Subscapularis pyomyositis, a rare cause of shoulder pain, in a patient without apparent risk factors: A case report.

INTRODUCTION: Pyomyositis, previously tropical, now seen more in temperate zones, particularly in those with HIV, cancer, or diabetes. Even healthy individuals, like athletes, can get it post-exercise or minor injuries. Our patient, in a desert-like area, adds an interesting aspect. Diagnosing is challenging due to deep tissue occurrence and subtle symptoms, leading to delayed detection and higher risks of morbidity. PRESENTATION OF CASE: A 45-year-old female patient presented with acute left shoulder pain and functional impairment, exacerbated by movement. Clinical examination revealed tenderness upon deep palpation in the left upper posterior thoracic region and restricted range of motion of the affected shoulder. DISCUSSION: Initial assessments at medical facilities suggested musculoskeletal strain and lower cervical disc prolapse despite normal X-ray results. MRI scans confirmed a developing abscess in the left subscapularis muscle, with intraoperative findings revealing extensive purulent fluid and necrotic tissue. Four surgeries drained the abscess and treated fat necrosis, with tailored antibiotics administered. Subsequent arthroscopy showed fibrous tissue, swelling, and inflammation. At the 3-month check-up, she had fully recovered, experiencing no pain or complications, and had almost regained full range of motion. CONCLUSION: Shoulder pyomyositis presents diagnostic challenges, causing delayed treatment. This case highlights the importance of considering pyomyositis in severe shoulder pain cases, even without typical risk factors or inconclusive X-rays. Timely recognition, surgical drainage, tailored antibiotics, and physical therapy are crucial. An interdisciplinary approach with orthopaedic surgery, infectious disease specialists, radiology, and physical therapy is vital for comprehensive management, improving outcomes, and reducing complications.

Necrotizing Fasciitis of the Thigh and Calf: A Reminder to Exclude a Perforated Intra-Abdominal Viscus: A Case Report.

CASE: Diverticular disease and its associated complications are an increasing problem among Western populations. Perforated diverticulitis results in intra-abdominal sepsis, which rarely causes a life-threatening necrotizing soft-tissue infection. We present the case of a 70-year-old man with a sigmoid diverticulitis perforation presenting as necrotizing fasciitis of the thigh and calf requiring serial debridement and major limb reconstruction. CONCLUSION: Clinicians should be aware of index presentations of diverticulitis and its recognized complications in this demographic group. For the orthopaedic and the general surgeon, knowledge of the dangers of the concomitant presence of these 2 conditions will substantially reduce morbidity and mortality.

Validation of a modified FRAX® tool for improving outpatient efficiency--part of the "Catch Before a Fall" initiative.

UNLABELLED: We have validated our touch-screen-modified FRAX® tool against the traditional healthcare professional-led questionnaire, demonstrating strong concordance between doctor- and patient-derived results. We will use this in outpatient clinics and general practice to increase our capture rate of at-risk patients, making valuable use of otherwise wasted patient waiting times. INTRODUCTION: Outpatient clinics offer an opportunity to collect valuable health information from a captive population. We have previously developed a modified fracture risk assessment (FRAX®) tool, enabling patients to self-assess their osteoporotic fracture risk in a touch-screen computer format and demonstrated its acceptability with patients. We aim to validate the accuracy of our tool against the traditional questionnaire. METHODS: Fifty patients over 50 years of age within the fracture clinic independently completed a paper equivalent of our touch-screen-modified FRAX® questionnaire. Responses were analysed against the traditional healthcare professional (HCP)-led questionnaire which was carried out afterwards. Correlation was assessed by sensitivity, specificity, Cohen's kappa statistic and Fisher's exact test for each potential FRAX® outcome of "treat", "measure BMD" and "lifestyle advice". RESULTS: Age range was 51-98 years. The FRAX® tool was completed by 88 % of patients; six patients lacked confidence in estimating either their height or weight. Following question adjustment according to patient response and feedback, our tool achieved >95 % sensitivity and specificity for the "treat" and "lifestyle advice" groups, and 79 % sensitivity and 100 % specificity in the "measure BMD" group. Cohen's kappa value ranged from 0.823 to 0.995 across all groups, demonstrating "very good" agreement for all. Fisher's exact test demonstrated significant concordance between doctor and patient decisions. DISCUSSION: Our modified tool provides a simple, accurate and reliable method for patients to self-report their own FRAX® score outside the clinical contact period, thus releasing the HCP from the time required to complete the questionnaire and potentially increasing our capture rate of at-risk patients.

Patterns of shoulder muscle coordination vary between wheelchair propulsion techniques.

This study investigated changes in the coordination patterns of shoulder muscles and wheelchair kinetics with different propulsion techniques by comparing wheelchair users' self-selected propulsion patterns with a semicircular pattern adopted after instruction. Wheelchair kinetics data were recorded by Smart(Wheel) on an ergometer, while EMG activity of seven muscles was recorded with surface electrodes on 15 able-bodied inexperienced participants. The performance data in two sessions, first using a self-selected and then the learned semicircular pattern, were compared with a paired t-test. Muscle coordination patterns across seven muscles were analyzed by principal component analysis. The semicircular pattern was characterized by significantly lower push frequency, significantly longer push length, push duration and push distance (p < 0.05, all cases) without a significant increase in push force, when compared with the self-selected pattern. In addition, our results show that in the semicircular propulsion technique, synergistic muscles were recruited in distinct phases and displayed a clearer separation between activities in the push phase and recovery phase muscles. An instruction session in semicircular propulsion technique is recommended for the initial use of a wheelchair after an injury.

Coordination patterns of shoulder muscles during level-ground and incline wheelchair propulsion.

The aim of this study was to investigate how the coordination patterns of shoulder muscles change with level-ground and incline wheelchair propulsion. Wheelchair kinetics and electromyography (EMG) activity of seven muscles were recorded with surface electrodes for 15 nondisabled subjects during wheelchair propulsion on a stationary ergometer and wooden ramp (4 degree slope). Kinetic data were measured by a SmartWheel. The kinetics variables and the onset, cessation, and duration of EMG activity from seven muscles were compared with paired t-tests for two sessions. Muscle coordination patterns across seven muscles were analyzed by principal component analysis. Push forces on the push rim and the percentage of push phase in the cycle increased significantly during incline propulsion. Propulsion condition and posture affected muscle coordination patterns. During incline propulsion, there was more intense and longer EMG activity of push muscles in the push phase and less EMG activity of the recovery muscles, which corresponded with the increased kinetic data total force output and longer push phase in the incline condition. This work establishes a framework for developing a performance feedback system for wheelchair users to better coordinate their muscle patterning activity.

Changes in surface electromyography signals and kinetics associated with progression of fatigue at two speeds during wheelchair propulsion.

The purpose of this study was to determine whether muscle balance is influenced by fatigue in a recordable way, toward creating novel defensive activity strategies for manual wheelchair users (MWUs). Wheelchair propulsion to a point of mild fatigue, level 15 on the Rating of Perceived Exertion scale, was investigated at two different speeds. Surface electromyographic (EMG) activity of 7 muscles was recorded on 14 nondisabled participants. Kinetic variables were measured using a SmartWheel. No significant effect was found of percentage endurance time on kinetic variables for the two propulsion speeds. Fatigue-related changes in the EMG spectra were identified as an increase of EMG intensity and a decrease of mean power frequency as a function of percent endurance time for the tested muscles under both fast and slow speed conditions. The greater increases in activity for propulsive muscles compared with recovery muscles during fast speed wheelchair propulsion indicated muscle imbalance associated with fatiguing wheelchair propulsion. This study shows how kinetic and EMG information might be used as feedback to MWUs to ensure that they conduct activity in ways that do not precipitate injury.

Effect of velocity on shoulder muscle recruitment patterns during wheelchair propulsion in nondisabled individuals: pilot study.

This study investigated how the recruitment patterns of shoulder muscles were influenced by wheelchair propulsion speed. Electromyography (EMG) activity of seven muscles was recorded with surface electrodes on 15 nondisabled subjects during wheelchair propulsion on a stationary ergometer. Kinetic data were measured by a SmartWheel. EMG total intensities were calculated to describe the muscle activation level, while the angles formed by first principal component and second principal component loading scores were calculated to describe the spectral content of EMG signals. Significant differences were observed in kinetic variables between the two testing speeds (p < 0.05). The EMG intensity of the tested muscles increased significantly with increased speed (p < 0.05). The push muscles showed a longer EMG duration, whereas the recovery muscles exhibited significantly earlier EMG onset and peak activities at the fast speed. The smaller angle values in the fast propulsion speed indicated that faster motor units were recruited to match the mechanical requirement for the faster motion. Pushing a manual wheelchair at a faster speed not only requires a higher level of propulsive muscle activity but also a higher level of recovery muscle activation.

Current issues and regulations in tendon regeneration and musculoskeletal repair with mesenchymal stem cells.

Mesenchymal stem cells are multipotent stromal cells residing within the connective tissue of most organs. Their surface phenotype has been well described. Most commonly, mesenchymal stem cells demonstrate the ability to differentiate into mesenchymal tissues (bone, catailge, fat, etc...), however, under the proper conditions these cells can differentiate into epithelial cells and neuroectoderm derived lineages. Their developmental plasticity also depends on the ability of mesenchymal stem cells to alter the tissue microenvironment by secreting soluble factors, as well as their capacity for differentiation in tissue repair. It is the cell-matrix interaction which defines the tissue characteristics. The molecular and functional heterogeneity of this cell population may confound interpretation of their differentiation potential, but it is this heterogeneity that is believed to provide for their therapeutic efficacy. Stem cell therapies are an attractive therapeutic approach for soft tissues as they offer a vehicle for repair and regeneration at the end of a needle. The early introduction of stem cell treatments into the therapeutic armamentarium involves both commercial and non-commercial multidisciplinary partnerships and has occurred in a climate of regulatory reform, so not all the relevant information resides in the public domain, but early clinical studies have shown promising results. Against this backdrop, novel techniques and early results of a small series of tendon and musculotendinous junction interventions are being published and other ongoing studies are yet to report their results. The issue of ensuring governance of these novel technologies falls upon both the scientific community and the established licensing authorities.

Tissue Engineering Stem Cells - An e-Governance Strategy.

The rules of governance are changing. They are necessarily becoming more stringent as interventions offered to treat conditions carry unpredictable side effects, often associated with novel therapeutic vectors. The clinical relevance of this relates to the obligations of those involved in research, to ensure the best protection for subjects whilst encouraging the development of the field. Existing evidence supports the concept of e-Governance both in operational health research and more broadly in the strategic domain of policy formation. Building on the impact of the UK Comprehensive Research Network and recent EU Directives, it is now possible to focus on the issues of regulation for cell therapies in musculoskeletal science through the development of the Advanced Therapeutic Medicinal Products (ATMP) category of research products. This article reviews the framework that has borne this and the need for more detailed Virtual Research Integration and Collaboration (VRIC) systems to ensure regulatory compliance. Technology research and development plans must develop in close association between tissue engineering and treating clinicians. The scope of this strategy relates to the handling of human tissues the transport and storage of specimens in accordance with current EU directives and the Human Tissue Authority (HTA) regulations.

Extending the role of a healthcare digital library environment to support orthopaedic research.

A digital archive, together with its users and its contents, does not exist in isolation; there is a cycle of activities which provides the context for the archive's existence. In arguing for the broadening of the traditional view of digital libraries as merely collections towards the processes of collecting and deploying, we have developed an extend ed digital library environment for orthopaedic surgeons which bridges the gap between the undertaking of experimental work and the dissemination of its results through electronic publication.