Time Course of Quality of Life Improvement Between Resection Arthroplasty and Metatarsophalangeal Joint-Preserving Forefoot Arthroplasty for Rheumatoid Arthritis.

BACKGROUND: Resection arthroplasty has long been a major treatment option for forefoot deformity caused by rheumatoid arthritis (RA). However, metatarsophalangeal (MTP) joint-preserving surgery is now surpassing classic resection arthroplasty. This study was performed to compare the postoperative results of these 2 operative methods. METHODS: Fifty-one toes of 40 patients with RA who underwent resection arthroplasty (resection group) or MTP joint-preserving arthroplasty (preservation group) from 2014 to 2017 for forefoot deformity were followed up for >1 year and were retrospectively analyzed. In the preservation group, open reduction of joint dislocation was performed if needed, and the deformity was corrected by metatarsal shortening osteotomy. The mean follow-up period was 21 months. The Japanese Society for Surgery of the Foot (JSSF) scales (objective outcome measures), the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) (subjective outcome measure), and radiographic indices were compared between the groups. The resection group and preservation group comprised 15 toes of 11 patients and 36 toes of 29 patients, respectively. RESULTS: There were no significant differences in the preoperative radiographic indices, JSSF scales, or SAFE-Q results between the 2 groups. The preservation group showed better JSSF scores at the last follow-up (median hallux scale, 89 vs 74; median lesser scale, 87 vs 79). In the preservation group, the SAFE-Q scores gradually improved with time until 12 months postoperatively. In the resection group, the scores decreased 3 months postoperatively and then improved and reached a plateau 6 months postoperatively. At 12 months postoperatively, there was no significant difference in the SAFE-Q scores between the 2 groups. CONCLUSIONS: MTP joint-preserving arthroplasty resulted in superior objective scores to resection arthroplasty in patients with RA forefoot deformity. Although the subjective scores did not differ between the groups at the last follow-up, the time course of postoperative quality of life improvement was different between the 2 surgeries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparative Study of Dorsal and Volar Plating for Ulnar Shortening Osteotomy.

Background: Postoperative results of ulnar shortening osteotomy for ulnar abutment syndrome were compared between groups of patients in whom the plate was placed on the volar side and those in whom the plate was placed on the dorsal side. Methods: A total of 35 wrists of 14 males and 21 females were evaluated. The average age of patients at surgery was 44.3 years, and the average follow-up period was 66.2 months. After transverse osteotomy was performed, the ulna was fixed using a 6-hole LC-LCP or a LC-DCP on the dorsal (group D) or the volar (group V) side, respectively. Imaging and clinical results, rates and reasons for implant removal were evaluated. Results: There were 27 patients in group D and 8 in group V. A significant difference was observed only in the postoperative grip strength compared with that of the unaffected side between groups V and D (102% and 87%, respectively). Implant removal was performed in 18 (64%) patients in group D and in 7 (88%) in group V, and the main reasons for this were pain in group V and discomfort in group D. Re-fracture occurred after implant removal in one patient in group D. Conclusions: There were no differences in the imaging and clinical results depending on the plate position. It is preferable to avoid implant removal by placing the lower profile plate on the dorsal side.

Midterm and Long-term Follow-up After Surgical Reconstruction for Lateral Polydactyly of the Foot With Mosaic-like Alignment of the Phalanx Bones.

BACKGROUND: The phalanx bones in several cases of lateral polydactyly of foot revealed complicated alignment with radiographic findings revealing medial-protrusion and lateral deviation of the middle phalanx. We previously defined such cases as showing "mosaic-like alignment" and demonstrated favorable postoperative outcomes using our surgical procedure. The aim of this study was to evaluate the midterm and long-term postoperative outcomes in such cases. METHODS: The study included 17 feet from 16 patients; 5 male and 11 female, with one bilateral case. The radiographic findings in all cases revealed a mosaic-like alignment of phalanges. Average age of the patients at the initial surgery was 12 months and average duration of post-operative follow-up was 89 months (60 to 132 mo). The surgical procedures were focused on the alignment between the distal and proximal phalanges independent of the middle phalanx alignment. Ligamentous joint stability was restored using collateral ligament reconstruction. We retrospectively evaluated post-operative outcomes, and subjective evaluation by the patients and parents was carried out. RESULTS: No cases revealed either varus or valgus deformities, pigmentation of the grafted skin, or functional disturbance. As for postoperative complications, we observed visible thickening in 7 toes, 3 of which further underwent partial resection of the middle phalanx. Subjective evaluation of the postoperative results by the patients and parents was "very satisfied" or "satisfied" in 15 of 16 cases. CONCLUSION: On the basis of our midterm to long-term postoperative outcomes, we believe that our method of surgical reconstruction provides a new option for the treatment of lateral polydactyly of the foot with mosaic-like alignment of the phalanx bones. LEVEL OF EVIDENCE: Level IV-therapeutic studies.

Phosphorylated Platelet-Derived Growth Factor Receptor-Positive Cells With Anti-apoptotic Properties Accumulate in the Synovium of Patients With Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disease caused by inflammation of the synovium and characterized by chronic polyarthritis that destroys bone and cartilage. Fibroblast-like synoviocytes (FLSs) in the synovium of patients with RA can promote cartilage and bone destruction by producing proteins such as matrix metalloproteinases and receptor activator of NF-κB ligand, thereby representing an important therapeutic target for RA. FLSs have several phenotypes depending on which cell surface proteins and adhesion factors are expressed. Identifying the cellular functions associated with different phenotypes and methods of controlling them are considered essential for developing therapeutic strategies for RA. In this study, synovial tissue was collected from patients with RA and control subjects who required surgery due to ligament injury or fracture. Immunohistological analysis was used to investigate the rates of positivity for phosphorylated platelet-derived growth factor receptor-αß (pPDGFRαß) and cadherin-11 (CDH11) expression, and apoptosis-related markers were assessed for each cell phenotype. Next, FLSs were isolated in vitro and stimulated with tumor necrosis factor-α (TNF-α) in addition to a combination of PDGF and transforming growth factor (2GF) to investigate pPDGFRαß and CDH11 expression and the effects of the inhibition of TNF and cyclin-dependent kinase (CDK) 4/6 on FLSs. Immunohistological analysis showed a large percentage of pPDGFRαß+CDH11- cells in the sub-lining layer (SL) of patients with RA. These cells exhibited increased B-cell lymphoma-2 expression, reduced TNF receptor-1 expression, resistance to cell death, and abnormal proliferation, suggesting a tendency to accumulate in the synovium. Further, in vitro 2GF stimulation of FLSs lowered, whereas 2GF + TNF stimulation increased the pPDGFRαß/CDH11 ratio. Hypothesizing that FLSs stimulated with 2GF + TNF would accumulate in vivo in RA, we determined the therapeutic effects of TNF and CDK4/6 inhibitors. The TNF inhibitor lowered the pPDGFRαß/CDH11 ratio, whereas the CDK4/6 inhibitor suppressed cell proliferation. However, a synergistic effect was not observed by combining both the drugs. We observed an increase in pPDGFRαß+CDH11- cells in the SL of the RA synovium and accumulation of these cells in the synovium. We found that the TNF inhibitor suppressed FLS activity and the CDK4/6 inhibitor reduced cell proliferation.

Surgical treatment for partial rupture of the distal biceps tendon using palmaris longus tendon graft: A case report.

We report a case of a partial rupture of the distal biceps tendon that was surgically treated using a palmaris longus tendon graft. A 58-year-old man complained of increasing pain with resisted elbow flexion and supination in the antecubital fossa. Magnetic resonance imaging revealed the irregularity of a distal attachment of the biceps brachii and peripheral signal changes. We diagnosed a partial rupture of the distal biceps tendon. Because conservative treatment failed, surgical treatment was performed through a single anterior approach. The insertion of the tendon was partially ruptured at the radial tuberosity. After the involved site was debrided, the palmaris longus tendon was grafted with suture anchors to reinforce the remaining tendon. Postoperative immobilization was not performed, and all moves were freed after 3 weeks. At the 6-year postoperative follow-up, the patient no longer experienced pain and returned to his original job without any limitations.

Sagittal band reconstruction in the index finger using a modified Elson technique.

PURPOSE: The Elson technique is a rigid reconstruction method for a hypoplastic or absent sagittal band in the treatment of chronic extensor digitorum communis (EDC) tendon dislocation. We performed a modified procedure based on the Elson technique for reconstruction of the radial sagittal band in case involving the index finger. We investigated the postoperative outcomes of chronic EDC dislocation after treatment with the original and modified Elson technique. METHODS: We examined five fingers of five patients (2 males and 3 females) with a mean age of 41 years. The chronic EDC tendon dislocation was due to an old trauma, or a spontaneous or congenital condition involving the index in two, middle in two, and ring finger in one patient. Sagittal band reconstruction was performed using the modified Elson technique for the index finger and the original technique for the other fingers. The mean duration of postoperative follow-up was 58 months. Clinical findings such as pain and discomfort at metacarpophalangeal flexion associated with the tendon dislocation, range of motion (ROM), and disabilities of the arm, shoulder and hand were evaluated. We also examined postoperative recurrence and subjective patient evaluation. RESULTS: All cases achieved pain-free stability of the EDC tendon with no recurrence, and full ROM was maintained at the latest examination after surgery. The postoperative subjective evaluation by the patients was "very satisfied" in four fingers and "neutral" in one finger. CONCLUSION: We demonstrated our modified Elson technique for the treatment of chronic extensor tendon dislocation of the index finger.

Treatment of forearm deformity with radial head dislocation because of multiple osteochondromas: a series of three cases treated by simple axis correction and distraction osteogenesis of the ulna.

Radial head dislocation in multiple osteochondroma leads to functional impairment and cosmetic problems, and surgical intervention has not been successful to date, with high rates of redislocation. Simple correction of the longitudinal axis and distraction oste8ogenesis of the ulna without corrective osteotomy of the radius were performed within 1 year of radial head dislocation. The mean age of the patients was 7.2 years and the postoperative follow-up duration was 63.6 months. In all cases, the dislocated radial head was repositioned without surgical invention involving the radius. All patients were pain free, with no impairment of daily activity, and all were satisfied with the cosmetic appearance, indicating successful medium-term postoperative outcomes for our surgical procedure.

PDGFR Signaling Mediates Hyperproliferation and Fibrotic Responses of Subsynovial Connective Tissue Cells in Idiopathic Carpal Tunnel Syndrome.

Fibrosis of the subsynovial connective tissue (SSCT) is a pathognomonic change in carpal tunnel syndrome (CTS). Identification of molecular targets and anti-fibrotic therapies could provide new treatment strategies for CTS. The contribution of SSCT cells to fibrosis and the signaling pathways that initiate and aggravate fibrosis in CTS remain unknown. Here we report that platelet-derived growth factor receptor alpha (PDGFRα) positive ( + ) cells accumulate in CTS SSCT and that the presence of fibrotic growth factor, PDGF-AA, results in increased proliferation of PDGFRα+ cells via PI3K/Akt signaling pathway. Although PI3K inhibition decreased proliferation, there was no change in fibrosis-related gene expression. Indeed, protein levels of fibrosis signaling mediator TGF-ß remained the same and the second messenger, Smad2/3, accumulated in the nucleus. In contrast AMP-activated protein kinase (AMPK) activation, which can be induced with metformin and AICAR inhibited proliferation, TGF-ß expression, and altered cell morphology in SSCT cells. Further we show that AMPK activation by metformin reduced collagen III levels and the ratio of Collagen I to Collagen III. Both AICAR and metformin reduced F-actin and significantly reduced the fiber cross alignment. Our results suggest that PDGFRa signaling may be an important fibrosis target and that activators of AMPK, may be an important therapeutic approach for treating CTS.

Effects of lubricant and autologous bone marrow stromal cell augmentation on immobilized flexor tendon repairs.

The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 10(5) BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair.

CORR® ORS Richard A. Brand Award for Outstanding Orthopaedic Research: Engineering flexor tendon repair with lubricant, cells, and cytokines in a canine model.

BACKGROUND: Adhesions and poor healing are complications of flexor tendon repair. QUESTIONS/PURPOSES: The purpose of this study was to investigate a tissue engineering approach to improve functional outcomes after flexor tendon repair in a canine model. METHODS: Flexor digitorum profundus tendons were lacerated and repaired in 60 dogs that were followed for 10, 21, or 42 days. One randomly selected repair from either the second or fifth digit in one paw in each dog was treated with carbodiimide-derivatized hyaluronic acid, gelatin, and lubricin plus autologous bone marrow stromal cells stimulated with growth and differentiation factor 5; control repair tendons were not treated. Digits were analyzed by adhesion score, work of flexion, tendon-pulley friction, failure force, and histology. RESULTS: In the control group, 35 of 52 control tendons had adhesions, whereas 19 of 49 treated tendons had adhesions. The number of repaired tendons with adhesions in the control group was greater than the number in the treated group at all three times (p = 0.005). The normalized work of flexion in treated tendons was 0.28 (± 0.08), 0.29 (± 0.19), and 0.32 (± 0.22) N/mm/° at Day 10, Day 21, and Day 42 respectively, compared with the untreated tendons of 0.46 (± 0.19) at Day 10 (effect size, 1.5; p = 0.01), 0.77 (± 0.49) at Day 21 (effect size, 1.4; p < 0.001), and 1.17 (± 0.82) N/mm/° at Day 42 (effect size, 1.6; p < 0.001). The friction data were comparable to the work of flexion data at all times. The repaired tendon failure force in the untreated group at 42 days was 70.2 N (± 8.77), which was greater than the treated tendons 44.7 N (± 8.53) (effect size, 1.9; p < 0.001). Histologically, treated repairs had a smooth surface with intrinsic healing, whereas control repairs had surface adhesions and extrinsic healing. CONCLUSIONS: Our study provides evidence that tissue engineering coupled with restoration of tendon gliding can improve the quality of tendon healing in a large animal in vivo model. CLINICAL RELEVANCE: Tissue engineering may enhance intrinsic tendon healing and thus improve the functional outcomes of flexor tendon repair.

A comparative study of the effects of growth and differentiation factor 5 on muscle-derived stem cells and bone marrow stromal cells in an in vitro tendon healing model.

PURPOSE: To investigate the ability of muscle-derived stem cells (MDSCs) supplemented with growth and differentiation factor-5 (GDF-5) to improve tendon healing compared with bone marrow stromal cells (BMSCs) in an in vitro tendon culture model. METHODS: Eighty canine flexor digitorum profundus tendons were assigned into 5 groups: repaired tendon (1) without gel patch interposition (no cell group), (2) with BMSC-seeded gel patch interposition (BMSC group), (3) with MDSC-seeded gel patch interposition (MDSC group), (4) with GDF-5-treated BMSC-seeded gel patch interposition (BMSC+GDF-5 group), and (5) with GDF-5-treated MDSC-seeded gel patch interposition (MDSC+GDF-5 group). After culturing for 2 or 4 weeks, the failure strength of the healing tendons was measured. The tendons were also evaluated histologically. RESULTS: The failure strength of the repaired tendon in the MDSC+GDF-5 group was significantly higher than that of the non-cell and BMSC groups. The stiffness of the repaired tendons in the MDSC+GDF-5 group was significantly higher than that of the non-cell group. Histologically, the implanted cells became incorporated into the original tendon in all 4 cell-seeded groups. CONCLUSIONS: Interposition of a multilayered GDF-5 and MDSC-seeded collagen gel patch at the repair site enhanced tendon healing compared with a similar patch using BMSC. However, this increase in vitro was relatively small. In the clinical setting, differences between MDSC and BMSC may not be substantially different, and it remains to be shown that such methods might enhance the results of an uncomplicated tendon repair clinically. CLINICAL RELEVANCE: Muscle-derived stem cell implantation and administration of GDF-5 may improve the outcome of tendon repair.

Repopulation of intrasynovial flexor tendon allograft with bone marrow stromal cells: an ex vivo model.

PURPOSE: Delayed healing is a common problem whenever tendon allografts are used for tendon or ligament reconstruction. Repopulating the allograft with host cells may accelerate tendon regeneration, but cell penetration into the allograft tendon is limited. Processing the tendon surface with slits that guide cells into the allograft substrate may improve healing. The purpose of this study was to describe a surface modification of allograft tendon that includes slits to aid cell repopulation and lubrication to enhance tendon gliding. METHODS: Canine flexor digitorum profundus tendons were used for this study. Cyclic gliding resistance was measured over 1000 cycles. Tensile stiffness was assessed for normal tendon, tendon decellularized with trypsin and Triton X-100 (decellularized group), tendon decellularized and perforated with multiple slits (MS group) and tendon decellularized, perforated with slits and treated with a carbodiimide-derivatized hyaluronic acid and gelatin (cd-HA-gelatin) surface modification (MS-SM group). To assess tendon repopulation, bone marrow stromal cells (BMSCs) were used in the decellularized and MS groups. DNA concentration and histology were evaluated and compared to normal tendons and nonseeded decellularized tendons. RESULTS: The gliding resistance of the decellularized and MS groups was significantly higher compared with the normal group. There was no significant difference in gliding resistance between the decellularized and MS group. Gliding resistance of the normal group and MS-SM group was not significantly different. The Young's modulus was not significantly different among the four groups. The DNA concentration in the MS group was significantly lower than in normal tendons, but significantly higher than in decellularized tendons, with or without BMSCs. Viable BMSCs were found in the slits after 2 weeks in tissue culture. CONCLUSIONS: Tendon slits can successfully harbor BMSCs without compromising their survival and without changing tendon stiffness. Surface modification restores normal gliding function to the slit tendon. CLINICAL RELEVANCE: A multislit tendon reseeded with BMSCs, with a surface treatment applied to restore gliding properties, may potentially promote tendon revitalization and accelerate healing for tendon or ligament reconstruction applications.

The effect of surface modification on gliding ability of decellularized flexor tendon in a canine model in vitro.

PURPOSE: To investigate the gliding ability and mechanical properties of decellularized intrasynovial tendons with and without surface modification designed to reduce gliding resistance. METHODS: We randomly assigned 33 canine flexor digitorum profundus tendons to 1 of 3 groups: untreated fresh tendons, to serve as a control; tendons decellularized with trypsin and Triton X-100; and tendons decellularized as in group 2 with surface modification using carbodiimide-derivatized hyaluronic acid and gelatin (cd-HA-gelatin). Tendons were subjected to cyclic friction testing for 1,000 cycles with subsequent tensile stiffness testing. We qualitatively evaluated the surface roughness after 1,000 cycles using scanning electron microscopy. RESULTS: The gliding resistance of the decellularized group was significantly higher than that of both the control and cd-HA-gelatin tendons (0.20, 0.09, and 0.11 N after the first cycle; and 0.41, 0.09, and 0.14 N after 1,000 cycles, respectively). Gliding resistance between the control and cd-HA-gelatin groups was not significantly different. The Young modulus was not significantly different between groups. The surfaces of the control and cd-HA-gelatin-treated tendons appeared smooth after 1,000 cycles, whereas those of the decellularized tendons appeared roughened under scanning electron microscopy observation. CONCLUSIONS: Decellularization with trypsin and Triton X-100 did not change tendon stiffness. However, although this treatment was effective in removing cells, it adversely altered the tendon surface in both appearance and gliding resistance. Surface modification with cd-HA-gelatin improved the tendon surface smoothness and significantly decreased the gliding resistance. CLINICAL RELEVANCE: The combination of decellularization and surface modification may improve the function of tendon allografts when used clinically.

Nonunion of the ulnar styloid associated with distal radius malunion.

PURPOSE: Malunion is a complication of distal radius fractures and may be associated with a nonunion of the ulnar styloid. We tested the null hypothesis that there is no difference in outcome between patients without ulnar styloid fracture and those with the ulnar styloid nonunion after corrective radial osteotomy for distal radius malunion. METHODS: A total of 19 patients with dorsally angulated distal radius malunion who had simultaneous radial closing-wedge and ulnar shortening osteotomies were included. There were 16 women and 3 men with a mean age of 63 years. All patients were followed up for a minimum of 1 year. During surgery, the accompanying ulnar styloid nonunion was not internally fixed in any patient. Eight patients had no ulnar styloid fracture, and 11 had a nonunion of the ulnar styloid. Each group of patients was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder, and Hand score. RESULTS: There were no differences in the demographic and preoperative radiographic measurements between the nonfracture and nonunion groups. Postoperative radiographic measurements and functional outcomes improved significantly compared with the preoperative status in both groups. There were no significant differences in postoperative radiographic measurements, motion, strength, pain scores, Mayo scores, or Disabilities of the Arm, Shoulder, and Hand scores between the 2 groups. Four of the 11 ulnar styloid nonunions were healed within 1 to 12 months after corrective radial osteotomy. CONCLUSIONS: An accompanying ulnar styloid nonunion in patients with distal radius malunion has no apparent adverse effect on outcome or function after corrective radial osteotomy. An accompanying nonunion of the ulnar styloid can heal following corrective radial osteotomy.

Skeletal muscle and bone marrow derived stromal cells: a comparison of tenocyte differentiation capabilities.

This study investigated the comparative ability of bone marrow and skeletal muscle derived stromal cells (BMSCs and SMSCs) to express a tenocyte phenotype, and whether this expression could be augmented by growth and differentiation factor-5 (GDF-5). Tissue harvest was performed on the hind limbs of seven dogs. Stromal cells were isolated via serial expansion in culture. After four passages, tenogenesis was induced using either ascorbic acid alone or in conjunction with GDF-5. CD44, tenomodulin, collagen I, and collagen III expression levels were compared for each culture condition at 7 and 14 days following induction. Immunohistochemistry (IHC) was performed to evaluate cell morphology and production of tenomodulin and collagen I. SMSCs and BMSCs were successfully isolated in culture. Following tenocytic induction, SMSCs demonstrated an increased mean relative expression of tenomodulin, collagen I, and collagen III at 14 days. BMSCs only showed increased mean relative expression of collagen I, and collagen III at 14 days. IHC revealed positive staining for tenomodulin and collagen I at 14 days for both cell types. The morphology of skeletal muscle derived stromal cells at 14 days had an organized appearance in contrast to the haphazard arrangement of the bone marrow derived cells. GDF-5 did not affect gene expression, cell staining, or cell morphology significantly. Stromal cells from either bone marrow or skeletal muscle can be induced to increase expression of matrix genes; however, based on expression of tenomodulin and cell culture morphology SMSCs may be a more ideal candidate for tenocytic differentiation.

Clinical outcomes of corrective osteotomy for distal radial malunion: a review of opening and closing-wedge techniques.

BACKGROUND: Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is ongoing discussion over whether an opening or closing-wedge osteotomy should be employed. The purpose of the present study was to retrospectively compare the clinical and radiographic results of conventional opening-wedge osteotomy with those of our closing-wedge technique. METHODS: We retrospectively evaluated forty-two patients with extra-articular distal radial malunion who were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients were managed with radial opening-wedge osteotomy and interpositional bone graft or bone-graft substitute, and twenty were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The mean duration of follow-up was thirty-six months (range, twelve to 101 months) for the opening-wedge cohort and twenty-eight months (range, twelve to eighty-seven months) for the closing-wedge cohort. The two techniques were comparable in terms of complications. Postoperative volar tilt and ulnar variance improved significantly compared with the preoperative status in each cohort (p < 0.05). Restoration of ulnar variance to within defined criteria (-2.5 to 0.5 mm) was significantly more frequent in the closing-wedge cohort than in the opening-wedge cohort (p < 0.001). The postoperative mean extension-flexion arc of the wrist (p < 0.001) and Mayo wrist score (p = 0.008) were significantly better in the closing-wedge cohort. Differences between the two cohorts in terms of the pronation-supination arc, grip strength, pain-rating score, and DASH scores were not significant. CONCLUSIONS: The closing-wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.

Efficacy of radial styloid targeting screws in volar plate fixation of intra-articular distal radial fractures: a biomechanical study in a cadaver fracture model.

BACKGROUND: The locking screws target the radial styloid, theoretically provide greater stability against radial styloid fragment. However, it is unknown whether the radial styloid locking screws increased the stability of the volar plating system fixation along the entire distal radius or not. In this study, we evaluated the stability of the volar plating system fixation with or without the radial styloid screws using a biomechanical study in a cadaver fracture model. METHODS: Six matched pairs of fresh-frozen human cadaver wrists complete from the proximal forearm to the metacarpal bones were prepared to simulate standardized 3-part intra-articular and severe comminuted fractures. Specimens were fixed using the volar plating system with or without 2 radial styloid screws. Each specimen was loaded at a constant rate of 20 mm/min to failure. Load data was recorded and, ultimate strength and change in gap between distal and proximal fragments were measured. Data for ultimate strength and screw failure after failure loading were compared between the 2 groups. RESULTS: The average ultimate strength at failure of the volar plate fixation with radial styloid screws (913.5 ± 157.1 N) was significantly higher than that without them (682.2 ± 118.6 N). After failure loading, the average change in gap between the ulnar and proximal fragment was greater than that between the radial and proximal fragment. The number of bent or broken screws in ulnar fragment was higher than that in radial fragment. The number of specimens with bent or broken screws in cases with radial styloid screws was fewer than that in the fixation without radial styloid screws group. CONCLUSION: The ulnar fragment is more intensively stressed than the radial fragment under axial loading of distal radius at full wrist extension. The radial styloid screws were effective in stable volar plate fixation of distal radial fractures.

Functional outcomes after arthroscopic treatment of lateral epicondylitis.

BACKGROUND: The purpose of this study was to evaluate surgical outcomes of arthroscopic débridement for lateral epicondylitis using a validated, patient-assessed scoring system as well as conventional outcome measures. We also wanted to identify potential predictive factors that may be associated with the outcomes. METHODS: A total of 20 elbows in 18 patients with chronic lateral epicondylitis who underwent arthroscopic surgery were included. There were nine men and nine women with a mean age of 54 years (range 42-71 years). Operative treatment consisted of débridement of the extensor carpi radialis brevis (ECRB) origin and resection of the radiocapitellar synovial plica interposed in the joint. Outcomes were assessed using a patient rating, visual analogue scale (VAS) pain score, the Japanese Orthopaedic Association (JOA) elbow score, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. The average length of follow-up was 28 months (range 24-40 months). RESULTS: After surgery, according to the patients' reports, 14 of 20 elbows were much better, and 6 elbows were better. A mean preoperative VAS pain score at rest of 3.9 points improved to 0.3 points (P < 0.0001), and that during activity improved from 7.8 points to 0.9 points (P < 0.0001). The mean preoperative JOA elbow score of 29 points was improved to 90 points (P < 0.0001). The mean postoperative DASH score was 10.6 (range 0-50). Absent of T2-weighted high signal focus of the ECRB origin on preoperative magnetic resonance imaging (MRI) (P = 0.02) and receiving public assistance (P = 0.01) were significantly associated with worse DASH scores. CONCLUSIONS: Arthroscopic release was a satisfactory procedure for chronic lateral epicondylitis. Preoperative MRI of the ECRB origin and socioeconomic factors were significantly associated with postoperative residual symptoms evaluated with the DASH score.

Changes in urinary NTX levels in patients with primary osteoporosis undergoing long-term bisphosphonate treatment.

BACKGROUND: Bisphosphonates, antiresorptive drugs, are widely used to treat osteoporosis patients. However, recent reports indicated that several osteoporosis patients who underwent long-term bisphosphonate therapy subsequently developed severe suppression of bone turnover. We investigated whether urinary crosslinked N-telopeptide of type I collagen (NTX), a bone resorption marker, in osteoporosis patients was highly suppressed during long-term treatment with alendronate or risedronate. METHODS: We investigated 87 primary osteoporosis outpatients who were treated with alendronate or risedronate for more than 2 years. All patients were women, with an average age of 72.6 years. Altogether, 49 patients were treated with alendronate and 38 with risedronate, and the average administration period was 3.5 years. We defined high suppression as NTX being reduced <9.3 nmol bone collagen equivalent/mmol.Cr and a 35% decrease from baseline. RESULTS: In total, 11 of 87 patients (12.6%) had high NTX suppression based on the above criteria. The incidences of high suppression of NTX at 1,2,3,and 4 years after starting the treatment were 0%, 1.1%, 11.9%, and 4.7%, respectively. The average age, bone mineral density, and NTX values at baseline and the administration period were not associated with high suppression of NTX during alendronate or risedronate treatment. Regarding suppression of NTX during long-term treatment, there was no significant difference between alendronate and risedronate. CONCLUSIONS: The results suggested that long-term treatment with bisphosphonates necessitates careful follow-up of the patients.

The relationship between the pressure adjacent to the ulnar nerve and the disease causing cubital tunnel syndrome.

We investigated the relationship between cubital tunnel pressure in patients with cubital tunnel syndrome with osteoarthritis and those without osteoarthritis. We studied 31 elbows in 29 patients. We divided the patients into two groups: one associated with osteoarthritis and the other not associated with osteoarthritis. In the latter group, there was ulnar nerve subluxation in 10 elbows and cubitus valgus in 3. Cubital tunnel pressure was measured intraoperatively with a fiberoptic microtransducer. The extraneural pressure with the elbow flexed was significantly increased in patients with osteoarthritis and those without osteoarthritis. The pressure within the cubital tunnel in osteoarthritic elbows was significantly higher than that in those without osteoarthritis. Moreover, the pressure of osteoarthritic elbows significantly increased from proximally to distally within the cubital tunnel, whereas the pressure in elbows without osteoarthritis was high only proximally. Thus, cubital tunnel pressure could be a more important causative factor for cubital tunnel syndrome in the elbows with osteoarthritis than in those without osteoarthritis.