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

We used ultrasonography in ten children with pulled elbow to compare measurements of the radiocapitellar distance (RCD) on the affected and the unaffected sides. Similar measurements were made in a group of ten age-matched normal children. The mean RCD in pronation of the affected and normal sides in the patients with pulled elbows was 7.2 mm +/- 0.7 and 3.8 mm +/- 0.5, respectively (p < 0.0001). In the normal children the mean RCD in pronation was 4.5 mm +/- 0.5. We conclude that ultrasonography is of value for documenting pulled elbow in children

We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery. Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids

We used ultrasonography to examine 36 children suffering from transient synovitis and 12 children with early Perthes' disease. Widening of the joint space was revealed by ultrasonography in all affected hips with either disease. In the patients with transient synovitis, capsular distension was attributed to synovial effusion, while in the patients with Perthes' disease it was produced by thickening of the synovial membrane. Neither capsular distension nor thickening of the joint cartilage was seen in the contralateral normal hip in the patients with transient synovitis, but they were common in early Perthes' disease. Ultrasonography may provide significant diagnostic clues to differentiate early Perthes' from transient synovitis

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

Ultrasonography of the hip was performed sequentially by two different examiners in 75 infants. The ultrasound strips were reviewed twice by three paediatric orthopaedic surgeons and classified by the Graf method. The intraobserver and interobserver agreement between the interpretations was analysed using simple and weighted kappa coefficients calculated for agreement on the Graf classification and for grouping as normal (types 1A to 2A), and abnormal requiring treatment (types 2B to 4). When examining the same ultrasound strip, intraobserver agreement for the Graf classification was substantial (mean kappa 0.61), but interobserver agreement was only moderate (kappa 0.50). For the grouping into normal and abnormal, the mean kappa value for intraobserver agreement was 0.67 and for interobserver agreement 0.57. Because of the significant differences in agreement between normal and abnormal hips, we analysed a subgroup of those with at least one abnormal interpretation. Intraobserver agreement within this subgroup showed moderate reliability (kappa 0.41), but interobserver agreement was only fair (kappa 0.28). Interpretations of two different strips performed sequentially showed significantly lower agreement with an intraobserver kappa value of 0.29 and an interobserver value of 0.28. In the subgroup with at least one abnormal reading, the intraobserver kappa was 0.09 and the interobserver 0.1. Our findings suggest that both the technique of performing ultrasonography and the interpretation of the image may influence the result

We used ultrasonography to study 26 hips with slipped capital femoral epiphyses. In recently slipped epiphyses the ultrasound image revealed a step at the anterior physeal outline (mean 6.4 mm), diminished distance between the anterior acetabular rim and the femoral metaphysis (mean 4.3 mm) and an effusion. As metaphyseal remodelling progressed the physeal step decreased. The femoral neck appeared straighter in hips which had been symptomatic for longer than three weeks. It was possible to measure posterior epiphyseal displacement without projectional errors and the method was accurate in diagnosing minimal slip and in staging displacement. The suggested criteria are, less than 7 mm for a mild slip, 7 to 11 mm for a moderate slip and more than 11 mm for a severe slip. We recommend ultrasonography for the diagnosis, staging and follow-up management of slipped upper femoral epiphysis

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

Aims. Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method. Patients and Methods. A total of 15 children (ten boys, five girls) with idiopathic clubfoot were evaluated at a mean of 6.8 years (5.4 to 8.1) after complete percutaneous division of the Achilles tendon. The contour and subjective thickness of the tendon were recorded, and superficial defects and its strength were assessed clinically. The echogenicity, texture, thickness, peritendinous irregularities and potential for deformation of the tendon were evaluated by ultrasonography. Results. The appearance of the Achilles tendon was slightly abnormal, with more thickening and less conspicuous contours than a normal tendon. Its strength was grossly normal, with no insufficiency of the triceps surae. Ultrasonographic findings revealed a mild fusiform thickening in 12 children (80%). The tissue at the site of the repair had a slightly hypoechoic, fibrillar quality with hyperechoic striation and the anterior contour was irregular and blurred. There was a focal narrowing within the healing tissue in two children. Conclusion. This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms. There were minor abnormalities which did not appear to affect function. Cite this article: Bone Joint J 2017;99-B:139–44

We studied the quantity and rate of formation of new bone during lengthening of 17 limb segments in 10 patients using dual-energy X-ray absorptiometry (DEXA), ultrasonography and radiography. Whereas new bone was detected by both DEXA and ultrasonography within 1 to 2 weeks of distraction, it was not visible on the radiographs until 4 to 8 weeks. Limb alignment and gap measurement were accurately assessed by DEXA without the need for standard radiographs or scanograms. With ultrasound the distraction gap appeared as an echolucent window which narrowed progressively producing a hyper-reflecting line after which further consolidation could not be assessed. As measured by DEXA the density of the new bone at this stage was approximately 45% of control values and did not represent normal cortication. Whereas ultrasound could be used to identify defects in mineralisation and to determine when to dynamise the fixator system, DEXA could measure the quantity and rate of formation of bone throughout lengthening

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

Aims

Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury.

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

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning.

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot.

The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot.

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.

We have compared the sonographic findings of six femoral fractures with soft-tissue interposition which required open reduction with those of a control group of 40 other femoral fractures. Ultrasound assessment before operation showed that the fractured end of the proximal fragment had penetrated the quadriceps muscle anteriorly while the distal fragment lay beneath it. Transverse scans showed less soft-tissue thickness over the end of the proximal fragment in the problem cases. Radiographic image intensification did not provide any additional information. Ultrasound is of value in demonstrating soft-tissue interposition at the fracture site before femoral nailing.

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.

We describe a new technique for examining the infant hip using ultrasound. Both hips are imaged simultaneously via an anterior approach. The examination can be done with the hip either extended or flexed and abducted. The method has three advantages: 1) since both hips are imaged simultaneously, lines can be drawn to assist in determining the relationship between the femoral head and the pelvis; 2) proximal, anteroposterior and lateral displacement of the femoral head can all be demonstrated; 3) the method is applicable to the infant in a harness or a plaster cast to demonstrate maintenance of reduction of a dislocated hip. The usual direction of dislocation of the femoral head was anterior and lateral. Proximal migration was also observed in cases with more severe dislocation. In flexion, the dislocated head of the femur often moved posterior to the acetabulum. Of 1276 hips, in 638 infants aged from three weeks to one year, 49 showed congenital dislocation. The accuracy of our anterior method of sonography in diagnosing congenital dislocation of the hip compared well with the method of Graf and with radiography.

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

The October 2023 Wrist & Hand Roundup. 360. looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials

The December 2023 Spine Roundup. 360. looks at: Does size matter in adolescent pedicle screws?; Effect of lumbar fusion and pelvic fixation rigidity on hip joint stress: a finite element analysis; Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients; Rett syndrome-associated scoliosis a national picture

The diagnosis of a meniscal tear may require MRI, which is costly. Ultrasonography has been used to image the meniscus, but there are no reliable data on its accuracy. We performed a prospective study investigating the sensitivity and specificity of ultrasonography in comparison with MRI; the final outcome was determined at arthroscopy. The study included 35 patients with a mean age of 47 years (14 to 73). There was a sensitivity of 86.4% (95% confidence interval (CI) 75 to 97.7), a specificity of 69.2% (95% CI 53.7 to 84.7), a positive predictive value of 82.6% (95% CI 70 to 95.2) and a negative predictive value of 75% (95% CI 60.7 to 81.1) for ultrasonography. This compared favourably with a sensitivity of 86.4% (95% CI 75 to 97.7), a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 81.3% (95% CI 74.7 to 87.9) for MRI. Given that the sensitivity matched that of MRI we feel that ultrasonography can reasonably be applied to confirm the clinical diagnosis before undertaking arthroscopy. However, the lower specificity suggests that there is still a need to improve the technique to reduce the number of false-positive diagnoses and thus to avoid unnecessary arthroscopy

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. The aim of this study was to compare the characteristics and outcomes of L-shaped and reverse L-shaped rotator cuff tears. Methods. A total of 82 shoulders (81 patients) after arthroscopic rotator cuff repair were retrospectively enrolled. The mean age of the patients was 62 years (SD 6), 33 shoulders (40.2%) were in male patients, and 57 shoulders (69.5%) were the right shoulder. Of these, 36 shoulders had an L-shaped tear (group L) and 46 had a reverse L-shaped tear (group RL). Both groups were compared regarding characteristics, pre- and postoperative pain, and functional outcomes. Muscle status was assessed by preoperative MRI, and re-tear rates by postoperative ultrasonography or MRI. Results. Patients in group RL were significantly older than in group L (p = 0.008), and group RL was significantly associated with female sex (odds ratio 2.5 (95% confidence interval 1.03 to 6.32); p = 0.041). Mean postoperative pain visual analogue scale (VAS) score was significantly greater (group L = 0.8 (SD 1.5), group RL = 1.7 (SD 2.2); p = 0.033) and mean postoperative American Shoulder and Elbow Surgeons (ASES) score was significantly lower in group RL than group L (group L = 91.4 (SD 13.1), group RL = 83.8 (SD 17.9); p = 0.028). However, postoperative mean VAS for pain and ASES score were not lower than the patient-acceptable symptom state scores. Mean retracted tear length was significantly larger in group L (group L = 24.6 mm (SD 6.5), group RL = 20.0 mm (SD 6.8); p = 0.003). Overall re-tear rate for 82 tears was 11.0% (nine shoulders), and re-tear rates in group L and RL were similar at 11.1% (four shoulders) and 10.9% (five shoulders), respectively (p = 1.000). No significant intergroup difference was found for fatty degeneration (FD) or muscle atrophy. Within group L, postoperative FD grades of supraspinatus and subscapularis worsened significantly (p = 0.034 and p = 0.008, respectively). Mean postoperative pain VAS (male = 1.2 (SD 1.8), female = 1.3 (SD 2.0)) and ASES scores (male = 88.7 (SD 15.5), female = 86.0 (SD 16.8)) were similar in male and female patients (p = 0.700 and p = 0.475, respectively). Regression analysis showed age was not a prognostic factor of postoperative pain VAS or ASES scores (p = 0.188 and p = 0.150, respectively). Conclusion. Older age and female sex were associated with reverse L-shaped tears. Although the postoperative functional outcomes of patients with reverse L-shaped tears were satisfactory, the clinical scores were poorer than those of patients with L-shaped tears. Surgeons should be aware of the differences in clinical outcome between L-shaped and reverse L-shaped rotator cuff tears. Cite this article: Bone Joint J 2022;104-B(3):394–400

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

SUMMARY. A retrospective cohort study of 19 patients of EOS who underwent MCGR rod instrumentation with subsequent serial distractions, measured using ultrasonography. The degree of distraction achieved during each session were analyzed and subgroup analysis done. HYPOTHESIS. The degree of distraction/ distractibility of the MCGR rod is closely linked to the etiology of EOS. The degree of distraction achieved at each session progressively diminishes with successive distractions. STUDY DESIGN. Retrospective cohort study. INTRODUCTION. MCGR rods have gained popularity as an alternative to traditional growing rods for the treatment of Early-onset scoliosis (EOS), serially distracting with an aim to mimic the normal spinal growth, which can be achieved in an outpatient setting using external remote controller. The use of ultrasound as a tool to measure the degree of distraction achieved has been validated previously. However the association between the etiological diagnosis of EOS and the degree of distraction achieved has not been studied previously. METHODS. We performed a retrospective cohort study of 19 patients with EOS of varying etiologies who underwent MCGR rod instrumentation at our institution since 2016. Their hospital records were analyzed to assess the demographics, distraction interval and the degree of distraction achieved at each session. RESULTS. 19 patients (12 females and 7 males) were included in the study. The average age of the study population was 7 years (4–13 years). The average follow up was 2.1 years (1–4). The following were the etiological diagnoses: Idiopathic EOS(8), Neuromuscular scoliosis(5), Syndromic(5), Congenital(1). The average interval between each distraction was 109.8days (88.2–140.6). The overall mean distraction was 1.66mm (0.6–3.427). The mean distraction achieved for the concave rod was 1.69mm (0.6–3.03) as against 1.59mm (0.2–3.427) for the convex rod. The degree of distraction achieved per session was the greatest in patients with neuromuscular scoliosis 2.79mm (0.94–4.62), while it was the least in Congenital scoliosis 0.99mm (0.8–2.93). The degree of distraction in Syndromic and Idiopathic scoliosis groups were 2.19mm (0.1–4.2) and 1.50mm (0.2–4.45) respectively. The mean distraction achieved during the first session after MCGR instrumentation was 2.82mm (0.4–9.8) as against 1.98mm (0.1–4.2) and 1.18mm (0.2–2.3), achieved during the 5. th. and 10. th. distractions respectively. CONCLUSIONS. The average distraction of the MCGR rod achieved per session depends upon the etiological diagnosis of EOS. Neuromuscular curves are the most amenable to MCGR distractions, while the congenital curves are the least. The degree of distraction achieved progressively diminishes with each successive distractions. The distraction achieved slumps to 70% of the initial distraction by the 5. th. session and further declines to 41% of the initial distraction by the 10. th. session. TAKE HOME MESSAGE. The distractibility of the MCGR rod is closely linked to the etiology of EOS. MCGR rods are most effective in cases of neuromuscular scoliosis, while least effective in congenital scoliosis. The law of diminishing returns holds true even with MCGR rods

Purpose of the study: Morton neurinoma is a well defined anatomic entity despite certain questions about the pathogenic mechanisms. Diagnosis of the metatarsalgia sometimes produced can be difficult due to the frequency of an associated static metatarsalgia. Magnetic resonance imaging has not met expectations. We have oriented our research towards ultrasonography which can provide high quality information with good reliability. Material and methods: We reviewed the files of 11 patients with Morton neurinoma which led to 14 operations (bilateral cases or two localizations on the same foot). The series included three men and eight women, mean age 56 years. The operation was conducted under locoregional anesthesia and consisted in tumor resection via the plantar commissure, with removal of the entire neurinoma. Ultrasonography used a high-frequency probe (6–13 MHz linear scan). The compartments were studied via the plantar aspect and the dorsal aspect using static and stress positions. MRI had been performed in two patients before the ultrasound. Results: Eight of the eleven patients had an associated syndrome (hallux valgus, disharmonious length with mid metatarsal weight bearing). Objective signs (Mudler’s sign, hyoesthesia), were noted in seven patients. The neurinoma was confirmed in all cases at surgery; in two cases, ultrasonography demonstrated a neurinoma where the MRI had been negative. The operative specimen was typical. Two compartments were explored because of the ultrasound results which were highly suggestive; two tumors were demonstrated at surgery. Clinical outcome at mean seven months was good in ten patients and fair in one. Discussion: Ultrasonography should no longer be considered as «operator-dependent». It enables the detection of mid-sized neurinomas measuring about 2 cm. Magnetic resonance imaging has been less productive for diagnosis; many studies have been reported without surgical confirmation of MRI-negative cases. False negatives are frequent and patient follow-up is insufficient to determine whether the symptoms persist or resolve after surgery. Conclusion: Ultrasonography is a simple examination devoid of iatrogenic risk. The use of stress images has greatly improved performance. This low cost examination may not however be necessary because the diagnosis of Morton is basically clinical

Objectives. The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. Methods. A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis. Results. The incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups. Conclusion. In patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541

Ultrasonography for rotator cuff disease is a cheap and non-invasive investigation. Our study investigates the tendon specific pathologies leading to misinterpretation of ultrasound findings and their implication for the surgical management. On hundred and five consecutive patients who had an ultrasound scan by a single musculoskeletal radiologist and then underwent shoulder arthroscopy by a single shoulder surgeon for rotator cuff pathologies were included. Surpraspinatus Tendon (SST): There was a sensitivity of 90%. The relatively low positive predictive value (76%) and specificity (42.5%) were influenced by a high number of false positives. This was a mixed group of 23 cases, in which ultrasonography had described either a full-thickness (FTT) or partial-thickness (PTT) tear when arthroscopy did not show any evidence for a cuff tear. Seven of these cases were described as FTT with dimensions less than 1 cm and in ten cases the radiologist described a “possible sub-centimetre tear”. Subscapularis Tendon (SSC): There was a specificity of 100%. The poor negative predictive value (78%) and sensitivity (26%) were caused by a high number of false negatives. Further analysis of the 20 “false negative” patients showed four FTT and sixteen PTT. All partial thickness tears involved the superior fibres of the subscapularis tendon. Our results confirm that USG is a reliable investigation in larger full thickness tears, particularly of the superior rotator cuff (SST). The reliability is significantly reduced in sub-centimetre tears and partial thickness tears, particularly of the subscapularis tendon. Associated tendon pathologies like intra-tendinous calcifications and intra-substance tears make an accurate diagnosis even more difficult and add to the tendency to ‘over-diagnose’ tears of the rotator cuff with use of ultrasonography. The shoulder surgeon should be aware of the potential misinterpretation of ultrasonography findings and be prepared to adjust the surgical procedure accordingly

Introduction. Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided. Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties. Patients and methods. All patients prior to the surgeries are evaluated laboratory and duplex venous ultrasonography examinations to exclude thrombophilic or hemophilic conditions, and existence of DVT. Then, the thrombophilic, and also prolonged immobility, obesity, malignant tumors, cardiovascular dysfunction and DVT patients are regarded as high risk for VTE. These are offered a prophylaxis consisting of a removable inferior vena cava (IVC) filter, together with anticoagulant medication. Usually, the filter is removed three months after the surgery. In other patients, the arthroplasties are carried out under the spinal or epidural anesthesia with IPC on both feet. IPC is also applied, except for the periods of ambulation, usually two to three days of hospitalization after surgery. Full weight bearing ambulation with a walker is allowed on post-op day one. Patients receive aspirin (acetylsalicylic acid) 325 mg daily for six weeks starting the night of surgery. Pain is controlled with celecoxib (COX-2 selective nonsteroidal anti-inflammatory drug) 400 mg daily, and oral narcotics for break through pain. Before discharge, usually within three days post surgery, all patients are evaluated DVT by duplex venous ultrasonography. The incidence of blood loss, wound complications, and subcutaneous ecchymosis are recorded. Results and discussion. Although the incidence rate of all DVT (symptomatic and asymptomatic) after the arthroplasties was 2–3%, there was no patient readmitted or reoperated with critical bleeding, wound complications, nor fatal DVT/PE in this time period. The cost for the preoperative screening examinations, i.e. blood test and duplex venous ultrasonography, is approximately 200 US dollars. This is much less expensive than the cost associated with more aggressive anticoagulation agents and our procedures provided an acceptable level of outcomes with minimal risk of severe complications. Conclusions. The efficacy and safety of multimodal prophylaxis which employs aspirin against symptomatic PE in selected patients with hip and knee arthroplasties was demonstrated. Thus our protocol is recommended as a first choice for VTE prophylaxis

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination. Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography. Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases. Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators. Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability

We used high-resolution ultrasonography to image the ulnar collateral ligament in 39 patients who had sustained recent injuries of the metacarpophalangeal joint of the thumb. All the patients were subsequently operated on and the lesions of the ligament were recorded. In 36 patients the preoperative ultrasonographic diagnosis was correct. Five of these showed no rupture of the ligament. In the other 31, ultrasonography correctly distinguished between rupture in situ (15) and rupture with dislocation of the ligament (16). Misdiagnosis by ultrasonography in three cases was due to delay of the investigation (three weeks after injury) in one, to technical error in one and to misinterpretation of the image in one

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Objectives. Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue. Methods. A total of 20 fresh-frozen AT specimens were used. In ten specimens, ink was injected into the RB. The remaining ten specimens were split into two groups to be injected with radiological contrast medium into the RB either with or without ultrasonography guidance (USG). Results. In specimens injected with ink, diffusion outside the RB was observed with staining of the anterior portion of the AT. In eight contrast-injected specimens (five USG, three non-USG), a similar localised diffusion pattern was observed, with the contrast identified superiorly and anteriorly. In two contrast-injected specimens (non-USG), the diffusion pattern was more extensive. Conclusion. This study confirmed the existence of connections between the RB and the AT, especially rich in the anteroinferior portion of the tendon, which should be considered a weak zone for substances injected into the RB. We hypothesise that this part of the AT might be most vulnerable to rupture after corticosteroid injections. Cite this article: P. A. Pękala, B. M. Henry, J. R. Pękala, K. Piska, K. A. Tomaszewski. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone Joint Res 2017;6:446–451. DOI:10.1302/2046-3758.67.BJR-2016-0340.R1

Aims

The aim of this study was to investigate the outcomes of arthroscopic decompression of calcific tendinitis performed without repairing the rotator cuff defect.

Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use mechanical prophylaxis without anticoagulant drugs. A randomised controlled trial was performed to evaluate whether the incidence of post-operative venous thromboembolism was reduced by using pharmacological anticoagulation with either fondaparinux or enoxaparin in addition to our prophylactic mechanical regimen. A total of 255 Japanese patients who underwent primary unilateral cementless total hip replacement were randomly assigned to one of three postoperative regimens, namely injection of placebo (saline), fondaparinux or enoxaparin. There were 85 patients in each group. All also received the same mechanical prophylaxis during and after the operation, regardless of their assigned group. The primary measurement of efficacy was the presence of a venous thromboembolic event by day 11, defined as deep-vein thrombosis detected by ultrasonography, documented symptomatic deep-vein thrombosis or documented symptomatic pulmonary embolism. The duration of follow-up was 12 weeks. The rate of venous thromboembolism was 7.2% with the placebo, 7.1% with fondaparinux and 6.0% with enoxaparin (p = 0.95 for the comparison of all three groups). Our study confirmed the effectiveness and safety of mechanical thromboprophylaxis without the use of anticoagulant drugs after total hip replacement in Japanese patients

Introduction. Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis. However, it is a still big problem that there is a possibility of death in pulmonary embolism (PE) after TKA. We previously reported that there was more incidence of asymptomatic PE than estimated in general by detail examinations. But it was difficult to whom we decided to perform additional examinations except the patients with some doubtful symptoms. Therefore, we investigated detail of PE patients after primary TKA to find out anything key point in PE. Methods. Consecutive ninety-nine patients who underwent primary TKA from January 2015 to March 2018 were applied. There were 23 male and 76 females included, and the mean age was 73.7 years old. There were 96 cases of osteoarthritis, 2 cases of osteonecrosis and one of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses and air tourniquet during operation. There were 35 cases of one-staged bilateral TKA and 64 of unilateral TKA. Detail examinations with contrast enhanced CT (CE-CT) and venous ultrasonography (US) were performed at the 3rd day after surgery. Next, we applied ultra sound cardiogram (UCG) to the patients diagnosed as PE by CE-CT, we checked right ventricular overload (RVO) to treat PE. These images were read by a single senior radiologist team. Results. CE-CT was performed in 87 patients (87.8%) and US was in all patients. The incidence of deep vein thrombosis (DVT) was 67 patients (67.6%), and all of these was distal type DVT. PE was 17 patients (17.1%), and each of patients had no symptoms. RVO was detected in 5 patients (5.0%), and two of them (2.0%) had decreased SpO2 in early 90% perioperative period. All patients did not change rehabilitation protocol and progress was good until discharge. Conclusion. We investigated consecutive 99 patients for DVT/PE after primary TKA using CE-CT and venous US. And we performed UCG to PE patients. One of the important findings to decide detail examination for asymptomatic PE was decrease in SpO2 during early perioperative period. It might be the only finding except symptom. We also have to be more aware about high incidence of asymptomatic PE and more careful to the patients after TKA to prevent complications. For any figures or tables, please contact authors directly