Extra-Articular Stabilization for the Treatment of Recurrent Sternoclavicular Joint Instability: A Report of Two Cases.

CASE: A 22-year-old man and a 14-year-old adolescent boy, who exhibited moderate general joint laxity, experienced recurrent sternoclavicular joint instability without traumatic events. The patients were successfully treated with extra-articular stabilization using autologous tendon grafts without surgical exposure of the sternoclavicular joint. CONCLUSION: Atraumatic instability of the sternoclavicular joint is rare but often results in recurrent instability accompanied by discomfort, pain, and limitations in activities. Extra-articular stabilization, which reinforces the anterior capsule of the sternoclavicular joint and prevents anterior displacement of the proximal clavicle at the elevated arm position, could be a viable surgical option for this pathological condition.

Two-year follow-up after operative treatment of an osseous Bankart lesion with a flap-detached cartilage lesion of the glenoid: A case report.

Glenoid articular cartilage lesion is a rare complication following traumatic anterior dislocation of the shoulder. We report the case of a 14-year-old male rugby player with traumatic anterior shoulder instability, an extensively flapped lesion on the glenoid articular cartilage, and an osseous Bankart lesion. Arthroscopic findings revealed that the glenoid cartilage was flap-detached, extending from the anteroinferior to the center. Repair of the osseous Bankart lesion using suture anchors and resection of the unstable peripheral part of the cartilage was performed arthroscopically. The main region of the injured articular surface was left untouched. During postoperative follow-up, absorption of the glenoid articular surface near the suture anchor holes was identified. Arthroscopic examination three months post-surgery showed that the flap detached lesion of the residual cartilage was stable and appeared adapted on the glenoid surface. The resected area was covered by fibrous tissue. A follow-up computed tomography scan revealed that the osseous lesion was united. The patient returned to his previous sports capacity eight months following the operation. At the 2-year-follow-up, magnetic resonance imaging revealed that the glenoid surface was remodeled to a flattened round shape with no signs of osteoarthritis, exhibiting proper conformity of the joint surfaces to the humeral head. Arthroscopic Bankart repair using suture anchors may cause bone resorption at the glenoid surface, leading to remodeling of the glenoid surface from the damaged glenoid cartilage lesion in young patients.

Longitudinal MR quantification of the fat fraction within the supraspinatus and infraspinatus muscles in patients with shoulder pain.

RATIONALE AND OBJECTIVES: Knowing the natural history of fatty degeneration of rotator cuff muscles is important for estimating the risk and rate of progression to cuff tear arthropathy (CTA). The purpose of this study was to investigate the changes in rotator cuff muscle fatty degeneration over time quantitatively in patients treated conservatively for shoulder pain. MATERIALS AND METHODS: Thirty patients with a baseline and follow-up shoulder MRI, including a 2-point Dixon sequence, which were performed at least 1 year apart, were included. We classified patients into 3 groups: "full-thickness tear" (n = 7), "partial-thickness tear" (n = 13), and "no-tear" (n = 10) groups. The fat fraction in the supra- and infraspinatus muscles, and the rate of change in the fat fraction (ΔFfr) were calculated using the formula "fat fraction of follow-up MRI/fat fraction of initial MRI." We investigated the difference in ΔFfr among the 3 groups and the degree of progression to CTA. RESULTS: Statistically significant differences in ΔFfr within the supraspinatus and infraspinatus muscles were found among full-thickness, partial-thickness, and no-tear groups (2.54 vs 1.02 vs 0.75, p < 0.001 and 1.96 vs 1.07 vs 0.73, p = 0.021, respectively). Overall, 71.4% of the full-thickness tear group showed progression of CTA, and 28.6% of the full-thickness tear group needed reverse shoulder arthroplasty within an average follow-up period of 34 months. CONCLUSIONS: MR quantification, together with the knowledge of change in fatty degeneration over time, may be useful for the management of patients with shoulder pain.

Uncemented total hip arthroplasty using alumina ceramic bearings at a minimum of 14 years of follow-up.

INTRODUCTION: The effectiveness of modern ceramic bearings has been well established in reducing the osteolysis associated with wear of the bearing surfaces in total hip arthroplasty (THA). However, there are limited mid- to long-term follow-up data for complications associated with ceramic bearings. MATERIALS AND METHODS: This case series analyzed 124 consecutive primary uncemented THAs in 108 patients with a mean age of 61 years using alumina ceramic-on-alumina ceramic bearing couples. Seventy THAs (56%) were evaluated at a minimum 14 years of follow-up; the mean follow-up period was 16 ± 1 years (14-20 years). Kaplan-Meier survivorship was determined with revision surgery for any reason as the end point. Complications were recorded focusing on osteolysis, ceramic fracture, and abnormal sounds until the final follow-up. Clinical data were scored according to the Merle d'Aubigne and Postel hip score at 14 years after THA. RESULTS: The survivorship was 93.5% (95% CI 86.7-97.0%) at 14-years postoperatively. Five patients (4.0%) underwent revision surgery due to instability or infection before 1-year postoperatively. Two patients (1.6%) underwent revision surgery due to ceramic liner fracture at 9- and 12-years postoperatively, respectively. There was no radiographic evidence of osteolysis. A total of 27 complications occurred: dislocations (n = 7/124), squeaking sounds (n = 3/124), clicking sounds (n = 6/124), ceramic liner fractures (n = 2/124), periprosthetic fractures (n = 4/124), deep infections (n = 2/124), transient sciatic nerve palsy (n = 2/124), and femoral stem breakage (n = 1/124). The Merle d'Aubigne and Postel hip score was 16.8 ± 1.4 points. CONCLUSIONS: The survivorship analysis demonstrates the uncemented THA using alumina ceramic bearings may provide favorable clinical outcome and can offer minimal wear at a minimum 14-year follow-up. Revision surgery was mostly required due to instability and infection in the short-term, and implant breakage in the mid- to long-term.

Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes.

BACKGROUND: Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair. PURPOSE: To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft. RESULTS: Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001). CONCLUSION: A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

Clinical Characteristics and Surgical Outcomes for Collision Athletes with Traumatic Posterior Instability.

BACKGROUND: Diagnosis and treatment of traumatic posterior instability of the shoulder have not been described in detail. The author investigated surgical outcomes for traumatic posterior shoulder joint instability in collision athletes. METHODS: The author surgically treated patients with a diagnosis of traumatic shoulder joint instability and investigated those that had been followed up for >2 years after surgery. RESULTS: Seven shoulders in six collision athletes with a history of traumatic injury were examined. All cases were negative for the general laxity sign and positive for the posterior jerk test; five shoulders showed positive anterior apprehension. Posterior glenoid osseous defects were found in three shoulders, and one shoulder injury involved anterior and posterior osseous lesions. As surgical treatment, one posterior capsulolabral lesion, two posterior osseous lesions, and three combined anterior and posterior capsulolabral lesions were repaired arthroscopically. In a patient with a combined anterior and posterior osseous lesion, the Bristow procedure was perfromed after arthroscopic osseous repair. Patients returned to competition at an average of 6.8 months after surgery. One patient developed anterior subluxation at 7 months, and another exhibited posterior re-dislocation at 8 months after returning to competition. CONCLUSION: Traumatic posterior instability in collision athletes often involves glenoid osseous lesions and is frequently accompanied by anterior apprehension and lesions. Although collision athletes can return to play after arthroscopic repair, such activity is associated with a risk of re-dislocation.

The relationship between high-signal intensity changes in the glenohumeral joint capsule on MRI and clinical shoulder symptoms.

BACKGROUND/OBJECTIVE: High-signal intensity changes in the glenohumeral joint capsule on T2-and proton density-weighted magnetic resonance imaging are known as characteristic finding that is often observed in patients with frozen shoulder. We investigated the associations between high-signal intensity changes in the joint capsule on magnetic resonance imaging and the presence of rotator cuff tears and shoulder symptoms in patients with shoulder pain. METHODS: The medical records of 230 patients with shoulder pain who underwent magnetic resonance imaging at our hospital were reviewed. Patients were divided into three groups according to the presence and/or degree of rotator cuff tears (none, partial, or complete). The frequency of high-signal intensity changes in the joint capsule and its relationship with shoulder symptoms and the severity of rotator cuff tears were assessed. By quantitatively evaluating the intensity on MRI, the ratio between the joint capsule and the long head of the biceps (HSIC ratio) was calculated and compared with 15 healthy subjects. RESULTS: High-signal intensity changes were diagnosed in 165 (72%) patients, and it was significantly associated with night pain and range of motion limitation (p < 0.01). High-signal intensity changes were present in 66 patients (70%) with no rotator cuff tears, in 69 (71%) with partial rotator cuff tears, and in 36 (80%) with complete rotator cuff tears, without differences in their occurrence (p = 0.60), but were significantly associated with night pain in all the groups (p < 0.01) without differences in tear severity (p = 0.63). The ratio in the high-signal intensity changes (HSIC) positive group was approximately six times higher than that in the HSIC-negative and control groups (P < 0.01). Multivariate logistic regression analysis revealed that night pain is significantly associated with high-signal intensity changes (p < 0.01). CONCLUSION: Shoulder pain is a common and reliable clinical finding in patients with high-signal intensity changes, regardless of the presence and/or degree of rotator cuff tears, Such changes may indicate night pain and range of motion limitation in patients.

Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament.

BACKGROUND: Adult acquired flatfoot deformity (AAFD) is caused by impaired medial ligamentous structures and posterior tibialis tendon dysfunction (PTTD). Although degeneration and trauma could separately cause AAFD, how these factors interact in the pathomechanism of AAFD is unclear. The joint capsule in the medial ankle is considered an important structure, providing passive stability by limiting joint movement. Previous reports on the joint capsule suggest its involvement in pathological changes of the ankle, but because of the high priority placed on the ligaments, few reports address the ankle joint from the joint capsule standpoint. The current study aimed to anatomically examine the medial ankle joint, focusing on the deltoid and spring ligaments in perspective of the joint capsule. METHODS: We conducted a descriptive anatomical study of 19 embalmed cadavers (mean 82.7 years, range 58 to 99). We included 22 embalmed cadaveric ankles. We detached the joint capsule in 16 ankles from the anterior to posteromedial joint, analyzed the capsular attachments of the ankle and adjacent joints, and measured the widths of the bony attachments. We histologically analyzed the joint capsule using Masson's trichrome staining in 6 ankles. RESULTS: The capsule could be separated as a continuous sheet, including 3 different tissues. The anterior capsule was composed of fatty tissue. Between the medial malleolus and talus, the capsule was strongly connected and was composed of fibrous tissue, normally referred to as the deep deltoid ligament. The tibial attachment formed a steric groove, and the talar side of the attachment formed an elliptical depressed area. On the medial part of the subtalar and talonavicular joints, the capsule covered the joints as cartilaginous tissue, normally referred to as the superomedial ligament of the spring ligament. The outer side of the cartilaginous and fibrous tissue formed the sheath floor of the posterior tibialis tendon. Histological analysis revealed three different tissue types. CONCLUSIONS: The capsules of the ankle, subtalar, and talonavicular joints could be detached as a continuous sheet. The deltoid and the superomedial ligament of the spring ligaments could be interpreted as a part of the continuous capsule, which had different histological features. LEVEL OF EVIDENCE: Descriptive Laboratory Study.

Post-operative pain control following arthroscopic rotator cuff repair: peri-articular injection versus interscalene brachial plexus block.

PURPOSE: To compare post-operative pain relief with peri-articular injection (PI) versus interscalene brachial plexus block (IBPB) after arthroscopic rotator cuff repair (ARCR) surgery. METHODS: We retrospectively reviewed 121 consecutive patients undergoing ARCR surgery divided into two groups: the PI group and the IBPB group. We compared complications and self-reported pain score measured using a Numerical Rating Scale (NRS) during the initial 24 hours after surgery. RESULTS: The NRS scores recorded in the recovery room (0), 0.5, and four hours post-operatively were higher in the PI group (n = 38) than the IBPB group (n = 52) (2.1 vs. 0.8, p = 0.014; 1.4 vs. 0.5, p = 0.0069; and 1.3 vs. 0.5, p = 0.012, respectively). However, the NRS scores recorded at 16, 20, and 24 hours post-operatively were lower in the PI group than in the IBPB group (1.4 vs. 3.1, p < 0.0001; 1.4 vs. 3.2, p < 0.0001; and 1.7 vs. 3.2, p = 0.00046, respectively). The incidences of post-operative nausea and temporary numbness in the upper arm were significantly lower in the PI group than in the IBPB group (7.9% vs. 33%, p = 0.0052; and 13% vs. 85%, p < 0.0001, respectively). CONCLUSIONS: Although IBPB provided superior pain control during the initial few hours after ARCR surgery, PI was superior from 16 to 24 hours post-operatively. The rates of side effects, such as nausea and temporary arm numbness, were also lower in the PI group than in the IBPB group.

Comparison Between Isotropic 3-Dimensional Fat-Suppressed T2-Weighted Fast Spin Echo (FSE) and Conventional 2-Dimensional Fat-Suppressed Proton-Weighted FSE Shoulder Magnetic Resonance Imaging at 3-T in Patients With Shoulder Pain.

OBJECTIVE: The aims of this study were to compare isotropic 3-dimensional fat-suppressed T2-weighted fast spin echo (FSE) imaging (T2FS) with 2-dimensional fat-suppressed proton-density-weighted FSE imaging (2D-PDFS) and evaluate feasibility of isotropic 3-dimensional FSE shoulder imaging at 3-T magnetic resonance imaging (MRI). METHODS: Seventy-eight patients who underwent shoulder MRI were evaluated. Three-dimensional T2FS and 2D-PDFS were qualitatively graded for delineation of anatomic structures. In quantitative analysis, mean relative signal intensity and relative signal contrast between each structure of the shoulder were compared. RESULTS: Three-dimensional T2FS showed significantly higher scores for rotator cuff (P = 0.020), lower scores for bone (P < 0.001), and higher relative contrast of rotator cuff to fluid (P < 0.001) and labrum to fluid (P < 0.001) in comparison with 2D-PDFS. No significant difference in relative signal intensity of the rotator cuff, labrum, joint fluid, cartilage, and bone marrow was demonstrated. CONCLUSIONS: Isotropic 3-dimensional FSE MRI has similar image quality and diagnostic performance to conventional 2-dimensional sequence in evaluation of the rotator cuff.

Intra- and inter-observer reproducibility of shoulder laxity tests: Comparison of the drawer, modified drawer and load and shift tests.

BACKGROUND: Conventional tests of shoulder laxity have been shown to have poor reliability due to the difficulty in palpating the subtle movements of the shoulder joint beneath the musculature. Modified drawer test that is performed while the soft tissues surrounding the shoulder are loosened has been proposed to facilitate glenohumeral joint movement and improve reliability. We hypothesised that the modified drawer test would have an improved intra- and inter-observer reproducibility in comparison to the drawer and load and shift tests. Correlation of shoulder laxity measured by these tests with generalized joint laxity was also assessed. METHODS: Forty healthy volunteers underwent bilateral shoulder examination in the clinic using the three tests for anterior and posterior laxity assessment by a consultant shoulder surgeon and a resident. The examination was repeated three months later by the same examiners in the same cohort. Intra- and inter- observer reproducibility was calculated using Kappa values. The correlation of shoulder with generalized joint laxity was also investigated. RESULTS: The modified drawer test showed significantly improved intra-observer reproducibility compared to the drawer test, but not to the load and shift (κ = 0.173, -0.042, and 0.009, respectively). There were no significant differences in the inter-observer reproducibility between the three tests (κ = 0.054, 0.055, and 0.056, respectively). Moderate correlation was noted between shoulder and generalized joint laxity when modified drawer test was used (r = 0.417). CONCLUSIONS: The modified drawer test improves intra- but not inter- observer reproducibility compared to the drawer test. Shoulder laxity assessed by the modified test correlated to generalized joint laxity. The modified drawer test has an improved reproducibility and correlation to generalized joint laxity over the conventional tests.

Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture.

BACKGROUND/OBJECTIVE: Ankle fractures, even if treated surgically, usually take a long time to heal. For all patients with ankle fracture, immobilisation is a critical part of treatment. Short-leg walking boots (WBs) have been reported to be an effective alternative to plaster casts (PCs) that could shorten this postoperative recuperative period. The aim of this study was to compare the functional recovery of a conventional PC with that of a WB after surgery for ankle fractures. METHODS: Forty-seven patients (mean age, 53.9 ± 12 years) who had undergone surgical operation for an unstable ankle fracture from January 2008 to October 2014 were reviewed retrospectively. Either a PC or a WB was prescribed postoperatively, with 25 patients and 22 patients, respectively. The time that it took the patient to stand unipedal on the affected side after allowing full-weight bear and to walk without crutches were used for assessment of functional recovery. The prevalence of postoperative loss of reduction and nonunion was also reviewed. RESULTS: Both the time of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, p = 0.01; WB, 1.4 weeks; PC, 3.1 weeks, p = 0.03). There were no patients with loss of reduction or nonunion. CONCLUSION: Patients who used WBs showed a significantly faster recovery. WBs have an adjustable heel lift that allows users to change the ankle position slightly plantarflexed that helps walking in a postoperative swollen ankle. WBs are easy to slip on, and it is easy to adjust the ankle position in conformity with swelling so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. The Rocker bottom design minimises the sagittal plane motion in the specific joint of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activity at a faster rate.

Reliability of MR Quantification of Rotator Cuff Muscle Fatty Degeneration Using a 2-point Dixon Technique in Comparison with the Goutallier Classification: Validation Study by Multiple Readers.

RATIONALE AND OBJECTIVES: Presurgical assessment of fatty degeneration is important in the management of patients with rotator cuff tears. The Goutallier classification is widely accepted as a qualitative scoring system, although it is highly observer-dependent and has poor reproducibility. The objective of this study was to quantify fatty degeneration of the supraspinatus muscle using a 2-point Dixon technique in patients with rotator cuff tears by multiple readers, and to evaluate the reproducibility compared to Goutallier classification. MATERIALS AND METHODS: Two hundred patients with rotator cuff tears who underwent magnetic resonance imaging (MRI), including 2-point Dixon sequence at 3.0-T, were selected retrospectively. Qualitative and quantitative analyses of fatty degeneration were performed by two radiologists and three orthopedic surgeons independently. The fat quantification was performed by measuring signal intensity values of in phase (S(In)) and fat image (S(Fat)), and calculating fat fraction as S(Fat)/S(In). The reproducibility of MR quantification was analyzed by the intra- and interclass correlation coefficients and Bland-Altman plots. RESULTS: The interobserver agreement of the Goutallier classification among five readers was moderate (k = 0.51), whereas the interclass correlation coefficient regarding fat fraction value quantified in 2-point Dixon sequence was excellent (0.893). The mean differences in fat fraction values from the individual segmentation results were from -0.072 to 0.081. Proposed fat fraction grading and Goutallier grading showed similar frequency and distribution in severity of rotator cuff tears. CONCLUSIONS: Fat quantification in the rotator cuff muscles using a 2-point Dixon technique at 3.0-T MRI is highly reproducible and clinically feasible in comparison to the qualitative evaluation using Goutallier classification.

Correlation of alpha angle between various radiographic projections and radial magnetic resonance imaging for cam deformity in femoral head-neck junction.

PURPOSE: Radial magnetic resonance imaging (MRI) along the axis of the femoral head neck is the gold standard for detection of cam deformity of the proximal femur. This study was performed to identify which plain radiographic projection was best correlated with radial MRI. METHODS: Five different plain radiographic projections and 18 slices of radial MRI were applied to 35 consecutive hips with groin pain and positive impingement sign. Alpha angles were measured to detect the asphericity of the femoral head-neck junction in all images. Radiographs were taken in anteroposterior pelvis, cross-table lateral, 90° Dunn, 45° Dunn and modified 45° Dunn views. Pearson's correlation coefficients were determined to assess the association between the alpha angle obtained from radial MRI and each radiographic technique. The sensitivity, specificity, positive and positive predictive values and accuracy of plain radiographic alpha angle measurements were assessed using a threshold alpha angle value of 50.5° for cam deformity. RESULTS: Pearson's correlation coefficients in the alpha angle values between MRI and plain radiographic projections were 0.45, 0.70, 0.62, 0.81 and 0.69 for the anteroposterior pelvis, cross-table lateral, 90° Dunn, 45° Dunn and modified 45° Dunn views, respectively. In terms of sensitivity and accuracy, the 45° Dunn view had the greatest values. CONCLUSIONS: Alpha angle of the 45° Dunn view was best correlated with that of radial MRI. The 45° Dunn view had better sensitivity and accuracy than other radiographic projections. The 45° Dunn view may be preferable for screening of cam deformity. LEVEL OF EVIDENCE: II.

MRI for the diagnosis of scapular dyskinesis: a report of two cases.

Scapular dyskinesis describes the altered position of the scapula and/or abnormal movements of the scapulothoracic joint. It is caused by bony anatomical variations, bursitis, tumors, and muscular pathological conditions including loss of innervation and fibrosis. Scapular dyskinesis is just as often subclinical as it is symptomatic, and as the periscapular anatomical changes may not result in patient symptoms, a precise diagnosis of the etiology and pathophysiology has been a challenge. Scapular bony prominence is a common etiology of scapular dyskinesis, but does not always result in morbidity. We report a case of a 39-year-old man in whom an extensive MRI with fluid-sensitive imaging sequences covering the whole of the scapula was beneficial in diagnosing the inflammation adjacent to the bony deformity, which confirmed the etiology of scapular dyskinesis. Furthermore, in a 41-year old man without any anatomical variances, a similar MRI showed inflammation at the subscapular fossa that suggested altered scapular kinematics. An arthroscopic debridement of the lesion improved the symptoms. MRI in conjunction with plain radiographs, CT and physical examination enabled a precise diagnosis of the etiology. Fluid-sensitive MR images are important in defining the presence of inflammation, and are beneficial in determining the pathological significance of findings through other diagnostic measures.

Simultaneous Bilateral Transient Osteoporosis of the Hip without Pregnancy.

Transient osteoporosis of the hip (TOH) is a rare disorder characterized by acute severe coxalgia and temporary osteopenia in the proximal femur. Although most cases were unilateral or staged bilateral TOH, some authors reported that the pregnant patients simultaneously had TOH in their bilateral hips. However, there has been no report of simultaneous bilateral TOH in the patient without pregnancy. A 25-year-old Japanese woman without pregnancy had acute simultaneous bilateral hip pain. Plain X-ray of the bilateral hips did not show a periarticular osteopenia. However, magnetic resonance image obtained one week after the onset demonstrated increased T2-weighted signal intensity and decreased T1-weighted signal intensity in the bilateral femoral heads. She was treated conservatively, and follow-up magnetic resonance image at seven weeks after the onset returned to normal bone marrow signal intensity. Her bilateral coxalgia subsided gradually. At one year after the onset, she had no sign of symptomatic flair. Our experience with this case indicates that recognizing the possibility of simultaneous bilateral TOH is important unless the patient is pregnant, and magnetic resonance image is predictable test to make a diagnosis of TOH, even in the absence of abnormal finding on plain X-ray.

Predicting Retear after Repair of Full-Thickness Rotator Cuff Tear: Two-Point Dixon MR Imaging Quantification of Fatty Muscle Degeneration-Initial Experience with 1-year Follow-up.

Purpose To determine the degree of preoperative fatty degeneration within muscles, postoperative longitudinal changes in fatty degeneration, and differences in fatty degeneration between patients with full-thickness supraspinatus tears who do and those who do not experience a retear after surgery. Materials and Methods This prospective study had institutional review board approval and was conducted in accordance with the Committee for Human Research. Informed consent was obtained. Fifty patients with full-thickness supraspinatus tears (18 men, 32 women; mean age, 67.0 years ± 8.0; age range, 41-91 years) were recruited. The degrees of preoperative and postoperative fatty degeneration were quantified by using a two-point Dixon magnetic resonance (MR) imaging sequence; two radiologists measured the mean signal intensity on in-phase [S(In)] and fat [S(Fat)] images. Estimates of fatty degeneration were calculated with "fat fraction" values by using the formula S(Fat)/S(In) within the supraspinatus, infraspinatus, and subscapularis muscles at baseline preoperative and at postoperative 1-year follow-up MR imaging. Preoperative fat fractions in the failed-repair group and the intact-repair group were compared by using the Mann-Whitney U test. Results The preoperative fat fractions in the supraspinatus muscle were significantly higher in the failed-repair group than in the intact-repair group (37.0% vs 19.5%, P < .001). Fatty degeneration of the supraspinatus muscle tended to progress at 1 year postoperatively in only the failed-repair group. Conclusion MR imaging quantification of preoperative fat fractions by using a two-point Dixon sequence within the rotator cuff muscles may be a viable method for predicting postoperative retear. (©) RSNA, 2016.

Quantification of Fatty Degeneration Within the Supraspinatus Muscle by Using a 2-Point Dixon Method on 3-T MRI.

OBJECTIVE: The objective of this study was to quantify fatty degeneration of the supraspinatus muscle by using a 2-point Dixon technique on 3-T MRI and to evaluate the correlation of muscular atrophy and fat fraction values among different severities of rotator cuff tears across differing ages and sexes. SUBJECTS AND METHODS: Patients with shoulder pain (n = 359) were evaluated by shoulder MRI on a 3-T unit, including a 2-point Dixon sequence for quantification of muscle atrophy and fatty degeneration within the supraspinatus muscle. Two board-certified musculoskeletal radiologists evaluated the degree of rotator cuff tears in three groups: full-thickness tear (n = 63), partial tear (n = 54), and no tear (n = 242). In quantitative analysis, we measured signal intensity values of in-phase images (SIn) and fat images (SFat) within the supraspinatus muscle, and the fat fraction was calculated as SFat/SIn. The Thomazeau occupation ratio was used as a quantitative index of muscular atrophy. Fat fraction and muscle atrophy were evaluated among these groups. RESULTS: Fat fraction values were changed with the degree of rotator cuff tears and were (mean ± SD) 0.258 ± 0.123 among patients with full-thickness tears, 0.166 ± 0.067 among patients with partial tears, and 0.128 ± 0.061 among patients with no tears, with statistically significant differences (p < 0.001). The values were higher in female than in male patients in all groups. The Pearson correlation coefficient was 0.348 between age and fat fraction value, and 0.664 between muscular atrophy rate and fat fraction value. CONCLUSION: An increase in supraspinatus fatty degeneration was statistically significantly correlated with severity of supraspinatus tears and moderately correlated with muscular atrophy. Fatty degeneration tends to progress more rapidly than muscular atrophy in female patients, with statistically significant sex differences.

Combined Arthroscopic Bankart Repair and Coracoid Process Transfer to Anterior Glenoid for Shoulder Dislocation in Rugby Players: Evaluation Based on Ability to Perform Sport-Specific Movements Effectively.

PURPOSE: To evaluate the outcomes of a combination of an arthroscopic Bankart repair and an open Bristow procedure in relation to the subjective quality of performance in movements that are typical in rugby. METHODS: Forty shoulders in 38 players who underwent surgery for traumatic anterior instability of the shoulder were reviewed. In all cases, arthroscopic Bankart repair was followed by a Bristow procedure, with preservation of the repaired capsular ligaments, during the same operation. The mean age at the time of surgery was 21 years. Patients were asked to describe common rugby maneuvers (tackle, hand-off, jackal, and saving) preoperatively and postoperatively as "no problem," "insufficient," or "impossible." RESULTS: There were no recurrent dislocations at a mean follow-up of 30.5 months. The mean Rowe score improved significantly from 65.0 (range, 55 to 75) to 97.5 (range, 95 to 100) (P < .001) after surgery. Preoperatively, regarding the tackling motion, none of the patients reported having no problem, whereas the ability was described as insufficient for 23 shoulders and impossible for 17 shoulders. Postoperatively, no problem with tackling was reported for 36 shoulders, whereas insufficiency was reported for 4. The results for the hand-off, jackal, and saving maneuvers were similar (P < .001). No patient rated any of the motions as impossible postoperatively. CONCLUSIONS: This combined surgical procedure clearly is effective in preventing recurrent dislocation in rugby players; however, some players complained of insufficiency in the quality of their play when they were tackling or performing other rugby-specific movements. LEVEL OF EVIDENCE: Level IV, case series.

MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica.

OBJECTIVES: The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR). METHODS: MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed. RESULTS: The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05). CONCLUSIONS: Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.