Posterior Dislocation of the Sternoclavicular Joint in a Patient With Hemophilia: A Case Report.

Posterior sternoclavicular joint (SCJ) dislocations are rare but serious injuries. We report our experience with a patient with hemophilia who experienced posterior dislocation of the SCJ and was treated with an open repair technique.  A 17-year-old man with hemophilia had a posterior dislocation of the SCJ and the proximal clavicle was an approximation to the brachiocephalic artery. Cardiovascular surgeons and pediatricians were consulted on the day of injury. The patient underwent open reduction of the SCJ and the SCJ was stabilized with strong sutures using a tension-band technique. The patient returned to playing rugby three months after surgery. Posterior dislocation of the SCJ has a risk of vascular injury. Although our patient required more attention because of his hemophilia, the surgery was successful through collaboration with other departments. Reconstruction of the SCJ using a tension-band technique with strong sutures was useful and allowed early return to sports.

Biomechanical Comparison of Stability and Strength After Ulnar Collateral Ligament Reconstruction With Suture Anchor Fixation Versus Bone Tunnels.

Background: Ulnar collateral ligament (UCL) injuries occur frequently in baseball players, and UCL reconstruction is performed when nonoperative treatment fails. Purpose: To compare a novel all-suture anchor method of UCL reconstruction with a method using bone tunnels (Ito method) by investigating the displacement against valgus torque and the failure strength. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric upper extremities (mean age, 82.0 years) were utilized in this study. To evaluate the displacement against valgus torque, the valgus stability test was performed for 4 anterior oblique ligament (AOL) conditions: intact AOL, resected AOL, reconstructed using the anchor method, and reconstructed using the Ito method. The load-to-failure test was performed to evaluate the failure strength of the anchor and Ito methods. Displacement against valgus load was compared between conditions using the repeated-measures 2-way analysis of variance with Bonferroni post hoc test, and failure strength between the anchor and Ito methods was compared using the unpaired t test. Results: Displacements of the intact AOL and anchor method were significantly greater than those of the resected AOL at both 60° and 90° of flexion (intact AOL: P = .005 and P < .001, respectively; and anchor method: P = .024 and P < .001, respectively). The displacement of the Ito method at 90° of flexion was significantly greater than that of the resected AOL (P = .003), but no significant difference was observed at 60° of flexion (P = .109). There were no significant differences in displacement between the anchor and Ito methods at any flexion angle, nor was there a significant difference in failure torque between the anchor and Ito methods (16.3 ± 3.1 vs 17.6 ± 2.3 N·m, respectively; P = .537). Conclusion: The displacement and failure strength against a valgus load after UCL reconstruction using a suture anchor on the ulnar side were equal to those using bone tunnels. Clinical Relevance: UCL reconstruction using a suture anchor on the ulnar side is simpler and less invasive than using bone tunnels, with similar outcomes.

Postoperative complications of reverse total shoulder arthroplasty: a multicenter study in Japan.

Background: Reverse total shoulder arthroplasty (RSA) has been approved since 2014 in Japan, and the number of RSA cases has been accumulating. However, only short-to medium-term outcomes have been reported, with a small number of case series, because of its short history in Japan. This study aimed to evaluate complications after RSA in hospitals affiliated with our institute, with comparison to those in other countries. Methods: A multicenter retrospective study was performed at 6 hospitals. In total, 615 shoulders (mean age: 75.7 ± 6.2 years; mean follow-up: 45.2 ± 19.6 months) with at least 24 months of follow-up were included in this study. The active range of motion was assessed pre-and postoperatively. The 5-year survival rate was evaluated for reoperation for any reason in 137 shoulders with at least 5 years of follow-up using Kaplan-Meier analysis. Postoperative complications were evaluated, including dislocation; prosthesis failure; deep infection; periprosthetic, acromial, scapular spine, and clavicle fractures; neurological disorders; and reoperation. Furthermore, imaging assessments, including scapular notching, prosthesis aseptic loosening, and heterotopic ossification were evaluated on postoperative radiography at the final follow-up. Results: All range of motion parameters were significantly improved postoperatively (P < .001). The 5-year survival rate was 93.4% (95% confidence interval: 87.8%-96.5%) for reoperation. Complications occurred in 256 shoulders (42.0%), with reoperation in 45 (7.3%), acromial fracture in 24 (3.9%), neurological disorders in 17 (2.8%), deep infection in 16 (2.6%), periprosthetic fracture in 11 (1.8%), dislocation in 9 (1.5%), prosthesis failure in 9 (1.5%), clavicle fracture in 4 (0.7%), and scapular spine fracture in 2 (0.3%). Regarding imaging assessments, scapular notching was observed in 145 shoulders (23.6%), heterotopic ossification in 80 (13.0%), and prosthesis loosening in 13 (2.1%). Conclusion: This is the first large case series to investigate the complications after RSA in Japan, and the overall frequency of complications after RSA was similar to that in other countries.

Effect of arthroscopic subacromial decompression during arthroscopic repair of small to medium-sized rotator cuff tears.

Background: Although arthroscopic subacromial decompression (ASD) is a commonly used procedure during arthroscopic rotator cuff repair (ARCR), the effect of ASD on the clinical outcomes for ARCR is controversial. The purpose of this study was to compare the clinical outcomes of ARCR with or without ASD. Methods: Patients (n = 315 with 320 shoulders) who underwent ARCR for small to medium-sized rotator cuff tears were followed for at least 24 months. ARCR was performed with ASD (180 shoulders, group A) or without ASD (140 shoulders, group N). There were no significant differences in patient demographics, including mean age and mean follow-up time. Rotator cuff repair was performed using the suture-bridge technique in all shoulders, and all patients were treated using the same rehabilitation protocol after surgery. University of California at Los Angeles score, Constant score, re-tear rates, revision surgery rates, and operating time were compared between groups. Re-tear was defined as Sugaya classification Types 4 and 5 using postoperative magnetic resonance imaging at more than 12 months. Results: There was no statistically significant difference in clinical outcomes before and after ARCR between groups. However, the University of California at Los Angeles scores and Constant scores significantly improved in both groups after surgery (P < .001). Furthermore, there was no major difference in the re-tear rates between groups A (7/180 shoulders, 3.9%) and N (11/140 shoulders, 7.9%) (P = .146). Revision surgeries were performed on 3/180 shoulders (1.7%) in group A (due to postoperative deep infection in one shoulder and revision ARCR for re-tear in two shoulders). No revisions surgeries were needed in group N patients (P = .259). The mean surgical time for group A was 62.0 ± 27.0 minutes (29-138 min.) and 52.4 ± 26.1 minutes (17-124 min.) for group N (P = .007). Conclusion: These results suggest that ASD has a limited effect on clinical outcomes of ARCR for small to medium-sized rotator cuff tears.

Evaluation of articular changes using a rat mono-iodoacetate-induced shoulder arthritis model by histology and radiology.

The rat mono-iodoacetate (MIA) arthritis model has been used in studies on the hip, knee, and ankle joints. Few studies have explored its utility in shoulder arthritis research, and none have evaluated the effects of time and different MIA doses on arthritis progression. Therefore, we developed a rat MIA shoulder arthritis model to evaluate articular changes through radiological and histological analyses. Sprague-Dawley rats (n = 108) were equally divided into groups that were intra-articularly injected with 0.5 mg of MIA (in 50 µL of purified water), 2.0 mg of MIA (in 50 µL of purified water), or purified water (50 µL; sham group). Throughout the study period, 18 rats (six per group) were evaluated by computed tomography and assessed using the Larsen's classification system; 90 rats were further evaluated histologically using the Osteoarthritis Research Society International scoring system. Computed tomography revealed that the groups injected with MIA developed arthritis and osteophytes 14 days after injection, which progressed temporally. The Larsen's grades worsened over time; at all time points, the scores were higher in the group injected with 2.0 mg of MIA than in the group injected with 0.5 mg of MIA. Furthermore, concurrent with the worsening Larsen's grades, the Osteoarthritis Research Society International scores also significantly increased over time; at all time points, they were higher in the group injected with 2.0 mg of MIA than in the group injected with 0.5 mg of MIA. Our rat MIA shoulder arthritis model revealed radiologically and histologically confirmed temporal and MIA dose-dependent arthritic changes.

Imaging and histological evaluation of the long head of the biceps tendon in the presence of different types of rotator cuff tears.

BACKGROUND: A comparison of changes in the long head of the biceps tendon for different types of rotator cuff tears has not been previously performed. Furthermore, the correlation between the thickening and degeneration of the long head of the biceps tendon and the cause of these changes have not been fully clarified. We evaluated the relationship between degenerative changes in the long head of the biceps tendon and rotator cuff tears in a rat model using imaging and histology. METHODS: Ninety-six 12-week-old Sprague-Dawley rats were divided into anterior (subscapularis tear), anterosuperior (subscapularis, supraspinatus, and infraspinatus tears), superior (supraspinatus and infraspinatus tears), and control groups. The long head of the biceps tendon was harvested at 4 or 12 weeks postoperatively. The cross-sectional areas of the intra- and extra-capsular components of the tendon were measured using micro-computed tomography, and the affected/normal ratio of the cross-sectional area was calculated. Masson's trichrome staining and Alcian blue staining were performed for histologic analysis, with degenerative changes described using the modified Bonar scale. The correlation between the affected/normal ratio and Bonar scores was evaluated. RESULTS: The affected/normal ratio was higher for the anterior and anterosuperior groups than for the control group at 4 and 12 weeks. The ratio increased for the intra-articular portion in the superior group and for both the intra- and extra-articular portions in the anterior and anterosuperior groups. Degeneration considerably progressed in the anterior and anterosuperior groups compared with the control group from weeks 4 to 12 and was greater in the intra- than in the extra-articular portion. The ratio correlated with extracellular matrix score. CONCLUSIONS: Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively, which was more significant in the intra- than in the extra-articular portion. Histologic evaluation indicated that the extracellular matrix likely caused these degenerative changes.

Return to sports and physical work after anatomical and reverse shoulder arthroplasty.

BACKGROUND: No consensus has been reached on the return to sports or physical work after shoulder arthroplasty due to a shortage of literature. The purpose of this study was to investigate return to sports or physical work after anatomical total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA), as well as the clinical and radiographic outcomes. METHODS: The inclusion criteria were as follows: 1) aTSA or RSA between 2012 and 2017, and 2) patients who preoperatively participated in sports or physical work. The exclusion criteria were as follows: 1) revision arthroplasty, 2) fracture/dislocation, 3) fracture sequelae, 4) postinfection, and 5) <2-year follow-up. Sports and physical work were classified as low-, medium-, or high-load activities. Range of motion, Constant score, sport or work return, and radiographic findings were evaluated and compared between aTSA and RSA groups. RESULTS: The subjects who met the criteria were 90 shoulders in 86 patients. The aTSA group consisted of 30 shoulders (10 men and 20 women) with a mean age of 71 ± 8 years (range, 56-85). The RSA group consisted of 60 shoulders (39 men and 21 women) with a mean age of 72 ± 6 years (range, 56-83). Active range of motion significantly improved after surgery in all directions in the aTSA group but only in flexion and external rotation in the RSA group. Postoperative external and internal rotations, as well as postoperative Constant scores and satisfaction, were significantly better in the aTSA than in the RSA group. In the aTSA group, the return rate was 93%, and the complete return rate was 70%. In the RSA group, the return rate was 83%, and the complete return rate was 30%. The complete return rate was significantly higher in the aTSA than in the RSA group. Only one aTSA shoulder showed loosening of the glenoid implant, and 8 RSA shoulders demonstrated low-grade scapular notching. CONCLUSION: The return to sports or physical work rates after aTSA and RSA were high; however, the complete return rates were significantly higher in the aTSA group than in the RSA group. No radiographic failures were identified except for one asymptomatic glenoid loosening with a midterm follow-up.

Clinical outcomes of anatomic total shoulder arthroplasty for primary shoulder osteoarthritis did not differ between elderly and younger Japanese patients.

Background: Few studies on the outcomes of anatomic total shoulder arthroplasty (aTSA) in Asian populations have been reported. In addition, approximately one-third of primary aTSA were performed for patients 80 years or older in Japan, but the indication of aTSA for the primary shoulder osteoarthritis in the elderly population remained unclear. The purposes of this study were (1) to investigate clinical outcomes of aTSA in Japanese patients with primary glenohumeral osteoarthritis and (2) to compare clinical outcomes between patients 80 years or older and 70 years or younger. We hypothesized that aTSA would yield favorable outcomes in Japanese patients and that the outcomes of aTSA in patients 80 years or older would be comparable to those 70 years or younger. Methods: Patient records were retrospectively reviewed to collect patients who underwent aTSA for glenohumeral osteoarthritis between August 2011 and September 2017. The inclusion criterion of this study was aTSA performed for glenohumeral osteoarthritis. Exclusion criteria were as follows: (1) secondary osteoarthritis, (2) revision surgery, and (3) < 24-month follow-up. Range of motion (ROM) and Constant score were evaluated, and complications were investigated. Rotator cuff integrity was assessed by ultrasonography. We compared the outcomes between patients 80 years or older and 70 years or younger. Results: Seventy-seven shoulders (72 patients) met the study criteria. There were 14 men and 58 women with a mean age of 75 years (range, 57-93 years) at the time of surgery. The mean follow-up was 40 months (range, 24-84 months). The Constant score significantly improved from preoperative 54 (range, 35-78) to postoperative 89 (range 69-100, P = .03). Range of motion also showed significant improvement after surgery: flexion, 90° (range, 60°-130°) to 140° (range, 90°-170°); external rotation at the side, from 7° (range, -10 to 60°) to 40° (range, 5°-70°); internal rotation, from buttock (range, buttock-L3) to L2 level (range, buttock-T8) (P <.001 for all). Postoperative subscapularis tendon tears were detected in 3 shoulders (5%). Complications other than rotator cuff tears were observed in 5 shoulders (6%). Postoperative Constant score and ROM significantly improved in both elderly and younger patients without significant differences. Conclusion: The clinical outcomes after aTSA in the Japanese population demonstrated significant improvements in ROM and Constant score with a low complication rate in the mid-term follow-up. aTSA should be indicated even in elderly patients because they also demonstrated comparable outcomes to younger patients.

Return to Sport After Arthroscopic Rotator Cuff Repair in Middle-Aged and Elderly Swimmers.

BACKGROUND: No reports have been published on the clinical outcomes, including return to sport, after rotator cuff repair in middle-aged and elderly swimmers with rotator cuff tears. PURPOSE: To retrospectively investigate clinical outcomes and return to sport after arthroscopic rotator cuff repair in middle-aged and elderly swimmers. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic rotator cuff repair and met the following criteria were included: (1) age older than 45 years, (2) rotator cuff tears confirmed during surgery, (3) arthroscopic suture bridge rotator cuff repair, (4) primary surgery, and (5) swam more than once a week before surgery. The exclusion criteria were as follows: (1) irreparable large and massive tears, (2) shoulder instability, (3) arthritis or rheumatic disorders, or (4) less than 2-year follow-up. We investigated functional outcomes including range of motion; the University of California, Los Angeles (UCLA) score; the American Shoulder and Elbow Surgeons (ASES) score; return to swimming; and the return rates for each style of swimming. In addition, the functional outcomes and findings of magnetic resonance imaging were compared between the group with complete return and the group with incomplete or failed return. RESULTS: A total of 32 shoulders in 31 middle-aged and elderly swimmers (5 males, 26 females) were included. The mean age was 65 years (range, 47-78 years), and the mean follow-up was 47 months (range, 24-86 months). Return to swimming was achieved in 31 (97%) shoulders at a mean of 8 months (range, 3-24 months), and complete return was achieved in 18 (56%) shoulders at a mean of 12 months (range, 3-24 months). The return rate was 97% for freestyle, 83% for breaststroke, 74% for backstroke, and 44% for butterfly stroke. Postoperative UCLA and ASES scores were significantly higher in the group with complete return than in the group with incomplete or failed return (P = .001 and .01, respectively). Postoperative forward elevation was significantly better in the complete return group (P = .01). CONCLUSION: This study demonstrated that 97% of elderly swimmers who underwent arthroscopic rotator cuff repair could return to swimming. The complete return rate was 56%; however, the group with incomplete or failed return showed poorer active forward elevation. Freestyle had the highest complete return rate, whereas the butterfly stroke had the lowest return rate. It may be important to achieve good active forward elevation postoperatively to return to swimming.

Treatment of Atypical Ulnar Fractures Associated with Long-Term Bisphosphonate Therapy for Osteoporosis: Autogenous Bone Graft with Internal Fixation.

Long-term bisphosphonate use has been suggested to result in decreased bone remodelling and an increased risk of atypical fractures. Fractures of this nature commonly occur in the femur, and relatively few reports exist to show that they occur in other bones. Among eight previous reports of atypical ulnar fractures associated with bisphosphonate use, one report described nonunion in a patient who was treated with cast immobilization and another described ulna nonunion in one of three patients, all of whom were treated surgically with a locking plate. The remaining two surgical patients achieved bone union uneventfully following resection of the osteosclerotic lesion and iliac bone grafting before rigid fixation. We hypothesized that the discontinuation of bisphosphonate therapy, the use of teriparatide treatment, and low-intensity pulsed ultrasound (LIPUS) might have been associated with fracture healing.

Effect of duloxetine on neuropathic pain in patients intolerant to continuous administration of pregabalin.

PURPOSE: We examined duloxetine's effectiveness in the treatment of neuropathic pain in patients who were intolerant to continuous pregabalin administration. MATERIALS AND METHODS: The present study is a retrospective study of patients diagnosed with neuropathic pain with neuropathic leg pain as the chief complaint. We analyzed 20 cases in which pregabalin was changed to duloxetine because of adverse effects (16 cases) or treatment failure (4 cases). The incidence of adverse events after duloxetine administration was used as the primary endpoint, with the secondary endpoint being the leg pain level based on a numerical rating scale (NRS). RESULTS: The incidence of adverse events after starting duloxetine was 40%. Average leg pain scores measured on the NRS were 8.4±1.4, 6.4±1.4, and 4.1±2.0 at the time of the patients' first visit, pregabalin discontinuation, and after switching to duloxetine, respectively. A significant difference in NRS scores was found between the first visit and pregabalin discontinuation and also between pregabalin discontinuation and after the switch to duloxetine (p<0.05), indicating that pain decreases over time. Furthermore, NRS scores significantly declined between the patients' first visit and after the switch to duloxetine (p<0.05). The improvement in NRS score was 20±12.8% after pregabalin administration and 23±12.0% after duloxetine administration compared with baseline scores (no significant difference between pregabalin and duloxetine; p>0.05). CONCLUSION: When patients with neuropathic pain are unable to tolerate pregabalin because of adverse effects, changing the medication to duloxetine may be an option.

Hemolytic C-type lectin CEL-III from sea cucumber expressed in transgenic mosquitoes impairs malaria parasite development.

The midgut environment of anopheline mosquitoes plays an important role in the development of the malaria parasite. Using genetic manipulation of anopheline mosquitoes to change the environment in the mosquito midgut may inhibit development of the malaria parasite, thus blocking malaria transmission. Here we generate transgenic Anopheles stephensi mosquitoes that express the C-type lectin CEL-III from the sea cucumber, Cucumaria echinata, in a midgut-specific manner. CEL-III has strong and rapid hemolytic activity toward human and rat erythrocytes in the presence of serum. Importantly, CEL-III binds to ookinetes, leading to strong inhibition of ookinete formation in vitro with an IC(50) of 15 nM. Thus, CEL-III exhibits not only hemolytic activity but also cytotoxicity toward ookinetes. In these transgenic mosquitoes, sporogonic development of Plasmodium berghei is severely impaired. Moderate, but significant inhibition was found against Plasmodium falciparum. To our knowledge, this is the first demonstration of stably engineered anophelines that affect the Plasmodium transmission dynamics of human malaria. Although our laboratory-based research does not have immediate applications to block natural malaria transmission, these findings have significant implications for the generation of refractory mosquitoes to all species of human Plasmodium and elucidation of mosquito-parasite interactions.

[Novel approach toward infectious diseases--combating malaria by using genetically engineered mosquitoes].

Malaria is a devastating disease that kills millions of people every year, yet there has been little progress in controlling this disease. Mosquitoes are obligatory vectors for the disease and this part of the parasite cycle represents a potential weak link in transmission. Therefore, control of parasite development in the mosquito has considerable promise as a new approach in the fight against malaria. In recent year, methods for the genetic modification of mosquitoes have been developed, and effector genes whose products interfere with Plasmodium development in the mosquito are beginning to be identified. Here we review strategies to alter mosquito vector competence and consider issues related to translating this knowledge to field applications.