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Nanomaterials show great promise as bone regeneration materials. They can be used as fillers to strengthen bone regeneration scaffolds, or employed in their natural form as carriers for drug delivery systems. A variety of experiments have been conducted to evaluate the osteogenic potential of bone regeneration materials. In vivo, such materials are commonly tested in animal bone defect models to assess their bone regeneration potential. From an ethical standpoint, however, animal experiments should be minimized. A standardized in vitro strategy for this purpose is desirable, but at present, the results of studies conducted under a wide variety of conditions have all been evaluated equally. This review will first briefly introduce several bone regeneration reports on nanomaterials and the nanosize-derived caveats of evaluations in such studies. Then, experimental techniques (in vivo and in vitro), types of cells, culture media, fetal bovine serum, and additives will be described, with specific examples of the risks of various culture conditions leading to erroneous conclusions in biomaterial analysis. We hope that this review will create a better understanding of the evaluation of biomaterials, including nanomaterials for bone regeneration, and lead to the development of versatile assessment methods that can be widely used in biomaterial development. [ABSTRACT FROM AUTHOR]

Background: The connection of 25-hydroxyvitamin D [25(OH)D] with bone metabolism is reported to occur indirectly through parathyroid hormone (PTH) activity. However, we hypothesized that 25(OH)D insufficiency raises the risk of bone fracture independent of PTH, since 25(OH)D insufficiency is not always accompanied by hyperparathyroidism. The aim of this study was to show a direct association between 25(OH)D, bone turnover markers, and fractures that was independent of PTH. Methods: We measured serum 25(OH)D in a group of 330 postmenopausal osteoporotic women who did not have secondary hyperparathyroidism. We analyzed the effects of 25(OH)D insufficiency [25(OH)D < 20 ng/mL] on the expression of several bone markers, including serum bone alkaline phosphatase (BAP), osteocalcin (OC), urinary N-terminal telopeptide of type-I collagen and free deoxypyridinoline (DPD), and inorganic phosphorus (IP), as well as on the prevalence of vertebral fractures. Results: OC/BAP ratios and IP levels were significantly lower and DPD was significantly higher in 25(OH)D insufficient patients. These effects were independent of age, PTH, and estimated glomerular filtration rate (eGFR). 25(OH)D insufficiency, a low OC/BAP ratio, and low IP were related to the presence of prior vertebral fractures independent of PTH, bone mineral density (BMD), and eGFR. Conclusions: We propose that 25(OH)D insufficiency is associated with a low OC/BAP ratio and high DPD in postmenopausal osteoporosis patients without hyperparathyroidism. This pathological condition is associated with an increased incidence of prior vertebral fractures independent of PTH, BMD, and eGFR. [ABSTRACT FROM AUTHOR]

Background: It is well known that carpal tunnel syndrome (CTS) can occur in a wide range of time periods after distal radius fracture (DRF). Few studies have evaluated in detail the relationship between fracture and electrophysiological finding characteristics and time to onset of CTS after DRF. To clarify the characteristics of CTS after DRF, we classified a large number of clinical cases based on the period from the injury to onset of CTS. These cases were analyzed retrospectively. Methods: We reviewed 105 wrists with CTS following DRF. Patients’ ages ranged from 13 to 89 years. These 105 wrists were divided into three groups according to the period of post-fracture onset of CTS. Twenty-eight wrists were classified into the acute onset group (when the symptoms of CTS occurred within 1 week after fracture). Forty-seven wrists were classified into the subacute onset group (when symptoms of CTS occurred from 1 to 12 weeks after fracture). The remaining 30 wrists were classified into the delayed onset group (when symptoms of CTS occurred more than 12 weeks after fracture). Deformity of the distal radius on X-ray films was evaluated and distal motor latency (DML) of the median nerve was recorded to compare values among these three groups. Results: In the acute onset group, 68% had an AO C-type fracture and 46% were caused by a high-energy injury. The percentage of this fracture pattern and mechanism was significantly higher in the acute onset group than in the other groups ( P < 0.05; Kruskal-Wallis test). In the subacute onset and delayed onset groups, 79% and 63% had an A-type fracture and more than 90% were caused by a low-energy injury. In the delayed onset group, the incidence of prolonged DML in the contralateral wrists was 71%, which was significantly higher than in the other two onset groups ( P < 0.05; Kruskal- Wallis test). Conclusions: There were three onset patterns of CTS after DRF, and each CTS onset pattern had different etiologic mechanisms and different clinical features of CTS. In the acute onset group, a high-energy fracture pattern was associated with CTS. In the subacute and the delayed onset groups, lowenergy injury in elderly women was associated with CTS. Both deformity of the fracture and preexisting median nerve dysfunction were suggested as predisposing factor for CTS. [ABSTRACT FROM AUTHOR]

Abstract: Background: Osteoarthritis (OA) is the most common skeletal disease worldwide. Although thumb carpametacarpal joint (CMJ) OA is also frequently encountered, the etiologies remain largely unknown. Method: We analyzed 20 patients who had thumb CMJ OA with accompanying joint pain and categorized a total of 37 thumbs according to the Eaton and Littler staging system. Results: In patients with advanced OA, bone alterations as detected by magnetic resonance imaging (MRI) were observed in almost all of the painful joints. The frequency of bone alterations in the thumb CMJ increased with OA severity. In contrast, MRI revealed no bone alterations in thumbs with no pain and less pain in bilateral thumb basal pain, even in radiographically advanced OA. Conclusions: While the incidence of bone cysts in the CMJ was higher with OA staging, OA severity had no apparent correlation with pain. Thus, it is possible that the cause of thumb CMJ pain in advanced OA is bone alterations. [ABSTRACT FROM AUTHOR]

The article discusses research which investigated the use of magnetic resonance imaging (MRI) for identifying lesions in patients with capitellar osteochondritis dissecans (COCD). Topics explored include the grading and stages of COCD lesions, the results of the preoperative radiographic grading and MRI staging performed, and the difference between MRI and International Cartilage Repair Society (ICRS) COCD lesion classifications.

Background: Chronic pain, a challenging issue worldwide, requires better treatment. Objective and Study design: In this prospective, open-label study, we examined the frequency of adverse effects associated with treatment with a fixed-dose combination of tramadol/acetaminophen 37.5/325 mg following gradually increased administration in outpatients with chronic musculoskeletal pain (focusing on degenerative spinal disorders and degenerative joint disorders). In all cases, tramadol/acetaminophen administration reached a plateau within 2 months and the frequency of adverse events were evaluated at that time. Results and Conclusion: Patients with degenerative spinal disorders had significantly higher rates of overall adverse events and constipation (the most common adverse event) than patients with joint disorders. [ABSTRACT FROM AUTHOR]

Background: Since proximal pole fractures of the scaphoid are frequently overlooked, the poor vascularity in the proximal pole fragment often leads to nonunion. Vascularized bone grafts have been recently tested in cases with scaphoid proximal pole nonunion, but the indication for this treatment has not been well established. Alternatively, we have been treating such patients with a non-vascularized iliac bone graft and Herbert-type screw fixation with considerable success. The purpose of this investigation is to evaluate these cases retrospectively and clarify the surgical efficacy of our procedure. Methods: Between 1996 and 2009, 11 consecutive patients with proximal pole scaphoid nonunion were treated with a non-vascularized corticocancellous iliac bone graft and Herbert-type screw fixation. They were all male aged from 12 to 26 years. In two patients, avascular changes were recognized in the proximal pole in preoperative radiographs or MRI. Follow-up ranged from 12 to 76 months. Results: Bone union was radiographically confirmed in all patients, who returned to their former activities without any complications. The period from operation to union ranged from 12 to 24 weeks. The mean Mayo modified wrist score was 76.4 points preoperatively and 91.4 points postoperatively, and was improved in all cases. Conclusions: A non-vascularized iliac bone graft with Herbert-type screw fixation obtained satisfactory clinical and radiographic results in cases with scaphoid proximal pole nonunion, regardless of the vascularity in the proximal fragment. [ABSTRACT FROM AUTHOR]

A 76-year-old woman presented history of left hip joint pain on walking, which occurred after she bent to move a planter. Plain radiographs showed no fracture. Bone scintigraphy revealed accumulation, and magnetic resonance imaging showed a low signal area on T1-weighted images. We diagnosed an insufficiency fracture and pain decreased naturally on conservative treatment. Insufficiency fracture of the acetabulum should be considered when elderly patients have hip joint pain. Magnetic resonance imaging and bone scintigraphy is most useful for the diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Hip fractures are commonly associated with osteoporosis and pose a risk for secondary fractures. Although the administration of anti-osteoporotic drugs is recommended after fractures to mitigate this risk, the potential effect of strong anti-resorptive drugs (e.g., denosumab) on fracture healing processes have not been extensively studied. This prospective study aimed to evaluate the feasibility of early denosumab administration after femoral intertrochanteric fracture surgery and to compare its effect on fracture healing to that of bisphosphonate-treated patients., Materials and Methods: Patients who underwent surgery for intertrochanteric femoral fragility fractures between November 2018 and November 2020 were prospectively examined. Patients were randomized into two groups (denosumab [DSM] and ibandronate [IBN] groups) using a simple randomization procedure. Physical findings, plain radiographs, and computed tomography (CT) were used to evaluate fracture healing at 3 months postoperatively., Results: Physical findings showed no significant differences between the two groups in pain on loading, tenderness at fracture site, or walking ability. There were inter-rater differences in radiological fracture healing rate: plain radiographs, 57.5%-81.8% in the DSM group and 51.5%-90.9% in the IBN group; CT, 51.5%-72.7% in the DSM group and 45.4%-81.8% in the IBN group. Although there were variations, there were no significant differences in the fracture healing rate between groups on plain radiographs or CT among all three raters., Conclusions: Early administration of denosumab after intertrochanteric femoral fracture surgery did not delay radiological or clinical fracture healing times when compared with ibandronate administration., Competing Interests: Declaration of competing interest The Authors declares that there is no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Purpose: Advanced-stage trapeziometacarpal (TMC) osteoarthritis of the thumb often presents with concomitant hyperextension deformity of the metacarpophalangeal (MCP) joint. Although several studies have reported simultaneous procedures to correct this deformity, the indication for these procedures remains controversial. The purpose of this study was to evaluate changes in the range of motion (ROM) of the thumb MCP joint before and after TMC arthrodesis., Methods: We evaluated the functional flexion and extension and functional ROM of the MCP joints during the performance of 10 activities of daily living tasks before and after TMC arthrodesis in 10 thumbs of 9 patients with Eaton stage III TMC osteoarthritis and hyperextension deformity of the MCP joint., Results: The mean functional flexion of the MCP joint increased from 26° to 38°, and the mean functional extension of the MCP joint decreased from 16° to 5° of hyperextension. There was no change in the mean total arc of functional ROM of the MCP joint., Conclusions: The MCP joint motion shifted from extension to flexion after TMC arthrodesis, and the total arc of functional ROM of the MCP joint was similar before and after arthrodesis., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Level of Evidence: IV.

Introduction: Cognitive function is an important factor that affects functional recovery after hip fracture (HipFx) surgery. The literature on the pathophysiology of dementia in HipFx patients is scarce. We performed a differential diagnosis of dementia in HipFx patients using clinical and brain MRI findings., Methods: This is a prospective study in which brain MRI was evaluated for patients with HipFx for research purposes. One-hundred-and-five HipFx patients (85 females and 20 males) who underwent surgery and were subsequently able to undergo brain MRI at our hospital were evaluated. The mean age was 84 years. The presence of dementia was determined based on clinical findings and whether the patient meets its diagnostic criteria according to the International Classification of Diseases 10th Edition (ICD-10). The differential diagnosis of dementia was made based on brain MRI findings and the dementia diagnostic flow chart published in the Clinical Practice Guideline for Dementia 2017 (Japanese Society of Neurology). The Voxel-based Specific Regional Analysis System for Alzheimer's Disease (VSRAD) advance 2 diagnostic software was used to evaluate atrophy of the para-hippocampal gyrus., Results: Fifty-six (53%) patients were clinically diagnosed with dementia according to the ICD-10 criteria. The MRI findings were diverse: Alzheimer's disease (AD)-type, asymptomatic multiple ischemic cerebral lesions, past symptomatic cerebral infarction or cerebral hemorrhage, Binswanger's disease (BW)-type, chronic subdural hematoma, disproportionately enlarged subarachnoidal hydrocephalus (DESH), and their combinations thereof. A combination of MRI and clinical findings of dementia patients demonstrated the following distribution of dementia subtypes: AD (n = 20), vascular dementia (n = 33), AD and BW vascular dementia (n = 3)., Conclusion: This study revealed that the brain MRI findings of HipFx patients were diverse. Although vascular dementia is found to be common in this particular population, this could be an incidental finding. Further study is warranted to clarify the specificity of our findings by increasing the number of patients, setting the control, and investigating whether dementia subtypes affect postoperative gait acquisition and fall risk., Competing Interests: The authors have declared that no competing interests exist.

We present an original technique for determining the tension of the extensor pollicis longus tendon after reconstruction. We treated 20 patients using this technique for an extensor pollicis longus tendon graft or extensor indicis tendon transfer and reviewed the results. The tension of the reconstructed extensor pollicis longus was adjusted so that the centre of the distal edge of the thumbnail was elevated 2 cm above the operation table. The mean retropositional distance of the treated thumbs was 1.2 cm less than the contralateral thumbs. The mean total active motion of the thumb was 90%. This technique resulted in satisfactory thumb function. Level of evidence: IV.

Background: Cubital tunnel syndrome (CuTS) is generally treated successfully by surgery and recurrent cases are rare. This study retrospectively investigated the clinical characteristics of recurrent CuTS caused by ganglion., Methods: We evaluated nine patients who were surgically treated for recurrent CuTS caused by ganglion. Age distribution at recurrence ranged from 43 to 79 years. The initial surgery for CuTS had been performed using various methods. The asymptomatic period from initial surgery to recurrence ranged from 22 to 252 months. Clinical, diagnostic imaging, and operative findings during the second surgery were analyzed. All patients were treated by anterior subcutaneous ulnar nerve transposition with ganglion resection and later examined directly within a mean of 71 months after the second surgery., Results: The interval from recurrence to consultation was shorter than two months for eight cases. Chief complaints included numbness with or without pain in the ring and little fingers in all patients and resting pain in the medial elbow in five patients. Elbow osteoarthritis was present in all cases. Although four of 10 ganglia were palpable, ultrasonography and magnetic resonance imaging could identify all ganglia preoperatively. The ulnar nerve typically had become entrapped by the ganglion posteriorly and by fascia, scar tissue, and/or muscle anteriorly. Chief complaints and ulnar nerve function were improved in all patients following revision surgery., Conclusions: The acute onset of numbness with or without intolerable pain in the ring and little fingers after a long-term remission period following initial surgery for CuTS in patients with elbow osteoarthritis appears to be the characteristic clinical profile of recurrent CuTS caused by ganglion. As ganglia are often not palpable, ultrasonography and magnetic resonance imaging are recommended for accurate diagnosis.

Purpose: Imaging criteria for diagnosing compressive ulnar neuropathy at the elbow (UNE) have recently been established as the maximum ulnar nerve cross-sectional area (UNCSA) upon magnetic resonance imaging (MRI) and/or ultrasonography (US). However, the levels of maximum UNCSA and diagnostic cutoff values have not yet been established. We therefore analyzed UNCSA by MRI and US in patients with UNE and in controls., Methods: We measured UNCSA at 7 levels in 30 patients with UNE and 28 controls by MRI and at 15 levels in 12 patients with UNE and 24 controls by US. We compared UNCSA as determined by MRI or US and determined optimal diagnostic cutoff values based on receiver operating characteristic curve analysis., Results: The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm 2 ) as well as for US (17 ± 7 mm 2 ). A cutoff value of 11.0 mm 2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients., Conclusions: By measuring UNCSA with MRI or US at 1 cm proximal to the ME, patients with and without UNE could be discriminated at a cutoff threshold of 11.0 mm 2 with high sensitivity, specificity, and reliability., Type of Study/level of Evidence: Diagnostic III., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Capitellar osteochondritis dissecans (OCD) is a focal injury of the articular cartilage involving separation of a segment of cartilage from the subchondral bone that is infrequently encountered in the dominant-side elbow of adolescent throwing athletes 1,2 . The literature suggests that patients may achieve better short and mid-term results when treated with certain types of surgical procedures 3,4 . Selection of the appropriate surgical method should be based on the International Cartilage Repair Society (ICRS) OCD classification system 5 . For lesions involving ≤50% of the surface area of the capitellum, debridement with microfracture and/or loose body removal have shown excellent results. For lesions involving >50% of the surface area of the capitellum and classified as ICRS OCD III or IV, autologous osteochondral grafting may be the most suitable treatment 6-8 . Bone peg grafting (BPG) has been shown to be an effective treatment option for early-stage capitellar OCD that can preserve the local hyaline cartilage 9,10 ., Description: Using direct vision and with arthroscopy, the continuity of the capitellar surface and the stability of the capitellar lesion were evaluated according to the ICRS OCD classification 5 . BPG was indicated for adolescents with ICRS OCD I or II. The elbow was opened between the extensor carpi ulnaris and the anconeus muscle (Kocher interval). Another skin incision of 3 cm in length was made at the posterior aspect of the metaphysis of the ipsilateral olecranon. Three, 4, or 5 bone pegs of approximately 20 mm in length were harvested from the posterior ulnar cortex. A Kirschner wire of 3 mm in diameter was used for drilling holes in the lesion, and then the bone pegs were inserted with tweezers to a depth of 10 mm. Next, a flat-surfaced rod was placed on the head of each bone peg to press it to a depth slightly lower than the articular cartilage surface. Postoperatively, the elbow was immobilized for 3 weeks. Throwing was allowed at 6 months, and a return to competitive baseball at preinjury levels was permitted at 8 months after BPG., Alternatives: Arthroscopic debridement of the lesion.Arthroscopic bone marrow stimulation or microfracture.Fragment fixation using metal implants or biodegradable materials.Use of autologous osteochondral graft from the distal aspect of the femur or from a rib., Rationale: Our follow-up study after BPG revealed that 10 of 11 patients with ICRS OCD I or II capitellar OCD could return to their preinjury baseball ability and that 8 of the 11 lesions completely healed as seen radiographically 11 . Radiographic and magnetic resonance imaging (MRI) findings showed that BPG could secure the lesion to the osseous floor as a physiological scaffold. Fragment fixation with metal implants or biodegradable materials carries a risk of damaging cartilage surfaces, and autologous osteochondral grafting is too invasive for this early-stage lesion. BPG is indicated for ICRS OCD I or II lesions, especially with central positioning and/or occupying <75% of the size of the capitellum in the coronal plane 11 .

Osteoporosis is a worldwide health concern. Although treatment with denosumab plus the active vitamin D alfacalcidol has been found to improve femoral neck (FN) and distal forearm bone mineral density (BMD), there have been no reports on the efficacy or adverse effects of denosumab plus eldecalcitol (ELD) in primary osteoporosis patients. Fifty-six treatment-naïve post-menopausal women with primary osteoporosis were recruited and divided into denosumab plus native vitamin D or denosumab plus ELD. Ultimately, 26 subjects in the native vitamin D group and 24 in the ELD group were analyzed. Lumbar and total hip BMD significantly increased in both groups. However, there was no significant difference in the percent increase of lumbar and total hip BMD between two groups. FN-BMD was significantly increased from 6 to 12 months in the ELD group compared with baseline. This study revealed that combination therapy with denosumab and ELD could improve FN-BMD more effectively than denosumab plus native vitamin D. Thus, the addition of ELD may enhance the effects of denosumab treatment for primary osteoporosis.

Osteoporosis is characterized by the systemic impairment of bone mass, strength, and microarchitecture, leading to an increased risk of fragility fracture. Bisphosphonates (BPs) are the first-line drugs for osteoporosis. Vitamin D is considered to be essential for osteoporotic treatment. However, long-term effects of BPs on the serum levels of 25-hydroxyvitamin D 3 (25(OH)D 3 ) are unknown. Accordingly, in this retrospective study, we collected clinical data of 41 post-menopausal Japanese women with osteoporosis treated with BP for over 3 years, without vitamin D supplementation. We measured lumbar and femoral neck bone mineral density (BMD) and serum levels of bone specific alkaline phosphatase (BAP) as a bone formation marker, and tartrate-resistant acid phosphatase (TRACP)-5b as a bone resorption marker, before and after the 3-year treatment. Serum 25(OH)D 3 , 1,25(OH) 2 D 3 , and whole parathyroid hormone (PTH) were also measured. Notably, no fracture occurred during the treatment. Compared with baseline values, 25(OH)D 3 levels were significantly increased from 21.6 to 26.4 ng/mL (P = 0.006), despite no vitamin D supplementation. 1,25(OH) 2 D 3 and whole PTH levels tended to be decreased from 62.6 to 57.8 pg/mL and 27.3 to 25.1 pg/mL, respectively. Both bone formation and resorption markers were significantly suppressed (P < 0.01). Both lumbar BMD (7.3% increase) and femoral neck BMD (4.1% increase) were significantly improved (P < 0.0001) after 3 years of the treatment. Thus, even without vitamin D supplementation, serum 25(OH)D 3 levels were significantly increased after 3-year BP therapy. These results suggest that vitamin D supplementation might not be required in the long-term BP therapy for osteoporosis.

This study aimed to clarify the effects of short-term bisphosphonate (BP) administration in Japanese osteoporotic patients retrospectively. Daily minodronate (MIN) at 1 mg/day (MIN group) or weekly risedronate (RIS) at 17.5 mg/week (RIS group) was primarily prescribed for each patient. We analyzed the laboratory data of 35 cases (18 of MIN and 17 of RIS) before the start of treatment and at 4 months afterward. The changes in 25(OH)D 3 , whole parathyroid hormone (PTH), serum pentosidine, and the bone turnover markers urinary cross-linked N-telopeptide of type I collagen (NTX), serum tartrate-resistant acid phosphatase (TRACP)-5b, bone-specific alkaline phosphatase (BAP), and undercarboxylated osteocalcin were evaluated. Overall, serum 25(OH)D 3 was significantly decreased from 21.8 to 18.4 ng/mL at 4 months, with a percent change of -14.7%. Whole PTH increased significantly from 23.4 to 30.0 pg/mL, with a percent change of 32.1%. Serum pentosidine rose from 0.0306 to 0.0337 μg/mL, with a percent change of 15.2%. In group comparisons, 25(OH)D 3 and pentosidine showed comparable changes in both groups after 4 months of treatment, whereas whole PTH became significantly more increased in the MIN group. All bone turnover markers were significantly decreased at 4 months in both groups. Compared with the RIS group, the MIN group exhibited significantly larger value changes for urinary NTX, serum TRACP-5b, and BAP at the study end point. This study demonstrated that serum 25(OH)D 3 became significantly decreased after only 4 months of BP treatment in Japanese osteoporotic patients and confirmed that MIN more strongly inhibited bone turnover as compared with RIS., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Closed flexor tendon ruptures in the little finger can be caused by fracture or nonunion of the hook of the hamate, but no case of the disorder secondary to the sclerosis and thinning of the hamate hook has been reported. We report two rare cases with this complication due to rough surface of the hamate hook. Carpal tunnel view radiographs and computed tomography showed the sclerosis and thinning of the hook.

As a bisphosphonate, minodronate (MIN) is one of the strongest inhibitors of bone resorption. However, there have been no reports directly comparing the antiresorptive effects of monthly MIN with those of monthly risedronate (RIS). We enrolled 30 cases of osteoporosis (OP; 16 in the MIN group [mean age: 68.2 years] and 14 in the RIS group [mean age: 68.1 years]) to investigate the early effects of treatment by monthly MIN or RIS over a 4-month period using bone turnover marker values. Only female patients were enrolled to avoid gender bias. Urinary cross-linked N-telopeptide of type I collagen (NTX) before treatment and at 1, 2, and 4 months of therapy, as well as serum bone alkaline phosphatase and alkaline phosphatase before treatment and at 4 months afterwards, were evaluated. All bone turnover marker values were significantly decreased at 4 months in both groups. The changes in urinary NTX at the study end point for RIS and MIN were -30.1% and -63.1%, respectively. From 2 months of treatment, the antiresorptive effects on urinary NTX by MIN were significantly higher than those by RIS, indicating that MIN more immediately and strongly inhibited bone absorption. Thus, monthly MIN seems to suppress bone resorption faster and more strongly than RIS in OP treatment.

Dislocation of the radial head is often encountered as a result of a pediatric Monteggia fracture. We report two rare cases of tardy ulnar nerve palsy associated with anterior radial head dislocation combined with anterior bowing of the ulna. They had cubitus valgus deformity, valgus instability, and osteoarthritis of the elbow, and had elbow injury more than 40 years back. They were diagnosed with chronic radial head dislocation long after a Bado type 1 Monteggia fracture. Anterior subcutaneous ulnar nerve transposition yielded favorable results. It is important to recognize the possibility of tardy ulnar nerve palsy caused by an improperly treated Monteggia fracture.

The aim of this study was to investigate if differences in leg positioning affect spinal bone mineral density (BMD) measurements and the detection of low bone mass. Subjects included 1039 Japanese patients, 878 women and 161 men (mean ages: 67 and 71 years, respectively). Spinal BMD (L1-4) was measured using dual-energy X-ray absorptiometry (DXA) with patients lying in 2 different positions: (1) supine on the scanning table with hips flexed and knees flexed over a 90° support pad (the standard position) and (2) simply supine (the supine position). Predictive indices were calculated for spinal DXA acquired with patients in the supine position. A BMD T-score of -2.5 or lower was set as the threshold for low bone mass. For the standard and the supine positions during scanning in women, BMDs were 0.911 and 0.915 g/cm(2), respectively; in men, they were 1.117  and 1.124 g/cm(2), respectively. The estimated systematic bias in BMD between the positions was 0.42% (95% confidence interval: 0.24, 0.59; p = 0.009). Random errors in the densitometry measurements for the standard and supine positions were 0.66% and 0.84%, respectively. There was no significant difference between the errors (p= 0.164). The likelihood ratios of a positive and negative test for the detection of low bone mass following supine DXA were 121.0 and 0.066, respectively, compared with results acquired using the standard position. In conclusion, DXA measurements acquired with patients in the supine position slightly overestimated BMD vs the standard position. However, the clinical equivalency between the positioning methods for DXA is preserved to the extent that low bone mass can be reliably detected in the supine position., (Copyright © 2016 International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

The syndrome of pregnancy- and lactation-associated osteoporosis is a rare disorder whose precise etiology and treatment are largely unknown. We herein report two such cases occurring in the early postpartum period that led to multiple fragility compression fractures. Combination therapy of vitamin D and vitamin K enabled a marked gradual increase in bone mineral density.

Background: Most of the alkaline phosphatase (ALP) isoenzymes are derived from the bones and liver. High levels of ALP are often encountered during routine blood investigation in elderly patients. However, because ALP includes various isoenzymes from other tissues, an accurate diagnosis is usually not possible on the basis of elevated ALP alone., Aims: To identify the cause of increased ALP in postmenopausal women., Methods: We measured serum ALP in a group of 626 postmenopausal osteoporotic women before and after treatment with a bisphosphonate (either alendronate or risedronate). We analyzed the correlations between ALP levels and bone metabolic markers or hepatic function markers., Results: The ALP and BAP levels of people in their 80s were significantly higher than those of people in their 60s. With bisphosphonate therapy, the BAP decreased, and the elevated ALP decreased to normal range levels. ALP was highly and significantly correlated with BAP both before and after treatment. The changes in levels of ALP correlated well with the changes in BAP levels before and after bisphosphonate therapy. Markers of liver function correlated with total ALP (p < 0.01), but the correlation was much smaller than that between ALP and BAP., Discussion: Bisphosphonate treatment lowered ALP levels, and this decrease was strongly correlated with a decrease in BAP. Among blood test data, the decrease in BAP had the strongest correlation with the ALP decrease., Conclusion: For treatment of osteoporosis, ALP is an acceptable alternative to BAP. Elevated ALP in postmenopausal women is mainly caused by high bone turnover.

Purpose: To identify risk factors for tendon attrition after volar locking plate fixation of distal radius fractures., Methods: We prospectively assessed attrition of the flexor pollicis longus tendon at volar plate removal in 127 hands in 126 patients. We also evaluated preoperative lateral wrist radiographs, sonographs, and crepitus with flexor pollicis longus tendon motion and compared the demographic and radiographic characteristics of patients with and without tendon attrition. Multivariate logistic regression analysis was employed to identify the factors independently associated with tendon attrition., Results: We found 12 cases of tendon attrition (10%) and 1 that presented with tendon rupture in our cohort. Crepitus was recognized in 14 patients (11%): 6 cases (50%) were among the 12 hands in 12 patients with tendon attrition whereas 8 (7%) were detected in the remaining 114 hands in 113 patients. Logistic regression examination revealed that audible crepitus and volar placement of the plate in lateral radiographs were independent predictors of tendon attrition., Conclusions: Crepitus and volar placement of hardware in lateral radiographs were independent risk factors for flexor tendon attrition after volar plating for distal radius fracture. These results may facilitate surgical decisions regarding early plate removal to prevent possible tendon rupture., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The exponential increase in the incidence of fragility fractures in older people is attributed to attenuation of both bone strength and neuromuscular function. Decrease in bone mineral density (BMD) does not entirely explain this increase. The objective of this study is to investigate the effect of age on various parameters related to bone health with aging, and to identify combinations of factors that collectively express the bone metabolic state in healthy postmenopausal women. Height, weight, and grip strength were measured in 135 healthy postmenopausal volunteer women. Hip BMD, biomechanical indices derived from quantitative computed tomography (QCT), cross-sectional areas of muscle and fat of the proximal thigh, and various biochemical markers of bone metabolism were measured. A smaller group of factors explanatory for bone health was identified using factor analysis and each was newly named. As a result, the factors bone mass, bone turnover, bone structure, and muscle strength had the greatest explanatory power for assessing the bone health of healthy postmenopausal women. Whereas dual X-ray absorptiometry parameters only loaded on the factor bone mass, QCT parameters loaded on both the factors bone mass and bone structure. Most bone turnover markers loaded on the factor bone turnover, but deoxypyridinoline loaded on both bone turnover and muscle strength. Age was negatively correlated with bone mass (r = -0.49, p < 0.001) and muscle strength (r = -0.67, p < 0.001). We conclude that aging is associated as much with muscle weakening as with low BMD. More attention should be paid to the effects of muscle weakening during aging in assessments of bone health.

Bisphosphonates are effective in increasing bone mineral density (BMD), but fragility fractures can still occur despite bisphosphonate treatment. The purpose of this study was to determine if long-term bisphosphonate users have characteristic findings in the musculoskeletal system, which could put them at risk of developing typical or atypical femoral fractures. We recruited 40 female patients who had taken bisphosphonates for more than 3 years. The control group included 60 volunteers who were matched by age, body mass index, and dual-energy X-ray absorptiometry-derived BMDs. We measured the skeletal muscle cross sectional area around the proximal thigh and buckling ratio of the femoral neck using quantitative computed tomography (qCT) and several biochemical markers of bone metabolism. Those parameters were compared between the groups. While no significant differences of buckling ratio derived from qCT were detected, the skeletal muscle cross sectional area was significantly smaller in the long-term bisphosphonate users than in the controls. Furthermore, the serum pentosidine level was significantly higher in the bisphosphonate users than in the controls. To determine if those differences were attributable to bisphosphonate treatment, we further compared those parameters between before and after 3 years of bisphosphonate treatment in 32 patients. After 3 years of bisphosphonate treatment, the BMD of the femoral neck and serum pentosidine level increased but not the skeletal muscle cross sectional area. In the present study, the skeletal muscle mass did not match the bone mass in long-term bisphosphonate users, thus suggesting that increases in BMD by bisphosphonates are unlikely to have secondary positive effects on the surrounding skeletal muscles. Also, serum pentosidine levels were greater in the long-term bisphosphonate users. Further study is necessary to test if such patients are prone to develop typical or atypical femoral fractures., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Based on the results of numbers of the clinical trials, the medicines that prevent hip fracture are alendronate, risedronate, and denosumab, which are all antiresorptive. Although currently evidence is not available, combination anabolic and antiresoprtive therapy using teriparatide and denosumab is expected to efficiently prevent hip fracture because such therapy increases hip bone mineral density more than either drug alone.

Background: Arthrodesis of the carpometacarpal (CM) joint of the thumb has been recognized as a common technique that gives pain relief, stability, and strength, but it has some disadvantages, such as nonunion, pantrapezial osteoarthritis, and reduced mobility., Methods: Thirteen thumbs of 12 patients with CM joint arthritis who underwent CM joint arthrodesis were reviewed retrospectively. The average age of the patients was 61.0 years. The follow-up period ranged from 2 to 5 years. Arthrodesis was performed with a T-plate and an autogenous iliac cancellous bone graft for all patients., Results: All thumbs had radiographic evidence of union, and there was no nonunion. No reduction of motion of the interphalangeal and metacarpophalangeal joint of the thumb was found after surgery. Postoperatively, scaphotrapeziotrapezoid arthritis and metacarpophalangeal arthritis progressed in two joints each. The Disabilities of the Arm, Shoulder, and Hand score improved from 39.9 (range 8-69) to 11.1 (range 0-23.1). All patients had no or slight problems of the thumb and no complaints related to the pelvis in daily living and were either very satisfied or satisfied with the surgery., Conclusions: Arthrodesis of the thumb CM joint with a plate and bone graft achieved satisfactory results in all cases with very few complications. This procedure is a valuable tool in middle-aged and elderly patients with thumb CM joint arthritis.

Background: Osteoarthritis (OA) is the leading cause of musculoskeletal pain and functional disability worldwide. However, the etiology of this condition is still largely unknown., Case Report: We report the clinical course of an elderly man with knee OA., Conclusions: Plain radiographs and MRI examinations performed during follow-up suggested that the pathophysiology of the patient's knee OA and joint pain may have been primarily due to bone alterations.

Background: The clinical characteristics of wild-type transthyretin amyloid deposition among patients with carpal tunnel syndrome (CTS) have not been well investigated., Methods: One-hundred and seven patients with idiopathic CTS who underwent carpal tunnel release were enrolled. They underwent physical examination of the hand, nerve-conduction study, and magnetic resonance imaging (MRI) study of the wrist, and completed a patient-oriented questionnaire. The tests, except for MRI, were repeated 1, 3, and 6 months postoperatively. Synovial tissue was obtained during surgery and analyzed by Congo red and immunohistochemical staining. Ordinal logistic regression analysis was used to evaluate the significance of different clinical and subjective findings between patients with and without amyloid deposition. Postoperative improvements were also compared., Results: Wild-type transthyretin amyloid deposition was observed for 38 patients. Greater symptom severity and 2-point discrimination scores, and larger cross-sectional areas of the carpal tunnel, were significantly correlated with a larger amount of preoperative amyloid deposition. However, the presence and amount of preoperative amyloid deposition did not affect postoperative improvements in physical findings and nerve-conduction studies., Conclusions: Although transthyretin amyloid deposition can worsen CTS symptoms, postoperative improvements were similar for patients with and without this deposition.

We present a rare case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. Children with elbow pain and/or swelling with fever should be carefully examined for septic arthritis. Pseudomonas aeruginosa should always be kept in mind in such cases to avoid any delay in effective treatment.

Purpose: To evaluate the efficacy of a technique to preserve the extrinsic vascular supply to the ulnar nerve after transposition and its effect on blood flow and clinical outcome., Methods: We included 36 patients with cubital tunnel syndrome. The patients were randomly selected to undergo vascular pedicles-sparing surgery for anterior ulnar nerve transposition (VP group) or nerve transposition and artery ligation (non-VP group). Blood flow to the ulnar nerve was estimated intraoperatively at 3 locations in the cubital tunnel before and after transposition using a laser Doppler flowmeter. Clinical results at 3, 6, and 12 months after surgery were also compared between the 2 groups., Results: The blood flow before ulnar nerve transposition was not significantly different between the groups. Blood flow at all 3 locations after the ulnar nerve transposition was significantly higher in the VP group than in the non-VP group. Blood flow in the non-VP group reduced to values between 28% and 52% from the pre-transposition baseline values. After surgery, no significant differences were observed in the clinical results between the groups, except for the Disabilities of the Arm, Shoulder and Hand scores at 12 months after surgery, which was greater in the non-VP group., Conclusions: The procedure of preserving the extrinsic vascular pedicles can prevent compromise of blood flow to the ulnar nerve immediately after nerve transposition. However, this procedure had no correlation to improved recovery of ulnar nerve function after surgery., Type of Study/level of Evidence: Therapeutic II., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

It has not been established whether unilateral or bilateral hip dual-energy X-ray absorptiometry (DXA) is preferable for the diagnosis of osteoporosis. We investigated the discordance in DXA measurements in bilateral hips to determine whether unilateral DXA is valid for osteoporosis diagnosis. The subjects were 2964 Japanese patients without a previous diagnosis of primary osteoporosis. We measured bilateral femoral bone mineral density (BMD) and calculated indices, related to the unilateral results, for predicting contralateral hip osteoporosis. A likelihood ratio (LR) of a negative test (LR [-]) of less than 0.2 was considered to exclude the diagnosis. In the normal spinal BMD group, the sensitivity of unilateral DXA for women was 27-73% and LR (-) was 0.28-0.73; the sensitivity for men was 0-50% and LR (-) was 0.51-1.00; the diagnosis of contralateral osteoporosis was not excluded. Sensitivity increased and LR (-) increased with worsening spinal BMD status; however, LR (-) did not meet the cutoff for exclusion. We could exclude unilateral hip osteoporosis, in women only, by performing contralateral femoral DXA; this necessitated lowering the T-score cutoff from -2.5 to -2.0. Unilateral femoral DXA is not useful for excluding the diagnosis of contralateral hip osteoporosis., (Copyright © 2014 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

The distal radius constitutes a proximal part of the wrist joint, which bears axial load from the carpal bones. Based on the biomechanical experiments, the load transmitted from the carpal bones to the distal articular surface of the radius is greater to the lunate fossa than the scaphoid fossa. The findings are consistent with the results obtained from HR-pQCT analysis of the distal radius. As ageing, bone mineral densities of the distal radius decrease, and structures of the cortical and trabecular bones also deteriorate. Such deterioration can be prevented by osteoporotic medicines such as PTH or bisphosphonate. Denosumab has been shown to increase mechanical indices of the bone structure of the distal radius. The distal radius of the individual is fractured when the load over approximately 5 times (2.5SD) of the weight is applied. It is possible to predict load of fracture in the distal radius from the results of DXA derived BMD or HR-pQCT derived bone parameters. We should not miss the opportunity of treatment for osteoporosis when the patients with fragility distal radius fracture are seen.

Purpose: This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties., Methods: We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ(2) test, and binary regression analysis., Results: One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed., Conclusions: The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

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.

It is one of the most important challenges for preventing hip fractures to establish an accurate non-invasive assessment of hip fracture risk. Quantitative computed tomography (QCT) is able to analyze not only volumetric bone mineral density (mg/cm3) of trabecular and cortical bone compartment separately, but also geometry and biomechanical parameters in bone such as cross-sectional area, cortical bone thickness, section modulus, buckling ratio etc. The analysis of geometry and biomechanical parameters at hip could provide better prediction of hip fracture risk, better understanding pathogenesis of hip fractures, and thus better selection of drug and/or lifestyle-based interventions.

We retrospectively reviewed the long-term clinical outcomes of one-stage flexor tendon grafting for seven paediatric patients with isolated flexor digitorum profundus (FDP) tendon injuries in Zones 1 or 2. Free tendon grafts (one palmaris longus tendons and six plantaris tendons) were used for reconstruction by Pulvertaft's procedure. The ages of the patients at reconstruction ranged from 7 to 15 (mean 11) years. The time from injury to surgery ranged from three to 78 (mean 25) months. These patients were followed up from 2.5 to 21 years after surgery (mean 8.5 years). All cases were started on early active extension and passive flexion according to the modified Kleinert mobilization for postoperative rehabilitation. The mean active motion after surgery was 49° (range 20-80°) for the DIP joints and 106° (range 95-110°) for the PIP joints. The total active range of motion was on average 237° (range 195-275°). Excellent results were achieved in five patients, good in one, and fair in one. Growth arrest of the distal phalanx was seen in one patient. One-stage flexor tendon grafting in paediatric patients combined with early controlled mobilization can be used to reconstruct neglected isolated ruptures of the FDP tendon with satisfactory results.

Background: The present study measured longitudinal changes in bone turnover markers in elderly patients with vertebral fracture and investigated the relationship among bone turnover markers, duration of bed rest and bone mineral density (BMD)., Methods: Criteria for patient selection were 50 years in age and older, and presence of VF. Serum bone-specific alkaline phosphatase (BAP) was measured as a marker of bone formation. Urinary crosslinked N-terminal telopeptides of type I collagen (NTX) was measured as a marker of bone resorption. In principle, samples were collected just after injury, within 24 h, and 1, 2, 3, 5 and 8 weeks after. We also measured duration of bed rest and BMD., Results: The study population consisted of 42 cases. The average BMD of the lumbar vertebrae was 0.670 ± 0.174 g/cm2. Bed rest period was 17.9 ± 8.8 days. BAP showed significantly higher values at 2 and 3 weeks compared with the baseline value. Thereafter, BAP progressively decreased until 8 weeks. Urinary NTX was increased soon after the onset of pain with the same patterns in BAP. Urinary NTX values reached a peak at 3 weeks, and then they kept significantly higher values until 8 weeks. The peak value of serum BAP was affected by the duration of bed rest, although that of the urinary NTX was not. The peak values of serum BAP and urinary NTX showed negative correlations with the initial BMD values., Conclusions: Bone turnover markers remained higher at 8 weeks, even patients symptom was healed after VF. Bone turnover markers were affected on physical activity and BMD.

Background: The Patient-Rated Wrist Evaluation is a regionspecific, self-administered questionnaire consisting of a pain scale (PRWE-P) and a functional scale (PRWE-F), with the latter consisting of specific function (PRWE-SF) and usual function (PRWE-UF). The PRWE was cross-culturally adapted from the original English version by the Impairment Evaluation Committee, Japanese Society for Surgery of the Hand (JSSH). The purpose of this study was to test the reliability, validity, and responsiveness of the Japanese version of PRWE (PRWE-J)., Methods: A consecutive series of 117 patients with wrist disorders completed the PRWE-J, the JSSH version of the Disabilities of the Arm, Shoulder, and Hand (DASH-JSSH) questionnaire and the 36-Item Short-Form Health Survey (SF-36). Of the 117 patients, 71 were reassessed for test-retest reliability 1 or 2 weeks later. Reliability was investigated by reproducibility and internal consistency. To analyze the validity, a factor analysis (principal axis factoring) of PRWE-J and correlation coefficients between PRWE-J and DASH-JSSH were obtained. Responsiveness was examined by calculating the standardized response mean (SRM) (mean change/SD) and effect size (mean change/SD of baseline value) after open surgery in 50 patients., Results: Cronbach's alpha coefficients for PRWE-P, PRWE-F, and PRWE were 0.90, 0.95, and 0.95, respectively. The intraclass correlation coefficients (ICCs) for the same were 0.86, 0.93, and 0.92, respectively. Unidimensionality of PRWE-P was con-firmed. Bidimensionality of PRWE-F was confirmed and separated clearly into PRWE-SF and PRWE-UF. The correlation coefficients between PRWE-P and PRWE-F or DASH-JSSH were 0.63 or 0.63, respectively. The correlation coefficient between PRWE-F and DASH-JSSH was 0.80. The correlation coefficients between DASH-JSSH and PRWE-SF or PRWE-UF were 0.76 or 0.73, respectively. Moderate correlation was observed in "physical functioning" for SF-36 and PRWE-SF (r = -0.46), PRWE-F (r = -0.46), or PRWE (r = -0.46). The SRMs/effect sizes of PRWE-P, PRWE-F, or PRWE were respectively excellent: 1.7/2.2, 1.2/1.3, 1.6/1.9., Conclusions: The PRWE-J has evaluation capacities equivalent to those of the original PRWE.

Closed tendon rupture is a well-known complication of Kienböck disease, but only 11 cases have been reported. We reviewed six cases of Kienböck disease with subcutaneous rupture of a tendon. There were five cases of 4th extensor tendons and one case of the flexor digitorum profundus tendons of the ring finger and little finger. Radiographs showed protrusion of the segmented lunate or the deformed lunate in all cases. Intraoperative findings confirmed rupture of the wrist joint capsule by these lunate lesions. We then reviewed 11 reported cases in English and 48 cases in Japanese and confirmed that all cases had similar clinical characteristics and radiological features to our own, except the involved digits of flexor tendon rupture. Our case was unique in that the ulnar side tendons were ruptured, while in the reported cases the radial flexor tendons were more susceptible to rupture than the ulnar ones. Closed rupture of tendons should be recognised as a complication in patients over middle age with stage IIIb or IV asymptomatic or less symptomatic Kienböck disease.

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.

In Japan, spinal dual-energy X-ray absorptiometry (DXA) has been commonly performed for diagnosing osteoporosis but scanning the proximal femur is not done widely. The latest Japanese guidelines for prevention and treatment of osteoporosis, revised in 2006, recommend bone mineral density (BMD) measurement at both spine and hip for diagnosing osteoporosis, although there have been no reports that proved the necessity of those measurements. One thousand forty-one women and 485 men with clinical suspicion of osteoporosis were enrolled in this study, and DXA was performed at both spine and hip. The proportions of the patients who had inconsistency between diagnosis of osteoporosis from spinal DXA and that of hip were estimated. As a result, 22% of women and 15% of men had an inconsistency with the diagnosis of osteoporosis using DXA at each measurement site. There was inconsistency in diagnosing osteoporosis using DXA at the spine and proximal femur measurement sites. Because spine and femoral DXA measurements complement each other in the diagnosis of osteoporosis, BMD measurement at both spine and hip should be performed for all Japanese patients who are suspected osteoporosis, regardless of age and sex.