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.

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.

Satisfaction With Elbow Function and Return Status After Autologous Osteochondral Transplant for Capitellar Osteochondritis Dissecans in High School Baseball Players.

BACKGROUND: Osteochondral autograft transplant (OAT), a surgical treatment for capitellar osteochondritis dissecans (OCD), has favorable rates of elbow recovery and return to sports in adolescents. However, few reports have investigated how long patients continue to play baseball after OAT and their satisfaction with their treatment outcome. PURPOSE: To evaluate the rate of boys who played baseball and received OAT for OCD in junior high school or earlier (age <15 years) and continued to play baseball in high school and the players' satisfaction with their elbow function during play. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 32 elbows of boys who played baseball and received OAT at age ≤15 years (mean, 14.1 years) were examined and divided into pitcher (n = 11) and nonpitcher (n = 21) groups according to their player position before surgery. The clinical Timmerman-Andrews score at the end of their high school baseball, participation percentage of players who continued to play baseball, and satisfaction level during play (on a scale of 0-10 during pitching and batting and in a 4-choice format) were compared between the 2 groups. RESULTS: The Timmerman-Andrews scores significantly improved after surgery in both groups, with no significant difference between the groups. Of the 32 players, 30 (93.8%) continued to play baseball throughout high school, including all players in the pitcher group and 19 (90.5%) of those in the nonpitcher group. The percentage of players who continued to pitch was 55.6% (6/11) in the pitcher group. Satisfaction with elbow joint function at the time of pitching was significantly lower in the pitcher group. Further, 5 players reported being "a little unsatisfied" because of elbow pain during pitching. All of the players indicated satisfaction with elbow function during batting. CONCLUSION: The percentage of players who received OAT for OCD in junior high school and continued to play baseball in high school was favorable. However, satisfaction with elbow function during throwing was lower in pitchers than in nonpitchers. CLINICAL RELEVANCE: Before surgery, consent should be obtained from patients who are pitchers after it is explained that satisfaction with elbow joint function during pitching could be decreased after OAT.

Pathologic Fractures Extended to the Metacarpal Head Related with Enchondromas at the Metacarpal Neck.

We present two cases of pathologic fractures extended to the metacarpal head related with enchondromas at the metacarpal neck treated by surgery. The timing of surgery varied between the two cases. The first was operated without delay, using tumor curettage and ß-TCP (tricalcium phosphate) packing in the cavity, followed by internal fixation of the fracture using a screw and Kirshner wires. In the second case, tumor curettage and ß-TCP packing was performed after fracture union. Favorable clinical outcomes were obtained for both cases.

Synovial Osteochondromatosis at the Carpometacarpal Joint of the Thumb.

Synovial osteochondromatosis (SOC) is a benign tumor characterized by synovial connective tissue metaplasia. SOC commonly affects major joints including the knee followed by the hip, elbow, and wrist. SOC cases in the hand are not reported as often as SOC of major joints. Particularly SOC of the carpometacarpal joint of the thumb is rare. We report on a 57-year-old female with primary SOC of the carpometacarpal joint of her left thumb. Surgical excision was performed and the patient had no symptoms with full range of motion of her left thumb. At 3 years of follow-up, there was no recurrence.

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.

Scanning and transmission electron microscopic observation of femoral head feeding vessels in stroke-prone spontaneously hypertensive rats.

Stroke-prone spontaneously hypertensive rats (SHRSP) are known to show necrosis of the femoral head with a frequency of about 50%. This rat has thus been used as an animal model for necrosis of the femoral head in many studies. In a detailed investigation of feeding vessel disorders that cause femoral head necrosis, we observed changes over time in the feeding vessels using scanning electron microscopy and transmission electron microscopy. In scanning electron microscopy of vascular casts, abnormal findings in feeding vessels of SHRSP with aging from the immature stage included contortion and bending in the lumen with overall narrowing. Under transmission electron microscopy, decreased numbers of smooth muscle cells and increased amounts of collagen fibers were marked, and these changes with hypertrophy of vascular walls might be similar to those of arteriolosclerosis. The structural changes first revealed by transmission electron microscopic observation might cause the friability of the feeding vessels so that contortion and bending occurred, suggesting transient obstruction of blood flow to the femoral head and subsequent induction of femoral head necrosis. These findings should help in understanding the causes of femoral head necrosis in humans, including Perthes' disease.

Early exercise in spinal cord injured rats induces allodynia through TrkB signaling.

Rehabilitation is important for the functional recovery of patients with spinal cord injury. However, neurological events associated with rehabilitation remain unclear. Herein, we investigated neuronal regeneration and exercise following spinal cord injury, and found that assisted stepping exercise of spinal cord injured rats in the inflammatory phase causes allodynia. Sprague-Dawley rats with thoracic spinal cord contusion injury were subjected to assisted stepping exercise 7 days following injury. Exercise promoted microscopic recovery of corticospinal tract neurons, but the paw withdrawal threshold decreased and C-fibers had aberrantly sprouted, suggesting a potential cause of the allodynia. Tropomyosin-related kinase B (TrkB) receptor for brain-derived neurotrophic factor (BDNF) was expressed on aberrantly sprouted C-fibers. Blocking of BDNF-TrkB signaling markedly suppressed aberrant sprouting and decreased the paw withdrawal threshold. Thus, early rehabilitation for spinal cord injury may cause allodynia with aberrant sprouting of C-fibers through BDNF-TrkB signaling.

An ultrastructural study on the ligamentum flavum of the cervical spine in patients with ossification of the posterior longitudinal ligament.

Some histological analyses of the ossification of the posterior longitudinal ligament (OPLL) have been reported, but no ultrastructural studies of the ligamentum flavum (LF) in patients with OPLL have been published to date. To understand the pathology of the ossification of the spinal ligament, we examined, by electron microscopy, ultrastructural changes in the LF in cases of OPLL and made a comparison with the LF in cervical spondylotic myelopathy (CSM). Subjects were three men and two women with cervical OPLL who underwent longitudinal spinous process-splitting laminoplasty. During surgery, a small piece of the LF was collected from C2-C3 to C7-T1 and was then analyzed by light and electron microscopy. We observed atrophic elastic bundles with a two-layer structure and disarrangement, a partially torn area, the disappearance of microfibrils, and an enlarged interstitium with an irregular alignment of collagen fibrils. We observed some properties of a cell preceding its death: the initial phase may be the disappearance of the plasma-membrane, followed by the scattering of many organellae around its degenerated nucleus. Finally, many extracellular plasma membrane-invested particles that resemble matrix vesicles remain there without phagocytosis. These results suggest that ultrastructural abnormalities exist in the spinal ligament in cases of ossification of the spinal ligament.

Regional difference in the appearance of apoptotic cell death in the ligamentum flavum of the human cervical spine.

Ossification or calcification of the ligamentum flavum (LF) is relatively common in the middle and lower cervical, thoracic, and lumbar spine but extremely rare in the upper cervical region. This clinical fact suggests that there exist local factors promoting or preventing ossification or calcification of LF. However, little is known about the differences in the ultrastructure and cellular alterations of the LF between the different spinal levels, even in the cervical spine. With electron microscopy, we examined samples of LF collected surgically from the upper and lower cervical spine regions; we then studied the apoptotic appearance of ligament cells using a preferential labeling method. We found direct evidence of apoptosis of ligament cells in the LF. Apoptosis was more apparent in the upper region samples than in the lower region samples. The spaces around the normal fibroblasts were filled with thick collagen fibrils, but the collagen fibrils disappeared around the apoptotic bodies and thin fibrils were formed. The difference of the level of apoptosis may correlate to the ultrastructural difference of LF, and our data will benefit further investigations seeking to clarify the mechanism of various pathological conditions in the human LF.

Cervical muscle strength after laminoplasty.

To determine changes in cervical muscle strength after laminoplasty and to evaluate the relation between muscle strength and neck pain, we measured maximum isometric muscle strength using a handheld dynamometer. We also investigated neck pain before surgery and every month after surgery in 21 subjects who had undergone French-door laminoplasty. Muscle strength decreased particularly 1 month after surgery, the extensor muscles being affected more than the flexors. The strength of both muscle groups increased gradually; and at 1 year after surgery they had regained their presurgical status. All of the subjects complained of severe neck pain after 1 month. Their complaints began to decrease a few months after surgery, although they were still present in nine patients at 1 year after surgery. The correlation between muscle strength and neck pain was strongly negative for extension and flexion in men and for extension in women. No correlation was found between flexor muscle strength and neck pain in women. The extension/flexion ratio was significantly high in the neck pain group 1 year after surgery. Our results suggest that symptoms within a few months after surgery are due to surgical trauma to the soft tissues but that chronic neck pain derives from an imbalance of the two muscle strengths.