Correction of Congenital Ring-Little Finger Metacarpal Synostosis Through Simultaneous Interpositional Allograft Bone After Split Osteotomy of the Synostosis Site and Distraction Lengthening of the Fifth Metacarpal.

PURPOSE: We attempted a technique for patients with congenital ring-little finger metacarpal synostosis involving simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal along with correction of the metacarpal joint abduction contracture. The purpose of this study was to describe the surgical technique and its outcomes. METHODS: We reviewed the medical records of children with congenital ring-little finger metacarpal synostosis treated surgically at our institute. Eight hands of six children with an average age of 5.0 (range, 1.7-9.3) years were treated by simultaneous interpositional allograft bone after split osteotomy, distraction lengthening, and tenotomy of abductor digiti minimi. We measured the metacarpal head-to-capitate area ratios from serial radiographs and analyzed them according to age. We also measured the change in the intermetacarpal angle (IMA) and metacarpal length ratio during an average of 8.1 (range, 1.4-16.8) years of follow-up. These changes were compared with changes in seven hands of five children with an average age of 8.1 (range, 1.5-15.6) years treated by the same method, but without a distraction lengthening of the fifth metacarpal and followed up for an of average 12.1 (range, 4.1-19.8) years, as a control group. RESULTS: Abnormal metacarpal head-to-capitate area ratio before surgery was normalized in all patients within the first 2 years after surgery. The IMA change averaged 39.8°, and the metacarpal length ratio changed by 17%. The control group showed an average IMA change of 36.6° and metacarpal length ratio change of 6%. CONCLUSIONS: Simultaneous interpositional allograft bone after split osteotomy of the synostosis site and distraction lengthening of the fifth metacarpal with correction of metacarpal joint abduction contracture can restore the radiographic parameters in congenital ring-little finger metacarpal synostosis. The normalized ossification of the fifth metacarpal head indicates that the surgical procedure is probably safe. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Hand and wrist - what the hand surgeon wants to know from the radiologist.

Hand surgeons, as unique specialists, appreciate the complexity of the anatomy of the hand. A hand is not merely a group of anatomic structures but a separate organ that works by feeling, sending information to the brain, and enabling a variety of movements, from precise skills to firm tasks. Acute and chronic problems interfere with complicated hand function and potentially influence work or daily life activities for a long time. Thus, the surgeon's role is to propose appropriate treatment with predictable results. This paper attempts to specify the preoperative considerations and their influence on the choice of surgical procedure and the assessment of results potentially influencing further treatment. We have divided the manuscript by anatomical structures, which is a natural surgical assessment and planning approach. The most common problems were highlighted to introduce the method of decision-making and surgical solutions.

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.

Diagnosis of Neurogenic Thoracic Outlet Syndrome Based on the Clinical Status.

OBJECTIVES: At our institute, we devised a clinical algorithm for diagnosis of neurogenic thoracic outlet syndrome (TOS). Our approach assisted in the accurate diagnosis and in detection of patients likely to benefit from surgical treatment. The purposes of this study were to propose our diagnostic approach to neurogenic TOS, and to describe the outcomes of surgical and conservative treatment. METHODS: Patients (n = 91) who were suspected to have neurogenic TOS, and therefore, underwent a routine clinical protocol from January 2012 to January 2018 were reviewed. Through the clinical protocol, diagnosis of "true neurologic TOS", "symptomatic TOS", and "not likely TOS" was made. The visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder and Hand (DASH) score were used to assess the treatment outcomes. Satisfaction with surgery was assessed according to the Derkash classification as excellent, good, fair, or poor. RESULTS: Among 91 patients with presumed neurogenic TOS, 25 patients were "true neurologic TOS", 61 patients were "symptomatic TOS", and five patients were "not likely TOS". Nineteen patients underwent supraclavicular decompression of the brachial plexus whose mean age at the time of surgery was 36.4 years. The VAS average pain score improved from 3.6 to 0.8, and the DASH score improved from 38.4 to 17.1. According to the Derkash classification, ten patients (53%) rated their recovery as excellent, four (21%) as good, and five (26%) as fair. Sixty-seven patients underwent conservative treatment. At the last follow-up visit, their VAS and DASH score were 2.3 and 11.8, respectively. CONCLUSIONS: By using an algorithm, we diagnosed the patients suspected to have neurogenic TOS into three groups based on clinical status. We surgically treated 19 patients using supraclavicular approach, and achieved favorable outcomes.

Early Surgical Treatment of Both Tumor and Fracture in Patients With Enchondroma of the Hand Combined With Pathologic Fracture.

PURPOSE: The aims of this study were to evaluate the degree of cortical thinning and the tumor area in simple radiographs in patients with enchondroma of the hand combined with pathologic fracture and to determine the surgical outcome of simultaneous tumor curettage and internal fixation of fracture. METHODS: We enrolled 23 bone lesions of 21 patients diagnosed with enchondroma of the hand. Of them, 9 bone lesions of 8 patients had pathologic fracture. We evaluated the degree of cortical thinning and tumor area in simple radiographs and compared them between patients with and without pathologic fracture. For patients with pathologic fracture, we performed curettage of the tumor through the fracture site and fixed the fracture using K-wires. We then evaluated the clinical outcome of these patients using the visual analog scale to measure pain intensity and Takigawa's criteria 1 year after surgery. RESULTS: There was a significant difference in the degree of cortical thinning between the 2 groups (P < 0.001); however, there was no significant difference in the percentage of tumor area (P = 0.259). The average time from surgery to bony union was 8.5 weeks in patients with pathologic fracture. The patients reported that they could return to their previous activities of daily living within 12 weeks of surgery. The average visual analog scale score was 0.6 at 1 year after surgery, and 6 patients were graded as excellent and 2 as good according to Takigawa's criteria. CONCLUSIONS: Cortical thinning seems to be related to pathologic fracture. Our scoring system for cortical thinning may be helpful in evaluating the risk for pathologic fracture. Early 1-stage surgical treatment for pathologic hand fracture with enchondroma is a very useful method with satisfactory outcomes that could shorten the treatment period.

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.

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.

The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea.

PURPOSE: There have not been well-designed survey studies investigating the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic resident education. METHODS: A 58-question, web-based survey was administered to orthopaedic residents in South Korea. A total of 229 orthopaedic residents from 43 hospitals completed the survey questionnaire. RESULTS: The average working time of 72.7 hours/week before the pandemic was decreased to 65.6 hours/week during the pandemic (p < 0.001). The time working in the operating room was significantly decreased during the pandemic, but not in the emergency centre and outpatient clinic. The education times for lecture and clinical case discussion were decreased during the pandemic (both, p < 0.001), respectively. While the use of traditional teaching methods was decreased, the use of online-based teaching methods was increased (p < 0.001). However, satisfaction level with online-based teaching methods was significantly lower compared with that of traditional teaching methods. The average working time exposed to the patients with COVID-19 was 9.7 hours/week. About 47.6% of orthopaedic residents experienced isolation or quarantine. The average score for quality of life, which was 68.9 out of 100 scores before the pandemic, decreased to 61.7 during the pandemic (p < 0.001). The most stressful factor for orthopaedic residents during the pandemic was family/relative health, followed by their own health and residency program. CONCLUSION: The COVID-19 pandemic had a significant impact on orthopaedic resident education in South Korea. Therefore, flexible and sustainable strategies are necessary to prepare for the future as well as the current pandemic situation.

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.

Comparative adherence to weekly oral and quarterly intravenous bisphosphonates among patients with limited heath literacy who sustained distal radius fractures.

Individuals with limited health literacy (HL) are less likely to obtain preventive care. We designed a study to compare adherence to weekly oral and quarterly intravenous bisphosphonates among patients with low HL. The study enrolled a total of 432 female patients who presented with a distal radius fracture caused by low-energy trauma. Participant HL was measured using the Newest Vital Sign tool, and patients were randomized to weekly oral or quarterly intravenous bisphosphonate groups. Subjects in the intravenous bisphosphonate group received intravenous injections of 3 mg ibandronate every 3 months, and those in the oral bisphosphonate group self-administered 70 mg alendronate orally once each week for 12 months. The adherence to weekly oral or quarterly intravenous bisphosphonates was analyzed by HL level. The rate of adherence to quarterly intravenous bisphosphonates was significantly higher than that for weekly oral bisphosphonates in patients with inadequate HL (73 vs. 46%, p = 0.001), whereas no significant differences were observed between HL groups in adherence to intravenous bisphosphonate. Conversely, the rate of adherence to orally administered bisphosphonates was significantly lower in patients with inadequate HL than in those with appropriate HL (46 vs. 65%, p = 0.005). After controlling for confounding variables, inadequate HL, the presence of comorbidities, and weekly oral bisphosphonates were associated with a higher likelihood of nonadherence to osteoporosis treatment. Thus patients with limited health literacy can achieve rates of adherence to quarterly intravenous bisphosphonates, as opposed to weekly oral bisphosphonates, similar to rates among patients with appropriate literacy.

Preoperative Pain Sensitization Is Associated With Postoperative Pillar Pain After Open Carpal Tunnel Release.

BACKGROUND: Postoperative pillar pain (deep-seated wrist pain worsened by leaning on the heel of the hand) sometimes occurs after carpal tunnel release (CTR), leading to weakness in the hand and delayed return to work. Increased pain sensitivity has been found to be associated with worse symptoms and poorer treatment response in a number of chronic musculoskeletal conditions, but few studies have investigated the association of pain sensitization with pillar pain after CTR. QUESTIONS/PURPOSES: (1) Is preoperative pain sensitization in patients with carpal tunnel syndrome (CTS) associated with increased severity of pillar pain after open CTR? (2) What other demographic, electrophysiological, or preoperative clinical characteristics are associated with pillar pain after CTR? METHODS: Over a 35-month period, one surgeon performed 162 open carpal tunnel releases. Patients were eligible if they had sufficient cognitive and language function to provide informed consent and completed a self-reported questionnaire; they were not eligible if they had nerve entrapment other than CTR or if the surgery was covered by workers compensation insurance. Based on these criteria, 148 (91%) were approached for this study. Of those, 17 (9%) were lost to followup before 12 months, leaving 131 for analysis. Their mean age was 54 years (range, 32-78 years), and 81% (106 of 131) were women; 34% (45 of 131) had less than a high school education. We preoperatively measured pain sensitization by assessing the patients' pressure pain thresholds by stimulating pressure-induced pain in the pain-free volar forearm and administering a self-reported Pain Sensitivity Questionnaire minor subscale, an instrument that assesses pain intensity in daily life situations. We evaluated postoperative pillar pain using the "table test" (having the patient lean on a table with their weight on their hands placed on the table's edge with elbows straight) with an 11-point ordinal scale at 3, 6, and 12 months after their surgical procedures. We conducted bivariate and multivariable analyses to determine whether the patients' clinical, demographic, and pain sensitization factors were associated with their postoperative pillar pain severity after CTR. RESULTS: After controlling for relevant confounding variables such as age, education level, and functional states, we found that increased pillar pain severity was associated with the pressure pain threshold (ß = -1.02 [-1.43 to -0.61], partial R = 11%, p = 0.021) and Pain Sensitivity Questionnaire minor (ß = 1.22 [0.73-1.71], partial R = 17%, p = 0.013) at 3 months, but by 6 months, only Pain Sensitivity Questionnaire minor (ß = 0.92 [0.63-1.21], partial R = 13%, p = 0.018) remained an associated variable for pillar pain. Additionally, gender (women) was associated with increased pain severity at 3 (ß = 0.78 [0.52-1.04], partial R = 9%, p = 0.023) and 6 months (ß = 0.72 [0.41-1.01], partial R = 8%, p = 0.027). At 3 months, pressure pain threshold, Pain Sensitivity Questionnaire minor, and gender (women) collectively accounted for 37% of the variance in pillar pain severity; at 6 months, Pain Sensitivity Questionnaire minor and gender (women) accounted for 21% of the variance, but no relationship between those factors and pillar pain was observed at 12 months. CONCLUSIONS: Gender (women) and preoperative pain sensitization measured by pressure pain threshold and self-reported Pain Sensitivity Questionnaire were associated with pillar pain severity up to 3 and 6 months after CTR, respectively. However, the influence of pain sensitization on pillar pain was diminished at 6 months and it did not show persistent effects beyond 12 months. Pain sensitization seems to be more important in the context of recovery from surgical intervention (in the presence of a pain condition) than in healthy states, and clinicians should understand the role of pain sensitization in the postoperative management of CTS. Future research may be needed to determine if therapeutic interventions to reduce sensitization will decrease the risk of pillar pain. LEVEL OF EVIDENCE: Level III, prognostic study.