Fatty Atrophy Research Articles

P035 Inflammatory myopathy and metabolic disorders causing myopathies

Abstract Background/Aims Myopathies due to inborn errors of metabolism can be difficult to differentiate from inflammatory myopathies. Careful history, examination and laboratory tests are required to establish the diagnosis. We present a case of Riboflavin Transport Deficiency (Brown-Vialetto-Van Laere syndrome) masquerading as an inflammatory myopathy. Methods A 37-year-old lady presented with severe proximal muscle weakness. She had background of sensory neuropathy and chronic anaemia. Notably, her sister had a history of similar symptoms. Creatine Kinase (CK) was 360 IU/L and lactate dehydrogenase (LDH) was 1700 IU/L. Inflammatory markers were normal. The Ro52 antibody was weakly positive. Electromyography showed evidence of a sensory neuropathy with myopathic features. There was symmetrical fatty infiltration and atrophy of the thigh muscles on magnetic resonance imaging (MRI). Positron emission tomography (PET-CT) scan showed widespread intense uptake in skeletal muscle groups. She was given 3 pulses of IV methyprednisolone followed by oral prednisolone which did not provide clinical benefit. Intravenous immune globulin was given when she developed bulbar weakness, with difficulty swallowing and breathing. She required non-invasive ventilation and nasogastric feed. There were necrotic and regenerative muscle fibres on the muscle biopsy, in keeping with rhabdomyolysis. Electron microscopy showed abundant lipid accumulation, suggestive of a metabolic disorder. Urinary organic acids were raised, triggering an acylcarnitines blood spot test, which were increased. This was compatible with riboflavin transport 'Brown-Vialetto-Van-Laere syndrome'. Riboflavin 500mg TDS was started resulting in significant clinical improvement. Prednisolone was weaned, genetic testing sent, and she was transferred for neurorehabilitation. Results Riboflavin Transport Deficiency (Brown-Vialetto-Van Laere syndrome) is an autosomal recessive neurodegenerative genetic disorder. It affects females and males equally. Symptoms can appear in infants as well as adults. These include hearing and visual loss, bulbar palsy leading to dysphagia and speech problems. Paralysis of diaphragm may cause breathing difficulty. Initially it affects the proximal muscles and then generalized muscle weakness. Molecular genetic testing is required to confirm diagnosis. Patients may have abnormal plasma levels of flavin or acylcarnitine. Acylcarnitines are biological intermediates, used in the diagnosis of fatty acid oxidation disorders. Treatment includes riboflavin supplementation and supportive measures. Response to treatment is variable. Conclusion This lady was initially managed as inflammatory myopathy but did not respond to high dose methylprednisolone. There were atypical features including normal inflammatory markers, MRI thighs showing predominantly fatty infiltration and muscle atrophy and the muscle biopsy with abundant lipid accumulation suggestive of a metabolic disorder. We are awaiting full results of genetic testing. This case is a reminder of the importance of tissue diagnosis and reassessing the initial diagnosis if the clinical picture changes or patients do not respond as expected to treatment. Disclosure M. Malik: None. A. Mason: None. B. Davidson: None. J. Furby: None.

The association between spondylolisthesis and decreased muscle health throughout the lumbar spine for patients with operative lumbar spinal stenosis.

There are data underlining the relationship between muscle health and spine related pathology, but little data regarding changes in paralumbar muscle associated with lumbar spondylolisthesis. We aimed to define changes in paralumbar muscle health associated with spondylolisthesis. A retrospective review was performed on consecutive patients with lumbar spine pathology requiring an operation. A pre-operative lumbar MRI was analysed for muscle health measurements including lumbar indentation value (LIV), paralumbar cross-sectional area divided by body mass index (PL-CSA/BMI), and Goutallier classification of fatty atrophy. All measurements were taken from an axial slice of a T2-weighted image at lumbar disc spaces. Baseline health-related quality of life scores (HRQOLs), narcotic use and areas of stenosis were tracked. We performed Chi-square analyses and student's t test to determine statistically significant differences between cohorts. There were 307 patients (average age 56.1 ± 16.7years, 141 females) included within our analysis. 112 patients had spondylolisthesis. There were no differences in baseline HRQOLs between the spondylolisthesis cohort (SC) and non-spondylolisthesis cohort (non-SC). There were significantly worse PL-CSA/BMI at L2-L3 (p = 0.03), L3-L4 (p = 0.04) and L4-L5 (p = 0.02) for the SC. Goutallier classification of paralumbar muscle was worse for SC at L1-L2 (p = 0.04) and at L4-L5 (p < 0.001). Increased grade of spondylolisthesis was associated with worse PL-CSA at L1-L2 (p = 0.02), L2-L3 (p = 0.03) and L3-L4 (p = 0.05). Similarly, there were worse Goutallier classification scores associated with higher-grade spondylolisthesis at all levels (p < 0.05). There are significant detrimental changes to paralumbar muscle health throughout the lumbar spine associated with spondylolisthesis.

Endoscopic transfer of gluteus maximus and tensor fasciae latae for massive gluteus medius tear: Preliminary results

We report preliminary results for a novel technique of endoscopic Whiteside transfer for massive gluteus medius tear: i.e., tendon reinsertion not or only partly feasible and/or severe fatty atrophy of the muscle. Endoscopic transfer of gluteus maximus and/or tensor fasciae latae is associated to gluteus medius tendon reinsertion if at least partial tendon repair is feasible. In a continuous series of 6 patients at a minimum 2 years’ follow-up, there was 1 early failure; 2 patients showed no improvement in pain and limping; 3 had satisfactory results, including 2 with complete resolution of limping and pain. Endoscopic Whiteside transfer associated to gluteus medius tendon repair provided only moderate results in terms of recovery of abduction power and resolution of Trendelenburg gait.

Gluteus minimus tendon: MR imaging features and patterns of tendon tearing.

To highlight the spectrum of pathology and patterns of gluteus minimus tendon tearing observed on MR imaging of the hip. Retrospective review of consecutive hip MRI exams with findings of gluteus minimus tendon (GMin) pathology. A total of 194 exams in 178 patients (148 female, mean age 61) were reviewed. MRI exams are assessed for GMin: tendinopathy, partial, or complete tendon tears. GMin muscular fatty atrophy, enthesopathic cortical irregularities of the greater trochanter (GT), and peri-trochanteric edema or bursal fluid collections were assessed in all cases. In all cases of complete GMin tendon tearing, position and relationship of GMin tendon were assessed relative to its normal insertion site and adjacent soft tissues. Clinical indications for MR imaging included hip pain (n= 151), and weakness or altered gait (n= 13). Insertional GMin tendinopathy was seen in 72, partial tearing in 81, and complete tendon tearing in 40 cases. Complete tendon tearing without proximal retraction was observed in 38/40 cases with soft tissue continuity visualized between distal tendon fibers and the proximal vastus lateralis muscle. Peri-trochanteric bursal fluid (n= 61), osseous irregularities of the GT (n= 118), and fatty atrophy GMin (n= 102) were statistically associated with partial or complete GMin tendon tearing (p< 0.001). The spectrum of GMin tendon pathology observed on MR imaging ranges from tendinopathy to complete tears. The majority of complete distal GMin tendon tears from the greater trochanter show continuity of distal tendon fibers with the proximal vastus lateralis, distally tethering and limiting proximal tendon retraction.

Rotator cuff fatty infiltration and muscle atrophy do not impact clinical outcomes after reverse total shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff.

The clinical significance of rotator cuff muscle quality following reverse total shoulder arthroplasty (RTSA) remains uncertain. The purpose of this study was to evaluate the influence of rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on clinical outcomes following RTSA for glenohumeral osteoarthritis (GHOA). One hundred eight shoulders with primary GHOA that underwent RTSA with a lateralized glenosphere for GHOA with a minimum of 2-year follow-up were identified from a prospectively maintained registry. Each rotator cuff muscle was assessed on preoperative magnetic resonance imaging for FI and quantitative amount of MA. Pre- and postoperative outcomes included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numerical Evaluation (SANE) score, visual analog scale pain score, and range of motion (ROM) measurements. Eighty-one patients with a mean age of 70.7 ± 5.4 years (range: 57-85) were included who underwent RTSA with a mean follow-up of 2.1 years (range: 2-3.9 years). There was a significant improvement in all outcome measures postoperatively (P < .01). Twenty-two patients (27.1%) had moderate to severe combined infraspinatus and teres minor FI. There was no significant difference in the postoperative external rotation or clinical outcomes compared with those patients with only mild FI (P > .05). Forty-three patients (53.1%) had moderate to severe global rotator cuff FI. There was no significant difference in postoperative outcomes compared with those patients with only mild FI (P < .01). Univariate analysis did not reveal any significant association between the degree of FI or MA of any individual rotator cuff muscle and postoperative clinical outcomes or ROM. The size ratio of the posterior rotator cuff to the subscapularis muscle was positively correlated with preoperative SANE scores but negatively correlated with absolute postoperative and change in preoperative to postoperative SANE scores. However, there were no significant correlations between this size ratio and the other outcome measures. Rotator cuff muscle quality as assessed by MA and FI does not impact clinical outcomes following RTSA with a lateralized glenosphere in patients with GHOA and an intact rotator cuff.

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears

BackgroundGluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair.MethodsAll sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance.Results38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes.ConclusionWhile fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Correlation between lower lumbar multifidus muscles fatty atrophy and corresponding level degenerative diseases in patients with low back pain using MRI

Correlation between lower lumbar multifidus muscles fatty atrophy and corresponding level degenerative diseases in patients with low back pain using MRI

Skeletal Muscle Function, Structure, and Metabolism in Patients With Heart Failure With Reduced Ejection Fraction and Heart Failure With Preserved Ejection Fraction.

Reduced exercise capacity in patients with heart failure (HF) could be partially explained by skeletal muscle dysfunction. We compared skeletal muscle function, structure, and metabolism among clinically stable outpatients with HF with preserved ejection fraction, HF with reduced ejection fraction, and healthy controls (HC). Furthermore, the molecular, metabolic, and clinical profile of patients with reduced muscle endurance was described. Fifty-five participants were recruited prospectively at the University Hospital Jena (17 HF with preserved ejection fraction, 18 HF with reduced ejection fraction, and 20 HC). All participants underwent echocardiography, cardiopulmonary exercise testing, 6-minute walking test, isokinetic muscle function, and skeletal muscle biopsies. Expression levels of fatty acid oxidation, glucose metabolism, atrophy genes, and proteins as well as inflammatory biomarkers were assessed. Mitochondria were evaluated using electron microscopy. Patients with HF with preserved ejection fraction showed compared with HF with reduced ejection fraction and HC reduced muscle strength (eccentric extension: 13.3±5.0 versus 18.0±5.9 versus 17.9±5.1 Nm/kg, P=0.04), elevated levels of MSTN-2 (myostatin-2), FBXO-32 (F-box only protein 32 [Atrogin1]) gene and protein, and smaller mitochondrial size (P<0.05). Mitochondrial function and fatty acid and glucose metabolism were impaired in HF-patients compared with HC (P<0.05). In a multiple regression analysis, GDF-15 (growth and differentiation factor 15), CPT1B (carnitine palmitoyltransferase IB)-protein and oral anticoagulation were independent factors for predicting reduced muscle endurance after adjusting for age (log10 GDF-15 [pg/mL] [B, -54.3 (95% CI, -106 to -2.00), P=0.043], log10 CPT1B per fold increase [B, 49.3 (95% CI, 1.90-96.77), P=0.042]; oral anticoagulation present [B, 44.8 (95% CI, 27.90-61.78), P<0.001]). Patients with HF with preserved ejection fraction have worse muscle function and predominant muscle atrophy compared with those with HF with reduced ejection fraction and HC. Inflammatory biomarkers, fatty acid oxidation, and oral anticoagulation were independent factors for predicting reduced muscle endurance.

Minimal Damage to the Supinator Muscle After the Double-Incision Technique for Distal Biceps Tendon Repair.

Background:The effect of the double-incision technique on the supinator muscle is unclear.Purpose:The aim of this study was to quantify fatty atrophy of the supinator muscle and map the area of muscle damage.Study Design:Case series; Level of evidence, 4.Methods:A total of 19 male patients (median age, 43 years) who underwent distal biceps tendon repair were included in the analysis. Patients with a minimum of 12 months of follow-up were included. The following variables were analyzed: range of motion; shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Summary Outcome Determination (SOD) score; and isokinetic peak force and endurance in supination. Quantitative analysis and mapping of fatty infiltration of the supinator muscle were based on the calculation of proton density fat fraction on magnetic resonance imaging scans of both elbows using the IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) sequence.Results:At an average follow-up of 24 months (range, 12-64 months), the median SOD score was 9.0 (95% CI, 7.8-9.4), and the mean QuickDASH score was 6.7 (95% CI, 0.0-14.1). A difference of 17% in peak torque was measured between repaired and nonrepaired elbows (repaired elbow: 9.7 N·m; nonrepaired elbow: 11.7 N·m; P = .11). Endurance was better in the repaired elbow than the nonrepaired elbow (8.4% vs 14.9% work fatigue, respectively; P = .02). The average fat fraction of the supinator muscle was 19% (95% CI, 16%-21%) in repaired elbows and 14% (95% CI, 13%-16%) in contralateral elbows (P = .04). The increase in fat fraction was located in a limited area between the radius and ulna at the level of the bicipital tuberosity.Conclusion:The assessment of the supinator muscle showed a limited increase in fat fraction between the radius and ulna at the level of the bicipital tuberosity. No significant effect on supination strength was highlighted.

Incidence of tensor fascia lata muscle atrophy after using the modified Watson-Jones anterolateral approach in total hip arthroplasty.

Post-operative tensor fascia lata (TFL) muscle atrophy due to superior gluteal nerve (SGN) injury during total hip arthroplasty (THA) can affect patients' post-operative hip function. This study aimed to determine the incidence of TFL muscle atrophy in THA performed via the modified Watson-Jones anterolateral approach and the risk factors for TFL atrophy. We reviewed pre- and post-operative magnetic resonance imaging (MRI) data of 164 patients who underwent cementless THA via the modified Watson-Jones approach at one institution. TFL atrophy was defined as worsening of ≥ 2 grades in the Goutallier classification or > 40% decrease in the cross-sectional area (CSA) of the TFL on post-operative MRI compared to that on preoperative MRI. Patients' backgrounds were compared between those with or without TFL atrophy to determine the risk factors of TFL atrophy. Fatty atrophy grade and CSA of the gluteus minimus and medius were also evaluated. Thirteen (8.0%) cases of TFL atrophy were detected. The mean body mass index (BMI) in the cases with TFL atrophy was significantly higher than in those without TFL atrophy (p = 0.012). The fatty atrophy grade was worse post-operatively than preoperatively; moreover, the CSA of the gluteus minimus decreased. We found a low incidence of TFL atrophy due to SGN injury after THA using the modified Watson-Jones approach. High BMI can be a risk factor for nerve injury. The gluteus minimus can be injured directly during surgery. We suggest that overexposure of the surgical site should be avoided, especially in patients with high BMI.

Proximal humeral fracture morphology in patients with advanced cuff tear arthropathy: an observational study in a surgically treated cohort.

In the presence of cuff tear arthropathy (CTA), joint kinematics is alternated and fracture configuration might be different. The purpose of this study was to identify fracture patterns in patients with advanced CTA to facilitate recognition and treatment. Radiographs and computed tomography scans of all patients undergoing surgical treatment for a proximal humeral fracture (PHF) in our institution during a 5-year period were retrospectively analyzed. Fracture pattern according to the AO-OTA and Resch classification and the presence of CTA were evaluated. Glenoid configuration according to Walch, fatty atrophy of the supraspinatus muscle and the centrum-collum-diaphyseal (CCD) angle were analyzed. A total of 574 out of 713 patients were included. Twenty-three patients (4%) with a mean age of 82 ± 8years showed advanced CTA with acetabularization of the acromion (≥ stage 3 according to Hamada/Fukuda). There were exclusively valgus fractures with a mean CCD angle of 158° ± 18°. Patients with CTA ≥ grade 3 had a nearly twofold greater risk (risk ratio: 1.8; confidence interval (CI): 95% 1.6-1.9; p < 0.0001) of sustaining a valgus fracture compared to patients without or with CTA < grade 3. The risk for a tuberosity fracture was nearly twofold greater in patients without or with mild CTA (risk ratio: 1.68; confidence interval (CI): 95% 1.17-2.40; p = 0.0046) compared to those with advanced CTA. In advanced CTA, a predominantly valgus fracture pattern can be observed. In addition, fractures of the greater tuberosity were significantly less frequent and were rarely displaced. Up to date, no classification system for PHF has been developed in the setting of CTA although it might indicate a different treatment, and therefore, recognition is crucial. However, when present, this changes the fracture pattern and ability to treat the fracture as the rotator cuff can no longer be utilized as a means of reducing the fragments.

The Anatomical Course of the Superior Gluteal Nerve With Regard to the Direct Anterior Approach for Primary and Revision Total Hip Arthroplasty

BackgroundDuring primary and revision total hip arthroplasty (THA) lesions of the superior gluteal nerve (SGN) can substantially compromise patient outcome. For the primary direct anterior approach (DAA) and its proximal approach extensions, especially the muscular branch entering the tensor fasciae latae (TFL) muscle is at risk. SGN lesions can result in fatty atrophy and functional loss of the TFL. Therefore, the course and branching pattern of the SGN were examined and related to the DAA and its proximal approach extension. The aim of the study is to describe safe and danger zones for the SGN with regard to the DAA and its proximal extensions. MethodsTwenty-five formalin-fixed cadavers with 48 hemipelves were dissected. The course, distribution, and branching pattern of the SGN and its muscular branch inserting into the TFL muscle were investigated with regard to the DAA with the help of anatomical landmarks like the greater trochanter and the iliac tubercle. ResultsIn 72.9% of the specimens the SGN passed the greater sciatic foramen superior to the piriformis muscle with one main trunk. The muscular branch of the SGN supplying the TFL divided from the main branch in 89.6% of the specimens at the level of the greater sciatic foramen. Before entering the TFL muscle the muscular branch showed a variable branching pattern in the interval between the gluteus medius and minimus. A danger zone for the SGN with regard to the DAA was found in the proximal fourth of the skin incision. ConclusionSpecial care in proximal instrument placement should be taken during the DAA. When extending the DAA proximally manipulations in the proximal, caudal surgical window should be performed with the utmost care.

How to Measure Glenoid Bone Stock and Version and Why It Is Important: A Practical Guide

Shoulder osteoarthritis (OA) is a common and debilitating condition and a source of high morbidity and medical expenditures across the world among individuals older than 60 years. Shoulder OA results in the gradual destruction of articular cartilage of the humeral head and glenoid component, causing inflammation, pain, and a restricted range of motion. Most patients are diagnosed with shoulder OA after experiencing shoulder pain and stiffness, and the diagnosis is often made after medical and physical histories are obtained and physical and imaging examinations are performed. Use of various surgical techniques such as total anatomic or reverse shoulder arthroplasty and hemiarthroplasty has increased in recent years, resulting in reduced morbidity and improved functional status of patients. However, the rate of surgical complications such as premature loosening of components is significant, reducing the effectiveness of such procedures. Data in the literature indicate that high-grade fatty infiltration of the rotator cuff muscle before surgery is associated with postoperative glenoid component loosening. High-grade rotator cuff fatty infiltration and atrophy have been found to be associated with more severe Walch classification-based glenoid morphology subtypes, increased joint line medialization, glenoid bone loss, and increased pathologic glenoid version. The authors describe how advanced imaging techniques are used for preoperative evaluation of the shoulder and discuss how to measure glenoid version and bone stock and classify glenoid morphology types on the basis of Walch classification, as these parameters are commonly used in surgical planning. Methods involving the use of Friedman and paleoglenoid lines for respective measurements are illustrated by using three-dimensional CT and MRI case examples. ©RSNA, 2020.

Outcomes Following Double-Row and Medial Double-Pulley Rotator Cuff Repair

Multiple arthroscopic double-row repair techniques have been developed to treat full-thickness rotator cuff tears. However, healing rates and functional outcomes vary among these repair methods. A suture tape and medial double-pulley (STDP) technique that incorporated 2-mm suture tape for a knotless double-row with a broad double-mattress suture medially was developed as an alternative method to other double-row repair techniques. This prospective study reviewed the functional outcomes and healing rates of full-thickness supraspinatus tendon tears repaired using an STDP technique. Of 33 consecutive patients who underwent arthroscopic rotator cuff repair with an STDP construct, 24 patients with a minimum of 1 year of follow-up were included in the study. Preoperative fatty atrophy was recorded. Ultrasound imaging was used to assess rotator cuff healing at a minimum of 6 months postoperatively. Range of motion and functional outcome scores were evaluated at final follow-up. Mean active forward elevation improved from 124° preoperatively to 160° postoperatively. Comparing preoperative and postoperative values, the American Shoulder and Elbow Surgeons score improved from 45.9 to 90.8, the Single Assessment Numeric Evaluation score improved from 34.6 to 87.1, and the visual analog scale score decreased from 5.3 to 1.3. Twenty-one of 24 patients (88%) were satisfied with their outcomes. Ultrasound evaluation demonstrated complete healing in 88% of the cohort. The STDP technique is a technically efficient method of obtaining medial fixation in a double-row repair and appears to demonstrate clinically acceptable results. Healing was observed in 88% of cases, and functional outcome showed a statistically significant improvement. [Orthopedics. 2021;44(1):e125-e130.].

MARS MRI assessment of fatty degeneration of the gluteal muscles in patients with THA: reliability and accuracy of commonly used classification systems.

Fatty degeneration of the gluteal muscles on metal artefact reduction sequence (MARS) MRI has been shown to correlate with poor functional outcomes, particularly in patients with total hip arthroplasty (THA). Standardized, reliable classification systems that permit assessment of fatty gluteal infiltration are needed for clinical decision making. This study aimed to compare the reproducibility and accuracy of commonly used MRI classification systems for fatty gluteal atrophy in THA patients. MARS magnetic resonance images of 82 patients with unilateral THA were analysed by three independent trained observers. The readers evaluated fatty degeneration of the gluteus minimus, gluteus medius, and gluteus maximus according to 3 widely used classification systems: Goutallier, Quartile, and Bal and Lowe. Interobserver and intraobserver repeatability were determined using the weighted Kappa test. Quantitative evaluation of the proportion of intramuscular fat based on MR signal intensities was obtained and represented the gold standard. Mean interobserver agreement for the Quartile classification system (0.93) was higher compared with Goutallier classification system (0.87) and the Bal and Lowe classification system (0.83; range 0.79-0.88; p = 0.04). Intraobserver repeatability was significantly higher for the Quartile classification system (weighted kappa 0.91, 0.89, 0.85) compared with the Bal and Lowe classification system (weighted kappa 0.83, 0.77, 0.75; p < 0.01) and Goutallier classification system (weighted kappa 0.83, 0.77, 0.75; p = 0.04). Agreement with the gold standard measurements was significantly higher in the Quartile classification system (0.88, 0.84, 0.81) compared with the Goutallier classification system (0.80, 0.77, 0.78; p = 0.02) and Bal and Lowe classification system (0.76, 0.74, 0.73; p < 0.01). This study directly compared three clinically used MRI classification systems for fatty gluteal muscle atrophy in THA patients. Our findings demonstrate that although all three classification systems demonstrate good reproducibility and accuracy, the Quartile classification system is superior to the others in terms of intraobserver reliability and accuracy to quantify fatty gluteal degeneration in THA patients.

An Update on Surgical Management of the Repairable Large-to-Massive Rotator Cuff Tear.

➢ Despite an evolving array of surgical options and technologies available to perform rotator cuff repair, as well as advances in postoperative rehabilitation strategies, reported failure rates remain high, with large-to-massive rotator cuff tears showing higher failure rates than small-to-medium-sized tears.➢ Preoperative magnetic resonance imaging is critical for judging the potential repairability of a large-to-massive rotator cuff tear based on imaging characteristics, including tear size and retraction, length and attenuation of the tendon stump, and fatty infiltration or atrophy in the rotator cuff muscle bellies. Advanced fatty infiltration and atrophy in the rotator cuff muscles have been found to be independent predictors of retear following repair of large-to-massive tears.➢ While there is some evidence that double-row rotator cuff repairs have lower failure rates for larger tears, a double-row repair may not always be possible in some chronic, retracted large-to-massive rotator cuff tears that cannot be completely mobilized and have tendon loss.➢ Strategies to augment rotator cuff repairs are based on the desire to improve the mechanical integrity and biologic healing environment of the repair, and they have shown promise in improving healing rates following repair of large-to-massive tears.➢ While most patients report pain relief and have increased patient-reported outcomes scores after surgery, studies have shown that patients with an intact repair have better functional scores, range of motion, and strength, and less fatty degeneration compared with patients with a failed repair.

Calf And Foot Injury- Crossfit

HISTORY: A 51-year-old female presented with three-year worsening left lower leg and foot pain. No injury at time of onset but was active with CrossFit five times weekly. Pain began on bottom of forefoot with radiation through the sole of foot to posterior calf and popliteal fossa. Pain described as 7-8/10 in intensity, constant, sharp/stabbing in nature, with burning sensation on the bottom of foot. Associated with weakness of the left ankle, foot drop requiring patient to wear an ankle-foot orthotic, swelling, and color changes with her foot turning blue/red intermittently. Pain was unrelieved with oral NSAIDS, steroids, and only temporary relief with topical anti-inflammatory gel, heat/ice, deep tissue massage, and dry-needling with physical therapy. PHYSICAL EXAMINATION: Examination revealed skin color changes with blue discoloration of left foot that was cool to touch. Tender to palpation maximally over left gastrocnemius muscle, Achilles tendon, sole and ball of foot; 0/5 strength with left ankle dorsiflexion/plantar flexion, ankle inversion/eversion or great toe extension. Sensation intact to light touch in L2-S2 dermatomes. Reflexes normal and symmetric bilaterally. DIFFERENTIAL DIAGNOSIS: 1.Peripheral nerve damage secondary to entrapment/compression 2.Vascular insufficiency 3.Complex regional pain syndrome TEST AND RESULTS: MRI without IV contrast of left tibia/fibula, foot, ankle: - Mild intramuscular edema within gastrocnemius and soleus, focal fatty atrophy adjacent to medial soleus muscle. Generalized subcutaneous edema throughout ankle. EMG: -No evidence of left lumbosacral radiculopathy, left lower limb mononeuropathy, or large fiber peripheral neuropathy US lower extremity Veins: - No DVT in left lower extremity Ankle brachial index: - Normal arterial Doppler study on the left leg during rest with normal PVR waveforms. NM bone scan: - No abnormal blood flow or blood pool uptake involving the left foot or ankle. Mild radiotracer uptake in left midfoot. FINAL/WORKING DIAGNOSIS: Complex regional pain syndrome TREATMENT/OUTCOMES: 1. Physical Therapy focused on strengthening exercises and desensitization techniques 2. Diclofenac topical gel applied up to four times daily 3. Gabapentin 600mg BID 4. Referral to Pain Medicine for lumbar sympathetic nerve block

Two different types of postoperative sagittal imbalance after long instrumented fusion to the sacrum for degenerative sagittal imbalance.

Few studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI). Eighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared. Forty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group. Optimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

Intervertebral disc herniation effects on multifidus muscle composition and resident stem cell populations.

AbsractBackgroundParaspinal muscles are crucial for vertebral stabilization and movement. These muscles are prone to develop fatty infiltration (FI), fibrosis, and atrophy in many spine conditions. Fibro‐adipogenic progenitors (FAPs), a resident muscle stem cell population, are the main contributors of muscle fibrosis and FI. FAPs are involved in a complex interplay with satellite cells (SCs), the primary myogenic progenitor cells within muscle. Little is known about the stem cell composition of the multifidus. The aim of this study is to examine FAPs and SCs in the multifidus in disc herniation patients. Multifidus muscle samples were collected from 10 patients undergoing decompressive spine surgery for lumbar disc herniation. Hamstring muscle was collected from four patients undergoing hamstring autograft ACL reconstruction as an appendicular control. Multifidus tissue was analyzed for FI and fibrosis using Oil‐Red‐O and Masson's trichrome staining. FAPs and SCs were visualized using immunostaining and quantified with fluorescence‐activated cell sorting (FACS) sorting. Gene expression of these cells from the multifidus were analyzed with reverse transcription‐polymerase chain reaction and compared to those from hamstring muscle. FI and fibrosis accounted for 14.2%± 7.4% and 14.8%±4.2% of multifidus muscle, respectively. The multifidus contained more FAPs (11.7%±1.9% vs 1.4%±0.2%; P<.001) and more SCs (3.4%±1.6% vs 0.08%±0.02%; P=.002) than the hamstring. FAPs had greater α Smooth Muscle Actin (αSMA) and adipogenic gene expression than FAPs from the hamstring. SCs from the multifidus displayed upregulated expression of stem, proliferation, and differentiation genes.ConclusionThe multifidus in patients with disc herniation contains large percentages of FAPs and SCs with different gene expression profiles compared to those in the hamstring. These results may help explain the tendency for the multifidus to atrophy and form FI and fibrosis as well as elucidate potential approaches for mitigating these degenerative changes by leveraging these muscle stem cell populations.

Imaging in dermatomyositis in adults and children.

Dermatomyositis is a rare autoimmune disorder in which an abnormal immune reaction against vascular endothelial antigens and endomysium leads to obstructive inflammatory changes of blood vessels within muscles, skin and other tissues. The disease is characterized by involvement of muscles, and less frequently of other systems, including the gastrointestinal tract, heart and lungs. Dermatomyositis may be diagnosed based on a detailed patient history, through clinical examination, detection of characteristic physical findings and certain specialized tests. Additional imaging studies may be performed to aid in the diagnosis. These include magnetic resonance imaging and ultrasound of the affected muscles. Magnetic resonance imaging is the modality of choice in the diagnostic work-up and monitoring of dermatomyositis affecting muscles, fasciae, and the subcutis. It may recognize acute inflammatory edematous changes in the affected muscles as well fatty replacement and atrophy. The role of ultrasound to diagnose and follow up muscle echogenicity, vascularity, elasticity and volume during treatment has increased over the last years in both adults and children. Ultrasound is used to discriminate between high and low disease activity, may show features of subclinical disease and may be used to confirm remission.