Toshihiko Imaeda

Validation of the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder, and Hand questionnaire.

BackgroundThe Disability of the Arm, Shoulder and Hand (DASH) questionnaire is a region-specific self-administered questionnaire that consists of a disability/symptom (DASH-DS) scale, and two optional modules, the work (DASH-W) and the sport/music (DASH-SM) modules. The DASH was cross-culturally adapted and developed by the Impairment Evaluation Committee, Japanese Society for Surgery of the Hand. The purpose of this study was to test the reliability, validity, and responsiveness of the Japanese version of DASH (DASH-JSSH).MethodsA series of 72 patients with upper extremity disorders completed the DASH-JSSH, the medical outcomes study 36-item short-form health survey (SF-36), and the Visual Analog Scale (VAS) for pain. Thirty-eight of the patients were reassessed for test-retest reliability 1 or 2 weeks later. Reliability was investigated by reproducibility and internal consistency. To analyze the validity, a principal component analysis and correlation coefficients between the DASH-JSSH and the SF-36 were obtained. Responsiveness was examined by calculating the standardized response mean (mean change/SD) and effect size (mean change/SD of baseline value) after carpal tunnel release of the 17 patients with carpal tunnel syndrome.ResultsCronbach’s alpha coefficients in the DASH-DS and DASH-W were 0.962 and 0.967, respectively. The intraclass correlation coefficients for the same were 0.82 and 0.85, respectively. The unidimensionality of the DASH-DS and DASH-W were confirmed. The correlations between the DASH-DS score and the subscale of the SF-36 scale ranged from −0.29 to −0.73. The correlation coefficient between the DASH-DS and the DASH-W was 0.79. The standardized response mean/effect size of DASH-DS, DASH-W, and VAS for pain were −0.48/−0.26, −0.68/−0.41, and −0.40/−0.40, respectively. DASH-DS and DASH-W were as moderately sensitive as VAS for pain.ConclusionThe DASH-DS and DASH-W Japanese version have evaluation capacities equivalent to those of the original and other language versions of the DASH.

The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain.

Forty-five patients with persistent ulnar-sided wrist pain and a positive ulnocarpal stress test were investigated by X-ray, arthrography, 99mTechnetium bone scanning, magnetic resonance imaging and wrist arthroscopy. Ulnar wrist pathology was positively identified in nine of 45 patients by X-ray, 18 of 37 by arthrography, 19 of 27 by bone scan, four of 33 by MRI, and in all 45 patients by arthroscopy. The final diagnosis was ulnocarpal abutment syndrome in 28 patients, traumatic triangular fibro-cartilage (TFC) tear in six, lunotriquetral (LT) ligament tear in five, TFC and LT ligament tear in one, wrist arthritis in four and cartilaginous free body in one. The ulnocarpal stress test is a useful provocative test, and a positive test suggests the presence of ulnar-sided wrist pathology. The test is sufficiently sensitive to warrant further investigation by arthroscopy.

The Influence of Age and Sex on Ulnar Variance

Ulnar variance was measured in 325 normal wrists and 41 wrists with Kienböck’s disease. A positive correlation between ulnar variance and age was confirmed in normal wrists, and it was lower in males than in females. Therefore, studies comparing ulnar variance in abnormal and normal wrists require carefully selected age- and sex-matched controls. There was no significant difference in ulnar variance between Japanese with normal wrists and those affected by Kienböck’s disease, when the effects of sex and age were taken into account. Based on these results, we believe that ulnar variance is highly unlikely to be an important predisposing factor in Kienböck’s disease.

Anatomy of trapeziometacarpal ligaments

The stabilizing ligaments of the thumb trapeziometacarpal joint were identified and studied during anatomic dissections of 30 hand specimens. Five main ligamentous structures were identified: (1) the anterior oblique ligament, (2) the ulnar collateral ligament, (3) the first intermetacarpal ligament, (4) the posterior oblique ligament, and (5) the dorsoradial ligament. It was observed that the anterior oblique ligament is the primary stabilizer of the trapeziometacarpal joint and is taut in abduction, extension, and pronation. The first intermetacarpal, ulnar collateral, and posterior oblique ligaments appear to be secondary stabilizers. In every specimen, the first intermetacarpal, ulnar collateral, and posterior oblique ligaments merged to form a force nucleus at the base of the first metacarpal. The dorsoradial ligament did not play a primary or secondary role in thumb stability. The clinical correlation of this anatomic study suggests that, at the minimum, the reconstruction of a primary thumb trapeziometacarpal ligament (anterior oblique ligament) is essential in the treatment of degenerative arthritis to maintain thumb stability.

Analysis of scaphoid fracture displacement by three-dimensional computed tomography

Scaphoid fracture displacement was studied in twenty-five patients using three-dimensional computed tomography. Fracture displacement was more readily detected and distinct in three-dimensional computed tomography images than in plain radiography. Two different types of offset of the distal fragment with respect to the proximal fragment are described on three dimensional computed tomography; volar type and dorsal type. In the volar type, the distal fragment overhung in the volar direction relative to the proximal fragment and was frequently accompanied by humpback deformity and axial rotation. In the dorsal type, the distal fragment slipped dorsal on the proximal fragment and was commonly accompanied by humpback deformity. The volar type had a transverse or vertical fracture line on both the volar and dorsal surfaces of the scaphoid, while the dorsal type had a horizontal fracture line. The volar type was frequently found when the fracture was distal, whereas the dorsal type was noted more frequently for proximally located fracture.

Radial shortening for KIenböck's disease: Factors affecting the operative result

The operative results of radial shortening in 23 patients with Kienböcks disease were analysed on the basis of age, stage of disease, ulnar variance and the amount of radial shortening. The patients age was found to be the factor which affected the operative result most and unsatisfactory results were obtained in patients over 30 years old. However, neither the clinical stage nor ulnar variance affected the results significantly and the results in patients with ulnar zero or plus were no worse than in patients with ulnar minus. The risk of ulnar wrist pain was increased when the radius was shortened more than 4 mm in patients with positive or zero ulnar variance. This was an important cause of unsatisfactory operative results.

Magnetic resonance imaging in scaphoid fractures

The use of a 1.5 tesla superconducting M.R. imager and surface coil was found to enhance the ability of M.R.I, to depict the fine anatomy of the wrist. Five healthy volunteers and 28 patients with scaphoid fractures underwent M.R.I., which made possible a definitive diagnosis of scaphoid fractures at an early stage. A fresh fracture was identified by decreased or iso signal intensity on the T1-weighted image and increased signal intensity on the T2-weighted image. This increase continued until bony union was apparent on radiographs. On the T2-weighted image, high signal intensity was characteristic of fresh fractures and suggested that bony union was possible. When bony union was complete, the intensity of the signal for the scaphoid on both T1 and T2-weighted images returned to normal. M.R.I. should thus prove useful in the diagnosis of scaphoid fractures.

Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children.

BACKGROUND There have been few reports on the long-term outcomes after the operative treatment of missed Monteggia fracture-dislocations in children. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes after open reduction for the treatment of a missed Monteggia fracture-dislocation. METHODS We postoperatively investigated the clinical and radiographic outcomes for twenty-two children with a missed Monteggia fracture. The study group included fourteen boys and eight girls who had had a mean age of ten years (range, four years to fifteen years and eleven months) at the time of open reduction. Each patient had been managed with open reduction of the radial head combined with a posterior bending elongation ulnar osteotomy and anular ligament reconstruction. Clinical and radiographic outcomes were reviewed over a mean duration of follow-up of seven years. RESULTS The postoperative Mayo Elbow Performance Index at the time of follow-up ranged from 65 to 100, with nineteen excellent, two good, one fair, and no poor results. The radial head remained in a completely reduced position in seventeen patients and was subluxated in five patients at the time of the latest follow-up. In four patients, osteoarthritic changes were observed at the radiohumeral joint. Radiographically, there were fifteen good, seven fair, and no poor results. A good radiographic result was obtained in all of the patients who had undergone open reduction within three years after the injury or before the age of twelve years, whereas a fair result was obtained in seven of the remaining eight patients. CONCLUSIONS If open reduction for the treatment of a missed Monteggia fracture is performed when the patient is less than twelve years of age or within three years after the injury, good long-term clinical and radiographic outcomes can be expected.

Validation of the Japanese Society for Surgery of the Hand Version of the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH-JSSH) questionnaire

BackgroundThe Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire is a region-specific, self-administered questionnaire, which consists of a disability/symptom (QuickDASH-DS) scale, and the same two optional modules, the work (DASH-W) and the sport/music (DASH-SM) modules, as the DASH. After the Japanese version of DASH (DASH-JSSH) was cross-culturally adapted and developed, we made the Japanese version of QuickDASH (QuickDASH-JSSH) by extracting 11 out of 30 items of the DASH-JSSH regarding disability/symptoms. The purpose of this study was to test the reliability, validity, and responsiveness of QuickDASH-JSSH.MethodsA series of 72 patients with upper extremity disorders completed the QuickDASH-JSSH, the 36-Item Short-Form Health Survey (SF-36), and the Visual Analog Scale (VAS) for pain. Thirty-eight of the patients were reassessed for test–retest reliability 1 or 2 weeks later. Reliability was investigated by the reproducibility and internal consistency. To analyze the validity, a principal component analysis and the correlation coefficients between the QuickDASH-JSSH and the SF-36 were obtained. The responsiveness was examined by calculating the standardized response mean (SRM; mean change/SD) and effect size (mean change/SD of baseline value) after carpal tunnel release of the 17 patients with carpal tunnel syndrome.ResultsCronbach’s alpha coefficient in the QuickDASH-DS was 0.88. The intraclass correlation coefficient (ICC) for the same was 0.82. The unidimensionality of the QuickDASH-DS was confirmed. The correlation coefficients between the QuickDASH-DS and the DASH-DS, DASH-W, or the DASH-SM were 0.92, 0.81, or 0.76, respectively. The correlation coefficients between the QuickDASH-DS score and the subscales of the SF-36 ranged from −0.29 to −0.73. The correlation coefficient between the QuickDASH-DS score and the VAS for pain was 0.52. The SRM/effect size of QuickDASH-DS was −0.54/−0.37, which indicated moderate sensitivity.ConclusionThe Japanese version of QuickDASH has equivalent evaluation capacities to the original QuickDASH.

High prevalence of wild-type transthyretin deposition in patients with idiopathic carpal tunnel syndrome: a common cause of carpal tunnel syndrome in the elderly

Carpal tunnel syndrome is the most common type of entrapment neuropathy. However, the cause of carpal tunnel syndrome remains unclear in most cases. Senile systemic amyloidosis, induced by wild-type transthyretin deposition, is a prevalent aging-related disorder and often accompanied by carpal tunnel syndrome. In this study, we measured the frequency of unrecognized wild-type transthyretin deposition in patients with idiopathic carpal tunnel syndrome. One hundred twenty-three patients with carpal tunnel syndrome, including 100 idiopathic patients, treated by carpal tunnel release surgery were analyzed. Tenosynovial tissues obtained at surgery were analyzed by Congo red and immunohistochemical staining. If staining for transthyretin was positive, the entire transthyretin gene was analyzed by direct DNA sequencing. We also analyzed tenosynovial tissues from 32 autopsy cases as controls. Thirty-four patients (34.0%) with idiopathic carpal tunnel syndrome showed amyloid deposition in the tenosynovial tissue, and all amyloid showed specific immunolabeling with antitransthyretin antibody. Direct DNA sequencing of the entire transthyretin gene did not reveal any mutations, indicating that all amyloid deposits were derived form wild-type transthyretin. Statistical analysis using logistic regression showed that the prevalence of transthyretin deposition in the idiopathic carpal tunnel syndrome group was significantly higher than that in controls (odds ratio, 15.8; 95% confidence interval, 3.3-5.7), and age and male sex were independent risk factors for transthyretin amyloid deposition. Our results demonstrate that wild-type transthyretin deposition is a common cause of carpal tunnel syndrome in elderly men. It is likely that many patients develop carpal tunnel syndrome as an initial symptom of senile systemic amyloidosis.