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We evaluated the tendon length and excursion after extensor tendon grafting following ruptures at the distal radioulnar joint in eight patients. The mean patient age was 70.8 years (range 58 to 84), and the mean follow-up period was 63 months (range 12 to 129). Radiographic markers were placed on ends of the grafted tendon to assess changes in length and passive excursion. The mean length of the grafted tendon and mean passive excursion were 68.2 mm and 4.4 mm immediately after tendon grafting, 76.1 mm and 7.1 mm at 1 year postoperatively, and 76.3 mm and 7.3 mm at final follow-up, respectively. The mean elongation of the grafted tendon was 12% and mean increase of excursion was 2.9 mm. We recommend that tension set during extensor tendon grafting should be with the metacarpophalangeal joint of the affected finger in a slightly extended position as compared with adjacent fingers. Level of evidence IV

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

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy worldwide, but there are few reports investigating its prevalence using subjects diagnosed by both clinical symptoms and nerve conduction studies (NCSs) in a population-based cohort. This study aimed to determine the epidemiology of CTS diagnosed by sensory disturbance findings and NCSs using a randomly sampled resident population. Methods: Subjects aged between 50 and 89 years were randomly sampled from the basic resident registry of a rural Japanese town. Subjects indicating a history of CTS surgery in a written questionnaire were classified as having past CTS. Subjects with both sensory disturbance of the median nerve area and delays in NCSs were diagnosed as having present CTS. Subjects with past or present CTS were judged as affected with CTS. We calculated the prevalence of CTS and investigated for possible risk factors. Results: Seventeen subjects (14 female and 3 male) were affected with CTS among 379 enrolled subjects. Adjusting these results to Japanese population values, the weighted prevalence of CTS was 4.7% (female: 7.2%, male: 1.8%) in the Japanese population aged 50 to 89 years. Statistically significant positive correlations were found between CTS and female, higher BMI, rheumatoid arthritis, and trigger digit. In females affected with CTS, third metacarpal length was significantly shorter than in those without CTS. Conclusions: This epidemiological study clarified the prevalence of CTS among Japanese seniors as 4.7%. Female, higher BMI, rheumatoid arthritis, trigger digit, and shorter third metacarpal length in females were risk factors for CTS.

Introduction Cognitive function is an important factor that affects functional recovery after hip fracture (HipFx) surgery. The literature on the pathophysiology of dementia in HipFx patients is scarce. We performed a differential diagnosis of dementia in HipFx patients using clinical and brain MRI findings. Methods This is a prospective study in which brain MRI was evaluated for patients with HipFx for research purposes. One-hundred-and-five HipFx patients (85 females and 20 males) who underwent surgery and were subsequently able to undergo brain MRI at our hospital were evaluated. The mean age was 84 years. The presence of dementia was determined based on clinical findings and whether the patient meets its diagnostic criteria according to the International Classification of Diseases 10th Edition (ICD-10). The differential diagnosis of dementia was made based on brain MRI findings and the dementia diagnostic flow chart published in the Clinical Practice Guideline for Dementia 2017 (Japanese Society of Neurology). The Voxel-based Specific Regional Analysis System for Alzheimer’s Disease (VSRAD) advance 2 diagnostic software was used to evaluate atrophy of the para-hippocampal gyrus. Results Fifty-six (53%) patients were clinically diagnosed with dementia according to the ICD-10 criteria. The MRI findings were diverse: Alzheimer’s disease (AD)-type, asymptomatic multiple ischemic cerebral lesions, past symptomatic cerebral infarction or cerebral hemorrhage, Binswanger’s disease (BW)-type, chronic subdural hematoma, disproportionately enlarged subarachnoidal hydrocephalus (DESH), and their combinations thereof. A combination of MRI and clinical findings of dementia patients demonstrated the following distribution of dementia subtypes: AD (n = 20), vascular dementia (n = 33), AD and BW vascular dementia (n = 3). Conclusion This study revealed that the brain MRI findings of HipFx patients were diverse. Although vascular dementia is found to be common in this particular population, this could be an incidental finding. Further study is warranted to clarify the specificity of our findings by increasing the number of patients, setting the control, and investigating whether dementia subtypes affect postoperative gait acquisition and fall risk.

In osteoporosis patients receiving antiresorptive medications, stopping the drug and delaying tooth extraction has been suggested to reduce the risk of osteonecrosis of the jaw (ONJ). However, postponing tooth extraction for ≥ 2 months was associated with an increased risk of delayed wound healing beyond 8 weeks after extraction, a risk factor for developing ONJ. A long waiting time before tooth extraction could result from concern about a potential increased risk of osteonecrosis of the jaw (ONJ) in osteoporosis patients. We clarified whether a long waiting time before tooth extraction during the past year may be associated with an increased risk of delayed wound healing beyond 8 weeks after tooth extraction, which may be a risk factor of ONJ. Of 5639 patients aged ≥ 60 years who visited our 20 clinics or hospitals and answered a structured questionnaire, 426 patients (151 men, 275 women) aged 60–96 years comprised the final participants in this study. Self-reported kyphosis was used as a surrogate marker of vertebral fractures. Stepwise logistic regression analysis, adjusted for covariates, was used to calculate the odds ratio (OR) and the 95% confidence interval (CI) for the presence of delayed wound healing longer than 8 weeks after tooth extraction during the past year based on the duration before extraction. Subjects who had waited > 2 months for tooth extraction had a significantly higher risk of delayed wound healing compared with those whose tooth was extracted within 1 month (OR = 7.23; 95% CI = 2.19–23.85, p = 0.001) regardless if antiresorptive medications for osteoporosis were used. The presence of self-reported kyphosis was significantly associated with an increased risk of delayed wound healing (OR = 5.08; 95% CI = 1.11–23.32, p = 0.036). A long waiting time before tooth extraction may be a risk factor for delayed wound healing beyond 8 weeks after extraction in patients aged ≥ 60 years.

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 The natural history and pathogenesis of the skeletal abnormalities found in neurofibromatosis type 1 (NF1) are poorly understood, and the therapeutic options for these manifestations remain limited. This report first describes the clinical outcomes of denosumab treatment for a patient with NF1 suffering from osteoporosis. Methods We enrolled a patient with NF1 under denosumab treatment for osteoporosis, prior fractures, and no improvement in bone mineral density (BMD) over 3 years of alendronate therapy. BMD was monitored by dual-energy X-ray absorptiometry. Tested laboratory data included bone-specific alkaline phosphatase, urinary type I collagen amino-terminal telopeptide, tartrate-resistant acid phosphatase 5b, 1-alpha, 25-dihydroxyvitamin D3, and parathyroid hormone. BMD and laboratory data were evaluated before, between 2 and 4 months, and at 6, 12, 18, and 24 months of treatment. Case presentation During 2 years of denosumab therapy for osteoporosis in a 58-year-old female NF1 patient with prior fractures, BMD increased by 6.5% in the lumbar spine and 10.6% in the total hips, and bone turnover markers were notably improved. No fractures occurred during the latter half of treatment. Conclusion Denosumab represents an effective treatment option for osteoporosis in NF1 patients.

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.

Atypical femoral fracture (AFF) has emerged as one of the most concerning issues in the management of osteoporosis. However, the surgical and other treatment methods for AFF have not been f...

Osteoporosis is a worldwide health concern. Although treatment with denosumab plus the active vitamin D alfacalcidol has been found to improve femoral neck (FN) and distal forearm bone mineral density (BMD), there have been no reports on the efficacy or adverse effects of denosumab plus eldecalcitol (ELD) in primary osteoporosis patients. Fifty-six treatment-naïve post-menopausal women with primary osteoporosis were recruited and divided into denosumab plus native vitamin D or denosumab plus ELD. Ultimately, 26 subjects in the native vitamin D group and 24 in the ELD group were analyzed. Lumbar and total hip BMD significantly increased in both groups. However, there was no significant difference in the percent increase of lumbar and total hip BMD between two groups. FN-BMD was significantly increased from 6 to 12 months in the ELD group compared with baseline. This study revealed that combination therapy with denosumab and ELD could improve FN-BMD more effectively than denosumab plus native vitamin D. Thus, the addition of ELD may enhance the effects of denosumab treatment for primary osteoporosis.

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

This study aimed to clarify the effects of short-term bisphosphonate (BP) administration in Japanese osteoporotic patients retrospectively. Daily minodronate (MIN) at 1 mg/day (MIN group) or weekly risedronate (RIS) at 17.5 mg/week (RIS group) was primarily prescribed for each patient. We analyzed the laboratory data of 35 cases (18 of MIN and 17 of RIS) before the start of treatment and at 4 months afterward. The changes in 25(OH)D3, whole parathyroid hormone (PTH), serum pentosidine, and the bone turnover markers urinary cross-linked N-telopeptide of type I collagen (NTX), serum tartrate-resistant acid phosphatase (TRACP)-5b, bone-specific alkaline phosphatase (BAP), and undercarboxylated osteocalcin were evaluated. Overall, serum 25(OH)D3 was significantly decreased from 21.8 to 18.4 ng/mL at 4 months, with a percent change of -14.7%. Whole PTH increased significantly from 23.4 to 30.0 pg/mL, with a percent change of 32.1%. Serum pentosidine rose from 0.0306 to 0.0337 μg/mL, with a percent change of 15.2%. In group comparisons, 25(OH)D3 and pentosidine showed comparable changes in both groups after 4 months of treatment, whereas whole PTH became significantly more increased in the MIN group. All bone turnover markers were significantly decreased at 4 months in both groups. Compared with the RIS group, the MIN group exhibited significantly larger value changes for urinary NTX, serum TRACP-5b, and BAP at the study end point. This study demonstrated that serum 25(OH)D3 became significantly decreased after only 4 months of BP treatment in Japanese osteoporotic patients and confirmed that MIN more strongly inhibited bone turnover as compared with RIS.

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.

We present an original technique for determining the tension of the extensor pollicis longus tendon after reconstruction. We treated 20 patients using this technique for an extensor pollicis longus tendon graft or extensor indicis tendon transfer and reviewed the results. The tension of the reconstructed extensor pollicis longus was adjusted so that the centre of the distal edge of the thumbnail was elevated 2 cm above the operation table. The mean retropositional distance of the treated thumbs was 1.2 cm less than the contralateral thumbs. The mean total active motion of the thumb was 90%. This technique resulted in satisfactory thumb function. Level of evidence: IV

Background: There are several methods for measuring edema of the hand. While the volumetric techniques, finger circumference measurement, and figure-of-eight techniques have undergone extensive psychometric testing, alternative methods of measuring hand size, such as circumferential finger size determination using a ring gauge (ring gauge method; RGM) and tape measurement of hand girth taken along the distal palmar crease (metacarpal head tape measure method; MHTM), have not. This study's aim is to examine the reliability and validity of the RGM and the MHTM. Methods: In this cross-sectional study, two examiners measured 22 hands in 22 patients with hand edema using the RGM and the MHTM 3 times each to determine intra- and inter-tester reliability. The validity of each method was established using the finger circumference measurement and figure-of-eight method, respectively. Results: The intra-class correlation coefficient (ICC) obtained for intra-tester reliability was 0.99–0.98 for both methods. ICCs for inter-tester reliability were 0.97–0.98 for the RGM and 0.98 for the MHTM. Pearson product-moment correlation values between the RGM and finger circumference measurement were 0.92–0.96, while those between the MHTM and figure-of-eight method were 0.84–0.90. Conclusions: The RGM and the MHTM are reliable and valid evaluation tools for the assessment of hand size.

As a bisphosphonate, minodronate (MIN) is one of the strongest inhibitors of bone resorption. However, there have been no reports directly comparing the antiresorptive effects of monthly MIN with those of monthly risedronate (RIS). We enrolled 30 cases of osteoporosis (OP; 16 in the MIN group [mean age: 68.2 years] and 14 in the RIS group [mean age: 68.1 years]) to investigate the early effects of treatment by monthly MIN or RIS over a 4-month period using bone turnover marker values. Only female patients were enrolled to avoid gender bias. Urinary cross-linked N-telopeptide of type I collagen (NTX) before treatment and at 1, 2, and 4 months of therapy, as well as serum bone alkaline phosphatase and alkaline phosphatase before treatment and at 4 months afterwards, were evaluated. All bone turnover marker values were significantly decreased at 4 months in both groups. The changes in urinary NTX at the study end point for RIS and MIN were −30.1% and −63.1%, respectively. From 2 months of treatment, the antiresorptive effects on urinary NTX by MIN were significantly higher than those by RIS, indicating that MIN more immediately and strongly inhibited bone absorption. Thus, monthly MIN seems to suppress bone resorption faster and more strongly than RIS in OP treatment.

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.

Most of the alkaline phosphatase (ALP) isoenzymes are derived from the bones and liver. High levels of ALP are often encountered during routine blood investigation in elderly patients. However, because ALP includes various isoenzymes from other tissues, an accurate diagnosis is usually not possible on the basis of elevated ALP alone. To identify the cause of increased ALP in postmenopausal women. We measured serum ALP in a group of 626 postmenopausal osteoporotic women before and after treatment with a bisphosphonate (either alendronate or risedronate). We analyzed the correlations between ALP levels and bone metabolic markers or hepatic function markers. The ALP and BAP levels of people in their 80s were significantly higher than those of people in their 60s. With bisphosphonate therapy, the BAP decreased, and the elevated ALP decreased to normal range levels. ALP was highly and significantly correlated with BAP both before and after treatment. The changes in levels of ALP correlated well with the changes in BAP levels before and after bisphosphonate therapy. Markers of liver function correlated with total ALP (p

Patient: Male, 83 Final Diagnosis: Osteoarthritis Symptoms: Knee joint pain Medication: — Clinical Procedure: Resting Specialty: Orthopedics and Traumatology Objective: Challenging differential diagnosis Background: Osteoarthritis (OA) is the leading cause of musculoskeletal pain and functional disability worldwide. However, the etiology of this condition is still largely unknown. Case Report: We report the clinical course of an elderly man with knee OA. Conclusions: Plain radiographs and MRI examinations performed during follow-up suggested that the pathophysiology of the patient’s knee OA and joint pain may have been primarily due to bone alterations.

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.

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.

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 D

Osteogenesis imperfecta (OI) is an inherited bone disorder that causes fractures due to impaired production of collagen type I. In recent years, denosumab, a human monoclonal antibody against receptor activator of nuclear factor κB ligand (RANKL), has become widely used as an anti-osteoclastic agent for osteoporosis. This study investigated osteoporotic cases of OI to examine effects of denosumab on bone fragility. This was a retrospective, consecutive case series that included 3 female patients aged 42, 40, and 14 years, respectively. One patient carries a point mutation (c.G769A) in the COL1A1 gene, encoding collagen type I alpha 1 chain, which causes an amino-acid substitution (p.G257R). By contrast, no mutation was found in the analyzed regions of the OI responsive genes in another two patients (mother and daughter). These three patients underwent subcutaneous injection of denosumab every 6 months. All patients underwent dual-energy X-ray absorptiometry for bone mineral density (BMD) measurement of the lumbar 1-4 spine (L-BMD) and bilateral hips (H-BMD) before and during treatment. BMD and laboratory data were evaluated before, between 2 and 4 months, and at 6, 12, 18, and 24 months of therapy. No fractures or severe side effects, such as hypocalcemia, were observed during denosumab treatment. Both L-BMD and H-BMD were increased by denosumab. At 24 months, the mean percentage changes in L-BMD and H-BMD were 14.7% and 15.1%, respectively. In conclusion, no bone fragility fractures occurred during 2 years of denosumab administration in OI patients. Denosumab therefore is a good therapeutic option in the OI patients.

Bisphosphonates (BPs) increase bone mineral density (BMD) through the inhibition of osteoclast activity. Among BPs, ibandronate (IBN) is a strong inhibitor of bone resorption. However, the effects of a vitamin D analogue, alfacalcidol (ALF), on IBN treatment for osteoporosis is unknown. Fifty-three treatment-naive post-menopausal women with primary osteoporosis were recruited and divided into IBN-treatment group (IBN group) and IBN with ALF group (IBN/ALF group). IBN (1.0 mg) was intravenously injected once a month, with or without oral ALF (1.0 μg/day). Ultimately, 19 subjects in IBN group and 26 in IBN/ALF group were analyzed. Bone turnover markers were examined at 4, 6, 12, and 18 months, and BMD was measured at 6, 12, and 18 months. Compared with pre-treatment, bone turnover markers significantly decreased in both groups after 4 months. The levels of serum N-terminal propeptide of type-1 procollagen and tartrate-resistant acid phosphatase-5b, and urinary N-terminal telopeptide of type-I collagen were significantly lower in IBN/ALF group than those in IBN group at 12 months. Lumbar 1-4 (L)-BMD significantly increased from 6 months in IBN/ALF group and at 18 months in IBN group. L-BMD was significantly higher in IBN/ALF group (6.6% increase) than in IBN group (3.4%) at 18 months. Total hip (H)-BMD significantly increased from 6 months in IBN/ALF group and tended to improve in IBN group. H-BMD was significantly higher in IBN/ALF group (4.8%) than in IBN group (3.2%) at 18 months. In conclusion, treatment with ALF in combination with IBN improves BMD in post-menopausal women with osteoporosis.

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: 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.

Chronic pain, a challenging issue worldwide, requires better treatment. In this prospective, open-label study, we examined the frequency of adverse effects associated with treatment with a fixed-dose combination of tramadol/acetaminophen 37.5/325 mg following gradually increased administration in outpatients with chronic musculoskeletal pain (focusing on degenerative spinal disorders and degenerative joint disorders). In all cases, tramadol/acetaminophen administration reached a plateau within 2 months and the frequency of adverse events were evaluated at that time. Patients with degenerative spinal disorders had significantly higher rates of overall adverse events and constipation (the most common adverse event) than patients with joint disorders.

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.

It is unclear whether osteoporosis itself is a main risk factor for delayed wound healing after tooth extraction in humans. In this study, we evaluated the association between experience of delayed wound healing after last tooth extraction and self-reported kyphosis, with the possibility of having vertebral fractures, in Japanese patients. Among the 1,504 patients who responded to the structured questionnaire survey, 518 patients (134 men and 384 women) aged 55–97 years finally participated in this study. Patients who self-reported mild-moderate kyphosis were more likely to have problematic delayed wound healing after last tooth extraction than those who reported severe kyphosis (odds ratio [OR] 4.98; 95% confidence interval [CI], 1.86–13.38 and OR 2.30; 95% CI, 0.52–10.22, respectively) (p for trend = 0.005). Japanese patients with vertebral fractures may have a higher risk of having problematic delayed wound healing after tooth extraction.

Objectives: The aim of this study was to investigate whether bone alterations detected by hip magnetic resonance imaging (MRI) were associated with subsequent primary hip OA. Methods: We enrolled 7 patients with hip joint pain from their first visit, at which hip joints were classified as grade 0 or I on the Kellgren-Lawrence grading scale. Plain radiographs and magnetic resonance imaging (MRI) were performed on all cases, and pain was assessed with the Denis pain scale. Average age, height, weight, body mass index, bone mineral density (L1-4), central edge angle, Sharp’s angle, and acetabular hip index were calculated. Results: Within two months of the onset of pain, 4 of the 7 cases showed broad bone signal changes, while 3 cases showed local signal changes in the proximal femur on hip MRI. Three to 6 months after the onset of pain, in all patients whose pain was much improved, plain radiographs showed progression to further-stage OA. Conclusion: Our findings suggest that bone abnormalities in the proximal femur might be involved in the pathogenesis of primary hip OA.

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.