A Surgical Case of Partially Unroofed Coronary Sinus Atrial Septal Defect in an Elderly Patient Diagnosed by Preoperative Contrast-Enhanced Computed Tomography.

Unroofed coronary sinus syndrome is a rare congenital cardiac anomaly, involving some anatomical variations. Approximately 60% of patients with unroofed coronary sinus syndrome have a concomitant atrial septal defect, which is termed unroofed coronary sinus atrial septal defect (CSASD). The precise detection of these abnormalities has been usually difficult with conventional echocardiography, mostly due to its small and complex structures. Herein, we report a case with unroofed coronary sinus atrial septal defect, in which preoperative contrast-enhanced computed tomography (CT) was useful in the operative decision making. We successfully repaired the defective roof of the coronary sinus with a bovine patch, while eliminating the inter-atrial shunt. The patient's postoperative course was uneventful with no residual shunt.

Association between intraoperative findings and postoperative knee range motion after cruciate-retaining total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) alleviates pain and improves daily living activities in individuals with end-stage osteoarthritis of the knee. However, up to 20% of patients have sub-optimal outcomes after TKA. OBJECTIVE: No studies have clarified the intraoperative factors that affect postoperative range of motion (ROM) after cruciate-retaining (CR) TKA. Thus, this study aims to clarify these factors. METHODS: Patients with knee osteoarthritis with varus knee deformity who underwent CR-TKA between May 2019 and December 2020 were included in this study. One year after surgery, patients were stratified into two groups based on knee flexion: Group F (over 120∘) and Group NF (below 120∘). Patient backgrounds including age, body mass index, hip knee angle, preoperative range of motion for both extension and flexion, intraoperative center joint-gap measurements of 0∘, 30∘, 45∘, 60∘, 90∘, and 120∘ of knee flexion using a tensor, intraoperative anterior-posterior (AP) laxity measurements of 30∘ and 90∘ of knee flexion using an instrumental laximeter were compared between the groups. Univariate analyses between the groups were used to construct the initial model. The receiver operating characteristic curve was also analyzed. The predictive variables included in the final model were selected by stepwise backward elimination. RESULTS: Intraoperative AP laxity with 30∘ of knee flexion smaller than 10.8 mm was a significant positive prognostic factor (OR: 1.39, 95% CI: 1.08-1.79, P= 0.011) of postoperative ROM over 120∘ of knee flexion one year after surgery. The sensitivity, specificity, PPV, and NPV were 70.9%, 82.4%, 92.9%, and 46.7%, respectively. CONCLUSION: Intraoperative AP laxity smaller than 10.8 mm was a significant positive predictive factor for obtaining knee flexion greater than 120∘ one year after surgery when using CR-TKA and its PPV was high up to 92.9%.

Clinical outcomes and cost-effectiveness of manipulation under brachial plexus block versus physiotherapy for refractory frozen shoulder: a prospective observational study.

Background: Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS. Methods: This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio. Results: Visual analog scale (P < .001), range of motion (P < .001), and American Shoulder and Elbow Surgeons and Constant Scores (P < .001) in the MUB group were significantly superior to those in the PT group at 1, 3, 6, and 12 months after treatment. The median cost and total quality-adjusted life year in the MUB and PT groups were $1375 versus $2751 and 2.95 versus 2.68, respectively, and the cost-effectiveness ratio between the MUB and PT groups was calculated as -$560. Conclusions: The new MUB procedure provides a shorter treatment period, better clinical outcomes, and higher cost-effectiveness in patients with refractory FS compared to PT.

Transoral traumatic perforation of the pyriform sinus by a marker pen: report of an infant case.

BACKGROUND: Perforation of the pyriform sinus, included in hypopharyngeal injury, is a rare condition typically caused by iatrogenic factors. We present a case of an infant who developed deep cervical and mediastinal abscesses due to a traumatic pyriform sinus perforation caused by accidentally falling with a marker pen in the mouth. CASE PRESENTATION: An 11-month-old healthy male infant fell on a trampoline with a marker pen in his mouth. The patient developed swelling in the neck 3 h after the incident and was taken to a regional general hospital. Although a laryngoscopy showed no perforation in the oral cavity or posterior pharynx, a computed tomography (CT) scan revealed significant emphysema extending from the cervix to the mediastinum. The patient was transferred to our tertiary hospital and admitted to the intensive care unit, where he was mechanically ventilated, and antibiotic therapy was initiated. On day 3 of admission, a CT scan revealed deep abscesses in the cervical and upper posterior mediastinum with pneumomediastinum. Although his respiratory status stabilized and he was temporarily weaned, the fever recurred. Pharyngoesopagography revealed significant leakage of contrast from the left pyriform sinus to the mediastinum. Consequently, surgical drainage of the abscess was performed on day 10. Two low-pressure continuous suction drains were placed, one in the posterior mediastinum and the other close to the pyriform sinus. Pharyngoesophagography on postoperative day (POD) 7 demonstrated decreased contrast leakage into the posterior mediastinum. The patient was initiated on enteral nutrition through a nasogastric tube. The patient was discharged on POD 31 after the suction drains were replaced with open Penrose drains, and enteral nutrition via nasogastric tube was continued at home. The Penrose drains were removed on POD 54, and salivary leakage ceased on POD 111. CONCLUSIONS: Although injuries to the oral cavity and posterior pharynx are more easily recognized, the existence of injury in the pyriform sinus can be challenging to evaluate. However, prompt and appropriate management, including intubation, antibiotic therapy, surgical drainage, and nutritional support, is critical in preventing life-threatening complications.

Morphological and histological evaluation of the tendon-bone junction in porcine shoulders to create a rotator cuff tear and repair model.

BACKGROUND: This study aimed to morphologically and histologically examine whether pig is useful as models for rotator cuff tear (RCT). METHODS: The morphology of the scapula and humerus bones was evaluated by taking X-ray and three-dimensional computed tomography (3D CT) scans of the right shoulders of five female pigs (age: 4 months). The rotator cuff (RC) footprint at the humeral insertion of these was observed and its shape was measured. Next, they underwent general anesthesia and an acute rotator cuff tear/rotator cuff repair (RCT/RCR) model was created using a deltoid split approach. Four weeks after surgery, the animals were euthanized, the shoulder joints were harvested, and the repaired RC was evaluated by hematoxylin and eosin staining and toluidine blue staining. RESULTS: The scapula of the pig had a vestigial acromion, in contrast to that in humans. The supraspinatus and infraspinatus tendons were connected so as to overlap each other and attached to the postero-superior part of the greater tuberosity. These tendons were located extra-articularly, separate from the joint capsule. The average antero-posterior length of the foot print was 17.4 ± 0.7 mm on the medial margin and 19.1 ± 2.2 mm on the lateral margin. The maximum medial-to-lateral width of it was 5.1 ± 0.5 mm. In all RCT/RCR models at 4 weeks after surgery, the repaired RC compound tendon was visually confirmed to be continuous with the footprint. Histologically, it was confirmed that regeneration of the four-layer structure of the bone-tendon junction had occurred. CONCLUSION: Porcine supraspinatus and infraspinatus attachment to the greater tuberosity have a structure similar to that of sheep and dogs, which is advantageous for creating the RCT/RCR model. It might be used for future in vivo studies of shoulder joint diseases. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Pigs could potentially serve as a viable model for rotator cuff tears.

Relationship between pain and range of motion in frozen shoulder.

Background: A frozen shoulder (FS) is characterized by pain and limited range of motion (ROM). Although physical assessment of ROM is important for diagnosing and staging FS, ROM cannot be accurately assessed in clinical practice because of pain and muscle contraction. This study aimed to measure changes in shoulder joint ROM before and after anesthesia (ΔROM) in patients with FS and investigate the factors affecting these changes. Methods: This study included 54 patients (age, 55.6 ± 9.4 years; 17 males; disease duration, 6.6 ± 3.4 months) with FS before manipulation under transmission anesthesia. FS was defined as having a ROM in external rotation (ER) that was less than 50% of that in the unaffected shoulder. Pain at night and during motion was assessed using a numerical rating scale. Before anesthesia, the passive ROM of forward flexion (FF), abduction (AD), and ER were measured in the supine position. After confirming that the anesthesia was effective, passive ROM was measured again. Results: The ROM in the FF, AD, and ER after anesthesia was significantly higher than that before anesthesia (P < .001). ΔROM in the FF, AD, and ER was significantly correlated with pain at night (r = 0.51, P < .001; r = 0.45, P < .001; and r = 0.39, P = .004, respectively). Furthermore, ΔROM in the ER was significantly correlated with pain during motion (r = 0.31, P = .023) and disease duration (r = -0.31, P = .021). Conclusion: The ROM of the FS is susceptible to pain and muscle contraction. Interventions, such as physical therapy, may be recommended after pain relief.

Effects of evocalcet on parathyroid calcium-sensing receptor and vitamin D receptor expression in uremic rats.

Little is known about the effect of the recently developed calcimimetic evocalcet (Evo) on parathyroid calcium-sensing receptor (CaSR) and vitamin D receptor (VDR) expression. We examined the effects of Evo and cinacalcet (Cina) on CaSR and VDR expression in 5/6 nephrectomized Sprague-Dawley rats fed a high-phosphorus diet for 4 weeks to develop secondary hyperparathyroidism (SHPT). These uremic rats were divided into 4 groups-baseline control (Nx4W) and groups with additional treatment with either the Vehicle, Evo, or Cina for 2 weeks; normal rats were used as normal controls (NC). Blood parameters and parathyroid tissue were analyzed. CaSR and VDR expression levels were determined using immunohistochemistry. The degree of kidney injury and hyperphosphatemia was similar in the uremic groups (Nx4W, Vehicle, Cina, and Evo). Serum parathyroid hormone levels were significantly higher in the Nx4W and Vehicle groups than in the NC group. This increase was significantly suppressed in the Cina and Evo groups compared with that in the Vehicle group. Serum calcium levels were significantly and equally lower in the Cina and Evo groups relative to those in the Vehicle group. CaSR expression was significantly lower in the Nx4W and Vehicle groups than in the NC group. This downregulation was of an equally lesser magnitude in the Cina and Evo groups. A similar trend was observed for VDR expression. These results indicate that Evo and Cina treatment can increase parathyroid CaSR and VDR expression in uremic rats with SHPT, which could provide better control of mineral and bone disorder markers.

Fibroblast Growth Factor 23 Exacerbates Cardiac Fibrosis in Deoxycorticosterone Acetate-Salt Mice With Hypertension.

Fibroblast growth factor 23 (FGF23) is associated with cardiovascular disease in patients with chronic kidney disease; however, the mechanisms underlying the effect of FGF23 on cardiac function remain to be investigated. Herein, we studied the effect of continuous intravenous (CIV) FGF23 loading in a deoxycorticosterone acetate (DOCA)-salt mouse model with mild chronic kidney disease and hypertension as well as heart failure with a preserved ejection fraction. Wild-type male mice were randomly allocated to 4 groups: normal control, vehicle-treated DOCA-salt mice, FGF23-treated DOCA-salt mice, and FGF23- and calcitriol-treated DOCA-salt mice. The DOCA-salt mice received the agents via the CIV route for 10 days using an infusion minipump. DOCA-salt mice that received FGF23 showed a marked increase in the serum FGF23 level, and echocardiography in these mice revealed heart failure with a preserved ejection fraction. These mice also showed exacerbation of myocardial fibrosis, concomitant with an inverse and significant correlation with Cyp27b1 expression. Calcitriol treatment attenuated FGF23-induced cardiac fibrosis and improved diastolic function via inhibition of transforming growth factor-ß signaling. This effect was independent of the systemic and local levels of FGF23. These results suggest that CIV FGF23 loading exacerbates cardiac fibrosis and that locally abnormal vitamin D metabolism is involved in this mechanism. Calcitriol attenuates this exacerbation by mediating transforming growth factor-ß signaling independently of the FGF23 levels.

Changes of biomarkers for erythropoiesis, iron metabolism, and FGF23 by supplementation with roxadustat in patients on hemodialysis.

This study aimed to confirm changes in biomarkers of erythropoiesis and iron metabolism and serum fibroblast growth factor 23 (FGF-23) during darbepoetin-α treatment and then switching to the hypoxia-inducible factor prolyl hydroxylase inhibitor roxadustat. A total of 28 patients on hemodialysis who received weekly doses of darbepoetin-α were switched to roxadustat. Biomarkers for erythropoiesis and iron metabolism and intact and C-terminal FGF-23 were measured in blood samples collected before the HD session on days - 7 (darbepoetin-α injection), - 4, and - 2, and days 0 (switch to roxadustat treatment, three times weekly), 3, 5, 7, 14, 21, and 28. Erythropoietin and erythroferrone levels were elevated on day - 4 by darbepoetin-α injection and decreased to baseline levels at day 0. Levels of erythropoietin were not significantly increased by roxadustat supplementation, but erythroferrone levels were continuously elevated, similar to darbepoetin-α treatment. Hepcidin-25 and total iron binding capacity were significantly decreased or increased in patients treated with roxadustat compared with darbepoetin-α. Changes of intact and C-terminal FGF-23 levels were parallel to changes of phosphate levels during roxadustat treatment. However, the actual and percentage changes of intact FGF-23 and C-terminal FGF-23 in patients with low ferritin levels were greater than those in patients with high ferritin levels. Roxadustat might stimulate erythropoiesis by increasing iron usage through hepcidin-25, which was suppressed by erythroferrone in the physiological erythropoietin condition. Changes of intact FGF-23 and C-terminal FGF-23 levels might be affected by roxadustat in patients on hemodialysis, especially those with a low-iron condition.

Evaluation of muscle stiffness in adhesive capsulitis with Myoton PRO.

Background: Adhesive capsulitis (AC) is characterized by pain and limited range of motion, caused by stiffness of the joint capsule and coracohumeral ligament. On the other hand, there have been few reports on muscle stiffness in AC. The purpose of this study was to assess muscle stiffness in patients of AC with a portable and noninvasive device, Myoton PRO. We hypothesized that muscle stiffness around shoulder joint increases in AC. Methods: At first, we surveyed correlation between Myoton PRO and shear wave elastography with phantoms. Second, reproducibility and repeatability of healthy volunteers with Myoton PRO were evaluated. Finally, muscle stiffness was measured in 40 patients who were diagnosed with AC. Muscle stiffness was quantitatively measured with Myoton PRO. We compared the stiffness of the anterior deltoid (AD), pectoralis major, and latissimus dorsi (LD) in AC patients on both the affected and nonaffected sides. Results: Correlation coefficient in shear wave elastography and Myoton PRO was 0.99(P = .001). Reliability of intraoperator and interoperator with Myoton PRO was 0.9 or higher. Muscle stiffness values (N/m) of the AD, pectoralis major, and LD were 355 ± 61, 252 ± 54, 207 ± 51 in the affected sides and 328 ± 50, 252 ± 41, 186 ± 37 in the nonaffected sides, and the differences were significant in the AD and LD (P = .005, P = .002, respectively). Conclusions: We used Myoton PRO to evaluate muscle stiffness in AC. The AD and LD muscles of AC patients were significantly stiffer on the affected side compared to the nonaffected side.

Aortic Valve Reconstruction With Autologous Pericardium Versus a Bioprosthesis: The Ozaki Procedure in Perspective.

Background We assessed the Ozaki procedure, aortic valve reconstruction using autologous pericardium, with respect to its learning curve, hemodynamic performance, and durability compared with a stented bioprosthesis. Methods and Results From January 2007 to January 2016, 776 patients underwent an Ozaki procedure at Toho University Ohashi Medical Center. Learning curves, aortic regurgitation (AR), and peak gradient, assessed by serial echocardiograms, valve rereplacement, and survival were investigated. Valve performance and durability were compared with 627 1:1 propensity-matched patients receiving stented bovine pericardial valves implanted from 1982 to 2011 at Cleveland Clinic. Learning curves were observed for aortic clamp and cardiopulmonary bypass times, AR prevalence, and early mortality. Decreased aortic clamp time was observed over the first 300 cases. New surgeons performing parts of the procedure after case 400 resulted in a slight increase in aortic clamp and cardiopulmonary bypass times. Among matched patients, the Ozaki cohort had more AR than the PERIMOUNT cohort (severe AR at 1 and 6 years, 0.58% and 3.6% versus 0.45% and 1.0%, respectively; P[trend]=0.006), although with a steep learning curve. Peak gradient showed the opposite trend: 14 and 17 mm Hg for Ozaki and 24 and 28 mm Hg for PERIMOUNT at these times (P[trend]<0.001). Freedom from rereplacement was similar (P=0.491). Survival of the Ozaki cohort was 85% at 6 years. Conclusions Patients undergoing the Ozaki procedure had lower gradients but more recurrent AR than those receiving PERIMOUNT bioprostheses. Although recurrent AR is concerning, results confirm low risk and good midterm performance of the Ozaki procedure, supporting its continued use.

Younger age is a significant factor for poorer adherence in fracture patients who received low-intensity pulsed ultrasound: A retrospective study.

BACKGROUND: The factors for poor adherence to therapy in patients with postoperative fracture who are treated with low-intensity pulsed ultrasound remain unknown. Therefore, we designed a retrospective cohort study to determine the various factors for poorer adherence to therapy in patients with postoperative fracture who were treated with low-intensity pulsed ultrasound therapy. METHODS: We retrospectively analyzed the data of postoperative patients who underwent low-intensity pulsed ultrasound after fracture surgery from January 2010 to May 2019. The patients were categorized into two groups as follows: group G, including those with a good adherence rate (>72%), and group P, including those with a poor adherence rate (<72%). Factors, such as age, sex, how the rental cost of low-intensity pulsed ultrasound was paid (by the patients themselves or by the insurance company), living (alone or with someone), insurance claim item (fractures within 3 weeks after osteosynthesis or delayed or non-union fractures), low-intensity pulsed ultrasound device-type (earlier- or next-generation), duration of low-intensity pulsed ultrasound use, fracture site (upper or lower limb), frequency of hospital visits (regular or irregular), and employment status (employed/unemployed) were compared between groups G and P. RESULTS: In total, 96 patients (74 and 22 patients in groups G and P, respectively) who underwent low-intensity pulsed ultrasound were included in the study. Univariate analysis revealed that younger patients (P < 0.001) and patients who did not regularly visit the hospital (P = 0.024) were more likely to have poorer adherence to therapy. Multiple logistic regression analysis revealed that age was the only independent, pertinent factor for poorer adherence to therapy (odds ratio, 8.570; 95% confidence interval, 2.770-26.50; P < 0.001), with a cutoff value of 41 years. CONCLUSIONS: Younger age is a significant factor for poorer adherence in patients undergoing low-intensity pulsed ultrasound therapy.

Efficacy of fracture stem in reverse shoulder arthroplasty for 3- or 4-part proximal humerus fractures.

BACKGROUND: This study compared the clinical results of fracture stems and conventional stems using the same glenoid component in reverse shoulder arthroplasty for proximal humerus fractures in the elderly. METHODS: This retrospective study included 35 patients who underwent Grammont-type reverse shoulder arthroplasty for proximal humerus fractures from 2014 to 2020. The average age at surgery was 79.2 (range, 65-92) years, with 33 female shoulders. Fracture types per Neer classification were 3-part fracture, 4-part fracture, in 13 and 22 shoulders, respectively. The final follow-up period was 35 (range, 24-81) months. The Constant score, American Shoulder and Elbow Surgeons score, shoulder range of motion, and healing of greater tuberosities at the final follow-up of AEQUALIS™ REVERSED (Conventional stem group: n = 15) and AEQUALIS™ REVERSED FX (Fractured stem group: n = 20) were retrospectively investigated. RESULTS: There were no statistically significant differences in age at surgery, sex, body mass index, fracture type, waiting time from injury to surgery, or preoperative general condition between the groups. The Constant and American Shoulder and Elbow Surgeons scores of the fractured stem group were significantly higher than those of the conventional stem group (P = 0.038 and P = 0.023, respectively). The anterior elevation and external rotation at the side of the fractured stem group also showed significantly higher values than those of the conventional stem group (fractured stem group vs. conventional stem group: anterior elevation 127° ± 25° vs. 105° ± 35°, P = 0.041; external rotation 28° ± 13° vs. 13° ± 12°, P = 0.015). The greater tuberosity healing rate was 46.7% (7/15) in the conventional stem group and 85.0% (17/20) in the fractured stem group (P＝0.027). CONCLUSIONS: The findings suggest that use of a fracture-specific stem rather than a conventional stem in Grammont-type reverse shoulder arthroplasty for proximal humerus fractures improves tuberosity healing, postoperative range of motion, and clinical scores.

Honeycomb-Layered Oxides With Silver Atom Bilayers and Emergence of Non-Abelian SU(2) Interactions.

Honeycomb-layered oxides with monovalent or divalent, monolayered cationic lattices generally exhibit myriad crystalline features encompassing rich electrochemistry, geometries, and disorders, which particularly places them as attractive material candidates for next-generation energy storage applications. Herein, global honeycomb-layered oxide compositions, Ag2 M2 TeO6 ( M = Ni , Mg , etc $M = \rm Ni, Mg, etc$ .) exhibiting Ag $\rm Ag$ atom bilayers with sub-valent states within Ag-rich crystalline domains of Ag6 M2 TeO6 and Ag $\rm Ag$ -deficient domains of Ag 2 - x Ni 2 TeO 6 ${\rm Ag}_{2 - x}\rm Ni_2TeO_6$ ( 0 < x < 2 $0 < x < 2$ ). The Ag $\rm Ag$ -rich material characterized by aberration-corrected transmission electron microscopy reveals local atomic structural disorders characterized by aperiodic stacking and incoherency in the bilayer arrangement of Ag $\rm Ag$ atoms. Meanwhile, the global material not only displays high ionic conductivity but also manifests oxygen-hole electrochemistry during silver-ion extraction. Within the Ag $\rm Ag$ -rich domains, the bilayered structure, argentophilic interactions therein and the expected Ag $\rm Ag$ sub-valent states ( 1 / 2 + , 2 / 3 + $1/2+, 2/3+$ , etc.) are theoretically understood via spontaneous symmetry breaking of SU(2)× U(1) gauge symmetry interactions amongst 3 degenerate mass-less chiral fermion states, justified by electron occupancy of silver 4 d z 2 $4d_{z^2}$ and 5s orbitals on a bifurcated honeycomb lattice. This implies that bilayered frameworks have research applications that go beyond the confines of energy storage.

One-Year Romosozumab Treatment Followed by One-Year Denosumab Treatment for Osteoporosis in Patients on Hemodialysis: An Observational Study.

There is limited evidence on the use of romosozumab (ROMO) in the treatment of osteoporosis in patients on hemodialysis (HD); thus, we aimed to investigate this topic. This prospective, observational, single-center cohort study included 13 prior osteoporosis treatment-naïve patients on HD with osteoporosis. They first received ROMO once monthly for 12 months (210 mg; subcutaneously once every month). Thereafter, they received denosumab (DENO) for an additional 12 months (60 mg; subcutaneously once every 6 months). We examined the incidence of new fractures; treatment safety; and temporal changes in the bone mineral density (BMD), bone metabolism markers, and vascular calcification. No new cases of fractures were noted. The median one-year percentage changes (from the baseline) in the BMDs at the lumbar spine (LS), total hip (TH), and femoral neck (FN) were + 9.0%, + 2.5%, and + 4.7%, respectively. These changes were maintained for 24 months. The corresponding relative changes from the baseline to 24 months thereafter were + 14.9%, + 5.4%, and + 6.5%, respectively. The percentage changes in TH BMD and FN BMD were negatively correlated with baseline BMD. Coronary artery and thoracic aorta calcification scores increased slightly from baseline to 12 months thereafter. However, fatal events (cardiovascular disease-associated and all-cause deaths) did not occur during ROMO treatment. Effectiveness of ROMO was better in patients who had severe osteoporosis with low TH BMD, low FN BMD, and high tartrate-resistant acid phosphatase 5b level at ROMO initiation.

Giant pulmonary bulla causing respiratory compromise in a very low-birthweight infant.

Acquired cystic lung disease in premature infants is a serious respiratory complication, and pulmonary interstitial emphysema (PIE) has been widely reported. We report a rare case of giant pulmonary bulla in an infant treated with bullectomy where chest computed tomography was useful in directing treatment.

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.

Can tibia-first total knee arthroplasty using computer-assisted system improve anterior and posterior knee stability?

BACKGROUND: Total knee arthroplasty (TKA) is a widely performed procedure to alleviate pain and restore function of patients with end-stage knee osteoarthritis. OBJECTIVE: The study aim was to determine if tibia-first (TF) total knee arthroplasty (TKA) using a novel computer-assisted surgery (CAS) system can yield better anterior and posterior (AP) knee stability. METHODS: Patients with knee osteoarthritis with obvious varus knee who met the indication for and underwent TKA from May 2019 to November 2020 were included. Forty-one measured resection (MR)-TKAs and 32 TF-TKAs were compared. The varus-valgus ligament balance and joint tension at a joint center-gap setting equal to the tibial-baseplate thickness were measured, and appropriate polyethylene inserts with 0∘, 30∘, 45∘, 60∘, 90∘, and 120∘ of knee flexion were placed. A Kneelax 3 arthrometer was used to measure knee AP laxity in the postoperative anesthetized patients with 30∘ and 90∘ of knee flexion. RESULTS: The horizontal gap balance was significantly closer in the TF-TKA group than the MR-TKA group for 0∘, 30∘, 45∘, and 60∘ of knee flexion. In contrast, no significant differences were observed for 90∘ and 120∘ of knee flexion. No significant differences in joint-gap tensions among all knee-flexion angles were observed. Translation was significantly smaller in the TF-TKA group than the MR-TKA group for AP laxity with 30∘ of knee flexion (8.8 ± 2.9 mm vs. 10.7 ± 3.1 mm, P= 0.0079). In contrast, no significant AP laxity was observed with 90∘ of knee flexion (7.2 ± 2.8 mm vs. 7.2 ± 3.5 mm). CONCLUSION: TF-TKA using a novel CAS system provided better AP knee stability with close to horizontal gap balances.

Evaluation of Tibial Tunnel Location with the Femoral Tunnel Created Behind the Resident's Ridge in Transtibial Anterior Cruciate Ligament Reconstruction.

Few studies have determined whether a femoral bone tunnel could be created behind the resident's ridge by using a transtibial (TT) technique-single bundle (SB)-anterior cruciate ligament (ACL) reconstruction. The aim of this study was to clarify (1) whether it is possible to create a femoral bone tunnel behind the resident's ridge by using the TT technique with SB ACL reconstruction, (2) to define the mean tibial and femoral tunnel angles during anatomic SB ACL reconstruction, and (3) to clarify the tibial tunnel inlet location when the femoral tunnel is created behind resident's ridge. Arthroscopic TT-SB ACL reconstruction was performed on 36 patients with ACL injuries. The point where 2.4-mm guide pin was inserted was confirmed, via anteromedial portal, to consider a location behind the resident's ridge. Then, an 8-mm diameter femoral tunnel with a 4.5-mm socket was created. Tunnel positions were evaluated by using three-dimensional computed tomography (3D-CT) 1 week postoperatively. Quadrant method and the resident's ridge on 3D-CT were evaluated to determine whether femoral tunnel position was anatomical. Radiological evaluations of tunnel positions yielded mean ( ± standard deviation) X- and Y-axis values for the tunnel centers: femoral tunnel, 25.2% ± 5.1% and 41.6% ± 10.2%; tibial tunnel, 49.2% ± 3.5%, and 31.5% ± 7.7%. The bone tunnels were anatomically positioned in all cases. The femoral tunnel angle relative to femoral axis was 29.4 ± 5.5 degrees in the coronal view and 43.5 ± 8.0 degrees in the sagittal view. The tibial tunnel angle relative to tibial axis was 25.5 ± 5.3 degrees in the coronal view and 52.3 ± 4.6 degrees in the sagittal view. The created tibial bone tunnel inlet had an average distance of 13.4 ± 2.7 mm from the medial tibial joint line and 9.7 ± 1.7 mm medial from the axis of the tibia. Femoral bone tunnel could be created behind the resident's ridge with TT-SB ACL reconstruction. The tibial bone tunnel inlet averaged 13.4 mm from the medial tibial joint line and 9.7 mm medial from the tibia axis.