Introduction. In patients with shoulder pain one of the important initial determinations is to assess the integrity of the rotator cuff. Clinical examination is often inconclusive. Compared with MRI and arthrography, ultrasound allows dynamic evaluation, is non-invasive, less expensive, less time-consuming and more acceptable to patients. The aim of the present study was to evaluate the accuracy of high resolution shoulder ultrasonography compared with arthroscopy in a series of consecutive patients with clinically suspected rotator cuff disease. Materials and methods. 100 shoulders in 99 consecutive patients with shoulder pain who had undergone standardised pre-operative ultrasonography and subsequent arthroscopy between May 2004 and March 2006 were included in the study. There were 53 males and 46 females with a mean age of 59 years. The mean time interval between the ultrasonographic and the arthroscopic examinations was 227 days. For full thickness tears ultrasonography showed a sensitivity of 100%, specificity 83%, positive predictive value 80%, negative predictive value 100% and accuracy 90%. Ultrasonography showed a sensitivity of 83% in detecting partial thickness tears, specificity 94%, positive predictive value 86%, negative predictive value 93% and accuracy 91%. Discussion. The use of high resolution shoulder ultrasonography to diagnose rotator cuff tears has achieved only limited acceptance by orthopaedic surgeons. Refinements in scanning technique, modern equipment with improved resolution capabilities and clarification of criteria for diagnosing rotator cuff tears have improved the accuracy of shoulder ultrasonography. Conclusion. In our experience ultrasonography is found to be a highly accurate technique for detecting rotator cuff tears. However the success of an ultrasonographic examination is heavily dependent on the experience of the operator

The use of high resolution ultrasonography for the detection of rotator cuff tears has achieved only limited acceptance by orthopaedic surgeons. Uncertainty about the accuracy of ultrasonography may be a contributing factor. The purpose of this study was to evaluate the accuracy of high-resolution ultrasonography compared to shoulder arthroscopy in the detection of rotator cuff tears. 100 consecutive patients with shoulder pain in whom arthroscopic surgery was planned underwent standardized preoperative ultrasonography. The ultrasound examinations were done by a single experienced musculoskeletal radiologist using a standard protocol. The findings at ultrasound were classified into intact cuff, tendinopathy, partial-thickness tear, and full-thickness rotator cuff tears. The size of the tear was measured in centimetres. The location was designated as subscapularis, supraspinatus, infraspinatus, or a combination. All of the subsequent shoulder arthroscopies were done by a single surgeon. The presence or absence of a rotator cuff tear and the size and extent of the tear when present were recorded. We then compared the ultrasonographic findings with the definitive operative findings. For the detection of rotator cuff tears, ultrasound had a sensitivity of 95% and a specificity of 94%; accuracy 95%. There was 100% sensitivity for full thickness tears (specificity 91% and accuracy 95%), while for partial-thickness tears there was a sensitivity of 80%, (specificity 98% and accuracy 95%). In experienced hands, ultrasound is a highly accurate diagnostic method for detecting rotator cuff tears. The results of this study compare favourably with the published results of magnetic resonance imaging for the investigation of this condition. Furthermore, dynamic imaging and comparison with the opposite shoulder is possible with ultrasonography

Introduction. We investigated whether grey scale early ultrasonography could be used for the accurate initial diagnosis of non displaced occult scaphoid fractures. Methods. This is a prospective blind clinical study that includes 36 patients that came to the emergency room with suspected clinical symptoms for scaphoid fracture but negative initial X-ray's. After that, a high resolution ultrasonography (without Doppler) was performed. Both wrists of each patient were examined, for comparison. After 14 days, new X-rays were performed, which compared to the early sonographic results of the patients. Results. 25 out of the 36 patients that were included in the study found with subperiosteal hematoma, while 11 of them had also cortical discontinuity. Besides, follow-up X-rays were diagnostic of fracture in 22 patients. 7 patients were ultrasound-positive for fracture but their late X-ray's remained negative, while 4 patients were ultrasound-negative with positive X-ray's. We performed a CT scan on these 11 patients, where we found early ultrasound's sensitivity: 87.5%, specificity: 75%, positive prognostic value: 84% and negative prognostic value: 72%. On the other hand, late X-ray's had sensitivity: 87.5%, specificity: 91%, positive prognostic value: 95% and negative prognostic value: 78% in the detection of occult fractures. Conclusion. The use of early scaphoid ultrasound in the E.R. is valuable in the hands of the orthopaedic surgeon and decongests the radiology department and the national health system from further specific and expensive imaging studies. So, this examination offers the possibility to reduce the time of diagnosis of these occult fractures, so as to provide early and correct treatment. Level of Evidence. II

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

The value of ultrasonography (US) was assessed for studying the position of the navicular and the cuboid in children with clubfeet (CF). In most studies on the management of CF, more than 50% of the patients have required surgical treatment for correcting foot deformities. In addition, repeat surgery is commonly needed for correction of residual foot deformities, especially persistent forefoot adduction usually due to medial displacement of the navicular and sometimes also the cuboid. These conditions have often been overlooked at the initial surgery. The authors examined 50 CF and 100 normal feet by US in children during the first year of life. With the transducer, the position of the navicular was studied along the medial border of the foot, and the position of the cuboid along the lateral border of the foot. The results indicated that 1) Severe medial displacement of the navicular towards the medial malleolus, which might not be possible to reveal by clinical examination, was commonly seen in children with CF and 2) severe medial displacement of the cuboid was seen considerably less frequently. Ultrasonography, using the most recent type of equipment, is a helpful tool when deciding if the navicular and the cuboid need to be re-aligned by open reduction in children with CF during the first year of life

Introduction The accuracy of ultrasonography has been reported to be high in diagnosing full thickness rotator cuff tears if measurements are made in both in the coronal and sagital planes. The purpose of this study is to determine how well pre-operative shoulder ultrasound rotator tear measurements when performed only in the coronal plane, the common practice in Israel, predicts the intra-operative surgical findings. Materials and Methods Fifty consecutive patients who underwent open rotator cuff repairs were included in the study. All patients underwent a pre-operative ultrasound by the same experienced musculoskeletal ultrasoundist. Rotator cuff tears were measured in the coronal plane only. This was compared with the tear size measured intra-operatively. Regression analysis was done between the two variables. Results The mean size of rotator cuff tears as determined by ultrasonography was 15.56±8.07mm and the measure size of the tears intraoperatively was 27.94±9.8 mm. The result of the regression analysis of the two variables was R2= 0.268405 for the first 25 patients and R2= 0.310309 for the second 25 patients. Discussion Using ultrasound it is easy to visualize the extent of rotator tears in the coronal plane, but more time consuming to measure the extent in the sagital plane, where the tear may have its greatest extension. Ultrasound measurements tear measurements in this study, made only in the coronal plane correlated poorly with intraoperative findings and only minimally improved over the time course of the study. Conclusion Proper assessment of a possible candidate for a rotator cuff repair should include an ultrasound with the tear size measured specifically in both the coronal and sagital planes

Aim: We have carried out a prospective study to compare duplex ultrasonography and transcutaneous oxygen tension as predictors of wound healing after knee arthroplasty. Methods and Materials: 53 patients were included in the study. All underwent pre-operative duplex scans of their lower limbs. In addition, transcutaneous oxygen tension measurements were made adjacent to the proposed incision pre-operatively and on days 1, 3 and 7 post knee arthroplasty. Wound healing was assessed using the ASEPSIS wound score. Results: 4 wounds had evidence of delayed wound healing. Duplex ultrasonography was a poor predictor of such problems; however there was a significant correlation between pre-operative transcutaneous oxygen tension and post-operative wound scores. Conclusion: Pre-operative transcutaneous oxygen tension measurement is a better predictor of wound healing after knee replacement surgery than duplex ultrasonograph, and may be a useful adjunct to the investigation of patients at risk of wound problems post knee arthroplasty

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic echocardiography (UCG) was performed, and then we consulted cardiologist to treat for PE. Results. CE-CT was performed in 42 patients (82.3%), otherwise nine patients (17.7%) could not take the examination because of exclusion criteria. There was no side-effect regard to contrast medium. The incidence of DVT and/or PE was 32 patients (62.7%), including two PE (3.9%), 21 DVT (41.1%) and nine both PE and DVT (17.6%). Six-teen patients were used LDUH routinely for 3 days after surgery. Five patients were used continuous heparin administration and oral warfarin instead of using LDUH because of medical co-morbidities. Additional continuous heparin administration and oral warfarin after LDUH use was needed in 26 patients. Three patients who had duodenal ulcer with chronic pancreatitis, massive PE with right heart strain and multiple DVT/PE with HIT antibody were needed another treatment. Conclusion. We prospectively investigated 51 patients for DVT/PE after primary TKA using CE-CT and venous US. The incidence of DVT/PE after primary TKA was 62.7%, including 21.5% of PE, as high frequency in Japanese patients

Introduction. In Mid-Europe developmental dysplasia of the hip (DDH) is diagnosed using the sonographic hip screening described by Graf. To learn the necessary standards three courses are mandatory. However, little is known about learning curves and measurement errors of doctors at different levels of training and experience. Material and Methods. Between 1997 and 2002 participants of the basic, advanced and final hip ultrasonogra-phy course were evaluated by a questionnaire and 34 normal and pathological sonograms. They were asked to measure the alpha and beta angle. “Normal” angles of each hip were created through the mean values of two experienced course organizers. Results. 186 doctors (40% orthopedic surgeons, 60% pediatricians) were evaluated. The group included 20% interns, 60% residents and 20% consultants. An average time of 6.3 months lay between the basic and the advanced, and of 16.7 months between the advanced and the final course. The evaluation of the sonograms according to Graf showed major inter-observer differences of up to 30°. Participants had more difficulties in evaluating a correct beta angle than an alpha angle. Sonographic pictures of minor quality and pathological hips produced more difficulties than pictures of Graf type I and II hips. In the basic course all measurements showed an average difference of 3,6°, in the advanced course of 3,1° and in the final course of 4,2°. The number of examinations between courses did not correlate with good measurements. Conclusion. Even participants of all three courses seem to develop major systemic errors if ultrasonography is regularly applied without supervision. Therefore, regular training and supervision should be mandatory in order to guarantee good quality

Aims: The purpose of this study is to evaluate the possible utility of a low-cost radiation-free technique for predicting degenerative changes in the lumbar spine. Methods: In 117 patients with low back pain or pain in the lower limb, ultrasonographic parameters (speed of sound, broadband ultrasound attenuation, stiffness) of the calcaneus were correlated with (1) evidence for degenerative changes and stenosis on magnetic resonance scans of the lumbar spine and (2) Oswestry Low Back Pain Disability Questionnaire Score. Linear and logistic regression as well as ROC curves analyses were used to evaluate the correlation. Results: Lumbar spine stenosis was associated with elevated calcaneal ultraso-nographic parameters. For the identiþcation of a narrowing of the lumbar spinal canal below 100mm2 of dural sac crosssectional area, speed of sound showed an 89% sensitivity in males older than 60. In these patients, we also found a signiþcant positive correlation between ultrasonographic parameters and scores on a MRI-based degenerative scale. No signiþcant correlation was found between disability score and lumbar spine degeneration or ultrasonographic parameters. Conclusions: Calcaneal ultrasonography is frequently used as a diagnostic test for osteoporosis. Its values are highly correlated with lumbar spine stenosis in elderly symptomatic males, and this low-cost radiation-free diagnostic method can be used to identify those patients needing more extensive diagnostic testing

Introduction and purpose: Our aim was to determine a morphometric relation between the long head of the brachial biceps and the bicipital groove with respect to the subscapular tendon, and its repercussion on functional imbalance of the shoulder. Materials and methods: For this analytical observational crossover study we took a sample of 30 right-handed, sedentary, duly informed male subjects. The morphometric study was carried out with ultrasonography using a cross-section of the long head of the brachial biceps. Results: In the dominant limb: 1. Bicipital groove (depth 2.6 mm, width 13.4 mm, internal angle 149.8°); 2. Long head of the brachial biceps (area 1.35 mm, internal angle 152.53°, echogenicity 97.95); 3. Subscapular thickness 4.53 mm. In the non-dominant limb: 1. Bicipital groove (depth 2.9 mm, width 12.5 mm, internal angle 145.73°); 2. Long head of the brachial biceps (area 1.07 mm, internal angle 141.32°, echogenicity 112.72); 3. Subscapular thickness 4.12 mm. Conclusions: The greater the thickness of the subscapular tendon: 1. Bicipital groove (greater width and internal angle, less echogenicity and depth); 2. Long head of the brachial biceps (greater area and internal angle, less echogenicity). Therefore, there is a greater risk of dislocation of the long head of the brachial biceps and functional instability of the shoulder

Previous investigations have postulated that the asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis, although there is no correlation between breast asymmetry and curve type or scoliosis magnitude. This breast asymmetry is supposed to be linked with anatomic and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomic and haemodynamic parameters of internal mammary artery have been made to justify or to reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Twenty female adolescents with right thoracic scoliosis and 16 comparable female individuals without spine deformity were included in this study. Standing roentgenograms of the whole spine were made in all scoliotics to measure scoliosis curve, vertebral rotation and concave and convex rib-vertebra-angle at three vertebrae (apical, one level above and one below the apical vertebra). The Color Doppler Ultrasonography was used to measure at the origin of internal mammary artery its lumen diameter, cross sectional area, time average mean flow and flow volume per minute in scoliotics and controls and were compared each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship. The reliability of color Doppler ultrasonography was high and the intraobserver variability low (ANOVA, P=0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex and concave rib-vertebra-angle one level above the apical vertebrae (P< 0.01), convex rib-vertebra angle one level below the apical vertebra (P< 0.05), and concave apical rib-vertebra angle (P< 0.01). The left internal mammary artery time average increases with only the convex rib-vertebra angle one level above the apical vertebra (P< 0.05). The right and left internal mammary artery flow volume increases with the convex rib-vertebra-angle one level above the apical vertebra (P< 0.05), while the right internal mammary artery flow volume increases furthermore with the apical concave rib-vertebra-angle (P< 0.01) and concave rib-vertebra angle one level above the apical vertebra (P< 0.01). The concave apical rib-vertebra-angle (P< 0.01) and concave rib-vertebra-angle one level above the apical vertebra (P< 0.01) increases with left internal mammary artery cross sectional area. We concluded that anatomic and haemodynamic flow parameters measured at the origin of internal mammary artery are significantly correlated with apical rib-vertebra-angle in female adolescents suffering from right convex idiopathic thoracic scoliosis. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall thus could not justify previous theories for development of right thoracic scoliosis in female adolescents

Introduction: Foot and ankle injuries are common in the Emergency Department (ED)1. Of those which require radiographs, in accordance with the Ottawa Foot and Ankle Rules, approximately 22% have a fracture.2 In the last decade ultrasound has been developing as a tool for emergency musculoskeletal assessment – it is inexpensive, rapid and visualises soft tissue and bony structures.

Methods: This diagnostic cohort study was designed to determine whether ultrasound could detect acute bony and non-bony foot and ankle injuries. Ottawa Rules positive patients over 16 year of age without obvious dislocation/compound fracture were eligible. An ultrasound scan (USS) for bony injury was performed by a member of the ED, blinded to radiographic findings. Patient management was determined according to the radiographs. Significant fractures were defined as a breadth greater than 3 mm (as per the Ottawa Foot & Ankle Rules study group)3. All radiographic reporting was conducted blind to the results of the USS. All USS operators received a specific 2-day training in musculoskeletal ultrasound prior to the trial.

Results: One hundred and ten subjects were recruited. eleven had significant radiological fractures, ten of which were seen on ultrasound. The single missed fracture arose due to the operator not scanning proximally enough on the fibula. On re-scanning following radiographic review the fracture was clearly seen on ultrasound. To date the sensitivity of USS is 90.9%, with 95% CI (65.7, 98.3). The specificity is 90.9% with 95% CI (88.1, 91.7). The positive predictive value is 0.526, with a 95% CI (0.380, 0.569). The negative predictive value is 0.989, with a 95% CI (0.959, 0.998). The positive likelihood ratio is 10.00, with a 95% CI (5.526, 11.901) and the negative likelihood ratio is 0.100, with a 95% CI (0.018, 0.389).

Conclusion: Our pilot study demonstrates that ultrasound shows great promise for the sensitive detection of foot and ankle fractures.

Ultrasound detects fracture healing earlier than conventional radiographic methods; however, its clinical applicability is limited by subjective nature of interpretation. An ultrasonographic scoring system was developed to quantify fracture healing objectively.

Fifty closed traumatic diaphyseal fractures of less than three weeks, treated by IM Nails, were subjected to serial radiographic and USG examinations (2–24 weeks) by LOGIQ 500 USG machine using 7.5MHz linear transducer. USG parameters included were Echogenecity (EC), Visibility of IM Nail (VIMN), Bridging Callus (BC), and Continuity of Cortex (CC). Marks were allotted from 0–3 for each parameter in the three fracture zones. Three portals were used and mean was obtained. Disorganized echopattern was also defined by us. The results were statistically analyzed and compared with radiological findings using Bone Formation (BF) score.

At 2 weeks, 94% had EC score of < 3, increasing significantly at each follow-up. Defective unions had EC less than 3 at all the times. BC score of 9 was obtained by 94% at 2 weeks increasing to 100% at 8 wks. In non-union score remained 0. VIMN did not provide any statistically significant information. CC were significant only 12 weeks onwards.

USG Score parallels the appearance and progressive mineralization of callus in the fracture gap. Healing pattern can be predicted more definitely in the earlier stages where EC score has more positive predictive value and statistical significance than radiological BF score. EC> 3, BC> 3 and absence of DE was considered an essential USG criteria to conclude fracture union. The advantage over radiological assessment is lost after 12 weeks. We also conclude that a fracture will probably end up in delayed union nonunion if, at 6–8 weeks, the fracture has EC score < 1 or does not show bridging callus in any of the sonographic portals (BC score < 3) or has a disorganized echopattern in any of the sonographic portals.

Aim: Many risk factors for DDH are well documented. This study was undertaken to investigate whether multiple pregnancy is a risk factor for developmental dysplasia of hips. Method: During a 10-year period from 1989 to 1998, 39826 newborn babies had their hips scanned. Of these, 1022 (2.6%) babies were non-singletons. Inclusion criteria for our study were all non-singletons, who had their hips scanned in the þrst week after birth. We analyzed the results of their hip scans and calculated the risk for developing DDH either alone or with other risk factor and other variables like the gender, mode of delivery, birthweight and the length of pregnancy. Results: Of the 1022 babies, 825 (80.7%) had their hips scanned in the þrst week. M: F: 49.6%: 50.4%. We had 397 sets of twins, 9 sets of triplets and 1 set of quadruplet. 78% of this group had a normal presentation. 21% (181) of these babies were breech. There was no family history associated with any of the multiple births. Ultrasound abnormality was seen in 30 hips (1.8%). 1 patient had Pavlik harness treatment for persistent ultrasound abnormality. No signiþcant correlation was seen in the gender or in the length of pregnancy. Conclusion: Though it is a general impression that the hips of the non-singletons are under high mechanical stress during pregnancy and would be expected to have a relatively high incidence of DDH, from our study it is evident that the risk is no greater than the normal singletons.

Osteoarthritis (OA) of the knee joint is a complex peripheral joint disorder with multiple risk factors. We aimed to examine the relationship between the grade of knee OA and anterior thigh length (ATL). A total of 64 geriatric patients who had no total hip or knee replacement with a BMI of ≥30 were evaluated. Patients' OA severity was determined by two independent experts from bilateral standing knee radiographs according to the Kellgren-Lawrence (KL) grade. Joint cartilage structure was assessed using ultrasonography (US). The ATL, the gastrocnemius medialis (GC), the rectus femoris (RF) and the rectus abdominis (RA) skeletal muscle thicknesses as well as the RF cross-sectional area (CSA) were measured with US. Sarcopenia was diagnosed using the handgrip strength (HGS), 5× sit-to-stand test (5xSST) and bioelectrical impedance analysis. The median (IQR) age of participants was 72 (65–88) years. Seventy-one per cent of the patients (n=46) were female. They were divided into the sarcopenic obese (31.3 %) and the non-sarcopenic obese (68.8%) groups. KL grade of all patients correlated negatively with the ATL (mm) and the thickness of GC (mm) (r= -0,517, p<0.001 and r= -0.456, p<0.001, respectively). In the sarcopenic obese and the non-sarcopenic obese groups, KL grade of the all patients was negatively correlated with ATL (mm) and thickness of GC (mm) (r= -0,986, p<0.001; r= -0.456, p=0.05 and r= -0,812, p=0.002; r= −0,427, p=0.006). KL grade negatively correlated with the RF thickness in the sarcopenic obese group (r= -0,928, p=0.008). In conclusion, OA risk may decrease as the lower extremity skeletal muscle mass increases. Acknowledgments: Feza Korkusuz MD is a member of the Turkish Academy of Sciences (TÜBA)

Aims. Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities. Methods. A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4. o. at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021). Results. The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively. Conclusion. The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance. Cite this article: Bone Jt Open 2023;4(4):234–240

We report a long term experience on massive rotator cuff tears treated by the means of a nonresorbable transosseously fixed patch combined with a subacromial decompression. From December 1996 until August 2002, a total of 41 patients were treated with a synthetic interposition graft and subacromial decompression. All patients had a preoperative ultrasound evidence of a primary massive full-thickness tear that was thought to be irreparable by simple suture. All patients were evaluated pre- and postoperatively using the Constant and Murley score, DASH questionnaire, Simple Shoulder Test, VAS scale for pain, ultrasound and plain radiographs. The patients consisted of 23 men and 18 women aged 51–80 years (mean 67 years). We had a lost of follow up of 6 patients. One patient had a total shoulder arthroplasty at 7.7 years and one patient had a redo with a new synthetic graft at 9.6 years. They were followed up for a mean of 7.2 years. Their mean preoperative Constant and Murley score improved from 25.7 preoperatively to 69.6. Similar improvements were seen with the DASH score (56.6 to 23.3), SST (1.2 to 7.9) and VAS scale (75.4 to 14.1). Anatomically, the repair resulted in mean acromio-humeral interval of 6.6 mm. Ultrasound showed a further degeneration of the rotator cuff with tears posteriorly from the interposition graft. In 67.7% of all patients the graft was continuous present. Histology – obtained from one patient scheduled for a reversed shoulder arthroplasty- showed partial ingrowth of peri-tendinous tissue. Despite ongoing degeneration of the cuff in nearly half our population, restoring a massive rotator cuff defect with a synthetic interposition graft and subacromial decompression can give significant and lasting pain relief with a significant improvement of ADL, range of motion and strength. Role of ultrasonography in shoulder pathology: Consistency with clinical and operative findings K. W. Chan, G. G. McLeod Department of Trauma and Orthopaedic Surgery, Perth Royal Infirmary, Perth PH1 1NX, United Kingdom. Shoulder disorders are common and main causes of shoulder pain with/without functional deficit include adhesive capsulitis (frozen shoulder), impingement syndrome and rotator cuff pathology. The sensitivity and specificity of ultrasonography have been reported as 80% and 100% respectively in the literature. We carried out a retrospective case note review of patients that underwent ultrasonography of shoulder, comparing the radiological findings with clinical diagnosis and operative findings. 58 patients, 36 male and 22 female attended the orthopaedic outpatient clinic with painful shoulder and underwent ultrasonography of shoulder during the period of study. Mean age of patients is 55 (range 28 to 78 years old). 33 patients had ultrasonography of right shoulder, 20 patients had ultrasonography of left shoulder while 5 patients had ultrasonography of both shoulders. 79% (50/63) of the ultrasonography findings were consistent with clinical diagnosis. 17 patients had normal findings on ultrasonography and were discharged fully. 25 patients with clinical and radiological diagnosis of biceps tendon tear, calcifying tendinosis and partial/full thickness rotator cuff tear were treated conservatively. 19% (4/21) of patients with diagnosis of calcifying tendinosis had decompression surgery. 38% (8/21) of patients with diagnosis of partial/full thickness rotator cuff tear had decompression surgery + rotator cuff repair. The degree of rotator cuff tear in operative findings for 6 out of 8 patients (75%) that underwent decompression surgery +/− rotator cuff repair were consistent with ultrasonography findings. 4 patients had inconclusive ultrasonography findings and had magnetic resonance imaging to further confirm the pathology. We conclude that ultrasonography should be used as the first line of investigation in aiding the clinical diagnosis and management of shoulder disorders as it is non-invasive and cost effective. The sensitivity of ultrasonography in detecting shoulder pathology is 75% from this study

Musculoskeletal ultrasound (MSK-US) can have many uses for orthopaedic surgeons, such as assisting in clinical diagnosis for muscle, tendon and ligament injuries, providing direct guidance for joint injections, or assessing the adequacy of a reduction in the emergency department. However, proficiency in sonography is not a requirement for Royal College certification, and orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK-US course in an orthopaedic surgery program. A MSK-US course for orthopaedic surgery residents was developed by an interdisciplinary team involving a paediatric orthopaedic surgeon, an emergency physician with a fellowship in point-of-care ultrasonography, and an orthopaedic surgery resident. Online videos were created to be viewed by residents prior to a half-day long practical course. The online portion covered the basics of ultrasonography, as well as the normal and abnormal appearance of musculoskeletal structures, while the practical portion applied those principles to the examination, injection, and aspiration of joints, and ultrasound-guided fracture reduction. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was filled by the participants prior to the course. Resident's knowledge acquisition was measured with a written pre-course, same-day post-course and six-month follow-up tests. Residents were also scored on a practical shoulder examination immediately after the course and at six-month follow-up. An online survey was also sent to evaluate residents' satisfaction with different aspects of the course (NAS). Change in test scores were calculated using an ANOVA and a Wilcoxon signed-rank test. Ten orthopaedic surgery residents underwent the MSK-US curriculum. Pre-course interest to MSK-US was moderate (65%) and prior exposure was low (1.5 hours mean total experience). MSK-US has been previously mostly observed in the emergency department and sports orthopaedic clinic. Satisfaction with the online curriculum, hands-on practice session and general quality of the course were high (8.78, 8.70 and 8.60/10 respectively). Written test scores improved significantly from 50.7 ± 17% to 84 ± 10.7% immediately after the course (p < 0 .001) and suffered no significant drop at six months (score 75 ± 8.7%, p=0.303). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at six months (p=0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at six months (p=0.007–0.018) but did not significantly increase clinical usage frequency. A MSK-US curriculum was successfully developed and implemented using an interdisciplinary approach. The course was rated high quality and succeeded in improving the residents' knowledge, skills, and comfort with MSK-US. This improvement was maintained at six months on the written test, but did not result in higher frequency of use by the residents

In a four-year retrospective study, we assessed the use of ultrasonography in diagnosing hip dysplasia in 86 high-risk babies. Dysplasia was graded on the Harcke classification. Risk factors included breach presentation, positive family history, foot abnormalities, caesarean section and genu recurvatum. If the ultrasonography at birth showed abnormalities, follow-up ultrasonography was done at three and six weeks. If there were abnormal findings at six weeks, the patient entered the treatment protocol. Whether or not ultrasonography showed abnormalities at six weeks, the acetabular index was measured radiologically at 12 weeks. There were 17 Harcke-III hips, 30 Harcke-IV hips and four Harcke-V hips. The Harcke-V hips were treated in a Pavlik splint from birth. Three babies underwent closed reduction at 12 weeks, followed by application of a spica cast. At six weeks, 10 of the Harcke-IV hips and 12 of the 17 Harcke-lll hips were normal. The mean acetabular index at 12 weeks was 28°. Ultrasonography provides an effective way of screening for hips at risk and the efficacy of treatment can easily be measured