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Background This study was performed to compare glenoid version and inclination measured using two-dimensional (2D) images from computed tomography (CT) scans or three-dimensional (3D) reconstructed bone models. Methods Thirty patients who had undergone conventional CT scans were included. Two orthopedic surgeons measured glenoid version and inclination three times on 2D images from CT scans (2D measurement), and two other orthopedic surgeons performed the same measurements using 3D reconstructed bone models (3D measurement). The 3D-reconstructed bone models were acquired and measured with Mimics and 3-Matics (Materialise). Results Mean glenoid version and inclination in 2D measurements were –1.705º and 9.08º, respectively, while those in 3D measurements were 2.635º and 7.23º. The intra-observer reliability in 2D measurements was 0.605 and 0.698, respectively, while that in 3D measurements was 0.883 and 0.892. The inter-observer reliability in 2D measurements was 0.456 and 0.374, respectively, while that in 3D measurements was 0.853 and 0.845. Conclusions The difference between 2D and 3D measurements is not due to differences in image data but to the use of different tools. However, more consistent results were obtained in 3D measurement. Therefore, 3D measurement can be a good alternative for measuring glenoid version and inclination.

Rotator cuff tear (RCT) is a common injury that causes pain and disability in adults. The quantitative diagnosis of the RCT can be crucial in determining a treatment plan or monitoring treatment efficacy. Currently, only a few diagnosis tools, such as magnetic resonance imaging (MRI) and ultrasound imaging (US), are utilized for the diagnosis. Specifically, US exhibited comparable performance with MRI while offering a readily available diagnosis of RCTs at a lower cost. However, three-dimensional(3D) US and analysis of the regions are necessary to enable a better diagnosis of RCTs. Therefore, we developed a wide-field 3D US platform with a semi-automatic 3D image segmentation algorithm for 3D quantitative diagnosis of RCTs. The 3D US platform is built based on a conventional 2D US system and obtains 3D US images via linear scanning. With respect to 3D segmentation algorithm based on active contour model, frequency compounding and anisotropic diffusion methods were applied, and their effects on segmentation were discussed. The platform was used for clinical examination after evaluating the platform via the RCT-mimicking phantoms. As verified by the Dice coefficient(average DC: 0.663, volume DC: 0.723), which was approximately up to 50% higher than that obtained with conventional algorithms, the RCT regions segmented by the developed algorithm significantly matched the ground truth. The results indicated that the wide-field 3D US platform with the 3D segmentation algorithm can constitute a useful tool for improving the accuracy in the diagnosis of RCTs, and can eventually lead to better determination of treatment plans and surgical planning.

Background This study was conducted to compare the radiological and clinical outcomes of internal fixation using a Polarus humeral nail for treatment of a humeral shaft fracture according to fracture types. Methods From 43 patients, 13 were excluded and 30 patients were included. The 30 patients were divided into 2 groups: 15 in group I (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen classification type A and B) and 15 in group II (type C). The mean age was 63.1 years (range, 20–87 years), and mean follow-up period was 2.3 years (range, 1.0–6.1 years). The causes of injuries were as follows: 12, traffic accidents; 14, simple slips; 2, simple falls; 2, contusions after lower energy trauma. Radiological and clinical evaluations were performed. Results Radiological union was confirmed by plain anteroposterior and lateral radiographs on average of 5.0 months in group I, and 8.4 months in group II, respectively. Differences between the two groups were statistically significant (p

A rotator cuff tear (RCT) is an injury in adults that causes difficulty in moving, weakness, and pain. Only limited diagnostic tools such as magnetic resonance imaging (MRI) and ultrasound Imaging (UI) systems can be utilized for an RCT diagnosis. Although UI offers comparable performance at a lower cost to other diagnostic instruments such as MRI, speckle noise can occur the degradation of the image resolution. Conventional vision-based algorithms exhibit inferior performance for the segmentation of diseased regions in UI. In order to achieve a better segmentation for diseased regions in UI, deep-learning-based diagnostic algorithms have been developed. However, it has not yet reached an acceptable level of performance for application in orthopedic surgeries. In this study, we developed a novel end-to-end fully convolutional neural network, denoted as Segmentation Model Adopting a pRe-trained Classification Architecture (SMART-CA), with a novel integrated on positive loss function (IPLF) to accurately diagnose the locations of RCT during an orthopedic examination using UI. Using the pre-trained network, SMART-CA can extract remarkably distinct features that cannot be extracted with a normal encoder. Therefore, it can improve the accuracy of segmentation. In addition, unlike other conventional loss functions, which are not suited for the optimization of deep learning models with an imbalanced dataset such as the RCT dataset, IPLF can efficiently optimize the SMART-CA. Experimental results have shown that SMART-CA offers an improved precision, recall, and dice coefficient of 0.604% (+38.4%), 0.942% (+14.0%) and 0.736% (+38.6%) respectively. The RCT segmentation from a normal ultrasound image offers the improved precision, recall, and dice coefficient of 0.337% (+22.5%), 0.860% (+15.8%) and 0.484% (+28.5%), respectively, in the RCT segmentation from an ultrasound image with severe speckle noise. The experimental results demonstrated the IPLF outperforms other conventional loss functions, and the proposed SMART-CA optimized with the IPLF showed better performance than other state-of-the-art networks for the RCT segmentation with high robustness to speckle noise.

Background: As a side effect of interscalene brachial plexus block (ISBPB), stellate ganglion block (SGB) causes reductions in pupil size (Horner’s syndrome) and cardiac sympathetic nervous activity (CSNA). Reduced CSNA is associated with hemodynamic instability when patients are seated. Therefore, instantaneous measurements of CSNA are important in seated patients presenting with Horner’s syndrome. However, there are no effective tools to measure real-time CSNA intraoperatively. To evaluate the usefulness of pupillometry in measuring CSNA, we investigated the relationship between pupil size and CSNA. Methods: Forty-two patients undergoing right arthroscopic shoulder surgery under ISBPB were analyzed. Pupil diameters were measured at 30 Hz for 2 s using a portable pupillometer. Bilateral pupil diameters and CSNA (natural-log-transformed low-frequency power [0.04–0.15 Hz] of heart rate variability [lnLF]) were measured before ISBPB (pre-ISBPB) and 15 min after transition to the sitting position following ISBPB (post-sitting). Changes in the pupil diameter ([right pupil diameter for post-sitting – left pupil diameter for post-sitting] – [right pupil diameter for pre-ISBPB – left pupil diameter for pre-ISBPB]) and CSNA (lnLF for post-sitting – lnLF for pre-ISBPB) were calculated. Results: Forty-one patients (97.6%) developed Horner’s syndrome. Right pupil diameter and lnLF significantly decreased upon transition to sitting after ISBPB. In the linear regression model (R2 = 0.242, P = 0.001), a one-unit decrease (1 mm) in the extent of changes in the pupil diameter reduced the extent of changes in lnLF by 0.659 ln(ms2/Hz) (95% CI [0.090, 1.228]). Conclusions: Pupillometry is a useful tool to measure changes in CSNA after the transition to sitting following ISBPB. [ABSTRACT FROM AUTHOR]

Background: Although simple posterolateral or posterior elbow dislocations are relatively common and usually stable after closed reduction, simple posteromedial dislocations are extremely rare and poorly characterized. We investigated the clinical characteristics, soft-tissue injury patterns, treatments, and outcomes of a series of posteromedial elbow dislocations without relevant osseous lesions.Methods: We retrospectively reviewed 20 cases of simple posteromedial elbow dislocations without relevant osseous lesions that were treated at 7 fellowship training hospitals during a 10-year period. Soft-tissue injury patterns in 15 cases were investigated with use of magnetic resonance imaging. Clinical outcomes were evaluated after an average of 56.1 months (range, 24 to 93 months) with use of the Mayo Elbow Performance Score (MEPS) and the Quick-DASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]) score. Complications were also evaluated.Results: On magnetic resonance imaging, significant tears of the lateral collateral ligament complex and common extensor group were observed in all cases. Seventeen cases (85%) required surgical treatment for acute instability. Fourteen cases underwent only lateral complex repair and 3 underwent repair of both the medial and lateral complexes. At the time of the latest follow-up, the mean MEPS and Quick-DASH scores were 85.8 ± 15.0 and 10.5 ± 16.3, respectively. Seventeen patients (85%) had a satisfactory clinical outcome. Complications following treatment included 4 patients with heterotopic ossification; 2 of these patients also experienced posttraumatic elbow stiffness, which was treated with arthrolysis at 8 and 18 months after the initial operation.Conclusions: Posteromedial elbow dislocations without relevant osseous lesions are associated with a more severe soft-tissue injury, especially to the lateral complex, resulting in a high rate of surgical treatment. With careful post-reduction evaluation, either operative or nonoperative treatment provided satisfactory clinical outcomes.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: To determine the natural progression of conservatively treated rotator cuff tears, we evaluated changes in radiologic and clinical parameters in patients whose recalcitrant tears were neglected after conservative treatment. Methods: A total of 73 patients with recalcitrant rotator cuff tears in spite of conservative treatment were included in this study. We measured changes in tear size and in the extent of fatty infiltration of the rotator cuff by comparing the initial and final follow-up magnetic resonance imagings (MRIs). To determine factors influencing the change in tear size, we collected the medical history of patients taken at the time of initial admission. Results: The average follow-up period was 20.1 months, and the average increase in tear size across this period was 6.2 mm. In terms of steroid injection, we found that the increases in tear size of the steroid injection group (p=0.049) and of the sub-group that had received more than three steroid injections (p=0.010) were significantly greater than that of the non-steroid injection group. Conclusions: We found that the increase in cuff tear size was on average 6.2 mm across the follow-up period, indicating that neglecting cuff tears may cause them to progress into more severe tears. We also observed that a history of steroid injection might be a possible risk factor for a worse prognosis of cuff tears. Therefore, we suggest that patients with rotator cuff tears and a history of steroid injection are recommended aggressive modes of treatment such as surgery. [ABSTRACT FROM AUTHOR]

Reverse total shoulder arthroplasty has been performed with promising results in rotator cuff tear arthropathy. However, the global complication of the reverse total shoulder arthroplasty is relatively higher than that of the conventional total shoulder arthroplasty. Neurologic complications after reverse total shoulder arthroplasty are rare but there are sometimes remaining sequelae. The cause of the neurologic complication is multifactorial, including arm traction, position and the design of the implant. Most cases of neurologic palsy following reverse total shoulder arthroplasty occur in the axillary nerve and the radial nerve. The authors report on a case of a 71-year-old man with isolated musculocutaneous nerve palsy after reveres total shoulder arthroplasty with related literature. [ABSTRACT FROM AUTHOR]

Background: We investigated the risk factors for the recurrence of anterior shoulder instability after arthroscopic surgery with suture anchors and the clinical outcomes after reoperation. Methods: A total of 281 patients (February 2001 to December 2012) were enrolled into our study, and postoperative subluxation and dislocation were considered as recurrence of the condition. We analyzed radiologic results and functional outcome including the American Shoulder and Elbow Surgeons Evaluation Form, the Korean Shoulder Society Score, and the Rowe scores. Results: Of the 281 patients, instability recurred in 51 patients (18.1%). Sixteen out of 51 patients (31.4%) received a reoperation. In terms of the functional outcome, we found that the intact group, comprising patients without recurrence, had a significantly better functional outcome than those in the recurrent group. Age and the size of glenoid defect at the time of initial surgery significantly differed between intact and recurrent group (p<0.05). We found that the number of dislocations, the time from the initial presentation of symptoms to surgery, and the number of anchor points significantly differed between initial operation and revision group (p<0.05). The functional outcome after revision surgery was comparable to intact group after initial operation. Conclusions: Eighteen percent of recurrence occurred after arthroscopic instability surgery, and 5.6% received reoperation surgery. Risk factors for recurrence were young age and the initial size of glenoid defect. In cases of revision surgery, good clinical outcomes could be achieved using additional suture anchor. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study was to investigate the roles of dickkopf-1 (DKK-1) and integrin-related focal adhesion kinase (FAK) by TNF-α on the migration of fibroblast-like synoviocytes (FLSs) in RA. Methods. Wound scratch assays were performed to assess FLS migration. Western blotting was used to measure the levels of DKK-1, Wnt signalling molecules and FAK signalling molecules. Quantitative realtime PCR was used to measure the expression levels of DKK-1, integrin αv, laminin, fibronectin, E-cadherin, MMP-8 and MMP-13. The concentrations of DKK-1, TNF-α and GSK-3β were measured by ELISA. Genetic silencing of TNF-α was achieved by the transfection of small interfering RNA into cells. Results. Migrating RA FLSs exhibited higher levels of DKK-1 and TNF-α expression compared with those in OA FLSs and/or stationary RA FLSs. Moreover, migrating FLSs exhibited significantly higher levels of FAK, p-JNK, paxillin and cdc42 expression, whereas the level of cytosolic β-catenin was lower. WAY-262611, Wnt pathway agonist via inhibition of DKK-1, markedly inhibited cell migration of RA FLSs through the accumulation of cytosolic β-catenin and suppression of FAK-related signalling pathways. TNF-α treatment to RA FLSs up-regulated expression of DKK-1, integrin αv, fibronectin, laminin and MMP-13. TNF-α stimulation also suppressed cytosolic β-catenin and E-cadherin expression in a time-dependent manner. Moreover, TNF-α small interfering RNA-transfected migrating FLSs exhibited decreased activation of integrin-related FAK, paxillin, p-JNK and cdc42 signalling pathways. Conclusion. This study demonstrates that the activation of DKK-1 and the integrin-related FAK signalling pathway stimulated by TNF-α induces the dissociation of β-catenin/E-cadherin, thus promoting RA FLS migration. [ABSTRACT FROM AUTHOR]

Background: To compare the treatment of the proximal humerus fracture using a Polarus nail or Philos plate, we aimed to analyze the functional recovery and the factors affecting the selection between the two types of surgery. Methods: The study included 107 patients with proximal humerus fracture who underwent surgery at our institution. Of these patients, 67 underwent surgery with Polarus nails (G1) and 40 with Philos plates (G2). In G1, the cases of two- and three-part fractures were 60 and 7 cases, in G2, the cases of two-, three-, and four-part fractures were 28, 10, and 2 cases, respectively. The average age was 61 years old, and the average follow-up period was 32.5 months. We compared radiological results, the functional recovery retrospectively. Results: The radiological union time was 6.8 weeks and 8.7 weeks on average in G1 and G2 (p < 0.05). At the one-year follow-up period, these were visual analogue scale (VAS) 1.355, forward flexion (FF) 130.968, external rotation (ER) 50.161, internal rotation (IR) L2 in G1, and VAS 0.781, FF 135.806 ER 51.25, IR L1 in G2, respectively, showing no significant differences between the two groups (p > 0.05). Similar observations were made at the final follow-up. In terms of functional recovery, no significant differences were seen at the one-year or at the final follow-up period (p > 0.05). Conclusions: For the surgical treatment of proximal humeral fracture, the selection of the type of surgery is affected by the fracture pattern. However, both methods give satisfactory outcomes and do not show significant differences in the functional outcome after the surgery. [ABSTRACT FROM AUTHOR]

A 16-year-old female weight-lifter with average records of 70 kg for the snatch event and 90 kg for the clean and jerk event suffered chronic ulnar collateral ligament injury, and underwent ulnar collateral ligament reconstruction. An ultrasonographic evaluation was performed at six weeks, three months, six months, nine months, and one year after the operation. The horizontal and vertical distances measured during the initial ultrasonographic examination as well as at six weeks, three months, six months, nine months, and one year after the operation were 8.4 mm, 2.0 mm, 2.6 mm, 2.8 mm, 2.7 mm, 2.7 mm, and -1.2 mm, 2.4 mm, 1.0 mm, 0.0 mm, 0.0 mm, 0.0 mm, respectively. The lifting records at one year after the operation were 65 kg for the snatch event and 90 kg for the clean and jerk event. The ultrasonographic method of serial examination was useful for evaluation of the rehabilitation program and for deciding on the time to return to competition. [ABSTRACT FROM AUTHOR]

Background: To evaluate the efficacy of the subclavian portal approach for the arthroscopic repair of isolated subscapularis tendon tear. Methods: We used the subclavian portal to carry out arthroscopic repair of the isolated subscapularis tendon tear. The surgery was carried out in 18 cases (average age of 53) from May 2006 to December 2009 with a mean follow-up period of 35 months. Of these cases, 13 patients had the tear in their dominant arms, 16 were male, and 12 were from traumatic ruptures with on average 7.6 months of symptom period to operation. Additional surgery, acromioplasty and subacromial debridement, were carried out on 4 cases each during the subscapularis repair. The integrity of cuff status was assessed by ultrasonographic examination at 6 months and at 1 year after operation. Results: The initial average range of motion in forward flexion, external rotation, and internal rotation were 160°, 50° and L4, respectively. At the 1 year follow-up period, these improved to 160°, 52° and T12, respectively. The initial average functional scores were assessed by KSS, ASES, UCLA, and Constant scoring systems, which were 67, 60, 26, and 65, respectively. These scores improved progressively with time. At 3 months after operation, the scores were 74, 67, 27, and 74; at 6 months, 83, 77, 31, and 75; at 1 year, 88, 86, 32, and 79; and at the final follow-up of 35 months, 84, 92, 34, and 84. Conclusions: In the repair of isolated subscapularis tendon tear, the subclavian portal approach provided a good angle for anchor insertion and sufficient space to manage the upper portion of the tendon tear. In turn, these provisions resulted in satisfactory clinical results. [ABSTRACT FROM AUTHOR]

Purpose: To know if magnetic resonance image (MRI) re-examination is needed before surgery, we compared the pre-operative MRI recorded at different time points and the corresponding arthroscopic findings. Materials and Methods: Depending on the timing of evaluation, the MRI was classified into three groups: group A, MRI was taken 1 month before the surgery (44 cases, average 16 days); group B, 1-6 months before the surgery (41 cases, average 91 days); and group C, 6-12 months before the surgery (25 cases, average 230 days). The anterior to posterior tear size (length) and medial retraction size (width) of rotator cuff tear were measured for each group and they were compared with the actual arthroscopic findings. Results: Results of this study showed that arthroscopic rotator cuff tear length and width were larger than those of MRI. The difference of the rotator cuff tear size was 3.6(±1.2) mm of length and 0.6(±0.4) mm of width in group A, 4.2(±1.7) mm and 2.4(±1.1) mm in group B, and 4.5(±2.1) mm and 3.0(±1.5) mm in group C. There was a tendency of the larger size difference for longer pre-operative period, but it was not statistically significant. Conclusion: The rotator cuff tear size did not show remarkable differences between pre-operative MRI taken within 1 year before surgery and the actual arthroscopy. It is concluded that additional MRI evaluation is not required within 1 year. [ABSTRACT FROM AUTHOR]

Background: Nineteen patients with septic arthritis of the glenohumeral joint were treated with a combination of arthroscopic irrigation and débridement and systemic antibiotics according to bacterial sensitivity. We retrospectively reviewed the series to determine the efficacy and safety of this treatment. Methods: There were seventeen men and two women, with a mean age of fifty-nine years. Underlying medical disease was present in thirteen patients, with six of them having diabetes. The average duration of symptoms prior to the arthroscopic lavage was three weeks. Fifteen patients had had local injections into the shoulder joint. The arthroscopic staging of the infection was based on the modified criteria of Gächter. The functional outcome was evaluated with use of the UCLA scoring system. Results: As determined at arthroscopy, one infection was classified as stage I; seven, as stage II; nine, as stage III; and two, as stage IV. Staphylococcus was the most common organism identified. The infection was eradicated completely with a single arthroscopic procedure in fourteen patients. The mean UCLA score at the time of the last followup was 26 points, with a mean score of 23.7 points for the eleven patients with a rotator cuff tear and 29 points for the eight with an intact rotator cuff. Patients who had had symptoms for no more than two weeks prior to the arthroscopic lavage had better results than those who had had symptoms for longer than two weeks. Conclusions: Arthroscopic débridement for the treatment of septic arthritis of the shoulder is safe and efficient, particularly in the early stages of the disease. Underlying medical diseases such as diabetes, prior injections, or a preexisting rotator cuff tear were seen in a high proportion of these patients. [ABSTRACT FROM AUTHOR]

Abstract Background A classical approach to produce interscalene brachial plexus block (ISBPB) consistently spares the posterior aspect of the shoulder and ulnar sides of the elbow, forearm, and hand, which are innervated by the lower trunk of the brachial plexus (C8–T1). As an alternative to the classical approach, a caudal approach to ISBPB successfully produces anesthesia of the ulnar sides of the elbow, forearm, and hand. However, its beneficial effects on anesthesia in the posterior aspect of the shoulder have not been investigated. In addition, the C8 nerve root is not routinely selectively blocked during ISBPB. Therefore, we will compare the C5 to C7 and C5 to C8 nerve root blocks during a caudal approach to ISBPB to assess the clinical benefit of C8 nerve blocks for the surgical anesthesia of the posterior aspect of the shoulder. Methods/design In this prospective parallel-group single-blind randomized controlled trial, 74 patients scheduled to undergo arthroscopic shoulder surgery under ISBPB are randomly allocated to receive the C5 to C7 or C5 to C8 nerve root block at a 1:1 ratio. The primary outcome is pain intensity, which is rated as 0 (no pain), 1 (mild pain), or 2 (severe pain), during the introduction of a posterior portal into the glenohumeral joint. The secondary outcomes are (1) the extent of the ipsilateral sensory, motor, hemidiaphragmatic, and stellate ganglion blockade, (2) changes in the results of a pulmonary function test, (3) incidence of complications related to ISBPB, (4) postoperative numerical pain rating scale scores, (5) patients’ satisfaction with the ISBPB, (6) dose and frequency of analgesic use, and (7) incidence of conversion to general anesthesia. Discussion This study is the first to evaluate the beneficial effects of the C8 nerve root block during ISBPB, which has rarely been performed due to the technical challenge in visualizing and blocking the C8 nerve root. It is expected that a C8 nerve root block performed during ISBPB will provide sufficient surgical anesthesia of the posterior aspect of the shoulder, which cannot be achieved by a classical approach to ISBPB. Trial registration ClicnicalTrials.gov, NCT03487874. Registered on 4 April 2018.