Tenosynovial and Cardiac Transthyretin Amyloidosis in Japanese Patients Undergoing Carpal Tunnel Release.

Background: Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is a life-threatening progressive disease. Recent studies have shown that the detection of transthyretin (TTR) amyloid in tenosynovial tissue may play an important role in the diagnosis of cardiac amyloidosis. The aim of this study was to determine the prevalence of TTR amyloid deposits in surgical tissue of patients undergoing carpal tunnel surgery and to clarify the clinical significance of concomitant cardiac examination with 99 mTc-labeled pyrophosphate (99 mTc-PYP) scintigraphy in those patients with TTR deposition. Methods and Results: We evaluated 79 consecutive patients undergoing carpal tunnel release surgery and biopsy of tenosynovial tissue. The mean (±SD) age of the patients at surgery was 71.6±12.5 years (range 30-95 years); 32 patients (41%) were male. TTR amyloid deposition in tenosynovial tissue was observed in 27 patients (34%). Sixteen of those 27 patients underwent 99 mTc-PYP scintigraphy. Of those 16 patients, 3 (19%) had Grade 2 uptake on 99 mTc-PYP scintigraphy. None of the 3 patients with a diagnosis of ATTRwt-CA had apparent cardiac symptoms and left ventricular wall thickness >13 mm. Conclusions: Concomitant cardiac examination with 99 mTc-PYP scintigraphy in patients who had TTR amyloid deposition in tenosynovial tissue resulted in the identification of 19% of patients with a diagnosis of ATTRwt-CA. This diagnostic approach seems to be useful for the early diagnosis of the disease.

Humeral Avulsion of the Lateral Collateral Ligament of the Elbow Concomitant with the Medial Epicondyle Fracture of a Child with General Joint Laxity.

Medial epicondyle fracture is a common elbow injury for children, and it was reported that 30-50% of this fracture was associated with elbow dislocation. However, dysfunction of the lateral collateral ligament (LCL) complex accompanied with the medial epicondyle fracture has rarely been reported. In this report, a 13-year-old girl who had a humeral avulsion of the LCL concomitant with a displaced medial epicondyle fracture was presented. Since her general joint laxity had been recognized from past medical history and the humeral avulsion of the LCL was clearly confirmed by ultrasonography, simultaneous surgical repair for the LCL avulsion and medial epicondyle fracture was conducted and satisfactory outcome was achieved. Although general joint laxity does not tend to receive attention in trauma as much as chronic conditions, it should be borne in mind to prevent overlooking important soft tissue damage coexisting with apparent fractures.

Splinting for the carpometacarpal joint relieves experimental basal thumb pain and loss of pinch strength.

BACKGROUND: Splinting is a quite common intervention for the first carpometacarpal (CMC) osteoarthritis, however, underlying mechanisms of biomechanical and analgesic effects has not been fully investigated. The aim of this study was to develop an experimental basal thumb pain model and to elucidate the effects of CMC splinting on the pain profile and motor function. METHODS: In 14 healthy subjects, experimental basal thumb pain was induced by hypertonic saline injection into the dorsal radial ligament located on base of the first metacarpal bone. Isotonic saline was injected contralaterally as a control. Two experimental sessions with or without CMC splinting were conducted. Before, during and after injections, tip pinch strength was measured and surface electromyography of the abductor pollicis brevis (APB), first dorsal interosseous (FDI) and extensor pollicis longus (EPL) during tip pinch were evaluated in each session. RESULTS: Hypertonic saline induced significantly greater pain compared with baseline and isotonic saline (p < 0.01). Following hypertonic saline injection, the tip pinch strength decreased compared with baseline, concomitant with reduction of electromyographical activity of APB and FDI, but not of EPL (p < 0.05). The CMC splinting significantly improved the experimental pain, loss of pinch strength and inhibited intrinsic muscle activity compared with bare hand (p < 0.05). CONCLUSIONS: A novel experimental model mimicking the first CMC joint pain was developed. The CMC splinting relieved the basal thumb pain and augmented pinch strength as well as intrinsic muscle activity. This study provides new insights into the pain relief and pinch strength improvement by splinting for painful CMC joint disorders. SIGNIFICANCE: Newly developed experimental basal thumb pain model decreased tip pinch strength approximately 50%, concomitant with the reduction of intrinsic muscle activities. Splinting for the first carpometacarpal joint significantly improved experimental pain, loss of pinch strength and inhibited intrinsic muscle activity compared with bare hand.

Physeal Bar Resection Under Guidance With a Navigation System and Endoscopy for Correction of Distal Radial Deformities After Partial Growth Plate Arrest.

Partial growth plate arrest caused by trauma may lead to severe deformity and dysfunction. The Langenskiöld method is a surgical technique that involves resection of the physeal bar causing partial growth plate arrest. However, it is a technically demanding procedure. We used the Langenskiöld method under guidance with a navigation system and endoscopy and obtained good results in 2 cases. We consider that use of these tools can be a helpful adjunct to the carrying out this procedure.

Joint Arthroplasty With Osteochondral Grafting From the Knee for Posttraumatic or Degenerative Hand Joint Disorders.

PURPOSE: To describe the operative procedure and report the clinical outcomes of articular surface reconstruction for various hand joint disorders using autologous osteochondral grafts from the knee. METHODS: Ten patients underwent articular surface reconstruction for hand joint disorders with autologous osteochondral grafts from the patellofemoral joint. Mean patient age was 35 years (range, 15-52 y). The patients were followed for an average of 48 months (range, 16-89 mo). Arthroplasty was performed on the metacarpophalangeal joint in 4 cases, and on the proximal interphalangeal joint in 6 cases. The patients' clinical outcomes were evaluated with joint range of motion, visual analog scale (0-10 points), and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Histological examination was performed in 3 cases after surgery. RESULTS: Graft union was confirmed in all cases without radiographic evidence of resorption or necrosis. Follow-up radiographic examinations showed good graft incorporation without signs of osteoarthritis such as joint space narrowing. The finger flexion-extension arc improved significantly from an average of 21° to 61°. The mean visual analog scale also improved significantly from 7.0 to 1.5. The mean total active motion showed a significant improvement from 151° before surgery to 201° after surgery, and the mean DASH score improved significantly from 33 to 12. There were no significant differences for the arc of finger motion and DASH score between metacarpophalangeal and proximal interphalangeal joint disorders or between hemiarthroplasty and total joint arthroplasty. Histological examination revealed viable chondrocytes in the implanted cartilage. CONCLUSIONS: Autologous osteochondral grafting from the patellofemoral joint provided satisfactory outcomes and may be a useful option for joint surface reconstruction of traumatic or degenerative hand joint disorders. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Improved quality of cartilage repair by bone marrow mesenchymal stem cells for treatment of an osteochondral defect in a cynomolgus macaque model.

BACKGROUND AND PURPOSE: Integration of repaired cartilage with surrounding native cartilage is a major challenge for successful tissue-engineering strategies of cartilage repair. We investigated whether incorporation of mesenchymal stem cells (MSCs) into the collagen scaffold improves integration and repair of cartilage defects in a cynomolgus macaque model. METHODS: Cynomolgus macaque bone marrow-derived MSCs were isolated and incorporated into type-I collagen gel. Full-thickness osteochondral defects (3 mm in diameter, 5 mm in depth) were created in the patellar groove of 36 knees of 18 macaques and were either left untreated (null group, n = 12), had collagen gel alone inserted (gel group, n = 12), or had collagen gel incorporating MSCs inserted (MSC group, n = 12). After 6, 12, and 24 weeks, the cartilage integration and tissue response were evaluated macroscopically and histologically (4 null, 4 gel, and 4 MSC knees at each time point). RESULTS: The gel group showed most cartilage-rich reparative tissue covering the defect, owing to formation of excessive cartilage extruding though the insufficient subchondral bone. Despite the fact that a lower amount of new cartilage was produced, the MSC group had better-quality cartilage with regular surface, seamless integration with neighboring naïve cartilage, and reconstruction of trabecular subchondral bone. INTERPRETATION: Even with intensive investigation, MSC-based cell therapy has not yet been established in experimental cartilage repair. Our model using cynomolgus macaques had optimized conditions, and the method using MSCs is superior to other experimental settings, allowing the possibility that the procedure might be introduced to future clinical practice.

Operative treatment of metacarpal and phalangeal fractures in athletes: early return to play.

BACKGROUND: Evaluating the outcomes of operative treatment for metacarpal and phalangeal fractures in athletes returning early to play and discussing the more effective methods that permit rapid early return to athletic activity. METHODS: We retrospectively identified a total of 105 metacarpal or phalangeal fractures in 105 athletes with conservative or operative treatment in our department. Of these, 20 athletes required an early return to sport because of a pending important game in their competition within 1 month after injury. Therefore, they underwent surgical treatment with open reduction and internal fixation of metacarpal or phalangeal fractures in an attempt to achieve an early return to their chosen sport at their usual competitive level. The patients included 6 rugby football players, 2 soccer goalkeepers, 3 American football players, 3 handball players, 2 baseball players and 4 who participated in other sports. The clinical records of preoperative and postoperative radiographs were available for all patients, and clinical outcome was evaluated by total active motion (TAM). RESULTS: The patients were followed up for a mean of 27 (24-43) months. At the latest follow-up examination, bone union was obtained in all cases. In cases with metacarpal and phalangeal fractures, the average TAM was 263° (range 240°-270°). CONCLUSION: We consider that an early comeback to training and competition can be permitted exclusively for patients with metacarpal and phalangeal fractures. It is important for the attending physician to administer such treatment after obtaining informed consent and develop a trusting relationship with the patient and other related individuals while paying attention to their hope of quick recovery.

Ultrasound-assisted closed reduction of distal radius fractures.

PURPOSE: To assess the accuracy and ability of ultrasound for monitoring closed reduction for distal radius fractures. METHODS: Consecutive patients undergoing ultrasound-guided closed reduction of acute, displaced distal radius fractures between January 2003 and December 2006 at our department were enrolled. The control group was extracted from patients who underwent a closed reduction for similar fractures under fluoroscopy or without any imaging assistance. To confirm the accuracy of the ultrasonography measurements, displacement distance values were compared with those on radiographic imaging before and after reduction. X-ray parameters for pre- and postreduction, reduction time, total cost, and success rate were compared between the ultrasound-guided and the control groups. RESULTS: The ultrasound-guided group consisted of 43 patients (mean age, 68 y) and the control group consisted of 57 patients, which included 35 patients (mean age, 74 y) with fluoroscopic reduction and of 22 patients (mean age, 72 y) with reduction unaided by imaging. There were no significant displacement differences between radiographic and ultrasound measurements. In x-ray parameters for pre- and postreduction, there were no significant differences between the 2 groups. Ultrasound-guided reduction took longer than the other 2 methods. The success rate of the ultrasound and the fluoroscopic groups were similar (95% and 94%, respectively). CONCLUSIONS: Our data suggest that ultrasound assistance can aid reduction of distal radius fractures as well as fluoroscopy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients.

BACKGROUND: There is a conflict in the treatment of distal radius fractures in elderly patients, because fracture reduction does not appear to be as strongly associated with functional outcomes as in younger patients. The purpose of this study was to evaluate radiographic findings of acceptable reduction without leading to wrist dysfunction and poor outcomes. METHODS: Fifty-two active and healthy elderly patients with conservatively managed distal radius fractures were included in the study. They consisted of 7 men and 45 women, all 60 years or older. Radiographic assessment included volar tilt, radial inclination and ulnar variance, and outcome evaluation included the Mayo wrist score and DASH score. As a control group, the preoperative radiographic and clinical outcomes were examined as well for 19 patients older than 60 with malunion, for whom corrective osteotomy was performed because of wrist dysfunction. The radiographic parameters and clinical outcomes were compared between the two groups in a statistical manner. Correlation coefficients of the radiographic parameters with Mayo wrist score and DASH score were analyzed by multiple regression. RESULTS: Volar tilt (mean -1.2°) and ulnar variance (mean 2.5 mm), as well as Mayo wrist score (mean 80.0 points) and DASH score (mean 8.6 points) in the objective group were significantly superior to those in the control group when comparing radiographic parameters and clinical outcomes. There was no significant difference between the two groups in regard to RI (mean 14.9°). Multiple regression analysis revealed that volar tilt and ulnar variance were significantly correlated with the clinical outcomes in the objective. CONCLUSION: The parameters of volar tilt and ulnar variance had a significant correlation with clinical outcomes. Clinical outcomes significantly worsened when those parameters exceeded a tolerable range. In elderly patients, it is important to determine an appropriate therapeutic modality for a distal radius fracture when considering the acceptable parameters for alignment.

Scaphoid excision and 4-bone arthrodesis versus proximal row carpectomy: a comparison of contact biomechanics.

PURPOSE: We compare scaphoid excision and 4-bone arthrodesis (FBA) with proximal row carpectomy (PRC) in terms of contact pressure, area, and location. METHODS: Six cadaveric forearms underwent simulated FBA with K-wires. We measured pressures in the radiocarpal joint with Fuji contact film after we applied a 200-N load via the wrist tendons with the wrist in neutral, flexion, and extension. We repeated the experiment after excising the lunate and triquetrum, to create a PRC in the same specimens. RESULTS: Contact pressure in the PRC wrist was significantly greater, by 25%, compared with the FBA wrist for all wrist positions. The PRC wrist had a significantly smaller contact area, by 43%, compared with the FBA wrist. In the FBA wrist, lunate contact was more dorsal in flexion but more volar in extension. In the PRC wrist, capitate contact was more dorsal and radial in flexion, whereas the contact was more volar and ulnar in extension. Comparing contact location, FBA contact was significantly more ulnar than PRC contact in wrist flexion. We found no significant difference in contact translation (the distance between the contact locations in the positions of wrist flexion and extension) for the lunate in FBA or the capitate in PRC. CONCLUSIONS: The FBA wrist has significantly lower contact pressure (P < .001), greater contact area (P < .001), and equal contact translation compared with the PRC wrist. These qualities may make FBA less susceptible to degeneration over time. By advancing our understanding of the biomechanics of both wrist procedures, we may better tailor them to the individual patient. CLINICAL RELEVANCE: Current biomechanical evidence is lacking for common motion-preserving procedures for wrist arthritis. Comparing contact pressure, area, and location provides a biomechanical basis of our clinical understanding of these surgeries.

An anatomic and biomechanical study of the oblique retinacular ligament and its role in finger extension.

PURPOSE: To analyze the anatomy and contribution of the oblique retinacular ligament (ORL) to distal interphalangeal (DIP) joint extension force with varying angles of proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joint flexion. METHODS: Forty fresh-frozen fingers were dissected. The fingers were mounted in a custom jig, and the force required to flex the DIP joint was assessed with the PIP joint flexed 0°, 30°, 60°, and 90° and with the MCP joint flexed 0°, 45°, and 90°. The force was measured in the intact specimen, and then all measurements were repeated following sectioning of the ORL and then the central slip. RESULTS: The ORL was present on the radial and ulnar aspects of all but 2 fingers. The ORL tended to be the most robust in the ring finger. In the intact specimen, DIP flexion resistance force was maximum at 30° of PIP joint flexion and minimum at 90° of PIP joint flexion. There was a significant difference between the 90° position and all other positions of the PIP joint with respect to flexion force in the intact specimen. This meant that less force was required to flex the DIP joint at 90° of PIP joint flexion. Sectioning of the ORL revealed that it contributed 25% to the total force required to flex the DIP joint with the PIP joint at 0°, 31% at 30°, 18% at 60°, and 3% at 90° of flexion. The MCP joint position had no effect. Sectioning the central slip produced a significant increase in force required to flex the DIP joint at 90° of PIP joint flexion. CONCLUSIONS: In this study, the ORL was usually present, and it contributed up to 30% of the passive resistance to DIP joint flexion. The intact central slip accounted for the decrease in DIP joint extensor tone at 90° of PIP joint flexion. CLINICAL RELEVANCE: The ORL plays a small role in passively resisting DIP flexion.

Spatiotemporal control of proliferation and differentiation of bone marrow-derived mesenchymal stem cells recruited using collagen hydrogel for repair of articular cartilage defects.

Articular cartilage has a poor healing capacity, and cartilage regeneration is not always warranted to achieve healing. On the other hand, collagen scaffolds have been shown to support regeneration of articular cartilage defects in animal models, whereas bone morphogenetic protein-2 (BMP-2) is known to cause chondrogenic differentiation of marrow-derived mesenchymal stem cells (MSCs). The purpose of this study was to evaluate the effectiveness of intra-articular administration of BMP-2 into bone marrow-derived MSCs recruited to defects using original collagen hydrogel in rabbits at various time points. Full-thickness defects were created in both knees, then collagen hydrogels were transplanted, and BMP-2 was supplied for 1-week periods, as follows. BMP-2 was administered immediately after the operation for 1 week (BMP0-1 group), and BMP-2 was administered between weeks 1 and 2 after the operation (BMP1-2 group). BMP2 was administered between weeks 2 and 3 (BMP2-3 group). Specimens were then obtained, and bromodeoxyuridine (BrdU)-positive cells were enumerated and histologic grading was also performed. In addition, the gene expression analysis was performed using quantitative real-time reverse transcription polymerase chain reaction (RT-PCR) assays. Enumeration of BrdU-positive cells showed a significant increase in the BMP0-1 group compared with the other groups. Similarly, histologic scores in the BMP0-1 group were superior for up to 8 weeks. Finally, RT-PCR findings revealed that immediate BMP-2 administration enhanced chondrogenic differentiation.

Spontaneous rupture of the flexor digitorum profundus and superficialis of the index finger and the flexor pollicis longus without labor-associated tendon loading.

Closed ruptures of the flexor tendon have been described in association with distinct underlying pathologies. The spontaneous rupture of the flexor tendon secondary to axial tendon loading alone is infrequent. The previously reported cases with spontaneous rupture were mostly men aged 30 to 60 years. In addition, rupture occurred during manual labor with the fingers engaged in forceful or resisted flexion. Labor-associated forceful usage, in addition to gender and age, has been implicated in the pathogenesis of the stressful rupture of the flexor tendon. Here we report a case with spontaneous rupture of the flexor digitorum profundus (FDP) and superficialis of the index finger as well as the flexor pollicis longus (FPL). Unlike the previously reported cases the present patient was an elderly woman engaged in no apparent occupational activities. In the present case, however, the patient had a particular predisposing condition. The patient used only the right hand during her whole lifetime because of a perinatal brachial plexus injury on the contralateral arm. The present case may show that the tendons of an elderly patient could yield to the axial loading of normal levels of activities of daily living when the usage is as incessant as in the present patient.