Prevalence of AAV2.5 neutralizing antibodies in synovial fluid and serum of patients with osteoarthritis.

Osteoarthritis (OA) is a leading cause of disability with no cure and only supportive therapy. Adeno-associated virus (AAV) serotype 2.5 is being used in a Phase I clinical trial to deliver the interleukin-1 receptor antagonist into knee joints with OA. Neutralizing antibodies (Nab) directed against AAV2.5, if present, could inhibit gene transfer. Here, we report the prevalence of AAV2.5 Nab in the sera and synovial fluids of patients with OA. Nab titers were measured by their ability to inhibit in vitro transduction by AAV2.5 encoding GFP. Of 44 synovial fluids from patients with mid-stage and advanced OA, 43% had undetectable Nab; 25% had low titers (<1:100), 16% had medium titers (1:100-1:1000) and 16% had high titers (>1:1000) of Nab. Titers of AAV2.5 Nabs correlated with those of AAV2, but not with those of AAV5. Serum titers of AAV2.5 Nab correlated positively with titers in synovial fluid, and were never less than the matched synovial fluid titers. These findings suggest that high titers of Nab against AAV2.5 are uncommon in the synovial fluids of patients with OA, and individuals with high synovial fluid Nab titers can be identified by measuring titers in the serum.

Diagnostic Imaging of A2 Pulley Injuries: A Review of the Literature.

Injury to the A2 pulley is caused by high eccentric forces on the flexor-tendon-pulley system. Accurate diagnosis is necessary to identify the most appropriate treatment options. This review summarizes the literature with respect to using ultrasound (US) to diagnose A2 pulley injuries, compares ultrasound to magnetic resonance imaging and computed tomography, and identifies current knowledge gaps. The results suggest that US should be used as the primary imaging modality given high accuracy, relatively low cost, ease of access, and dynamic imaging capabilities. Manual resistance is beneficial to accentuate bowstringing, but further research is needed to determine best positioning for evaluation.

Recommended Musculoskeletal and Sports Ultrasound Terminology: A Delphi-Based Consensus Statement.

OBJECTIVES: The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. METHODS: A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%. RESULTS: Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein. CONCLUSIONS: The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

American Medical Society for Sports Medicine sports ultrasound curriculum for sports medicine fellowships.

Sports ultrasound is commonly used by sports medicine physicians to enhance diagnostic and procedural accuracy. This expert consensus statement serves as an update to the 2015 American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Although written in the context of the American sports medicine fellowship training model, we present a stepwise progression in both diagnostic and interventional sports ultrasound that may be applicable to the broader sports medicine community. The curriculum is divided into 12 units with each unit including didactic instructional sessions, practical hands-on instruction, independent scanning practice sessions and mentored clinical experience. To assist with prioritisation of learning, we have organised relevant pathology and procedures as essential, desirable and optional The expanded content can serve as an outline for continuing education postfellowship or for any physician to further advance their sports ultrasound knowledge and skill. We also provide updated scanning protocols, sample milestones and a sample objective structured clinical examination to aid fellowships with implementation of the curriculum and ongoing assessment of fellow progress.

Recommended musculoskeletal and sports ultrasound terminology: a Delphi-based consensus statement.

The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Accuracy of Ultrasound Compared to Magnetic Resonance Imaging in the Diagnosis of Thumb Ulnar Collateral Ligament Injuries: A Prospective Case Series.

This prospective case series compared the accuracy of ultrasound (US) to magnetic resonance imaging (MRI) in differentiating complete displaced (CD) thumb ulnar collateral ligament (UCL) tears from nondisplaced injuries in 10 patients with suspected traumatic thumb UCL injuries. Ultrasound identified 100% (2 of 2) of MRI-documented CD tears, both of which were further confirmed during surgical repair. Ultrasound identified the absence of CD tears in the remaining 8 patients. Although MRI is the reference standard imaging modality for characterizing thumb UCL injuries, ultrasound should be considered an accurate, cost-effective, and alternative imaging modality to differentiate surgical versus nonsurgical thumb UCL injuries.

Role of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve for diagnosis and potential treatment of chronic lateral elbow pain.

OBJECTIVE: To examine diagnostic and therapeutic utility of novel ultrasound-guided perineural injection of posterior antebrachial cutaneous nerve in chronic lateral elbow pain. MATERIALS AND METHODS: We performed a retrospective analysis of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve with local anesthetic with or without corticosteroid in patients with chronic lateral elbow pain. Data variables collected included patient demographics, illness course, diagnostic ultrasound findings, immediate pre- and post-injection pain using numeric rating pain scale between 0 and 10, injection complications, and post-injection outcomes. RESULTS: Fifteen patients (9 females and 6 males) with average age 46.9 (range 16-69 years) underwent 20 perineural injections between 2009 and 2019. Patients had on average 84% reduction in pain immediately after the injection (median pre- and post-procedure numeric rating pain scale of 6 and 0, respectively, p < 0.001). Patients had pain relief for an average of 15 h (range 2-48 h) when only local anesthetic was injected, compared with average pain relief of 26.5 days (range 2 h-43 days) when local anesthetic was combined with corticosteroid, p = 0.01. CONCLUSION: Novel ultrasound-guided perineural anesthetic injections around the posterior antebrachial cutaneous nerve can be performed safely and have diagnostic and potentially therapeutic utility in select patients with chronic refractory lateral elbow pain.

American Medical Society for Sports Medicine Sports Ultrasound Curriculum for Sports Medicine Fellowships.

ABSTRACT: Sports ultrasound is commonly used by sports medicine physicians to enhance diagnostic and procedural accuracy. This expert consensus statement serves as an update to the 2015 American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Although written in the context of the American sports medicine fellowship training model, we present a stepwise progression in both diagnostic and interventional sports ultrasound that may be applicable to the broader sports medicine community. The curriculum is divided into 12 units with each unit including didactic instructional sessions, practical hands-on instruction, independent scanning practice sessions, and mentored clinical experience. To assist with prioritization of learning, we have organized relevant pathology and procedures as essential, desirable, and optional. The expanded content can serve as an outline for continuing education postfellowship or for any physician to further advance their sports ultrasound knowledge and skill. We also provide updated scanning protocols, sample milestones, and a sample objective structured clinical examination (OSCE) to aid fellowships with implementation of the curriculum and ongoing assessment of fellow progress.

Sonoanatomy and Pathology of the Gluteus Minimus Tendon.

Gluteus minimus disorders are a potential source of greater trochanteric or anterior hip pain. Disorders of the gluteus minimus tendon most commonly occur in conjunction with gluteus medius tendon abnormalities but can also occur in isolation. Understanding the sonoanatomy of the gluteus minimus muscle-tendon unit is a prerequisite for recognizing and characterizing gluteus minimus tendon disorders, which, in turn, guides treatment for patients with greater trochanteric or anterior hip pain syndromes.

Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel.

INTRODUCTION: The aim of this study was to assess alterations in median nerve (MN) biomechanics within the carpal tunnel resulting from ultrasound-guided hydrodissection in a cadaveric model. METHODS: Twelve fresh frozen human cadaver hands were used. MN gliding resistance was measured at baseline and posthydrodissection, by pulling the nerve proximally and then returning it to the origin. Six specimens were treated with hydrodissection, and 6 were used as controls. RESULTS: In the hydrodissection group there was a significant reduction in mean peak gliding resistance of 92.9 ± 34.8 mN between baseline and immediately posthydrodissection (21.4% ± 10.5%; P = 0.001). No significant reduction between baseline and the second cycle occurred in the control group: 9.6 ± 29.8 mN (0.4% ± 5.3%; P = 0.467). DISCUSSION: Hydrodissection can decrease the gliding resistance of the MN within the carpal tunnel, at least in wrists unaffected by carpal tunnel syndrome. A clinical trial of hydrodissection seems justified. Muscle Nerve 57: 25-32, 2018.

Accessory neuropathy after sternotomy: Clinico-anatomical correlation supporting an inflammatory cause.

Inflammatory etiologies are becoming increasingly recognized as explanations of some neuropathies, especially those occurring in the perioperative period. Although "brachial neuritis" is known to affect extraplexal nerves, accessory nerve palsy following median sternotomy has been attributed to stretch on the nerve. To better elucidate stretch as a potential cause, a cadaveric study was performed. Two patients who developed accessory nerve palsy following median sternotomy are presented to illustrate features consistent with the diagnosis of a perioperative inflammatory neuropathy. Five adult unembalmed cadavers underwent exposure of the bilateral accessory nerves in the posterior cervical triangle. A median sternotomy was performed and self-retaining retractors positioned. With the head in neutral, left rotation and right rotation, retractors were opened as during surgery while observing and recording any accessory nerve movements. The self-retaining sternal retractors were fully opened to a mean inter-blade distance of 13 cm. Regardless of head position, from the initial retractor click to maximal opening there was no gross movement of the accessory nerve on the left or right sides. Opening self-retaining sternal retractors does not appear to stretch the accessory nerve in the posterior cervical triangle. Based on our clinical experience and cadaveric results, we believe that inflammatory conditions, (i.e., idiopathic brachial plexitis) can involve the accessory nerve, and might be triggered by surgical procedures. Clin. Anat. 31:417-421, 2018. © 2017 Wiley Periodicals, Inc.

Correction to: A multi-center analysis of adverse events among two thousand, three hundred and seventy two adult patients undergoing adult autologous stem cell therapy for orthopaedic conditions.

The published online version contains mistake in Acknowledgment Section. The author name "Steve Gorin, M.D." should have been "Steven Gorin, D.O, M.S.Ed.".

Sonoanatomy and Pathology of the Posterior Band of the Gluteus Medius Tendon.

Greater trochanteric pain syndrome is a common clinical entity that most often results from disorders of the gluteus medius tendon. There are two distinct bands of the gluteus medius tendon, and abnormalities may affect the anterior or posterior band in isolation or simultaneously. Although abnormalities of the anterior band are more common, awareness and sonographic detection of posterior band abnormalities is essential to guide treatment in the setting of greater trochanteric pain syndrome.

Sonographic Visualization of the Posterior Cutaneous Nerve of the Forearm: Technique and Validation Using Perineural Injections in a Cadaveric Model.

OBJECTIVES: To determine the ability to sonographically identify the posterior cutaneous nerve of the forearm (PCNF) and its distal epicondylar branches using sonographically guided perineural injections in an unembalmed cadaveric model. METHODS: A single experienced operator used a 12-3-MHz linear array transducer to identify the PCNF and its distal epicondylar region branches in 10 unembalmed cadaveric specimens (6 right and 4 left) obtained from 10 donors. Sonographically guided perineural PCNF injections were then completed with a 22-gauge, 38-mm stainless steel needle to deliver 0.25 mL of 50% diluted colored latex at 3 points along the PCNF. The latex location was then confirmed via dissection. RESULTS: The 10 donors included 4 male and 6 female cadavers aged 48 to 94 years (mean, 73 years) with body mass indices of 19 to 37 kg/m2 (mean, 26 kg/m2 ). The operator sonographically identified the PCNF and several distal branches traversing over or directly adjacent to the lateral epicondyle in all 10 specimens. Only 7 of 10 specimens showed a distinct PCNF bifurcation into anterior and posterior divisions, and all 7 were accurately identified and localized on sonography. There was no evidence of latex overflow to clinically relevant adjacent structures or injury to regional vessels or nerves. CONCLUSIONS: High-resolution sonography can identify the PCNF and its distal epicondylar branches. Sonographic evaluation of the PCNF should be included in the evaluation of patients presenting with refractory or atypical lateral elbow pain syndromes. Diagnostic and therapeutic sonographically guided procedures targeting the PCNF or its lateral epicondylar branches are feasible and warrant further investigation.

Ultrasound of the Gruberi Bursa With Cadaveric and MRI Correlation.

OBJECTIVE: The purpose of this study was to describe the appearance and ultrasound characteristics of the Gruberi bursa using a cadaveric model and retrospective ultrasound imaging review. MATERIALS AND METHODS: For the cadaveric study, ultrasound of the dorsolateral ankle of a foot-ankle specimen was performed and was followed by injection of latex between the extensor digitorum longus (EDL) tendons and the talus and dissection. For the ultrasound imaging review, the radiology database was searched for ultrasound studies performed from September 15, 2000, through April 1, 2015, to identify subjects with a dorsolateral foot or ankle fluid collection detected on ultrasound. Images were retrospectively reviewed to characterize the location and size of the fluid collection, assess for the number of locules, and evaluate the compressibility of the fluid collection. It was determined whether the ultrasound findings were significantly different from chance: CI and p values were obtained from performing a test for one proportion. RESULTS: Dissection of a cadaveric specimen revealed latex within a well-defined region between the EDL tendons and the dorsolateral talus; this location is consistent with a Gruberi bursa. For the image review, the imaging examinations of 162 subjects (age range, 16-88 years; 31 male subjects and 131 female subjects) were reviewed. On the ultrasound images, a fluid collection with its epicenter between the dorsolateral talus and EDL was found in 93% of ankles. Of the fluid collections identified on ultrasound, 98% were unilocular and 94% were anechoic. Of these fluid collections, 133 were assessed for compressibility, and 89% were compressible. The positive findings for a Gruberi bursa that were different from chance (p < 0.0001) were a fluid collection being located between the EDL tendons and the dorsolateral talus and being unilocular, anechoic, and compressible. CONCLUSION: The Gruberi bursa characteristically is located between the EDL and the talus; on ultrasound, the Gruberi bursa is most commonly unilocular, anechoic, and compressible.

Role of Sonography in the Diagnosis and Treatment of Common Peroneal Neuropathy Secondary to Fabellae.

The fabella is a sesamoid bone situated in the posterolateral knee, which may contribute to posterolateral knee pain by impinging on the adjacent common peroneal nerve (CPN). Although anatomic studies have established an relationship between the fabella and CPN, we present 4 cases of posterolateral knee pain radiating into the anterolateral leg in which sonography was able to determine the source of the pain as CPN compression by an adjacent fabella. In 2 of these cases, resolution of symptoms was achieved with ultrasound-guided CPN blocks, whereas 1 case was surgically treated, and another was managed with oral analgesics. These cases illustrate the utility of diagnostic and interventional sonography in the evaluation and treatment of posterolateral knee pain secondary to fabellar impingement of the CPN.

A multi-center analysis of adverse events among two thousand, three hundred and seventy two adult patients undergoing adult autologous stem cell therapy for orthopaedic conditions.

INTRODUCTION: The purpose of the present investigation is to report on detailed complications among a much larger group of 2372 orthopaedic patients treated with stem cell injections who were followed in a treatment registry for up to nine years. METHODS: All patients underwent an MSC-based, percutaneous injection treatment of an orthopaedic condition between December 2005 and September 2014 at one of 18 clinical facilities. Treated areas of the body included the knee, hip, ankle/foot, hand/wrist, elbow, shoulder, and spine. The patients were followed prospectively via enrollment in a treatment registry. Patients were followed prospectively at one, three, six and 12 months, and annually thereafter, using an electronic system, ClinCapture software. RESULTS: A total of 3012 procedures were performed on 2372 patients with follow-up period of 2.2 years. A total of 325 adverse events were reported. The majority were pain post-procedure (n = 93, 3.9 % of the study population) and pain due to progressive degenerative joint disease (n = 90, 3.8 % of the study population). Seven cases reported neoplasms, a lower rate than in the general population. The lowest rate of adverse events was observed among patients injected with BMC alone. CONCLUSION: Lowest rate of adverse events was among those patients receiving BMC injections alone, but the higher rate of AEs for BMC plus adipose and cultured cells was readily explained by the nature of the therapy or the longer follow-up. There was no clinical evidence to suggest that treatment with MSCs of any type in this study increased the risk of neoplasm.

The effect of magnification on sonographically measured nerve cross-sectional area.

INTRODUCTION: The primary aim of this investigation was to determine whether use of write-zoom magnification affects sonographically determined cross-sectional area (CSA) of peripheral nerves. METHODS: CSAs of the median (MN) and posterior interosseous (PIN) nerves were measured in 22 limbs from 11 asymptomatic volunteers using both standard imaging and write-zoom magnification. CSA measurements were repeated on the same images 1 week later. RESULTS: The average CSA of write-zoomed images for the MN was significantly larger at both measurement sessions (week 1: 11.1 mm(2) write-zoom vs. 10.0 mm(2) standard, P = 0.019; week 2: 11.8 mm(2) vs. 10.4 mm(2), P = 0.023). Similar differences were noted for the PIN (week 1: 2.3 mm(2) vs. 1.9 mm(2), P = 0.002; week 2: 2.5 mm(2) vs. 1.9 mm(2), P = 0.001). CONCLUSIONS: Write-zoom magnification may significantly increase the measured CSA of peripheral nerves. These changes appear to be more substantial when smaller nerves are measured.

Role of Sonography in Surgical Decision Making for Iatrogenic Spinal Accessory Nerve Injuries: A Paradigm Shift.

The spinal accessory nerve (SAN) is susceptible to iatrogenic injury in the posterior cervical triangle. Early diagnosis and management of suspected SAN transection injuries are crucial in the restoration of shoulder stability and function. Although neurologic examination and electrodiagnostic testing can assess SAN function, they cannot assess nerve continuity. We report the use of sonography to prospectively evaluate the SAN in 6 patients with suspected iatrogenic SAN injury. Sonography directly visualized SAN transection in 4 cases, whereas sonographic findings were reported as "probable" transection in the fifth case and was nondiagnostic in the sixth case in the setting of extensive scarring.

Sonographically guided sternoclavicular joint injection: description of technique and validation.

OBJECTIVES: The primary purpose of this investigation was to describe and validate a sonographically guided technique for injecting the sternoclavicular joint (SCJ) using a cadaveric model. METHODS: A single experienced operator (J.S.) completed 13 sonographically guided SCJ injections on 7 unembalmed cadaveric specimens (4 male and 3 female) using an out-of-plane, caudad-to-cephalad technique to place 1 mL of diluted blue latex into the joint. Within 72 hours, study coinvestigators dissected each specimen to determine the injectate location. RESULTS: All 13 injections accurately placed latex into the SCJ with a predilection for the clavicular side (accuracy, 100%; 95% confidence interval, 73%-100%). Three injections (23%) placed all latex on the clavicular side of the SCJ in the presence of a complete intra-articular disk. Dissection revealed incomplete degenerated disks in the remaining 10 joints. Seven of these injections (54%) clearly placed more than 80% of the latex on the clavicular side, whereas the remaining 3 injections (23%) showed nearly equal latex distribution between the clavicular and sternal sides. No injection resulted in neurovascular injury or extracapsular flow. CONCLUSIONS: Sonographically guided SCJ injections can be considered in the diagnosis and management of patients presenting with medial shoulder pain syndromes and, using the technique described herein, have a predilection to target the clavicular portion of the joint. In younger patients with possible complete intra-articular disks or in patients with sternal-side conditions, practitioners should consider confirming sternal-side flow after injection or attempt to specifically target the sternal side of the joint.