Quantitative Sonographic Assessment of the Quadriceps Femoris Muscle in Healthy Japanese Adults.

OBJECTIVES: The aim of this study was to evaluate the relationships among aging, muscle strength, and image feature analysis of the quadriceps femoris muscle and to evaluate the relationship between aging, muscle strength, and sonographic findings. METHODS: One hundred forty-five healthy volunteers participated in the study. The participants were classified into 6 groups on the basis of sex and age. To assess muscle quality, texture analysis was defined with the following parameters: mean, skewness, kurtosis, inverse difference moment, sum of entropy, and angular second moment. The knee extension force in the sitting position and thickness of the quadriceps femoris muscle were also measured. RESULTS: The quadriceps femoris thickness, skewness, kurtosis, inverse difference moment, angular second moment, and muscle strength were significantly decreased in elderly participants versus those in the younger and middle-aged groups (P < .05). In contrast, the mean and sum of entropy were significantly decreased in the younger group compared with the middle-aged and elderly groups. CONCLUSIONS: Sonography has the capacity to quantitatively assess muscular morphologic changes due to aging and could be a valuable tool for early detection of musculoskeletal disorders.

Association of lubricin concentration in synovial fluid and clinical status of osteoarthritic knee.

OBJECTIVES: Although lubricin plays a role in controlling inflammation and pain as well as being a mechanical lubricant, clinical relevance of lubricin concentration in synovial fluid (SF) is unknown. The purpose was to determine whether lubricin concentration in SF is associated with the clinical status of the knee. METHODS: SF was obtained from 61 knee joints from patients who underwent any knee surgery with several stages of knee osteoarthritis. Lubricin/PRG4 concentration in SF was measured by enzyme-linked immunosorbent assay (ELISA). Clinical evaluations of the knee by the Kellgren and Lawrence (K-L) system, Knee Society Score (KSS), and the range of knee motion, and assessment of joint laxity were performed. Association of lubricin concentration in SF and these clinical factors was statistically analyzed. RESULTS: There was no significant correlation between lubricin concentration in SF and age, sex, K-L grade, or KSS. However, lubricin concentration was significantly correlated with anteroposterior laxity (R = 0.50, p < 0.001), full flexion angle (R = 0.39, p < 0.01), and range of knee motion (R = 0.38, p < 0.01), but not full extension angle, varus laxity, or valgus laxity. CONCLUSIONS: Lubricin concentration was correlated with joint flexibility, but not with clinical symptoms, including pain at that time.

Stress Fractures of the First Rib Related to Swinging of a Baseball Bat: Two Case Reports.

Stress fractures of the first rib are uncommon, and few reports have described the occurrence of this injury in overhead-throwing athletes. Furthermore, although there have been a few reports of first rib stress fractures on the throwing side in baseball players, fractures on the nonthrowing side are very rare. Here, we report 2 cases of first rib stress fractures on the nonthrowing side related to swinging of a baseball bat. The cause of the fractures in the present cases may have been repetitive traction and shear force on the first rib resulting from muscle exertion while swinging a bat. Conservative treatment that considered the mechanism of stress fractures resulted in a symptom-free and complication-free return to baseball. The patient's background should be considered for an accurate understanding of the injury mechanism, adequate conservative therapeutic plan, and a successful return to baseball.

Increased blood flow in the anterior humeral circumflex artery correlates with night pain in patients with rotator cuff tear.

BACKGROUND: Night pain is a particularly vexing symptom in patients with rotator cuff tear. It disturbs sleep and decreases quality of life, and there is no consensus regarding its etiology. Based on arthroscopic surgical observations of synovitis around the rotator interval or capsule surface in rotator cuff tear, we hypothesized that blood flow from the artery feeding the capsule increases blood supply to the synovium. This study aimed to investigate the relationship between blood flow and night pain using pulse Doppler ultrasonography. METHODS: A series of 47 consecutive patients with rotator cuff tear was evaluated. The peak systolic velocity and resistance index of blood flow in the ascending branch of the anterior humeral circumflex artery were evaluated using pulse Doppler ultrasonography. We also investigated 20 normal shoulders in healthy volunteers. The peak systolic velocity and resistance index were compared between affected and unaffected sides in patients and between dominant and nondominant sides in controls. RESULTS: Anterior humeral circumflex artery peak systolic velocity and resistance index did not differ between sides in control subjects or in patients with rotator cuff tear without night pain. However, anterior humeral circumflex artery peak systolic velocity and resistance index did differ significantly between sides in patients with rotator cuff tear with night pain. CONCLUSIONS: This study revealed anterior humeral circumflex artery hemodynamics in patients with rotator cuff tear and normal subjects using Doppler ultrasonography. Night pain, particularly involving aching, appears to be related to the hemodynamics. These findings suggest that investigating the hemodynamics of patients with rotator cuff tear with night pain may lead to greater understanding of the etiology of this symptom.

In vivo kinematics of a low contact stress rotating platform total knee arthroplasty system under weight bearing and non-weight bearing condition.

BACKGROUND: The patterns and magnitudes of axial femorotibial rotation are variable due to the prosthesis design, ligamentous balancing, and surgical procedures. We aimed to investigate the effects of the weight bearing (WB) condition on the kinematics of mobile-bearing total knee arthroplasty (TKA). METHODS: We examined 12 patients (19 knees) implanted with a low contact stress (LCS) mobile-bearing TKA system using a two-dimensional to three-dimensional registration technique. The in vivo kinematics of dynamic deep knee flexion under WB and non-WB (NWB) conditions were compared. We evaluated the knee range of motion, femoral axial rotation relative to the tibial component, anteroposterior translation, and kinematic pathway of the femorotibial contact point for both the medial and lateral sides. RESULTS: Under the WB condition, the mean range of motion was 117.8° ± 16.7°. Under the NWB condition, the mean range of motion was 111.0° ± 4.4°. The mean range of axial rotation from full extension to maximum flexion was 3.0° ± 1.5° under the WB condition and 2.2° ± 1.0° under the NWB condition. With regard to the anteroposterior translation, the LCS mobile-bearing TKA system showed the same kinematic patterns under both conditions, except for axial rotation at 0°, 10°, and 110°. From hyperextension to maximum flexion, the kinematic pattern reflected a central pivot under both conditions. CONCLUSIONS: In conclusion, this study demonstrated that, in an LCS mobile-bearing TKA system, knee kinematics showed the same patterns under NWB and WB conditions, except for axial rotation at the early phase. Further understanding of knee kinematics could provide us with useful information for future design concepts of TKA implants.

[Diagnostic ability of ultrasonography for the rotator cuff tear: comparison with ultrasonography and MRI findings].

Ultrasonography (US) is a non-invasive method which can assess not only solid tissue organs but also soft tissues such as tendons and nerves. However, it has not been fully understood that US is a useful tool for the depiction of periarticular structure. We compared the diagnostic accuracies between US and magnetic resonance imaging (MRI) in the patients with rotator cuff tear (RCT). Seventy patients, who underwent arthroscopic surgery, preoperative US and MRI examinations at Gifu University Hospital from January 2010 to April 2013 (49 male, 21 female, mean age 59.7 +/- 15.9) were included in this study. The diagnostic accuracy, sensitivity and specificity of US and MRI were 94.3% and 94.3%, 95.8% and 97.9%, 90.9% and 84.6%, respectively, when the intraoperative finding was regarded as a gold standard. These results suggest that US is useful for the diagnosis of RCT as equal as MRI.

Primary total hip arthroplasty with a spongy metal surface acetabular component for hip dysplasia.

We evaluated the clinical and radiographic results of primary total hip arthroplasty for 81 dysplastic hips (71 patients) using cementless Spongiosa Metal II cups (ESKA Implants, Lübeck, Germany). The mean follow-up period was 6.4 years (minimum 5 years), and the preoperative mean Japanese Orthopaedic Association hip score had improved from 45.2 to 87.4 points at the latest follow-up. The radiographic outcome was no aseptic loosening in all 81 hips. The hip center was located significantly more superior than in the contralateral normal hip in 45 patients, but the difference was less than 10 mm; however, there was no significant difference in the lateral position of the hip center. The use of a Spongiosa Metal II cup for dysplastic hips provided satisfactory 5- to 10-year clinical and radiographic results.

Arthroscopic Long Head of the Biceps Transposition for Superior Capsular Augmentation Results in Comparable Clinical Outcomes to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tears.

Purpose: To describe a modified arthroscopic technique of long head of biceps transposition (LHBT) for superior capsular augmentation; to investigate the outcomes and effectiveness of LHBT in patients with irreparable rotator cuff tears; and to compare the results with those of arthroscopic partial repair (APR) after a 2-year minimum follow-up. Methods: We retrospectively reviewed patients who underwent arthroscopic repair of large to massive superior rotator cuff tears. The inclusion criteria were an irreparable rotator cuff with inability of the tendon to reach the original footprint and postoperative follow-up for a minimum of 2 years. We investigated 22 patients followed up for 30.7 months (mean); 10 patients underwent isolated partial repair and 12 patients underwent LHBT combined with partial repair. The acromiohumeral interval (AHI) was measured using anteroposterior radiographs. Cuff integrity was defined using Sugaya's classification 2 years postoperatively. Clinical outcomes were assessed preoperatively and during postoperative follow-up (minimum 2 years) using the American Shoulder and Elbow Surgeons and University of California, Los Angeles shoulder rating scales. Results: Postoperative functional scores significantly improved in both groups. In the LHBT group, both American Shoulder and Elbow Surgeons and University of California, Los Angeles scores significantly improved postoperatively from 52.0 ± 14.6 to 89.3 ± 10.4 points (P = .002) and 15.2 ± 2.2 to 32.5 ± 2.6 points (P = .002), respectively. In addition, the AHI at the final follow-up was significantly greater in the LHBT group (7.5 ± 2.0 mm) than in the APR group (5.8 ± 1.9 mm) (P = .032). The retear rate, forward flexion, and postoperative functional scores at the final follow-up were better in the LHBT group; however, the intergroup differences were not statistically significant. Conclusions: Arthroscopic LHBT for irreparable rotator cuff tears showed comparable clinical outcomes and improvement in postoperative AHI compared with APR after a minimum 2-year follow-up. Level of Evidence: Level III, retrospective comparative trial.

Blood flow in the anterior humeral circumflex artery reflects synovial inflammation of the shoulder joint in rotator cuff tears.

Background: An association has been reported between rotator cuff tear and inflammation. We hypothesized that blood flow in the anterior humeral circumflex artery would reflect synovial inflammation in the shoulder. This study aimed to clarify the association of blood flow in the anterior humeral circumflex artery with synovial inflammation and shoulder pain in patients with rotator cuff tears. Methods: In this prospective, cross-sectional study, tissue samples from the synovium in the rotator interval were obtained from 33 patients undergoing arthroscopic rotator cuff repair. Reverse transcription-polymerase chain reaction and real-time polymerase chain reaction were performed to determine the messenger RNA expression of inflammatory mediators, growth factors, and matrix metalloproteinases. Additional tissue samples were fixed for histologic evaluation. Before surgery, we measured the peak systolic velocity in the anterior humeral circumflex artery using pulse Doppler ultrasonography. Results: The peak systolic velocity in the anterior humeral circumflex artery was positively correlated with the messenger RNA expression of interleukin 1ß, interleukin 8, and matrix metalloproteinase 3 genes (r = 0.49, P = .004; r = 0.55, P = .001; and r = 0.39, P = .026, respectively), as well as histologic synovitis scores (r = 0.48, P = .005). Additionally, it was significantly higher in patients with resting pain than in those without resting pain (P = .048). Conclusion: The peak systolic velocity in the anterior humeral circumflex artery is associated with the severity of synovial inflammation. Our results suggest that assessing the peak systolic velocity in the anterior humeral circumflex artery is useful for evaluating the severity of synovial inflammation.

Total Shoulder Arthroplasty in a Patient with Nail-Patella Syndrome: A Case Report.

CASE: A 62-year-old woman with a medical history of nail-patella syndrome (NPS) presented with chronic right shoulder pain. Physical examination revealed that her right shoulder had a restricted range of motion. Radiograph of the shoulder revealed arthritic changes with glenohumeral joint space narrowing, inferior humeral head osteophytes, and posterior glenoid wear. The patient was successfully treated with total shoulder arthroplasty (TSA). The patient had an uneventful postoperative course and was satisfied with her quality of life at the 30-month follow-up. CONCLUSION: TSA may be successfully performed with careful reaming of the hypoplastic glenoid fossa in patients with NPS.

Relationship between the morphology of the greater tuberosity and radiological and clinical outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Degenerative greater tuberosity (GT) changes are often associated with rotator cuff tears. However, little is known about the impact of GT morphology on surgical outcomes. The aim of this study was to examine the relationship between clinical and radiological outcomes, after rotator cuff repair, and GT morphology. METHODS: We retrospectively investigated shoulders that underwent arthroscopic repair of nontraumatic full-thickness supra-/infraspinatus tears. The exclusion criteria were a lack of either radiographs or magnetic resonance images, revision surgery, partial repair, complications such as infection or dislocation, and follow-up < 2 years. GT morphology on radiographs was classified into 5 groups: normal, sclerosis, bone spur, roughness, and femoralization. The acromiohumeral interval (AHI) was measured on anteroposterior radiographs. Fatty degeneration of the cuff muscles was evaluated using the global fatty degeneration index (GFDI). Postoperative cuff integrity was classified using Sugaya's classification at 2 years after surgery. Clinical outcomes were assessed preoperatively and at postoperative 2 years with the Japanese Orthopaedic Association score and the University of California, Los Angeles shoulder rating scale. RESULTS: The study included 220 shoulders in 212 patients (104 men and 108 women), with a mean age of 66 years (range 43-85). The mean follow-up period was 28 months (range, 24-60 months). Seven shoulders (3.2%) were classified as normal, 65 (29.5%) as sclerosis, 55 (25.0%) as bone spur, 78 (34.5%) as roughness, and 15 (6.8%) as femoralization. The preoperative AHI, in the roughness and femoralization groups, was significantly smaller than that in the sclerosis (P < .01) and bone spur groups (P < .001). The roughness and femoralization groups had a greater number of large tears (P = .006). In the roughness and femoralization groups, mean GFDI was significantly higher than that in the sclerosis group (P < .001 for both). Repaired cuff integrity was not different between all groups, respectively. Both Japanese Orthopaedic Association and University of California, Los Angeles scores improved postoperatively from 73.3 to 95.6 points and 18.2 to 34.0 points (P < .001 for both), respectively, and there were no significant differences between all groups, respectively. CONCLUSION: Roughness or femoralization of the GT was related to larger tears, with smaller AHI and higher GFDI. Repaired cuff integrity and clinical outcomes in shoulders with roughness or femoralization of the GT were not inferior to shoulders with the other types of GT morphologies in this study. Arthroscopic repair can be indicated for shoulders with advanced changes of the GT, if fatty degeneration of the cuff muscles is not severe.

Cementless total hip arthroplasty using a spongy metal surface hip prosthesis with a collarless, proximally porous-coated stem.

A collarless, proximally porous-coated type of Spongiosa Metal II hip prosthesis was used for cementless total hip arthroplasty in 52 hips, and 48 hips were followed and assessed during a mean follow-up period of 6.3 years (minimum 5 years). There were 8 hips (16.7%) that had stress shielding, and 2 hips (4.2%) that had thigh pain. In terms of stability, the stem was bony stable in 39 hips, fibrous stable in 6, and unstable in 3. The stability of the stem was significantly correlated with the stem canal filling ratio. It was suggested that the much more proximal transfer of loading stress by a collarless, proximally porous-coated stem is not suitable for the Spongiosa Metal II series because it may unacceptably reduce the stability of the stem.

Two-stage revision surgery for hip prosthesis infection using antibiotic-loaded porous hydroxyapatite blocks.

BACKGROUND: Infection of a hip prosthesis is one of the most severe complications encountered in orthopedic practice. Two-stage reconstruction using an antibiotic-impregnated cement spacer has become a popular procedure for the treatment of this condition. However, there are some disadvantages with the use of antibiotic-loaded cement, including low biocompatibility, a very low release ratio, and the possibility of thermal damage to the antibiotic. We have developed an effective drug delivery system for osteomyelitis in which porous hydroxyapatite (HA) blocks are loaded with an antibiotic by the vacuum method. We report here a modification of this delivery system applied for the first stage of two-stage reconstruction surgery against infected hip prosthesis. PATIENTS AND METHODS: Eight consecutive patients who developed hip prosthesis infection underwent two-stage revision total hip arthroplasty (THA) using antibiotic-loaded porous HA blocks prepared by the vacuum method. Thorough debridement and insertion of antibiotic-loaded HA blocks was performed in the first stage, followed by conversion to THA after eradication of infection in the second stage. RESULTS: The mean interval between the stages was 16.8 weeks. There were no complications related to the use of the antibiotic-loaded HA blocks. The patients were followed up for an average of 49 months with no evidence of recurrent infection. The mean Japanese Orthopedic Association hip score improved from 45.1 before surgery to 79.6 at the latest follow-up. INTERPRETATION: This simple approach utilizing antibiotic-impregnated HA blocks prepared by the vacuum method is considered to be effective for treatment of hip prosthesis infection.

Classification of stress fractures of the first rib in adolescent athletes.

Stress fractures of the first rib occur infrequently in adolescent athletes; therefore, there have been few case reports. Initial radiographs do not always lead to the diagnosis of first rib stress fractures. This study proposed a classification system and a possible mechanism for stress fractures of the first rib using three-dimensional computed tomography (3D-CT). The data of 10 stress fractures of the first rib in adolescent athletes obtained using 3D-CT between 2007 and 2018 were reviewed. Fractures of the first rib were classified according to the location and type of the fracture line. Stress fractures of the first rib were classified into three types: type 1, center-transverse fracture; type 2, center to posterior-oblique fracture; and type 3, posterior-transverse fracture. There were three type 1 fractures, five type 2 fractures, and two type 3 fractures. The fracture lines of types 1 and 2 were on the deep groove of the subclavian artery between the anterior and middle scalene muscle attachments, which is the thinnest and weakest portion of the first rib. However, the fracture line of type 3 was across the posterior part of the first rib and located slightly away from the deep groove of the subclavian artery. A 3D-CT classification of stress fractures of the first rib in adolescent athletes was proposed. Our results suggested that there are three types of the fracture and different mechanisms that cause this type of injury. This classification system helped to implement adequate conservative therapeutic plans based on the proposed mechanism.

Suprascapular Nerve Entrapment Caused by Protrusion of an Intraosseous Ganglion of the Glenoid into the Spinoglenoid Notch: A Rare Cause of Posterior Shoulder Pain.

We describe a case of suprascapular nerve entrapment caused by protrusion of an intraosseous ganglion of the glenoid into the spinoglenoid notch. A 47-year-old man with left shoulder pain developed an intraosseous cyst in the left glenoid, which came into contact with the suprascapular nerve. The area at which the patient experienced spontaneous shoulder pain was innervated by the suprascapular nerve, and 1% xylocaine injection into the spinoglenoid notch under ultrasonographic guidance relieved the pain. Therefore, we concluded that the protrusion of an intraosseous cyst of the glenoid into the spinoglenoid notch was a cause of the pain, and performed curettage. Consequently, the shoulder pain was resolved promptly without suprascapular nerve complications, and the cyst was histologically diagnosed as an intraosseous ganglion. This case demonstrated that the intraosseous ganglion of the glenoid was a benign lesion but could be a cause of suprascapular nerve entrapment syndrome. Curettage is a useful treatment option for a ganglion inside bone and very close to the suprascapular nerve.

Mid-Term Results of the SL-PLUS Femoral Prosthesis The Influence of Femoral Bone Type.

BACKGROUND: Cementless fixation of the femoral stem has been shown to be durable and predictable in total hip arthroplasty (THA), primarily as a result ofrecent improvements in prosthesis geometry and porous surface. Although patients with osteoporotic bone have been considered poor candidates for the use of a cementless femoral component, some recent studies have indicated satisfactory results. However, the indications and selection criteria of cementless stems based on the morphology of the femoral canal have not been established. PURPOSE: We aimed to assess and compare the mid-term results of cementless THA with an SL-PLUS® femoral component in patients classified as Dorr types A, B, and C. METHODS: We evaluated the clinical and radiographic results of primary THA with the cementless SL-PLUS® stem for 34 hips (25 patients). The preoperative femoral bones were classified as Dorr types A, B, and C in 12, 15, and 7 hips, respectively. Implant survival rates were calculated, hip function was evaluated using the Japanese Orthopaedic Association hip score, and radiographic signs were determined from anteroposterior radiographs. RESULTS: The mean follow-up period was 9.4 years (range: 7 to 13 years), and the mean Japanese Orthopaedic Association hip score improved from 43.8 points preoperatively to 85.3 points at the latest follow-up. The overall implant survival rate was 100% at 10 years; radiographic loosening or revision for any reason was used as the endpoint. Third and fourth degrees of stress shielding were observed in 29.4% of cases and were found to be significantly associated with a low cortical index, a Dorr type C femur, and a larger stem size. CONCLUSIONS: The use of the SL-PLUS® stem provided satisfactory mid-term clinical and radiographic results in patients with any type of femoral canal morphology.

Treatment of Humeral Fracture after Shoulder Arthroplasty using Functional Brace: A Case Report.

INTRODUCTION: A periprosthetic humeral fracture is rare after shoulder arthroplasty, and such cases have considerable problems. Patients with this kind of fracture are often complicated by osteopenia, other types of severe disease, or are elderly. Surgical treatment of this fracture type carries some risk, and surgeons may be unsure about the most appropriate approach to adopt. CASE REPORT: The present case occurred in a 78-year-old woman with an osteoporotic humeral bone, and chronic dislocation of shoulder after shoulder arthroplasty. There were many risk factors for revision surgery or ostheosynthesis. Therefore, we decided to treat the patient by functional bracing. Fortunately, complete radiographic union was confirmed at 17 weeks. She returned to daily life with good functional activity. CONCLUSION: In our opinion, it is acceptable to select functional bracing for periprosthetic humeral fractures after shoulder arthroplasty without stem loosening in elderly patients with an osteoporotic humeral bone.

A pilot study to assess Fatty infiltration of the supraspinatus in patients with rotator cuff tears: comparison with magnetic resonance imaging.

The aim of this study was to quantitatively assess the echo intensity of the supraspinatus muscle and compare magnetic resonance imaging and ultrasound findings for 27 patients (12 women, 15 men, 65.8 ± 11.5 y). Tear size and fatty infiltration were determined by magnetic resonance imaging; five stages were assigned based on Goutallier's classification. Gray-scale histogram analysis was used for ultrasound assessment, which was performed in both subcutaneous fat and supraspinatus muscle in three different regions; the echo intensity ratio was the ratio of echo intensity in subcutaneous fat to that in the supraspinatus muscle. Sonograms of 27 shoulders revealed 3 shoulders with a partial tear, and 4 with a small tear, 6 with a medium tear, 6 with a large tear and 4 with a massive tear; 4 shoulders had no tear. Supraspinatus muscle echo intensity and echo intensity ratio were significantly lower in the stage 0 and 1 than in stages 2-4. Our study suggests that ultrasound can quantitatively and objectively assess fatty infiltration in the rotator cuff muscle.