Evaluation of Radiographic Instability of the Trapeziometacarpal Joint in Women With Carpal Tunnel Syndrome.

PURPOSE: To determine whether median nerve dysfunction measured by electrophysiologic studies in carpal tunnel syndrome (CTS) is associated with thumb trapeziometacarpal (TMC) joint instability. METHODS: We evaluated 71 women with CTS and 31 asymptomatic control women. Patients with generalized laxity or TMC joint osteoarthritis were excluded. We classified the electrophysiologic severity of CTS based on nerve conduction time and amplitude and assessed radiographic instability of the TMC joint based on TMC joint stress radiographs. We compared subluxation ratio between patients with CTS and controls and performed correlation analysis of the relationship between the electrophysiologic grade and subluxation ratio. RESULTS: Thirty-one patients were categorized into the mild CTS subgroup and 41 into the severe CTS subgroup. There was no significant difference in subluxation ratio between the control group and CTS patients or between the control group and CTS subgroup patients. Furthermore, there was no significant correlation between electrophysiologic grade and subluxation ratio. CONCLUSIONS: This study demonstrated that patients with CTS did not have greater radiographic TMC joint instability compared with controls, and suggests that TMC joint stability is not affected by impaired median nerve function. Further studies could investigate how to better evaluate proprioceptive function of TMC joint and whether other nerves have effects on TMC joint motor/proprioceptive function, to elucidate the relationship between neuromuscular control of the TMC joint, its stability, and its progression to osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Is surgery for brachial plexus schwannomas safe and effective?

BACKGROUND: Schwannomas rarely are found in the brachial plexus, and although they are benign, they present significant challenges to surgical treatment. To our knowledge, there are few studies investigating the surgical outcomes of patients with brachial plexus tumors. QUESTIONS/PURPOSES: We analyzed the outcomes of 19 patients with brachial plexus schwannomas and asked: (1) How do these patients present? (2) Where are the tumors located in the brachial plexus? (3) What are the complications and neurologic results of patients after excision of the tumor? METHODS: From February 2002 to August 2012, one orthopaedic hand surgeon treated 19 patients with schwannomas of the brachial plexus. We retrospectively reviewed the medical records and MRI data of all patients. There were 11 women and eight men, with a mean age of 50.2 years (range, 32-63 years). The tumor was located on the right side in eight patients and on the left in 11 patients. We evaluated neurologic deficits preoperatively and neurologic deficits and local recurrence of tumors postoperatively. Minimum followup was 12 months (mean, 37.2 months; range, 12-90 months). RESULTS: The most common initial presentation was a palpable mass. The masses were located at all levels along the brachial plexus, including the root, trunk, cord, and terminal branches. The smallest mass was 1.5 × 1.5 × 0.5 cm and the largest was 11 × 10 × 6 cm. Fourteen of the 19 patients did not have any postoperative neurologic deficits. All the removed masses were proven histologically to be schwannomas. Of the five patients who had postoperative neurologic deficits, three had transient sensory deficits, one had weakness of the flexor pollicis longus and second flexor digitorum profundus, and another had weakness of the extensor pollicis longus. No recurrence was observed during the followup period. CONCLUSIONS: Schwannomas of the brachial plexus are a potentially curable lesion with an acceptable surgical risk of injury to neurovascular structures. With precise surgical techniques, these tumors can be removed to improve symptoms with minimal morbidity. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Radial collateral ligament injury of the little finger proximal interphalangeal joint in young pianists.

PURPOSE: To report the features of radial collateral ligament injury of the little finger proximal interphalangeal joint in young piano players. METHODS: Between 2005 and 2012, we treated 6 cases of radial collateral ligament injury of the little finger proximal interphalangeal joint in young piano players at a single referral center. We conducted a retrospective review of charts and radiographs and telephone-interviewed all patients at a mean follow-up of 33 months (range, 12-66 mo) to evaluate features of this injury. RESULTS: All patients were girls with a mean age of 10 years (range, 8-12 y), and all had injuries in their right hands. Patients had been playing piano for a mean 3.8 years (range, 3-5 y) and practicing for a mean 1.8 hours per day (range, 1-3 h). Pain was commonly aggravated when they played octaves or advanced pieces requiring extensive finger movements. All patients were playing on standard-size piano keyboards and had generalized hypermobility with a mean Beighton and Horan score of 6.3 (range, 5-9). Two patients had an ulnar deviation deformity of 10° and 15° each at the proximal interphalangeal joint whereas the others had no fixed joint deformity. Five patients showed improvement with conservative treatment, but 1 patient underwent surgery. CONCLUSIONS: In our practice, all piano-related radial collateral ligament injuries were in female preadolescents with evidence of generalized hypermobility; patients had been playing piano extensively, suggesting that the injury could have resulted from stress on the joint during piano playing. Future studies should further evaluate the efficacy of modifying keyboard size, techniques, and repertoires for piano lessons and of patient education for this type of injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The effect of patient involvement in surgical decision making for carpal tunnel release on patient-reported outcome.

PURPOSE: To investigate whether patient-reported outcomes are different according to patients' preference or experience in surgical decision making for carpal tunnel release. METHODS: We preoperatively surveyed 85 patients who underwent carpal tunnel release regarding their preferred role in the process of surgical decision making and assessed their experienced role in the actual decision making 6 months after surgery using a Control Preference Scale. For patient-reported surgical outcomes, we used the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these outcomes with those of patients having different preferences or experiences in surgical decision making and also compared the outcomes according to whether the preferred roles match the experienced roles. RESULTS: The Disabilities of the Arm, Shoulder, and Hand scores were not significantly different between patients with different preferences for involvement in decision making for surgery or between those with different experiences in the actual decision making. However, those who experienced the same level of involvement as they had preferred were found to have better Disabilities of the Arm, Shoulder, and Hand scores than those who experienced a more active role or a more passive role than they had preferred. CONCLUSIONS: This study demonstrates that patient-reported outcomes were not different between those with different preferences or experiences in surgical decision making for carpal tunnel release. However, this study suggests that patients whose experience in decision making matched with their preference may have better subjective outcomes after carpal tunnel release. This suggests that patients with carpal tunnel syndrome may benefit from physicians' efforts of identifying patients' preferences for involvement in decision making and matching the identified preferences to the decision-making process. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The relationship between positive or negative phrasing and patients' coping with lateral epicondylitis.

BACKGROUND: Research suggests that phrases with negative content can affect patients' response to medical procedures and how they cope with medical illnesses. We hypothesized that patients with lateral epicondylitis who describe their condition in positive phrases cope better than those who do not. METHODS: We prospectively followed up 91 patients with lateral epicondylitis for 12 months. The patients indicated their baseline coping status based on the Pain Catastrophizing Scale (PCS) and were discharged with a wait-and-see policy. During follow-up interviews, the patients described the nature of their condition in their own words and were then categorized into either positive or negative phrasing groups. We compared these two groups regarding current coping status and whether they had sought additional treatment. We also analyzed for the factors associated with these outcomes. RESULTS: There were no significant differences in baseline PCS scores between the two groups. At follow-up, patients in the positive phrasing group (n = 62) had significantly lower PCS scores and were less likely to seek additional treatment than those in the negative phrasing group (n = 29). Multivariable analyses showed that positive phrasing and low pain levels were independently associated with improvement in PCS scores and that negative phrasing and depression were independently associated with patients' seeking additional treatment. CONCLUSION: Patients' positive phrasing about their condition are associated with improvement in their coping status and with less use of medical resources in the case of lateral epicondylitis. This study suggests that patients with more positive attitudes toward their illness cope and comply better when a wait-and-see treatment is recommended by their physicians.

The effect of buffered lidocaine in local anesthesia: a prospective, randomized, double-blind study.

PURPOSE: Open carpal tunnel decompression under local anesthesia is routinely done by many surgeons. However, patients complain of pain during the injection of local anesthesia. This prospective, double-blind, randomized study was to compare the pain visual analog scale (VAS) scores of local anesthesia using lidocaine with and without sodium bicarbonate in patients with bilateral carpal tunnel syndrome. METHODS: Twenty-five patients underwent bilateral simultaneous carpal tunnel decompression. All had topical anesthetic cream applied on the palm and wrist before the lidocaine block. In a randomized manner, half of the hands were blocked with nonbuffered lidocaine and half were blocked with buffered lidocaine. Pain was evaluated on a VAS score. RESULTS: The mean pain VAS score in the hand with buffered lidocaine was 4.6 ± 1.5 and 6.5 ± 1.5 for the hand with nonbuffered lidocaine. After adjustment for individual threshold of the pain, the mean pain VAS score changed into 4.6 ± 1.3 with buffered lidocaine and 6.6 ± 1.7 without buffered lidocaine. CONCLUSIONS: In open carpal tunnel surgery, the use of buffered lidocaine for local anesthesia reduces the anesthetic pain effectively. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Radial polydactyly: proposal for a new classification system based on the 159 duplicated thumbs.

BACKGROUND: Polydactyly is one of the most common congenital differences that affect the hand. It has various anatomic and morphologic features. Although the Wassel classification has been used widely for radial polydactyly, it is based on the anatomic level of duplication and has some limitations in describing the concrete morphology of the duplication. The authors devised a new classification system based on the anatomic pattern of duplication to facilitate surgical correction of the deformity and evaluated surgical outcomes. METHODS: A total of 159 duplicated thumbs in 142 patients who were treated surgically from 1990 to 2007 and followed for > 12 months were included in this series. The authors categorized all cases of radial polydactyly into the following: type I (joint type), where the extra digit has its own joint at its origin; type II (single epiphyseal type), where the origin of the extra digit is derived directly from the common epiphysis; type III (osteochondroma-like type), where the origin of the extra digit resembles an osteochondroma; and type IV (hypoplastic type), where the extra digit is connected to the main digit by soft tissue alone. All patients underwent surgical treatment based on this classification. The surgical outcomes were assessed using the Tada score. RESULTS: Of the 159 radial polydactyly cases, 84 (50%) were classified as the joint type-37 (22%) as the osteochondroma-like type, 33 (19%) as the single epiphyseal type, and 15 (9%) as the hypoplastic type. All the cases were classified with the proposed classification system. In the evaluation of the surgical outcomes, 134 (84%), 17 (11%), and 8 (5%) were rated as good, fair, and poor, respectively. CONCLUSIONS: This new classification system for radial polydactyly is practical and closely related to the surgical strategies. LEVEL OF EVIDENCE: Diagnostic IV.

A correlation exists between subchondral bone mineral density of the distal radius and systemic bone mineral density.

BACKGROUND: Intraarticular distal radius fractures are common and risk articular congruity owing to disruption of the subchondral bone. Studies regarding microstructure and mechanical properties of the distal radius, however, focus only on the cortical and trabecular bones in the metaphysis and not on the subchondral bone. QUESTIONS/PURPOSES: This study was conducted to (1) quantify the regional bone mineral density of the subchondral plate in the distal radius; (2) analyze the topographic distribution pattern of the subchondral bone mineral density; and (3) evaluate the correlation between the subchondral bone mineral density and the potentially related clinical factors of age, height, weight, BMI, systemic bone mineral densities, socio-occupational classification, and hand osteoarthritis grading. METHODS: Eighty postmenopausal women with a mean age of 68 years (range, 52-88 years) were enrolled in this study. Digital images of the distal radii of the subjects were scanned by conventional CT and processed to provide the regional bone mineral density of the subchondral plate using a CT osteoabsorptiometry technique. The estimated subchondral bone mineral density was analyzed to evaluate the topographic pattern and its correlation with various clinical factors, including age, height, weight, BMI, degree of hand osteoarthritis, socio-occupational class, and systemic bone mineral density measured in the lumbar spine and hip. RESULTS: During topographic analysis of a densitometric map, a bicentric distribution of the subchondral bone mineral density was found. Among the clinical factors, only the systemic bone mineral density measured by dual-energy x-ray absorptiometry in the femur neck and lumbar spine had a significant correlation with the subchondral bone mineral density of the distal radius. CONCLUSION: Systemic bone mineral density correlates substantially with the subchondral bone mineral density of the distal radius as a constitutional factor, whereas other local factors arising from the gravitational load or joint reaction force are not associated with the subchondral bone mineral density of the distal radius. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Minimal epicondylectomy improves neurologic deficits in moderate to severe cubital tunnel syndrome.

BACKGROUND: Previous studies of minimal medial epicondylectomy for cubital tunnel syndrome included patients with mild disease, making it difficult to determine how much this procedure improved sensory and motor impairments in patients with moderate to severe disease. QUESTIONS/PURPOSES: We asked if minimal epicondylectomy improved sensory and motor impairments in patients with moderate to severe cubital tunnel syndrome. METHODS: We retrospectively reviewed 25 patients treated with minimal medial epicondylectomy for advanced cubital tunnel syndrome involving motor weakness between January 2003 and February 2009. Preoperatively, five patients had Medical Research Council (MRC) Grade 4 motor strength without atrophy (McGowan Grade IIA), nine had MRC Grade 3 motor strength with detectable atrophy (McGowan Grade IIB), and 11 had MRC Grade 3 or less motor strength with severe atrophy (McGowan Grade III). Postoperatively we obtained DASH scores and evaluated improvement of sensory impairment and motor impairment: excellent with minimal sensory deficit and motor deficit, good with mild deficits, fair with improved but persistent deficit(s), and poor with no improvement. The minimum followup was 13 months (mean, 46 months; range, 13-86 months). RESULTS: The mean DASH score was 14 points (range, 2-47 points). Of the 25 patients, sensory improvement and motor improvement were excellent in 16 patients, good in five, fair in two, and poor in two. Twenty-three of the 25 patients improved at least one McGowan grade. There were no complications, such as medial elbow instability. CONCLUSIONS: Minimal medial epicondylectomy can improve sensory and motor impairments for patients with moderate to severe cubital tunnel syndrome. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

The radiologic relationship of the shoulder girdle to the thorax as an aid in diagnosing neurogenic thoracic outlet syndrome.

PURPOSE: Neurogenic thoracic outlet syndrome (NTOS) is produced by compression of the brachial plexus in the thoracic outlet. The lower position of the shoulder girdle relative to the upper thorax may be related to NTOS. We investigated this hypothesis using plain cervical radiographs. METHODS: We conducted this case-control study using plain cervical anteroposterior and lateral radiographs in 63 NTOS patients and 126 carpal tunnel syndrome patients who were matched for age and sex. To estimate the position of the shoulder girdle relative to the upper thorax, we analyzed the level of the clavicle using 2 parameters: the number of vertebrae visible in a lateral radiograph and the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph. The number of vertebrae visible in a lateral radiograph was the parameter for the level of the lateral part of the clavicle relative to the upper thorax, whereas we used the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph to determine the level of the medial part of the clavicle. RESULTS: Both parameters were greater in the NTOS group than in the control group, which suggests that the level of the shoulder girdle was lower in the NTOS group than in the control group. In addition, the risk of NTOS was increased in patients with lower shoulder girdle position. CONCLUSIONS: The lower placement of the shoulder girdle relative to the upper thorax was related to NTOS. Physicians may be able to estimate the position of the shoulder girdle using plain cervical radiographs when NTOS is clinically suspected. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

The effect of multiple channeling on the structural integrity of repaired rotator cuff.

PURPOSE: The purpose of this study was to investigate the effect of adding multiple channeling of the greater tuberosity on the structural integrity of the repaired rotator cuff tendon. METHODS: Fifty-six consecutive patients who underwent arthroscopic rotator cuff repair and postoperative computed tomography arthrography (CTA) were included in this study; 31 consecutive patients that underwent conventional repair and 25 subsequent patients that underwent conventional repair with multiple channeling. Using CTA, the repaired rotator cuff was evaluated as either intact, incomplete, or complete leakage at the insertion and in the tendon separately. The integrity type and overall integrity was then determined by the combination of the insertion and tendon grade. Factors affecting integrity were also evaluated. RESULTS: At the insertion, multiple channeling significantly improved integrity; complete leakage in 35.5% in the conventional group and 4.0% in the multiple channeling group (P = 0.017). In the tendon, no significant difference was observed between the two groups. Integrity types were significantly different between the two groups (P = 0.009). For overall integrity, discontinuity was more frequently identified in the conventional group (35.5%) than in the multiple channeling group (16.0%), but it was not statistically significant. With regard to causes of discontinuity, all were due to retears in the conventional group, while 75% were due to new tears in the multiple channeling group (P = 0.009). CONCLUSION: Multiple channeling is simple and easily performed without any special instrument and might augment the healing of repaired rotator cuff tendons. It could be a useful technique in rotator cuff repair helping healing.

The effect of dividing muscles superficial to the transverse carpal ligament on carpal tunnel release outcomes.

PURPOSE: To test the hypothesis that division of muscle fibers lying over or within the transverse carpal ligament (TCL) in an open carpal tunnel release does not have an effect on outcomes in patients with carpal tunnel syndrome (CTS). METHODS: A total of 152 patients with a mean age of 57 years (range, 31-83 y) diagnosed with CTS were enrolled for intraoperative observation of the muscles overlying or within the TCL as seen through a 3-cm incision. These muscles when present were incised layer by layer in line with division of the TCL. Patients were divided into 3 groups according to the extent of the muscles covering the TCL. We compared the 3 groups for outcomes of surgery at 6 months in terms of the Boston and Disabilities of the Arm, Shoulder, and Hand (DASH) scores, grip and pinch powers, and scar pain. RESULTS: Of the 152 patients, 75 had a purely ligamentous TCL (group 1), 52 had muscle fibers covering 50% or less of the incision length (group 2), and 25 had muscle fibers covering more than 50% of the incision length (group 3). There were no differences in the postoperative Boston symptom and function scores and the DASH scores among the groups. In addition, there were no differences in the grip and pinch strengths and scar pain. CONCLUSIONS: Division of the muscles overlying or within the TCL in line with the third web space incision does not affect postoperative outcomes after carpal tunnel release in terms of the Boston and DASH scores, grip and pinch powers, and scar pain.

Incidence of clinically diagnosed and surgically treated carpal tunnel syndrome in Korea.

PURPOSE: Most epidemiologic studies on carpal tunnel syndrome (CTS) have been performed on specific regional or occupational groups, or on general populations in the West. The authors undertook to determine the incidence of clinically diagnosed and surgically treated CTS in the Korean general population. METHODS: A retrospective, nationwide cohort study was performed using data collected from 2005 to 2007 (inclusive) by the Korean Health Insurance Review Agency, which covers 97% of the population. We analyzed the incidence of clinically diagnosed, electrophysiologically diagnosed, and surgically treated CTS in patients aged over 20 years, and the influences of gender and age on incidence. RESULTS: The incidence of total clinically diagnosed CTS and electrophysiologically diagnosed CTS in patients over 20 years of age was 4.96 and 0.98 per 1,000 person-years, respectively. The incidence of surgically treated CTS was 0.29 per 1,000 person-years. The age-adjusted female to male incidence ratio of diagnosed CTS was 2.58 (95% confidence interval, 2.56-2.59) and that of surgically treated CTS was 5.82 (95% CI, 5.64-6.00). Women aged 50 to 59 years had the highest incidence of CTS (18.11 per 1,000 person-years), whereas men showed a slow increase in incidence with age, highest at 60 to 69 years. CONCLUSIONS: Compared with Western studies, our study of the Korean population shows a similar incidence of CTS but a lower incidence of surgery. Korean women with CTS are more likely to be treated surgically than men. Further studies may be warranted to identify ethnic, gender, and socioeconomic factors that influence surgical treatment rates.

Evaluation of early postoperative pain and the effectiveness of perifracture site injections following volar plating for distal radius fractures.

PURPOSE: Few studies have investigated the effectiveness of early postoperative pain control regimens after volar plating for distal radius fractures. This study evaluated postoperative levels of pain after volar plating of distal radius fractures under axillary nerve block in patients with and without injections of local anesthetics, narcotics, and epinephrine around the fracture site. METHODS: Perioperative pain levels were prospectively assessed in 44 consecutive patients who had had volar plating for a distal radius fracture under axillary nerve block at a mean time of 2.8 days after trauma. Intravenous, patient-controlled analgesia and prescheduled analgesic medications were administered to all patients. In addition, patients were randomly allocated to 2 groups: perifracture site injection (PI; n = 22) and no perifracture site injection (no-PI; n = 22). At the end of surgery, PI group patients were administered perifracture site injections and blocks of the superficial radial and interosseous nerves with a local anesthetic mixture consisting of ropivacaine, morphine, and epinephrine. During the first 48 hours after surgery, pain visual analog scale (VAS) scores (0 to 100), total amount of narcotic consumption, incidences of additional narcotic requirement, and opioid-related side effects were assessed. RESULTS: The overall mean pain VAS scores among all 44 study subjects were 29 before surgery, and 58, 47, 40, and 27 at 4, 8, 24, and 48 hours after surgery, respectively. Thirteen patients needed additional pain rescue despite the multimodal analgesic approach used. No intergroup differences were observed between the PI and no-PI groups in terms of VAS pain scores, total narcotic consumption, adjuvant pain rescue incidence, and opioid-related side effects. CONCLUSIONS: Postoperative mean pain VAS scores after volar plating of distal radius fractures were found to be 58 at 4 hours and 47 at 8 hours. Perifracture site injections were not found to provide any additional pain control benefit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Effect of passive stretching on simple camptodactyly in children younger than three years of age.

PURPOSE: To present the effectiveness of passive stretching as a treatment for camptodactyly, without any other form of physiotherapy or splinting. METHODS: From May 2003 to August 2008, 61 digits of 22 patients were treated conservatively using passive stretching exercises. All children were less than 3 years old and had no other anomalies. Flexion contractures before and after treatment in mild, moderate, and severe groups were measured and changes were analyzed statistically. The correlations between various clinical factors and treatment outcome were also analyzed statistically. The average follow-up period was 26 months (range, 12-47 mo). RESULTS: Mean flexion contracture improved from 20° to 1° in the mild group (p < .001), from 39° to 12° in the moderate group (p < .001), and from 75° to 28° in the severe group (p < .001). Of the clinical factors examined, only initial flexion contracture was found to be significantly correlated with treatment outcome (r = -0.287, p = .0025). CONCLUSIONS: Passive stretching can effectively improve flexion deformity in camptodactyly in infants and young children. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Under-meniscal portal: an alternative portal for an easy access to the medial and lateral menisci.

Approach to the pathologies in the posterior horn of the medial meniscus in a tight knee may be a challenging technique to the arthroscopic surgeon in certain patients. The pie-crusting technique of the medial collateral ligament which can be done percutaneously to open up a tight posteromedial compartment would be a good option in such patients. Here, the authors introduce a useful alternative portal for approaching the posterior horn of the medial meniscus, the under-meniscal portal. The under-meniscal portal is located under the menisci and can be placed safely and easily without any complication. It is also helpful for approaching the unstable underside of the horizontal tear in the anterior horn of the lateral meniscus. The authors suggest the under-meniscal portal as a good alternative portal for managing challenging lesions in the posterior horn of the medial meniscus and the anterior horn of the lateral meniscus.

Fetal mesenchymal stem cells derived from human umbilical cord sustain primitive characteristics during extensive expansion.

Stem cells of fetal origin lie between embryonic and adult stem cells in terms of potentiality. Because of the ethical controversy surrounding embryonic stem cells and the relatively inferior quality of adult stem cells, the use of fetal stem cells would be an attractive option in future therapeutic applications. Here, we have investigated primitive characteristics of human umbilical-cord-derived fetal mesenchymal stem cells (UC fMSCs) during extensive expansion. We have successfully isolated and cultured UC fMSCs from all UC samples, but with two early fungal contaminations. UC fMSCs proliferated without significant evidence of morphological changes, and the average cumulative population-doubling level was over 25 for about 3 months. UC fMSCs showed the positive expression of several CD markers, known to be related to MSCs, including CD73 (SH-3, 4), CD90 (Thy-1), CD105 (SH-2), CD117 (c-kit), and CD166 (ALCAM). They demonstrated primitive properties throughout the expansion period: multilineage differentiation potentials examined by functional assays, a variety of pluripotent stem cell markers including Nanog, Oct-4, Sox-2, Rex-1, SSEA-3, SSEA-4, Tra-1-60, and Tra-1-81, minimal evidence of senescence as shown by beta-galactosidase staining, and the consistent expression of telomerase activity. These results suggest that UC fMSCs have more primitive properties than adult MSCs, which might make them a useful source of MSCs for clinical applications.

Clinical Outcome of Lateral Wedge Osteotomy of the Radius in Advanced Stages of Kienböck's Disease.

BACKGROUND: Radius osteotomies showed favorable clinical outcome in Kienböck's disease. However, few articles have been published on the long-term outcome of lateral wedge osteotomy of the radius in patients with advanced stage Kienböck's disease. METHODS: Eleven patients with Lichtman stage IIIB/IV Kienböck's disease (group A; mean follow-up period, 86.1 months; range, 48 to 163 months) and 14 patients with Lichtman stage IIIA Kienböck's disease (group B; mean follow-up period, 85.1 months; range, 49 to 144 months) underwent radial wedge osteotomy between August 2004 and August 2012. Radiological changes of the lunate and radiocarpal joint were compared between two groups after osteotomy. The wrist flexion/extension angle, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were evaluated preoperatively and at the final follow-up. The Nakamura Scoring System (NSSK) was used for comprehensive understanding of radiological and clinical outcomes. RESULTS: Nine patients of group A and 11 patients of group B showed radiological improvement in the lunate regarding sclerosis, cystic changes, or fragmentation. No patients showed progression of arthritic changes in radiocarpal and midcarpal joints. The wrist flexion/extension angle, grip strength, and DASH score were significantly improved in both groups after operation, but intergroup difference was not statistically significant at the final follow-up (p = 0.149, p = 0.267, and p = 0.536, respectively). The mean NSSK was 21.6 (range, 15 to 27) in group A and 21.8 (range, 15 to 26) in group B. CONCLUSIONS: Radial wedge osteotomy yielded excellent radiological and functional outcomes in advanced stages of Kienböck's disease and these results were comparable to those of Lichtman stage IIIA disease. This technique could be a useful alternative to salvage procedures in the treatment of Lichtman stage IIIB/IV Kienböck's disease without severe radiocarpal arthritis.

The Effect of Psychological Factors on the Outcomes of Carpal Tunnel Release: A Systematic Review.

BACKGROUND: Several studies report that psychological factors are associated with outcomes of carpal tunnel release. However, interpretation of the association is difficult as there are diverse outcome parameters and patient expectations are different. We performed a systematic review to assess the relationships between psychological factors and the various outcome parameters. METHODS: We identified 611 papers and selected 8 papers that fit the inclusion criteria. Psychological factors assessed were anxiety, depression, pain catastrophizing, coping, and mental health status. Outcomes of interest included satisfaction and measures of perceived level of function, pain, and physical measures of recovery. RESULTS: For satisfaction and perceived level of function as the outcome, three studies reported a significant association, one study found an association approaching a value of significance, and one study reported no association. For pain as the outcome, two studies reported a significant association. For physical measures, one study reported no association. CONCLUSIONS: This systematic review found that depression correlates with postoperative pain, but that the association is less clear between psychological factors and outcomes such as satisfaction, perceived level of symptom and function, and physical measures of recovery. As pain may not be a primary symptom or outcome of CTS, we consider that the current literature does not strongly support the association between psychological factors and outcomes of CTR. This review could be of benefit during preoperative counseling in patients with psychological disturbances.

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study.

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint.