The Role of Botulinum Neurotoxin A in the Conservative Treatment of Fractures: An Experimental Study on Rats.

This paper explores the role of botulinum neurotoxin in aiding fracture recovery through temporary muscle paralysis. Specifically, it investigates the effects of botulinum neurotoxin-induced paralysis of the sternocleidomastoid muscle on clavicle fractures in rats. The research aims to assess safety, effectiveness, and the impact on fracture healing. Healthy male Albino Wistar rats were divided into four groups: clavicle fracture, botulinum neurotoxin injection, both, and control. Surgeries were conducted under anaesthesia, and postoperatively, animals were monitored for 28 days. Euthanasia and radiological assessment followed, examining fracture healing and muscle changes, while tissues were histopathologically evaluated. The modified Lane-Sandhu scoring system was used for the radiographic evaluation of clavicle fractures, and the results varied from complete healing to nonunion. Histopathological examination at 28 days postfracture showed fibrous tissue, mesenchymal cells, and primary callus formation in all groups. Despite varied callus compositions, botulinum neurotoxin administration did not affect clavicle healing, as evidenced by similar scores to the control group. Several studies have explored botulinum neurotoxin applications in fracture recovery. Research suggests its potential to enhance functional recovery in certain types of fractures. Theoretical benefits include managing muscle spasticity, aiding reduction techniques, and preventing nonunion. However, botulinum neurotoxin's transient effect and nonuniversal applications should be considered. The present study found that botulinum toxin had no clear superiority in healing compared to controls, while histological evaluation showed potential adverse effects on muscle tissue. Further research is essential to understand its risk-benefit balance and long-term effects.

Muscle Oxygenation, Neural, and Cardiovascular Responses to Isometric and Workload-matched Dynamic Resistance Exercise.

Differences in blood flow patterns and energy cost between isometric and dynamic resistance exercise may result to variant cardiovascular, neural, and muscle metabolic responses. We aimed to compare the cardiovascular, baroreceptor sensitivity, and muscle oxygenation responses between workload-matched, large muscle-mass isometric and dynamic resistance exercises. Twenty-four young men performed an isometric and a dynamic double leg-press protocol (4 sets×2 min) with similar tension time index (workload). Beat-by-beat hemodynamics, baroreceptor sensitivity, muscle oxygenation, and blood lactate were assessed. The increase in blood pressure was greater (p<0.05) in the 1st set during dynamic than isometric exercise (by ~4.5 mmHg), not different in the 2nd and 3rd sets, and greater in the 4th set during isometric exercise (by ~5 mmHg). Dynamic resistance exercise evoked a greater increase in heart rate, stroke volume, cardiac output, and contractility index (p<0.05), and a greater decline in peripheral resistance, baroreceptor sensitivity, and cardiac function indices than isometric exercise (p<0.05). Participants exhibited a greater reduction in muscle oxyhemoglobin and a greater increase in muscle deoxyhemoglobin in dynamic versus isometric exercise (p<0.001-0.05), with no differences in total hemoglobin and blood lactate. In conclusion, large muscle-mass, multiple-set isometric exercise elicits a relatively similar blood pressure but blunted cardiovascular and baroreceptor sensitivity responses compared to workload-matched dynamic resistance exercise. Differences in blood pressure responses between protocols appear small (~5 mmHg) and are affected by the number of sets. The muscle oxidative stimulus is greater during dynamic resistance exercise than workload-matched isometric exercise.

The Action of Botulinum Toxin A on the Sternocleidomastoid Muscle: An Experimental Study on Rats.

In this study, we aim to investigate the effective dose of botulinum neurotoxin A that results in paralysis of the sternocleidomastoid muscle for a minimum duration of 28 days in Wistar rats. This research is the first in a series of studies to investigate the value of botulinum toxin A in the healing of clavicle fractures through the temporary paralysis of the sternocleidomastoid. A surgical incision was made under general anaesthesia, and botulinum neurotoxin A in respective doses of 4 and 6 international units (IU) or normal saline in equivalent volumes were injected directly into the exposed muscle. Electromyography was conducted on days 0, 7, and 28 following substance administration to determine the extent of muscle paralysis. Electromyography on day 0 showed no paralysis in either group. Animals injected with neurotoxin all exhibited paralysis on days 7 and 28 that was weaker in the group injected with the smaller dose of 4 IU. One death occurred in the group injected with the higher dose (6 IU), whereas in the control group, no paralysis was seen. Botulinum neurotoxin A in a dose of 6 IU resulted in complete paralysis of the sternocleidomastoid in rats for a minimum of 28 days. A dose of 4 IU resulted in less potent paralysis but was safer in our research. Botulinum neurotoxin is a substance utilised in cosmetics and therapeutics for many years, yet research shows that its use can be expanded to target a wider range of pathologies. In this series of studies, we aim to explore the neurotoxin's applications on the treatment of clavicle fractures. To investigate this, we need to first establish the duration of its action on the sternocleidomastoid muscle.

Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair.

PURPOSE: To evaluate the significance of untreated primary acromioclavicular joint (ACJ) osteoarthritis, encountered during arthroscopic rotator cuff repair (RCR), as a cause of persistent symptomatology and need for revision surgery. METHODS: In a cohort of 811 consecutive patients older than 55 years who underwent RCR, the effect of primary ACJ osteoarthritis presence was prospectively examined. A total of 497 patients with mild/moderate and severe ACJ osteoarthritis based on preoperative MRI evaluation were allocated to Group A (n = 185, symptomatic ACJ) and Group B (n = 312, asymptomatic ACJ). Distal clavicle excision was not performed regardless of the presence of pain. The minimum follow-up was 28 months (28-46). The visual analogue scale (VAS) pain scores were assessed for ACJ pain on palpation, the cross body adduction test, the Constant-Murley, and the American Shoulder and Elbow Surgeons (ASES). RESULTS: The overall loss to follow-up rate was 3.82% (19 patients: 11 in Group A and eight in Group B). The mean ASES score at the latest follow-up was 91.16 ± 9.3 and 92.37 ± 10.44 in Groups A and B, respectively, and the mean Constant-Murley score was 96.36 ± 5.7 and 95.76 ± 4.6 in Groups A and B, respectively. There was no statistical significance between regarding both scores. Localised ACJ pain on palpation and pain on cross body adduction were diminished in both the symptomatic and asymptomatic group. There were five cases (1%: two in Group A and three in Group B) with persistent ACJ pain who had failed the conservative treatment, and ACJ excision was necessary to alleviate the symptoms. All revision operations were uncomplicated with symptom resolution. CONCLUSION: Untreated ACJ osteoarthritis, symptomatic or not, encountered during arthroscopic RCR is associated with a low percentage of failure. Routine distal clavicle excision is not absolutely necessary, even in patients with symptomatic ACJ osteoarthritis. LEVEL OF EVIDENCE: II, Prospective cohort study.

Non-surgical treatment as the first step to manage peritrochanteric space disorders.

PURPOSE: Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders. METHODS: A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders. RESULTS: Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications. CONCLUSION: Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology. LEVEL OF EVIDENCE: V.

Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique.

PURPOSE: The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection. METHODS: The study cohort consisted of 23 chronic low back pain patients (23-67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy. RESULTS: The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2-3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced. CONCLUSION: The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

Superior Capsular Reconstruction of the Shoulder Using the Long Head of the Biceps Tendon: A Systematic Review of Surgical Techniques and Clinical Outcomes.

Background and Objectives: Superior capsular reconstruction (SCR) with the use of a fascia lata autograft or a dermal allograft is an established treatment in treating irreparable rotator cuff (RC) tears. The long head of the biceps tendon (LHBT) has been recently proposed as an alternative graft for SCR. The purpose of this study was to present the surgical techniques and clinical studies utilizing the LHBT for SCR. Material and Methods: Medline, Scopus, and the Cochrane library were searched for relevant studies up to December 2020. The primary outcomes were pain intensity improvement and the incidence of RC and LHBT graft retears. Secondary outcomes were functional scores and acromiohumeral distance (AHD) improvements. Results: Nine studies described surgical techniques of SCR using the LHBT, and four clinical studies reported the outcomes of the technique. The mean pain intensity improved from 4.9 ± 2.3 to 1.6 ± 1.5 in terms of the visual analog scale, exceeding the minimum clinically important difference for adequate pain relief. Significant improvements were also noted in functional scores and AHD. When compared with other repair techniques for massive RC tears, i.e., the double-row repair, the transosseous-equivalent technique with absorbable patch reinforcement, and the traditional SCR with a fascia lata autograft, there were no significant differences in pain and function improvements. Conclusion: SCR using the LHBT is a useful treatment option for massive RC tears; it is equally effective with the traditional SCR and other established techniques. It presents numerous advantages being a safe, easy, time-saving, and cost-effective method. The only precondition for the technique is the presence of an intact LHBT. Additional clinical trials are necessary to determine which treatment is superior for treating massive RC tears, as well as to evaluate the long-term results of the technique.

Histology and Immunohistochemistry of Radial Arteries Are Suggestive of an Interaction between Calcification and Early Atherosclerotic Lesions in Chronic Kidney Disease.

Background and Objectives: recent studies suggest an implication of immune mechanisms in atherosclerotic disease. In this paper, the interaction between inflammation, calcification, and atherosclerosis on the vessel walls of patients with chronic kidney disease (CKD) is described and evaluated. Materials and Methods: patients with stage V CKD, either on pre-dialysis (group A) or on hemodialysis (HD) for at least 2 years (group B), in whom a radiocephalic arteriovenous fistula (RCAVF) was created, were included in the study. The control group included healthy volunteers who received radial artery surgery after an accident. The expressions of inflammatory cells, myofibroblasts, and vascular calcification regulators on the vascular wall were estimated, and, moreover, morphometric analysis was performed. Results: the expressions of CD68(+) cells, matrix carboxyglutamic acid proteins (MGPs), the receptor activator of nuclear factor-kB (RANK) and RANK ligand (RANKL), and osteoprotegerin (OPG), were significantly increased in CKD patients compared to the controls p = 0.02; p = 0.006; p = 0.01; and p = 0.006, respectively. In morphometric analysis, the I/M and L/I ratios had significant differences between CKD patients and the controls 0.3534 ± 0.20 vs. 0.1520 ± 0.865, p = 0.003, and 2.1709 ± 1.568 vs. 4.9958 ± 3.2975, p = 0.03, respectively. The independent variables correlated with the degree of vascular calcification were the intensity of CD34(+), aSMA(+) cells, and OPG, R2 = 0.76, p < 0.0001, and, with intima-media thickness (IMT), the severity of RANKL expression R2 = 0.3, p < 0.0001. Conclusion: atherosclerosis and vascular calcification in CKD seem to be strongly regulated by an immunological and inflammatory activation on the vascular wall.

Hamstring to quadriceps strength ratio and cross-sectional area of the quadriceps and hamstrings muscles assessed using extended field-of-view ultrasonography.

This study examined whether the association between hamstring (H) and quadriceps (Q) strength with size depends on the region and the muscle used to examined cross-sectional area (CSA). Maximum isometric contraction knee extension and flexion torque was obtained from 20 young participants while Q and H CSA was recorded using extended field of view ultrasonography at four sections along the thigh. Stepwise linear regression models using the maximum CSA of individual muscles showed a significant association of quadriceps (R2 = 0.793) and hamstring (R2 = 0.275) CSA with MVC torque (p < 0.05). The association was lower when maximum or section-specific muscle group CSAs were used as indices of size. The H:Q CSA ratio showed a significant association (R2 = 0.275, p < 0.05) and a moderate correlation (r = 0.48) with H:Q torque ratio. These results indicated that the association between muscle CSA and strength differs between the knee extensors and flexors. Amongst the various indices of muscle size, the combination of maximum CSA values of each muscle displayed the greatest relationship between strength and CSA. The H:Q CSA ratio can explain a significant but small part of the H:Q isometric strength ratio.

Postoperative Administration of Alpha-tocopherol Enhances Osseointegration of Stainless Steel Implants: An In Vivo Rat Model.

BACKGROUND: Alpha-tocopherol, a well-known antioxidative agent, may have a positive effect on bone formation during the remodeling phase of secondary fracture healing. Fracture healing and osseointegration of implants share common biological pathways; hence, alpha-tocopherol may enhance implant osseointegration. QUESTIONS/PURPOSES: This experimental study in rats assessed the ability of alpha-tocopherol to enhance osseointegration of orthopaedic implants as determined by (1) pull-out strength and removal torque and (2) a histomorphological assessment of bone formation. In addition, we asked, (3) is there a correlation between the administration of alpha-tocopherol and a reduction in postoperative oxidative stress (as determined by malondialdehyde, protein carbonyls, reduced and oxidized glutathione and their ratio, catalase activity and total antioxidant capacity) that develops after implantation of an orthopaedic implant? METHODS: This blinded study was performed in study and control groups, each consisting of 15 young adult male Wistar rats. On Day 0, a custom-designed stainless-steel screw was implanted in the proximal metaphysis of both tibias of all rats. On Day 1, animals were randomized to receive either alpha-tocopherol (40 mg/kg once per day intraperitoneally) or saline (controls). Animals were treated according to identical perioperative and postoperative protocols and were euthanized on Day 29. All animals completed the study and all tibias were suitable for evaluation. Implant pullout strength was assessed in the right tibias, and removal torque and histomorphometric evaluations (that is, volume of newly formed bone surrounding the implant in mm, percentage of newly formed bone, percentage of bone marrow surrounding the implant per optical field, thickness of newly formed bone in µm, percentage of mineralized bone in newly formed bone, volume of mature newly formed bone surrounding the implant in mm and percentage of mineralized newly formed bone per tissue area) were performed in the left tibias. The plasma levels of alpha-tocopherol, malondialdehyde, protein carbonyls, glutathione, glutathione disulfide, catalase, and the total antioxidant capacity were evaluated, and the ratio of glutathione to oxidized glutathione was calculated. RESULTS: All parameters were different between the alpha-tocopherol-treated and control rats, favoring those in the alpha-tocopherol group. The pullout strength for the alpha-tocopherol group (mean ± SD) was 124.9 ± 20.7 newtons (N) versus 88.1 ± 12.7 N in the control group (mean difference -36.7 [95% CI -49.6 to -23.9]; p < 0.001). The torque median value was 7 (range 5.4 to 8.3) versus 5.2 (range 3.6 to 6 ) N/cm (p < 0.001). The newly formed bone volume was 29.8 ± 5.7 X 10 versus 25.2 ± 7.8 X 10 mm (mean difference -4.6 [95% CI -8.3 to -0.8]; p = 0.018), the percentage of mineralized bone in newly formed bone was 74.6% ± 8.7% versus 62.1% ± 9.8% (mean difference -12.5 [95% CI -20.2 to -4.8]; p = 0.003), the percentage of mineralized newly formed bone per tissue area was 40.3 ± 8.6% versus 34.8 ± 9% (mean difference -5.5 [95% CI -10.4 to -0.6]; p = 0.028), the glutathione level was 2 ± 0.4 versus 1.3 ± 0.3 µmol/g of hemoglobin (mean difference -0.6 [95% CI -0.9 to -0.4]; p < 0.001), the median glutathione/oxidized glutathione ratio was 438.8 (range 298 to 553) versus 340.1 (range 212 to 454; p = 0.002), the catalase activity was 155.6 ± 44.6 versus 87.3 ± 25.2 U/mg Hb (mean difference -68.3 [95% CI -95.4 to -41.2]; p < 0.001), the malondialdehyde level was 0.07 ± 0.02 versus 0.14 ± 0.03 µmol/g protein (mean difference 0.07 [95% CI 0.05 to 0.09]; p < 0.001), the protein carbonyl level was 0.16 ± 0.04 versus 0.27 ± 0.08 nmol/mg of protein (mean difference -0.1 [95% CI 0.05 to 0.15]; p = 0.002), the alpha-tocopherol level was 3.9 ± 4.1 versus 0.9 ± 0.2 mg/dL (mean difference -3 [95% CI -5.2 to -0.7]; p = 0.011), and the total antioxidant capacity was 15.9 ± 3.2 versus 13.7 ± 1.7 nmol 2,2-diphenyl-1-picrylhydrazyl radical/g of protein (mean difference -2.1 [95% CI -4.1 to -0.18]; p = 0.008). CONCLUSIONS: These results using an in vivo rat model support that postoperatively administered alpha-tocopherol can enhance the osseointegration of an orthopaedic implant, although a cause and effect relationship between the administration of alpha-tocopherol and a reduction in postoperative stress cannot be securely established. CLINICAL RELEVANCE: These findings suggest that postoperative administration of alpha-tocopherol is a promising approach to enhance osseointegration of orthopaedic implants in patients. Further studies with different animal models and/or different implants and those evaluating the alpha-tocopherol dose response are needed before performing clinical trials that will examine whether these promising, preliminary results can be extrapolated to the clinical setting as well.

Management of the Pediatric Pulseless Supracondylar Humeral Fracture: A Systematic Review and Comparison Study of "Watchful Expectancy Strategy" Versus Surgical Exploration of the Brachial Artery.

BACKGROUND: Pulseless hand after a supracondylar humeral fracture (SHF) in children is well known in the bibliography. Although things are clearer in the management of a "pale pulseless hand," controversy still exists about the "pink pulseless hand" (PPH). METHODS: We reviewed the literature from the electronic database PubMed for studies with main object the vascular injuries after SHF in children and especially the pulseless hand. The primary search terms were "supracondylar humeral fracture" and "vascular injuries". In our final study, 16 articles were gathered and analyzed. RESULTS: We collected 608 pulseless SHFs, regardless of the vascular status, 203 PPHs, and 109 pale pulseless hands. We compared two different strategy methods when the hand remained pulseless after the reduction and fixation of the fracture: (1) the close observation strategy and (2) the surgical exploration of the artery. The close observation strategy was the treatment of choice in PPH, whereas the surgical exploration of the brachial artery was mostly performed in pale pulseless hands. CONCLUSIONS: Closed reduction and fixation of the fracture should be the priority in all pulseless SHFs, both pink and pale. In poorly perfused pale hands, after the reduction and fixation of the fracture, there is a chance that radial pulse may return (we found that this chance is approximately 30%). If not, immediate surgical exploration of the artery is strongly indicated. In well-perfused pink hands, the traditional dogma of "watchful waiting" should not be revisited as long as no signs of deterioration of the vascular status appear. LEVEL OF EVIDENCE: Level I-Systematic review of level I studies.

Anterior cruciate ligament deficiency reduces walking economy in "copers" and "non-copers".

PURPOSE: Patients with ACL injury requiring surgical treatment (non-copers) demonstrate altered neuromuscular control and gait pattern compared with those returning to their pre-injury activities without surgery (copers). Pathological gait pattern may increase the energy cost of walking. We compared the energy cost of flat, uphill, and downhill walking between ACL-deficient and healthy individuals and between "copers" and "non-copers". METHODS: Nineteen young males with unilateral ACL injury were allocated into "copers" and "non-copers" according to their ability to return to pre-injury activity without ACL reconstruction. Lysholm and IKDC scales were recorded, and a control group (n = 10) matched for physical characteristics and activity levels was included. All participants performed 8-min walking tasks at 0, +10, and -10 % gradients. Energy cost was assessed by measurement of oxygen consumption (VO2). HR and ventilation (VE), respiratory exchange ratio (RER), and VE/VO2 were also measured. RESULTS: VO2 and HR were higher in ACL-deficient patients than in controls during walking at 0, +10, and -10 % gradients (p < 0.01-0.05). There were no differences between "copers" and "non-copers" in VO2 and HR for any gradient. No differences were observed in VE, RER, and VE/VO2 among the three groups. CONCLUSIONS: The walking economy of level, uphill, and downhill walking is reduced in ACL-deficient patients. Despite the improved functional and clinical outcome of "copers", their walking economy appears similar to that of "non-copers" but impaired compared with healthy individuals. The higher energy demand and effort during locomotion in "copers" and "non-copers" has clinical implications for designing safer rehabilitation programmes. The increased energy cost in "copers" may be another parameter to consider when deciding on the most appropriate therapeutic intervention (operative and non-operative), particularly for athletes. LEVEL OF EVIDENCE: II.

Anatomic single-bundle anterior cruciate ligament reconstruction improves walking economy: hamstrings tendon versus patellar tendon grafts.

PURPOSE: Anterior cruciate ligament (ACL) injury is associated with a pathologic gait pattern and increased energy cost during locomotion. ACL reconstruction could improve the gait pattern. Hamstrings tendon (HAM) and bone-patellar tendon-bone (BPTB) grafts are usually used for reconstruction. The aim of this study was to compare the efficacy of anatomic ACL reconstruction with HAM and BPTB grafts on improving and normalizing the energy cost and physiologic reserves during flat, uphill, and downhill walking. METHODS: Twenty male subjects with unilateral ACL injuries were randomly assigned to ACL reconstruction with a HAM (n = 10) or BPTB (n = 10) graft. Ten matched controls were also enrolled. All participants performed three 8-min walking tasks at 0, +10, and -10 % gradients before and 9 months after surgery. Energy cost (oxygen consumption, VO2), heart rate (HR), and ventilation (VE) were measured. Lysholm/IKDC scores were recorded. RESULTS: Pre-operatively, VO2, HR, and VE were higher in the HAM and BPTB groups than in controls during walking at 0, +10, and -10 % gradients (p < 0.001-0.01). Post-operatively, both HAM and BPTB groups showed reduced VO2, HR, and VE during the three walking tasks (p < 0.001-0.01). Although the post-operative VO2 in both surgical groups reached 90-95 % of the normative (control) value during walking, it remained elevated against the value observed in controls (p < 0.001-0.01). The HAM and BPTB groups showed no differences in post-surgical VO2 or HR during walking at all three gradients. CONCLUSION: Anatomic ACL reconstruction with either HAM or BPTB graft resulted in similar short-term improvements in energy cost and nearly normalized locomotion economy and cardiorespiratory reserves during flat, uphill, and downhill walking. The improved locomotion economy is an additional benefit of anatomic ACL reconstruction, irrespective of the type of graft used, that the orthopaedic surgeons should consider. LEVEL OF EVIDENCE: II.

Use of Ultrasound to Monitor Biceps Femoris Mechanical Adaptations after Injury in a Professional Soccer Player.

This study examined the use of ultrasound to monitor changes in the long head of the biceps femoris (BF) architecture of aprofessional soccer player with acute first-time hamstring strain. The player followed a 14 session physiotherapy treatment until return to sport. The pennation angle and aponeurosis strain of the long head of the biceps femoris (BF) were monitored at 6 occasions (up until 1 year) after injury. The size of the scar / hematoma was reduced by 63.56% (length) and 67.9% (width) after the intervention and it was almost non-traceable one year after injury. The pennation angle of the fascicles underneath the scar showed a decline of 51.4% at the end of the intervention while an increase of 109.2% of the fascicles which were closer to deep aponeurosis was observed. In contrast, pennation angle of fascicles located away from the injury site were relatively unaffected. The treatment intervention resulted in a 57.9% to 77.3% decline of maximum strain per unit of MVC moment and remained similar one year after the intervention. This study provided an example of the potential use of ultrasound-based parameters to link the mechanical adaptations of the injured muscle to specific therapeutic intervention. Key pointsChanges in fascicle orientation after biceps femoris mild tear were reduced after a 28 day intervention and remained similar one year after injury.Tendon/aponeurosis strain per unit of moment of force decreased during the course of the therapeutic intervention.Future studies could utilize ultrasonography to monitor mechanical responses after various types of hamstring injury and interventions in order to improve criteria for a safe return to sport.

Judo-related traumatic posterior sternoclavicular joint dislocation in a child.

Judo is a combat sport with high risk of injury. We present a rare case of traumatic left posterior sternoclavicular (SC) joint dislocation, inflicted to a 12-year-old boy during a judo contest. An extensive literature review did not reveal any case of posterior SC joint dislocation in judo. The patient was treated with closed reduction under general anesthesia. At 2-year follow-up, his left upper extremity had full range of motion, and he did not complain of any residual symptoms. He decided to discontinue judo training; however, he participates in other physically demanding sports. Although not often encountered, posterior SC joint dislocation is a challenging and critical medical problem that can be fatal if not promptly diagnosed and treated on time and should be considered in the differential diagnosis of trauma-related anterior chest pain.

Circulating angiogenic biomolecules at rest and in response to upper-limb exercise in individuals with spinal cord injury.

OBJECTIVE: Individuals with spinal cord injury (SCI) show structural and functional vascular maladaptations and muscle loss in their lower limbs. Angiogenic biomolecules play important roles in physiological and pathological angiogenesis, and are implicated in the maintenance of muscle mass. This study examined the responses of angiogenic molecules during upper-limb aerobic exercise in patients with SCI and in able-bodied (AB) individuals. METHODS: Eight SCI patients with thoracic lesions (T6-T12, ASIA A) and eight AB individuals performed an arm-cranking exercise for 30 minutes at 60% of their VO2max. Plasma concentrations of vascular endothelial growth factor (VEGF-A165), VEGF receptor 1 (sVEGFr-1), VEGF receptor 2 (sVEGFr-2), metalloproteinase 2 (MMP-2), and endostatin were measured at rest, after exercise, and at 1.5 and 3.0 hours during recovery. RESULTS: The two-way analysis of variance showed non-significant main effects of "group" and significant main effects of "time/exercise" for all angiogenic biomolecules examined (P < 0.01-0.001). The arm-cranking exercise significantly increased plasma concentrations of VEGF, sVEGFr-1, sVEGFr-2, MMP-2, and endostatin in both groups (P < 0.001-0.01). The magnitude of the increase was similar in both patients with SCI and AB individuals, as shown by the non-significant group × time interaction for all angiogenic parameters. CONCLUSIONS: Upper-limb exercise (arm-cranking for 30 minutes at 60% of VO2max) is a sufficient stimulus to trigger a coordinated circulating angiogenic response in patients with SCI. The response of angiogenic molecules to upper-limb aerobic exercise in SCI appears relatively similar to that observed in AB individuals.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis.

PURPOSE: Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS: A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS: Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS: Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.

Bone Regeneration with Mesenchymal Stem Cells in Scaffolds: Systematic Review of Human Clinical Trials.

The aim of the study is to determine the effectiveness of stem cells in scaffolds in the treatment of bone deficits, in regard of bone regeneration, safety, rehabilitation and quality of life in humans. The systematic review was conducted in accordance with PRISMA 2020. A systematic search was conducted in three search engines and two registries lastly in 29-9-2022.for studies of the last 15 years. The risk of bias was assessed with RoB-2, ROBINS- I and NIH Quality of Before-After (Pre-Post) Studies with no Control group. The certainty of the results was assessed with the GRADE assessment tool. Due to heterogeneity, the results were reported in tables, graphs and narratively. The study protocol was published in PROSPERO with registration number CRD42022359049. Of the 10,091 studies retrieved, 14 were meeting the inclusion criteria, and were qualitatively analyzed. 138 patients were treated with mesenchymal stem cells in scaffolds, showing bone healing in all cases, and even with better results than the standard care. The adverse events were mild in most cases and in accordance with the surgery received. When assessed, there was a rehabilitation of the deficit and a gain in quality of life was detected. Although the heterogeneity between the studies and the small number of patients, the administration of mesenchymal stem cells in scaffolds seems safe and effective in the regeneration of bone defects. These results pave the way for the conduction of more clinical trials, with greater number of participants, with more standardized procedures.

In vivo and in vitro examination of the tendinous inscription of the human semitendinosus muscle.

The aim of this study was to examine the tendinous inscription (TI) of the human semitendinosus (ST) muscle using dissection (cadavers) and ultrasound (in vivo). Ultrasonography (US) scans were taken in 18 young males at rest and at maximum voluntary contraction (MVC). Further, the ST was dissected and removed from its origins in 10 cadaveric specimens (5 cadavers). The cadaveric long arm of the TI was 6.67 ± 0.64 cm (6.45 ± 1.21 in US) while the shorter arm was 2.39 ± 0.38 cm (1.99 ± 0.75 in US). The angle formed by the two TI arms ranged from 53.19 (US) to 56.05° (cadavers) while more superficial fascicles intersected the inscription at significantly higher angles (range 31.98 ± 6.15 to 34.69 ± 7.71°) compared with deeper fascicles (p < 0.05). Fascicle length did not differ between compartments, but it was significantly smaller in superficial compared with deeper layers (p < 0.05). With the exception of the angle between the TI arm and the deep aponeurosis, all measured angles as well as the length of the long arm of the TI increased significantly from rest to MVC (p < 0.05). The role of the TI probably lies in the local interconnections with the fascicles of either compartment, which upon contraction is such that the ST muscle contracts as one muscle. However, the TI arm morphology changes from rest to MVC, indicating a nonuniform displacement of the TI, mainly between the superficial and deeper layers of the muscle.

Radial head replacement with the MoPyC pyrocarbon prosthesis.

BACKGROUND: Radial head fractures often pose therapeutic dilemmas. We present the early results of patients who underwent radial head replacement with the MoPyC prosthesis (Bioprofile, Tornier, Saint-Ismier, France). MATERIALS AND METHODS: We re-evaluated patients who underwent post-traumatic radial head resection and implantation of the MoPyC prosthesis due to pain and motion restriction. All patients underwent radiographic evaluation. Clinical evaluation was performed using the Broberg-Morrey and the Mayo Elbow Performance Score (MEPS) scales. RESULTS: Thirty-two patients (20 men, 12 women; mean age, 54 years; 22 dominant upper limbs) were evaluated. Twenty had a comminuted radial head fracture (Mason IV, 15; Mason III, 5), 2 from radial head fracture malunion, and 10 had complex elbow injuries (comminuted radial head fractures with ligamentous ruptures with or without coronoid process fractures). Mean follow-up was 27 months (range, 21-46 months). The mean results at the latest follow-up were flexion-extension, 130° (range, 105°-150°); pronation, 74° (range, 60°-80°); and supination, 72° (range, 60°-80°). No laxity was evident during valgus and varus stress tests. Mean grip strength was 96% of the contralateral side. Broberg-Morrey scores were excellent in 33%, good in 44%, and fair in 23%. MEPS results were excellent in 80%, good in 17%, and fair in 3%. There were 6 cases of periprosthetic lucencies or osteolysis of the radius without any clinical signs of loosening. CONCLUSIONS: Radial head replacement with the MoPyC pyrocarbon prosthesis (when performed in carefully selected patients) yields satisfactory results regarding range of motion and function of the elbow joint.