Clinical and Radiological Outcomes of Medial Meniscal Allograft Transplantation Combined With Realignment Surgery.

BACKGROUND: The outcomes of medial meniscal allograft transplantation (MMAT) combined with high tibial osteotomy (HTO) compared with isolated MMAT remain unclear. PURPOSE: To compare the clinical and radiological results of MMAT combined with HTO and isolated MMAT. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective study included 42 consecutive patients, who were divided into group M (isolated MMAT; n = 22) and group H (MMAT combined with HTO with a varus angle >3°; n = 20). Group differences in subjective knee scores, isokinetic muscle strength test, and radiological outcomes (Kellgren-Lawrence grade, mechanical axis, graft extrusion, graft status, and articular cartilage loss) were compared. RESULTS: The mean follow-up period was 29.2 ± 4.9 months and 27.4 ± 5.3 months for groups M and H, respectively. The Lysholm score improved from 55.4 ± 9.5 to 81.3 ± 9.7 and from 52.6 ± 8.9 to 84.2 ± 10.2 in groups M and H, respectively (both P < .001). The International Knee Documentation Committee subjective score improved from 51.4 ± 10.3 to 79.6 ± 9.4 and from 49.3 ± 11.4 to 81.4 ± 8.3 in groups M and H, respectively (both P < .001). Both groups showed no significant differences in subjective knee scores and isokinetic extensor strength at the final follow-up. The rate of preoperative and postoperative high International Cartilage Regeneration & Joint Preservation Society grade (≥3) did not differ between the 2 groups. Group M showed greater coronal graft extrusion than did group H (3.3 ± 0.7 mm vs 2.7 ± 0.8 mm; P = .014); the rate of pathologic graft extrusion (≥3 mm) was not higher in group M (40.9%) than in group H (20%) with the number of patients available (P = .143). Both groups showed no significant difference in the graft status. Graft tears were observed in 2 patients (9%) in group M and 1 patient (5%) in group H (P = .607). CONCLUSION: Clinical scores significantly improved after isolated MMAT and MMAT combined with HTO compared with preoperative values, and their short-term outcomes were similar. Postoperative graft extrusion was greater in patients who underwent isolated MMAT, implying that active correction of varus alignment during MMAT may help in intra-articular biomechanics.

Usefulness of 3-Dimensional Computed Tomography Assessment of Femoral Tunnel after Anterior Cruciate Ligament Reconstruction.

Positioning of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction is the most crucial factor for successful procedure. Owing to the inter-individual variability in the intra-articular anatomy, it can be challenging to obtain precise tunnel placement and ensure consistent results. Currently, the three-dimensional (3D) reconstruction of computed tomography (CT) scans is considered the best method for determining whether femoral tunnels are positioned correctly. Postoperative 3D-CT feedback can improve the accuracy of femoral tunnel placement. Precise tunnel formation obtained through feedback has a positive effect on graft maturation, graft failure, and clinical outcomes after surgery. However, even if femoral tunnel placement on 3D CT is appropriate, we should recognize that acute graft bending negatively affects surgical results. This review aimed to discuss the implementation of 3D-CT evaluation for predicting postoperative outcomes following ACL re-construction. Reviewing research that has performed 3D CT evaluations after ACL reconstruction can provide clinically significant evidence of the formation of ideal tunnels following anatomic ACL reconstruction.

Feasibility of MRI for the evaluation of interosseous ligament vertical segment via subtalar arthroscopy correlation: comparison of 2D and 3D MR images.

BACKGROUND: Interosseous ligament vertical segment (IOLV) and calcaneofibular ligament (CFL) have been reported to be important in stabilizing the subtalar joint. Unlike CFL, there is not much information regarding the comparison of MRI results with surgical evaluation of IOLV and the comparison between 2D and 3D MRI on IOLV evaluation. The feasibility of MRI in IOLV evaluation has yet to be reported. The purpose of this study was to evaluate the validity and reliability of MRI in IOLV tear detection via correlation with arthroscopic results. We also compared the diagnostic performance of 2D and 3D MR images. METHODS: In this retrospective study, 52 patients who underwent subtalar arthroscopy after ankle MRI were enrolled. Arthroscopic results confirmed IOLV tear in 25 cases and intact IOLV in 27 cases. Two radiologists independently evaluated the IOLV tears using only conventional 2D images, followed by isotropic 3D images, and comparison with arthroscopic results. RESULTS: Only the 2D sequences interpreted by two readers showed a sensitivity of 64.0-96.0%, a specificity of 29.6-44.4%, a positive predictive value of 51.6-56.4%, and a negative predictive value of 57.1-88.9%. Addition of isotropic 3D sequences changed the sensitivity to 60.0-80.0%, specificity to 63.0-77.8%, positive predictive value to 64.3-76.9%, and negative predictive value to 66.7-80.8%. The overall diagnostic performance of isotropic 3D sequences (AUC values: 0.679-0.816) was higher than that of 2D sequences (AUC values: 0.568-0.647). Inter-observer and intra-observer agreement between the two readers was moderate-to-good for both 2D and 3D sequences. The diagnostic accuracy in 19 patients with tarsal sinus fat obliteration tended to increase from 26.3-42.1% to 57.9-73.7% with isotropic 3D sequences compared with 2D sequences. CONCLUSIONS: Isotropic 3D MRI was feasible for the assessment of IOLV tear prior to subtalar arthroscopy. Additional 3D sequences showed higher diagnostic accuracy compared with conventional 2D sequences in IOLV evaluation. Isotropic 3D sequences may be more valuable in detecting IOLV tear in case of tarsal sinus fat obliteration.

Adolescents show a lower healing rate of anterolateral ligament injury and a higher rotational laxity than adults after anterior cruciate ligament reconstruction.

BACKGROUND: This study aimed to compare anterolateral ligament (ALL) injuries in anterior cruciate ligament (ACL) ruptures, as well as ALL healing and clinical outcomes following ACL reconstruction between adolescents and adults. METHODS: This retrospective study involved 98 patients who underwent ACL reconstruction. They were divided into two groups according to age: group A (adolescents, 16-20 years of age; n = 49) and group B (adults, 21-45 years of age; n = 49). Subjective scores including ACL-Return to Sport after Injury (ACL-RSI) scale and objective tests were assessed. Follow up magnetic resonance imaging (MRI) and second-look arthroscopy was conducted at 1-year and 2-year follow up, respectively. RESULTS: Good healing rate of ALL was higher in adults than in adolescents (P = 0.048). Graft tension and synovial coverage showed no significant differences between two groups. Group A showed a higher rate of high-grade pivot shift and a lower ACL-RSI at last follow up than group B (P = 0.126 and P = 0.016). Poor healing of ALL was significantly associated with lower ACL-RSI and failure to return to sports (P < 0.001 and P = 0.001). Re-rupture of the ACL graft was found in four (8.2%) and one (2.0%) of group A and B, respectively. CONCLUSIONS: Adolescents showed a lower healing rate of ALL, a lower ACL-RSI, a higher rate of high-grade pivot shift than adults. Moreover, poor healing of ALL was significantly associated with a lower ACL-RSI and failure to return to sports. We suggest that adolescents need to pay more attention to the presence of ALL injury.

Effect of atelocollagen on the healing status after medial meniscal root repair using the modified Mason-Allen stitch.

INTRODUCTION: Addition of collagen during medial meniscal root repair (MMRR) may improve meniscal root healing minimising fibrous scar tissue formation. The purpose of this study was to verify the effect of atelocollagen on MMRR using the modified Mason-Allen stitch when compared with that of the conventional pullout repair by assessing the clinical and radiological outcomes. HYPOTHESIS: It was hypothesised that atelocollagen would enhance the healing effect on the meniscal root following MMRR. Moreover, we presumed that MMRR with atelocollagen application might reduce meniscal extrusion by promoting healing. MATERIALS AND METHODS: A total of 47 patients who underwent MMRR using the modified Mason-Allen stitch between 2015 and 2016 were included, and they were divided into group A (atelocollagen application; n=25) and group R (MMRR without atelocollagen application; n=22). The postoperative clinical outcomes, radiological outcomes, and meniscal root healing and medial compartment cartilage status on follow-up magnetic resonance imaging (MRI) were compared between the two groups. RESULTS: Mean follow-up duration was 26.4±4.8 months in group A and 27.1±5.2 months in group R (p=0.598). Mean duration from surgery to follow-up MRI was 12.5±1.4 months in group A and 12.7±1.2 months in group R (p=0.604). The subjective knee scores improved significantly in both groups at the last follow-up (all, p<0.001). The Kellgren-Lawrence (K-L) grade progressed in 16% and 22.7% in group A and group R, respectively (p=0.351). Follow-up MRI showed progression of cartilage loss in the medial compartment in 28% and 40.9% in group A and group R, respectively (p=0.355). In terms of meniscal root healing, 18 (72%) and 12 (54.5%) patients had complete healing, and 6 (24%) and 8 (36.4%) patients had partial healing in groups A and R, respectively. The mean value of the intra-meniscal signal intensity (IMSI) of the meniscal root based on MRI in group A was significantly lower than that in group R (p<0.001). The medial meniscal extrusion in groups A and R decreased by 0.2±0.1mm and 0.1±0.3mm following MMRR without significant differences (p=0.056 and p=0.229, respectively). The IMSI presented significant negative correlations with the root healing status and significant positive correlations with K-L grade progression (p<0.05). DISCUSSION: Atelocollagen application during MMRR yielded lower IMSIs, suggesting better healing, than did conventional pullout root repair. However, this technique could not demonstrate beneficial effects on meniscal extrusion. LEVEL OF EVIDENCE: III, retrospective case-control study.

Medial knee osteoarthritis precedes medial meniscal posterior root tear with an event of painful popping.

BACKGROUND: An event of painful popping is a highly predictive clinical sign of medial meniscal posterior root tears (MMPRTs) in middle-aged to older patients. There are lacks of studies about the prevalence of a painful popping event and the condition of the medial compartment at the time of popping event in MMPRTs. HYPOTHESIS: We hypothesized that most of MMPRTs with a single painful popping event would show pre-existed pathologic medial meniscal extrusion (MME) and articular cartilage degeneration, and larger contact area of medial femoral condyle to medial tibial plateau could affect the MME. In addition, MME would be correlated with knee osteoarthritis. PATIENTS AND METHODS: Thirty-eight patients (mean age 58.5±10.5) who had painful popping within 3 weeks were included. On MRIs, absolute MME, relative percentage of extrusion (RPE), MME-medial femoral condyle (MFC)/medial tibial condyle (MTC) at 0° ratio, and medial compartments' Modified Outerbridge Scale (MOS) were evaluated. Kellgren-Lawrence (K-L) grade was also assessed. RESULTS: The MME parameters including absolute MME, RPE, and the ratio between MME and MFC/MTC at 0° were 2.9±1.2mm, 22.0±10.3%, and 3.2±1.3. Patients who with MOS and K-L grade≥2 were 33 (86.8%) and 32 (84.2%). Patients were divided into MME≥3mm (group G, n=20) and MME<3mm (groupL, n=18). The MME parameters were significantly greater in group G than group L (all, p<0.001). The group G had worse osteoarthritis progression in terms of MOS and K-L grade than the group L (p=0.035 and 0.077, respectively) MME≥3mm showed significantly association with MOS≥3 (p=0.045). DISCUSSION: More than 80% of MMPRT patients with an event of painful popping within 3 weeks showed that medial compartment degeneration preceded the event of popping. Therefore, identification of MME and articular cartilage degeneration at the time of painful popping in MMPRTs could be helpful when the surgeon determines the most appropriate treatment. LEVEL OF EVIDENCE: IV, Case-series.

Evaluation of Anterolateral Ligament Injuries and Concomitant Lesions on Magnetic Resonance Imaging After Acute Anterior Cruciate Ligament Rupture.

PURPOSE: To evaluate the prevalence and characteristics of anterolateral ligament (ALL) injuries with a ruptured acute anterior cruciate ligament (ACL) and to analyze the presence of concomitant bone contusions and meniscal lesions. METHODS: From March 2015 to March 2017, we retrospectively analyzed 378 patients who underwent primary ACL reconstructions. Using magnetic resonance imaging, we evaluated the presence of ALL injury and concomitant lesions within 3 weeks of the injury. Meniscal tears were also identified on representative arthroscopic images. RESULTS: Following the inclusion criteria, we included a total of 275 patients in this study. The mean duration from ACL rupture to magnetic resonance imaging examination was 5.0 ± 6.0 days. We visualized ALL in 98.2% of patients, of whom 64% had ALL injuries (10.9%, 4.7%, and 48.4% were complete ruptures, Segond fracture, and partial ruptures, respectively). We found that ALL injuries were most commonly found in the femoral location. The intra- and interobserver agreement on the severity of ALL injury (κ = 0.83 and 0.81, respectively) and the location of ALL injury (κ = 0.85 and 0.84, respectively) were excellent. The association between ALL injury and lateral meniscal lesions was significant (P = .03). In particular, the proportion of the lateral meniscal posterior horn radial tears was significantly larger in nonintact ALL than in intact ALL (P = .042). The correlation between the severity of ALL injury and the degree of bone contusion at lateral compartments was significant but weak (P < .001). CONCLUSIONS: We found that more than half of acute ACL ruptures have ALL injuries. The presence of ALL injury was significantly associated with the presence of lateral meniscal lesions, especially lateral meniscal posterior horn radial tears, or lateral bone contusions. Interestingly, the severity of ALL injury significantly correlated with the degree of lateral bone contusions. LEVEL OF EVIDENCE: Level III, diagnostic cross-sectional study.

Early Results of Transcatheter Arterial Embolization for Relief of Chronic Shoulder or Elbow Pain Associated with Tendinopathy Refractory to Conservative Treatment.

PURPOSE: To evaluate the effectiveness and safety of transcatheter arterial embolization to relieve pain associated with shoulder and elbow tendinopathy refractory to conservative treatment. MATERIALS AND METHODS: This study included 13 patients (15 cases) who underwent embolization between November 2015 and December 2016 to treat chronic shoulder pain (6 with rotator-cuff tendinopathy, 2 with calcific tendinitis) or elbow pain (7 with lateral epicondylitis) refractory to conservative treatment. Microspheres were used in the first 4 cases, and imipenem/cilastatin sodium was used in the remaining 11. Visual analog scale (VAS) score changes were recorded. Decrease in VAS score and degree of enhancement on digital subtraction angiography were compared. RESULTS: The technical and clinical success rates were 100% (15/15) and 73% (11/15), respectively. The mean VAS scores at baseline, 1 day, 1 week, 1 month, and 4 months after embolization were 6.1, 5.8, 5.1, 4.3, and 2.5, respectively (P < .05 after 1 wk). Pain improved in 9 of 10 cases (90%) with "evident" enhancement and 3 of 5 cases (60%) with no evident enhancement. The VAS scores in the evident enhancement group decreased more than those in patients with no evident enhancement (4.5 vs 1.8; P < .05). Forearm cutaneous erythema was noted in 1 patient treated with microspheres. CONCLUSIONS: Transcatheter arterial embolization may be an option for relieving pain associated with chronic shoulder and elbow tendinopathy refractory to conservative treatment. The degree of angiographic enhancement might be a possible factor affecting the degree of pain relief after embolization.

Subtalar instability: imaging features of subtalar ligaments on 3D isotropic ankle MRI.

BACKGROUND: MRI analysis of subtalar ligaments in the tarsal sinus has not been well performed. We retrospectively investigated the appearance of subtalar ligaments using 3D isotropic MRI and compared imaging findings of subtalar ligaments between patients with subtalar instability (STI) and controls. METHODS: Preoperative MRIs of 23 STI patients treated with arthroscopic subtalar reconstruction were compared to MRIs of 23 age- and sex-matched control subjects without STI. Thickness and width of anterior capsular ligament (ACL) and interosseous talocalcaneal ligament (ITCL) as well as thickness of calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) were measured. Abnormalities in ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed. RESULTS: STI patients had significantly smaller ACL thickness and ACL width than controls (ACL thickness: 1.73 mm vs. 2.22 mm, p = 0.007; ACL width: 7.21 mm vs. 8.80 mm, p = 0.004). ACL thickness of ≤2.1 mm had a sensitivity of 66.7% and a specificity of 66.7% for diagnosis of STI. ACL width of ≤7.9 mm had a sensitivity of 80.0% and a specificity of 76.2% for the diagnosis of STI. However, thickness and width of ITCL, thickness of CFL, or thickness of ATFL was not significantly different between the two groups. Absence or complete tear of ACL was significantly more frequent in STI patients than that in controls (34.8% vs. 8.7%, p = 0.035). Complete tear of CFL and ATFL was more common in STI patients than that in controls, although the difference between the two groups was not statistically significant. Abnormalities of ITCL, cervical ligament, or inferior extensor retinaculum were not significantly different between the two groups. CONCLUSIONS: MRI features of thin or narrow ACLs may suggest STI. Absence or complete tear of ACL was significantly more common in STI patients than that in controls.

Serial Changes in 3-Dimensional Supraspinatus Muscle Volume After Rotator Cuff Repair.

BACKGROUND: There is considerable debate on the recovery of rotator cuff muscle atrophy after rotator cuff repair. PURPOSE: To evaluate the serial changes in supraspinatus muscle volume after rotator cuff repair by using semiautomatic segmentation software and to determine the relationship with functional outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Seventy-four patients (mean age, 62.8 ± 8.8 years) who underwent arthroscopic rotator cuff repair and obtained 3 consecutive (preoperatively, immediately postoperatively, and later postoperatively [≥1 year postoperatively]) magnetic resonance imaging (MRI) scans having complete Y-views were included. We generated a 3-dimensional (3D) reconstructed model of the supraspinatus muscle by using in-house semiautomatic segmentation software (ITK-SNAP) and calculated both the 2-dimensional (2D) cross-sectional area and 3D volume of the muscle in 3 different views (Y-view, 1 cm medial to the Y-view [Y+1 view], and 2 cm medial to the Y-view [Y+2 view]) at the 3 time points. The area and volume changes at each time point were evaluated according to repair integrity. Later postoperative volumes were compared with immediately postoperative volumes, and their relationship with various clinical factors and the effect of higher volume increases on range of motion, muscle power, and visual analog scale pain and American Shoulder and Elbow Surgeons scores were evaluated. RESULTS: The interrater reliabilities were excellent for all measurements. Areas and volumes increased immediately postoperatively as compared with preoperatively; however, only volumes on the Y+1 view and Y+2 view significantly increased later postoperatively as compared with immediately postoperatively ( P < .05). There were 9 patients with healing failure, and area and volume changes were significantly less later postoperatively compared with immediately postoperatively at all measurement points in these patients ( P < .05). After omitting the patients with healing failure, volume increases later postoperatively became more prominent ( P < .05) in the order of the Y+2 view, Y+1 view, and Y-view. Volume increases were higher in patients who healed successfully with larger tears ( P = .040). Higher volume increases were associated only with an increase in abduction power ( P = .029) and not with other outcomes. CONCLUSION: The supraspinatus muscle volume increased immediately postoperatively and continuously for at least 1 year after surgery. The increase was evident in patients who had larger tears and healed successfully and when measured toward the more medial portion of the supraspinatus muscle. The volume increases were associated with an increase in shoulder abduction power.

Stress ultrasound in baseball players with ulnar collateral ligament injuries: additional value for predicting rehabilitation outcome.

BACKGROUND: The purpose of this study was to evaluate the additional value of stress ultrasound (US) for predicting rehabilitation outcome in baseball players with ulnar collateral ligament (UCL) injury. METHODS: Stress US and magnetic resonance imaging (MRI) in 41 baseball players with UCL injury who received rehabilitation treatment for more than 6 weeks were retrospectively compared between the rehabilitation group (n = 23) and surgery group (n = 18). The MRI grade of UCL injury was assessed as intact continuity, low-grade partial tear, high-grade partial tear, and complete tear. To estimate sonographic joint laxity, we assessed 3 sonographic criteria as present or absent: ligamentous waviness, joint gapping, and intra-articular ring-down artifact. In addition, the presence of concomitant tenderness was checked during stress US. The diagnostic validity of MRI with and without stress US was analyzed as a predictor for the rehabilitation outcome. RESULTS: The MRI grade was higher in the surgery group than in the rehabilitation group (P < .001). Sonographic joint laxity showing the ring-down artifact and concomitant tenderness with stress were significantly more frequent in the surgery group (P = .024 and P = .006, respectively). Sensitivity, specificity, and accuracy were 61.1%, 86.9%, and 75.6%, respectively, for MRI alone and 83.3%, 56.5%, and 68.2%, respectively, for the combination of MRI with joint laxity showing the ring-down artifact. For MRI in combination with joint laxity and concomitant tenderness, these values were 72.2%, 82.6%, and 78.0%, respectively. CONCLUSION: The addition of stress US showing the ring-down artifact and concomitant tenderness was helpful for predicting the rehabilitation outcome of UCL injuries.

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.

Superior Labral Cleft after Superior Labral Anterior-to-Posterior Tear Repair: CT Arthrographic Features and Correlation with Clinical Outcome.

PURPOSE: To evaluate the presence of a superior labral cleft at postoperative computed tomographic (CT) arthrography after superior labral anterior-to-posterior lesion (SLAP) repair and to correlate CT arthrographic appearance with clinical outcomes. MATERIALS AND METHODS: The institutional review board approved this retrospective study, and the requirement to obtain informed consent was waived. Fifty-six patients who underwent CT arthrography after arthroscopic SLAP repair were included. Two musculoskeletal radiologists retrospectively reviewed CT arthrographic images for the presence, size, location, direction, and shape of a superior labral cleft, which was defined as a detectable contrast material-filled focal discontinuity of the labrum within anchor fixation sites of the glenoid. In addition, the glenoid osteolysis ratio was calculated on the basis of the CT arthrographic images. Clinical outcome was evaluated with use of the American Shoulder and Elbow Surgeons (ASES) scoring system. Continuous variables, such as patient age, interval between imaging and surgery, ASES score, and osteolysis ratio, were compared by using the Mann-Whitney U test. RESULTS: A superior labral cleft was observed in 27 of the 56 patients (48%). The mean width and depth of the superior labral clefts was 2.1 mm ± 1.1 and 2.8 mm ± 0.8, respectively. The superior labral clefts extended posterior to the biceps anchor in 16 of the 27 patients (59%), were curved medially in 24 (89%), and had a smooth margin in 22 (81%). No significant association was observed between the presence of a superior labral cleft and the ASES score (P = .805) or patient age (P = .290). Superior labral clefts were observed more commonly in cases with a long interval since surgery (P = .007) and a high osteolysis ratio (P = .011). CONCLUSION: Superior labral clefts are frequently observed on CT arthrographic images after arthroscopic SLAP repair and do not correlate with clinical outcome.

Charcoal-induced granuloma that mimicked a nodal metastasis on ultrasonography and FDG-PET/CT after neck dissection.

Charcoal can be used for preoperative localization of metastatic lymph nodes in the neck. Charcoal remains stable without causing foreign body reactions during as hort period. However, foreign body reactions may develop if charcoal is left in situ for more than 6 months. We reported a case of charcoal granuloma mimicking local recurrence on fluorodeoxyglucose-positron emission tomography/computed tomography and ultrasonography in a 47-year-old woman who had cervical lymph node dissection due to metastatic invasive ductal carcinoma of the breast.

Detection of skeletal muscle metastasis: torso FDG PET-CT versus contrast-enhanced chest or abdomen CT.

BACKGROUND: Skeletal muscle metastasis (SMM) in cancer patients has not been sufficiently evaluated regarding prevalence and proper method of detection. PURPOSE: To determine the prevalence of SMM and compare the diagnostic competencies for SMM of torso F-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) and contrast-enhanced chest or abdomen CT. MATERIAL AND METHODS: We investigated 18,225 PET-CT studies of 6359 cancer patients performed from 2005 to 2012. The PET-CT studies describing potential SMM were retrieved and the corresponding medical records were reviewed. The gold standard for SMM was histopathologically-proven SMM or imaging study-based disease progression. The detectability of SMM was compared between PET-CT and contrast-enhanced CT. RESULTS: Twenty-six patients had 84 SMM lesions, representing a SMM prevalence of 0.41%. Lung cancer was the most common SMM-associated malignancy (54%) and the gluteal/pelvic girdle muscle was the most frequently involved SMM site (37%). All 84 SMM lesions were visualized on PET-CT (100%). Of these PET-CT positive 84 SMM lesions, 51 lesions were in the CT field of view (FOV) (61%), whereas 33 lesions were out of the CT FOV (39%). Among these 51 lesions, 17 lesions showed rim-enhancing nodules/masses (33%), eight lesions showed homogeneously enhancing nodules (16%), three lesions showed heterogeneously enhancing nodules (6%), and 23 SMM lesions (45%) were non-diagnostic by CT. All 51 SMM lesions within CT FOV were detected on PET-CT (100%), whereas only 28 were visualized on CT (54.9%), resulting in a significant difference (P < 0.005). On average, 2.6 more organs with concomitant metastases were found when SMM was revealed by PET-CT. CONCLUSION: The prevalence of SMM was as low as 0.41% in the current large cohort of cancer patients. Torso PET-CT was a more competent modality than contrast-enhanced CT in the detection of SMM.

Clinical and ultrasonographic outcomes of arthroscopic suture bridge repair for massive rotator cuff tear.

PURPOSE: The purpose of this study was to analyze the outcomes of arthroscopic suture bridge repairs of massive rotator cuff tears. METHODS: Thirty-six patients with massive rotator cuff tears that had been repaired by arthroscopic suture bridge repair were enrolled in this study. The mean follow-up period after surgery was 37.6 ± 8.9 months (range, 25 to 56). Arthroscopic en masse suture bridge repair was used in delaminated tears. The integrity of the repaired rotator cuff was examined by ultrasonography 4.5 months, 1 year, and 2 years after surgery. Functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, range of motion, and muscle power. RESULTS: Twenty-seven cases (75%) showed complete healing on serial ultrasonography, whereas recurrent tears were detected in the remaining 9 cases (25%). Five retears were smaller than, and the other 4 were the same as or larger than, the initial tear. Overall mean functional scores and values improved after surgery. Although the 4 larger retears had a poorer outcome with respect to ASES score than the healed group (P = .005), the Constant score for these 4 retears did not significantly differ at the last follow-up (P = .175). Mean ASES and Constant scores for the larger tear group were also relatively satisfactory (64.2 and 63.0, respectively). Fatty degeneration of the supraspinatus on preoperative magnetic resonance images was associated with a high retear rate (P = .003, odds ratio = 13.664). CONCLUSIONS: Massive rotator cuff tears can be treated successfully by arthroscopic en masse suture bridge repair with satisfactory results. Larger retears had some adverse effects on functional outcome, whereas patients with smaller retears did not significantly differ in functional outcome from the healed group. Fatty degeneration of the supraspinatus on preoperative magnetic resonance images is a poor prognostic indicator. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

How to assess scapular dyskinesis precisely: 3-dimensional wing computer tomography--a new diagnostic modality.

BACKGROUND: Aberrations in scapular motion are believed to be associated with the presence of shoulder or elbow pathologies. There are many methods to evaluate scapular kinematics, but they have certain limitations. Nevertheless, it is believed that appropriate rehabilitation for each type of scapular dyskinesis is important. METHODS: Eighty-nine athletes were videotaped and seven blinded observers categorized scapular dyskinesis into 4 types, which was followed by 3-dimensional (3D) wing computer tomography (CT). Four blinded examiners evaluated 5 angles [upward rotation (UR), internal rotation (IR), anterior tilting (AT), superior translation (ST), and protraction (PRO)] on the 3D wing CT. Inter-rater reliability (IRR) was calculated for both the methods. CT scan measurements were compared with the 4 observational types to establish the validity. RESULTS: The IRR with observational assessment of scapular dyskinesis into 4 types was good, 0.780. The 3D wing CT analysis had a very high IRR, 0.972. There was a statistically significant correlation between observational assessment and 3D wing CT analysis. The UR angle, ST angle in type 3 scapular dyskinesis, and AT angle in type 1 scapular dyskinesis were increased as compared with those in the other types of scapular dyskinesis. All these measurements were made in the resting position of the scapula. CONCLUSION: The 3D wing CT analysis allows precise quantification of a position associated with scapular dyskinesis. Therefore, 3D wing CT can be considered as an alternative method for assessing scapular dyskinesis.

Acute coccydynia related to precoccygeal calcific tendinitis.

Symptomatic deposits of calcium hydroxyapatite have been reported in various sites other than the shoulders or hips. Sudden-onset coccydynia can lead to the discovery of calcific deposition in the precoccygeal region. We present the case of precoccygeal calcific tendinitis in a patient with acute coccydynia.

Cervical epidural lymphangioma presenting as a hemorrhagic cyst: a case report.

STUDY DESIGN: A case report. OBJECTIVE: We report a case of epidural lymphangioma in the cervical spine, and it manifested as a hemorrhagic cyst. SUMMARY OF BACKGROUND DATA: Intraspinal lymphangioma is an uncommon tumor with only a few cases reported in the literature. Epidural lymphangioma presenting as a hemorrhagic cyst is extremely rare. METHODS: The patient chosen was a 43-year-old woman with the chief complaint of neck pain and right upper extremity numbness of 2-month duration. RESULTS: Cervical spine magnetic resonance (MR) imaging revealed an epidural cystic mass extending to the right C6-C7 neural foramen. The mass showed fluid-fluid levels on T2-weighted image and high-signal intensity on diffusion-weighted image. Surgical resection and histologic analysis confirmed the diagnosis of epidural lymphangioma with internal hemorrhage. CONCLUSION: Epidural lymphangioma is a rare benign tumor. However, it should be included in the differential diagnosis of hemorrhagic cystic mass in the epidural space, which presented with fluid-fluid levels on MR imaging and high-signal intensity on diffusion weighted imaging.