR was performed using standard Agee s technique under Bier s block. All the charts were traced, no major complications were noted. Of the 135 patients who underwent surgery, 52 patients were lost to follow-up, and 3 patients had developed dementia. Four patients who developed recurrence and required another operation were excluded from the study. The Boston questionnaire was then sent out to the remaining 76 patients (94 hands). The Boston questionnaire, a selfadministered questionnaire for the assessment of severity of symptoms and functional status in patients who have carpal tunnel syndrome developed by Levine, was used. This questionnaire was also translated into Mandarin, and prepared in a bilingual (English/Mandarin) fashion. Two additional questions with regards to patient satisfaction and scar discomfort were added. A pilot trial of the bilingual questionnaire was performed on some patients in the ward, to confirm the accuracy of the presentation. Subsequently, a letter, with the self-administered Boston questionnaire enclosed was mailed out to all 76 patients. Non-responders were interviewed via telephone by independent doctors. In the questionnaire, there are 11 questions for symptom severity scoring, including 2 questions on night pain; 3 questions on daytime pain; 1 question on numbness; 1 question on paresthesia; 2 questions on nocturnal numbness, and 2 on motor power. Eight questions on daily activities are for functional severity scoring. The score for symptom severity scale varies from 1 (no symptoms) to 5 (very severe symptoms), and the score for the functional scale varies from 1 (no difficulty) to 5 (cannot do that activity). The mean scores and standard deviation for symptom severity, functional status scales, and individual symptoms were calculated. We also classified the range, with a score of 1-2 representing absence to mild symptoms (satisfactory result), 2-3 as mild to moderate (acceptable result), 3-4 as moderate to severe (fair result), and 4-5 as severe to very severe symptoms (unacceptable result). Patient satisfaction was assessed under 4 categories excellent, good, poor, and very poor. Scar pain was graded as no pain, mild pain, moderate pain, severe pain, and very severe pain. Results Of the 76 patients who were sent a copy of the questionnaire, 28 patients (36 hands) responded (36.84%). The mean age was 55 years (range years) at the time of operation, and the gender distribution was 23 females, and 5 males. Six patients had bilateral release and 22 patients had unilateral release done. The mean follow-up period was 120 months (range from months). No complications were recorded intraoperatively, or postoperatively. The mean (± SD) symptom severity score is 1.41 (± 0.68), and the mean (± SD) functional status score is 1.32 (± 0.5). Table 1 shows the mean values with standard deviations of symptom severity, functional status scores, and a breakdown of the mean values for individual symptoms. Table 1 Mean (SD) values of symptom severity, functional status scores, and scores for individual symptoms Symptom severity scores 1.41(0.68) Functional status scores 1.32(0.5) Night pain 1.41(0.79) Day pain 1.39(0.86) Numbness 1.57(1.03) Weakness 1.48(0.73) Paresthesia 1.32(0.55) Nocturnal numbness 1.43(0.78) THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

20 53 Table 2 The severity of the individual symptoms Symptom No Mild Moderate Severe Night pain 24(85.72%) 3(10.71%) 1(3.57%) Day pain 23(82.14%) 3(10.71%) 1(3.57%) 1(3.57%) Numbness 20(71.43%) 4(14.28%) 2(7.14%) 2(7.14%) Weakness 20(71.43%) 6(21.43%) 2(7.14%) Paresthesia 20(71.43%) 7(25%) 1(3.57%) Nocturnal numbness 18(64.29%) 8(28.57%) 1(3.57%) 1(3.57%) Values are number of patient (%) Table 3 Comparison of the mean scores (SD) with the former studies (using Boston questionnaire for assessment) Our study (10 years ECTR) (n= 28) Katz study (2 years OCTR) (15) (n=29) Bradley study (1 year miniopen carpal tunnel release) (16) (n=34) Lanvin study (1 year OCTR) (14) (n=38) Symptom severity score 1.41(0.68) 1.87(1.03) 1.3(0.41) 1.9(1.0) Functional status score 1.32(0.5) 1.87(1.09) 1.32(0.52) 2.0(1.1) Night pain 1.41(0.79) 1.5(0.93) Day pain 1.39(0.86) 1.76(1.0) Numbness 1.57(1.03) 1.86(1.06) Weakness 1.48(0.73) 2.24(1.05) Paresthesia 1.32(0.55) 1.74(1.11) Nocturnal numbness 1.43(0.78) 1.74(0.95) Patient satisfaction 100% excellent/good 72% excellent/good 91% excellent/good Table 4 Comparison with long-term results of OCTR Symptoms Our study (n = 28) Nancollas study 1995 (17) (n = 60) Pain 92.86%(G/E) * 7.14%(F/P) ** 88.33%(G/E) 11.67%(F/P) Numbness 85.72%(G/E) 14.28%(F/P) 85%(G/E) 15%(F/P) Weakness 92.86%(G/E) 7.14%(F/P) 68.33%(G/E) 31.67%(F/P) Night symptoms 94.65%(G/E) 5.35%(F/P) 85%(G/E) 15%(F/P) *G/E: Good/Excellent **F/P: Fair/Poor Thirteen of twenty-seven patients (50%) had no symptom deficit at all, and fifteen patients (57.14%) had no functional deficit at all. Table 2 shows the severity for the individual symptoms. One patient had severe pain, and another two had severe numbness. These patients were interviewed again on the phone, and offered further clinical examination at our clinic. However, only the patient with severe pain presented at the clinic, and re-examination revealed that her pain was due to osteoarthritis in both hands. Thirteen patients (46.43%) rated the operation as excellent, and the remainder rated it as good (53.57%). Twenty-six patients (96.43%) had no scar pain, and only 1 patient (3.57%) had mild scar pain. We then compared the scores from our study, with previous studies that used the same questionnaire for the assessment of results following conventional open carpal tunnel release (OCTR) and mini-open carpal tunnel release. The results are illustrated in Table 3. Finally, we compared our study to a study on the subjective assessment of long-term outcomes of OCTR (17) (Table 4) Discussion James CY Chow introduced endoscopic carpal tunnel release by a double portals technique in 1987, and then single portal endoscopic carpal tunnel release (ECTR) was developed by JM Agee and FC Kiry in Since then, endoscopic techniques for carpal tunnel release have been well established and gained popularity over the last few years. JRCOST VOL.38 NO.3-4 July-October 2014