Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication.

BACKGROUND: The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society. METHODS: The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS: The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature. CONCLUSIONS: The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Metatarsal Periosteal Plantar Ganglion Cyst Associated With Stress Fracture: A Case Report.

We encountered a rare case of a periosteal ganglion cyst at the plantar aspect of the metatarsal that induced a stress fracture in a 77-year-old female. The clinical manifestation of the plantar ganglion cyst of the foot was not evident because of its location deep beneath the plantar fascia. A pressure cortical indentation was detected at the metatarsal neck on the initial radiographs. Magnetic resonance imaging showed a stress fracture of the metatarsal with a ganglion cyst. The stress fracture was thought to have resulted from several factors, including structural weakness due to bony absorption from the ganglion cyst, osteoporosis that induced a fragility fracture, and a load-induced fatigue fracture. The fracture completely healed following complete resection of the ganglion cyst with the surrounding periosteum along with medication for osteoporosis. When confirmation of a stress fracture is necessary or when presentation of a stress fracture is atypical, magnetic resonance imaging should be considered to confirm or rule out any other associated pathologic features. Resection of the periosteal ganglion cyst with the surrounding periosteum is important to prevent recurrence.

Open Reduction and Internal Fixation of Dorsal Fracture-Dislocation of the Proximal Interphalangeal Joint Using a Plate: A Series of 37 Patients.

Background: Open reduction and internal fixation with a plate is one of the alternative treatments for fracture-dislocation of the proximal interphalangeal (PIP) joint. However, it does not always lead to satisfactory results. The aim of this cohort study is to describe the surgical procedure and discuss the factors affecting the treatment results. Methods: We retrospectively reviewed 37 cases of consecutive unstable dorsal fracture-dislocation of the PIP joint treated using a mini-plate. The volar fragments were sandwiched with a plate and dorsal cortex, and screws were used as subchondral support. The average rate of articular involvement was 55.5%. Five patients had concomitant injuries. The mean age of the patients was 40.6 years. Mean time between injury and operation was 11.1 days. The average postoperative follow-up duration was 11 months. Active ranges of motion, % total active motion (TAM) were evaluated postoperatively. The patients were divided into two groups according from Strickland score and Gaine score. Fisher's exact test, Mann-Whitney U test and a logistic regression analysis were used to evaluate the factors affecting the results. Results: The average active flexion, flexion contracture at the PIP joint, and % TAM were 86.3°, 10.5° and 80.6%, respectively. Group I included 24 patients who had both excellent and good scores. Group II included 13 patients who had neither excellent nor good scores. When the groups were compared, there was no significant relationship between the type of fracture-dislocation and the extent of articular involvement. There were significant associations between outcomes and patient age, period from injury to surgical intervention and presence of concomitant injuries. Conclusions: We concluded that meticulous surgical technique leads to satisfactory results. However, factors, including the patient's age, time from injury to surgery and the presence of concomitant injuries needing adjacent joint immobilisation, contribute to unsatisfactory outcomes. Level of Evidence: Level IV (Therapeutic).

Subungual extraskeletal chondroma with finger nail deformity: case report.

We report a subungual extraskeletal chondroma with a convex nail deformity originating from the index finger in a 39-year-old man. The tumor was excised and its histopathology showed obvious nuclear pleomorphism. However, the Ki-67 (MIB-1) labeling index was less than 1%, indicating low proliferative activity; it was classified as an extraskeletal chondroma with atypical features. There was no recurrence over a 3-year postoperative period.

Custom-made splint treatment for osteoarthritis of the distal interphalangeal joints.

PURPOSE: We investigated the usefulness of a custom-made splint for treatment of painful osteoarthritis of the distal interphalangeal (DIP) joints. The splint was designed to be easily detachable so as not to diminish finger pad sensation or interfere with proximal interphalangeal joint motion. METHODS: We enrolled 25 patients (24 women and one man, mean age 58 y) with painful osteoarthritis of the DIP joints of the fingers and thumbs in this cohort study. Nineteen patients had multiple affected digits in one or both hands. Splints were applied to protect and immobilize the DIP joints. We assessed the outcome of this treatment using the visual analog scale pain score and the Quick Disabilities of the Arm, Shoulder, and Hand score for subjective assessment of symptoms. The mean follow-up period after wearing the splint until assessment was 6 months. Subjects were assessed 6 months after they started wearing the splint. RESULTS: Pain decreased from 100% at pretreatment to 34% at final follow up. So, the average improvement ratio was 66%. The Quick Disabilities of the Arm, Shoulder, and Hand disability/symptom score changes were not statistically significant (28 points pretreatment and 17 points at final follow-up). CONCLUSIONS: This splint reduced pain from DIP osteoarthritis according to the visual analog scale; however, this does not enable the patient to obtain completely satisfactory function of the upper extremities.

Painful Snapping of Thumb Caused by a Displaced Non-Union Fragment from the Trapezium: A Case Report.

There are only a few reports regarding snapping thumb caused by the pathology of the extensor tendon. We report a rare case of snapping thumb caused by a displaced non-union fragment from the trapezium in a 54-year-old man treated with the surgical resection. The intraoperative findings and the outcome are described.

Flexor Tendon Avulsion Injury Associated with Distal and Proximal Phalanx Fracture: A Case Report.

We present an extremely rare case of avulsion injury of the flexor digitorum profundus and the flexor digitorum superficialis tendons associated with fracture of the distal phalanx and bone bruise of the proximal phalangeal base of the small finger. Because of the nondisplaced transverse fracture of the distal phalanx, the early diagnosis of the injury was missed. The patient was treated with two-stage flexor tendon graft and the outcome was acceptable.

Flexor digitorum profundus tendon rupture associated with distal radius fracture malunion: a case report.

We present a case of subcutaneous flexor tendon rupture of the index finger following malunion of a distal radius fracture. The cause of the tendon rupture was mechanical attrition due to a bony prominence at the palmar joint rim in the distal radius due to malunion. Corrective osteotomy and the Sauvé-Kapandji procedure were carried out for the wrist pain and forearm rotation disability and a tendon graft was carried out for the flexor tendon rupture. Recovery was satisfactory.

A large intra-articular loose body in the metacarpophalangeal joint of the middle finger mimicking a calcified tumorous lesion: a case report.

We will report on a case with a large intra-articular loose body in the metacarpophalangeal (MP) joint of the middle finger in a 30-year-old-male, which was mimicking a calcified tumourous lesion adjacent to the palmar side of the metacarpal head. It was easily removed through the palmar approach.

Comminuted fractures of the radial head: comparison of resection and internal fixation. Surgical technique.

BACKGROUND: Satisfactory internal fixation of comminuted radial head fractures is often difficult to achieve, and radial head resection has been the accepted treatment. In this study, we compared the results of radial head resection with those of open reduction and internal fixation in patients with a comminuted radial head fracture. METHODS: Twenty-eight patients with a Mason type-III radial head fracture (some with associated injuries) were enrolled in the study. Fifteen patients underwent radial head resection as the initial treatment (Group I), and thirteen patients underwent open reduction and internal fixation (Group II). The age at the operation averaged 41.1 and 38.2 years, respectively, and the duration of follow-up averaged ten and three years, respectively. The outcomes were assessed on the basis of pain, motion, radiographic findings, and strength measured with Cybex testing. The overall outcome was rated with the functional rating score described by Broberg and Morrey and with the American Shoulder and Elbow Surgeons Elbow Assessment Form. RESULTS: Elbow motion averaged 15.5 degrees (extension loss) to 131.4 degrees (flexion) in Group I and 7.1 degrees to 133.8 degrees in Group II. The carrying angle and ulnar variance averaged 8.2 degrees and 1.9 mm in Group I and 1.5 degrees and 0.5 mm in Group II. Compared with Group II, Group I had a loss of strength in extension, pronation, and supination (p < 0.01). The Broberg and Morrey functional rating score averaged 81.4 points in Group I and 90.7 points in Group II (p = 0.0034). The score on the American Shoulder and Elbow Surgeons Elbow Assessment Form averaged 87.3 points in Group I and 94.6 points in Group II (p = 0.0031). CONCLUSIONS: The patients in whom the comminuted radial head fracture was treated with open reduction and internal fixation had satisfactory joint motion, with greater strength and better function than the patients who had undergone radial head resection. These results support a recommendation for open reduction and internal fixation in the treatment of this fracture.

Locking of the metacarpophalangeal joint of the thumb by a loose body: a case report.

We report a case with locking of the metacarpophalangeal (MP) joint of the thumb in a 15-year-old high school baseball catcher, which was caused by an intra-articular loose body arising from osteochondritis dissecans. The loose body was removed arthroscopically, enabling early return to full MP joint function.

Comminuted fractures of the radial head. Comparison of resection and internal fixation.

BACKGROUND: Satisfactory internal fixation of comminuted radial head fractures is often difficult to achieve, and radial head resection has been the accepted treatment. In this study, we compared the results of radial head resection with those of open reduction and internal fixation in patients with a comminuted radial head fracture. METHODS: Twenty-eight patients with a Mason type-III radial head fracture (some with associated injuries) were enrolled in the study. Fifteen patients underwent radial head resection as the initial treatment (Group I), and thirteen patients underwent open reduction and internal fixation (Group II). The age at the operation averaged 41.1 and 38.2 years, respectively, and the duration of follow-up averaged ten and three years, respectively. The outcomes were assessed on the basis of pain, motion, radiographic findings, and strength measured with Cybex testing. The overall outcome was rated with the functional rating score described by Broberg and Morrey and with the American Shoulder and Elbow Surgeons Elbow Assessment Form. RESULTS: Elbow motion averaged 15.5 degrees (extension loss) to 131.4 degrees (flexion) in Group I and 7.1 degrees to 133.8 degrees in Group II. The carrying angle and ulnar variance averaged 8.2 degrees and 1.9 mm in Group I and 1.5 degrees and 0.5 mm in Group II. Compared with Group II, Group I had a loss of strength in extension, pronation, and supination (p < 0.01). The Broberg and Morrey functional rating score averaged 81.4 points in Group I and 90.7 points in Group II (p = 0.0034). The score on the American Shoulder and Elbow Surgeons Elbow Assessment Form averaged 87.3 points in Group I and 94.6 points in Group II (p = 0.0031). CONCLUSIONS: The patients in whom the comminuted radial head fracture was treated with open reduction and internal fixation had satisfactory joint motion, with greater strength and better function than the patients who had undergone radial head resection. These results support a recommendation for open reduction and internal fixation in the treatment of this fracture.

Extensive Periosteal Chondroma in the Middle Phalanx with Pathological Fracture Reconstructed with Strut Bone Grafting.

We report of a pathological fracture of the middle phalanx of the little finger due to periosteal chondroma. The periosteal chondroma occupied an extensive area of the middle phalanx extending to the proximal interphalangeal joint, and the fracture involved the distal interphalangeal articular surface. The fracture was internally fixed using a strut bone grafting after resection of the chondroma. One year and four months after the operation, remodeling of the phalanx had completed without recurrence and functional loss.

Carpal Tunnel Syndrome with Wrist Trigger Caused by Hypertrophied Lumbrical Muscle and Tenosynovitis.

We present a case of carpal tunnel syndrome involving wrist trigger caused by a hypertrophied lumbrical muscle with flexor synovitis. The case was a 40-year-old male heavy manual worker complaining of numbness and pain in the median nerve area. On active flexion of the fingers, snapping was observed at the carpal area, and forceful full grip was impossible. Tinel's sign was positive and an electromyographic study revealed conduction disturbance of the median nerve at the carpal tunnel. Magnetic resonance imaging revealed edematous lumbrical muscle with synovial proliferation around the flexor tendons. Open carpal tunnel release was performed under local anesthesia. Synovial proliferation of the flexor tendons was found and when flexing the index and middle fingers, the lumbrical muscle was drawn into the carpal tunnel with a triggering phenomenon. After releasing the carpal tunnel, the triggering phenomenon and painful numbness improved.

Conservative treatment using a newly designed custom-made wrist splint for ulnocarpal abutment syndrome.

BACKGROUND: Immobilization of the wrist joint with a splint is an established approach for ulnar-sided pain due to ulnocarpal abutment syndrome. However, patients have a tendency to stop wearing the splints because of its inconvenience and there have been no reports based on splint therapy. OBJECTIVE: We investigated the usefulness of a newly designed custom-made aluminum splint for ulnar-sided wrist pain. STUDY DESIGN: This was a cohort study of the aluminum splint therapy for the patients who had been primarily treated with a conventional splint but ceased to use it because of the inconvenience in activities of daily living. METHODS: The subjects included 10 female patients (mean age = 44.2 years). The outcome was assessed using the visual analogue scale score for pain, the disabilities of the arm, shoulder and hand score, range of motion of the wrist, and the grip strength. The mean follow-up period after wearing the aluminum splint was 8.8 months. RESULTS: All parameters, including the visual analogue scale pain and disabilities of the arm, shoulder and hand scores, improved significantly (p < 0.05) following use of the aluminum splint relative to the pretreatment scores. Seven patients continued to use the aluminum splint, and three of the seven had complete remission from related pain. CONCLUSION: Constant use of the aluminum splint during the study period was associated with improvement in the ulnar-sided wrist pain scores, which reconfirmed that increased adherence to splint use in daily activities is an important intentional behavioral strategy. CLINICAL RELEVANCE: Although the custom splint is effective for alleviation of wrist pain in ulnocarpal abutment syndrome, continuity of splint use is a key element of conservative treatment. This study showed that a splint that patients were willing to wear in their daily life was a useful device for alleviation of pain.

Reconstructive procedure to repair chronic injuries to the collateral ligament of metacarpophalangeal joints of the hand.

We have devised a reconstructive procedure to repair chronic injuries to the collateral ligament of metacarpophalangeal (MCP) joints. It comprises palmaris longus tendon grafting into a bone tunnel and suturing onto the base of the residual ligament without involving fixation of the tendon graft stump. Thirteen patients were treated for injured MCP joints: thumb/ulnar, ten cases; thumb/radial, two; and middle finger/radial, one. All patients had pain and instability of average 41 degrees in the affected MCP joints. The patients were followed at an average period of five years and nine months. Pain and joint instability disappeared in all patients. The mean MCP joint range of motion (ROM) was 1 degrees on extension and 58 degrees on flexion. The tip pinch strength averaged 4.8 kg. The gratifying results obtained using this method are attributed to the fact that optimal tension of the ligament and satisfactory ROM can be achieved during the course of rehabilitation.

The relationship between nerve conduction velocity and fiber morphology during peripheral nerve regeneration.

We analyzed the relationship between motor nerve conduction velocity (MCV) and morphological changes in regenerating nerve fibers at different times after sciatic nerve transection to identify reliable indices of functional recovery. Thirty rats were divided into five equal groups, one control group and four groups subjected to sciatic nerve transection and immediate suturing, followed by regeneration for 50, 100, 150, and 200 days, respectively. MCV was measured in each group, followed by morphometric analyses of fibers of the common peroneal nerve. MCV increased progressively with time after nerve transection, although it remained lower than the control velocity. Mean fiber diameter (axon plus myelin sheath) also increased with time after nerve transection. Recovery of mean fiber diameter was well correlated with MCV, even though regenerating nerves likely contained many small nonconducting fibers. In contrast, the change in the mean diameter of regenerating axons and relative myelin thickness (g-ratio) did not provide an accurate measure of recovery as they were not increasing in a time-dependent manner. Furthermore, internodal length changed only slightly with increasing fiber diameter in regenerating nerves; therefore, the regression relation between fiber diameter and internodal length was not a sensitive index of recovery. MCV and mean fiber diameter were the most sensitive indices of functional recovery during sciatic nerve regeneration.

Application of a navigation system for contouring anatomical plasty of the distal end of the humerus.

The effectiveness of navigation systems in performing accurate orthopaedic surgery has been reported previously, but there have been no reports on the application of navigation in surgeries involving bone resection around the elbow joint. In this study, anatomical plasty or bone resection was performed to restore anatomical morphology in 10 cases of osteoarthritis of the elbow and deformity of the distal end of the humerus. Bone resection was performed on the distal end of the humerus using navigation and on the proximal end of the ulna via freehand surgery. Postoperatively, the elbow function was evaluated and pre- and postoperative CT images were used to measure the bone resection. There were no complications arising from the use of navigation, and elbow function was improved in all cases. By evaluating the CT images, it was found that navigated resection of the fossae of the distal humerus was more effective than freehand resection of the processes of the proximal ulna, thus confirming the usefulness of navigation. In future, to fully confirm this finding, it will be necessary to conduct prospective controlled studies of cases in which navigation is used to perform arthroplasty, including those that involve the proximal end of the ulna.