Effect of early administration of alendronate after surgery for distal radial fragility fracture on radiological fracture healing time.

This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius. The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery. No differences between groups was observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). The radiographs were assessed by three independent assessors. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (SE 0.16)) and the no-ALN group (3.1 months (SE 0.15)) (p = 0.068). All the fractures healed in the both groups by the last follow-up. Improvement of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period. Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture healing times either radiologically or clinically.

Development and validation of an illustrated questionnaire to evaluate disabilities of the upper limb.

We have developed an illustrated questionnaire, the Hand20, comprising 20 short and easy-to-understand questions to assess disorders of the upper limb. We have examined the usefulness of this questionnaire by comparing reliability, validity, responsiveness and the level of missing data with those of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. A series of 431 patients with disorders of the upper limb completed the Hand20 and the Japanese version of the DASH (DASH-JSSH) questionnaire. The norms for Hand20 scores were determined in another cross-sectional study. Most patients had no difficulty in completing the Hand20 questionnaire, whereas the DASH-JSSH had a significantly higher rate of missing data. The standard score for the Hand20 was smaller than the reported norms for the DASH. Our study showed that the Hand20 questionnaire provided validation comparable with that of the DASH-JSSH. Explanatory illustrations and short questions which were easy-to-understand led to better rates of response and fewer missing data, even in elderly individuals with cognitive deterioration.

Construct validity of the Enneking score for measuring function in patients with malignant or aggressive benign tumours of the upper limb.

We evaluated the construct validity of the Musculoskeletal Tumour Society rating scale (Enneking score) as a functional measure for patients with sarcoma involving the upper limb. We compared the Enneking score by examining the correlation between two patient-derived outcome measures, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Medical Outcomes Study Short Form-36 (SF-36) as indicators of functional status in 40 patients with malignant or aggressive benign bone and soft-tissue tumours of the upper limb who had undergone surgical treatment. The frequency distributions were similar among the three scoring systems. As for the validity, Spearman's rank correlation coefficient of the Enneking score to the DASH questionnaire was -0.79 and that of the Enneking to the SF-36 subscales ranged from 0.38 to 0.60. Despite being a measure from the surgeon's perspective, the Enneking score was shown to be a valid indicator of physical disability in patients with malignant or aggressive benign tumours of the upper limb and reflected their opinion.

Comparison of responsiveness of the Japanese Society for Surgery of the Hand version of the carpal tunnel syndrome instrument to surgical treatment with DASH, SF-36, and physical findings.

BACKGROUND: The Japanese Society for Surgery of -the Hand version of the Carpal Tunnel Syndrome Instrument (CTSI-JSSH), which consists of two parts--one for symptom severity (CTSI-SS) and the other for functional status (CTSI-FS)--is a self-administered questionnaire specifically designed for carpal tunnel syndrome. The responsiveness of the CTSI-JSSH was compared with that of the JSSH version of the Disability of Arm, Shoulder, and Hand questionnaire (DASH), the official Japanese version of the 36-Item Short Form Health Survey (SF-36, version 1.2), and physical examinations to elucidate the role of the CTSI-JSSH for evaluating patients with carpal tunnel syndrome. METHODS: Preoperatively, a series of 60 patients with carpal tunnel syndrome completed the CTSI-JSSH, DASH, and SF-36. Results of physical examinations, including grip strength, pulp pinch, and static two-point discrimination of the thumb, index, and long fingers, were recorded. Three months after carpal tunnel release surgery the patients were asked to fill out the same questionnaires, and the physical examinations were repeated. The responsiveness of all the instruments was examined by calculating the standardized response mean (SRM) and effect size (ES). Correlation coefficients were calculated between questionnaire change scores and patient satisfaction scores as well as between the CTSI change scores and those of the DASH and SF-36. RESULTS: The largest responsiveness was observed in the CTSI-SS (SRM/ES: -1.00/-1.08) followed by the CTSI-FS (-0.76/-0.63), and bodily pain subscale of SF-36 (SF-36-BP, 0.45/0.55), and the DASH (-0.46/-0.47). Only the change scores of the CTSI-SS had significant correlation with patient satisfaction (r = 0.34, P < 0.01). An absolute value of Spearman's correlation coefficient of >0.5 was observed between the change scores of the CTSI-SS and the DASH, the CTSI-SS and the SF-36-BP, the CTSI-FS and the DASH, and the DASH and the SF-36-BP. CONCLUSION: The CTSI-JSSH was proven to be more sensitive to clinical changes after carpal tunnel release than the other outcome measures and should be used to evaluate patients with carpal tunnel syndrome who speak Japanese as their native language.

Does high-resolution MR imaging have better accuracy than standard MR imaging for evaluation of the triangular fibrocartilage complex?

We compared the findings of high-resolution MR imaging and standard MR imaging in the detection of tears of the triangular fibrocartilage in 33 patients with chronic wrist pain on the ulnar side. With arthroscopy as the standard of reference, sensitivity was 100%, specificity 53%, and accuracy 79% with the high-resolution MR imaging, against 83%, 67%, and 76% with the standard MR imaging. High-resolution MR imaging showed a higher sensitivity, but a decreased specificity in the assessment of the triangular fibrocartilage. The results showed that diagnosis of tears in the triangular fibrocartilage by MR imaging, even high-resolution MR imaging, is unsatisfactory, although further technological advances may well improve the accuracy.

Arthroscopic evaluation of radial osteotomy for Kienböck's disease.

To determine whether osteoarthritic changes of the perilunate articular cartilage improve following radial osteotomy for Kienböck's disease and correlate with clinical results, arthroscopic examination was performed in 18 patients concurrently with radial osteotomy and at the time of removal of implants after an average of 21 months. Clinical results were satisfactory. All patients improved the preoperative level of pain. Wrist function was improved in range of motion and grip strength. Radiographic findings also demonstrated prevention of further collapse of the lunate. However, follow-up arthroscopic examination revealed progression of osteoarthritis in the area of the lunate in two thirds of the cases. There was no correlation between arthroscopic observations and clinical results. A long-term follow-up period is therefore advocated for evaluation of radial osteotomy because of the possibility of additional progression of osteoarthritic changes.

Arthrography is superior to magnetic resonance imaging for diagnosing injuries of the triangular fibrocartilage.

The ability of single-injection radiocarpal arthrography and magnetic resonance imaging (MRI) to detect full-thickness tears of the triangular fibrocartilage were compared with wrist arthroscopy in 102 patients with wrist pain. The sensitivity of arthrography was 85%, and of MRI was 73%. Specificity was 100% for arthrography and 72% for MRI. Accuracy was 92% for arthrography, and 73% for MRI. Although future advances in MRI technology will probably improve its usefulness, single-injection wrist arthrography currently is superior to routine MRI for the detection of full-thickness triangular fibrocartilage tears.

Ulnar styloid malunion with dislocation of the distal radioulnar joint.

Four patients with dorsal dislocation of the distal radioulnar joint and ulnar styloid malunion had corrective osteotomy of the ulnar styloid. Dislocation of the distal radioulnar joint was reduced in three of four patients. Subluxation persisted in the remaining patient. Wrist function improved in all patients. These results support the contention that a displaced ulnar styloid fracture with distal radioulnar joint dislocation should be reduced and internally fixed. Corrective osteotomy is recommended for malunion of the ulnar styloid associated with dislocation of the distal radioulnar joint.

Hepatic injury localized to the field of total lymphoid irradiation.

A 37-year-old woman with severe aplastic anemia underwent allogeneic bone marrow transplantation following cyclophosphamide (CY) and total lymphoid irradiation (TLI). On day +30, a CT scan was carried out because of a mild elevation in liver enzymes, and it revealed a low density area with a sharp border in the left lobe corresponding to the irradiated area. MRI showed a hypersignal intensity on both T1 and T2-weighted images and suggested that hepatic damage was mainly severe fatty change. These abnormalities resolved with no treatment. CY with TLI for adult patients with severe aplastic anemia may induce hepatic injury.

Methodological assessment of combined spiral CT angiography and CT arterial portography.

BACKGROUND: To assess an optimal methodology of combined spiral computed tomographic (CT) angiography (CTA) and CT arterial portography (CTAP) for detection and characterization of liver tumors. METHODS: We performed spiral CTAP only in five patients with 30-32% contrast (subset A), CTAP combined with preceding spiral CTA using 30-32% contrast in 19 (subset B), and CTAP combined with preceding spiral CTA with 60-64% contrast in seven (subset C). The CT numbers of the aorta immediately before preceding CTA and subsequent CTAP and the CT numbers of malignant tumor and liver parenchyma with CTAP were measured. RESULTS: The differences of the CT number between the malignant tumor and liver parenchyma on CTAP were 61.1-161.8 (mean +/- SD, 114.5 +/- 39.3) HU, 50.7-164.8 (104.2 +/- 31.2) HU, and 101.2-368.3 (219.5 +/- 90.5) HU in subsets A, B, and C, respectively. Two cavernous hemangiomas showed pathognomonic findings with preceding CTA. CONCLUSION: Combination of preceding spiral CTA and subsequent spiral CTAP using 30% contrast with a 5-min interval is an optimal method for detection and characterization of liver tumors.

Detection and characterization of hepatic tumors: value of combined helical CT hepatic arteriography and CT during arterial portography.

OBJECTIVE: The purpose of our study was to evaluate the diagnostic accuracy of combining helical CT hepatic arteriography (CTA) with helical CT during arterial portography (CTAP) for detecting and characterizing hepatic tumors. MATERIALS AND METHODS: From January 1994 to September 1995, combined helical CTA and CTAP were performed in 52 patients (38 men and 14 women, 37-83 years old [mean, 64.1 years old]) with suspected primary or metastatic hepatic tumors before they were evaluated for hepatic resection. Retrospectively, two radiologists reviewed the CTAP images alone and subsequently matched CTA and CTAP images. The radiologists recorded a confidence level on a five-point scale for their evaluation of visible perfusion abnormalities as true lesions, and diagnostic accuracy was assessed using receiver-operating-characteristic analysis. Using the data sets obtained at the interpretation sessions by the radiologists, we determined sensitivities for CTAP alone and for combined CTA and CTAP in 28 malignant hepatic tumors that were confirmed in 19 patients who underwent definitive surgery. RESULTS: CTA revealed one hepatocellular carcinoma in a patient with severe cirrhosis and six adenomatous hyperplasias in another cirrhotic patient that CTAP failed to reveal. In comparison with CTAP alone, the combination of CTA and CTAP allowed significantly more accurate detection of lesions (area under receiver-operating-characteristic curve: 0.889 for CTAP alone versus 0.954 for CTA and CTAP combined, p < .01). The combination of CTA and CTAP also significantly raised the accuracy for characterizing hepatic tumors. Sensitivities for malignant hepatic tumors revealed in the 19 patients who underwent surgery were identical: 93% (26 of 28 tumors) with CTAP alone and with CTA and CTAP combined. CONCLUSION: Although combining CTA and CTAP does not significantly increase sensitivity for detecting hepatic tumors, the combined techniques significantly raise specificity in detecting hepatic tumors and accuracy in characterizing hepatic tumors.

Detection of micrometastatic prostate cancer cells in the bone marrow of patients with prostate cancer.

Thirty-five patients with prostate cancer were examined for micrometastases to the bone marrow using reverse transcription-polymerase chain reaction (RT-PCR) with primers specific for the prostate-specific antigen (PSA) gene. Of nine patients with bone metastases detectable by bone scan imaging, five patients had PSA mRNA expression in the bone marrow detectable by RT-PCR. Of 26 patients with negative bone scan findings, seven patients had PSA mRNA expression detectable in the bone marrow. RT-PCR could detect micrometastatic prostate cancer cells in the bone marrow that were not detectable by bone scan imaging. Of 16 patients with a serum PSA concentration of 25 ng ml(-1) or greater, only nine (56.3%) had bone metastases detected by bone scans. Of the remaining seven patients, five had micrometastases to the bone marrow detected by RT-PCR. Overall, 14 of 16 patients (87.5%) with a serum PSA concentration of 25 ng ml(-1) or greater had metastatic bone diseases including bone marrow micrometastases. Of 19 patients with a serum PSA concentration of less than 25 ng ml(-1), two (10.5%) had only micrometastatic disease detected by RT-PCR. A significant correlation was observed between the incidence of bone involvement and the serum PSA concentration. This study suggests that RT-PCR will potentially develop into a relevant tool to assess bone involvement including bone marrow micrometastases and establish a precise correlation between serum PSA concentration and metastatic bone disease in patients with prostate cancer.

Management of trans-scaphoid perilunate dislocations. Herbert screw fixation, ligamentous repair and early wrist mobilization.

A retrospective review of 28 patients with 29 trans-scaphoid perilunate dislocations who underwent open reduction and Herbert screw fixation is presented. The majority of the patients had satisfactory results at 24 months of follow-up. A significantly better range of wrist motion was obtained in postoperative patients treated with cast immobilization for 4 weeks compared with those treated for longer than 5 weeks. The scaphoid fractures united well, with proper alignment of the carpal bones, regardless of the length of cast immobilization. We recommend open reduction, internal scaphoid fixation using a Herbert screw, carpal ligament repair and early cast removal in the management of trans-scaphoid perilunate dislocations.

Nonpathological focal enhancements on spiral CT hepatic angiography.

BACKGROUND: To assess the frequency and characteristics of nonpathological focal enhancements seen on spiral computed tomographic (CT) hepatic angiography (CTA). METHODS: Spiral CTA and spiral CT arterial portography (CTAP) were performed in 31 patients with suspected liver malignancy prior to potential liver resection. The CTA images were retrospectively reviewed for focal enhancements by two radiologists. After determining nonpathological focal enhancements on CTA images based on the other radiographic tests, surgical exploration including intraoperative sonography, follow-up imagings, the frequency, size, site, and shape of nonpathological focal enhancements with CTA were assessed. RESULTS: Thirty-six nonpathological focal enhancements with CTA from 4 to 23 (mean = 11. 4) mm were seen in 14 (45.2%) of 31 patients. Thirteen (36.1%) of 36 nonpathological focal enhancements with CTA were not depicted with CTAP. Nonpathological focal enhancements with CTA were frequent in Couinaud segments III (27.8%), V (22.2%), and VI (19.4%). Twenty-three (63.9%) of 36 nonpathological focal enhancements were located in the edge of the liver. Shapes of 36 nonpathological focal enhancements with CTA included circular (n = 16), worm (n = 7), irregular (n = 6), dot (n = 6), and wedge (n = 1). CONCLUSION: In nearly half of patients, spiral CTA shows various shapes of small nonpathological focal enhancements more frequently in the liver edge.

Demonstration of false-negative findings on CT hepatic angiography.

False-negative findings on CT angiography (CTA) in two patients with hepatocellular carcinoma (HCC) were demonstrated. CTA images of one patient with an aberrant left hepatic artery branching from the left gastric artery and another patient whose right hepatic artery was occluded owing to an unknown cause failed to demonstrate HCCs. This report suggests one of the diagnostic pitfalls of CTA for diagnosis of liver tumors.

Overestimation ratio of hepatic lesion size on spiral CT arterial portography: an indicator of malignancy.

PURPOSE: To assess the reliability of the size-overestimation ratio obtained from spiral CT arterial portography (CTAP) and spiral equilibrium-phase CT (EPCT) in distinguishing malignant focal hepatic lesions from benign ones. METHODS: The CTAP images and EPCT images obtained five minutes after CTAP in 39 patients with focal hepatic lesions were retrospectively analyzed. Fifty-eight lesions (hepatocellular carcinoma [HCC], 33; metastasis, 10; liver cyst, 10; cavernous hemangioma, 2; adenomatous hyperplasia [AH], 2; focal nodular hyperplasia [FNH], 1) had their sizes measured on CTAP and EPCT images using the calipers on the CT console. RESULTS: The size-overestimation ratios (CTAP/EPCT) were 1.24+/-0.15 in HCC, 1.28+/-0.26 in metastasis, 1.02+/-0.23 in liver cyst, 0.98+/-0.34 in cavernous hemangioma, 0.94+/-0.39 in AH, and 1.00 in FNH. Mean size-overestimation ratios for benign- and malignant-lesion groups were 1.00+/-0.37 and 1.25+/-0.18, respectively (p < 0.0001). When a cutoff level was set at 1.05, sensitivity and specificity for malignancy were 91% and 93%, respectively. CONCLUSIONS: In comparison with EPCT, CTAP significantly overestimates the size of malignant hepatic tumors. This phenomenon may be an indicator of hepatic malignancy.

The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain.

Forty-five patients with persistent ulnar-sided wrist pain and a positive ulnocarpal stress test were investigated by X-ray, arthrography, 99mTechnetium bone scanning, magnetic resonance imaging and wrist arthroscopy. Ulnar wrist pathology was positively identified in nine of 45 patients by X-ray, 18 of 37 by arthrography, 19 of 27 by bone scan, four of 33 by MRI, and in all 45 patients by arthroscopy. The final diagnosis was ulnocarpal abutment syndrome in 28 patients, traumatic triangular fibrocartilage (TFC) tear in six, lunotriquetral (LT) ligament tear in five, TFC and LT ligament tear in one, wrist arthritis in four and cartilaginous free body in one. The ulnocarpal stress test is a useful provocative test, and a positive test suggests the presence of ulnar-sided wrist pathology. The test is sufficiently sensitive to warrant further investigation by arthroscopy.

Renal pelvic and ureteral carcinoma with huge hydronephrosis: US, CT, and MR findings.

A 78-year-old man presented huge hydronephrosis with a calculus in the left kidney, and underwent left nephroureterectomy under the diagnosis of renal pelvic and ureteral tumor. Histological examination disclosed renal pelvic and ureteral tumors featuring mixed histologic types of carcinoma. Magnetic resonance (MR) imaging was superior to computed tomography (CT) in its complete, detailed demonstration of the renal pelvic lesions. The imaging characteristics of CT, MR imaging, ultrasonography, and retrograde ureterography were discussed in the report.