Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs

OBJECTIVE

This study is to assess the diagnostic performance of magnetic resonance imaging (MRI) findings for type 1B triangular fibrocartilage complex (TFCC) tear of the wrist.

MATERIALS AND METHODS

This study retrospectively enrolled 78 patients to examine the diagnostic performance of preoperative MRI examinations in patients with type 1B TFCC tears. Thirty-nine participants had confirmed type 1B TFCC tear. The control group included 39 patients who were randomly selected from 1157 patients who underwent MRI for wrist pain. Both groups underwent a review of 19 MRI findings by two independent radiologists, and the correlation between each diagnostic finding and type 1B TFCC tear was assessed using the chi-squared test. The 19 MRI findings comprised eight primary signs of abnormalities in the distal or proximal lamina, in conjunction with 11 secondary signs suggestive of abnormalities in the surrounding structures.

RESULTS

The TFCC tear group demonstrated a significantly higher incidence of two primary MRI signs, i.e., fiber discontinuity and signal alteration in the distal lamina, as observed by both readers (R1, 74.4% vs. 38.5%, p = 0.003, and 87.2% vs. 43.6%, p < 0.001; R2, 74.4% vs. 35.9%, p = 0.001, and 87.2% vs. 53.8%, p < 0.003, respectively). Reader 2 identified a higher prevalence of two additional primary MRI signs: fiber discontinuity and signal alteration in the proximal lamina (all p < 0.05). None of the 11 secondary MRI signs demonstrated statistically significant associations with type 1B TFCC.

CONCLUSION

MRI manifestations of fiber discontinuity and signal alteration in the distal lamina may provide predictive markers for type 1B TFCC wrist tear.

Fracture Management in Chronic Kidney Disease: Challenges and Considerations for Orthopedic Surgeons

Orthopedic surgeons treating fractures need to consider comorbidities, including chronic kidney disease (CKD), which affects millions worldwide. CKD patients are at elevated risk of fractures due to osteoporosis, especially in advanced stages. In addition, fractures in CKD patients pose challenges due to impaired bone healing and increased post-fracture complications including surgical site infection and nonunion. In this article, we will discuss factors that must be considered when treating fractures in CKD patients. Perioperative management includes careful adjustment of hemodialysis schedules, selection of anesthetic methods, and addressing bleeding tendencies. Tourniquet usage for fractures in limbs with arteriovenous fistulae should be cautious. Pain medication should be administered carefully, with opioids like hydromorphone preferred over nonsteroidal anti-inflammatory drugs. Medical management after fractures should address underlying factors and include physical rehabilitation to reduce the risk of subsequent fractures. A comprehensive approach to fracture management in CKD patients can improve outcomes.

Volumetric assessment of ulnar nerves in cubital tunnel syndrome with 3D modeling of the MRI and its relationship with electrodiagnostic findings

BACKGROUND

Thickened nerve cross-sectional areas (CSA) have been investigated in compressive neuropathy, but the longitudinal extent of nerve swelling has yet to be evaluated. We did a volumetric assessment of the ulnar nerve in cubital tunnel syndrome (CuTS) with three-dimensional (3D) magnetic resonance imaging (MRI) modeling and investigated this relationship with clinical and electrodiagnostic parameters.

METHODS

We compared 40 CuTS patient elbow MRIs to 46 patient elbow MRIs with lateral elbow epicondylitis as controls. The ulnar nerve was modeled with Mimics software and was assessed qualitatively and quantitatively. The CSA and ulnar nerve volumes were recorded, and the area under the receiver operating characteristic (ROC) curve was calculated for diagnostic performance. We analyzed clinical and electrodiagnostic parameters to investigate their relationship with the 3D ulnar nerve parameters.

RESULTS

For the diagnosis of CuTS, the area under the curve value was 0.915 for the largest CSA and 0.910 for the volume in the ROC curve. The optimal cut-off was 14.53 mm2 and 529 mm3 respectively. When electrodiagnostic parameters were investigated, the 3D ulnar nerve volume was significantly inversely associated with motor conduction velocity, although there was no association between the largest CSA and any of the electrodiagnostic parameters.

CONCLUSIONS

The 3D ulnar nerve volume, which is an integration or multilevel measurement of CSAs, showed diagnostic usefulness similar to CSA, but it correlated better with conduction velocity, indicating demyelination or early-to-moderate nerve damage in CuTS.

A Lightweight Dynamic Hand Orthosis With Sequential Joint Flexion Movement for Postoperative Rehabilitation of Flexor Tendon Repair Surgery

During the postoperative hand rehabilitation period, it is recommended that the repaired flexor tendons be continuously glided with sufficient tendon excursion and carefully managed protection to prevent adhesion with adjacent tissues. Thus, finger joints should be passively mobilized through a wide range of motion (ROM) with physiotherapy. During passive mobilization, sequential flexion of the metacarpophalangeal (MCP) joint followed by the proximal interphalangeal (PIP) joint is recommended for maximizing tendon excursion. This paper presents a lightweight device for postoperative flexor tendon rehabilitation that uses a single motor to achieve sequential joint flexion movement. The device consists of an orthosis, a cable, and a single motor. The degree of spatial stiffness and cable path of the orthosis were designed to apply a flexion moment to the MCP joint prior to the PIP joint. The device was tested on both healthy individuals and a patient who had undergone flexor tendon repair surgery, and both flexion and extension movement could be achieved with a wide ROM and sequential joint flexion movement using a single motor.

How Does the Subchondral Bone Density Distribution of the Distal Humerus Change Between Early and Advanced Stages of Osteoarthritis?

BACKGROUND

The distribution of subchondral bone density in a joint represents stress that is applied to the joint. Knowing this information is important for understanding the pathophysiology of osteoarthritis (OA). In the elbow, however, this has not been studied before.

QUESTIONS/PURPOSES

(1) Is advanced-stage elbow OA associated with more radially distributed subchondral bone density than earlier stages? (2) What demographic (age and sex) and radiographic (osteophyte location and carrying angle) factors are associated with increased radial shift in subchondral bone density?

METHODS

Between March 2001 and December 2021, we treated 301 patients for elbow OA. We considered patients with plain radiographs and conventional CT scans as potentially eligible. Thus, 68% (206 patients) were eligible; a further 27% (80 patients) were excluded because of a history of any injury or surgery or known inflammatory joint disease, leaving 42% (126 patients) for analysis here. Their mean ± standard deviation age was 60 ± 10 years. Early OA with minimal joint space narrowing and osteophyte formation was found in 33% (42 of 126) of patients, and advanced OA was found in the remaining 67% (84 of 126). Three-dimensional distal humerus subchondral bone models were derived from CT images, and in the central intra-articulating portion, we measured the subchondral bone density in two different sites: where it articulates with the radius (SBDrad) and with the ulna (SBDulna). We further defined the SBDratio as the percent ratio of SBDrad to SBDulna. We also evaluated osteophyte severity based on its size at the radiocapitellar and ulnotrochlear joints, and alignment through measuring the carrying angle on radiographs. To assess interobserver reliability, two orthopaedic surgeons took measurements independently from each other. All measurements had excellent intraoberver and interobserver reliabilities. Then, we compared the subchondral bone parameters between early and advanced OA and performed a multivariable analysis of the factors associated with subchondral bone parameters, including age, sex, osteophyte location, and carrying angle.

RESULTS

Radial versus ulna subchondral bone density (SBDratio) was modestly higher in patients with advanced OA (118% ± 17%) than in patients with early OA (109% ± 17%, mean difference 9% [95% CI 2.3% to 15.3%]; p = 0.01). With increasing radial deviation in subchondral bone density, cubitus valgus had a modest association (β = 0.46 ± 0.23; p = 0.04) and severe osteophytes at the radiocapitellar joint had a large association (β = 9.51 ± 3.06; p = 0.002).

CONCLUSION

According to subchondral bone density distribution, stress concentration was more radially deviated in patients with the advanced stages of elbow OA than in those with the early stages. We also found that an increase in carrying angle is associated with radial deviation of stress. A future study that examines longitudinal changes in the subchondral bone density might be required to confirm changes in stress concentration with OA progression.

CLINICAL RELEVANCE

This study gives us insight into the potential pathophysiology of elbow OA in relation to elbow alignment. Although debridement of osteophytes in the ulnotrochlear joint is the most frequently performed procedure in patients with advanced elbow OA, our finding suggests that some patients with an increased carrying angle might benefit from management of the radiocapitellar joint as well, or from being informed of the future development of OA in the radiocapitellar joint, because stress at this site can be increased with the advancement of OA.

Spinal Sagittal Imbalance is Associated with Vertebral Fracture without a Definite History of Falls: Cross-Sectional, Comparative Study of Cohort with and without a Distal Radius Fracture

BACKGROUND

Treating osteoporosis in patients with a distal radius fracture (DRF) became paramount at the Fracture Liaison Service. Spinal sagittal imbalance emerged as a risk factor for subsequent fractures. Therefore, here we investigated the spinal profile of patients with DRF to investigate its association with a history of falls and prevalent vertebral fractures.

METHODS

We reviewed the cases of 162 women presenting with DRF and 162 age-matched women without fracture who underwent an osteoporosis evaluation including bone mineral density (BMD) and lateral spine imaging. We compared the incidence of prevalent vertebral fracture and sagittal vertical axis (SVA) to measure spinal sagittal imbalance. We also performed a regression analysis of the risks of prevalent vertebral fracture, such as age, body mass index (BMI), BMD, and SVA.

RESULTS

The SVA was significantly smaller (indicating more stable sagittal balance) in patients with a DRF versus controls (16 mm vs. 34 mm, respectively; p<0.001). The incidence of a prevalent vertebral fracture was similar between groups (12% vs. 15%, respectively; p=0.332). In both groups, the SVA was significantly greater in those with versus without a vertebral fracture. The vertebral fracture was significantly associated with age and SVA but not BMI or spinal BMD.

CONCLUSIONS

Spinal sagittal balance was superior in DRF patients, yet the frequency of prevalent vertebral fractures was similar. The identification of this unique spinal profile in patients with DRF may increase our understanding of osteoporotic fractures.

Intrinsic contracture of the hands in sarcoid myopathy

Hand involvement in sarcoidosis is rare and it presents as tenosynovitis, dactylitis, nodules and osteoarticular bony destruction. We describe an unusual presentation of progressive intrinsic muscle contracture of both hands in a 42-year-old woman with sarcoid myopathy who presented with painful swelling and weakness of all four extremities. Her systemic symptoms improved with oral corticosteroids, but the hand muscle contracture remained after resolution of myositis. Serial soft tissue releases of intrinsic muscle contracture improved hand function markedly. This case highlights that surgery is a viable option to treat intrinsic muscle contracture in patients with chronic sarcoid myopathy complicated with severe muscle contracture.

Three-Dimensional Analysis of the Trapezium Subchondral Bone and its Association with Trapeziometacarpal Joint Osteoarthritis

Subchondral bone properties are associated with the pathogenesis of osteoarthritis (OA), but this relationship has not been confirmed in the trapeziometacarpal joint (TMCJ). We aimed to evaluate the thickness (SBT) and density (SBD) of three-dimensional (3D) trapezium subchondral bone models derived from computed tomography (CT) images, and their relationships with early-stage TMCJ OA. We reviewed patients with a distal radius fracture who underwent conventional CT scans and such osteoporosis evaluations as bone mineral density (BMD) and bone turnover markers (BTMs). From 3D trapezium subchondral bone models, we measured SBT and SBD according to the OA stage and performed multivariate analyses to evaluate their associations with age, sex, body mass index, BMD, and BTMs. As results, a total of 156 patients (78 men and 78 age-matched women; mean age, 67 ± 10 years) were analyzed. There were 30 (19%) with grade 0, 71 (45%) with grade 1, 13 (8%) with grade 2, and 42 (27%) with grade 3 TMCJ OA. SBT was significantly lower in patients with grade 1 OA than those with grade 0 or grade 3 OA, but SBD generally increased according to the OA severity. Low SBT was associated with low BMD, and low SBD with low BMD, high osteocalcin levels, and severe OA grades. In conclusion, patients with early-stage radiographic TMCJ OA have a lower SBT at the trapezium, which may support the potential role of subchondral bone in OA pathogenesis. This study also shows that subchondral bone properties are associated with BMD and osteocalcin levels.

Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?

INTRODUCTION

Studies are conflicting regarding the relationship between ulnar styloid fracture (USF) location and distal radioulnar joint (DRUJ) instability in patients with distal radius fracture (DRF) and concomitant USF. The objective of this study was to determine the association of USF location with TFCC foveal tear and factors associated with DRUJ instability in patients with both DRF and USF.

MATERIALS AND METHODS

Fifty-four patients with both DRF and USF who had wrist MRI examination before surgery were analyzed. USF location (tip or base) and TFCC foveal insertion status (intact, partial tear, or complete tear or avulsion with fractured fragment) were evaluated. DRUJ stability was assessed intra-operatively after fixation of the radius. Factors potentially associated with DRUJ instability, such as age, gender, USF location, USF fragment gap, radioulnar distance, radial shortening, and TFCC foveal tear, were analyzed.

RESULTS

Among 54 patients, 37 (69%) and 17 (31%) had USF at the base and the tip, respectively. In patients with base fractures, TFCC foveal insertion was found to be disrupted in 89% (33/37) patients (complete tear in 11 and partial tear in 22) but intact in 11% (4/37). On the contrary, in patients with tip fractures, the insertion was found to be disrupted in 88% (15/17) patients (complete tear in 2 and partial tear in 13) but intact in 12% (2/17). After fixation of the radius, total 52% (28/54) patients showed DRUJ instability. Especially, DRUJ instability was found in 57% (21/37) of ulna styloid process base fracture patients and 41% (7/17) of ulna styloid process tip fracture patients. In univariate analysis, complete tear of TFCC foveal insertion and wider USF fragment distance were associated with DRUJ instability.

CONCLUSIONS

Tears of TFCC foveal insertion are common in patients with DRF and concomitant ulnar styloid base fractures. Based on the findings of this study, tear of TFCC foveal insertion seems to be also common in patients with DRF and concomitant ulnar styloid tip fractures. And also, DRUJ instability seems to be associated with a TFCC foveal tear independent of USF location.

A cross-sectional analysis of receptor for advanced glycation end-products in human skeletal muscle: a comparative analysis between patients with and without sarcopenia

Introduction Animal studies suggest that advanced glycation end-products (AGEs) and their interaction with receptor for AGEs (RAGE) are involved in sarcopenia, but their relationship in human skeletal muscles has yet to be elucidated. We aimed to determine whether RAGE expression in human skeletal muscle is associated with serum AGE levels and sarcopenia-related changes. Methods We retrospectively reviewed 33 consecutive women (mean age, 65 years) with distal radius fracture who had consented to donate a sample of forearm muscle for research purposes, which was taken during surgical fracture repair. The muscle RAGE expression was measured with immunohistochemistry staining and serum AGE levels using ELISA method. We compared RAGE expression and AGE levels in patients with and without sarcopenia. We also correlated RAGE expression with such clinical parameters as demographic factors, as well as sarcopenia-related changes, including grip strength, appendicular skeletal muscle mass, and muscle cross-sectional area (CSA) ratios. Results Twelve patients (36%) were diagnosed with sarcopenia. They had a significantly higher RAGE expression (p = 0.044) and AGE level (p < 0.001) than those without sarcopenia. The RAGE expression correlated significantly with a high AGE level (r = 0.510, p = 0.011) and correlated inversely with a muscle CSA ratio (r = -0.696, p < 0.001). Discussion/Conclusion This study shows that RAGE expression increases in sarcopenic patient skeletal muscles. This expression also correlates positively with serum AGE levels and inversely with muscle CSA ratios. Further studies are necessary to determine whether targeting RAGEs can be a therapeutic option for sarcopenia.

The association of index-to-ring finger ratio with trapeziometacarpal joint osteoarthritis in an elderly Korean population

OBJECTIVE

Index-to-ring finger ratio (IRFR) has been reported to be associated with joint osteoarthritis (OA). We aimed to evaluate the association between IRFR and trapeziometacarpal joint (TMCJ) OA in an elderly Korean population.

METHODS

A population-based sample included 604 participants with mean age of 74.8 years. IRFR was radiographically measured by the ratio of length of the right second to fourth phalangeal bones ("phalangeal IRFR") and metacarpal bones ("metacarpal IRFR"), and was visually classified as either type 1 (index finger longer than or equal to ring finger) or type 2 (index finger shorter than ring finger). Odds ratios (ORs) for the presence of OA (Kellgren-Lawrence (KL) grade > 1) and for severe OA (KL grade > 2) were analyzed using logistic regressions.

RESULTS

The phalangeal IRFR averaged 91.3%, the metacarpal IRFR 116.7%, and 304 out of 604 participants (50.3%) had type 2 IRFR. We found TMCJ OA in 112 participants (18.5%), and severe TMCJ OA in 37 participants (5.5%). Presence of TMCJ OA was significantly associated with age (OR 1.036; 95% CI 1.011-1.061) and metacarpal IRFR (OR 0.936; 95% CI 0.884-0.992), and severe TMCJ OA with age (OR 1.075; 95% CI 1.032-1.121) and type 2 IRFR (OR 3.057; 95% CI 1.128-8.288).

CONCLUSION

Radiographic, specifically metacarpal IRFR, was associated with the presence of TMCJ OA, and visual IRFR with severe TMCJ OA in both elderly Korean men and women. This study suggests that IRFR might serve as an easily measurable biomarker to identify patients vulnerable to TMCJ OA.

Prognostic factors determining long-term outcomes of conservative treatment for acute calcific periarthritis of the hand

Acute calcific periarthritis (ACP) of the hand is an uncommon disease that is usually self-limited. Although the conservative treatment is generally considered the primary intervention, the prognostic factors associated with long-term outcomes have yet to be identified. The purposes of this study were to investigate the long-term effects of conservative treatment and identify factors associated with long-term prognosis. We retrospectively reviewed 25 patients with a mean age of 46 years who were diagnosed with ACP of the hand and followed up over more than 2 years. Pain control with nonsteroidal anti-inflammatory drugs and activity restrictions were recommended for the initial treatment. Symptom persistence was defined as a visual analogue scale of more than 1. We compared patients with and without symptom persistence regarding potential prognostic factors such as age, gender, calcification size and type (type 1, amorphous and ill-defined; type 2, homogenous and well-defined), and joints and digits involved. Factors associated with symptom persistence were examined with multivariate analysis. At 2-year follow-up, 19 patients showed complete improvement, whereas 6 reported persistent symptoms. Symptom persistence was independently associated with the thumb involvement (odds ratio (OR), 149.77; 95% confidence interval (CI), 0.61-15.98; P = 0.02) and calcification type 2 (OR, 27.68; 95% CI, 0.50-11.08; P = 0.02). In our study, most patients with ACP of the hand reported symptom improvement with conservative treatment at 2 years of follow-up. Calcification of the thumb or calcification type (homogeneous with a well-defined margin) was independently associated with symptom persistence at 2 years.

Open Foveal Repair of the Triangular Fibrocartilage Complex Tears Associated with Symptomatic Ulnar Styloid Non-union

Background: Symptomatic ulnar styloid non-union can be treated by excision of the ulnar styloid fragment. For combined triangular fibrocartilage complex (TFCC) tears, several repair techniques such as arthroscopic repair, open repair to the fracture site or reconstruction using a tendon graft have been introduced. This study reports the technique and outcomes of open foveal repair of the TFCC with excision of the ulnar styloid fragment in patients with symptomatic ulnar styloid non-union and distal radioulnar joint (DRUJ) instability. Methods: Consecutive patients with symptomatic ulnar styloid non-union with TFCC tears and DRUJ instability who underwent excision of the ulnar styloid fragment and open foveal repair of the TFCC were retrospectively reviewed. After excising the ulnar styloid fragment, a capsular window was created between the triquetrum and TFCC, followed by attaching the TFCC to the fovea using three sutures through a bone tunnel from the ulnar cortex to the fovea. Additional ulnar shortening osteotomies were performed in patients with positive ulnar variance and ulnar impaction test. The outcomes were evaluated in terms of DRUJ stability and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: In total, 21 patients with a mean age of 40 were enrolled in the study. All patients demonstrated DRUJ stability at a mean follow-up duration of 14 months. The mean Quick DASH score significantly improved from 18.9 ± 11.7 to 2.5 ± 4.1 (p < 0.05). Eleven patients underwent combined ulnar shortening osteotomies, and no difference in the Quick DASH score was found between patients who underwent ulnar shortening osteotomy and those who did not. Conclusions: This study demonstrates that open foveal repair of the TFCC with ulnar styloid fragment excision is an effective strategy to surgically treat patients with symptomatic ulnar styloid non-union with TFCC tear and DRUJ instability. Level of Evidence: Level III (Therapeutic).

Grip Strength Measurement for Outcome Assessment in Common Hand Surgeries

Grip strength has been used to evaluate the upper extremity functional status and clinical outcomes following upper extremity trauma or surgery. Understanding general recovery patterns of grip strengthening can be helpful in assessing the patients’ recovery status and in assisting in preoperative consultations regarding expectations for recovery. We summarize related studies on grip strength measurement and recovery patterns in common hand conditions, including carpal tunnel syndrome, cubital tunnel syndrome, triangular fibrocartilage complex injury, and distal radius fractures.

The impact of acute fracture on interpretation of bone turnover marker measurements for patients starting anti-resorptive therapies

INTRODUCTION

Bone turnover markers (BTM) are used in evaluating patients' response to anti-resorptive agents (ARA). Fracture and its healing process, however, can influence the measurements, which might make their interpretation difficult in patients with a recent fracture. We aimed to evaluate the effect of oral ARA on changes in BTM levels in patients with a recent distal radius fracture (DRF).

METHODS

In 143 women who had a new DRF and then received oral ARA including selective estrogen receptor modulator (SERM, n = 101), and bisphosphonate (n = 42), we measured serum cross-linked C-telopeptides of type I collagen (CTXI) and osteocalcin, at baseline and six months, as well as lumbar and total hip bone mineral density (BMD) at baseline and one year after fracture. We determined the predictive value of BTM at six months in determining one-year responses in BMD.

RESULTS

Both BTM levels decreased significantly at six months, with the average decrease of 27 ± 63% for CTX-I and 11% ± 37% for osteocalcin. The percent changes of BTM at six months were independent predictors of the BMD change. Cutoff points of 50.0% CTX-I decrease and 23.5% for osteocalcin decrease had the highest sensitivities and specificities for detecting BMD responders for bisphosphonate users, but cutoffs could not be found for SERM users.

CONCLUSION

Although a fresh fracture can influence BTM, ARA therapy significantly reduced their levels and their percent change at six months could predict BMD improvement at one year. However, adjusted cutoff points can be necessary to increase sensitivity for detecting patients responsive to ARA treatment after a new DRF.

Ulnar nerve morphology on magnetic resonance imaging predicts nerve recovery after surgery for cubital tunnel syndrome

Magnetic resonance imaging (MRI) can evaluate nerve morphology in cubital tunnel syndrome (CuTS), but its value in predicting surgical outcome is unclear. The purpose of this study was to determine whether ulnar nerve morphology on MRI correlated with outcome after CuTS surgery. We reviewed 40 patients who had preoperative MRI and electrodiagnostic (EDX) examinations for CuTS and outcome evaluation 6 months and 2 years postoperatively. Using MRI, ulnar nerve cross-sectional area (UNCSA), changes in signal intensity, and any space-occupying lesion were evaluated. Other factors assessed were age, symptom duration and severity, type-2 diabetes and EDX parameters. Factors associated with unfavorable surgical outcome were identified. At 6 months postoperatively, 12 patients (30%) had excellent, 19 (47.5%) good, 8 (20%) fair and 1 (2.5%) poor results on modified Wilson-Krout criteria. On univariate analysis, unfavorable outcomes were associated with increased UNCSA, space-occupying lesion, and decreased motor nerve conduction velocity (mNCV), and on multivariate analysis with increased UNCSA 1 cm distal from the epicondyle only (model 1) or increased UNCSA 1 cm proximal from the epicondyle and decreased mNCV (model 2). At 2 years, 15 patients (37.5%) had excellent, 21 (52.5%) good, 3 (7.5%) fair and 1 (2.5%) poor results, and no factors correlated with unfavorable outcome. Increased UNCSA on MRI was associated with unfavorable outcome at 6 months but not at 2 years. This study suggests that morphologic ulnar nerve changes can predict delayed nerve recovery after surgery for CuTS.

Rheumatoid Hand Surgery in the Era of Biologic Therapy: A Rheumatologist-oriented Overview

Rheumatoid arthritis (RA) can cause significant hand and wrist damage and dysfunction. The aim of medical treatment is to eradicate inflammation and prevent damage to joints and soft tissues. Advances in newer biological therapies over the last two decades have resulted in greater remission rates and lower disease activity status. Despite these improvements, surgical intervention is still indicated in cases of disability, irreversible deformities, and severe pain. However, there are large variations in the surgical rates of common rheumatoid hand procedures, which may indicate clinical uncertainty or disagreement between treating rheumatologists and hand surgeons. In this review, we provide a basic overview of common problems of the hand and wrist in RA patients. The target audience is rheumatologists for their better understanding of surgical options and for better informed patient consultation before referring to hand surgeons.

Magnetic resonance imaging evaluation of patients with clinically diagnosed medial Epicondylitis

OBJECTIVE

We evaluated magnetic resonance imaging (MRI) findings in patients with clinically diagnosed medial epicondylitis (ME) and determined whether any of the MRI findings correlated with the follow-up pain level after nonoperative treatment.

MATERIALS AND METHODS

We retrospectively reviewed 83 patients who had undergone elbow MRI examinations for clinically diagnosed ME and who were followed-up for more than 6 months. Five categories of MRI findings were selected for qualitative grading: common flexor tendon (CFT) origin signal changes, ulnar collateral ligament (UCL) insufficiency, ulnar neuritis, bony changes of the medial epicondyle, and calcification. The mean follow-up after MRI examination was 21 months. We performed multivariate regression analysis to analyze whether any of these MRI findings were associated with the follow-up pain level after nonoperative treatment.

RESULTS

Positive MRI findings included CFT origin signal changes (66%), ulnar neuritis (40%), UCL insufficiency (30%), calcification (27%), and bony changes (18%). Multivariate analysis indicated that CFT origin signal changes were independently associated with the follow-up pain level (β = 3.387; p = 0.004).

CONCLUSION

In patients with clinically diagnosed ME, MRI demonstrated diverse abnormal findings in the CFT origin, ulnar collateral ligament, ulnar nerve, and bone. Among the findings, the severity CFT origin signal changes, which indicates the severity of tendon degeneration in ME, was associated with the follow-up pain level. This information can be helpful in consulting on the prognosis of nonoperative treatment in patients with clinically diagnosed ME.

Radiocapitellar incongruity of the radial head in magnetic resonance imaging correlates with pathologic changes of the lateral elbow stabilizers in lateral epicondylitis

OBJECTIVE

Post-traumatic posterolateral rotatory instability (PLRI) can be shown as radiocapitellar incongruity or posterior translation (PT) of the radial head in magnetic resonance imaging (MRI). We aimed to evaluate whether PT correlated with pathologic changes of lateral elbow stabilizers in patients with lateral epicondylitis.

MATERIALS AND METHODS

In MRIs of 160 patients with lateral epicondylitis, we measured PT of the radial head in the sagittal images. We qualitatively graded five lesions of the lateral elbow structures that included common extensor tendon (CET) lesion (grade 1-3), lateral collateral ligament complex (LCLC) insufficiency (grade 0-2), and absence or presence of bone marrow signal change, osteochondral lesion, and calcification. We analyzed whether the PT correlated with pathologic changes of the lateral elbow stabilizers and evaluated the diagnostic value of the PT for severe lesions.

RESULTS

The average PT was 1.9 mm. The PT correlated with both the CET lesion (p < 0.001) and LCLC insufficiency (p < 0.001). The optimal cutoff values of the PT for grade 3 CET lesion and grade 2 LCLC lesion were 2.6 and 2.8 mm, respectively. When potential PLRI was defined as the PT of > 3.4mm as suggested for post-traumatic PLRI, 21 patients had potential PLRI. The positive predictive values of the PT > 3.4mm were 76% for grade 3 CET lesions and 67% for grade 2 LCLC insufficiency.

CONCLUSION

This study demonstrates that PT of the radial head correlates with pathological changes of the lateral elbow stabilizers. As radiocapitellar incongruity is easy to measure quantitatively, it can be used for screening potential PLRI in patients with lateral epicondylitis.

A longitudinal histologic evaluation of vitamin D receptor expression in the skeletal muscles of patients with a distal radius fracture

We investigated the effect of vitamin D supplementation on the expression of muscle vitamin D receptor (VDR) and cross-sectional area (CSA) in patients with a distal radius fracture (DRF). Significant increases in VDR expression and CSA were observed, especially in vitamin D-deficient patients.

PURPOSE

Vitamin D supplementation is known to enhance muscle mass and function, but whether the VDR is essential in this process remains unknown. We evaluated the change in VDR expression and CSA in the forearm muscles following vitamin D supplementation in patients with a DRF.

METHODS

We prospectively recruited 18 women with a median age of 63.5 years who have a DRF. We obtained two biopsies of the forearm muscle, first at the time of fracture repair and then during hardware removal. We supplemented 1000 IU of vitamin D per day during a median interval of 8 months. We examined the changes in VDR expression and CSA by immunohistochemistry.

RESULTS

The median serum 25-hydroxyvitamin D [25(OH)D] increased from 14.3 to 32.1 ng/mL (P = 0.001). The median VDR expression increased from 0.72 to 0.78 (P = 0.002), and the median CSA increased from 1290.0 to 1685.8 μm² (P = 0.022). Significant increases in VDR expression and CSA were observed in vitamin D-deficient patients [25(OH)D] < 20 ng/mL, but not in vitamin D-non-deficient patients. The changes in VDR expression and CSA were in the same direction in 13 patients, but in the opposite direction in 5 patients.

CONCLUSION

Vitamin D supplementation may increase muscle VDR expression and CSA in patients with a DRF, especially in vitamin D-deficient patients. The increase in CSA without an increase in VDR expression in some patients indicates that the effect of vitamin D supplementation on muscle mass could be mediated by indirect effect of serum vitamin D restoration and by VDR.

Wrist Arthrodesis in Athetoid Type Cerebral Palsy: A Case Study of 2 Patients

Wrist arthrodesis has been used successfully for the management of severe wrist flexion deformity when soft tissue procedures would not provide adequate correction. However, in athetoid type cerebral palsy which has a component of involuntary movement, the outcome of wrist arthrodesis has not been discussed much. We present our experience in 2 athetoid type cerebral palsy patients who underwent wrist arthrodesis due to severe involuntary movement of the wrist. One patient had a nonunion and both patients had unexpected aggravation of involuntary movement in the adjacent joints. Secure fixation using a pre-contoured plate is necessary and preparation for iliac bone grafting should be considered as proximal row carpectomy is usually not necessary in these patients. In addition, although single-event, multi-level surgery is advocated for patients with cerebral palsy, potential additional procedures for the adjacent joints should be discussed preoperatively because unexpected aggravation of involuntary movement of adjacent joints can occur after stabilization of the wrist.

The Effect of Providing Audiovisual Surgical Information on Decisional Conflict in Patients Undergoing Plate Fixation for Distal Radius Fractures

Backgroud

Patients experiencing acute trauma have limited time for their involvement in shared decision making, which may lead to decisional conflict. The purpose of this study was to evaluate whether providing audiovisual surgical information can reduce decisional conflict when deciding between surgical and nonsurgical treatment in patients with distal radius fractures (DRFs) and to evaluate factors that may affect decisional conflict.

Methods

We prospectively enrolled 50 consecutive patients who presented with acute DRFs and chose to undergo surgery, for which volar plate fixation was recommended. We randomized these patients into 2 groups. The test group was given a video clip of audiovisual surgical information in addition to regular information while the control group was only given regular information. The video clip consisted of the purpose, procedure, and effect of the surgery, precautions and complications after the operation, and other treatment options that could be performed if operation was not performed. At 2 weeks after the surgery, we evaluated patients' decisional conflict using a decisional conflict scale (DCS). In addition, we evaluated factors that might affect decisional conflict, such as age, dominant hand, comorbidities, history of previous operations, perceived disability, and provision of the video clip.

Results

The test group showed significantly lower DCS scores than the control group (19.6 vs. 32.1, p = 0.001). In multivariate analysis, younger age and provision of the video clip were associated with lower DCS scores.

Conclusions

This study has demonstrated that providing information through audiovisual media such as video clips could reduce decisional conflict in patients who chose to undergo plate fixation for DRFs. This study also suggests that older patients may need more careful doctor-patient communication as they have more decisional conflict than younger patients.

Computed Tomography Evaluation of Forearm and Hand Muscles in Patients With Distal Radius Fracture

INTRODUCTION

Computed tomography (CT) can be used to assess bone status with measurement of Hounsfield unit (HU). The objective of this study was to evaluate whether HU of muscle might be associated with parameters of bone and muscle status.

METHODS

We reviewed 71 women aged over 50 yr of age who had distal radius fracture and underwent CT evaluation of affected wrist. We assessed HUs of forearm flexor muscles (flexor digitorum superficialis) and thenar muscles and bone HUs at the capitate and the ulnar head. Other parameters included femur neck and lumbar bone mineral density (BMD), upper extremity lean mass, hand grip strength, and muscle fiber cross-sectional area. We performed correlation analyses to determine associations between variables.

RESULTS

Thenar and forearm muscle HUs were significantly correlated with each other, but not with other parameters. HUs of the capitate and ulnar head were positively correlated with femur neck and lumbar BMDs and inversely correlated with age. Ulnar head HU was positively correlated hand grip strength.

CONCLUSIONS

HUs of forearm and thenar muscles did not show significant correlations with bone or muscle parameters, although bone HUs correlated well with bone mineral densities. These results support the opportunistic use of CT for evaluating bone fragility. Clinical usefulness of muscle HU measurement needs further studies.

Semiquantitative single-photon-emission computed tomography /computed tomography study to evaluate concomitant ulnar impaction syndrome in patients presenting with triangular fibrocartilage complex tears

Introduction

Patients presenting with tears of the triangular fibrocartilage complex (TFCC) can have ulnar positive variance, for which the clinical relevance to concomitant ulnar impaction syndrome (UIS) may be unclear. We hypothesized that maximum standardized uptake value (SUVmax), a semiquantitative single-photon-emission computed tomography/computed tomography (SPECT/CT) value, would distinguish between the traumatic TFCC tear and degenerative TFCC tear associated with the UIS. This study aimed to compare SUVmax between patients with TFCC tear only and patients with TFCC tear and UIS.

Methods

A total of 26 patients presenting with TFCC tears on magnetic resonance imaging (MRI) underwent semiquantitative SPECT/CT examinations. The diagnosis of concomitant UIS was made based on positive ulnar impaction tests and MRI findings. We compared the SUVmax between patients with and without concomitant UIS. We also calculated the cutoff value for the diagnosis of UIS using receiver operating characteristic curve analysis.

Results

Of 26 patients, 14 had concomitant UIS, and 12 had TFCC tears only. The SUVmax was significantly higher in patients with concomitant UIS than in those without UIS (p = 0.048). With a SUVmax cutoff value of 4.09 for UIS, sensitivity of 67% and specificity of 82% were obtained.

Conclusions

In the semiquantitative SPECT/CT examinations of patients with TFCC tears, those with concomitant UIS had a higher SUVmax than those without UIS. Semiquantitative SPECT/CT can be helpful in confirming concomitant UIS in patients with TFCC tears.

Upper Limb Reconstruction in Tetraplegic Patients: A Primer for Spinal Cord Injury Specialists

Cervical spinal cord injury (SCI) often causes debilitating loss of function of the upper limb. Upper extremity reconstruction surgery can restore some of the upper limb function in tetraplegic patients with SCI. The procedures are typically muscle-tendon unit transfer surgeries, which redistribute the remaining functional muscles to restore active elbow extension, key grip, and finger grasping. In addition to the tendon transfer surgeries, nerve transfers have emerged recently and are showing promising results. However, despite more than half of the tetraplegic patients can benefit from upper limb surgery, only a few of them receive the procedures. This missed opportunity may be due to the lack of communication between SCI specialists and hand surgeons, or the lack of awareness of such options among the specialists and patients. In this review, we provide a basic overview of upper limb reconstruction in tetraplegic patients with target audience of SCI specialists for their better understanding of the basic concept of surgery and information for patient consultation before referring to hand surgeons.

Evaluation of Hip Geometry Parameters in Patients With a Distal Radius Fracture

BACKGROUND

Patients with a distal radius fracture (DRF) have an increased risk of subsequent fractures including hip fractures. The purpose of this study was to evaluate whether women with a DRF have certain hip geometry parameters known to indicate susceptibility to hip fractures.

METHODS

We compared bone mineral density (BMD) and hip geometry parameters (hip axis length, neck shaft angle, mean cortical thickness, femur neck width, cross-sectional area [CSA], cross-sectional moment of inertia, section modulus, and buckling ratio) in 181 women with a DRF (DRF group) and 362 propensity score-matched women without a fracture (control group). We evaluated the associations between DRF and hip geometry parameters using logistic regression analysis.

RESULTS

The DRF group had lower hip BMD; lower cortical thickness, CSA, and section modulus; and higher buckling ratio than the control group (all p < 0.05). The occurrence of a DRF was significantly associated with decreases in neck shaft angle (odds ratio [OR], 1.047; 95% confidence interval [CI], 1.008-1.088) and CSA (OR, 3.114; 95% CI, 1.820-5.326) after adjusting for age, BMI, and total hip BMD.

CONCLUSIONS

In this study, women with a DRF were more likely than women without a DRF to have hip geometry parameters known to indicate susceptibility to hip fractures. Our results suggest that not only low hip BMD but also a decreased CSA could account for the increased risk of subsequent hip fracture in patients with a DRF.

A modified proximally based nail bed flap approach for benign subungual bone tumors in the distal phalanx

BACKGROUND

Complete tumor removal and damaged nail bed repair are critical factors that determine the success of subungual tumor excision. We examined a modified proximally based nail bed flap approach for excision of subungual bone tumors of the distal phalanx and present cases where this approach was used, along with postoperative functional and cosmetic outcomes.

METHODS

Twenty-four benign subungual bone tumors, identified from 23 patients (9 males and 14 females), were included in this study. All patients underwent tumor excision by the modified proximally based nail bed flap approach. Pain was assessed using a numeric rating scale, and cosmesis was self-assessed using a visual analog scale preoperatively and 1 year postoperatively. We measured sensation of the involved digit tip, relative to opposite-side sensation, using static and moving two-point discrimination and Semmes-Weinstein monofilament tests 1 year postoperatively. Lastly, we assessed postoperative nail deformities and tumor recurrence as potential surgical complications.

RESULTS

Mean pain severity and cosmesis were significantly improved 1 year postoperatively. There were no significant differences in the digit tip sensation between the involved and the opposite-side digits 1 year postoperatively. We observed one case of tumor recurrence and four cases of postoperative nail deformities.

CONCLUSIONS

The modified proximally based nail bed flap approach showed satisfactory functional and cosmetic outcomes. This approach enables a low rate of recurrence after removal of benign subungual bone tumors in the short term and cosmetically superior nail bed repair. Level of evidence: Therapeutic, IV.

Osteoporosis care after distal radius fracture reduces subsequent hip or spine fractures: a 4-year longitudinal study

We evaluated whether active osteoporosis care in patients experiencing their first distal radius fracture (DRF) reduces subsequent hip or spine fractures by comparing two cohorts. The incidence of subsequent fractures was significantly lower in the active care cohort than the other cohort in 4-year follow-up.

PURPOSE

Studies show that osteoporosis care in patients with osteoporotic fracture reduces subsequent fractures, but the impact of such active care in patients with distal radius fracture (DRF) has not been well studied. We evaluated how much osteoporosis care in patients experiencing their first DRF can reduce subsequent hip or spine fractures at 4-year follow-up.

METHODS

Active osteoporosis care by orthopedic surgeons for patients with DRF started from September 2009 at our institution, thus we had a unique opportunity to compare the two cohorts: pre-involvement (PreI) group (DRF before September 2009) and post-involvement (PostI) group (DRF from September 2009). We compared the two cohorts for subsequent hip or spine fracture incidence in the 4 years following DRF.

RESULTS

Overall, 1057 patients with a DRF (85% women; mean age, 70 years) were studied, of whom 205 patients were in PreI group and 852 in PostI group. Subsequent fractures occurred in 27 patients (2.6%), with a mean interval of 29 months after DRF. The incidence was significantly lower in the PostI group than in the PreI group (1.9% vs. 5.4%, p = 0.004), especially in hip fractures (0.4% vs. 2.9%, p = 0.002). The relative risk reduction was 65% for all subsequent fractures and 86% for hip fractures.

CONCLUSION

This study demonstrates that active osteoporosis care in patients with DRF significantly reduces subsequent fracture incidence even for the 4-year follow-up period. These findings add an evidence for the current proactive osteoporosis care programs such as fracture liaison services.

LEVEL OF EVIDENCE

Therapeutic level III.

Prevalence and distribution of MRI abnormalities in the articular cartilage and supporting ligaments in patients with early clinical stage first carpometacarpal joint osteoarthritis

OBJECTIVE

We used magnetic resonance imaging (MRI) to evaluate where articular degeneration begins and which ligaments are most often involved in the early clinical stage first carpometacarpal joint (CMCJ-1) osteoarthritis.

MATERIALS AND METHODS

We retrospectively analyzed the MRI findings of 26 patients with early clinical stage CMCJ-1 osteoarthritis and no radiologic abnormalities and 19 control patients without CMCJ-1 pain or osteoarthritis who underwent MRI for dorsal or ulnar wrist pain. Two observers blinded to group and clinical findings independently assessed the presence of chondral defects in four quadrants of the CMCJ-1: volar-ulnar (VU), volar-radial (VR), dorso-ulnar (DU), and dorso-radial (DR). The integrity of the four major ligaments of the CMCJ-1, i.e., the anterior oblique ligament (AOL), the intermetacarpal ligament (IML), the posterior oblique ligament (POL), and the dorsal radial ligament (DRL), was assessed. The observer reliability was analyzed using Cohen's kappa coefficient. The prevalence of cartilage lesions and ligament abnormalities in the osteoarthritic and control patients was compared using Fisher's exact test.

RESULTS

Cartilage lesions were significantly more common in the VU quadrant of the trapezium in the osteoarthritic patients than in the control patients (17/26 vs. 2/19; P = 0.002). AOL abnormalities were more common in the osteoarthritic patients than in the control patients (14/26 vs. 3/19; P = 0.009).

CONCLUSION

The MRI findings of early clinical stage CMCJ-1 osteoarthritis commonly demonstrated cartilage lesions in the VU quadrant of the trapezium and ligament abnormalities in the AOL.

Measurement and Interpretation of Handgrip Strength for Research on Sarcopenia and Osteoporosis

Handgrip strength (HGS) is associated with several chronic diseases, cognitive decline, length of hospital-stay, and mortality. More importantly, HGS is one of the diagnostic criteria of sarcopenia and gaining attention because of its relevance to bone mineral density (BMD) and osteoporotic fractures. As the measurement of HGS is widely used in clinical practice as well as in research, its accurate measurement and interpretation are becoming more crucial. This review describes how to use different types of dynamometers accurately, the impact of body and arm positions and anthropometric parameters on HGS, the current reference values of HGS for sarcopenia research, and the updates on the relationship between HGS and BMD and osteoporotic fractures.

Idiopathic Avascular Necrosis of Trapezoid in Adolescence: 3-Year Follow-Up

Avascular necrosis (AVN) is relatively uncommon in the carpal bones, although it most frequently involves the lunate and scaphoid. The trapezoid has abundant vascular channels from a rich network of dorsal and palmar vessels, and only a few cases of AVN have been reported in adults who sustained a traumatic insult. We present a rare case of idiopathic AVN of the trapezoid in an adolescent presenting with refractory pain at the second metacarpal base. Over a period of 36 months, follow-up symptom evaluations and serial magnetic resonance images showed prominent gradual improvement, consistent with spontaneous resolution.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly

PURPOSE

The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities.

METHODS

Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment.

RESULTS

Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges.

CONCLUSIONS

Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Hand as a Homunculus - A Perspective from Hand Acupuncture Therapy

Homunculus is a term used to refer to any representation of a miniature human being. In scientific fields, the word homunculus has been used to refer to any scale model of the human body that represents physiological, psychological, or other human functions. The hand is thought as a homunculus of the body in Hand Acupuncture Therapy, a type of alternative medicine in Korea. Hand acupuncture therapists believe stimulating the hand can improve bodily health. Although there is a need for scientific evidence regarding this concept, those that perform hand acupuncture seem to recognize the importance of hand in our body.

Parenting stress in mothers of children with congenital hand or foot differences and its effect on the surgical decision-making for their children

BACKGROUND

The main purposes of this study were to assess the levels of parenting stress in the mothers of children with congenital hand or foot differences and to evaluate the effects of this stress on the preferred roles of mothers in surgical decision-making for their children.

METHODS

This study included 89 mothers of children with polydactyly of the hand, polydactyly of the foot, a hypoplastic thumb, or macrodactyly. The parenting stress level was assessed using the Parenting Stress Index-Short Form (PSI-SF). Additionally, the mothers were requested to indicate their preferred and retrospectively perceived levels of involvement in surgical decision-making for their children using the Control Preferences Scale, which is comprised of five levels ranging from fully active to fully passive.

RESULTS

The average PSI-SF scores were 73.9, and 15 mothers (17%) had a clinically significant level of stress (PSI-SF ≥ 90). In the mothers of children with polydactyly of the foot, the PSI score was associated with the preferred role in surgical decision-making.

CONCLUSION

The assessment of parenting stress levels in the mothers of children with congenital hand or foot differences can play an important role in the screening of candidates who require psychiatric treatment or support. An evaluation of the PSI in mothers of children with congenital hand or foot differences may aid physicians to modify their style of decision-making based on the preferred role of the mother. Level of evidence: Level IV Therapeutic study.

Evaluation and Management of Osteoporosis and Sarcopenia in Patients with Distal Radius Fractures

Distal radius fractures (DRFs) are one of the most common fractures seen in elderly people. Patients with DRFs have a high incidence of osteoporosis and an increased risk of subsequent fractures, subtle early physical performance changes, and a high prevalence of sarcopenia. Since DRFs typically occur earlier than vertebral or hip fractures, they reflect early changes of the bone and muscle frailty and provide physicians with an opportunity to prevent progression of frailty and secondary fractures. In this review, we will discuss the concept of DRFs as a medical condition that is at the start of the fragility fracture cascade, recent advances in the diagnosis of bone fragility including emerging importance of cortical porosity, fracture healing with osteoporosis medications, and recent progress in research on sarcopenia in patients with DRFs.

Measurement of finger joint angle using stretchable carbon nanotube strain sensor

Strain sensors capable of monitoring complex human motions are highly desirable for the development of wearable electronic devices and healthcare monitoring systems. Excellent sensitivity and a wide working range of the sensor material are important requirements for distinguishing dynamic human motion. In this study, a highly stretchable strain sensor was fabricated via inkjet printing of single-walled carbon nanotube (SWCNT) thin films on a stretchable polydimethylsiloxane substrate. The sensor was attached to the metacarpophalangeal (MCP) joint of the hand in 12 healthy male subjects. The subjects placed their hands next to a conventional goniometer and flexed the MCP joint to predetermined angles. A linear relationship was found between the change in the length of the strain sensor and the intended angle of the MCP joint. The fabricated thin films showed high durability during repeated cycling (1,000 cycles) and good sensitivity with a gauge factor of 2.75. This study demonstrates that the newly developed stretchable CNT strain sensor can be used for effectively measuring MCP joint angles. This sensor may also be useful for the analysis of complex and dynamic hand motions that are difficult to measure using a conventional goniometer.

Factors influencing functional outcome of proximal interphalangeal joint collateral ligament injury when treated with buddy strapping and exercise

STUDY DESIGN

Prospective cohort.

INTRODUCTION AND PURPOSE

This study evaluates the factors influencing treatment outcomes of proximal interphalangeal (PIP) joint collateral ligament injuries when treated with buddy strapping.

METHODS

Sixty-seven patients treated with buddy strapping for a PIP joint injury were enrolled. The finger range of motion (ROM), grip strength, and a Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score were assessed at 3 and 6 months after the initial injury. The factors that were assessed for their influence on the functional outcomes included age, sex, hand dominance, affected finger, type of injury, injury severity, time to treatment, the duration of buddy strapping, and exercise training.

RESULTS

Buddy strapping for PIP joint injuries led to satisfactory results with 77% recovery of grip strength, 84% recovery in ROM, and mean QuickDASH scores of 14 at 6 months. A decrease in grip strength was associated with an increase in age and injury severity at 6 months, and these 2 factors accounted for 22% of the variance in the grip strength. A decrease in ROM was associated with the delayed treatment, which accounted for 18% of the variance in ROM at 6 months. An increased disability was associated with delayed treatment, female gender, and radial digit injury at 3 months, and these 3 factors accounted for 37% of the variance in disability. At 6 months, only the delayed treatment remained an associated factor, which accounted for 20% variance in disability.

DISCUSSION AND CONCLUSIONS

PIP collateral ligament injuries had very good outcomes with buddy strapping. However, delayed treatment was significantly associated with poor functional outcomes in terms of the ROM and disability. An increase in age and injury severity were associated with lower grip strength up to 6 months, whereas a female gender and radial digit injury were associated with an increased disability up to 3 months.

LEVEL OF EVIDENCE

2.

Prognostic Factors for Nonsurgically Treated Sagittal Band Injuries of the Metacarpophalangeal Joint

PURPOSE

The aim of this study was to evaluate the factors that influence the prognosis for patients with sagittal band injuries who were treated nonsurgically.

METHODS

A total of 94 patients who had been diagnosed with traumatic sagittal band injury and initially treated with 7 weeks of metacarpophalangeal (MCP) joint extension orthosis wear (5 weeks of full-time followed by 2 weeks of part-time use) were studied. The response to treatment, including finger range of motion (ROM), extensor tendon instability, grip strength, and functional outcome measured as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were assessed at 24-week follow-up. The factors that were assessed for their influence on the outcomes were age, sex, occupation, hand dominance, type of injury, injury severity, time to treatment, and the duration of orthosis wear. Potential predictor variables in bivariate analyses were entered into multivariable analyses to determine prognostic indicators of the outcomes.

RESULTS

After 24 weeks' follow-up, 67 patients (71%) achieved resolution of symptomatic tendon translocation with 83% of grip strength and 90% of ROM compared with the unaffected hand. The final mean QuickDASH scores was 15. Twenty-seven patients (29%) had persistently symptomatic tendon subluxation, and of those, 18 (19%) underwent surgical repair. There were significantly more manual laborers in the failure group than in the success group. Subjects in the treatment failure group were older, had longer symptom durations, and were more likely to have grade III injuries than were those in the success group. Multivariable analysis revealed that manual labor, longer symptom duration, and grade III injury were associated with a higher likelihood of treatment failure.

CONCLUSIONS

An MCP extension orthosis for sagittal band injury (5 weeks of full-time followed by 2 weeks of part-time use) led to mostly satisfactory results with 71% of patients achieving resolution of symptomatic tendon translocation, but manual labor, longer symptom duration, and grade III injury were associated with a higher likelihood of treatment failure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

WITHDRAWN: Internal fixation of unstable radial head fracture: A comparison of metallic and biodegradable implants

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The Effect of Vitamin D Deficiency Correction on the Outcomes in Women After Carpal Tunnel Release

PURPOSE

Studies suggest that vitamin D supplementation improves myelination and recovery after nerve injuries. The purpose of this study was to evaluate whether correction of vitamin D level leads to better surgical outcomes in women with both carpal tunnel syndrome (CTS) and vitamin D deficiency.

METHODS

We retrospectively reviewed 84 vitamin D-deficient women with CTS who underwent carpal tunnel release and then received daily vitamin D supplementation of 1,000 IU vitamin D for 6 months. We also reviewed 35 control patients who were vitamin D-nondeficient at baseline and thus did not receive the supplementation. At baseline and 6 months after surgery, we measured serum vitamin D levels, the Disabilities of the Arm, Shoulder, and Hand (DASH) score, motor conduction velocity, and grip and pinch strengths. We compared the outcomes of CTS related to vitamin D levels. We also correlated baseline and follow-up vitamin D levels with the assessed parameters.

RESULTS

At 6 months, 59 patients became vitamin D-nondeficient (≥ 20 ng/mL) and 25 were still vitamin D-deficient (< 20 ng/mL). Patients who became vitamin D-nondeficient had subtle but better DASH scores than patients who were still vitamin D-deficient or the control patients. Vitamin D levels at 6 months were found to have significant correlation with the DASH score at 6 months. Vitamin D levels at 6 months did not have significant correlation with motor conduction velocity or grip and pinch strengths.

CONCLUSIONS

Women with CTS and vitamin D deficiency showed subtle but better DASH scores after surgery when vitamin D deficiency was corrected by supplementation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Novel implant design of the proximal interphalangeal joint using an optimized rolling contact joint mechanism

Background

The aims of this study were to propose a novel implant design for the proximal interphalangeal joint (PIPJ) of the hand using a rolling contact joint (RCJ) mechanism and to derive an optimal implant design based on human PIPJ kinematics.

Methods

In total, 10 participants with normal PIPJs were enrolled in this study. True lateral finger radiographs were obtained in 10° increments from 0º (full extension) to 120° flexion of PIPJ. Radiographs were used to determine the average center of rotation, which formed the basis of a mathematical expression of the PIPJ kinematics. The variations in extensor tendon excursions in relation to the range of motion of PIPJ were determined using results from previous cadaveric studies. As the next step, a PIPJ implant design using an RCJ mechanism that was most consistent with the mathematically expressed PIPJ kinematics and tendon excursions was determined using a constrained optimization algorithm.

Results

The final proposed PIPJ implant had a relatively constant center of rotation over the entire PIPJ range of motion among the participants. In addition, the extensor tendon excursions of the proposed implant as applied to the phalangeal bones were similar to those of the human tendon. The proposed PIPJ implant achieved an acceptable position of the RCJ surface on the proximal and middle phalanges, which was derived from the constrained optimization algorithm.

Conclusions

A novel PIPJ implant design using an RCJ mechanism demonstrated acceptable outcomes in terms of PIPJ human kinematics and tendon excursions.

Factors affecting willingness to get assessed and treated for osteoporosis

Individuals with poor knowledge of osteoporosis and lower socioeconomic status, including being single and having a lower level of annual income, are less likely to be assessed or treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

INTRODUCTION

Despite the negative health consequences of osteoporosis and the availability of effective treatment, a pervasive and persistent prevention care gap for osteoporosis remains present throughout the world. We attempted to identify the factors affecting the willingness of patients to either undergo or avoid assessment and treatment for osteoporosis.

METHODS

A nationwide online survey was conducted in 926 Korean women over age 50. The survey included questions addressing three domains: (1) clinical and socio-demographic characteristics, (2) questions concerning the reasons for undergoing or avoiding osteoporosis assessment or treatment, and (3) knowledge of osteoporosis as measured using the modified Korean version of Facts on Osteoporosis Quiz. The assessed and non-assessed participants were compared in terms of their clinical and socioeconomic statuses, reasons for undergoing or avoiding osteoporosis management, and levels of knowledge of osteoporosis.

RESULTS

The highest-ranked reason for undergoing osteoporosis assessment was fear of osteoporotic fracture, while the highest-ranked reason for avoiding osteoporosis assessment was not feeling a need to get tested for osteoporosis. Participants who sought assessment for osteoporosis were older and more likely to be married, and had greater knowledge of osteoporosis than those who did not seek assessment. The two groups were found to be similar in terms of tobacco use and daily alcohol use. Patients who had been diagnosed with osteoporosis but either did not initiate or discontinued osteoporosis treatment within 1 year were younger and had lower levels of annual income than those who began and continued treatment.

CONCLUSION

Individuals with poor knowledge of osteoporosis and those of lower socioeconomic status, including those who were single and had a lower level of annual income, were less likely to be assessed and treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.