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.

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.

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: 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.

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 (ß = 0.46 ± 0.23; p = 0.04) and severe osteophytes at the radiocapitellar joint had a large association (ß = 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.

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.

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.

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 (ß = 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.

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.

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.

Is Thumb Proprioception Decreased in Patients With Trapeziometacarpal Joint Osteoarthritis?

Proprioception is thought to be essential for normal joint homeostasis, and its decreased function has been associated with an increased risk of joint diseases. However, only a few studies have been performed on the association between proprioceptive function in the trapeziometacarpal joint (TMCJ) and osteoarthritis. The purpose of this study was to compare TMCJ proprioceptive function in elderly women with radiographic TMCJ osteoarthritis relative to age-matched control women without osteoarthritis. We enrolled 19 women (mean age, 66 years) with symptomatic, radiographic Eaton and Littler grade 2, 3, and 4 TMCJ osteoarthritis and 19 age-matched control women without osteoarthritis. We evaluated thumb proprioception by using a joint-position reproduction test and compared the reposition error (RE) between the groups. We carried out a multivariate analysis for factors potentially associated with increased RE, such as age, body mass index, hand dominance, the presence of diabetes, pain level, and the presence of osteoarthritis. Also, a logistic regression analysis was performed for factors associated with the occurrence of TMCJ osteoarthritis. Patients with TMCJ osteoarthritis had greater RE than did the control patients in the joint-position reproduction test at 20°, 30°, and 40° of thumb palmar abduction. The multivariate analysis indicated that increased RE was associated with the presence of osteoarthritis, but not with the other factors assessed. The occurrence of TMCJ osteoarthritis was associated with increased RE at 20°, 30°, and 40° of thumb palmar abduction. This study showed that decreased proprioceptive function was associated with the presence of osteoarthritis in the TMCJ, although the causality remains unknown. Further studies on the role of proprioception in the pathogenesis of TMCJ osteoarthritis and the potential role of its training for disease prevention or treatment are required.

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.

Prognostic Value of Pain Sensitization During Early Recovery After Distal Radius Fracture in Complex Regional Pain Syndrome.

OBJECTIVE: To evaluate the influence of pain sensitization in the early recovery of distal radius fractures (DRFs) on the occurrence and prognosis of complex regional pain syndrome (CRPS) type I. METHODS: We enrolled 58 patients who were diagnosed with CRPS I based on Budapest criteria within six months after sustaining DRF; they were age- and gender-matched with 58 patients with DRF who did not have CRPS I. We commonly measured patients' pressure pain thresholds (PPTs) in the forearm and administered a Pain Sensitivity Questionnaire (PSQ) when patients complained of pain with numeric rating scale ≥4 at three-month follow-up. Participants were followed up three, six, and 12 months after injury, and the symptoms and sign of CRPS were evaluated at each follow-up. RESULTS: Patients with CRPS I were more likely to have sustained high-energy injuries, had severe fractures, and had significantly higher PSQ scores and lower PPTs than the age- and gender-matched controls. At 12 months after injury, CRPS symptoms improved in 52% (30/58) of patients who had been diagnosed with CRPS I at three months after injury. The initial degree of pain sensitization and high-energy injury were associated with persistence of CRPS symptoms up to 12 months after initial injury. CONCLUSIONS: Patients with CRPS I after DRF exhibited significantly higher pain sensitization in the early post-trauma period, and the degree of initial pain sensitization and high-energy injuries were associated with prolonged CRPS I signs and symptoms up to one year after initial injury.

Lower Trabecular Bone Score is Associated With the Use of Proton Pump Inhibitors.

INTRODUCTION: Trabecular bone score (TBS) provides indirect indices of trabecular microarchitecture and bone quality. Several studies have evaluated the influence of proton pump inhibitors (PPIs) on bone mass and geometric parameters, but no studies have evaluated the influence of PPIs on TBS. METHODS: We reviewed the medical records of 1505 women aged 40-89 yr who had bone mineral density (BMD) examinations as a part of the medical diagnosis and disease prevention program and who did not have osteoporotic fractures or conditions that could affect bone metabolism. Among these, we identified 223 women with exposure to PPIs and selected the same number of age- and body mass index (BMI)-matched control patients. We compared TBS and BMD between the PPI exposure group and the control group and performed multivariate regression analyses to determine whether TBS and BMDs are associated with age, BMI, and PPIs exposure. We also examined whether TBS and BMDs are associated with PPIs exposure timing (current, recent, and past). RESULTS: TBS and BMDs were significantly lower in the PPI exposure group than in the control group. In a multivariable linear regression analysis, TBS was significantly associated with age (p < 0.001) and PPI exposure (p = 0.02). In addition, all BMDs were found to be significantly associated with age, BMI, and PPI exposure. Lower TBS was associated with current PPIs use (p = 0.005), but not with recent or past PPIs usage. However, the influence of PPI exposure timing on the BMDs was not consistent between BMD measurement sites. CONCLUSIONS: This study found that TBS is lower in subjects with PPIs exposure than in controls. The association of lower TBS with current PPIs use suggests that trabecular bone quality could be affected early by PPIs, and but the effect might be reversible.

Older Age and Higher Body Mass Index Are Associated With a More Degraded Trabecular Bone Score Compared to Bone Mineral Density.

Trabecular bone score (TBS) may detect subjects with a more degraded microarchitecture but whose bone mineral density (BMD) reflects normal or osteopenia. The purpose of this study was to evaluate whether age and body sizes were associated with the discordance between BMD and TBS. We analyzed BMD and TBS in 1505 Korean women over 40 yr of age who had no history of osteoporotic fractures or conditions that affect bone metabolism. We considered 3 groups to have TBS values that reflected a more degraded TBS than their BMD values: (1) normal BMD but partially degraded TBS, (2) normal BMD but degraded TBS, and (3) osteopenia but degraded TBS. We compared subjects in these 3 groups with other subjects in terms of age and body sizes, and used multivariable logistic regression to analyze the odds ratios (ORs) for the occurrence of a more degraded TBS than their BMD level using age and body mass index (BMI). One hundred sixty subjects (10.6%) were found to have a more degraded TBS than their BMD level; these subjects were older, heavier, and had higher BMIs than the other subjects. Age (OR: 1.038, 95% confidence interval: 1.020-1.057, p< 0.001) and BMI (OR: 1.223, 95% confidence interval: 1.166-1.283, p< 0.001) were statistically significant in the multivariable analysis for the occurrence of this feature. Women with a more degraded TBS than their BMD level are older and have higher BMIs than the other subjects. It may be helpful to consider the possibility of trabecular bone degradation when clinically evaluating fracture risk in patients who are older or who have high BMIs with normal BMD or osteopenia.

Is There a Relation Between Lateral Epicondylitis and Total Cholesterol Levels?

PURPOSE: To investigate whether high total cholesterol (TC) levels are associated with lateral epicondylitis (LE). METHODS: We retrospectively reviewed all patients with LE who presented to our institution between 2011 and 2015. The inclusion criteria were a diagnosis of LE based on clinical history and physical examination findings and age between 40 and 55 years. For healthy controls, we obtained data from a national cohort (sixth Korean National Health and Nutrition Examination Survey) aged between 40 and 55 years. We compared TC levels between the groups, determined the incidence of hypercholesterolemia (TC level ≥ 240 mg/dL) according to the occurrence of LE, and calculated odds ratios for the occurrence of LE. We also evaluated whether cholesterol levels were associated with clinical findings of LE, such as pain level, onset age, symptom duration, and number of corticosteroid injections. RESULTS: The study comprised 289 patients with LE (mean age, 47.9 years) and 1,077 healthy individuals (mean age, 47.7 years). TC levels were significantly higher in patients with LE than in healthy individuals (205.0 mg/dL vs 194.6 mg/dL, P < .001). The mean difference of 10.4 mg/dL was clinically meaningful because a change of 10 mg/dL with medical intervention is considered significant. The incidence of hypercholesterolemia was higher in LE patients than in healthy controls (16.6% vs 9.0%, P < .001). After adjustment for age, sex, body mass index, and glucose level, patients with hypercholesterolemia (TC level ≥ 240 mg/dL) were 2.47 (95% confidence interval, 1.65-3.70) times more likely to experience LE than those with normal cholesterol levels (<200 mg/dL). TC levels correlated with pain level, onset age, and number of corticosteroid injections. CONCLUSIONS: A clinically meaningful difference in TC levels was found between LE patients and healthy controls. In addition, the incidence of hypercholesterolemia was higher in LE patients than in controls. The present findings suggest a potential association between high TC levels and LE. LEVEL OF EVIDENCE: Level III, case-control study.

Comparison of Ultrasound-Guided Versus Landmark-Based Corticosteroid Injection for Carpal Tunnel Syndrome: A Prospective Randomized Trial.

PURPOSE: Although a local corticosteroid injection for carpal tunnel syndrome (CTS) is frequently performed by palpation using anatomical landmarks, ultrasound (US) allows physicians to visualize and confirm placement of the injectate close to the median nerve, possibly improving the efficacy of the injection. The aim of this study was to compare the effectiveness and complications of US-guided steroid injections with landmark-based injections for CTS. METHODS: A total of 102 patients with CTS were randomized into 2 groups: landmark-based injection and US-guided injection. The response to treatment, including grip strength and the Boston Carpal Tunnel Questionnaires (BCTQ) was assessed at baseline and at 4, 12, and 24 weeks after the injection. RESULTS: The BCTQ symptom and function scores were similar in the 2 groups throughout the 24-week follow-up period, with the exception of significantly lower (better) symptom scores at 4-week follow-up in the US-guided injection group. The grip strength was similar in the 2 groups throughout the 24-week follow-up period. After 24 weeks, 12 patients (24%) in the landmark-based injection group and 9 patients (18%) in the US-guided injection group had undergone carpal tunnel surgery. Symptoms of median nerve irritation were more likely to occur in patients with landmark-based injections (14%) than in those with US-guided injection (2%). CONCLUSIONS: A US-guided steroid injection for CTS produces pain and functional results similar to those of landmark-based injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis.

PURPOSE: Pain sensitization is a contributing factor to conditions of chronic pain. The aim of this study was to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching exercises and the use of a counterforce brace. METHODS: We enrolled 131 patients who presented with isolated LE symptoms for less than 6 months. We initially measured pain sensitization by assessing patients' pressure pain thresholds (PPTs) in the contralateral middorsal forearm and administering a pain sensitization questionnaire (PSQ). For outcome assessments, we assessed the self-administered, patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at 6 and 12 months' follow-up. RESULTS: Initial PSQ scores correlated moderately with baseline DASH scores and slightly with symptom duration; PPTs correlated slightly with baseline DASH scores. After we accounted for confounding variables, patient-reported disability was associated with lower PPTs, higher PSQ scores, and manual labor at 6 months. These 3 factors accounted for 36% of variance in the DASH scores; however, at 12 months only the PSQ score was associated with higher DASH scores, accounting for 14% of variance. CONCLUSIONS: Pain sensitization during the early stages of LE correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. More research is needed to show whether early identification and treatment of pain sensitization will enhance LE treatment outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

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.

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.