Preoperative Evaluation of Thenar Muscles in Carpal Tunnel Syndrome by Ultrasonography.

This article aims to evaluate the usefulness of ultrasonography for the measurement of thenar muscles in carpal tunnel syndrome (CTS). A total of 85 patients with CTS who had a carpal tunnel release procedure were included in this study. The transducer was applied onto the palmar surface of the hand perpendicularly to the longitudinal axis of the first metacarpal bone. Thenar atrophy was evaluated visually and classified using the visual grading scale. A nerve conduction test was performed and classified according to the electrophysiological severity scale. This technique is more precise than visual evaluation because it is a quantitative assessment.

Evaluation of carpal tunnel release outcomes by the Japanese version of the carpal tunnel syndrome questionnaire compared to an electrophysiological severity grade.

BACKGROUND: The outcome of carpal tunnel release (CTR) one year postoperatively was assessed by the Japanese version of Carpal tunnel syndrome questionnaire, CTSI-JSSH. Patients were further graded by the electrophysiological severity scale and the CTSI-JSSH scores were compared amongst the Stages before surgery and one-year postoperatively. METHODS: This study included 247 hands and the mean age of the patients was 68 years (range:26-91). They completed the CTSI-JSSH consisting of the two subscales of the symptom scale (CTSI-JSSH-SS) and the functional scale (CTSI-JSSH-FS) both preoperatively and at the follow-up period of one year. The change of the scores of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH were examined. Electrophysiological examination was performed before CTR and graded according to the electrophysiological severity scale as Stage 1-5. The scores of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH were compared amongst Stage 1-5. RESULTS: All CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH scores improved significantly one-year postoperatively. Also, the standardized response mean (SRM) and effect size (ES) showed large responsiveness, i.e. 1.36/1.43, 1.12/1.08 and 1.43/1.45 respectively. There was no significant difference in the score of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH amongst any of the Stages preoperatively, while the scores in Stage 5 were significantly inferior to the ones in Stages 3 and 4 one-year postoperatively. CONCLUSIONS: The clinical outcomes of CTR were favorable by assessment of the CTSI-JSSH. We suggest the postoperative inferior scores in Stage 5 may be due to the potential axonal damage which could explain the disappearance of distal motor latency and sensory nerve conduction velocity in Stage 5.

Collagenase Clostridium Histolyticum Injection with Precise Needle Length Adjusted by Silicone Tube Interposition for Dupuytren Contracture.

We describe our injection method for Collagenase Clostridium Histolyticum using a medical silicone tube after determining the optimal depth by ultrasonography. This procedure adjusts the exposed needle length to the planned injection depth by placing a sterilized silicone tube over the needle. The restricted depth provides not only precise injection into the middle of the cords but also avoids needle tip migration through the cord and into the vital structures, which prevents possible complications. This method is safe and simple.

The Role of Electrophysiological Severity Scales for Decision-making with Regard to Surgery in Idiopathic Carpal Tunnel Syndrome.

The distribution of electrophysiological severity of carpal tunnel syndrome (CTS) in an outpatient setting and whether electrophysiological severity could be an objective tool for decision-making regarding choice of surgery were investigated. During conservative treatment, 1079 outpatients with idiopathic CTS were classified according to the electrophysiological severity scale (Stage 1-5). The results were provided to the patients and explained, but they were not indicated a treatment protocol intentionally. We recommended surgery to those outpatients who presented with difficulty in pinching due to severe thenar atrophy and/ or showing poor response to conservative treatment. However, the decision-making of surgical or nonsurgical treatment remained with patients. In the distribution of severity stages, Stage 4 was the most common (34%). Two hands were not classifiable. Surgery was chosen in 443 of 1077 hands (41.1%): The operation selection rate increased with severity of the stage and the patients with Stage 5 showed the greatest preference among Stage 1-5 (p<0.0001). This was shown in both female and male groups in gender analysis, and in both ≤ 69 y.o. and ≥70 y.o. groups in the age analysis. There was no significant difference between female and male hands, and ≤ 69 y.o. and ≥70 y.o. hands. Among varied reasons for the decision-making process for surgical treatment in CTS, electrophysiological severity scale plays an important role as an objective tool without being influenced by subjective elements; gender and age.

Recurrence of Enchondroma in a Middle Finger after Curettage and Back-filling with Calcium Phosphate Bone Cement: a Case Report.

We report a case of recurrence of enchondroma in a middle finger after curettage and back-filling with calcium phosphate bone cement (CPC). The radiograph showed a lytic lesion around the CPC filling which showed no signs of absorption after 12 years. The tumor was curated easily, however, a steel bar was needed to remove the CPC mass in a carefully manner not to break the cortex. CPC has an advantage of immediate biomechanical stability, on the other hand, a disadvantage of being unabsorbed inside of bone. Although enchondroma has a low recurrence rate after surgery generally, in consideration of recurrence, we recommend the use of absorbable materials when a use of artificial bone substitute to fill the defect is planned.

Characterization of progenitor cells derived from torn human rotator cuff tendons by gene expression patterns of chondrogenesis, osteogenesis, and adipogenesis.

BACKGROUND: It is important to regenerate the tendon-to-bone interface after rotator cuff repair to prevent re-tears. The cells from torn human rotator cuff were targeted, and their capacity for multilineage differentiation was investigated. METHODS: The edges of the rotator cuff were harvested during arthroscopic rotator cuff repair from nine patients, minced into pieces, and cultured on dishes. Adherent cells were cultured, phenotypically characterized. Then expandability, differentiation potential and gene expression were analyzed. RESULTS: Flow cytometry revealed that the mesenchymal stem cells (MSC)-related markers CD29, CD44, CD105, and CD166 were positive. However, CD14, CD34, and CD45 were negative. On RT-PCR analyses, the cells showed osteogenic, adipogenic, and chondrogenic potential after 3 weeks of culture under the respective differentiation conditions. In addition, SOX9, type II collagen, and type X collagen expression patterns during chondrogenesis were similar to those of endochondral ossification at the enthesis. CONCLUSIONS: The cells derived from torn human rotator cuff are multipotent mesenchymal stem cells with the ability to undergo multilineage differentiation, suggesting that MSCs form this tissue could be regenerative capacity for potential self-repair.

Application of Pain Quantitative Analysis Device for Assessment of Postoperative Pain after Arthroscopic Rotator Cuff Repair.

PURPOSE: The PainVision™ system was recently developed for quantitative pain assessment. Here, we used this system to evaluate the effect of plexus brachialis block on postoperative pain after arthroscopic rotator cuff repair. METHODS: Fifty-five patients who underwent arthroscopic rotator cuff repair were included in this study. First 26 cases received no plexus brachialis block (control group), and the next 29 cases received the plexus brachialis block before surgery (block group). Patients completed the visual analog scale at 4, 8, 16, and 24 hours after surgery, and the intensity of postoperative pain was assessed with PainVision™ at 16 hours. The postoperative use of non-steroidal anti-inflammatory agents was also recorded. RESULTS: The pain intensity at 16 hours after surgery assessed by PainVision™ was significantly lower in the block group than in the control group (block, 252.0 ± 47.8, control, 489.0 ± 89.1, P < 0.05). However, there were no differences in the VAS values at 16 hours between the 2 groups (block, 4.3 ± 0.6, control, 5.7 ± 0.4, P = N.S.). The pain intensity and VAS at 16 hours after surgery were highly correlated (r = 0.59, P = 0.006 in the block group and r = 0.62, P = 0.003 in the control group). The effect size of the assessment by PainVision™ was bigger than that of VAS (r=0.31 in VAS and 0.51 in Pain vision). CONCLUSION: The PainVision™ system could be useful to evaluate postoperative pain because it enables the quantification and comparison of pain intensity independent of individual pain thresholds.

Management of intolerance to casting the upper extremities in claustrophobic patients.

INTRODUCTION: Some patients showed unusual responses to the immobilization without any objective findings with casts in upper extremities. We hypothesized their that intolerance with excessive anxiety to casts is due to claustrophobia triggered by cast immobilization. The aim of this study is to analyze the relevance of cast immobilization to the feeling of claustrophobia and discover how to handle them. METHODS: There were nine patients who showed the caustrophobic symptoms with their casts. They were assesed whether they were aware of their claustrophobis themselves. Further we investigated the alternative immobilization to casts. RESULTS: Seven out of nine cases that were aware of their claustrophobic tendencies either were given removable splints initially or had the casts converted to removable splints when they exhibited symptoms. The two patients who were unaware of their latent claustrophobic tendencies were identified when they showed similar claustrophobic symptoms to the previous patients soon after short arm cast application. We replaced the casts with removable splints. This resolved the issue in all cases. CONCLUSIONS: We should be aware of the claustrophobia if patients showed unusual responses to the immobilization without any objective findings with casts in upper extremities, where removal splint is practical alternative to cast to continue the treatment successfully.

Electrophysiological assessment of carpal tunnel syndrome in elderly patients: one-year follow-up study.

PURPOSE: To objectively assess elderly patients with carpal tunnel syndrome to characterize their preoperative severity and prognosis after carpal tunnel release using a electrophysiological severity scale. METHODS: Electrophysiologic assessment was performed preoperatively and 1 year postoperatively following carpal tunnel release in 112 hands in patients over 70 years of age prospectively by the use of the following electrophysiological severity scale: stage 1, normal distal motor latency (DML) and normal sensory conduction velocity (SCV); stage 2, DML ≥ 4.5 milliseconds and normal SCV; stage 3, DML ≥ 4.5 milliseconds and SCV < 40.0 m/s; stage 4, DML ≥ 4.5 milliseconds and non-measurable SCV; stage 5; non-measurable DML and non-measurable SCV. Additionally, the outcomes of clinical symptoms of pain, nocturnal symptoms, numbness, loss of 2-point discrimination in the median nerve territory, and thenar atrophy were assessed. RESULTS: The mean age of patients was 77 years at the time of the operation. Preoperatively, the most common severity was stage 5 (70 of 112 hands, 63%), and clustering stage 4 and 5 together as severe resulted in 103 hands (92%). One year postoperatively, 97 hands (87%) demonstrated at least one stage improvement, and the numbers of mild (stage 1 or 2) increased from 3 (3%) to 45 hands (40%). Parallel with the electrophysiological improvement, pain and nocturnal symptoms resolved in 17 of 17 hands and 11 of 11 hands, respectively, in whom they were present preoperatively. Numbness, loss of 2-point discrimination, and thenar atrophy demonstrated the improvement in 96 of 112 (86%) hands, in 58 of 112 (52%) hands, and in 80 of 96 (83%) hands. CONCLUSIONS: We observed electrophysiologic improvement in 86% of elderly patients following carpal tunnel release. Electrophysiologic outcomes correlated with improvement in clinical variables. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Assessment of vascularized free fibula transplantation revealing a congenital aplastic posterior tibial artery: a case report.

INTRODUCTION: Anatomical abnormalities in the lower limb vessels are uncommon. However, the preoperative evaluation of the anatomical variations is very important for planning the operation procedure to prevent jeopardizing the donor leg. CASE PRESENTATION: In this case report, a 23-year-old Asian woman who was scheduled to have vascularized free fibula transplantation for reconstruction of her wrist after excision of bone tumor in her distal radius, was found to have congenital aplastic posterior tibial arteries in both legs. These findings were found on magnetic resonance angiography (our preferred methodology due to its simplicity). We planned testing the sufficiency of her pedal pulses after temporarily clamping her peroneal artery but prior to harvesting, to ensure minimal risk to the longevity of her donor leg. During the operation, after dissection of a 10cm segment of her fibula with the peroneal artery, the peroneal artery proximal to the graft was temporarily clamped and the tourniquet was released. As adequate sustainable pedal pulses were confirmed, the graft was harvested and transplanted to her wrist. There was no morbidity in her right leg postoperatively and the union of the grafted fibula was substantiated 10 months postoperatively. CONCLUSIONS: We concluded two findings: firstly, for accurate preoperative planning of a vascularized free fibula procedure, examination of the bilateral lower leg vasculature either by angiography or other imaging should be performed. Secondly, abnormalities are not in themselves reason to abandon the vascularized free fibula procedure. We contend that pedal pulses should be evaluated preoperatively and provided that adequate foot circulation can be confirmed (by temporarily clamping the vessels and releasing the tourniquet during the operation prior to harvesting the free vascularized fibula) the procedure should be successful without jeopardizing the donor leg.

The usefulness of ultrasonography as a guide for the treatment of delayed diagnosed tendon injury in a 2-year-old child.

In children, flexor pollicis longus (FPL) tendon injuries are uncommon. In delayed diagnosed cases, CT and MRI are hard to perform, even though to confirm the location of the lacerated proximal tendon end is preferable for the planning of operation procedure. In such condition, ultrasonography is suitable because of its characteristic feature of easy-to-perform procedure even in children. In this report, preoperative ultrasonography was practical in the delayed diagnosis of FPL tendon in a 2-year-old child to schedule the primary repair because the precise location of both FPL proximal and distal ends was identified. In addition, routine postoperative ultrasonography was also useful to track its healing process without concern about mutual communication due to the patient's age, which helped to promote active motion.

Delayed electrophysiological recovery after carpal tunnel release for advanced carpal tunnel syndrome: a two-year follow-up study.

Advanced carpal tunnel syndrome presents severe thenar atrophy with the absence of electrophysiological motor and sensory responses. Because of severity of these conditions, a substantial period of recovery after surgery is required before improvement becomes evident. In this electrophysiological-based study, the reappearance of distal motor latency (DML) at the abductor pollicis brevis and/or sensory nerve conduction velocity (SCV) after wrist stimulation were evaluated 1 year and 2 years after carpal tunnel release . To categorize outcomes, the following grading scale was used: stage I, normal DML and SCV; stage II, DML ≥ 4.5 ms and normal SCV; stage III, DML ≥ 4.5 ms and SCV < 40.0 ms; stage IV, DML ≥ 4.5 ms and nonmeasurable SCV; stage V: nonmeasurable DML and SCV. The authors found measurable DML and/or SCV and significant improvement both 1 year and 2 years postoperatively. Furthermore, the percentage of patients who recovered to the extent that they presented as mild carpal tunnel syndrome (stage I or II) increased significantly. They conclude that electrophysiological assessment of DML and SCV of advanced carpal tunnel syndrome using the above grading scale was effective as an objective evaluation tool of recovery after carpal tunnel release.

Platelet-rich plasma protects rotator cuff-derived cells from the deleterious effects of triamcinolone acetonide.

Triamcinolone acetonide (TA) injections are widely used to treat enthesopathy, but they may induce adverse effects such as tendon impairment and rupture. Platelet-rich plasma (PRP) is a blood fraction containing high platelet concentrations and various growth factors that play a role in tissue repair processes. The purpose of this study is to investigate whether TA has deleterious effects on human rotator cuff-derived cells, and if PRP can protect these cells from the effects of TA. Human rotator cuff-derived cells were cultured with and without TA and PRP, and the culture without any additive served as the control. Cell morphology was assessed at days 7 and 21. Cell viability was evaluated at days 1, 7, 14, and 21 by a water-soluble tetrazolium salt assay. Induction of apoptosis was measured by immunofluorescence staining and flow cytometry at day 7. Induction of cleaved caspase-3 was measured by immunofluorescence staining at day 7. The cells cultured with TA had a flattened and polygonal shape at day 7. The cells cultured with both TA and PRP were similar in appearance to control cells. Exposure to TA also significantly decreased cell viability, but cell viability did not decrease when PRP was added along with TA. The number of apoptotic cells increased with TA exposure, while addition of PRP prevented cell apoptosis. In conclusion, the deleterious effect of TA was prevented by PRP, which can be used as a protective agent for patients receiving local TA injections.

Arthroscopic bony bankart repair using double-threaded headless screw: a case report.

We present a case of arthroscopic fixation for bony Bankart lesion using a double-threaded cannulated screw. A 39-year-old man sustained a left shoulder injury from a motorcycle accident. Radiographs showed bony Bankart lesion and CT revealed 40% defect of glenoid articular surface. Arthroscopic fixation was performed using double-threaded cannulated screw after the bony fragment was reduced by suturing the labrum at the edge with a suture anchor. Arthroscopic bony Bankart repair using double-threaded cannulated screw fixation is effective because compression force could be applied between bony fragments and the screw head is not exposed in the glenohumeral joint.

Severe laceration of flexor tendons after locking palmar plate fixation of distal radius fracture: a case report.

We report a case of flexor pollicis longus and flexor digitorum profundus(II) laceration as a result of the severe tenosynovitis after volar locking plate fixation of distal radius fracture.

Nontraumatic true aneurysm of the superficial palmar arch: a case report.

A case of a 62 year-old woman with true aneurysm of the superficial palmar arch with no previous history of trauma is described. The aneurysm was resected without reconstruction based on intraoperative evidence of adequate finger perfusion after clumping the distal and proximal ends. Three years after the operation, there has been no recurrence of the aneurysm and the patient has neither complaints nor symptoms.

Localization of vascular endothelial growth factor during the early stages of osteochondral regeneration using a bioabsorbable synthetic polymer scaffold.

Vascular endothelial growth factor (VEGF) plays a critical role in chondrogenic differentiation in the growth plate of the epiphysis. This function is necessary for chondrocyte survival in cartilage development. We investigated the localization of VEGF in the osteochondral regeneration process using a bioabsorbable polymer scaffold. Osteochondral defects (5 mm in diameter and 5 mm in depth) were made on the femoral condyle of forty-eight skeletally mature female Japanese white rabbits. In total, twenty-four defects were filled with poly(DL-lactide-co-glycolide) scaffolds and the others were left untreated. The regeneration process was investigated macroscopically, histologically, immunohistochemically, and by gene expression analysis. In the early stages of osteochondral regeneration, bone ingrowth was observed in the deep zone of the scaffold with continuous VEGF expression; cartilage regeneration was observed in the superficial zone of the scaffold with decreased VEGF expression. In contrast, when the defect was left untreated, VEGF localization was observed throughout the entire defect area, and cartilage regeneration at the articular surface was delayed. We conclude that decrease in localization of VEGF at the articular surface in the postoperative early stage is closely related to the progression of cartilage regeneration in osteochondral defects.

A coincidental anterior interosseous nerve palsy after volar plate fixation of a distal radius fracture diagnosed by 3D-CT.

A case presented dysfunctional flexion of the thumb and index fingers after volar plate fixation for of distal radius fractures was diagnosed anterior interosseous nerve palsy and confirmed by 3D-CT. 3D-CT was useful to confirm the continuities of tendons, which excluded the most common complication of tendon ruptures after volar plate fixation. Also, it was superior to needle electromyography which is unreliable due to the accompanying damage of the pronator quadratus following volar plate fixation.

Modified tension band wiring fixation for avulsion fractures of the calcaneus in osteoporotic bone: a review of three patients.

Calcaneal avulsion fractures are not uncommon, and they are probably more likely in patients with osteoporosis. Closed manipulation for this type of fracture often fails to achieve acceptable reduction, and open reduction and internal fixation are usually required. However, open reduction and internal fixation with either a lag screw or Steinmann pins do not provide satisfactory fixation in patients with diabetes and elderly patients because of the presence of porotic bone. Levi described a tension band fixation system used to treat a calcaneal avulsion fracture using a simple technique performed with a transverse Kirschner wire through the os calcaneus, securing a figure-of-8 metal tension band wiring to the fragment. We report the successful treatment of 3 patients with calcaneal avulsion fractures using a modified tension band wiring technique, resulting in satisfactory recovery. Re-displacement of the fragment during the initial follow-up period was not reported, and bony union was achieved in all patients. We believe this technique is a useful surgical option for the treatment of calcaneal avulsion fractures.