New body surface indexes for germinal matrix: DIP joint extension boundary line and dorsal distal interphalangeal crease.

BACKGROUND: Knowledge of the proximal edge of the germinal matrix is essential to avoid injuries in the germinal matrix. The previous index such as terminal tendon insertion is not visible from the body surface. The purpose of this study was to examine the relationship between the proximal edge of the germinal matrix and the body surface indexes by ultrasonographic measurements. METHODS: All participants underwent X-rays of the hand and were grouped based on the presence or absence of osteoarthritis in the distal interphalangeal (DIP) joint. The distance from the proximal edge of the germinal matrix to dorsal distal interphalangeal crease (parameter D1), and to ''DIP joint extension boundary line'' (parameter D2) were measured using ultrasonography. RESULTS: Thirty middle fingers of 24 patients were enrolled; 13 fingers were in control group and 17 fingers were in Heberden's node group. The average of parameter D1 was 6.17 mm (SD 1.12) in the control group (N = 13), and was 7.04 mm (SD 1.31) in Heberden's node group (N = 17) without significant difference. The DIP joint extension boundary line was not visible in 7 fingers with severe DIP joint osteoarthritis. The average of parameter D2 was 0.00 mm (SD 0.00) in the control group (N = 13), and was 0.04 mm (SD 0.13) in Heberden's node group (N = 10). CONCLUSIONS: We suggest that DIP joint extension boundary line and dorsal distal interphalangeal crease are valuable indexes to predict the proximal edge of the germinal matrix from the body surface. Though the DIP joint extension boundary line was not visible in some cases, once it has been sighted, the line shows where the germinal matrix exactly is.

Evaluation of the first annular pulley stretch effect under isometric contraction of the flexor tendon in healthy volunteers and trigger finger patients using ultrasonography.

BACKGROUND: Isometric exercises for a flexed finger have been reported to be effective for treating trigger finger as the flexor tendon widens the space under the first annular (A1) pulley towards the palmar destination during the exercise. This study aimed to evaluate the structural changes during the A1 pulley stretch in healthy volunteers and patients with trigger finger using ultrasonography. METHODS: We enrolled 25 male and 14 female patients (39 middle fingers). The thickness of the subcutaneous tissue (parameter a), A1 pulley (parameter b), and the flexor tendon (parameter c) and the distance between the dorsal surface of the flexor tendon and the palmar surface of the metacarpal head (parameter d) were measured using ultrasonography of the metacarpophalangeal joint of the middle finger flexed at 45° at rest (pattern A) and under isometric contraction of the flexor tendon against an extension force of the proximal interphalangeal joint (pattern B). RESULTS: The average differences between patterns A and B in the healthy volunteers were 0.29 mm (parameter a; P = 0.02), 0.017 mm (parameter b; P = 0.63), 0.16 (parameter c; P = 0.26), and 0.41 (parameter d; P = 0.004), and those in patients with trigger finger were 0.22 mm (parameter a; P = 0.23), 0.019 mm (parameter b; P = 0.85), 0.03 mm (parameter c; P = 0.82), and 0.78 mm (parameter d; P < 0.001). The distance between the dorsal side of the A1 pulley and the palmar surface of the metacarpal head was also significantly increased by 0.57 mm (8.2%) in healthy volunteers (P < 0.001) and 0.81 mm (11%) in patients with trigger finger (P < 0.001). CONCLUSIONS: In this study, the space under the A1 pulley was expanded under isometric contraction of the flexor tendon. These findings support the effectiveness of pulley stretch exercises for the trigger finger condition.

Influence of surgical factors on patient satisfaction after bi-cruciate stabilized total knee arthroplasty: retrospective examination using multiple regression analysis.

BACKGROUND: One of the causes of dissatisfaction following total knee arthroplasty (TKA) is abnormal knee kinematics. A newly designed bi-cruciate stabilized (BCS) TKA system has been developed to produce close-to-normal kinematics because of its anatomic tibiofemoral articular geometry and cam-post mechanism. Although BCS TKA is expected to improve patient satisfaction, no reports have described the appropriate technique or soft tissue handling required to achieve excellent satisfaction with BCS TKA. This study is to identify intraoperative surgical predictors of patient satisfaction after BCS TKA. METHODS: We studied 104 knees with primary varus knee osteoarthritis that underwent BCS TKA with a navigation system retrospectively. Surgical parameters including coronal, sagittal and axial alignment and joint laxity in each compartment that affected patient satisfaction was evaluated. Satisfaction score was evaluated with use of the 2011 Knee Society Scoring system. The multivariate regression analysis included age, gender, body mass index and intraoperative parameters that correlated with satisfaction scores in the univariate analysis (P < 0.05). The current study focused on the patient satisfaction score at 1 year postoperatively and didn't evaluate the long term clinical results nor survivorship. RESULTS: The postoperative satisfaction score was 28.6 ± 8.1. Multivariate analysis showed that medial joint laxity at 30° flexion (P = 0.003), tibial excessive external rotation alignment (P = 0,009) and tibial varus alignment (P = 0.029) were predictors of poor satisfaction score. CONCLUSIONS: When performing BCS TKA, surgeons should pay attention to maintaining proper stability of the medial compartment at mid flexion range and should avoid tibial varus and excessive external rotational alignment.

Factors Associated With Surgical Intervention for Osteoarthritis of the Thumb Carpometacarpal Joint.

PURPOSE: This retrospective study aimed to analyze the initial clinical factors associated with surgical intervention for osteoarthritis of the thumb carpometacarpal (CMC) joint. METHODS: The study included patients who first visited our hand surgery clinic, were given the diagnosis of osteoarthritis of the thumb CMC joint between May 2012 and January 2015, and were observed for more than 3 years. Patients were classified into 2 groups according to whether they had undergone surgery during the follow-up period. The following variables were extracted and included in a bivariate analysis: sex, age, age at onset, disease duration, dominant hand, pain visual analog scale (VAS) scores at rest and during use, night pain, Eaton classification, use of an orthosis, number of injections, tender area, range of motion, grip strength, pinch strength, Kapandji abduction index, palmar abduction distance, grind test results, CMC joint shape on radiographs, dorsal subluxation ratio, volar tilt of the metacarpal, presence or absence of ossicles, and the surgeon who recommended the surgery. Variables with P values less than .05 in the bivariate analysis were included in a logistic regression model. RESULTS: The study included 80 thumbs of 48 patients. Pain scores at rest and during use, and the dorsal subluxation ratio were identified as factors significantly associated with surgical intervention in the bivariate analysis. The subsequent logistic regression analysis including these factors as explanatory variables also identified the VAS score at rest and dorsal subluxation ratio as significantly associated with surgical intervention. CONCLUSIONS: The VAS score at rest and the dorsal subluxation ratio at the first clinical visit were associated with the likelihood of future surgical intervention within 3 years in patients with osteoarthritis of the thumb CMC joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The effect of fibrin formulation on cell migration in an in vitro tendon repair model.

BACKGROUND: The purpose of this study was to determine the effect of fibrinogen concentration on cell viability and migration in a tissue culture tendon healing model. METHODS: Forty-eight canine flexor digitorum profundus tendons were randomly divided into three groups. In each group the tendons were lacerated and repaired augmented with a canine bone marrow stromal cell seeded fibrin interposition patch using either 5 mg/ml fibrinogen and 25 U/ml thrombin (physiological as a control), 40 mg/ml fibrinogen and 250 U/ml thrombin (low adhesive), or 80 mg/ml fibrinogen and 250 U/ml thrombin (high adhesive). The sutured tendons were cultured for two or four weeks. RESULTS: Failure load was not significantly different among the groups. Cell-labeling staining showed that the stromal cells migrated across the gap in the control and low adhesive groups, but there was no cell migration in the high adhesive group at two weeks. CONCLUSION: A high fibrinogen concentration in a fibrin patch or glue may impede early cell migration. LEVEL OF EVIDENCE: Not applicable because this study was a laboratory study.

Bone metastasis of limb segments: Is mesometastasis another poor prognostic factor of cancer patients?

OBJECTIVE: In contrast to acrometastasis, defined as bone metastasis to the hand or foot, the frequency and prognosis of bone metastasis of other limb segments remain unclear. To compare prognosis according to sites of bone metastasis, we defined two new terms in this study: 'mesometastasis' and 'rhizometastasis' as bone metastasis of 'forearm or lower leg' and 'arm or thigh', respectively. METHODS: A total of 539 patients who were registered to the bone metastasis database of The University of Tokyo Hospital from April 2012 to May 2016 were retrospectively surveyed. All patients who were diagnosed to have bone metastases in our hospital are registered to the database. Patients were categorized into four groups according to the most distal site of bone metastases: 'acrometastasis', 'mesometastasis', 'rhizometastasis' and 'body trunk metastasis'. RESULTS: The frequency of rhizometastasis (22.5%) or body trunk metastasis (73.1%) was significantly higher than that of acrometastasis (2.0%) or mesometastasis (2.4%). The median survival time after diagnosis of bone metastases for each group was as follows: 6.5 months in acrometastasis, 4.0 months in mesometastasis, 16 months in rhizometastasis, 17 months in body trunk metastasis and 16 months overall. In survival curve, there was a statistically significant difference between mesometastasis and body trunk metastasis. CONCLUSIONS: Our findings suggest that 'mesometastasis' could be another poor prognostic factor in cancer patients and that patients with mesometastasis should receive appropriate treatments according to their expected prognosis.

Ultrasonographic Classification of Scapholunate Interosseous Ligament Injury Associated With Distal Radius Fracture.

PURPOSE: Although scapholunate interosseous ligament (SLIL) injury is often associated with distal radius fracture, it is frequently missed in x-rays. The purpose of this study was to develop a diagnostic classification based on ultrasonography for SLIL injury and evaluate its diagnostic accuracy. METHODS: Patients who required surgery for distal radius fracture were included in this study. Ultrasonography and arthroscopy were performed in all patients. The original ultrasonography-based classification of the dorsal part of SLIL was developed as follows: for type A, the SLIL surface was outlined clearly as a continuous flat line; for type B, the SLIL surface was outlined clearly as a continuous bulged line; and for type C, the SLIL surface was not continuous, smooth, or outlined clearly. Arthroscopy was performed at the time of osteosynthesis. We classified its findings according to the arthroscopic classification system of Geissler et al and evaluated interobserver and intraobserver reliabilities for our classification on ultrasonography. We also studied the relationship between the ultrasonographic and arthroscopic classifications. RESULTS: In total, 40 patients were included in this study. Weighted κ values for interobserver and intraobserver reliabilities for our ultrasonographic classification were 0.83 (95% confidence interval, 0.70-0.96) and 0.88 (95% confidence interval, 0.77-0.99), respectively. There were 17 patients with type A, 14 with type B, and 9 with type C on ultrasonography. Ultrasonography had a sensitivity of 64% and specificity of 93% for the assumption that type C on ultrasonography corresponded to Geissler grades 3 and 4 on arthroscopy. No patient with type A on ultrasonography was classified as Geissler grades 3 and 4 on arthroscopy. CONCLUSIONS: We concluded that ultrasonography has a high specificity but low sensitivity for the diagnosis of SLIL injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic Ⅱ.

Minimal clinically important differences in Toronto Extremity Salvage Score for patients with lower extremity sarcoma.

BACKGROUND: The Toronto Extremity Salvage Score (TESS) is the most widely used patient-reported outcome measure for orthopaedic oncology patients. However, minimal clinically important differences (MCIDs) in the TESS have not been analyzed. The aim of this study was to define the MCIDs of TESS in patients with lower extremity sarcoma. METHODS: A total of 85 patients were investigated to calculate the MCIDs for TESS. Three different methods were used: 1) distribution-based methods based on one-half of the standard deviation and standard error of measurement (SEM) at the baseline, 2) anchor-based and receiver operating characteristic (ROC) analysis, and 3) anchor-based using Akaike's Information Criterion (AIC) analysis. RESULTS: The MCIDs at 6 months were 4.9-7.8 by distribution-based methods and 4.3-4.4 by anchor-based methods. The MCIDs at 12 months were 4.0-6.9 by distribution-based methods and 10.6-11.6 by anchor-based methods. CONCLUSIONS: We calculated MCID values for the TESS based on distribution- and anchor-based approaches. Our results seem reasonable since MCIDs calculated by the different approaches had similar values. This knowledge will enable clinicians to identify meaningful functional improvements in sarcoma patients.

Relationship between X-ray findings of lumbar spondylosis and knee pain.

BACKGROUND: The aim of this study was to investigate the correlation between radiographic measurement in lumbar spine and clinical information including symptoms or results of functional testing using a baseline data of longitudinal cohort study. METHODS: A total of 314 elderly subjects were recruited from 5 orthopedic clinics or affiliated facilities. Data for the present investigation were collected via an interviewer-administered questionnaire, which included questions on past medical history, drug history, pain area. And also results of functional testing and X-ray imaging of the lumbar spine were collected. Analysis was carried out to determine any correlation between results of X-ray imaging of the lumbar spine and other collected data, and sorted regarding Akaike Information Criterion (AIC). The correlations among these variables and odds ratio were also analyzed. RESULTS: T12/L1% disc height showed a minimum AIC value with buttock pain (- 4.57) and history of vertebral fracture (- 4.05). The L1/L2, L2/L3, and L3/L4% disc height had a minimal AIC value with knee pain (- 4.11, - 13.3, - 3.15, respectively), and odds ratio of knee pain were 3.5, 3.8, and 2.7, respectively. CONCLUSIONS: Correlation was recognized between the T12/L1% disc height and both buttock pain and previous vertebral fractures, and the L1/L2, L2/L3, and L3/L4% disc height showed a correlation with knee pain. Especially the L2/L3% disc height and knee pain had a strong correlation. It was suggested that these findings may provide additional basis to the concept that lumbar spinal lesion associates with knee pain clinically.

Development of a patient-oriented disease specific outcome measure of health-related quality of life (HRQOL) for musculoskeletal oncology patients.

BACKGROUND: According to improved functional outcome and life expectancy in orthopaedic oncology patients, there has been a growing interest in not only oncologic and functional outcomes but also health-related quality of life (HRQOL), including body image, mental status, or social activities, after surgery. However, there has been a lack of disease-specific measures focusing on the ability of orthopaedic oncology patients to evaluate their HRQOL comprehensively. Therefore, our aims in the present study were 1) to develop a patient-oriented disease-specific outcome measure of HRQOL for musculoskeletal oncology patients (COMMON-LE), and 2) to examine the practical applicability, reliability and validity of the COMMON-LE for patients with musculoskeletal tumors in the lower extremity. METHODS: The COMMON-LE was developed by expert committee of orthopaedic oncology and rehabilitation. A total of 101 patients were surveyed using the COMMON-LE, as well as the TESS, the MSTS score, and the SF-36, to assess their psychometric characteristics, including reliability, validity, and responsiveness. RESULTS: The COMMON-LE showed no marked floor and ceiling effects. Test-retest reliability and internal consistency determined using the intraclass correlation coefficient (0.928) and Cronbach's alpha (0.948-0.968), respectively, were excellent. Each domain of the COMMON-LE (pain, ADL, socioemotional condition and general health) was well correlated with the scores of the standard measures (SF-36, TESS, MSTS score). Factor analysis and the AIC network showed the questionnaire items of the COMMON-LE were clearly separable into three clusters according to their content, corresponding to each domain of the questionnaire. CONCLUSIONS: We have successfully developed and validated a disease-specific measure, the COMMON-LE, to evaluate not only physical function, but also various aspects of HRQOL in patients with musculoskeletal tumors. The COMMON-LE has sufficient reliability and internal consistency, and good validity, and appears to be practically applicable to this group of patients.

The utility of 25-question Geriatric Locomotive Function Scale for evaluating functional ability and disease activity in Japanese rheumatoid arthritis patients: A cross-sectional study using NinJa database.

OBJECTIVES: To investigate the distribution of 25-question Geriatric Locomotive Function Scale (GLFS-25) scores in Japanese rheumatoid arthritis (RA) patients and evaluate relationships with clinical variables. METHODS: Among 15,115 patients registered in the NinJa database for fiscal year 2015, 1710 with complete GLFS-25 and disease activity score-28 (DAS28) data were analyzed. Correlations between GLFS-25 score and clinical variables were assessed by Spearman coefficients. Mean GLFS-25 scores were compared among DAS28 groups (<2.6, 2.6-3.1, 3.2-5.0, ≥5.1) using the Kruskal-Wallis test. To evaluate the performance of the GLFS-25 and Health Assessment Questionnaire Disability Index (HAQ-DI) for predicting DAS28 ≥ 3.2 (moderate/high disease activity), receiver operator characteristic (ROC) curves were constructed. RESULTS: GLFS-25 score was significantly correlated with age, disease duration, DAS28, and HAQ-DI. GLFS-25 score increased in parallel with DAS28. The proportion of patients with locomotive syndrome stage 2 also increased with DAS28. Area under the curve values for HAQ-DI and GLFS-25 score were 0.739 and 0.768, respectively. At a GLFS-25 positive cutoff score ≥16, sensitivity was 0.716 and specificity was 0.661 for predicting DAS28 ≥ 3.2. CONCLUSION: This study documents the GLFS-25 score distribution in Japanese RA patients and demonstrates that GLFS-25 is a useful measure for evaluating functional ability in RA.

Reliability and Validity of the Musculoskeletal Tumor Society Scoring System for the Upper Extremity in Japanese Patients.

BACKGROUND: The Musculoskeletal Tumor Society (MSTS) scoring system developed in 1993 is a widely used disease-specific evaluation tool for assessment of physical function in patients with musculoskeletal tumors; however, only a few studies have confirmed its reliability and validity. QUESTIONS/PURPOSES: The aim of this study was to validate the MSTS scoring system for the upper extremity (MSTS-UE) in Japanese patients with musculoskeletal tumors for use by others in research. Does the MSTS-UE have: (1) sufficient reliability and internal consistency; (2) adequate construct validity; and (3) reasonable criterion validity in comparison to the Toronto Extremity Salvage Score (TESS) or SF-36? METHODS: Reliability was performed using test-retest analysis, and internal consistency was evaluated with Cronbach's alpha coefficient. Construct validity was evaluated using a scree plot to confirm the construct number and the Akaike information criterion network. Criterion validity was evaluated by comparing the MSTS-UE with the TESS and SF-36. RESULTS: The test-retest reliability with intraclass correlation coefficient (0.95; 95% CI, 0.91-0.97) was excellent, and internal consistency with Cronbach's α (0.7; 95% CI, 0.53-0.81) was acceptable. There were no ceiling and floor effects. The Akaike Information Criterion network showed that lifting ability, pain, and dexterity played central roles among the components. The MSTS-UE showed substantial correlation with the TESS scoring scale (r = 0.75; p < 0.001) and fair correlation with the SF-36 physical component summary (r = 0.37; p = 0.007). Although the MSTS-UE showed slight correlation with the SF-36 mental component summary, the emotional acceptance component of the MSTS-UE showed fair correlation (r = 0.29; p = 0.039). CONCLUSIONS: We can conclude that the MSTS is not an adequate measure of general health-related quality of life; however, this system was designed mainly to be a simple measure of function in a single extremity. To evaluate the mental state of patients with musculoskeletal tumors in the upper extremity, further study is needed.

Cross-cultural adaptation and validation of the Japanese version of the Toronto Extremity Salvage Score (TESS) for patients with malignant musculoskeletal tumors in the upper extremities.

BACKGROUND: The Toronto Extremity Salvage Score (TESS) is a widely used disease-specific patient-completed questionnaire for the assessment of physical function in patients with musculoskeletal tumors; however, there had not been the validated Japanese version of the TESS. The aim of this study was to validate the Japanese version of the TESS in patients with musculoskeletal tumors in the upper extremity. METHODS: After developing a Japanese version of the TESS, the questionnaire was administered to 53 patients to examine its reliability and validity in comparison with the Musculoskeletal Tumor Society (MSTS) scoring system and Short Form-36 (SF-36). RESULTS: Test-retest reliability with intraclass correlation coefficient (0.93) and internal consistency with Cronbach's alpha (0.90) were excellent. Factor analysis showed that the construct structure consisted of 3-item clusters, and the Akaike Information Criterion network also demonstrated that the items could be divided into 3 domains according to their content. The TESS strongly correlated with the MSTS rating scale (r = 0.750; P < 0.001) and the SF-36 physical functioning scale (r = 0.684; P < 0.001). However, as expected, the TESS had low correlations with the SF-36 mental health and role-emotional subscales and the MSTS scoring system manual dexterity domain. CONCLUSIONS: Our study suggests that the TESS is a reliable and valid instrument to measure patient-reported physical functioning in patients with upper extremity sarcoma.

Reliability and Validity of a Japanese-language and Culturally Adapted Version of the Musculoskeletal Tumor Society Scoring System for the Lower Extremity.

BACKGROUND: The Musculoskeletal Tumor Society (MSTS) scoring system is a widely used functional evaluation tool for patients treated for musculoskeletal tumors. Although the MSTS scoring system has been validated in English and Brazilian Portuguese, a Japanese version of the MSTS scoring system has not yet been validated. QUESTIONS/PURPOSE: We sought to determine whether a Japanese-language translation of the MSTS scoring system for the lower extremity had (1) sufficient reliability and internal consistency, (2) adequate construct validity, and (3) reasonable criterion validity compared with the Toronto Extremity Salvage Score (TESS) and SF-36 using psychometric analysis. METHODS: The Japanese version of the MSTS scoring system was developed using accepted guidelines, which included translation of the English version of the MSTS into Japanese by five native Japanese bilingual musculoskeletal oncology surgeons and integrated into one document. One hundred patients with a diagnosis of intermediate or malignant bone or soft tissue tumors located in the lower extremity and who had undergone tumor resection with or without reconstruction or amputation participated in this study. Reliability was evaluated by test-retest analysis, and internal consistency was established by Cronbach's alpha coefficient. Construct validity was evaluated using the principal factor analysis and Akaike information criterion network. Criterion validity was evaluated by comparing the MSTS scoring system with the TESS and SF-36. RESULTS: Test-retest analysis showed a high intraclass correlation coefficient (0.92; 95% CI, 0.88-0.95), indicating high reliability of the Japanese version of the MSTS scoring system, although a considerable ceiling effect was observed, with 23 patients (23%) given the maximum score. Cronbach's alpha coefficient was 0.87 (95% CI, 0.82-0.90), suggesting a high level of internal consistency. Factor analysis revealed that all items had high loading values and communalities; we identified a central role for the items "walking" and "gait" according to the Akaike information criterion network. The total MSTS score was correlated with that of the TESS (r = 0.81; 95% CI, 0.73-0.87; p < 0.001) and the physical component summary and physical functioning of the SF-36. CONCLUSIONS: The Japanese-language translation of the MSTS scoring system for the lower extremity has sufficient reliability and reasonable validity. Nevertheless, the observation of a ceiling effect suggests poor ability of this system to discriminate from among patients who have a high level of function.

Cross-cultural adaptation and validation of the Japanese version of the Toronto Extremity Salvage Score (TESS) for patients with malignant musculoskeletal tumors in the lower extremities.

BACKGROUND: Before this work a Japanese version of the Toronto Extremity Salvage Score (TESS), a disease-specific patient-completed questionnaire widely used to assess the physical function of patients with musculoskeletal tumors, had not been developed. The purpose of this study was cross-cultural adaptation and validation of the English-language version of the TESS to facilitate international comparisons of treatment results. METHODS: The TESS was translated into Japanese, back-translated into English, and reviewed by a committee to develop a consensus Japanese version of the TESS. One hundred and two patients were assessed by use of this Japanese version to examine its reliability and validity. RESULTS: Test-retest reliability and internal consistency determined by using the intraclass correlation coefficient (0.941) and Cronbach's alpha test (0.978), respectively, were excellent. Factor analysis showed that the structure consisted of a three-item cluster; the Akaike information criterion (AIC) network also demonstrated that the items could be divided into three domains in accordance with their content. The Japanese version of the TESS correlated with the Musculoskeletal Tumor Society rating scale (r = 0.811; P < 0.001) and the Short Form-36 physical component summary (r = 0.785; P < 0.001). CONCLUSIONS: Our study suggested that the Japanese version of the TESS is a reliable and valid instrument for measuring patient-reported functional outcome for patients with lower extremity sarcoma, and that it enables international comparisons of treatment results. The spatial association of each item demonstrated by using the AIC network also suggested that the underlying structure of the TESS reflected its coverage of a wide range of physical functions.

Acute tenosynovitis following an accidental injection of Bacille Calmette-Guérin (BCG) in a health care worker: A case report.

Case: A 36-year-old female healthcare worker with no past medical history, accidentally injected her flexed right middle finger with live attenuated Mycobacterium bovis bacillus Calmette-Guérin (BCG). Swelling and erythema around the injured area appeared two days after the needlestick injury. She was referred to the hospital and presented approximately nine days after self-inoculation. Surgical debridement was immediately performed. After 38 days, colonies were observed on cultures of the removed tissue on Ogawa's medium. This isolate was identified as M. bovis BCG by polymerase chain reaction (PCR) based on RD1 gene deletion. She had a history of BCG vaccination and her skin lesion appeared immediately after the accidental injection of M. bovis BCG. Therefore, in the differential diagnosis, the possibility that the lesion was an allergic reaction to BCG was considered. The subsequent culture results came back positive for M. bovis BCG and acute tenosynovitis caused by M. bovis BCG was diagnosed. The skin lesion was treated with anti-mycobacterial drugs and resolved. Discussion: The allergic reactions to BCG should be considered in the differential diagnosis of skin lesions following BCG vaccination. It is important to promptly submit a specimen for culture as delayed initiation of appropriate treatment can lead to a poor prognosis. In patients with accidental injection of M. bovis BCG, it is important to consider timely surgical excision and appropriate antimycobacterial therapy.

Ultrasonographic evaluation of displaced neurovascular bundle in Dupuytren disease.

PURPOSE: Neurovascular injury is a serious complication after surgery for Dupuytren disease. The purpose of this study was to evaluate the relationship between the cord and the neurovascular bundle ultrasonographically. METHODS: We included 22 healthy volunteers and 14 Dupuytren disease patients (25 fingers) in this study. We evaluated the cord and the digital artery with high-resolution ultrasound. We first investigated the effect of the angle of metacarpophalangeal joint on the position of the radial and ulnar digital arteries in volunteers without evidence of Dupuytren disease. We compared 3 parameters of the radial and ulnar digital arteries, including differences in depth, differences in lateral shift, and the shape of the cross-section of the artery, between volunteers and patients with Dupuytren disease. RESULTS: None of these parameters changed with flexion of the metacarpophalangeal joint of 0°, 30°, and 60°. Digital arteries and cords could be identified ultrasonographically in all patients, and we confirmed ultrasonographic findings by operative findings in 13 fingers. We classified the fingers into 3 subgroups based on the ultrasonographic findings: type A (n = 13), in which the cord was above the artery; type B (n = 5), in which the cord was below the artery; and type C (n = 7), in which the cord was located between the radial and ulnar digital arteries. Types A, B, and C corresponded to natatory cord/abductor digiti minimi cord, spiral cord, and central cord, respectively. Comparisons among volunteers and patient subgroups showed that the difference in depth in type B patients was significantly larger than that of the other groups. When we set the cutoff point of the difference in depth to 3 mm, sensitivity and specificity to detect the spiral cord were 80% and 76%, respectively. CONCLUSIONS: The relationship between the neurovascular bundle and the type of Dupuytren disease cord can be evaluated by high-resolution ultrasound. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Psychometric Properties of the Turkish Version of the JHand for the Patient-Oriented Outcome Measure for Patients with Hand and Elbow Disorders.

The JHand is an easy-to-understand questionnaire that includes questions that exclude hand dominance. It was developed to evaluate patients with hand and elbow disorders. However, JHand has not been translated and validated in the Turkish language. The aim of this study is to investigate the psychometric properties of the culturally adapted Turkish version of the JHand for Turkish patients. A total of 262 patients were included in the study. JHand, Disabilities of the Arm, Shoulder, and Hand Questionnaire, and Hand20 were used to evaluate patients. Internal consistency and test-retest analyses were applied to determine the reliability of the Turkish version of the JHand. Confirmatory factor analysis and similar scale validity were used to determine its validity. The Turkish version of the JHand showed high levels of internal consistency and excellent test-retest reliability (Cronbach α = 0.907, ICC = 0.923). The model fit indices of the Turkish version of the JHand had good and acceptable fit with reference values. Statistically positive and very strong correlations were found between JHand and DASH (r = .825, p < .001) as well as the JHand and Hand20 (r = .846, p < .001). The Turkish version of the JHand had excellent internal consistency and test-retest reliability as well as a high level of validity.

Fungal arthritis of the wrist caused by Candida parapsilosis during infliximab therapy for rheumatoid arthritis.

A 60-year-old woman with rheumatoid arthritis, who had been treated with infliximab, presented with uncontrollable wrist arthritis. Fungal arthritis caused by Candida parapsilosis was confirmed by examining her aspirated joint fluid. Her infliximab therapy was interrupted, and antifungal therapy with fluconazole was started. After the fungal infection had been ameliorated, surgical debridement and arthrodesis of the wrist joint were conducted, and her symptoms completely resolved. Although fungal arthritis is rare, it should be considered as a differential diagnosis of exacerbated monoarthritis in patients treated with biological agents.