Correlations of magnetic resonance imaging findings with clinical symptom severity and prognosis of frozen shoulder.

PURPOSE: To evaluate the correlation between indirect magnetic resonance (MR) arthrographic imaging findings and the clinical symptoms and prognosis of patients with frozen shoulder. METHODS: Indirect MR arthrography was performed for 52 patients with primary frozen shoulder (mean age 55.1 ± 9.0 years) and 52 individuals without frozen shoulder (mean age 53.1 ± 10.7 years); capsular thickening and enhancement of the axillary recess as well as soft tissue thickening of the rotator interval were evaluated. Clinical symptom severity was assessed using the Visual Analogue Scale for Pain (VAS Pain), simple shoulder test (SST), Constant score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion (ROM). At 6-month follow-up, we evaluated whether MR arthrography findings correlated with the clinical symptoms and prognosis. RESULTS: Capsular thickening and enhancement of the axillary recess as well as soft tissue thickening of the rotator interval were significantly greater in the patient group than in the controls (p < 0.001). Capsular thickening of the axillary recess did not correlate with clinical symptoms or ROM (n.s.); however, capsular enhancement correlated with clinical symptom severity according to VAS Pain (p = 0.005), SST (p = 0.046), and ASES scores (p = 0.009). Soft tissue thickening of the rotator interval did not correlate with clinical symptom severity, but was associated with external rotation limitation (p = 0.002). However, none of the parameters correlated with clinical symptoms at 6-month follow-up. CONCLUSIONS: Indirect MR arthrography provided ancillary findings, especially with capsular enhancement, for evaluating clinical symptom severity of frozen shoulder, but did not reflect the prognosis. MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions. LEVEL OF EVIDENCE: IV.

Rotator cuff tear and sarcopenia: are these related?

BACKGROUND: Sarcopenia is the loss of muscle mass and consequent loss of muscle function with aging. Its prevalence among the general population is 12% to 30% in those aged >60 years. We evaluated (1) the difference in the prevalence of sarcopenia between patients with rotator cuff tear and controls and (2) the sarcopenia severity according to the size of the rotator cuff tear. METHODS: Group 1 included 48 consecutive patients with chronic symptomatic full-thickness rotator cuff tears (mean age, 60.1 ± 6.5 years; range, 46-76 years), and group 2 included 48 age- and sex-matched patients. The sarcopenic index was evaluated by using the grip strength of the asymptomatic contralateral side and the skeletal muscle mass. RESULTS: No significant differences were found in the baseline data and demographic factors between the groups. The sarcopenic index was significantly inferior in the rotator cuff tear group than in the age- and sex-matched control groups (P = .041, .007, and .05, respectively). Patients with large to massive tears had a significantly inferior sarcopenic index than those with small and medium tears. CONCLUSION: The results showed that sarcopenia was more severe in patients with a chronic symptomatic full-thickness rotator cuff tear than in the age- and sex-matched control population and was correlated with the size of the tear, with the numbers available. Despite the individual variance in the underlying medical condition and physical activities, this study suggests that clinicians should consider the sarcopenic condition of patients with a rotator cuff tear, especially in elderly patients with large to massive tears.

Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial.

BACKGROUND: The aim of this prospective randomized study was to compare the efficacy of 3 injection methods, intra-articular injection, subacromial injection, and hydrodilatation (HD), in the treatment of primary frozen shoulder. METHODS: Patients with primary frozen shoulder were randomized to undergo intra-articular injection (n = 29), subacromial injection (n = 29), or HD (n = 28). Evaluations using a visual analog scale for pain, Simple Shoulder Test, Constant score, and passive range of shoulder motion were completed before treatment and 1 month, 3 months, and 6 months after treatment. RESULTS: Among the 3 injection methods for primary frozen shoulder, HD resulted in a greater range of motion in forward flexion and external rotation, a lower visual analog scale score for pain after 1 month, and better outcomes for all functional scores after 1 month and 3 months of follow-up. However, there were no significant differences in any clinical outcomes among the 3 groups in the final follow-up at 6 months. CONCLUSIONS: Although HD yielded more rapid improvement, the 3 injection methods for primary frozen shoulder resulted in similar clinical improvement in the final follow-up at 6 months.

Prognostic Factors of Arthroscopic Extensor Carpi Radialis Brevis Release for Lateral Epicondylitis.

PURPOSE: The purpose of this study was to analyze factors affecting the treatment outcomes and prognoses of arthroscopic debridement for refractory lateral epicondylitis. METHODS: We included 45 patients who had undergone arthroscopic extensor carpi radialis brevis release for chronic refractory lateral epicondylitis between October 2008 and December 2012. Demographic data, magnetic resonance imaging studies, and arthroscopic findings were examined and analyzed. RESULTS: The mean age of the enrolled patients (23 men and 22 women) was 45.9 ± 7.8 years, and the mean follow-up duration was 26.9 ± 9.0 months. All the patients showed significant clinical improvement on all parameters assessed using the visual analog scale (6.9 preoperatively to 0.9 postoperatively), the Upper Extremity Functional Scale (34.8 to 66.7), and the Mayo Elbow Score (63.5 to 92.3) (P < .05). There were no reports of serious surgical complications. At final follow-up, 37 patients (82.2%) were satisfied with their outcomes whereas 8 patients (17.8%) were dissatisfied. In terms of demographic factors, female sex was significantly different between the 2 groups. On preoperative magnetic resonance imaging, 7 patients in the satisfied group (18.9%) had a definite tendon lesion (grade III defect, ≥6 mm) whereas 6 patients in the dissatisfied group (75%) had a grade III defect (P = .016). CONCLUSIONS: Overall, clinical outcome scores showed improvement after arthroscopic extensor carpi radialis brevis release for refractory lateral epicondylitis. However, preoperative tendon status and sex were associated with dissatisfaction and poor postoperative outcomes after the arthroscopic release procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Non-Hodgkin's lymphoma at the medial clavicular head mimicking Tietze Syndrome.

We present a case of Non-Hodgkin's lymphoma involving medial clavicular head, which was initially diagnosed as Tietze syndrome. Non-Hodgkin's lymphoma arising from medial clavicular head is extremely rare, and CT, MRI findings have not been reported.

Periostin is a novel histological biomarker for the diagnosis of chondroid tumor.

BACKGROUND: The chondroid tumor is generally classified into three types, enchondroma, low-grade chondrosarcoma, and high-grade chondrosarcoma. A histological evaluation of a biopsy sample is the best predictor of the clinical course in most patients with carcinomas or sarcomas. Sometimes serological or molecular markers are used as prediction markers, but there has been no reliable marker for chondroid tumor diagnosis. Clinical and radiological, but not histological features, are still used in the diagnosis and staging of chondroid tumors. During a histopathological diagnosis, it has been difficult to distinguish between benign enchondroma and low-grade chondrosarcoma. To allow for more accurate treatments, new histological biomarkers for the differential diagnosis are needed. METHODS: Twenty-eight cases of enchondromas and thirty-three cases of low-grade chondrosarcoma were selected. Thirteen cases of non-tumorous cartilage were used for the control group, who underwent artificial joint surgery for degenerative arthritis. Surgically removed tissue specimens were formalin-fixed paraffin-embedded and hematoxylin and eosin (H&E) and immunohistochemistry (IHC) stains were performed. RESULTS: Periostin was expressed in chondroid tumors but not in the normal cartilage. Periostin was observed via immunostaining in the cytoplasm but not in the extracellular matrix of enchondroma tissue, and was observed in the cytoplasm and extracellular matrix of low-grade chondrosarcoma. The sensitivity and specificity of these stains were 93.9% and 96.4%, respectively. CONCLUSIONS: Based on these results, we suggest that periostin could be used as a novel prognostic marker to distinguish between enchondroma and low-grade chondrosarcoma.

Promotion of Chondrosarcoma Cell Survival, Migration and Lymphangiogenesis by Periostin.

BACKGROUND/AIM: Periostin exists as an extracellular matrix protein in several carcinomas and is related to metastasis and poor prognosis. It is mainly secreted from cancer associated fibroblasts, and not from carcinoma cells. As a tumor microenvironment component, periostin usually mediates tumor cell stemness, metastasis, angiogenesis and lymphangiogenesis. This study aimed to examine the role of periostin in chondrosarcoma. MATERIALS AND METHODS: To evaluate the effect of periostin on the proliferation of chondrosarcoma cells, MTT assay was performed on SW1353 cells and periostin knockdown SW1353 cells. Migration activity was examined using Boyden chamber. RESULTS: Periostin, secreted from chondrosarcoma cells, was found to support proliferation, and maintain stemness and migration of chondrosarcoma cells. Periostin also induced proliferation and migration of lymphatic endothelial cells. CONCLUSION: Periostin plays an important role in chondrosarcoma development and disease progression.

Biomarkers of chondrosarcoma.

Clinical outcome prediction is major concern to patients with cancer. Various molecular markers in various carcinomas have been identified in the past few decades. However, accurate predictors in chondrosarcoma have not been developed, even though chondrosarcoma is the second most common primary bone tumour. Chondrosarcoma is the cartilage-forming malignancy and shows a wide spectrum of clinicopathological behaviours. The majority of chondrosarcoma grows slowly and rarely metastasises, and adequate surgery leads to a good prognosis. However, wide surgical excision is acquired in high-grade chondrosarcoma, because this tumour is highly resistant to chemotherapy and radiotherapy. To decide best therapy, accurate diagnostic markers are also necessary in chondrosarcoma. It is reported that angiogenesis and lymphangiogenesis increase by chondrosarcoma staging, and they are promoted by leptin and adiponectin. Several microRNAs to regulate vascular endothelial growth factor (VEGF)-A and VEGF-C are also reported. Alpha-methylacyl-CoA racemase and periostin are proposed as new biomarkers for differential diagnosis of enchondroma and chondrosarcoma. This review summarises that chondrosarcoma diagnostic markers are currently reported.

Cystic Disease of the Groin Presenting as Compression of a Femoral Vessel.

In this study, we describe our diagnosis and treatment of two patients who presented with femoral vessel compression caused by a cystic lesion in the groin. One case was diagnosed as adventitial cystic disease (ACD) of the common femoral artery resulting in leg claudication and the other was diagnosed as a ganglion cyst (GC) causing femoral vein compression and unilateral leg swelling. The operative findings differed between these two cases with respect to the dissection of the cyst and femoral vessel, but the postoperative histological examination results were similar. The pathogenesis of ACD and GC is not fully understood, and further investigation is needed to delineate the exact pathology of these uncommon conditions.

Development of hybrid scaffolds using ceramic and hydrogel for articular cartilage tissue regeneration.

The regeneration of articular cartilage consisting of hyaline cartilage and hydrogel scaffolds has been generally used in tissue engineering. However, success in in vivo studies has been rarely reported. The hydrogel scaffolds implanted into articular cartilage defects are mechanically unstable and it is difficult for them to integrate with the surrounding native cartilage tissue. Therefore, it is needed to regenerate cartilage and bone tissue simultaneously. We developed hybrid scaffolds with hydrogel scaffolds for cartilage tissue and with ceramic scaffolds for bone tissue. For in vivo study, hybrid scaffolds were press-fitted into osteochondral tissue defects in a rabbit knee joints and the cartilage tissue regeneration in blank, hydrogel scaffolds, and hybrid scaffolds was compared. In 12th week after implantation, the histological and immunohistochemical analyses were conducted to evaluate the cartilage tissue regeneration. In the blank and hydrogel scaffold groups, the defects were filled with fibrous tissues and the implanted hydrogel scaffolds could not maintain their initial position; in the hybrid scaffold group, newly generated cartilage tissues were morphologically similar to native cartilage tissues and were smoothly connected to the surrounding native tissues. This study demonstrates hybrid scaffolds containing hydrogel and ceramic scaffolds can provide mechanical stability to hydrogel scaffolds and enhance cartilage tissue regeneration at the defect site.

Comparison of results between hook plate fixation and ligament reconstruction for acute unstable acromioclavicular joint dislocation.

BACKGROUND: In the present study, we aimed to compare clinical and radiographic outcomes between hook plate fixation and coracoclavicular (CC) ligament reconstruction for the treatment of acute unstable acromioclavicular (AC) joint dislocation. METHODS: Forty-two patients who underwent surgery for an unstable acute dislocation of the AC joint were included. We divided them into two groups according to the treatment modality: internal fixation with a hook plate (group I, 24 cases) or CC ligament reconstruction (group II, 18 cases). We evaluated the clinical outcomes using a visual analog scale (VAS) for pain and Constant-Murley score, and assessed the radiographic outcomes based on the reduction and loss of CC distance on preoperative, postoperative, and final follow-up plain radiographs. RESULTS: The mean VAS scores at the final follow-up were 1.6 ± 1.5 and 1.3 ± 1.3 in groups I and II, respectively, which were not significantly different. The mean Constant-Murley scores were 90.2 ± 9.9 and 89.2 ± 3.5 in groups I and II, respectively, which were also not significantly different. The AC joints were well reduced in both groups, whereas CC distance improved from a mean of 215.7% ± 50.9% preoperatively to 106.1% ± 10.2% at the final follow-up in group I, and from 239.9% ± 59.2% preoperatively to 133.6% ± 36.7% at the final follow-up in group II. The improvement in group I was significantly superior to that in group II (p < 0.001). Furthermore, subluxation was not observed in any case in group I, but was noted in six cases (33%) in group II. Erosions of the acromion undersurface were observed in 9 cases in group I. CONCLUSIONS: In cases of acute unstable AC joint dislocation, hook plate fixation and CC ligament reconstruction yield comparable satisfactory clinical outcomes. However, radiographic outcomes based on the maintenance of reduction indicate that hook plate fixation is a better treatment option.

Efficiency of ligamentotaxis using PLL for thoracic and lumbar burst fractures in the load-sharing classification.

The use of pedicle screws for short-segment implants has been known to be dangerous in patients who score a 7 or higher on McCormack's classification. The efficiency of ligamentotaxis of the posterior longitudinal ligament (PLL) and short-segment implants and fusion in relation to McCormack's classification has not been proven. The purpose of this study was to compare the clinical and radiological results of indirect decompression using PLL ligamentotaxis between patients with a high- (score of 7 or higher) or low-grade (score of 6 or less) fracture. Eighteen patients (19 levels) in the low-grade fracture group were compared with 23 patients (27 levels) in the high-grade fracture group. Clinical outcomes were measured using the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores; radiologic measures were determined using the spinal canal area and mean sagittal diameter; and the complications were evaluated and compared. A significant improvement in each groups was found in the mean pre- and postoperative spinal canal area, mean sagittal diameter, Cobb's angle, and anterior vertebral height compression rate. A significant difference was found between the 2 groups in the mean pre- and postoperative spinal canal area, mean sagittal diameter, and anterior vertebral height compression rate. Moreover, the VAS and ODI scores continued to significantly improve at the last follow-up in each group. No difference was found in the prevalence of complications. Despite a high score, no significant difference was found in the clinical and radiological results and the complications. Therefore, indirect decompression using PLL ligamentotaxis was found to be a useful technique for patients who recieve a high McCormack's classification score.

What do the patients want and worry in Korean patients who undergo arthroscopic rotator cuff surgery?

BACKGROUND: To specify what patients want and worry preoperatively is important in orthopedic practice. The aim of the current study was to analyze the patient characteristics of rotator cuff disease in Korean population who were willing to undergo arthroscopic surgery, and to evaluate the differences in expectations and concerns by age and gender. METHODS: We prospectively enrolled 303 patients who underwent rotator cuff surgery between April 2004 and August 2008. Three questionnaires were completed before surgery: the first one addressing preoperative patient's expectation, the second one focusing on concerns by covering 64 items using a visual analogue scale, and the third one evaluating patient's demographic characteristics. The characteristics of preoperative expectation, concern, and demographic data were evaluated according to gender and age group. RESULTS: Female patients had lower level of sports activity (p = 0.007) and lower levels of information (p = 0.028). Gender specific worries are about a caregiver during hospital stay, operating on the working side, fear about ugly scars, postoperative pain, applying makeup or combing hair. The older group responded that they can't be willing to change activities of daily living (p = 0.001), are not living with a spouse (p = 0.002), had previous shoulder operation history (p = 0.008), and had a lower level of information (p = 0.007). They especially worried about medical bills, worried about the physician being too young and inexperienced, postoperative pain, loss of arm function, and hospital food. CONCLUSIONS: Our data showed what Korean patients wanted and were concerned about prior to rotator cuff surgery. This can empower patients to formulate realistic expectations and make informed decisions. We feel that we can achieve higher levels of postoperative satisfaction by analyzing expectations and concerns in depth and addressing these proactively.

Reliability of Triggered EMG for Prediction of Safety during Pedicle Screw Placement in Adolescent Idiopathic Scoliosis Surgery.

STUDY DESIGN: We performed a prospective study to evaluate the reliability of using triggered electromyography (EMG) for predicting pedicle wall breakthrough during the placement of pedicle screw in adolescent idiopathic scoliosis surgery. PURPOSE: We wanted to correlate pedicle wall breakthrough with the triggered EMG threshold of stimulation and the postoperative computed tomography (CT) findings. OVERVIEW OF LITERATURE: Pedicle wall breakthrough has been reported to be difficult to evaluate by radiographs. Triggered EMG had been found to be a more sensitive test to detect this breakthrough. METHODS: Seven patients who underwent the insertion of 103 pedicle screws were evaluated. The triggered EMG activity was recorded from several muscles depending on the level of screw placement. The postoperative CT scans were read by a spine surgeon who was a senior fellow in orthopedics, and a musculoskeletal radiologist. RESULTS: The mean age at surgery was 12.6 years (range, 11 to 17 years). The preoperative mean Cobb angle was 54.7° (range, 45 to 65°). There were 80 thoracic screws and 23 lumbar screws. All the screws had stimulation thresholds of ≥ 6 mA, except 3 screws with the stimulation threshold of < 6 mA. Ten screws (9.7%) showed violation of the pedicle wall on the postoperative CT scans. Five screws penetrated medially and another five penetrated laterally. No postoperative neurologic complications were noted in any of the seven patients. CONCLUSIONS: Measuring the stimulation threshold of triggered EMG helps to assess the pedicle screw placement. Pedicle screws that had stimulation threshold of ≥ 6 mA were safe, with 90.3% reliability, as was assessed on the postoperative CT scans.