Evaluation of skeletal muscle elasticity using color Doppler shear wave imaging.

PURPOSE: This study aimed to (1) assess the precision and reproducibility of color Doppler shear wave imaging (CD SWI) by comparing it with shear wave elastography (SWE) via elasticity phantom measurements, and (2) investigate the potential clinical applications of CD SWI in the upper limb muscles by assessing the reproducibility of skeletal muscle elasticity evaluations. METHODS: Four elastography phantoms of different stiffness (6.0-7.5 wt%) were used to assess the precision and reproducibility of CD SWI (compared with SWE) at depths. Typical upper limb muscles of 24 men were also assessed for this comparison. RESULTS: At superficial depths (0-2 cm), the phantom measurements obtained using CD SWI and SWE were similar at all levels of stiffness. Furthermore, both methods were highly reliable, with almost perfect intra- and inter-operator reliabilities. At greater depths (2-4 cm), measurements obtained using both methods were similar at all stiffness levels. Although standard deviations (SDs) of the phantom measurements obtained using both methods at lower stiffness were similar, those at higher stiffness were different. The SD of the CD SWI measurements was < 50% of that of the SWE measurements. However, both methods were highly reliable in the phantom test, with almost perfect intra- and inter-operator reliabilities. The intra- and inter-operator reliabilities of the shear wave velocity measurements for typical muscles of the upper limbs were also substantial in clinical settings. CONCLUSION: CD SWI is a valid method for measuring elasticity, with precision and reliability as high as those of SWE.

Rehabilitation after Hip Fracture Surgery Improves Physical and Cognitive Function in Patients with or Without Sarcopenia.

Introduction: Sarcopenia is a prevalent risk factor for falls and fractures, and it affects the physical function and mortality of older people. The present study was performed to assess the prevalence of sarcopenia in patients who underwent rehabilitation after hip fracture surgery and to examine the association of sarcopenia with physical and cognitive function outcomes. Methods: This case-control study involved 132 patients who were admitted to a convalescent rehabilitation ward at a single hospital after surgical treatment of hip fractures from April 2018 to March 2020. The skeletal muscle mass index was examined using whole-body dual-energy X-ray absorptiometry. The Asian Working Group for Sarcopenia 2019 diagnostic criteria were applied on admission. We compared the walking speed, Mini-Mental State Examination (MMSE) score, and Functional Independence Measure (FIM) score between the sarcopenia group and non-sarcopenia group on admission and on discharge. Results: The prevalence of sarcopenia was 59.8%. In the non-sarcopenia group, the walking speed, MMSE score, FIM total score, FIM motor score, and FIM cognitive score were significantly lower on admission than those on discharge (P < .05). In the sarcopenia group, the walking speed, MMSE score, FIM total score, and FIM motor score were significantly lower on admission than those on discharge (P < .05); there was no significant difference in the FIM cognitive score between admission and discharge. On both admission and discharge, the MMSE score, FIM total score, FIM motor score, and FIM cognitive score were significantly better in the non-sarcopenia group than those in the sarcopenia group. Conclusions: After postoperative rehabilitation of hip fractures in patients with and without sarcopenia, physical and cognitive function outcomes on discharge were significantly better than those on admission. Patients with sarcopenia had significantly worse physical and cognitive function outcomes than patients without sarcopenia both on admission and on discharge.

Reduction of abnormal blood flow in frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block: semiquantitative analysis using dynamic magnetic resonance imaging.

Background: We previously reported a characteristic dynamic magnetic resonance imaging (MRI) change in patients with frozen shoulder (FS) and named this abnormal blood flow pattern the "burning sign". In this study, a semiquantitative method was used to evaluate changes in this abnormal blood flow pattern on dynamic MRI after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) in patients with FS. Methods: Nineteen patients with FS underwent MUC, with dynamic MRI performed before and after. We used dynamic MRI to semiquantitatively assess changes in the burning sign at the axillary pouch (AP) and rotator interval (RI) by examining the enhancement rate in the signal intensity and the enhancement velocity. Functional assessments included a numeric rating scale score, the range of shoulder motion, the American Shoulder and Elbow Surgeons score, and the Constant score. Results: The burning sign in the AP and RI was observed with dynamic MRI in all patients before MUC. The average interval from MUC until dynamic MRI was 8.2 months (range, 6-12). Clinical results for all patients improved after MUC. The before and after MUC enhancement rates (%) were 217 ± 51 and 85 ± 36 in the AP and 233 ± 61 and 73 ± 40 in the RI, respectively (both P < .001). The before and after MUC enhancement velocities (ms/s) were 902 ± 335 and 203 ± 125 in the AP and 1249 ± 634 and 213 ± 146 in the RI, respectively (both P < .001). Conclusion: Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after MUC in patients with FS.

Clinical results of reverse shoulder arthroplasty for comminuted proximal humerus fractures in elderly patients: a comparison between nonporous stems versus trabecular metal stems.

BACKGROUND: This study compared the clinical results for nonporous stems vs. trabecular metal (TM) stems used in reverse shoulder arthroplasty (RSA) for comminuted proximal humeral fractures (CPHFs) in elderly patients. METHODS: In this retrospective study, a total of 41 shoulders (39 women) of patients with CPHF aged >70 years who underwent RSA were investigated. The minimum follow-up period was 2 years. A total of 15 shoulders were treated with Grammont-style RSA using nonporous stems (the G-RSA group), and 26 shoulders were treated with RSA combining TM stems (the FR-RSA group). The American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, shoulder joint range of motion (ROM), and radiographic findings were compared between the 2 groups. RESULTS: ASES scores and Constant scores were significantly higher in the FR-RSA group than in the G-RSA group. External rotation at the side in the FR-RSA group was significantly higher than that in the G-RSA group. In the FR-RSA and G-RSA groups, the union rates at the greater tuberosity (GT) were 88.5% and 46.7%, respectively, and scapular notching rates were 20% and 7.7%, respectively. Based on a subanalysis, the age was lower, body mass index was higher, and ASES scores, Constant scores, and external rotation ROM were higher in the GT union group than in the GT nonunion group. CONCLUSION: GT bone union rates were high, and external rotation ROM of the shoulder joint were more improved for RSA using TM stems than those for RSA using nonporous stems in elderly patients with CPHF.

New method for acquiring the expected extension gap in total knee arthroplasty.

PURPOSE: Adjusting the soft-tissue balance during surgery is crucial in total knee arthroplasty (TKA). However, even using the gap technique, the expected tibial gap is sometimes not achievable. We developed a new method of proximal tibial cutting to acquire the expected tibial gap and insert a tibial liner of appropriate thickness. METHODS: This study included 128 patients who underwent medial pivot-type TKA for varus knee osteoarthrosis. After completion of the femoral cut using and removal of the bony spur at the medial tibia according to the preoperative plan, we inserted a trial femoral component to the distal femur. Applying valgus manual stress on the knee in extension, we measured the medial gap between the femoral trial and tibial plateau using calipers, defining this medial gap as "pre-gap". A proximal tibial cut was made referring to the pre-gap in the pre-gap group (n = 64). We defined Δgap as the difference between the expected tibial liner thickness and the final tibial liner thickness during surgery. We compared Δgap between the pre-gap group and a control group with conventional tibial cutting without pre-gap measurement (n = 64). RESULTS: The frequency of an ideal tibial cut (Δgap = 0) was 82% in the pre-gap group and 61% in the control group. The frequency of outliers (Δgap ≥ 2 mm) was 4% and 18%, respectively. The expected tibial liner was selected more frequently in the pre-gap group than in the control group. CONCLUSIONS: Our method was beneficial for acquiring the expected gap in extension to avoid an inadequate gap. LEVEL OF EVIDENCE III: Case-control study.

The course and clinical impact of articular magnetic resonance imaging findings 6 months after shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder.

BACKGROUND: In our previous study, iatrogenic capsular tears, bone bruises of the humeral head, and labral tears were detected on magnetic resonance imaging (MRI) performed 1 week after manipulation following ultrasound-guided cervical nerve root block in patients with frozen shoulder 6 months after manipulation. METHODS: We studied 25 patients with frozen shoulder. MRI was performed before, 1 week after, and 6 months after manipulation. On the basis of the course of MRI findings over a period of 6 months, the patients were divided into 2 groups: those with MRI findings of bone bruises, capsular tears, and/or labral tears (19 patients) and those with no MRI findings (6 patients). The clinical outcomes of the 2 groups at 6 months after manipulation were compared using the Wilcoxon matched-pairs test, the Mann-Whitney test, and the Fisher exact probability test for statistical analysis. RESULTS: At 1 week after manipulation, 96% of patients had capsular tears, 40% had bone bruises, and 20% had labral tears; these percentages had decreased at 6 months after manipulation to 4%, 20%, and 8%, respectively. No significant differences in clinical outcomes were noted between patients with residual MRI findings 6 months after manipulation and those without any MRI findings. CONCLUSION: Most of the iatrogenic capsular tears, bone bruises, and labral tears detected 1 week after manipulation had disappeared 6 months later. Residual MRI findings 6 months after manipulation had no significant correlation with clinical symptoms.

Blood flow evaluation by dynamic magnetic resonance imaging of symptomatic rotator cuff tears and frozen shoulders.

BACKGROUND: This study compared imaging findings of blood flow changes between symptomatic rotator cuff tear (RCT) and frozen shoulder (FS) by using 3-dimensional dynamic magnetic resonance imaging (MRI) to determine the clinical characteristics of symptomatic RCT. METHODS: The 2 study groups comprised 31 symptomatic RCT patients who underwent arthroscopic rotator cuff repair and 30 patients with FS. We denoted abnormal blood flow detected around the glenohumeral joint as the burning sign (BS). We evaluated the characteristics of dynamic MRI and compared them between BS-positive and BS-negative patients in the RCT group. RESULTS: All members of the FS group showed the BS. Conversely, the incidence of the BS in RCT patients was 53% (16 of 31). The BS in RCT and FS patients was observed in the rotator interval in 16 shoulders, in the axillary pouch in 3 shoulders (P < .01), and in the intertubercular groove in 10 RCT and 12 FS patients. In the RCT group, 16 patients with BS had a statistically significantly higher Numeric Rating Score at rest (P = .0005) and in motion (P = .04) than the 15 patients without BS and exhibited a higher rate of small and medium tears and a higher rate of shoulder contracture. CONCLUSION: Dynamic MRI of symptomatic RCT (53.3%) highlighted abnormal vascularization around the glenohumeral joint, which may be associated with pain and contracture in RCT as in FS.

Short-term clinical results of frozen shoulder treated with shoulder manipulation under ultrasound-guided cervical nerve root block at outpatient setting: A case series.

BACKGROUND: We evaluated the short-term clinical outcomes of frozen shoulder treatment via shoulder manipulation under ultrasound-guided cervical nerve root block (MUC). METHODS: This study included frozen shoulder patients who were unresponsive to conservative therapy for at least 6 months and were then treated with MUC. Patients with a rotator cuff tear, calcifying tendinitis, osteoarthritis, or any other shoulder disorder were excluded following X-ray, ultrasound, and magnetic resonance imaging evaluation. Although 25 patients were initially included, three patients were not followed-up for at least 1 year. We investigated a final total of 22 patients; the average age was 58 years and 59% were female. We measured shoulder pain, shoulder range of motion, and American Shoulder and Elbow Surgeons shoulder scores immediately prior to MUC, 1 week after MUC, and 1 year after MUC. A Short-Form 36-Item Health Survey was administered before MUC and 1 year after MUC. We used the Friedman and Wilcoxon signed-rank tests to identify statistical differences. Significance was defined as p < 0.05. RESULTS: MUC significantly improved shoulder pain during motion, range of motion, and American Shoulder and Elbow Surgeons scores 1 week after MUC. This improvement persisted at the 1-year follow-up. Seven of the eight Short-Form 36-Item Health Survey measures were significantly improved 1 year after MUC. One patient (4.5%) developed Horner's syndrome, although symptoms resolved within several hours without treatment. CONCLUSION: MUC for frozen shoulder was safe and resulted in a significant improvement in shoulder pain and range of motion 1 week after the procedure. This improvement persisted at the 1-year follow-up.

Characteristics of dynamic magnetic resonance imaging of idiopathic severe frozen shoulder.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of current techniques for dynamic 3-dimensional magnetic resonance imaging (MRI) in the diagnosis of idiopathic severe frozen shoulder (FS). MATERIALS AND METHODS: Subjects consisted of 5 healthy volunteers and 16 patients with idiopathic severe FS. We defined severe idiopathic FS as follows: range of motion ≤100° in forward flexion, ≤10° in external rotation, and ≤L5 in internal rotation. All patients suffered from continued global range of motion loss for at least 6 months. We evaluated the diagnostic characteristics of 3-dimensional dynamic MRI in FS patients compared with those in healthy volunteers. RESULTS: MRI of all FS patients displayed an abnormal intake of blood flow from the acromial arterial network and the branches of circumflex humeral arteries into the axillary pouch and the rotator interval. We named this finding "burning sign." The burning sign was present at all phases of the condition. In the FS group, the patients with enhanced deposition of contrast medium in the axillary pouch in the delayed phase (n = 11) had a statistically significant score for pain during exercise, higher than that of patients with reduced deposition of contrast medium at the same site (n = 5; P = .027). CONCLUSION: Burning sign is an abnormal finding that appears in dynamic MRI of severe FS. Hence, the burning sign may be associated with pain and inflammation in idiopathic FS.

Arthroscopic fixation with EndoButton for tibial eminence fractures visualised through a proximal superomedial portal: a surgical technique.

Most tibial eminence fractures are avulsion fractures of the anterior cruciate ligament (ACL) from its tibial insertion. This study describes a new arthroscopic technique using an additional proximal superomedial portal to visualise the tibial eminence fracture and to fix the fracture with the EndoButton to avoid the risk of fragment breakage. The proximal superomedial portal enables fracture reduction without damage to the intermeniscal ligament. Fixation with the EndoButton is strong enough to allow early rehabilitation with vigorous exercise. All 5 patients achieved bone union; no young patient had growth disturbance of the tibia; all knees were stable with excellent range of motion and negative Lachman and pivot shift tests and no flexion contracture. Arthroscopic fixation with the EndoButton visualised through the proximal superomedial portal is a safe, simple, and secure method for treating tibial eminence fractures, particularly in children with small fragments.

Magnetic resonance imaging and short-term clinical results of severe frozen shoulder treated with manipulation under ultrasound-guided cervical nerve root block.

BACKGROUND: We evaluated the magnetic resonance (MR) imaging findings and short-term clinical outcomes of severe idiopathic frozen shoulder treated with manipulation under ultrasound-guided cervical nerve root block (MUC). METHODS: The subjects were 30 patients (average age, 55.2 years; 12 men, 18 women) with severe frozen shoulder. Severe idiopathic frozen shoulder was defined as follows: a range of motion (ROM) of ≤ 100° in forward flexion, ≤ 10° in external rotation, and at or below the fifth lumbar vertebral level in internal rotation. Before the manipulation, all patients had continued global ROM loss for at least 6 months. Before and after manipulation, they underwent MR imaging. MR images and clinical results were evaluated 1 month after the procedure. RESULTS: In terms of the capsule tear pattern, MR imaging showed 14 midsubstance tears and 15 humeral avulsions of glenohumeral ligament-like lesions. An anterior labrum tear occurred in 4 shoulders, whereas 15 shoulders showed a bone bruise in the posterosuperior and anteromedial portions of the humeral head despite no humeral shaft fracture. There were significant improvements in the ROM, Constant-Murley score, American Shoulder and Elbow Surgeons score, and Numeric Rating Scale score from before treatment to 1 month after the procedure. CONCLUSION: MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head. Approximately 50% of patients are likely to experience bone bruising after MUC. Long-term follow-up of these patients should be performed carefully.

[Usefulness of POCUS in Orthopedic and Trauma Fields].

Recently, musculoskeletal ultrasonography has been becoming more common for diagnosis and treatment by ultrasound-guided intervention in the field of orthopedics. Because musculoskeletal ultrasound technology has rapidly advanced in recent years, and has many advantages, including no exposure to radiation, non-invasive, wide availability, cost-effectiveness, and the ability to be used in real-time in the general outpatient clinic. Traditional radiography was not able to detect soft tissue injury, but musculoskeletal ultrasonography enables the diagnosis of not only musculoskeletal disorders including soft tissue injury, but also fractures by dynamic examination. The first choice of diagnostic imaging should begin to shift to musculoskeletal ultra-sound from traditional radiography.

Ultrastructural change of ligamentum flavum in galactosialidosis.

PURPOSE: Galactosialidosis is an autosomal recessive lysosomal storage disease caused by deficiency of both α-neuraminidase and ß-galactosidase due to a defect of the protective protein/cathepsin A. Three clinical subtypes have been described, depending on the age of onset and severity of the symptoms: the early infantile, late infantile and juvenile/adult form. We report an adult-type patient who underwent surgery for galactosialidosis-related spinal deformity, and showed a favorable course thereafter. METHODS: The patient was a 50-year-old male, and he consulted our hospital with pain of the bilateral anterior thigh. Lumbar radiograph showed applanation and horn-like deformity of the L2 vertebral body, which is characteristic of this disease, narrowing of the L1/2 intervertebral space, and topical kyphosis. Fenestration between the L1/2, decompression of the L2 nerve root, and posterolateral fusion involving the T12 to L3 were performed. RESULTS: Immediately after surgery, pain of the lower limbs disappeared. During the 2-year postoperative follow-up, bone assimilation was achieved, showing a favorable course. Histological examination of the ligamentum flavum (LF) collected during surgery showed that the elastic fibers were thin, whereas the collagen fibers were abundant and dense. The ligament cells were swollen, and there were a large number of vacuoles in the cytoplasm. CONCLUSION: This is the first report on spinal surgery for adult-type galactosialidosis and histological examination of spinal LF.

Upside-down gliding of Lymnaea.

The pond snail Lymnaea stagnalis can often be observed moving upside down on its back just below the surface of the water. We have termed this form of movement "upside-down gliding." To elucidate the mechanism of this locomotion, we performed a series of experiments involving behavioral analyses and microscopic observations. These experiments were designed (1) to measure the speed of this locomotion; (2) to determine whether the mucus secreted from the foot of Lymnaea repels water, thereby allowing the snail to exploit the surface tension of the water for upside-down gliding; and (3) to observe the beating of foot cilia in this behavior. The beating of these cilia is thought to be the primary driving force for upside-down gliding. Our results demonstrate that upside-down gliding is an efficient active process involving the secretion of mucus that floats up to the water surface to serve as a substrate upon which cilia beat to cause locomotion at the underside of the water surface.