Prospects of perfusion contrast-enhanced ultrasound (CE-US) in diagnosing axillary lymph node metastases in breast cancer: a comparison with lymphatic CE-US.

Accurate diagnosis of lymph node (LN) metastasis is vital for prognosis and treatment in patients with breast cancer. Imaging 1modalities such as ultrasound (US), MRI, CT, and 18F-FDG PET/CT are used for preoperative assessment. While conventional US is commonly recommended due to its resolution and sensitivity, it has limitations such as operator subjectivity and difficulty detecting small metastases. This review shows the microanatomy of axillary LNs to enhance accurate diagnosis and the characteristics of contrast-enhanced US (CE-US), which utilizes intravascular microbubble contrast agents, making it ideal for vascular imaging. A significant focus of this review is on distinguishing between two types of CE-US techniques for axillary LN evaluation: perfusion CE-US and lymphatic CE-US. Perfusion CE-US is used to assess LN metastasis via transvenous contrast agent administration, while lymphatic CE-US is used to identify sentinel LNs and diagnose LN metastasis through percutaneous contrast agent administration. This review also highlights the need for future research to clarify the distinction between studies involving "apparently enlarged LNs" and "clinical node-negative" cases in perfusion CE-US research. Such research standardization is essential to ensure accurate diagnostic performance in various clinical studies. Future studies should aim to standardize CE-US methods for improved LN metastasis diagnosis, not only in breast cancer but also across various malignancies.

Clinical Outcomes of Bipolar Hemiarthroplasty with a Conjoined Tendon-Preserving Posterior Approach for Femoral Neck Fractures.

Background and Objectives: The conventional posterior approach in the lateral decubitus position is widely used for femoral neck fractures in femoral hemiarthroplasty. Postoperative dislocation is the major problem with this approach. The conjoined tendon-preserving posterior (CPP) approach is a less invasive surgical approach than the conventional posterior approach to the hip, maintains posterior stability, and preserves short external rotators and joint capsules. However, the mention was required to avoid muscle damage and whether muscle damage affects postoperative dislocation or not. The current study aimed to evaluate the clinical results of the CPP approach in hemiarthroplasty for femoral neck fractures and identify muscle damage risk factors. Materials and Methods: This study was a retrospective cohort study and included 170 hips in 168 patients. The mean age at the operation was 81.2 years. The preservation rate of the internal obturator muscle and gemellus inferior muscle and factors related to intraoperative short rotator muscle injury were investigated retrospectively. The postoperative complications and the relation between muscle damage and postoperative dislocation were investigated. Results: In the four hips (2.3%) with the obturator internus muscle damage, thirty-eight hips (22.4%) with gemellus inferior muscle damage were detected; in the muscle-damaged cases, the high body mass index (BMI) was significantly higher. The complication occurred in four hips (2.3%), including postoperative posterior dislocation in one hip without muscle damage (0.6%). Postoperative infection occurred in one hip (0.6%), and peroneal or sciatic nerve paralysis was suspected in two hips (1.1%). Conclusions: Compared to the conventional posterior approach in previous reports, the CPP approach reduces postoperative dislocation. A higher BMI is a risk factor for muscle damage, and the gemellus inferior muscle damage has no effect on postoperative dislocation. The CPP approach for BHA appeared to be an effective treatment method.

Minimal Influence on Muscle Strength and Patient Reported Outcome Measures by Conjoined Tendon Detachment in Anterolateral Muscle-Sparing Total Hip Arthroplasty.

Purpose: The conjoined external rotator tendon (CERT), composed of the tendons of the gemellus superior, obturator internus (OI), and gemellus inferior muscles, stabilizes the hip joint. The study investigates the clinical and radiological effects of the CERT release during anterolateral-supine approach (ALSA) total hip arthroplasty (THA). Methods: A cohort of 60 patients who underwent ALSA THA was examined. Pre- and post-operative muscle width, muscle strength, and radiological data were compared between the CERT-detached and preserved groups. In addition, Clinical assessments were performed using the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire and the short-form 36 questionnaires. Results: 58.3% had CERT detached, resulting in radiological atrophy of the OI muscle. Despite this, hip flexion, extension, and abduction muscle strength significantly improved at 6 months post-surgery. The detached CERT did not substantially affect patient-reported outcome measures, including pain and daily activities, within the 6-month follow-up. Discussion: The study suggests that while CERT detachment can lead to muscle atrophy, it has a limited impact on muscle strength and patient-reported outcome measures, indicating the muscle's potential redundancy. Preserving the CERT might enhance stability and prevent atrophy but could increase the risk of complications. CERT release is recommended when femur exposure is inadequate.

Large language model may assist diagnosis of SAPHO syndrome by bone scintigraphy.

OBJECTIVE: In this study, we employed a large language model to evaluate the diagnostic efficacy of radiology reports of bone scintigraphy in the context of identifying SAPHO syndrome, and further examined the potential of such a model to augment the diagnostic procedure. METHODS: Imaging data and clinical information of 151 patients (105/46 women/men, mean age: 53.5 years) who underwent bone scintigraphy for suspected SAPHO syndrome between January 2007 and December 2022 were retrospectively reviewed. ChatGPT-4.0 was used as the large language model. The diagnostic performance of the large language model was verified by comparing the cases judged to have SAPHO syndrome that fulfilled Kahn's classification criteria based on a combination of concise radiology reports and skin lesions such as palmoplantar pustulosis, with cases diagnosed with SAPHO syndrome by rheumatologists based on all clinical information. The diagnostic performance of the large language model was verified. RESULTS: The diagnostic accuracy of a large language model for analyzing bone scintigraphy radiology reports in conjunction with information about skin symptoms, such as palmoplantar pustulosis, achieved a sensitivity of 83.5%, specificity of 69.4%, and an overall accuracy of 76.8%. DISCUSSION: While this research is an initial endeavor dedicated to the utilization of a substantial language model in the creation of a database for imaging diagnostics of rheumatic conditions, it exhibits commendable diagnostic accuracy, particularly for diseases with a wide range of symptoms like SAPHO syndrome, indicating a positive outlook for subsequent studies. CONCLUSION: This research indicates the prospective value of extensive language models in scrutinizing radiology accounts from bone scintigraphy for the diagnosis of SAPHO syndrome.

Low Young's Modulus TiNbSn Alloy Locking Plates Accelerate Osteosynthesis in Rabbit Tibiae.

A new beta TiNbSn alloy with a low Young's modulus of approximately 40 GPa has been developed to resolve the stress shielding by Young's modulus divergence. In this study, the efficacy of TiNbSn alloy locking plates on bone repair is compared to that of commercially pure titanium (CP-Ti). The TiNbSn alloy and CP-Ti, which have Young's moduli of 49.1 GPa and 107 GPa, respectively, were compared. Male Japanese white rabbits were anesthetized, and osteotomy and osteosynthesis with locking plates were performed on the right tibia. The bone repair was assessed using micro-computed tomography (CT), histomorphometry, immunohistochemistry, and mechanical testing. Micro-CT, histomorphometry, immunohistochemistry, and mechanical testing were performed four weeks after osteotomy. Six weeks after surgery, micro-CT and mechanical testing were performed. Micro-CT analysis at four weeks after surgery showed that the intramedullary fracture callus in the TiNbSn alloy group had more bone volume and numerous bridging structures compared to the CP-Ti group (CP-Ti vs. TiNbSn alloy, 34.3 ± 13.1 mm3 vs. 61.3 ± 19.6 mm3, p = 0.02; mean ± standard deviation). At four weeks post-osteotomy, the healed tibia showed significantly higher strength in the TiNbSn alloy group compared with CP-Ti (CP-Ti vs. TiNbSn alloy, 81.3 ± 31.2 N vs. 133.7 ± 46.6 N, p = 0.04). TiNbSn alloy locking plates had a more positive impact on bone formation and bone strength restoration than the CP-Ti locking plates during the early phase of bone healing.

Anti-N-methyl-d-aspartate receptor encephalitis preceded by meningitis lasting up to 60 days.

Long-lasting meningitis complicated by N-methyl-d-aspartate receptor (NMDAR) encephalitis has not been discussed widely in the literature. Herein, we present two cases of anti-NMDAR encephalitis preceded by meningitis. The patients had 60- and 22-day periods of preceding meningitis, which improved with intravenous methylprednisolone and plasmapheresis. No tumors were detected in either of the patients. Although meningitis preceding anti-NMDAR encephalitis is not rare, our patients, especially those who had it for a duration of 60 days, had longer durations of meningitis. This manuscript foregrounds that anti-NMDAR encephalitis might be included in the differential diagnosis of long-lasting meningitis.

Pyoderma gangrenosum after surgery for forefoot deformity in a patient with rheumatoid arthritis: A case report.

Pyoderma gangrenosum (PG) is a rare inflammatory skin disease characterised by skin ulcers that are associated with autoimmune diseases. Although the effectiveness of immunosuppression with glucocorticoids and tumour necrosis factor inhibitors in treating PG has been reported, the utility of negative-pressure wound therapy (NPWT) for severe ulcerative lesions in patients with PG remains controversial. Herein, we report the case of a 76-year-old woman with rheumatoid arthritis who developed PG after undergoing surgery for a forefoot deformity. The patient showed improvement in deep ulcer lesions through NPWT while receiving treatment with abatacept and systemic glucocorticoids. Subsequent topical glucocorticoid therapy led to the remission of the PG. This case suggests that NPWT, when used under immunosuppressive conditions, does not exacerbate the pathergy and may be beneficial for treating severe ulcerative PG.

Assessment of clinical and radiological characteristics of Japanese patients with SAPHO syndrome.

OBJECTIVE: This study aimed to analyse the radiological characteristics and clinical diversity of Japanese patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome, a heterogeneous disorder. METHODS: Radiographs and clinical information from 115 Japanese patients (female/male: 81/34, mean age at onset: 48.7 years) diagnosed with SAPHO syndrome between January 2007 and December 2020 were retrospectively reviewed. Additionally, the treatment for SAPHO syndrome was explored. RESULTS: Among the 115 patients, 70 patients had complications, including palmoplantar pustulosis, acne, or psoriasis. Imaging studies included bone scintigraphy, magnetic resonance imaging, computed tomography, and positron emission tomography in 71, 58, 70, and 23 patients, respectively. The most frequent lesions were arthritis and hyperostosis of the sternoclavicular joints in 96 patients; spinal lesions, including sacroiliac arthritis were observed in 85 patients. Peripheral aseptic osteitis was observed in 22 patients, and the tibia was involved in 12. The treatments consisted of analgesics, bisphosphonates, conventional synthetic disease-modifying anti-rheumatic drugs, and biologics (tumour necrosis factor inhibitors and interleukin-23p19 inhibitors) in 85, 15, 23, and 10 patients (8 and 2 patients), respectively. CONCLUSION: Sternoclavicular hyperostosis and pustulosis are frequently observed in patients with SAPHO syndrome. Biological agents were more frequently used in patients with peripheral osteitis and arthritis.

TiNbSn stems with gradient changes of Young's modulus and stiffness reduce stress shielding compared to the standard fit-and-fill stems.

BACKGROUND: The difference between Young's moduli of the femur and the stem causes stress shielding (SS). TiNbSn (TNS) stem has a low Young's modulus and strength with gradient functional properties during the change in elastic modulus with heat treatment. The aim of this study was to investigate the inhibitory effect of TNS stems on SS and their clinical outcomes compared to conventional stems. METHODS: This study was a clinical trial. Primary THA was performed using a TNS stem from April 2016 to September 2017 for patients in the TNS group. Unilateral THA was performed using a Ti6Al4V alloy stem from January 2007 to February 2011 for patients in the control group. The TNS and Ti6Al4V stems were matched in shape. Radiographs were obtained at the 1- and 3-year follow-ups. Two surgeons independently checked the SS grade and appearance of cortical hypertrophy (CH). The Japanese Orthopaedic Association (JOA) scores before and 1 year after surgery were assessed as clinical scores. RESULTS: None of the patients in the TNS group had grade 3 or 4 SS. In contrast, in the control group, 24% and 40% of patients had grade 3 and 4 SS at the 1- and 3-year follow-ups, respectively. The SS grade was lower in the TNS group than in the control group at the 1- and 3-year follow-ups (p < 0.001). The frequencies of CH in both groups were no significant difference at the 1- and 3-year follow-ups. The JOA scores of the TNS group significantly improved at 1 year after surgery and were comparable to control group. CONCLUSION: The TNS stem reduced SS at 1 and 3 years after THA compared to the proximal-engaging cementless stem, although the shapes of the stems matched. The TNS stem could reduce SS, stem loosening, and periprosthetic fractures. TRIAL REGISTRATION: Current Controlled Trials. ISRCTN21241251. https://www.isrctn.com/search?q=21241251 . The date of registration was October 26, 2021. Retrospectively registered.

Two-stage revision knee arthroplasty for metallosis in a patient with rheumatoid arthritis: A case report.

We report a successful case of two-stage revision total knee arthroplasty performed for treating painless metallosis after total knee arthroplasty with a metal-backed patella. A 63-year-old woman diagnosed with rheumatoid arthritis underwent left total knee arthroplasty with a metal-backed patella at 32 years of age. The patient did not have knee pain; however, knee joint swelling, a strange noise, and pigmentation were reported 4 years ago. Radiographs showed cloud and metal-line signs anteriorly and posteriorly at the femoral condyle. Therefore, a two-stage surgery was performed for infection prevention and ease of performing posterior synovectomy. The patient underwent initial synovectomy via a posterior approach, followed by anterior synovectomy and revision total knee arthroplasty. Synovectomy was performed well without perioperative infection or failure of wound healing. In cases with metallosis after total knee arthroplasty, the two-stage revision total knee arthroplasty should be considered, depending on the degree of synovial proliferation and the risk of complications.

Long-term results of Chiari pelvic osteotomy on the preservation of hip function with mean follow-up of more than 30 years and its prognostic factors.

BACKGROUND: Clinical outcomes of Chiari pelvic osteotomy for acetabular dysplasia, including conversion to total hip arthroplasty (THA), have not been adequately explored. The purpose of this study was to examine the long-term results and clinical outcomes of Chiari pelvic osteotomy as the primary outcome and to analyze its prognostic factors as the second outcome. METHODS: This study was a multicenter, retrospective cohort study. Ninety-seven patients underwent Chiari pelvic osteotomy at three hospitals between March 1975 and October 1997. The long-term clinical outcomes of Chiari pelvic osteotomy, including conversion to THA and hip pain, were analyzed using the Kaplan-Meier method. In addition, the prognostic factors for conversion to THA after Chiari pelvic osteotomy were evaluated with clinical variables and radiographic parameters. RESULTS: The study included 51 hips in 45 patients (4 men and 41 women) with long-term follow-up. The survival rates assessed by Kaplan-Meier analysis with conversion to THA as an endpoint, were 90.2% (95% confidence interval (CI) 82.0-98.4%) at 20 years and 73.5% (95% CI 61.1-86.0%) at 30 years. In contrast, the Kaplan-Meier survival rates with the Japanese Orthopaedic Association hip score for pain ≤20 as an endpoint, were 86.3% (95% CI 76.8-95.7%) at 20 years and 65.6% (95% CI 52.3-79.0%) at 30 years. Only older age at osteotomy was the significantly poor prognostic factor for conversion to THA, with a hazard ratio of 1.11/year, 95% CI 1.06 to 1.18, (p < 0.01). CONCLUSION: Chiari pelvic osteotomy may still be a good alternative to bony reconstructive surgery for acetabular dysplasia especially in young patients. Only older age at the osteotomy was related to the poor prognosis of preserving hip function.

Impact of Octacalcium Phosphate/Gelatin (OCP/Gel) Composite on Bone Repair in Refractory Bone Defects.

In clinical settings, bone grafting is frequently used to treat bone defects. Therefore, the development of bone graft substitutes with superior bone formation ability is expected, instead of autogenous bone grafting. Octacalcium phosphate (OCP) has been developed as a bone graft substitute, and preclinical studies using OCP have reported superior bone formation ability compared with ß-tricalcium phosphate. Furthermore, OCP has been used in composite forms with natural polymers such as collagen and gelatin to improve the usability of OCP, and OCP/collagen composite forms have been clinically applied in the dental field because of their excellent usability and osteogenic potential. This review describes the development and preclinical results of OCP and OCP/gelatin (OCP/Gel) composites and prospects for future applications in orthopedics. The development of bone graft substitutes that achieve a high degree of biodegradability and strength will be needed for the clinical application of OCP composites in orthopedics in the future.

Feasibility of methotrexate discontinuation following tocilizumab and methotrexate combination therapy in patients with long-standing and advanced rheumatoid arthritis: a 3-year observational cohort study.

OBJECTIVES: Methotrexate (MTX) is associated with extensive side effects, including myelosuppression, interstitial pneumonia, and infection. It is, therefore, critical to establish whether its administration is required after achieving remission with tocilizumab (TCZ) and MTX combination therapy in patients with rheumatoid arthritis (RA). Therefore, the aim of this multicenter, observational, cohort study was to evaluate the feasibility of MTX discontinuation for the safety of these patients. METHODS: Patients with RA were administered TCZ, with or without MTX, for 3 years; those who received TCZ+MTX combination therapy were selected. After remission was achieved, MTX was discontinued without flare development in one group (discontinued [DISC] group, n = 33) and continued without flare development in another group (maintain [MAIN] group, n = 37). The clinical efficacy of TCZ+MTX therapy, patient background characteristics, and adverse events were compared between groups. RESULTS: The disease activity score in 28 joints-erythrocyte sedimentation rate (DAS28-ESR) at 3, 6, and 9 months was significantly lower in the DISC group (P < .05, P < .01, and P < .01, respectively). Further, the DAS28-ESR remission rate at 6 and 9 months and Boolean remission rate at 6 months were significantly higher in the DISC group (P < .01 for all). Disease duration was significantly longer in the DISC group (P < .05). Furthermore, the number of patients with stage 4 RA was significantly higher in the DISC group (P < .01). CONCLUSIONS: Once remission was achieved, MTX was discontinued in patients who responded favorably to TCZ+MTX therapy, despite the prolonged disease duration and stage progression.