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.

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.

Effects of metabolic syndrome on the functional outcomes of corticosteroid injection for De Quervain tenosynovitis.

Metabolic syndrome is a constellation of medical conditions that arise from insulin resistance and abnormal adipose deposition and function. In patients with metabolic syndrome and De Quervain tenosynovitis this might affect the outcome of treatment by local corticosteroid injection. A total of 64 consecutive patients with De Quervain tenosynovitis and metabolic syndrome treated with corticosteroid injection were age- and sex-matched with 64 control patients without metabolic syndrome. The response to treatment, including visual analogue scale score for pain, objective findings consistent with De Quervain tenosynovitis (tenderness at first dorsal compartment, Finkelstein test result), and Disability of the Arm, Shoulder, and Hand score were assessed at 6, 12, and 24 weeks follow-up. Treatment failure was defined as persistence of symptoms or surgical intervention. Prior to treatment, patients with metabolic syndrome had mean initial pain visual analogue scale and Disability of the Arm, Shoulder, and Hand scores similar to those in the control group. The proportion of treatment failure in the metabolic syndrome group (43%) was significantly higher than that in the control group (20%) at 6 months follow-up. The pain visual analogue scale scores in the metabolic syndrome group were higher than the scores in the control group at the 12- and 24-week follow-ups. The Disability of the Arm, Shoulder, and Hand scores of the metabolic syndrome group were higher (more severe symptoms) than those of the control group at the 12- and 24-week follow-ups. Although considerable improvements in symptom severity and hand function will likely occur in patients with metabolic syndrome, corticosteroid injection for De Quervain tenosynovitis is not as effective in these patients compared with age- and sex-matched controls in terms of functional outcomes and treatment failure. LEVEL OF EVIDENCE: III.

Effect of metabolic syndrome on the outcome of corticosteroid injection for carpal tunnel syndrome.

Diffuse peripheral nerve impairment is common in metabolic syndrome: in patients with metabolic syndrome and carpal tunnel syndrome this might affect the outcome of treatment by local corticosteroid injection. A total of 55 consecutive patients with carpal tunnel syndrome and metabolic syndrome treated with corticosteroid injection (10 mg triamcinolone acetonide) were age and sex matched with 55 control patients without metabolic syndrome. Grip strength, perception of touch with Semmes-Weinstein monofilaments and Boston Carpal Tunnel Questionnaires were assessed at the baseline and at 6, 12 and 24 weeks follow-up. The two groups had similar pre-operative grip strength and Boston Carpal Tunnel Questionnaire scores. The Boston Carpal Tunnel Questionnaire symptom and function scores of the metabolic syndrome group were significantly greater than the control group at 12 and 24 weeks follow-up. Except for significantly greater grip strength at the 12-week follow-up in the control group, there were no significant differences in grip strength between the groups. Semmes-Weinstein monofilament sensory index for the control group was significantly greater than that of the metabolic syndrome group throughout the 24-week follow-up. After 24 weeks, five patients (13%) in the control group and 13 patients (27%) in the metabolic syndrome group had had carpal tunnel surgery. Patients with metabolic syndrome are at risk for poor functional outcome and failure of treatment after corticosteroid injection for carpal tunnel syndrome. LEVEL OF EVIDENCE: Treatment benefits III.

Evaluation of vitamin D levels in women with carpal tunnel syndrome.

UNLABELLED: Studies suggest that vitamin D has a role in neuroprotection. We investigated whether vitamin D status is associated with carpal tunnel syndrome. Vitamin D levels were compared between carpal tunnel syndrome women (n = 135) and healthy control women (n = 135) or patients with other upper limb conditions (n = 135). There were no differences in vitamin D levels between the patients with carpal tunnel syndrome and the controls. However, women with carpal tunnel syndrome younger than 50 years old had significantly lower vitamin D levels than age-matched healthy control women (P = 0.023) or patients with other upper limb conditions (P = 0.035). When women with carpal tunnel syndrome and healthy control women were pooled, the incidence of carpal tunnel syndrome was higher in vitamin D deficient women than in non-deficient women, especially in those younger than 50 years. This study suggests a potential link between vitamin D status and the occurrence of carpal tunnel syndrome in women younger than 50 years but causation is not established. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic Level III.

Ray amputation for the treatment of foot macrodactyly in children.

Macrodactyly of the foot is a rare but disabling condition. We present the results of surgery on 18 feet of 16 patients, who underwent ray amputation and were followed-up for more than two years at a mean of 80 months (25 to 198). We radiologically measured the intermetatarsal width and forefoot area pre-operatively and at six weeks and two years after surgery. We also evaluated the clinical results using the Oxford Ankle Foot Questionnaire for children (OxAFQ-C) and the Questionnaire for Foot Macrodactyly. The intermetatarsal width and forefoot area ratios were significantly decreased after surgery. The mean OxAFQ-C score was 42 (16 to 57) pre-operatively, improving to 47 (5 to 60) at two years post-operatively (p = 0.021). The mean questionnaire for Foot Macrodactyly score two years after surgery was 8 (6 to 10). Ray amputation gave a measurable reduction in foot size with excellent functional results. For patients with metatarsal involvement, a motionless toe, or involvement of multiple digits, ray amputation is a clinically effective option which is acceptable to patients.

Surgical treatment of acute distal radioulnar joint instability associated with distal radius fractures.

This study investigates the question of whether open repair of acute distal radioulnar joint instability at the time of volar plating of distal radius fractures would enable early mobilization of the wrist without the risk of distal radioulnar joint instability. We evaluated 29 patients of mean age 53 years with a distal radius fracture and acute distal radioulnar joint instability who underwent volar plating of the radius combined with surgical repair of the triangular fibrocartilage complex or an ulnar styloid base fracture, followed by active motion exercise of the wrist at 1 week after surgery. At 1 year after treatment, all patients had a stable distal radioulnar joint and grip strength averaged 90% of the normal side. This study demonstrates that surgical repair of the triangular fibrocartilage complex or ulnar styloid fracture followed by early mobilization did not result in distal radioulnar joint instability, and suggests that the surgical treatment of distal radioulnar joint instability may permit early mobilization of the wrist in patients who are considered suitable for rapid rehabilitation after surgery. Type of study: Therapeutic Level IV.

Evaluation of female hormone-related symptoms in women undergoing carpal tunnel release.

As carpal tunnel syndrome is more common in women, particularly around the menopause, female-related risk factors are suspected to play a role in its pathogenesis. We have assessed whether female hormone-related symptoms are associated with upper extremity disabilities in women undergoing carpal tunnel release. A total of 92 women with a mean age of 53 years scheduled for surgery for carpal tunnel syndrome were assessed preoperatively for female hormone-related symptoms using the menopausal rating scale and other female-related factors such as menopausal status, pregnancy number and serum female hormone levels. Upper extremity disability was evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. DASH scores had a moderate correlation with total menopausal rating scale scores, but not with other female-related factors assessed. This study suggests that female hormone-related symptoms are associated with subjective upper extremity disabilities in women with carpal tunnel syndrome. This information may be helpful in addressing patients' complex symptoms or interpretation of outcomes in women with carpal tunnel syndrome.

Pre- and post-operative comorbidities in idiopathic carpal tunnel syndrome: cervical arthritis, basal joint arthritis of the thumb, and trigger digit.

We retrospectively reviewed 633 hands in 362 patients who had idiopathic carpal tunnel syndrome and underwent carpal tunnel release between 1999 and 2009. Electrophysiological studies and simple radiographs of the wrist, cervical spine, and basal joint of the thumb were routinely checked, and patients were also assessed for the presence of trigger digit or de Quervain's disease before and after surgery. Among 362 patients, cervical arthritis was found in 253 patients (70%), and C5-C6 arthritis was the most common site. Basal joint arthritis of the thumb was observed in 216 (34%) of the 633 hands. Trigger digit or de Quervain's disease was observed in 85 of the 633 hands (13%) before surgery, and developed in 67 hands (11%) after surgery. Cervical arthritis, basal joint arthritis, and trigger digit commonly coexist with idiopathic carpal tunnel syndrome. Patient education about these disorders is very important when they coexist with idiopathic carpal tunnel syndrome.

Characteristic radiographic features of the central ray in Apert syndrome.

We reviewed retrospectively seven patients with Apert acrosyndactyly and measured the size of the capitate ossification centre relative to that of the hamate and determined the relative position of the middle finger metacarpal relative to the ring finger metacarpal. We then compared those parameters in 197 normal children. In all patients, the middle finger metacarpal bone had migrated proximally relative to the ring finger metacarpal and the size of the capitate ossification centre was smaller than that of the hamate. After surgical release of the middle finger, relative proximal migration of the middle finger metacarpal was partially relieved and catch-up growth of the capitate was observed within several months. As fusion of the distal phalanges creates a diamond-shaped configuration, bone growth is markedly impaired in the middle finger ray. Therefore, early separation of the middle finger may be as important as early separation of the border digits.

Clinical dosimetric study of three radiotherapy techniques for postoperative breast cancer: Helical Tomotherapy, IMRT, and 3D-CRT.

This paper is to investigate the dosimetric characteristics of Helical Tomotherapy (HT), step-and-shoot intensity-modulated radiation therapy (SaS-IMRT) and three-dimensional conformal radiation therapy (3D-CRT) for the postoperative breast cancer as well as their dosimetric comparison of the normal tissues. CT images of 10 postoperative patients with early stage breast cancer were transferred into HT, SaS-IMRT and 3D-CRT planning systems respectively after the target region and normal tissues were outlined by the same physician to assure the contour consistency. Each prescribed dose for three different modalities of plans was given to a total of 50 Gy in 25 fractions. Doses and irradiated volumes in heart, lungs, as well as conformity index (CI) and homogeneity index (HI) were evaluated for detailed comparison. All three plans showed appropriate coverage for the prescribed target dose in the dosimetric comparison. The CI in HT and SaS-IMRT as well as 3D-CRT was 0.68 ± 0.12, 0.58 ± 0.08 and 0.40 ± 0.08, respectively. The HI were 1.10 ± 0.03, 1.14 ± 0.02 and 1.17 ± 0.04, which appeared intergroup significant differences (p < 0.05). V5, V10, as well as V20 of the heart were smallest in 3D-CRT than HT and SaS-IMRT. V5 of the ipsilateral lung was the smallest in 3D-CRT than HT and SaS-IMRT (p < 0.05); However, V20 and V30 were smaller in HT and SaS-IMRT than 3D-CRT (p < 0.05). V5 of the contralateral lung was the smallest in 3D-CRT than other groups, with V10~V30 were basically similar in numeric values with not obvious discrepancy. Comparing with SaS-IMRT and 3D-CRT, HT technique in treating breast cancer had the best conformity and homogeneity index as well as steepest dose gradient due to its highly modulated beamlets with rotational technique. The heart volume irradiated was the smallest in conventional 3D-CRT, with SaS-IMRT was the largest among the three techniques, as expected. The volume of the contralateral lung irradiated was the smallest in 3D-CRT than other groups. V5 of the ipsilateral lung was the smallest in 3D-CRT than other two groups. V10~V30 in HT and SaS-IMRT were similar and better than 3D-CRT dosimetrically. We conclude that HT technique had advantages over SaS-IMRT and 3D-CRT based on the dosimetric comparison in this study, especially in the high dose region of ipsilateral lung, target homogeneity and dose uniformity.

Musculofascial lengthening for the treatment of patients with medial epicondylitis and coexistent ulnar neuropathy.

The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5. These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms.

Two extension block Kirschner wire technique for mallet finger fractures.

We treated 32 displaced mallet finger fractures by a two extension block Kirschner-wire technique. The clinical and radiological outcomes were evaluated at a mean follow-up of 49 months (25 to 84). The mean joint surface involvement was 38.4% (33% to 50%) and 18 patients (56%) had accompanying joint subluxation. All 32 fractures united with a mean time to union of 6.2 weeks (5.1 to 8.2). Congruent joint surfaces and anatomical reduction were seen in all cases. The mean flexion of the distal interphalangeal joints was 83.1 degrees (75 degrees to 90 degrees ) and the mean extension loss was 0.9 degrees (0 degrees to 7 degrees ). No digit had a prominent dorsal bump or a recurrent mallet deformity. We believe that this technique, when properly applied, produces satisfactory results both clinically and radiologically.

Computed tomographic assessment of reduction of the distal radioulnar joint by gradual lengthening of the radius.

Congruency of the distal radioulnar joint was assessed by computed tomography after gradual lengthening of the radius in patients with considerable ulnar positive variance of mean 12 (range 10-17) mm and chronic dislocation of the distal radioulnar joint. Six patients of mean age 25 years were treated by radial osteotomy and subsequent gradual lengthening using either a single-rod or a half-ring external fixator, which was applied for a mean of 81 days. The causes of deformity were distal radial epiphyseal injury in four, malunion of a radius shaft fracture in one and Madelung deformity in one. Computed tomography scans taken at 1 year postoperatively demonstrated that all patients had a congruent distal radioulnar joint. All patients achieved symptom and radiographic parameter improvements at a mean follow-up of 40 months. A disadvantage was unattractive scars on a cosmetically important surface of the forearm. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction of the distal radioulnar joint can be obtained by gradual lengthening of the radius.

Creation of a "dorsal transverse intermetacarpal ligament" to prevent scissoring deformity in central ray amputation.

An adjunctive technique of ray approximation after central ray amputation is presented. This procedure creates a "dorsal transverse intermetacarpal ligament" by using a free tendon graft from the amputee to help prevent scissoring of the fingers, without the need for bony transposition or dorsal dermodesis.

Primary aneurysmal bone cyst of the patella: a case report.

Aneurysmal bone cysts account for less than 1% of primary bone tumours and have a predilection for the metaphyses of the long bones of the leg. Only 1% of all aneurysmal bone cysts occur in the patella. We report on a 30-year-old man with a primary aneurysmal bone cyst in the right patella treated with curettage. The defect was filled with demineralised bone matrix and allogeneic cancellous bone graft. At the 1.5-year follow-up, the bone graft was well incorporated, the patient experienced no pain or tenderness and had a full range of knee movement.

Arthroplasty for advanced Kienböck's disease using a radial bone flap with a vascularised wrapping of pronator quadratus.

We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck's disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9 degrees and 6 degrees , respectively (p < 0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck's disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate.

Raynaud's phenomenon in idiopathic carpal tunnel syndrome: postoperative alteration in its prevalence.

In a previous study the prevalence of Raynaud's phenomenon (RP) in patients with idiopathic carpal tunnel syndrome (CTS) was found to be 60% which is much higher than that in the general population. We undertook a further study of the same cohort of patients have both CTS and RP and who had an open release of the carpal tunnel, to observe the effects of the operation on RP. We observed whether the symptoms of RP improved, and repeated the cold provocation tests to see if the arterial pulse which was decreased before operation would recover. We rated the outcome as good when the patients showed both an improvement of the symptoms of RP and a normal pulse amplitude after exposure to cold, fair when the pulse amplitude recovered to more than two-thirds of that before exposure, and poor when cold hypersensitivity was persistent or showed the same degree of decreased pulse amplitude as observed before operation. Of the 18 patients with both conditions, ten (56%) had good and four (22%) fair results, with a mean recovery time of 4.2 months (6 weeks to 1 year) after operation. If the vasospasm seen in RP is an expression of vasomotor irritation in the carpal tunnel, these findings suggest that local compression of vasomotor fibres in the carpal tunnel can also be relieved by the release of this structure. Careful consideration, however, is still required in treating patients with both conditions since in some cases. RP may be superimposed or it may have other origins.

Prevalence of Raynaud's phenomenon in patients with idiopathic carpal tunnel syndrome.

Both idiopathic carpal tunnel syndrome (CTS) and Raynaud's phenomenon (RP) are common, and may have similar clinical symptoms. The degree of their coexistence is uncertain. We have examined 30 patients, who were diagnosed clinically and electromyographically as having idiopathic CTS, for the presence of RP using a cold provocation test with photoplethysmography. The patients' hands were exposed in water at 10 degrees C for five minutes. A total of 18 patients (60%) was found to have RP; this is much greater than would be expected from the prevalence in the general population. Raynaud's phenomenon should be considered when treating patients with CTS because of the possibility of coexistence and the similar symptoms of these two disorders.