Extracorporeal Shock Wave Therapy Combined With Platelet-Rich Plasma Injection to Treat the Nonunion of a Stress Fracture of the Proximal Phalanx of the Great Toe: A Case Report.

A 15-year-old female short-distance track and field athlete started to experience pain in her left great toe while competing. One month after the onset of symptoms, she was diagnosed with a stress fracture of the proximal phalanx of the great toe. Despite three months of conservative treatment, no bone healing was observed, resulting in a nonunion. To promote healing of the fractured area, a treatment method involving the combination of extracorporeal shock wave therapy (ESWT) with platelet-rich plasma (PRP) injection was pursued. Complete bone healing was achieved six weeks after the start of the treatment, enabling the patient to fully return to her sport. Based on our findings, the combined use of ESWT and PRP injections, both beneficial for bone healing, is a potentially effective treatment for nonunion of the stress fracture of the proximal phalanx of the great toe.

Multifaceted Treatment Using Advanced Modalities for Refractory Achilles Tendinopathy: A Case Report.

Achilles tendinopathy is a prevalent issue among athletes, often resistant to traditional treatments, and can persist chronically. This report presents a 23-year-old female track athlete suffering from refractory Achilles tendinopathy for four years. Despite initial treatments including rehabilitation, the use of insoles, steroid injections, and extracorporeal shock wave therapy, her symptoms persisted. Implementing a combination of innovative treatments - transarterial embolization, extracorporeal shock wave therapy, and prolotherapy - resulted in a significant improvement in symptoms. The case underscores the potential efficacy of a multifaceted approach, suggesting that a combination of treatments may be essential for addressing the complex pathology of chronic Achilles tendinopathy.

Optimal assessment for anterior talofibular ligament injury utilizing stress ultrasound entails internal rotation during plantarflexion.

OBJECTIVES: An optimal load and ankle position for stress ultrasound of the injured anterior talofibular ligament (ATFL) are unknown. The objectives of this study were to compare stress ultrasound and ankle kinematics from a 6 degree-of-freedom (6-DOF) robotic testing system as a reference standard for the evaluation of injured ATFL and suggest cut-off values for ultrasound diagnosis. METHODS: Ten fresh-frozen human cadaveric ankles were used. Loads and ankle positions examined by the 6-DOF robotic testing system were: 40 N anterior load, 1.7 Nm inversion, and 1.7 Nm internal rotation torques at 30° plantarflexion, 15° plantarflexion, and 0° plantarflexion. Bony translations were measured by ultrasound and a robotic testing system under the above conditions. After measuring the intact ankle, ATFL was transected at its fibular attachment under arthroscopy. Correlations between ultrasound and robotic testing systems were calculated with Pearson correlation coefficients. Paired t-tests were performed for comparison of ultrasound measurements of translation between intact and transected ATFL and unloaded and loaded conditions in transected ATFL. RESULTS: Good agreement between ultrasound measurement and that of the robotic testing system was found only in internal rotation at 30° plantarflexion (ICC â€‹= â€‹0.77; 95% confidence interval 0.27-0.94). At 30° plantarflexion, significant differences in ultrasound measurements of translation between intact and transected ATFL (p â€‹< â€‹0.01) were found in response to 1.7 Nm internal rotation torque and nonstress and stress with internal rotation (p â€‹< â€‹0.01) with mean differences of 2.4 â€‹mm and 1.9 â€‹mm, respectively. CONCLUSION: Based on the data of this study, moderate internal rotation and plantarflexion are optimal to evaluate the effects of ATFL injury when clinicians utilize stress ultrasound in patients. LEVEL OF EVIDENCE: III.

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners.

BACKGROUND: This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements. METHODS: Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests. RESULTS: Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance. CONCLUSION: The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

Ultrasound-Guided Hydrodissection for Sural Neuropathy After Calcaneus Fracture Surgery: A Case Report.

We present a case study of a 61-year-old man who experienced sural neuropathy following calcaneus fracture surgery, which was effectively treated using ultrasound-guided hydrodissection. Postoperatively, while the patient exhibited good bony fusion, he reported pain on the lateral side of the calcaneus. Ultrasound findings did not suggest any nerve discontinuity, but localized tenderness around the sural nerve was observed. After hydrodissection using 0.09% lidocaine, the patient's pain significantly decreased. Although hydrodissection alleviated the pain, complete resolution was achieved only post plate removal and neurolysis. This study represents the first report on the efficacy of hydrodissection for postoperative sural neuropathy, suggesting its potential as an effective treatment option.

Supine-Position Ultrasound-Assisted Arthroscopic Surgery for Elbow Joint Contracture: A Case Report.

A 16-year-old male had a right elbow contracture after dislocation. The patient underwent supine-position ultrasound-assisted arthroscopic surgery, combining open removal of the posterior oblique ligament with the medial collateral ligament. The elbow joint flexion angle improved from 120 degrees to 145 degrees, and the extension angle improved from -50 degrees to 0 degrees. The patient returned to sports without recurrence of elbow joint contracture three months after surgery. Supine-positioned ultrasound-assisted arthroscopic surgery for elbow joint contracture is a safe and effective technique that eliminates the need for intraoperative position changes and big skin incisions.

Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle?

BACKGROUND: In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change. METHODS: Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively. RESULTS: At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group. CONCLUSION: Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoided.

Focused Extracorporeal Shock Wave Therapy for Ischial Apophysitis in Young High-Level Gymnasts.

OBJECTIVE: We aimed to investigate the effect and safety of extracorporeal shock wave therapy (ESWT) on ischial apophysitis (IA) in young high-level gymnasts. We hypothesized that ESWT would be safe and effective in alleviating pain. DESIGN: Retrospective case series. SETTING: Funabashi Orthopedic Hospital. PATIENTS: The subjects were 18 high-level gymnasts (mean age of 13 years) with a chief complain of chronic buttock pain diagnosed with IA. INTERVENTIONS: Ten patients received only physiotherapy (PT), whereas 8 received both PT and ESWT to the ischial tuberosity. The basic protocol for ESWT was to use an energy dose of 0.20 mJ/mm 2 or less with 3000 shots per session at 4-week intervals. MAIN OUTCOME MEASURES: We investigated whether PT and ESWT relieved the pain and allowed the patient to return fully to gymnastics. Based on radiographs at the last observation, we examined whether early closure of the apophyseal line of the ischium and around hip joint on the affected side occurred. RESULTS: In the PT group, pain was relieved in 2 of 10 patients. In the ESWT group, pain was relieved and full return to gymnastics was possible in all 8 patients. None of the patients showed early closure of the apophyseal line. CONCLUSIONS: Extracorporeal shock wave therapy can be a safe and effective treatment option for IA in young high-level gymnasts.

Ultrasound findings of the deltoid ligament in patients with acute ankle sprains: A retrospective review.

BACKGROUND: The deltoid ligament is a complex structure composed of multiple ligaments located on the medial side of the ankle joint that can be injured by ankle sprains. Although there have been previous reports on ultrasound imaging of the injured deltoid ligament, a systematic method for depicting each ligament component has not been established. This study aimed to clarify the ultrasound findings of the deltoid ligament in ankle sprains using a systematic scanning protocol. METHODS: We examined the tenderness of the medial ankle and evaluated the ultrasound findings of the deltoid ligament in 169 sprained ankles with no fracture, within 3 days after injury. Observation and evaluation of the six components of the deltoid ligament were performed using a systematic scanning protocol with four probe positions. RESULTS: Of the 169 ankles, 48 ankles had tenderness in the deltoid ligament. Ultrasonography confirmed deltoid ligament damage in 13 of these 48 ankles. Of the 13 ankles, 3 ankles had damages only in the superficial layer, 3 ankles only in the deep layer, and 7 ankles in both the superficial and deep layers. CONCLUSIONS: We clarified the details of the damage pattern of the deltoid ligament in acute ankle sprains. It was possible to identify the superficial and deep layers of the ligament and to observe the damage pattern of each ligament component in detail, and it appeared that ultrasonography could be used as a tool to evaluate the damage pattern of the deltoid ligament in acute ankle sprains.

Ultrasound-Guided Lumbar Intradiscal Injection: A Case Report With a High-Resolution Ultrasound Image.

We present a case report demonstrating a new technique for intradiscal injection under ultrasound guidance in treating lumbar disc herniation. A 16-year-old female gymnast underwent this procedure and experienced relief from pain. Traditional methods have been noted for their technical challenges and potential risk of nerve root damage. In this case, our approach visualized the lateral side of the disc and improved needle visibility. This technique potentially offers a clearer high-resolution confirmation of the needle's position within the disc. It is considered that this technique is effective not only for performing precise injections but also for enhancing safety due to the clear depiction of the needle tip entering the intervertebral disc.

Ultrasound-guided screw fixation for patellar stress fracture in a female basketball player: A case report.

INTRODUCTION: Stress fracture of the patella is an overuse disorder that occurs in the lower extremity. Surgery may be considered if conservative treatment does not work or if a quicker and more reliable return to sports is expected. Surgery is usually performed under fluoroscopic guidance based on the premise that the proper placement of the internal fixation material can be determined on radiographic images. PATIENT CONCERNS: A 16-year-old female basketball player gradually became aware of pain in the anterior aspect of her right knee during basketball, without any particular history of trauma. A computed tomography scan revealed a small bone fragment on the lateral side of the distal end of the patella. DIAGNOSIS: Stress fracture of the patella. INTERVENTIONS: Since it was difficult to determine the exact location of the bone fragment on radiographs, the surgery was performed under ultrasound guidance rather than fluoroscopy. While checking the bone fragment with ultrasound images, insertion of the guide pin, drilling, and screw fixation were performed under ultrasound guidance. OUTCOMES: Postoperative computed tomography showed accurate screw insertion into the bone fragment. Two months after surgery, bony fusion was confirmed, and the patient returned to her preinjury level of basketball. CONCLUSION: Ultrasound-guided screw fixation was useful in this case in which internal fixation of fractures is difficult under fluoroscopic guidance.

Bone-patellar tendon-bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction.

PURPOSE: The primary purpose of this study was to evaluate the second-look arthroscopic findings 1 year postoperatively and magnetic resonance imaging (MRI) findings 2 years after anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft (BTB) or hamstring tendon autograft (HT). Secondary purpose included clinical results from physical examination, including range of motion, Lachman test, pivot shift test, and knee anterior laxity evaluation, and the clinical score for subjective evaluations at 2 years after surgery. METHODS: Between 2015 and 2018, 75 patients with primary ACL injuries were divided into either the BTB group (n = 30) or HT group (n = 45). When using HT, an anatomical double-bundle ACLR was performed. BTB was indicated for athletes with sufficient motivation to return to sporting activity. Graft maturation on second-look arthroscopy was scored in terms of synovial coverage and revascularization. All participants underwent postoperative MRI evaluation 2 years postoperatively. The signal intensity (SI) characteristics of the reconstructed graft were evaluated using oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. For clinical evaluation, the Lachman test, pivot shift test, KT-2000 evaluation, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were used. RESULTS: Arthroscopic findings showed that the graft maturation score in the BTB group (3.6 ± 0.7) was significantly greater than that in the anteromedial bundle (AMB; 2.9 ± 0.2, p = 0.02) and posterolateral bundle (PLB; 2.0 ± 0.9, p = 0.001) in the HT group. The mean MRI-SNQs were as follows: BTB, 2.3 ± 0.5; AMB, 2.9 ± 0.9; and PLB, 4.1 ± 1.1. There were significant differences between BTB, AMB, and PLB (BTB and AMB: p = 0.04, BTB and PLB: p = 0.003, AMB and PLB: p = 0.03). Second-look arthroscopic maturation score and MRI-SNQ value significantly correlated for BTB, AMB, and PLB. No significant differences were detected in clinical scores. There was a significant difference (p = 0.02) in the knee laxity evaluation (BTB: 0.9 ± 1.1 mm; HT: 2.0 ± 1.9 mm). CONCLUSION: BTB maturation is superior to that of double-bundle HT based on morphological and MRI evaluations following anatomical ACLR, although no significant differences were found in clinical scores. Regarding clinical relevance, the advantages of BTB may help clinicians decide on using the autograft option for athletes with higher motivation to return to sporting activity because significant differences were observed in morphological evaluation, MRI assessment, and knee anterior laxity evaluation between BTB and double-bundle HT. LEVEL OF EVIDENCE: Level IV.

Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial.

INTRODUCTION: The optimal pain management strategy for postoperative pain after anterior cruciate ligament reconstruction (ACLR) remains unclear. This study compared femoral nerve block (FNB) and adductor canal block (ACB) for pain management of early postoperative pain, knee function, and recovery of activity of daily living (ADL) after ACLR using hamstring autografts. MATERIAL AND METHODS: In this prospective, single-blind, randomised controlled trial, 64 patients aged 12-56 years who underwent anatomical double-bundle ACLR with a hamstring autograft between August 2019 and May 2020 were randomised to undergo preoperative FNB (n = 32) or ACB (n = 32). The peripheral nerve block was performed by a single experienced anaesthesiologist under ultrasound guidance. The primary outcomes were postoperative pain as evaluated using the visual analogue scale (VAS) at 3, 6, 12, 24, and 48 h postoperatively and the need for pain relief. The secondary outcome was knee function, including the recovery of range of motion, contraction of the vastus medialis, and stable walking with a double-crutch (ADL), as evaluated by blinded physical therapists. RESULTS: There were no significant differences in patient demographics between the two groups. The VAS scores, need for pain relief, knee function, and ADL did not significantly differ between the groups. CONCLUSION: FNB and ACB provided comparable outcomes related to early postoperative pain, knee function, and ADL after double-bundle ACLR using hamstring autografts. Further research is necessary to evaluate the mid- to long-term effect of each block on recovery of knee function and ADL. LEVEL OF EVIDENCE: I.

Joint effusion at 6 months is a significant predictor of joint effusion 1 year after anterior cruciate ligament reconstruction.

PURPOSE: This study aimed to assess the risk factors for prolonged joint effusion in patients undergoing double-bundle anterior cruciate ligament reconstruction (ACLR). METHODS: In total, 160 patients who underwent primary ACLR using autograft hamstring between 2015 and 2018 were retrospectively reviewed. Joint effusion was defined as any grade ≥ 2 (range, 0-3) according to the MRI Osteoarthritis Knee Score (MOAKS). Univariate and multivariate logistic regression analyses were performed. RESULTS: The median age of the patients was 25 years (range 14-68 years) at the time of the surgery; there were 89 women and 71 men. At 1 year, 46 (28.8%) patients experienced knee joint effusion, as defined by the MOAKS. Univariate analysis revealed that age, preoperative Kellgren-Lawrence (K-L) grade, and joint effusion at 6 months were significantly associated with joint effusion at 1 year. In the multivariate analysis, joint effusion at 6 months was significantly associated with joint effusion at 1 year (odds ratio, 68.0; 95% confidence interval, 22.1-209.4). No significant difference in the Lysholm scores was observed between patients with and without joint effusion at 1 year (n.s.). CONCLUSIONS: Joint effusion at 6 months was significantly associated with joint effusion 1 year after ACLR. LEVEL OF EVIDENCE: III.