Masseteric nerve ultrasound identification for dynamic facial reanimation purposes.

BACKGROUND: the masseteric nerve is one of the main options to neurotize free muscle flaps in irreversible long-term facial paralysis. Several preoperative skin marking techniques for the masseteric nerve have been proposed to limit the surgical dissection area, shorten the surgical time, and enable a safer dissection. However, these have shown variability amongst them and cannot preoperatively visualize the nerve. Thus, we aim to design an observational study to validate a high-frequency ultrasound (HFUS) nerve identification technique. METHODS: a systematic HFUS examination was designed and performed to visualize the masseteric nerve in 64 hemifaces of healthy volunteers. One-third were randomly selected to undergo an additional HFUS-guided needle electrostimulation to validate the HFUS image. RESULTS: the masseteric nerve was identified by HFUS in 96,9% of hemifaces (95% CI 0.89 to >0.99) and showed almost perfect agreement with direct needle stimulation as calculated with Cohen's kappa coefficient; 0.95 (CI 0.85 to 1.00). It was found within the masseter muscle, in between the deeper muscle bellies, at 18,3 mm (SD ±2,2) from the skin. Only in 12,9% of cases (95 CI 0.06 to 0.24) its course became adjacent to the mandible periosteum. Other important features, such as disposition in relation to the parotid gland or whether the nerve was directly covered by a thick intramuscular aponeurosis, could be well observed by HFUS. CONCLUSIONS: HFUS enables masseteric nerve identification and can give the surgeon specific information on anatomical relations for each examined individual prior to surgery.

High-resolution ultrasound tendon-to-bone distances in partial and complete finger flexor A2 pulley ruptures simulated in human cadaver dissection: toward understanding imaging of partial pulley ruptures.

Introduction: The A2 pulley tear is the most common injury in rock climbing. Whereas complete A2 pulley ruptures have been extensively researched, studies focused on partial A2 pulley ruptures are lacking. A2 pulleys rupture distally to proximally. High-resolution ultrasound imaging is considered the gold-standard tool for diagnosis and the most relevant ultrasound measurement is the tendon-to-bone distance (TBD), which increases when the pulley ruptures. The purpose of this study was to establish tendon-to-bone distance values for different sizes of partial A2 pulley ruptures and compare these values with those of complete ruptures. Material and methods: The sample consisted of 30 in vitro fingers randomly assigned to 5 groups: G1, no simulated tear (control); G2, simulated 5 mm tear (low-grade partial rupture); G3, simulated 10 mm tear (medium-grade partial rupture); G4, simulated 15 mm tear (high-grade partial rupture); and G5, simulated 20 mm or equivalent tear (complete rupture). A highly experienced sonographer blinded to the randomization process and dissections examined all fingers. Results: The tendon-to-bone distance measurements (medians and interquartile ranges) were as follows: G1, 0.95 mm (0.77-1.33); G2, 2.11 mm (1.78-2.33); G3, 2.28 mm (1.95-2.42); G4, 3.06 mm (2.79-3.28); and G5, 3.66 mm (3.55-4.76). Significant differences were found between non-torn pulleys and simulated partial and complete pulley ruptures. Discussion: In contrast, and inconsistent with other findings, no significant differences were found among the different partial rupture groups. In conclusion, the longer the partial pulley rupture, the higher the tendon-to-bone distance value. The literature is inconsistent regarding the tendon-to-bone distance threshold to diagnose a partial A2 pulley rupture. The minimum tendon-to-bone distance value for a partial rupture was 1.6 mm, and tendon-to-bone distance values above 3 mm suggest a high-grade partial pulley rupture (15 mm incision) or a complete pulley rupture.

Longer Tendon-Bone Distances of the A2 and A4 Annular Pulleys in Experienced High-Level Sport Climbers: Injury or Adaptation?

INTRODUCTION: Experienced high-level climbers are subject to a number of bone and soft tissue changes over the years and are also among the most exposed to pulley injuries. One of the main consequences of pulley rupture is the separation of the flexor tendons from the subjacent phalanges, also known as bowstringing. The purpose of this study was to determine whether this population has asymptomatic bowstringing of the A2 and/or A4 pulleys as determined by tendon-bone distance (TBD) values when compared to nonclimbers. METHODS: High-resolution ultrasound TBD measurements in active forced flexion were made for the A2 and A4 pulley of the ring finger bilaterally. Participants were 21 asymptomatic sport climbers who had 21 consecutive years of climbing at a level above 9.66 in the International Mountaineering and Climbing Federation difficulty metric scale. Control subjects were 21 age-matched nonclimbers. RESULTS: A significantly longer TBD-25% (0.3 mm) and 35% (0.4 mm) for the A2 and A4 pulleys, respectively-was found in the experienced climbers group (experienced climbers group: A2 1.6±0.5 mm and A4 1.6±0.4 mm; nonclimbers group: A2 1.2±0.1 mm and A4 1.2±0.2 mm). CONCLUSIONS: Our results suggest that bowstringing of A2 and A4 pulleys occurs in asymptomatic experienced high-level climbers, which could be interpreted as either an adaptive mechanism to workloads endured over years of climbing or a consequence of underdiagnosed pulley ruptures.

Minimally invasive ultrasound-guided vs open release for carpal tunnel syndrome in working population: A randomized controlled trial.

PURPOSE: To compare the clinical effectiveness of minimally invasive ultrasound (US)-guided vs open release for carpal tunnel syndrome. METHODS: In an open randomized controlled trial, 47 employed patients were allocated to US-guided carpal tunnel release (USCTR) and 42 to an open carpal tunnel release (OCTR) procedure. The main outcome was symptom severity measured by the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ-S). Secondary outcomes were hand functionality (BCTQ-F), nerve conduction, two-point discrimination, handgrip and pinch strength, pain (visual analog scale), work leave and complications. For BCTQ-S and BCTQ-F, minimal clinically important differences (MCID) were also considered. Follow-up duration was 12 months. RESULTS: Mixed model analyses detected no significant differences between the two treatment arms in BCTQ-S (P = .098) while BCTQ-F scores were significantly better in the USCTR group (P = .007). This benefit was, however, not supported by the MCID data. Remaining variables were similar in the two groups except pain which was lower in USCTR at 3 months follow-up. All variables but two-point discrimination showed significant improvement after 3 months. CONCLUSIONS: Our findings reveal similar symptom relief benefits following OCTR or USCTR in these patients. The patients in our USCTR group, however, reported better hand functional status and less pain.

Ultrasonographic Diagnosis of A2 or A4 Flexor Tendon Pulley Injury: A Systematic Review.

A2 or A4 annular finger pulley tears are common injuries in rock climbers. This study reviews the measurement procedures used and tendon-to-bone distance data obtained on high-resolution ultrasound images when diagnosing isolated rupture of the A2 or A4 pulleys. Out of 3447 records extracted, only 7 remained after applying the exclusion criteria. In diagnosing a complete rupture, tendon-to-bone distance used varied widely from 1.9 to 5.1 mm for A2 and from 1.8 to 3.1 mm for A4. Our findings point to a lack of consensus diagnostic criteria for pulley injuries and identify technical details needing further research.

Ultrasound classification of medial gastrocnemious injuries.

High-resolution ultrasound (US) has helped to characterize the "tennis leg injury" (TL). However, no specific classifications with prognostic value exist. This study proposes a medial head of the gastrocnemius injury classification based on sonographic findings and relates this to the time to return to work (RTW) and return to sports (RTS) to evaluate the prognostic value of the classification. 115 subjects (64 athletes and 51 workers) were retrospectively reviewed to asses specific injury location according to medial head of the gastrocnemius anatomy (myoaponeurotic junction; gastrocnemius aponeurosis (GA), free gastrocnemius aponeurosis (FGA)), presence of intermuscular hematoma, and presence of gastrocnemius-soleus asynchronous movement. Return to play (RTP; athletes) and return to work (RTW; occupational) days were recorded by the treating physician. This study proposes 5 injury types with a significant relation to RTP and RTW (P < .001): Type 1 (myoaponeurotic injury), type 2A (gastrocnemius aponeurosis injury with a <50% affected GA width), type 2B (gastrocnemius aponeurosis with >50% affected GA width), type 3 (free gastrocnemius aponeurosis (FGA) tendinous injury), and type 4 (mixed GA and FGA injury). The longest RTP/RTW periods were associated with injuries with FGA involvement. Intermuscular hematoma and Gastrocnemius-soleus asynchronous motion during dorsiflexion and plantarflexion were observed when the injury affected >50% of the GA width, with or without associated FGA involvement, and this correlated with a worse prognosis. The proposed classification can be readily applied in the clinical setting although further studies on treatment options are required.

Grip Force Measurement as a Complement to High-Resolution Ultrasound in the Diagnosis and Follow-Up of A2 and A4 Finger Pulley Injuries.

The ability of finger flexors to generate force has been studied in relation to climbing performance. However, not much attention has been paid to the decrease in finger grip force in relation to annular pulley injuries. The purpose of the present study was to determine if an injured annular pulley implies a finger flexor force decrease, as well as its relation to clinical and sonographic changes. We performed an observational study in 39 rock climbers with A2 or A4 pulley injuries to the 3rd or 4th fingers. The variables considered were pain upon palpation, ultrasound tendon-bone distance, and finger grip strength decrease. Three rock climbing grip types were considered: the one finger crimp, open crimp, and close crimp. Injured rock climbers presented a decrease in finger grip strength compared to non-injured controls when performing a one finger crimp (p < 0.001). There exists a significant correlation between a tendon-bone distance at the level of the injured pulley and a decreased finger grip strength measured by performing a one finger crimp (p = 0.006). A decrease in finger grip strength could be considered in the diagnostic and follow-up process of A2 and A4 pulley injuries to the 3rd and 4th fingers.

A Histoarchitectural Approach to Skeletal Muscle Injury: Searching for a Common Nomenclature.

In recent years, different classifications for muscle injuries have been proposed based on the topographic location of the injury within the bone-tendon-muscle chain. We hereby propose that in addition to the topographic classification of muscle injuries, a histoarchitectonic (description of the damage to connective tissue structures) definition of the injury be included within the nomenclature. Thus, the nomenclature should focus not only on the macroscopic anatomy but also on the histoarchitectonic features of the injury.

Effectiveness of low-frequency electrical stimulation in proprioceptive neuromuscular facilitation techniques in healthy males: a randomized controlled trial.

BACKGROUND: Hamstring muscle injuries are common in the sports field, with lack of hamstring flexibility being a risk factor. Stretching the hamstring muscles is an important part of the training and rehabilitation programs used to prevent or treat injury and improve performance. We aim to compare the immediate and follow-up effect on hamstring muscle flexibility between 2 different stretching protocols, proprioceptive neuromuscular facilitation (PNF) stretching and PNF stretching combined with electrostimulation. A second aim is to determine whether physical activity level is related to flexibility. METHODS: Design of study: Single-blind, randomized controlled trial; Participants: 30 healthy volunteers (30 men, 18-39 years old); Intervention: A 6-session intervention program spanning over 2 weeks and 1-week and 3-week follow-up. The control group underwent PNF stretching with a voluntary contraction. The experimental group underwent PNF stretching but the muscle contraction was triggered with an electrical stimulation device (TENS); Main outcome measu: Hamstring muscles flexibility was assessed using the Modified Sit and Reach (MSR) and the Back Saver Sit and Reach (BSSR) tests. Physical activity level was evaluated with the short form of the International Physical Activity Questionnaire (IPAQ). RESULTS: Both groups showed an overall increase in hamstring muscle flexibility. However, when comparing flexibility gain between baseline and the end of the stretching program (session 6), and at the 1-week and 3-week follow-ups, only the experimental group showed significant differences. No correlation between the IPAQ score and the degree of hamstring muscle flexibility was observed. CONCLUSIONS: Hamstring muscle PNF stretching combined with electrical stimulation to trigger muscle contraction during the muscle contraction phase of the stretch achieves better flexibility results when compared to PNF alone.

An Online- and Mobile-Based Application to Facilitate Exposure for Childhood Anxiety Disorders.

In the current paper, we describe an integrated online- and mobile-based application for the treatment of childhood anxiety disorders, Anxiety Coach. The technology is designed to increase the use of exposure therapy by therapists and patients. We begin by outlining the clinical content and design of the application, and then review the clinical administration and theoretical basis for the program. Next, using results from an implementation feasibility study, we illustrate how data collected during application use can inform therapists, supervisors, and researchers about process variables (i.e., use of exposure) and outcomes (i.e., symptom improvement). Implications of the potential for Anxiety Coach to increase access to evidence-based treatment and directions for further research are discussed.

Ultrasound classification of traumatic distal biceps brachii tendon injuries.

OBJECTIVE: The present work is aimed at analysing ultrasound findings in patients with distal biceps brachii tendon (DBBT) injuries to assess the sensitivity of ultrasound in detecting the different forms of injury, and to compare ultrasound results with magnetic resonance imaging (MRI) and surgical results. MATERIALS AND METHODS: A total of 120 patients with traumatic DBBT injuries examined between 2011 and 2015 were analysed. We compared ultrasound results with MRI results when surgery was not indicated and with MRI and surgical results when surgery was indicated. RESULTS: For major DBBT injuries (complete tears and high-grade partial tears), the concordance study between exploration methods and surgical results found that ultrasound presented a slight statistically significant advantage over MRI (ultrasound: κ = 0.95-very good-95% CI 0.88 to 1.01, MRI: κ = 0.63-good-95% CI 0.42 to 0.84, kappa difference p < 0.01). Minor injuries, in which most tendon fibres remain intact (tendinopathies, elongations and low-grade partial tears), are the most difficult to interpret, as ultrasound and MRI reports disagreed in 12 out of 39 cases and no surgical confirmation could be obtained. CONCLUSIONS: Based on present results and previous MRI classifications, we establish a traumatic DBBT injury ultrasound classification. The sensitivity and ultrasound-surgery correlation results in the diagnosis of major DBBT injuries obtained in the present study support the recommendation that ultrasound can be used as a first-line imaging modality to evaluate DBBT injuries.

Anatomical and histological study of human deep fasciae development.

PURPOSE: To characterize the connective tissue found between the subcutaneous adipose tissue and the underlying muscle tissue in different regions and at different stages of human fetal development. We aim to identify its structural similarities to adult deep fascia, and to establish its role in myofascial development. METHODS: Samples from the arm, forearm, low back and thigh regions (from sites topographically homologous to the adult deep fascia) of five fetus body donors were obtained to perform gross anatomy dissection and histologic sections. Sections were stained with hematoxylin-eosin and Masson trichrome stain to observe their overall structure. Antiserum to protein S100 was used to analyze the presence and distribution of nerve fibers, and immunohistochemistry processing with Tcf4 marker was used to ensure fibroblast activity. RESULTS: Gross anatomy and histological sections of fetal samples showed the presence of connective tissue topographically and morphologically equivalent to adult deep fasciae. Developing blood vessels and nerves were found evenly distributed within the connective tissue during early development and in the portion adjacent to the muscle at later stages. The presence of Tcf4+ fibroblasts was confirmed in all analyzed mesenchymal connective tissue. CONCLUSIONS: Deep fascia is present from week 21 of human development in the lower back and upper and lower limbs. Blood vessels and nerves develop parallel to it and occasionally cross it from the deep to superficial plane. The presence of Tcf4+ fibroblasts in the deep fascia suggests a crucial role for this structure in muscle morphogenesis.

Sonographic evaluation of the distal iliopsoas tendon using a new approach.

Sonography of the iliopsoas tendon plays an important role in the diagnosis and preoperative and postoperative management for the increasing number of patients under consideration for arthroscopically guided hip interventions such as iliopsoas tenotomy in a variety of conditions, including arthropathy, periarticular calcifications, and cam-type deformities of the femoral head. The ability to visualize the iliopsoas tendon pre-operatively can be helpful diagnostically in patients presenting with hip pain and can aid in planning surgery, while evaluating the tendon postoperatively is important in the assessment of causes of postoperative pain and other potential complications. We present a novel technique for visualizing the distal iliopsoas tendon complex in the longitudinal axis at its insertion on the lesser trochanter on sonography.

Multidisciplinary approach to the persistent double distal tendon of the biceps brachii.

PURPOSE: The aim of this study is to correlate the ultrasound (US) appearance of the persistent double or bifid distal tendon of the biceps brachii muscle with anatomical and histological data. This will provide a new model to study the pathological distal biceps brachii tendon (DBBT). METHODS: The DBBT of 20 cadaveric elbows were examined with linear array broadband US transducers (frequency band 14-6 MHz) using an anterior approach. Trypan blue dye was injected underneath the paratenon under US guidance in 16 specimens. After they were dissected, five of them were processed to obtain histological slices stained with hematoxylin-eosin and antiserum to protein S100. RESULTS: At US, the DBBT is a tendon in which the fascicles are organized in two different hyperechoic components separated by a hyperechoic septum related to the endotenon. The endotenon is lax, flexible, and makes folding and gliding of the two portions feasible. The DBBT is surrounded by a hyperechoic paratenon adjacent to the tendon surface, which is only differentiable by US when dye is interposed between such structures. CONCLUSIONS: The connective septum of endotenon located between the two main components of the DBBT is responsible for the US image of two separate tendons and functionally enables it to work as two separate entities, thus allowing respective folding and gliding. The paratenon surrounding the lacertus fibrosus and the DBBT plays an important stabilization role, enabling them to change shape and arrangement during joint motion. It is also an important conduit for nerves and blood vessels.