Prevalence and treatment rates of osteoporosis among individuals with rotator cuff tears.

BACKGROUND: The relationship between osteoporosis and rotator cuff tears has been reported previously. However, the treatment rate of osteoporosis in individuals with rotator cuff tear is still unknown. The aim of this study was to investigate the prevalence and treatment rate of osteoporosis in individuals with rotator cuff tears. METHODS: In this cross-sectional study, we enrolled 207 participants. Participants underwent comprehensive assessments, including shoulder ultrasonographic examinations and quantitative ultrasound measurements for bone status evaluation. Osteoporosis diagnosis was predicated on a calcaneus ultrasound bone densitometry, and the cutoff value was set as a T score of -1.455, with reference to a previous report. RESULTS: One hundred fifty-six participants were classified as individuals without rotator cuff tears (group A), and 51 participants were classified as those with (group B). The mean age in group A was significantly lower than that in group B (63 ± 10 vs. 68 ± 9, respectively; P = .003). In terms of the T score examined by quantitative ultrasound, the mean T score in group A was significantly higher than that in group B (-1.4 ± 1.3 vs. -1.9 ± 1.6, respectively; P = .0412). The percentage of subjects with a T score of -1.455 or less in group B was 60.8% (31/51). The proportion of subjects with a T score of -1.455 or less undergoing osteoporosis treatment was 14.5% (12/83) in group A and 12.9% (4/27) in group B, showing no significant difference. CONCLUSIONS: Participants with a rotator cuff tear had relatively high prevalence of osteoporosis. Among those with both a rotator cuff tear and osteoporosis, the proportion receiving osteoporosis treatment was l2.9%, a very low rate.

Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older.

Background: This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years. Methods: Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up. Results: The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients. Conclusions: Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years. Level of evidence: A retrospective study, case series (IV).

Potential of patellar height measurement methods in predicting recurrent patellar dislocation incidence: a case-control study.

BACKGROUND: Recurrent patellar dislocation (RPD) is a multifactorial disease that affects young and active people. Patellar height measurements are used clinically to screen and diagnose knee conditions. However, there are no known studies that have assessed and compared the performance of patellar height indices for predicting the incidence of RPD, which could be used to recommend surgical treatment after primary patellar dislocation. This case-control study aimed to determine if the patellar height index could be used to predict the incidence of RPD, and to identify the optimal method in terms of its diagnostic ability for RPD. METHOD: Altogether, 133 patients (52 patients with RPD [Group R] and 81 sex- and age-matched controls [Group C]) were enrolled in this study. The Insall-Salvati (IS), Blackburne-Peel (BP), Caton-Deschamps (CD), and modified IS (mIS) methods were used to measure the patellar height index. The intra-observer and inter-observer reliabilities of these four methods were determined using intraclass correlation coefficients. A receiver operating characteristic curve analysis was performed to evaluate the predictive ability of each index and identify the cut-off values that indicated significantly increased risk of RPD. RESULTS: Patient demographics were similar between the two groups. The inter-observer and intra-observer reliabilities were good for all four methods. In patients with RPD, the mean index values for the four methods were significantly higher than those in the matched controls. The area under the curve (AUC) values for IS, BP, CD, and mIS were 0.91 (standard error [SE], 0.03; 95% confidence interval [CI], 0.84-0.96), 0.72 (SE, 0.05; 95% CI, 0.63-0.81), 0.86 (SE, 0.03; 95% CI, 0.79-0.92), and 0.96 (SE, 0.01; 95% CI, 0.94-0.99), respectively. CONCLUSION: Patellar height indices had high predictive performance for the incidence of RPD. The mIS method had the highest AUC.

Arthroscopic Bankart repair with peeling osteotomy of the anterior glenoid rim preserves glenoid morphology.

BACKGROUND: A decrease in the glenoid size after arthroscopic Bankart repair (ABR) was common in shoulders without osseous fragments compared with those with osseous fragments. For cases of chronic recurrent traumatic anterior glenohumeral instability without osseous fragments, we have performed ABR with peeling osteotomy of the anterior glenoid rim (ABRPO) to make an intentional osseous Bankart lesion. The aim of this study was to compare the glenoid morphology after ABRPO with it after simple ABR. METHODS: The medical records of patients who underwent arthroscopic stabilization for chronic recurrent traumatic anterior glenohumeral instability were retrospectively reviewed. Patients with an osseous fragment, with revision surgery and without complete data were excluded. Patients were assigned to 1 of 2 groups: Group A, ABR without peeling osteotomy procedure or Group B, with ABRPO procedure. Computed tomography was performed preoperatively and 1 year after surgery. The size of the glenoid bone loss was investigated by the assumed circle method. The following formula was used to calculate the decreased size of the glenoid: (Δ) = (postoperative size of the glenoid bone loss) - (preoperative size of the glenoid bone loss). The size of the glenoid 1 year after surgery was assessed to determine if it had decreased (Δ > 0%) or not decreased (Δ ≤ 0%) relative to the preoperative size. RESULTS: This study evaluated 39 shoulders divided into 2 groups: 27 shoulders in Group A and 12 shoulders in Group B. In Group A, postoperative glenoid bone loss was significantly greater than preoperative glenoid bone loss (7.8 ± 6.2 vs. 5.5 ± 5.3, respectively, P = .02). In Group B, postoperative glenoid bone loss was significantly lower than preoperative glenoid bone loss (5.6 ± 5.4 vs. 8.7 ± 4.0, respectively, P = .02). The P value for the interaction of group (A or B) × time (preoperative or postoperative) was 0.001. The decreased size of the glenoid was significantly larger in Group A than in Group B (2.1 ± 4.2 vs. -3.1 ± 4.5, respectively, P = .001). The rate of shoulders in which the size of the glenoid decreased 1 year after surgery relative to the preoperative size was significantly higher in Group A than in Group B (63% [17/27] vs. 25% [3/2], respectively, P = .04). CONCLUSIONS: The study showed that ABRPO preserved the glenoid size better than simple ABR without a peeling osteotomy procedure.

Promethazine Downregulates Wnt/ß-Catenin Signaling and Increases the Biomechanical Forces of the Injured Achilles Tendon in the Early Stage of Healing.

BACKGROUND: Wnt/ß-catenin signaling suppresses the differentiation of cultured tenocytes, but its roles in tendon repair remain mostly elusive. No chemical compounds are currently available to treat tendon injury. HYPOTHESIS: We hypothesized that the inhibition of Wnt/ß-catenin signaling would accelerate tendon healing. STUDY DESIGN: Controlled laboratory study. METHODS: Tendon-derived cells (TDCs) were isolated from rat Achilles tendons. The right Achilles tendon was injured via a dermal punch, while the left tendon was sham operated. A Wnt/ß-catenin inhibitor, IWR-1, and an antihistamine agent, promethazine (PH), were locally and intramuscularly injected, respectively, for 2 weeks after surgery. The healing tendons were histologically and biomechanically evaluated. RESULTS: The amount of ß-catenin protein was increased in the injured tendons from postoperative weeks 0.5 to 2. Inhibition of Wnt/ß-catenin signaling by IWR-1 in healing tendons improved the histological abnormalities and decreased ß-catenin, but it compromised the biomechanical properties. As we previously reported that antihistamine agents suppressed Wnt/ß-catenin signaling in human chondrosarcoma cells, we examined the effects of antihistamines on TDCs. We found that a first-generation antihistamine agent, PH, increased the expression of the tendon marker genes Mkx and Tnmd in TDCs. Intramuscular injection of PH did not improve histological abnormalities, but it decreased ß-catenin in healing tendons and increased the peak force and stiffness of the healing tendons on postoperative week 2. On postoperative week 8, however, the biomechanical properties of vehicle-treated tendons became similar to those of PH-treated tendons. CONCLUSION: IWR-1 and PH suppressed Wnt/ß-catenin signaling and improved the histological abnormalities of healing tendons. IWR-1, however, compromised the biomechanical properties of healing tendons, whereas PH improved them. CLINICAL RELEVANCE: PH is a candidate repositioned drug that potentially accelerates tendon repair.

Scapular Winging following Sports-Related Injury in a Rugby Player.

The most common cause of medial scapular winging is long thoracic nerve palsy (LTN) and subsequent serratus anterior muscle dysfunction. A 16-year-old right-handed male high-school rugby player developed severe right-sided neck and shoulder pain after tackling an opponent while playing rugby. Six weeks after initial injury, the patient observed shoulder muscle weakness when performing his daily activities. On physical examination, limited active elevation of the right shoulder in the scapular plane and scapular winging was observed. Magnetic resonance imaging revealed atrophy of both the SA and subclavius muscles on the right side, and we initially suspected an LTN injury sustained. However, while detailing his history, the patient explained that he also had noted difficulty sucking high viscosity drinks such as shakes and smoothies since childhood. In addition, physical examination showed weakness of the orbicularis oculi muscle. Considering the facial muscle weakness, facioscapulohumeral dystrophy (FSHD) was also suspected, and genetic testing showed chromosome 4q35 deletion with restriction fragments 17 kb and 3 tandem repeated DNA confirming the diagnosis of FSHD. Clinicians should be aware that FSHD could be one of the differential diagnoses of scapular winging after sports injury, and surgeons should rule out the diagnosis of FSHD before performing any surgical treatment for SA palsy.

Long-Term Survivorship of Closed-Wedge High Tibial Osteotomy for Severe Knee Osteoarthritis: Outcomes After 10 to 37 Years.

BACKGROUND: High tibial osteotomy (HTO) was developed as a joint-preserving procedure to treat relatively young patients with isolated medial compartmental knee osteoarthritis (OA). Long-term survivorship after HTO is important to determine whether patients will need additional surgery. PURPOSE: To determine the long-term (>35-year) survivorship and prognostic factors for closed-wedge HTO (CWHTO) for severe medial OA. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively evaluated patients who underwent CWHTO for severe medial knee OA between 1983 and 2009 at our institution, Nagoya University Graduate School of Medicine (Nagoya, Japan). Patient demographics, follow-up period, and pre- and postoperative femoral-tibial angle (FTA) were reviewed. The patients or the relatives of the patients were interviewed by telephone to record postoperative status, including conversion to total knee arthroplasty (TKA). RESULTS: Of the 74 CWHTO procedures performed, we evaluated 56 procedures in 45 patients (mean age at time of surgery, 56.8 years). The mean follow-up period was 17.1 years. Nine knees (16.1%) underwent conversion to TKA. The mean time to TKA conversion was 15.6 years. Kaplan-Meier analysis revealed a 10-year survival rate of 90.1%, a 15-year rate of 83.8%, a 20-year rate of 75.9%, and a 35-year rate of 75.9%. Log-rank test showed that age ≥55 years (P = .044), body mass index (BMI) ≥25 kg/m2 (P = .0016), and preoperative FTA <185° (P = .0034) were risk factors associated with TKA conversion. Multivariate analyses adjusted for age and sex identified BMI ≥25 kg/m2 (hazard ratio [HR], 13.4; 95% CI, 1.7-106.9; P = .014) and preoperative FTA <185° (HR, 4.2; 95% CI, 1.1-16.6; P = .04) as risk factors associated with TKA conversion. CONCLUSION: The survival rate of CWHTO for severe medial knee OA was 90.1% at 10 years, 83.8% at 15 years, and 75.9% at 20 years and 35 years. Furthermore, a BMI ≥25 kg/m2 and FTA <185° were the independent risk factors associated with TKA conversion after CWHTO.

4-Methylumbelliferone suppresses catabolic activation in anterior cruciate ligament-derived cells via a mechanism independent of hyaluronan inhibition.

BACKGROUND: The anterior cruciate ligament (ACL) has a key role as a dynamic stabilizer of the knee joints, and ACL dysfunction caused by traumatic or degenerative rupture accelerates osteoarthritis progression. Thus, it is important to prevent the degenerative rupture of the ACL. 4-Methylumbelliferone (4-MU), a pre-approved drug, exerts anti-inflammatory effects in osteoarthritis chondrocytes. It was originally used as an inhibitor of hyaluronan synthesis in chondrocytes. METHODS: In this study, we investigated whether 4-MU affects the expression of catabolic factors, such as matrix metalloproteinase (MMP)-1, MMP-3, and interleukin (IL)-6, in ACL-derived cells and ACL explant cultures using immunohistochemistry, real-time RT-qPCR, and capillary western immunoassay. Furthermore, the hyaluronan concentration was evaluated using a colorimetric assay. Statistical analyses were conducted using analysis of variance for multi-group comparisons, followed by Tukey or Tukey-Kramer post hoc test. RESULTS: Our results revealed, for the first time, that 4-MU suppressed the IL-ß-induced upregulation of pro-catabolic factors, such as MMP-1, MMP-3, and IL-6, in ACL-derived cells. This suppressive effect was also observed in the cultured ligament tissues in ex vivo experiments. 4-MU also reversed an enhanced dependence on glycolysis in IL-1ß-activated ACL-derived cells. Furthermore, we found that the suppressive effects of 4-MU were exerted directly and not through the inhibition of hyaluronan synthesis. CONCLUSIONS: We conclude that 4-MU could be an effective and useful treatment for knee osteoarthritis, owing to its anti-inflammatory effect on, not only chondrocytes but also on ligament cells.

Spontaneous Pneumomediastinum in an Adolescent Soccer Player.

Spontaneous pneumomediastinum (SPM) is an uncommon and usually benign self-limiting clinical disorder found in young people, often without apparent precipitating factors or diseases. A pressure gradient exists between the peripheral pulmonary alveoli and the hilum, and increased intra-alveolar pressure causes rupture of the terminal alveoli. We present the case of a 15-year-old male soccer player who presented with a complaint of anterior chest pain and dysphagia after stopping the strong ball with his chest. His symptom gradually progressed over hours. We can make the diagnosis of SPM using by chest X-ray and computed tomography (CT) scanning. His symptoms were gradually resolved over the course of approximately one week with no exercise and careful observation. We believe that our case provides very useful information to alert clinicians and coaches regarding this rare disease that may occur in anyone including adolescent soccer players.

N1m amplitude growth function for bone-conducted ultrasound.

CONCLUSION: N1m growth indicates the differences in central auditory processing between bone-conducted ultrasound and air-conducted audible sound. OBJECTIVES: Bone conduction enables ultrasound to be heard by the human ear. Despite many studies, the perceptual mechanism of bone-conducted ultrasound has not yet been clarified completely. Therefore, this study investigated the ultrasonic perception of humans, especially as regards the effects of stimulus intensity or loudness. SUBJECTS AND METHODS: The effect of the stimulus level on N1m amplitude was measured over the psycho-acoustical dynamic range. RESULTS: The dynamic range for 30 kHz bone-conducted ultrasound (18.2 +/- 3.3 dB) was found to be significantly narrower than that for 1 kHz air-conducted sound (85.9 +/- 11.9 dB). As the stimulus level increased, the N1m amplitude in response to bone-conducted ultrasound grew faster than that to air-conducted sound. Although the growth of the N1m amplitude for air-conducted sound saturated below the uncomfortable loudness level (UCL), that for bone-conducted ultrasound continued to grow above the UCL.

Comparison between bone-conducted ultrasound and audible sound in speech recognition.

CONCLUSION: This study showed that it is possible to transmit language information using bone-conducted ultrasound (BCU) in normal-hearing subjects. Our results suggest the possibility of a difference in speech recognition between BCU and air-conducted audible sound (ACAS). OBJECTIVE: Ultrasound was audible when delivered by bone conduction. Some profoundly deaf subjects as well as normal-hearing subjects can discriminate BCU whose amplitude is modulated by different speech sounds. These findings suggest the usefulness of developing a bone-conducted ultrasonic hearing aid (BCUHA). However, the characteristics of BCU are still poorly understood. The aim of the present study was to compare BCU and ACAS in terms of their associated speech perception tendency and to investigate the different perceptual characteristics of BCU and ACAS. SUBJECTS AND METHODS: Speech discrimination tests using both BCU and ACAS were performed with normal-hearing subjects. BCU and ACAS were compared for intelligibility and hearing confusion. RESULTS: With BCU, the maximum percentage correct totaled about 75%. Our comparison of the hearing confusion with ACAS and BCU according to the individual syllabic nuclear group showed a clear difference in the incorrect rates. In addition, the stimulus nuclear groups were often perceived in other nuclear groups in BCU.

Estimation of factors influencing the results of tinnitus retraining therapy.

CONCLUSION: The factors of tinnitus loudness and Tinnitus Handicap Inventory (THI) score in tinnitus patients have the potential to relate to therapeutic results of tinnitus retraining therapy (TRT). OBJECTIVES: To confirm what factors in tinnitus influence the results of TRT. PATIENTS AND METHODS: Twelve factors were investigated in 53 patients with tinnitus, examining the relationship between these factors and the results of TRT. A THI score was determined before and 6 months after TRT introduction (pre- and post-TRT). Moreover, the change of THI score from pre- to post-TRT (delta THI) was referred to as the therapeutic effect of TRT. Based on the 12 factors, subjects were respectively divided into two groups, comparing delta THI between groups. RESULTS: Two groups of greater tinnitus loudness and higher THI score showed significant increases in delta THI, indicating that two factors of tinnitus loudness and THI score were related to the therapeutic effect of TRT.

The effect of visual information in speech signals by bone-conducted ultrasound.

A prototype for a bone-conducted ultrasonic hearing aid was developed for the profoundly deaf. Previous studies using bone-conducted ultrasonic hearing aid revealed intelligibility only with the use of acoustic media in transmitting language information. In this study, we investigated the effects of visual information (lip-reading information) on intelligibility in bone-conducted ultrasound perception of normal-hearing individuals. We found that lip-reading information had clear effects on bone-conducted ultrasound perception, showing that simultaneous presentation of audio and visual information improved intelligibility to levels sufficient for speech perception. Our findings also suggested the efficacy of use of signal processing techniques in improving the intelligibility of prior consonants. NeuroReport 21:119­122

Numerical and experimental study on the wave attenuation in bone--FDTD simulation of ultrasound propagation in cancellous bone.

In cancellous bone, longitudinal waves often separate into fast and slow waves depending on the alignment of bone trabeculae in the propagation path. This interesting phenomenon becomes an effective tool for the diagnosis of osteoporosis because wave propagation behavior depends on the bone structure. Since the fast wave mainly propagates in trabeculae, this wave is considered to reflect the structure of trabeculae. For a new diagnosis method using the information of this fast wave, therefore, it is necessary to understand the generation mechanism and propagation behavior precisely. In this study, the generation process of fast wave was examined by numerical simulations using elastic finite-difference time-domain (FDTD) method and experimental measurements. As simulation models, three-dimensional X-ray computer tomography (CT) data of actual bone samples were used. Simulation and experimental results showed that the attenuation of fast wave was always higher in the early state of propagation, and they gradually decreased as the wave propagated in bone. This phenomenon is supposed to come from the complicated propagating paths of fast waves in cancellous bone.

Assessment of ability to discriminate frequency of bone-conducted ultrasound by mismatch fields.

According to previous studies, ultrasound can be perceived through bone conduction and ultrasound amplitude modulated by different speech sounds can be discriminated by some profoundly deaf subjects as well as the normal-hearing. These findings suggest the usefulness of development of a bone-conducted ultrasonic hearing aid (BCUHA) for profoundly deaf subjects. In this study, with a view to developing a frequency modulation system in a BCUHA, the capability to discriminate the frequency of sinusoidal bone-conducted ultrasound (BCU) was evaluated by measuring mismatch fields (MMF). We compared MMFs between BCU (standard stimuli were 30 kHz, and deviant stimuli were 27 and 33 kHz) and air-conducted audible sound (ACAS; standard stimuli were 1 kHz, and deviant stimuli were 900 and 1100 Hz). MMFs were observed in all subjects for ACAS, however, not observed in a few subjects for BCU. Further, the mean peak amplitudes of MMF for BCU were significantly less than those for ACAS. These findings indicate that the discrimination capability of frequency of sinusoidal BCU is inferior to that of ACAS. It was also demonstrated that normal hearing could to some extent discriminate differences in frequency in sinusoidal BCU. The results indicate a possibility of transmission system for language information making use of frequency discrimination.

Effect of masker frequency on N1m amplitude in forward masking.

The effect of frequency on N1m has been investigated by various methods. However, it has not yet been measured using forward masking. In this study, the frequency specificity of N1m was investigated using forward masking. Although the masker frequency had some influence on N1m amplitudes, the results suggested that the frequency specificity of N1m was worse than that of a single-neuron or psychological tuning curve. This is probably because N1m includes various components, both frequency-specific and non-specific, some of which may be less affected by masking. Thus, our results agree with those of previous studies using intervening tones that suggested widespread neural representation in the auditory cortex.

Effect of a forward masker on the N1m amplitude: varying the signal delay.

Auditory sensation is affected by a forward masker, and this phenomenon has been demonstrated in a neural adaptation model and a temporal window (integration) model. To study forward masking in the central auditory system, the growth of the N1m amplitude was measured by varying the signal delay. In the adaptation model, the masking increases as the signal delay decreases. However, in our results, the minimum N1m amplitude was observed at a signal delay of 40 ms. As the signal delay decreased from 40 ms, the N1m amplitude increased although the masking increased. Our results suggest that the growth of the N1m amplitude largely depends on temporal integration at signal delays below 40 ms.

Ultrasonic masker clarifies ultrasonic perception in man.

Bone conduction enables ultrasound to be heard. Although several hypotheses about ultrasonic perception have been presented, the perception mechanism of bone-conducted ultrasound has not yet been established. In this study, to investigate ultrasonic perception, the amount of masking produced by 27-, 30- and 33-kHz bone-conducted ultrasonic maskers for air-conducted high-frequency sounds was measured in the frequency range of 8-18 kHz at 1-kHz intervals. The results showed that the air-conducted signals in the frequency range of 10-14 kHz were strongly masked by the ultrasonic maskers. When the masker intensity increased from 5 to 10 dB SL, the growth of masking was more than 10 dB in the frequency range of 9-15 kHz, and the masking spread strongly to lower frequencies. Furthermore, the dynamic range for bone-conducted ultrasound was clearly narrower than that for air-conducted high-frequency sounds. These results suggest that perception of bone-conducted ultrasound depends on inner hair cell activity induced by ultrasound, even without modulation being present, and does not depend on enhancement by the outer hair cells in the basal turn of the cochlea.