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Purpose Advanced-stage trapeziometacarpal (TMC) osteoarthritis of the thumb often presents with concomitant hyperextension deformity of the metacarpophalangeal (MCP) joint. Although several studies have reported simultaneous procedures to correct this deformity, the indication for these procedures remains controversial. The purpose of this study was to evaluate changes in the range of motion (ROM) of the thumb MCP joint before and after TMC arthrodesis . Methods We evaluated the functional flexion and extension and functional ROM of the MCP joints during the performance of 10 activities of daily living tasks before and after TMC arthrodesis in 10 thumbs of 9 patients with Eaton stage III TMC osteoarthritis and hyperextension deformity of the MCP joint. Results The mean functional flexion of the MCP joint increased from 26° to 38°, and the mean functional extension of the MCP joint decreased from 16° to 5° of hyperextension. There was no change in the mean total arc of functional ROM of the MCP joint. Conclusions The MCP joint motion shifted from extension to flexion after TMC arthrodesis, and the total arc of functional ROM of the MCP joint was similar before and after arthrodesis. Type of study/level of evidence Therapeutic V

Purpose We aimed to evaluate the extent of collagenase clostridium histolyticum (CCH) diffusion in Dupuytren’s contracture (DC) for tissues outside of the contracture cord using Magnetic Resonance Imaging (MRI) immediately after CCH injection. Methods: 10 male patients aged 57–79 with DC of the metacarpophalangeal (MCP) joints were examined. Extension deficits were 10–60°(mean, 34.3) and 0–60°(mean, 26.6) in the MCP and proximal interphalangeal (PIP) joints, respectively. CCH injection was performed according to the standard method. MRI was performed within 15 min of CCH injection. Results: In all 10 cases, the extended area of high-intensity signal change outside of the cord was observed on short-T1 inversion recovery images (STIRs). Continuity from the insertion site was observed in the area of signal change involving the flexor tendon and neurovascular bundle. The signal change area spanned distally and proximally beyond the injection level. The signal change area expanded along the tendon sheath but no signal changes were observed inside the flexor tendon, suggesting the tendon sheath serves as a protective barrier from the CCH solution. After 1 week of injection, the mean decrease in contracture was 32.5°(94.7%) for the MCP joint and 19.8°(74.4%) for the PIP joint. In nine out of 10 cases, the extension deficit was within five degrees of full extension in the affected finger. There was no neurovascular injury or tendon rupture at 3 months of observation. Conclusions: MRI indicated the possible leakage of the drug outside of the cord during the early phase after administration, suggesting that CCH could persistently affect healthy tissues until CCH inactivates its enzyme process.

Background: Cubital tunnel syndrome (CuTS) is generally treated successfully by surgery and recurrent cases are rare. This study retrospectively investigated the clinical characteristics of recurrent CuTS caused by ganglion.Methods: We evaluated nine patients who were surgically treated for recurrent CuTS caused by ganglion. Age distribution at recurrence ranged from 43 to 79 years. The initial surgery for CuTS had been performed using various methods. The asymptomatic period from initial surgery to recurrence ranged from 22 to 252 months. Clinical, diagnostic imaging, and operative findings during the second surgery were analyzed. All patients were treated by anterior subcutaneous ulnar nerve transposition with ganglion resection and later examined directly within a mean of 71 months after the second surgery.Results: The interval from recurrence to consultation was shorter than two months for eight cases. Chief complaints included numbness with or without pain in the ring and little fingers in all patients and resting pain in the medial elbow in five patients. Elbow osteoarthritis was present in all cases. Although four of 10 ganglia were palpable, ultrasonography and magnetic resonance imaging could identify all ganglia preoperatively. The ulnar nerve typically had become entrapped by the ganglion posteriorly and by fascia, scar tissue, and/or muscle anteriorly. Chief complaints and ulnar nerve function were improved in all patients following revision surgery.Conclusions: The acute onset of numbness with or without intolerable pain in the ring and little fingers after a long-term remission period following initial surgery for CuTS in patients with elbow osteoarthritis appears to be the characteristic clinical profile of recurrent CuTS caused by ganglion. As ganglia are often not palpable, ultrasonography and magnetic resonance imaging are recommended for accurate diagnosis.

Background The functional range of motion (fROM) of the metacarpophalangeal (MCP) joints during the performance of activities of daily living (ADL) has not yet been established. This study aimed to determine the fROM of all five digits and verify the accuracy and reproducibility of dynamic angle measurement using a single-axis electric goniometer (EG) during ADL movements of the hand. Methods This was a cross-sectional study. In EG suitability testing, we first confirmed the angles of a three-dimensional calibration device 10 times, and then compared EG readings with those determined by tomosynthesis images. Next, we determined the fROM of the MCP joints by evaluating all five digits of the dominant hands of 10 healthy adults performing 16 ADL. Intra-rater reproducibility of MCP joint data during task performance was assessed in two healthy adults. Results Static measurements of the triangular object showed variance to be within one degree in 39 of 40 trials. Differences between angles measured by the EG and those depicted by radiograph were a range of plus or minus five degrees in 88 of 96 digits. The fROM values for the thumb and index, middle, ring, and little fingers were −7.5 to 35.3, 10.6 to 67.8, 4.0 to 79.9, 3.0 to 83.9, and 2.9–91.4 degrees of flexion, respectively. Flexion angle in the fROM of the index finger was significantly smaller than those of the ring and little fingers. The flexion and extension angles of the thumb were significantly smaller than those of the four ulnar fingers. The intra-rater correlation coefficients of two participants were high at 0.94 and 0.93, respectively. Conclusions The method adopted in this study exhibited excellent accuracy and reproducibility and was therefore considered suitable for the real-time establishment of fROM flexion-extension angles of the MCP joints for all five digits. Our data are useful as a target arc of motion in the treatment of MCP joint disease or injury.

Mikio Kamimura,1 Akira Taguchi,2 Yukio Nakamura,3,4 Hidefumi Koiwai,5 Shota Ikegami,3 Shigeharu Uchiyama,3 Hiroyuki Kato3 1Center for Osteoporosis and Spinal Disorders, Kamimura Orthopedic Clinic, Matsumoto, Japan; 2Department of Oral and Maxillofacial Radiology, Matsumoto Dental University, Shiojiri, Japan; 3Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan; 4Department of Orthopedic Surgery, Showa-Inan General Hospital, Komagane, Japan; 5Koiwai Orthopedic Clinic, Komoro, Japan Background: While it is well known that teriparatide (TPTD) increases bone mineral density (BMD) in osteoporotic patients, it is unknown whether TPTD pretreatment affects BMD after denosumab (DMAb) therapy.Methods: Fifty-seven patients in TPTD-pretreated group and 35 patients in DMAb-alone group had been further analyzed, all of whom were treated by DMAb for 1.5 years. Vitamin D (400 IU) and Ca (600 mg) supplementation was used in all patients. The BMD of lumbar 1–4 vertebrae (L-BMD), bilateral total hips (H-BMD), and bilateral femoral neck (FN-BMD) was quantified at first visit, and at 4, 8, 12, and 18 months after daily TPTD treatment following four times DMAb treatment.Results: There were significant differences in L-BMD (p=0.004) and H-BMD (p=0.026) at baseline between TPTD-pretreated and DMAb-alone groups, although there was no significant difference in FN-BMD between the two groups. The increase of L-BMD by DMAb therapy was less in TPTD-pretreated group than in DMAb-alone group. There was no significant difference in H-BMD, although percent changes of H-BMD tended to be higher in the TPTD-pretreated group than those in the DMAb-alone group. Percent change in FN-BMD at 4 months (p=0.067) and 12 months (p=0.057) tended to be higher in TPTD-pretreated group than in DMAb-alone group. Percent change in FN-BMD at 18 months was significantly higher in TPTD-pretreated group (p=0.004) than in DMAb-alone group.Conclusion: These findings suggest that the pretreatment of TPTD might have enhanced the increase of BMD in cortical bones treated by DMAb. Thus, it is favorable that TPTD can be used for osteoporotic patients who have high fracture risks with cortical bones. Keywords: bone mineral density, cancelleous bones, cortical bone, daily teriparatide, denosumab, osteoporosis

Background During the surgery for a distal radius fracture, we encountered a large anomalous muscle lying across the distal radius. The muscle was identified as a flexor carpi radialis brevis muscle (FCRB), based on its location, function, and innervation. This experience led us to clarify its prevalence in living subjects and alert surgeons of its presence. Methods We reviewed wrist MRI scans of 515 hands of 379 patients with carpal tunnel syndrome (CTS). The prevalence of the FCRB was calculated. The cross sectional area (CSA) of the FCRB was compared with that of the hypothenar muscles. Signal intensity and fat infiltration of the FCRB were assessed using semiquantitative methods. The anterior compartment ratio (CSA of the anterior compartment of the forearm was divided by CSA of the forearm. CSA of the FCRB was excluded for measurement) was compared between patients with and without FCRB. Results We found seven hands of six patients (1.6%) with a FCRB. All of these tendons were inserted into the second metacarpal base. CSA of FCRB was smaller than that of the hypothenar muscles. Semiquantitative assessment revealed normal signal intensities of the FCRB compared with those of other muscles. The anterior compartment ratio was smaller in patients with FCRB than without FCRB. None of the FCRB in our series demonstrated any sign of tendinitis on MRI. Furthermore, the postoperative clinical course for those patients was uneventful. Conclusions Prevalence of FCRB in patients with CTS was 1.6%. FCRB should function as a wrist flexor. Its strength varied according to the individuals but was not greater than that of the hypothenar muscles. It is still unclear if the FCRB could cause the development of CTS. However, it was found that the FCRB could be a mass which occupies and narrows the anterior compartment.

Myostatin, a member of the transforming growth factor‐β (TGF‐β) superfamily, is expressed in developing and adult skeletal muscle and negatively regulates skeletal muscle growth. Recently, myostatin has been found to be expressed in tendons and increases tendon fibroblast proliferation and the expression of tenocyte markers. C2C12 is a mouse myoblast cell line, which has the ability to transdifferentiate into osteoblast and adipocyte lineages. We hypothesized that myostatin is capable of inducing tenogenic differentiation of C2C12 cells. We found that the expression of scleraxis, a tendon progenitor cell marker, is much higher in C2C12 than in the multipotent mouse mesenchymal fibroblast cell line C3H10T1/2. In comparison with other growth factors, myostatin significantly up‐regulated the expression of the tenogenic marker in C2C12 cells under serum‐free culture conditions. Immunohistochemistry showed that myostatin inhibited myotube formation and promoted the formation of spindle‐shaped cells expressing tenomodulin. We examined signaling pathways essential for tenogenic differentiation to clarify the mechanism of myostatin‐induced differentiation of C2C12 into tenocytes. The expression of tenomodulin was significantly suppressed by treatment with the ALK inhibitor SB341542, in contrast to p38MAPK (SB203580) and MEK1 (PD98059) inhibitors. RNAi silencing of Smad3 significantly suppressed myostatin‐induced tenomodulin expression. These results indicate that myostatin has a potential role in the induction of tenogenic differentiation of C2C12 cells, which have tendon progenitor cell characteristics, through activation of Smad3‐mediated signaling.

Ten patients had intrasynovial tendon grafting harvested from the toes for secondary flexor tendon reconstruction in nine fingers and one thumb in our institutes from 2009 to 2014. These patients were followed for a mean of 15 (range: 8–36) months. The ranges of total active motion of the proximal and distal interphalangeal joints of these nine fingers were 143° (range: 108–175°) and of the metacarpophalangeal and interphalangeal joints of one thumb were 110°. In conclusion, this technique is feasible and gives a good result when successful but with a high complication rate.Level of Evidence IV

Osteoporosis is characterized by the systemic impairment of bone mass, strength, and microarchitecture, leading to an increased risk of fragility fracture. Bisphosphonates (BPs) are the first-line drugs for osteoporosis. Vitamin D is considered to be essential for osteoporotic treatment. However, long-term effects of BPs on the serum levels of 25-hydroxyvitamin D3 (25(OH)D3) are unknown. Accordingly, in this retrospective study, we collected clinical data of 41 post-menopausal Japanese women with osteoporosis treated with BP for over 3 years, without vitamin D supplementation. We measured lumbar and femoral neck bone mineral density (BMD) and serum levels of bone specific alkaline phosphatase (BAP) as a bone formation marker, and tartrate-resistant acid phosphatase (TRACP)-5b as a bone resorption marker, before and after the 3-year treatment. Serum 25(OH)D3, 1,25(OH)2D3, and whole parathyroid hormone (PTH) were also measured. Notably, no fracture occurred during the treatment. Compared with baseline values, 25(OH)D3 levels were significantly increased from 21.6 to 26.4 ng/mL (P = 0.006), despite no vitamin D supplementation. 1,25(OH)2D3 and whole PTH levels tended to be decreased from 62.6 to 57.8 pg/mL and 27.3 to 25.1 pg/mL, respectively. Both bone formation and resorption markers were significantly suppressed (P < 0.01). Both lumbar BMD (7.3% increase) and femoral neck BMD (4.1% increase) were significantly improved (P < 0.0001) after 3 years of the treatment. Thus, even without vitamin D supplementation, serum 25(OH)D3 levels were significantly increased after 3-year BP therapy. These results suggest that vitamin D supplementation might not be required in the long-term BP therapy for osteoporosis.

Background: The aim of this study was to identify the risk factors for median nerve dysfunctions after volar locking plate (VLP) fixation for distal radius fracture (DRF).Methods: We prospectively assessed the incidence of median nerve symptoms (MNS) such as numbness, pain, paresthesia, or hypesthesia in the area innervated by the median nerve and evaluated post-operative nerve conduction (NC) in 91 hands of 121 patients after VLP fixation for DRF. Multivariate logistic regression analysis was conducted to identify factors independently associated with MNS and abnormal NC in the injured wrist.Results: There were 18 cases (20%) of MNS on the injured side, 9 hands (10%) of both MNS and abnormal NC, 11 hands (12%) with only abnormal NC, and 9 hands with only MNS. Sensitivity, specificity, and diagnostic accuracy of abnormal NC for diagnosing MNS were 50%, 86%, and 78%, respectively. Four cases did not respond to conservative treatment and received carpal tunnel release concomitantly with plate removal. Logistic regression examination revealed that volar placement of the plate and short stature were significant independent predictors of MNS, while patient age was the sole independent predictor of abnormal NC.Conclusions: Our study demonstrated that plate prominence, short stature, and age were significant independent risk factors for median nerve dysfunctions after VLP fixation for DRF.

Background:Bone peg grafting (BPG) has been advocated for early-stage humeral capitellar osteochondritis dissecans (COCD). However, the clinical and radiological results of BPG, along with its indications, have not been described in detail.Hypothesis:COCD classified as International Cartilage Repair Society (ICRS) osteochondritis dissecans (OCD) I or II in adolescent baseball players can be treated successfully by BPG.Study Design:Case series; Level of evidence, 4Methods:Eleven male baseball players (age range at surgery, 13-16 years) who underwent BPG for COCD were enrolled in this study. No improvement had been seen in any patient after 6 months of preoperative nonthrowing observation. During surgery, 2 to 5 bone pegs were inserted into the COCD lesion after confirmation of lesion stability to the bony floor. All patients were directly evaluated at 12 and 24 months after surgery by physical findings, radiological prognosis, and magnetic resonance imaging (MRI).Results:Of the 11 patients, 10 could return to comparable baseball ability levels within 12 months. The Timmerman-Andrews score improved significantly from a mean ± SD of 171.8 ± 12.1 preoperatively to 192.3 ± 6.5 at the final observation. Radiological healing of the lesions was determined as complete in 8 patients and partial in 3. Patients possessing a centrally positioned lesion or a lesion Conclusion:BPG enabled 91% of COCD patients with ICRS OCD I or II to return to preoperative baseball abilities within 12 months. Integration of the grafted site may continue until at least 24 months postoperatively. An ICRS OCD I or II lesion with central positioning and/or occupying

Background Although extensor tendon rupture associated with distal radioulnar joint disorder is often encountered, its treatment has not yet been established. We report the postoperative results for reconstruction of finger extensor tendon rupture due to distal radioulnar lesion and analyse the factors affecting postoperative extension lag. Methods We examined 74 index, middle, ring, or little fingers with extensor tendon rupture of 34 hands. Primary diseases were rheumatoid arthritis in 24 hands and osteoarthritis in 10. Reconstruction methods included tendon graft in 45 fingers, extensor indicis proprius tendon transfer in 15, and end-to-side adjacent tendon suture in 14. At final postoperative follow-up ranging from 12 to 40 (mean: 18) months, we measured metacarpophalangeal (MCP) joint range of motion and extension lag and statistically evaluated the relationship between postoperative extension lag and several clinical factors. Results We encountered no cases of re-rupture or worsening of finger flexion range after reconstruction. Mean postoperative active flexion of the MCP joint was 78.1 (range: 45–95) degrees. Mean postoperative extension lag was 10.3 (range: 0–50) degrees. We observed that postoperative extension lag was significantly larger in fingers associated with extensor tendon rupture in two or three additional fingers in the affected hand or in fingers of patients aged 80 years or over. The interval from rupture to reconstruction, reconstruction method, or arthritis type did not remarkably affect outcome. Conclusions This study uncovered that surgical intervention for extensor tendon rupture should be performed before three fingers become affected.

Background Various pathological elbow lesions are often complicated with ulnar neuropathy at the elbow (UNE), although the precise pathology, incidence, and clinical and neurological features of these lesions have not been identified. We therefore investigated elbow pathology and neurological severity in Japanese patients with UNE. Methods The medical records of 457 Japanese UNE patients who were surgically treated among 6 hospitals were retrospectively examined. Eligible patients had UNE diagnosed by physical findings and nerve conduction studies according to the criteria of the American Association of Electrodiagnostic Medicine. The elbows were analyzed with regard to age, gender, occupation, pathology at the elbow, and severity of nerve palsy. Results A total of 398 patients with 413 UNE elbows of a mean age of 63 years (range: 15–87) met the inclusion criteria. UNE elbows were predominantly in male patients (69.0%). Overall, 310 elbows (75.1%) had 1 or more elbow lesions: 238 elbows (76.8%) had a single lesion and 72 elbows (23.3%) had 2 or more lesions. The most common lesion was primary elbow osteoarthritis (EOA) occurring in 54.5% of elbows, followed next by medial elbow ganglion in 8.5% and cubitus valgus in 6.5%. Most elbows with medial elbow ganglion or cubitus valgus were associated with EOA. Entrapment sites were at the cubital tunnel in 84.5%–91.3% of UNE elbows, regardless of an association with elbow lesion. The incidence of McGowan grade III lesion was 50.8% in elbows with primary EOA, which was higher than the 35.0% in elbows with no lesion. Conclusions This study revealed that UNE had various isolated or combined elbow lesions. In Japanese UNE, primary or secondary EOA was found in 62.2% of cases and severe motor weakness was noted in 47.2%. The incidences of EOA and severe ulnar nerve palsy in the Japanese UNE are higher than those in Caucasians. Level of evidence Level IV; Prognostic—Investigating the effect of a patient characteristic on the outcome of a disease; Case series.

Purpose To identify risk factors for tendon attrition after volar locking plate fixation of distal radius fractures. Methods We prospectively assessed attrition of the flexor pollicis longus tendon at volar plate removal in 127 hands in 126 patients. We also evaluated preoperative lateral wrist radiographs, sonographs, and crepitus with flexor pollicis longus tendon motion and compared the demographic and radiographic characteristics of patients with and without tendon attrition. Multivariate logistic regression analysis was employed to identify the factors independently associated with tendon attrition. Results We found 12 cases of tendon attrition (10%) and 1 that presented with tendon rupture in our cohort. Crepitus was recognized in 14 patients (11%): 6 cases (50%) were among the 12 hands in 12 patients with tendon attrition whereas 8 (7%) were detected in the remaining 114 hands in 113 patients. Logistic regression examination revealed that audible crepitus and volar placement of the plate in lateral radiographs were independent predictors of tendon attrition. Conclusions Crepitus and volar placement of hardware in lateral radiographs were independent risk factors for flexor tendon attrition after volar plating for distal radius fracture. These results may facilitate surgical decisions regarding early plate removal to prevent possible tendon rupture. Type of study/level of evidence Diagnostic II.

Alfacalcidol (ALF) and eldecalcitol (ELD) are vitamin D analogues that can be combined with anti-resorption drugs, such as bisphosphonate (BP) for the treatment of osteoporosis (OP). There has been no report comparing the effects of those vitamin D analogs in combination with BPs. Twenty female patients with OP were enrolled, and all of them were treated with ALF and BPs. After switching from ALF to ELD, we examined the effectiveness of ALF and ELD. The averaged age was 69.4 years and the period of BP usage was between 1 to 13.4 years (mean period was 3.7 years). Serum corrected calcium, serum inorganic phosphorus, serum bone specific alkaline phosphatase (BAP), and serum tartrate-resistant acid phosphatase (TRACP)-5b were measured prior to ELD and at 6 months afterwards. Bone mineral density (BMD) of the lumbar spine (L-BMD), femoral neck, and total hip BMD were assessed one year before, prior to, and one year after ELD therapy commencement. Six months after switching from ALF to ELD, BAP and TRACP-5b values significantly decreased. After one year of ALF therapy, L-BMD, total hip BMD and femoral neck H-BMD values slightly increased. In contrast, a year following the change from ALF to ELD, L-BMD significantly increased and femoral neck BMD slightly increased, but total hip BMD did not. These results suggest that the treatment with ELD after ALF significantly suppressed bone turnover and increased L-BMD. Thus, the combined therapy with ELD is more effective for OP treatment than that with ALF.

Bilateral thumb amputation at the metacarpophalangeal (MCP) joint is a debilitative condition for which various reconstructive techniques have been reported [1,2]. In cases of unilateral thumb amputation at theMCP joint, toe-to-thumb transfer has become the gold standard for thumb reconstruction to achieve optimal functionality [3]. There have been two reports of bilateral toe-to-thumb transfers to date that objectively evaluated dysfunction and acquired function, but subjective assessment was not performed [4,5]. The disabilities of the arm, shoulder and hand (DASH) score is a patient-based questionnaire for total bilateral upper limb function [6]. Although it is an effective disability evaluation tool for upper limb reconstructive surgery after trauma [7], there have been few reports describing activities of daily life based on DASH score assessment after thumb reconstruction. This case report documents the outcome of a patient with bilateral thumb amputations treated with second toe-to-thumb transfers and the changes in functional results and DASH scores before and after each transfer.

We report the case of a 40-year-old woman with pseudoachondroplasia (PSACH), with a heterozygous mutation (c.806A > G, p.Asp269Gly) located in the Type 3 repeats domain of the cartilage oligomeric matrix protein gene, who complained of the unusual symptom of painful locking of the wrist. Her condition was caused by a non-traumatic enlargement of the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons along with bulbous swelling of the synoviums around them. Surgical treatment resolved these unusual tendon-related symptoms. Repetitive mechanical loading of the wrist in daily activities, including distal intersection tenosynovitis between the extensor pollicis longus tendon and ECRL and ECRB tendons, may have contributed to changes in the structural integrity of the tendons. We should pay more attention to tendon-related symptoms in patients with PSACH.

Background The clinical characteristics of wild-type transthyretin amyloid deposition among patients with carpal tunnel syndrome (CTS) have not been well investigated. Methods One-hundred and seven patients with idiopathic CTS who underwent carpal tunnel release were enrolled. They underwent physical examination of the hand, nerve-conduction study, and magnetic resonance imaging (MRI) study of the wrist, and completed a patient-oriented questionnaire. The tests, except for MRI, were repeated 1, 3, and 6 months postoperatively. Synovial tissue was obtained during surgery and analyzed by Congo red and immunohistochemical staining. Ordinal logistic regression analysis was used to evaluate the significance of different clinical and subjective findings between patients with and without amyloid deposition. Postoperative improvements were also compared. Results Wild-type transthyretin amyloid deposition was observed for 38 patients. Greater symptom severity and 2-point discrimination scores, and larger cross-sectional areas of the carpal tunnel, were significantly correlated with a larger amount of preoperative amyloid deposition. However, the presence and amount of preoperative amyloid deposition did not affect postoperative improvements in physical findings and nerve-conduction studies. Conclusions Although transthyretin amyloid deposition can worsen CTS symptoms, postoperative improvements were similar for patients with and without this deposition.

Background: Treatment for capitellar osteochondritis dissecans (COCD) lesions is usually based on their stability from the bony floor after arthroscopic or open direct observation. Thus, a noninvasive means of lesion stability assessment by use of imaging is desirable to preoperatively determine treatment strategy. Purpose: To evaluate our modified MRI staging system for COCD, we compared the results of MRI staging with the International Cartilage Repair Society (ICRS) classification for lesion stability. Intra- and interrater reliability for MRI staging was examined as well. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Fifty-two COCD lesions were preoperatively evaluated by T2-weighted MRI and classified into 5 stages: stage 1 = normally shaped capitellum with several spotted areas of high signal intensity that is lower than that of cartilage; stage 2 = as with stage 1 but with several spotted areas of higher intensity than that of cartilage; stage 3 = as with stage 2 but with both discontinuity and noncircularity of the chondral surface signal of the capitellum and no high signal interface apparent between the lesion and the floor; stage 4 = lesion separated by a high intensity line in comparison with cartilage; and stage 5 = capitellar lesion displaced from the floor or defect of the capitellar lesion noted. The MRI staging results were compared with the intraoperative ICRS classification for lesion stability of each patient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were all determined for fragment instability. Intra- and interrater correlations for our MRI staging were calculated among 3 examiners. Results: Preoperative MRI grading correctly matched ICRS classification in 49 of 52 patients (94%), with a sensitivity of 100% and a specificity of 80%. The PPV and NPV were 93% and 100%, respectively, for diagnosing lesion instability. Intrarater reliability (intraclass correlation coefficient [ICC]) for MRI staging was high at ICC(1, 1) = 0.86 and ICC(1, 2) = 0.90, as was interrater reliability at ICC(2, 1) = 0.82 and ICC(2, 3) = 0.88. Conclusion: The MRI staging system provides accurate and reliable evidence for estimating ICRS classification and instability of COCD and is useful to decide appropriate treatment.

The purpose of this study is to investigate the structural changes of the carpal tunnel, median nerve, and flexor tendons in magnetic resonance imaging (MRI) before and after endoscopic carpal tunnel release (ECTR). We studied 36 hands undergoing ECTR. In MRI, the cross-sectional area of the carpal tunnel and the median nerve at the hamate and the pisiform levels were measured. The distance from the volar side of carpal bone to the median nerve or tendons and the volar displacement were measured. In post-operative MRI, the transverse carpal ligament could not be well delineated and the carpal tunnel was significantly enlarged both at the hamate and pisiform levels. The median nerve was enlarged at the hamate level. The median nerve and flexor tendons significantly moved to the volar side. The volar displacement of the median nerve and flexor digitorum superficialis in the long and ring fingers was greater than the other tendons.

This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius. The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery. No differences between groups was observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). The radiographs were assessed by three independent assessors. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (se 0.16)) and the no-ALN group (3.1 months (se 0.15)) (p = 0.068). All the fractures healed in the both groups by the last follow-up. Improvement of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period. Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture healing times either radiologically or clinically. Cite this article: Bone Joint J 2013;95-B:1544–50.

Objectives: In this study, we aimed to investigate whether joint pain is derived from cartilage or bone alterations. Methods: We reviewed 23 hip joints of 21 patients with primary hip osteoarthritis (OA), which were classified into Kellgren–Laurence (KL) grading I to IV. Plain radiographs and magnetic resonance imaging (MRI) were obtained from all of the 23 joints. Two of the 21 patients had bilateral hip OA. Pain was assessed based on the pain scale of Denis. A Welch t test was performed for age, height, weight, body mass index, bone mineral density, and a Mann–Whitney U test was performed for KL grading. Results: Four of 8 hip joints with pain and OA showed broad signal changes detected by MRI. Fourteen hip joints without pain, but with OA did not show broad signal changes by MRI. Collectively, MRI analyses showed that broad signal changes in OA cases without joint pain or with a slight degree of joint pain were not observed, while broad signal changes were observed in OA cases with deteriorated joint pain. Conclusion: Our findings suggest that hip joint pain might be associated with bone signal alterations in the hips of OA patients.

We present the case of a patient with flexor digitorum profundus tendon laceration at the A2 pulley level caused by an injury to the base of the right ring finger by a knife. The patient was treated by flexor tendon reconstruction from the palm to the fingertip by using the left second toe flexor tendon as a graft, which improved the active range of motion. Further improvement was achieved by subsequent tenolysis, which eventually restored nearly normal function. Our experience with this case indicates that the intrasynovial tendon is a reasonable graft source for the synovial space in fingers and may enable restoration of excellent postoperative function.

Purpose This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties. Methods We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ 2 test, and binary regression analysis. Results One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed. Conclusions The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR. Level of Evidence Level IV, therapeutic case series.

Closed flexor tendon ruptures in the little finger can be caused by fracture or nonunion of the hook of the hamate, but no case of the disorder secondary to the sclerosis and thinning of the hamate hook has been reported. We report two rare cases with this complication due to rough surface of the hamate hook. Carpal tunnel view radiographs and computed tomography showed the sclerosis and thinning of the hook.

Purpose Imaging criteria for diagnosing compressive ulnar neuropathy at the elbow (UNE) have recently been established as the maximum ulnar nerve cross-sectional area (UNCSA) upon magnetic resonance imaging (MRI) and/or ultrasonography (US). However, the levels of maximum UNCSA and diagnostic cutoff values have not yet been established. We therefore analyzed UNCSA by MRI and US in patients with UNE and in controls. Methods We measured UNCSA at 7 levels in 30 patients with UNE and 28 controls by MRI and at 15 levels in 12 patients with UNE and 24 controls by US. We compared UNCSA as determined by MRI or US and determined optimal diagnostic cutoff values based on receiver operating characteristic curve analysis. Results The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm 2 ) as well as for US (17 ± 7 mm 2 ). A cutoff value of 11.0 mm 2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients. Conclusions By measuring UNCSA with MRI or US at 1 cm proximal to the ME, patients with and without UNE could be discriminated at a cutoff threshold of 11.0 mm 2 with high sensitivity, specificity, and reliability. Type of study/level of evidence Diagnostic III.

Dislocation of the radial head is often encountered as a result of a pediatric Monteggia fracture. We report two rare cases of tardy ulnar nerve palsy associated with anterior radial head dislocation combined with anterior bowing of the ulna. They had cubitus valgus deformity, valgus instability, and osteoarthritis of the elbow, and had elbow injury more than 40 years back. They were diagnosed with chronic radial head dislocation long after a Bado type 1 Monteggia fracture. Anterior subcutaneous ulnar nerve transposition yielded favorable results. It is important to recognize the possibility of tardy ulnar nerve palsy caused by an improperly treated Monteggia fracture.

Distal radius fracture (DRF) is often the first fragility fracture that occurs in postmenopausal women and exhibits the high risk of future fragility fractures at the other skeletal sites. So far, the other factors rather than bone mineral density have not been well investigated. Our aim was to determine the characteristics of the patients with previous fragility DRFs. We enrolled 48 postmenopausal women with a history of fragility DRF (fracture group) and age-matched 96 healthy postmenopausal women volunteers (control group). Hip BMD of all the participants was obtained using DXA. Geometrical parameters and biomechanical indices of the femoral neck were obtained using quantitative CT. Using CT images, the cross-sectional area of the skeletal muscle and fat inside the fascia was calculated at the proximal thigh. Twelve biochemical markers and hormones associated with bone metabolism were also measured. Each parameter was compared between the patients and controls by analysis of variance (ANOVA), followed by ANCOVA adjusting for femoral neck areal BMD. BMD of the femoral neck was significantly lower in the fracture group than the control, while skeletal muscle area was not. Femoral neck cortical thickness was significantly smaller and buckling ratio was significantly greater in the fracture group; however, after adjusting for BMD, the differences were no longer significant. Further, 25(OH)D, Urinary deoxypyridinoline (DPD), and serum and urinary pentosidine levels were significantly higher in the fracture group than in the control group; those differences remained significant after adjusting for BMD. The patients with previous DRFs exhibited lower BMD, which was not accompanied by lower skeletal muscle area or muscle strength. Further, bone metabolism alterations such as low 25(OH)D, high DPD, and high serum and urinary pentosidine levels were also observed in such patients, independent of the areal BMD determined by DXA. Level of Evidence: Prognotic Study.

The etiology of ankle osteoarthritis (OA) is largely unknown. We analyzed 24 ankle OA of 21 patients diagnosed by plain radiographs using magnetic resonance imaging (MRI). Ankle joint pain disappeared in 22 out of 24 joints by conservative treatment. MRI bone signal changes in and around the ankle joints were observed in 22 of 24 joints. Bone signal changes along the joint line were seen in 10 of 11 joints as a Kellgren-Lawrence (KL) grade of II to IV. Such signal changes were witnessed in only 4 of 13 joints with KL grade 0 or I. In the talocrural joint, bone alterations occurred in both tibia and talus bones through the joint line in cases of KL grade III or IV, while focal bone alterations were present in the talus only in KL grade I or II cases. Sixteen of 24 joints exhibited intraosseous bone signal changes, which tended to correspond to joint pain of any ankle OA stage. Our results suggest that bone alterations around the ankle joint might be one of the etiologies of OA and associated with ankle joint pain.

To identify a safe entry point for needle insertion in patients with idiopathic carpal tunnel syndrome (CTS), cross-sectional images of the wrist MRI of 45 normal volunteers and 180 consecutive patients with idiopathic CTS were reviewed. Insertion of the needle from the five different entry points into the carpal tunnel was simulated by drawing a 1-pixel line, and the incidence of contact with the median nerve was compared. In the CTS patients, the lowest incidence was 3% when inserted at one-third of the length between the FCR and FCU tendons on the ulnar side at the level of the distal part of the distal radioulnar joint and 4% at the mid point between the palmaris longus tendona and the flexor carpi ulnaris tendon. It was greater in the advanced stage of CTS than the less severe CTS. We recommend those two entry points.

Background: The present study measured longitudinal changes in bone turnover markers in elderly patients with vertebral fracture and investigated the relationship among bone turnover markers, duration of bed rest and bone mineral density (BMD). Methods: Criteria for patient selection were 50 years in age and older, and presence of VF. Serum bone-specific alkaline phosphatase (BAP) was measured as a marker of bone formation. Urinary crosslinked N-terminal telopeptides of type I collagen (NTX) was measured as a marker of bone resorption. In principle, samples were collected just after injury, within 24 h, and 1, 2, 3, 5 and 8 weeks after. We also measured duration of bed rest and BMD. Results: The study population consisted of 42 cases. The average BMD of the lumbar vertebrae was 0.670 ± 0.174 g/cm2. Bed rest period was 17.9 ± 8.8 days. BAP showed significantly higher values at 2 and 3 weeks compared with the baseline value. Thereafter, BAP progressively decreased until 8 weeks. Urinary NTX was increased soon after the onset of pain with the same patterns in BAP. Urinary NTX values reached a peak at 3 weeks, and then they kept significantly higher values until 8 weeks. The peak value of serum BAP was affected by the duration of bed rest, although that of the urinary NTX was not. The peak values of serum BAP and urinary NTX showed negative correlations with the initial BMD values. Conclusions: Bone turnover markers remained higher at 8 weeks, even patients symptom was healed after VF. Bone turnover markers were affected on physical activity and BMD.

Background: Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal techinique have not been well investigated. Methods: We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes-Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively. Findings: Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure >300 mm Hg was recorded in most of the patients. Interpretation: A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of pen-operative complications. Since time-pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety., Article, CLINICAL BIOMECHANICS. 25(9):893-898 (2010)

BackgroundThe Patient-Rated Wrist Evaluation is a regionspecific, self-administered questionnaire consisting of a pain scale (PRWE-P) and a functional scale (PRWE-F), with the latter consisting of specific function (PRWE-SF) and usual function (PRWE-UF). The PRWE was cross-culturally adapted from the original English version by the Impairment Evaluation Committee, Japanese Society for Surgery of the Hand (JSSH). The purpose of this study was to test the reliability, validity, and responsiveness of the Japanese version of PRWE (PRWE-J).MethodsA consecutive series of 117 patients with wrist disorders completed the PRWE-J, the JSSH version of the Disabilities of the Arm, Shoulder, and Hand (DASH-JSSH) questionnaire and the 36-Item Short-Form Health Survey (SF-36). Of the 117 patients, 71 were reassessed for test-retest reliability 1 or 2 weeks later. Reliability was investigated by reproducibility and internal consistency. To analyze the validity, a factor analysis (principal axis factoring) of PRWE-J and correlation coefficients between PRWE-J and DASH-JSSH were obtained. Responsiveness was examined by calculating the standardized response mean (SRM) (mean change/SD) and effect size (mean change/SD of baseline value) after open surgery in 50 patients.ResultsCronbach’s α coefficients for PRWE-P, PRWE-F, and PRWE were 0.90, 0.95, and 0.95, respectively. The intraclass correlation coefficients (ICCs) for the same were 0.86, 0.93, and 0.92, respectively. Unidimensionality of PRWE-P was confirmed. Bidimensionality of PRWE-F was confirmed and separated clearly into PRWE-SF and PRWE-UF. The correlation coefficients between PRWE-P and PRWE-F or DASH-JSSH were 0.63 or 0.63, respectively. The correlation coefficient between PRWE-F and DASH-JSSH was 0.80. The correlation coefficients between DASH-JSSH and PRWE-SF or PRWE-UF were 0.76 or 0.73, respectively. Moderate correlation was observed in “physical functioning” for SF-36 and PRWE-SF (r = −0.46), PRWE-F (r = −0.46), or PRWE (r = −0.46). The SRMs/effect sizes of PRWE-P, PRWE-F, or PRWE were respectively excellent: 1.7/2.2, 1.2/1.3, 1.6/1.9.ConclusionsThe PRWE-J has evaluation capacities equivalent to those of the original PRWE.

Background Capitellar osteochondritis dissecans (OCD) is a focal injury of the articular cartilage involving separation of a segment of cartilage from the subchondral bone that is infrequently encountered in the dominant-side elbow of adolescent throwing athletes1,2. The literature suggests that patients may achieve better short and mid-term results when treated with certain types of surgical procedures3,4. Selection of the appropriate surgical method should be based on the International Cartilage Repair Society (ICRS) OCD classification system5. For lesions involving ≤50% of the surface area of the capitellum, debridement with microfracture and/or loose body removal have shown excellent results. For lesions involving >50% of the surface area of the capitellum and classified as ICRS OCD III or IV, autologous osteochondral grafting may be the most suitable treatment6-8. Bone peg grafting (BPG) has been shown to be an effective treatment option for early-stage capitellar OCD that can preserve the local hyaline cartilage9,10. Description Using direct vision and with arthroscopy, the continuity of the capitellar surface and the stability of the capitellar lesion were evaluated according to the ICRS OCD classification5. BPG was indicated for adolescents with ICRS OCD I or II. The elbow was opened between the extensor carpi ulnaris and the anconeus muscle (Kocher interval). Another skin incision of 3 cm in length was made at the posterior aspect of the metaphysis of the ipsilateral olecranon. Three, 4, or 5 bone pegs of approximately 20 mm in length were harvested from the posterior ulnar cortex. A Kirschner wire of 3 mm in diameter was used for drilling holes in the lesion, and then the bone pegs were inserted with tweezers to a depth of 10 mm. Next, a flat-surfaced rod was placed on the head of each bone peg to press it to a depth slightly lower than the articular cartilage surface. Postoperatively, the elbow was immobilized for 3 weeks. Throwing was allowed at 6 months, and a return to competitive baseball at preinjury levels was permitted at 8 months after BPG. Alternatives Arthroscopic debridement of the lesion.Arthroscopic bone marrow stimulation or microfracture.Fragment fixation using metal implants or biodegradable materials.Use of autologous osteochondral graft from the distal aspect of the femur or from a rib. Rationale Our follow-up study after BPG revealed that 10 of 11 patients with ICRS OCD I or II capitellar OCD could return to their preinjury baseball ability and that 8 of the 11 lesions completely healed as seen radiographically11. Radiographic and magnetic resonance imaging (MRI) findings showed that BPG could secure the lesion to the osseous floor as a physiological scaffold. Fragment fixation with metal implants or biodegradable materials carries a risk of damaging cartilage surfaces, and autologous osteochondral grafting is too invasive for this early-stage lesion. BPG is indicated for ICRS OCD I or II lesions, especially with central positioning and/or occupying

Closed tendon rupture is a well-known complication of Kienböck disease, but only 11 cases have been reported. We reviewed six cases of Kienböck disease with subcutaneous rupture of a tendon. There were five cases of 4th extensor tendons and one case of the flexor digitorum profundus tendons of the ring finger and little finger. Radiographs showed protrusion of the segmented lunate or the deformed lunate in all cases. Intraoperative findings confirmed rupture of the wrist joint capsule by these lunate lesions. We then reviewed 11 reported cases in English and 48 cases in Japanese and confirmed that all cases had similar clinical characteristics and radiological features to our own, except the involved digits of flexor tendon rupture. Our case was unique in that the ulnar side tendons were ruptured, while in the reported cases the radial flexor tendons were more susceptible to rupture than the ulnar ones. Closed rupture of tendons should be recognised as a complication in patients over middle age with stage IIIb or IV asymptomatic or less symptomatic Kienböck disease.

In Japan, spinal dual-energy X-ray absorptiometry (DXA) has been commonly performed for diagnosing osteoporosis but scanning the proximal femur is not done widely. The latest Japanese guidelines for prevention and treatment of osteoporosis, revised in 2006, recommend bone mineral density (BMD) measurement at both spine and hip for diagnosing osteoporosis, although there have been no reports that proved the necessity of those measurements. One thousand forty-one women and 485 men with clinical suspicion of osteoporosis were enrolled in this study, and DXA was performed at both spine and hip. The proportions of the patients who had inconsistency between diagnosis of osteoporosis from spinal DXA and that of hip were estimated. As a result, 22% of women and 15% of men had an inconsistency with the diagnosis of osteoporosis using DXA at each measurement site. There was inconsistency in diagnosing osteoporosis using DXA at the spine and proximal femur measurement sites. Because spine and femoral DXA measurements complement each other in the diagnosis of osteoporosis, BMD measurement at both spine and hip should be performed for all Japanese patients who are suspected osteoporosis, regardless of age and sex.

We evaluated the correlation between Japanese versions of patient-oriented questionnaires and electrophysiological examinations in patients with carpal tunnel syndrome (CTS).A series of 45 patients who were diagnosed with carpal tunnel syndrome and subsequently underwent carpal tunnel release surgery were analyzed. There were 8 men and 37 women with an average age of 64.8 years. They completed the Japanese Society for Surgery of the Hand version of the Carpal Tunnel Syndrome Instrument (CTSI-JSSH), which consisted of a Symptom Severity Score (CTSI-JSSH-SS), Functional Score (CTSI-JSSH-FS), and Japanese Society for Surgery of the Hand version-Quick Disability of Arm, Shoulder, and Hand questionnaire (QuickDASH-JSSH) both preoperatively and 3 months postoperatively. Nerve conduction studies (NCSs) were also performed and included motor distal latency (MDL) and sensory nerve conduction velocity (SCV) measurements. The responsiveness of each instrument was evaluated by calculating the standardized response mean (SRM) and effect size (ES). Correlation coefficients between preoperative and postoperative questionnaire scores and NCS parameters were calculated.Responsiveness (SRM/ES) was as follows: CTSI-JSSH-SS (-1.06/-1.14), CTSI-JSSH-FS (-0.75/-0.74), Quick-DASH-JSSH (-0.65/-0.62), MDL (-1.45/-1.11), and the neurophysiological stage of the disease (-0.90/-1.42). No significant correlation was observed between the preoperative and postoperative patient-oriented questionnaires and nerve conduction studies (P0.05).Although NCSs and the Japanese version of patient-oriented questionnaires are highly responsive to treatment, they are not parallel. Multifaceted assessment of CTS treatment is possible by performing both outcome measurements.

Article, ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY. 23(8): 816-821 (2007)

Background Osteoarthritis (OA) is the most common skeletal disease worldwide. Although thumb carpametacarpal joint (CMJ) OA is also frequently encountered, the etiologies remain largely unknown. Method We analyzed 20 patients who had thumb CMJ OA with accompanying joint pain and categorized a total of 37 thumbs according to the Eaton and Littler staging system. Results In patients with advanced OA, bone alterations as detected by magnetic resonance imaging (MRI) were observed in almost all of the painful joints. The frequency of bone alterations in the thumb CMJ increased with OA severity. In contrast, MRI revealed no bone alterations in thumbs with no pain and less pain in bilateral thumb basal pain, even in radiographically advanced OA. Conclusions While the incidence of bone cysts in the CMJ was higher with OA staging, OA severity had no apparent correlation with pain. Thus, it is possible that the cause of thumb CMJ pain in advanced OA is bone alterations.

Yukio Nakamura,1,2 Mikio Kamimura,3 Shota Ikegami,1 Keijiro Mukaiyama,4 Masatoshi Komatsu,1 Shigeharu Uchiyama,1 Hiroyuki Kato11Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, 2Department of Orthopaedic Surgery, Showa Inan General Hospital, Komagane, 3Center of Osteoporosis and Spinal Disorders, Kamimura Clinic, Matsumoto, 4Department of Orthopaedic Surgery, Azumi General Hospital, Azumino, JapanAbstract: The syndrome ofpregnancy- and lactation-associatedosteoporosis is a rare disorder whose precise etiology and treatment are largely unknown. We herein report two such cases occurring in the earlypostpartumperiod that led to multiple fragility compression fractures. Combination therapy of vitamin D and vitamin K enabled a marked gradual increase in bone mineral density.Keywords: fracture, vitamin D, vitamin K, bone mineral density

The aim of this study was to investigate if differences in leg positioning affect spinal bone mineral density (BMD) measurements and the detection of low bone mass. Subjects included 1039 Japanese patients, 878 women and 161 men (mean ages: 67 and 71 years, respectively). Spinal BMD (L1-4) was measured using dual-energy X-ray absorptiometry (DXA) with patients lying in 2 different positions: (1) supine on the scanning table with hips flexed and knees flexed over a 90° support pad (the standard position) and (2) simply supine (the supine position). Predictive indices were calculated for spinal DXA acquired with patients in the supine position. A BMD T-score of -2.5 or lower was set as the threshold for low bone mass. For the standard and the supine positions during scanning in women, BMDs were 0.911 and 0.915 g/cm(2), respectively; in men, they were 1.117 and 1.124 g/cm(2), respectively. The estimated systematic bias in BMD between the positions was 0.42% (95% confidence interval: 0.24, 0.59; p = 0.009). Random errors in the densitometry measurements for the standard and supine positions were 0.66% and 0.84%, respectively. There was no significant difference between the errors (p= 0.164). The likelihood ratios of a positive and negative test for the detection of low bone mass following supine DXA were 121.0 and 0.066, respectively, compared with results acquired using the standard position. In conclusion, DXA measurements acquired with patients in the supine position slightly overestimated BMD vs the standard position. However, the clinical equivalency between the positioning methods for DXA is preserved to the extent that low bone mass can be reliably detected in the supine position.

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures. Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance. There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35). Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate. Cite this article: Bone Joint J 2015; 97-B:957–62.

Biochemical bone metabolic markers are affected by fractures, and total alkaline phosphatase (ALP) is considered one of the bone formation markers. Only a few reports have dealt with changes in bone formation markers during the healing process of bone fragility hip fractures. Despite the difference in the amount of callus formation and bone fusion rate, no significant differences in longitudinal change of total ALP between femoral neck and trochanter fracture have been reported.A total of 69 osteoporotic patients with femoral neck or trochanter fracture whose serum concentrations of total ALP were examined at least four times at six periodic examination points (1, 2, 3, 4, 6, and 8 weeks after surgery) and whose state of bone union was obtained within 24 weeks after surgery were selected for this retrospective study. The characteristic longitudinal change of total ALP during the healing process was shown, and the possibility of total ALP as a predictive factor for the state of osteosynthesis of hip fractures is discussed.Changes in the total ALP level according to the healing process were similar for femoral neck and trochanter fractures. The concentration of total ALP rose to a maximum at 3 weeks after surgery and then gradually decreased for both fractures. However, the range of change was significantly greater for trochanter fractures than for femoral neck fractures. For trochanter fractures, total ALP decreased from 3 to 6 weeks after surgery in all but one patient.Increases in the concentration of total ALP after surgery and the subsequent decreases may reflect the normal healing process. A significant difference in the changes of total ALP after surgery between femoral trochanter and neck fractures was shown. Periodic measurement of total ALP might be useful for obtaining information on the osteosynthesis state.

The present study measured changes in plasma pentosidine and bone turnover markers in elderly patients with osteoporosis treated using bisphosphonate. The relationship between pentosidine and bone turnover markers and bone mineral density (BMD) was investigated. This study consisted of post-menopausal osteoporotic women who could be treated using bisphosphonate for 3 years were included in the present analysis. The study population consisted of 58 cases, all women, ranging in age from 53 to 86 years (mean, 67.1 years). Bisphosphonate treatment significantly increased BMD of the lumbar spine to 0.914 ± 0.141 g/cm(2) and BMD of the femoral neck to 0.708 ± 0.086 g/cm(2) after 3 years (p 0.001 versus baseline). The mean BAP level was 27.3 ± 8.3 U/L in patients at baseline. After bisphosphonate treatment, BAP significantly decreased to 18.1 ± 7.2 U/L at 3 years (p 0.001). Urinary NTX also decreased after bisphosphonate treatment. After 3 years of treatment, urinary NTX significantly decreased from 50.0 ± 19.0 nmol BCE/mmol Cr to 24.6 ± 10.2 nmol BCE/mmol Cr at 3 years (p 0.001). Serum pentosidine levels were 0.0413 ± 0.0094 μg/mL at baseline and 0.0413 ± 0.0122 μg/mL after 3 years. They were not significantly changed by bisphosphonate treatment. Serum pentosidine levels were not changed by treatment with bisphosphonates. Thus, serum pentosidine may not be suitable as a marker of bone quality after 3 years of bisphosphonate treatment.

Objective: To correlate morphological findings of idiopathic carpal tunnel syndrome (CTS) with the function of the median nerve. Methods: In this study, 105 wrists of 105 women patients with idiopathic CTS, and 36 wrists of 36 female volunteers were subjected to nerve conduction studies and MRI. Cross sectional area, signal intensity ratio, and the flattening ratio of the median nerve, carpal tunnel area, flexor tendon area, synovial area, and intersynovial space, and the palmar bowing of the transverse carpal ligament (TCL) were quantified by MRI and correlated with the severity of the disease determined by nerve conduction studies. Results: Cross sectional areas of the median nerve, flexor tendons, and carpal tunnel, and the palmar bowing of the TCL of the CTS groups were greater than in the control group, but differences were not detected among the CTS groups for the area of the flexor tendons and the carpal tunnel. Enlargement, flattening, and high signal intensity of the median nerve at the distal radioulnar joint level were more significant in the advanced than in the earlier stages of the disease. Increase in palmar bowing of the TCL was less prominent in the most advanced group. Linear correlation between the area of the carpal tunnel and palmar bowing of the TCL was noted. Conclusion: Severity of the disease could be judged by evaluating not only longitudinal changes of signal intensity and configuration of the median nerve, but also palmar bowing of the TCL. Increased palmar bowing of the TCL was found to be associated with an increase in the area of the carpal tunnel.

Despite close proximity of the fracture site to the nerve, ulnar nerve palsy after surgery for fracture of the olecranon is uncommon. We examined 18 cases of fracture of the olecranon treated surgically retrospectively to see if there were any characteristics common to 4 cases of ulnar nerve palsy. Three cases of palsy with a comminuted fracture had fair or poor reduction as revealed by both the lateral and anteroposterior radiographs taken at the time of surgery. The other case, with little displacement of the fragment, had osteoarthritic changes at the medial side of the elbow. The mechanism of development of ulnar nerve palsy is considered to be multifactorial. However, it should be noted that evaluation of reduction of the fracture, not only on a lateral radiograph but also on an anteroposterior radiograph at the time of surgery, is important to prevent the ulnar nerve from being jeopardized.

The "virtual fluoroscopy" is a new navigation system that combines image-guided surgery and C-arm fluoroscopy. The purpose of this study was to evaluate the accuracy of this system in the case of pedicle screwing. The angular deviation in the axial and sagittal planes was measured using the bodies of 50 vertebral models. Another type of model was used to evaluate the positional deviation (two dimension and three dimension). The mean angular deviation on the axial plane was 1.3 degrees and that on the sagittal plane was 1.0 degree. The positional deviation was not recognised. This system provides quite accurate information. Using this system, the surgeon can insert surgical instruments, such as pedicle screws, while confirming the real time virtual image on the monitor displaying the surgical field, including the position and direction of the instruments, without being disturbed by his own hands or instruments and without radiation exposure.

To evaluate the differences in outcomes of treatment with denosumab alone or denosumab combined with vitamin D and calcium supplementation in patients with primary osteoporosis. Patients were split into a denosumab monotherapy group (18 cases) or a denosumab plus vitamin D supplementation group (combination group; 23 cases). We measured serum bone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase (TRACP)-5b and urinary N-terminal telopeptide of type-I collagen (NTX) at baseline, 1 week, as well as at 1 month and 2, 4, 8 and 12 months. We also measured bone mineral density (BMD) of L1–4 lumbar vertebrae (L)-BMD and bilateral hips (H)-BMD at baseline and at 4, 8 and 12 months. There was no significant difference in patient background. TRACP-5b and urinary NTX were significantly suppressed in both groups from 1 week to 12 months (except at 12 months for NTX). In the combination group, TRACP-5b was significantly decreased compared with the denosumab monotherapy group at 2 and 4 months (PP

Arthrodesis of the carpometacarpal (CM) joint of the thumb has been recognized as a common technique that gives pain relief, stability, and strength, but it has some disadvantages, such as nonunion, pantrapezial osteoarthritis, and reduced mobility.Thirteen thumbs of 12 patients with CM joint arthritis who underwent CM joint arthrodesis were reviewed retrospectively. The average age of the patients was 61.0 years. The follow-up period ranged from 2 to 5 years. Arthrodesis was performed with a T-plate and an autogenous iliac cancellous bone graft for all patients.All thumbs had radiographic evidence of union, and there was no nonunion. No reduction of motion of the interphalangeal and metacarpophalangeal joint of the thumb was found after surgery. Postoperatively, scaphotrapeziotrapezoid arthritis and metacarpophalangeal arthritis progressed in two joints each. The Disabilities of the Arm, Shoulder, and Hand score improved from 39.9 (range 8-69) to 11.1 (range 0-23.1). All patients had no or slight problems of the thumb and no complaints related to the pelvis in daily living and were either very satisfied or satisfied with the surgery.Arthrodesis of the thumb CM joint with a plate and bone graft achieved satisfactory results in all cases with very few complications. This procedure is a valuable tool in middle-aged and elderly patients with thumb CM joint arthritis.

A biomechanical analysis of the trapeziometacarpal joint was performed in 7 fresh-frozen normal human cadaveric hands to compare the kinematics of the trapeziometacarpal joint before and after surface total joint replacement. Using a 3-space magnetic Isotrak system (Polhemus, Colchester, VT), which provides a 3-dimensional analysis of motion of joints as well as translation, we found that kinematics and stability of the trapeziometacarpal joint could be duplicated by joint surface replacement arthroplasty provided that normal ligament tensions were present.