Inferior Limb Research Articles

Aristolochia pulvinata, a new species of Aristolochiaceae from Yunnan, Southwest China

Aristolochia pulvinata Yi-Fan Wang & Zhi-Jian Yin, a new species of Aristolochia subgenus Siphisia (Aristolochiaceae) from Yunnan Province, southwest China, is described and illustrated. Aristolochia pulvinata is distinguished by its unique characters: an elevated and thickened pulvinate structure in the inferior calyx limbs of its perianth. Morphologically, it resembles A. ovatifolia, A. melanocephala, A. utriformis, and A. luudamcui due to the similar thickening on the calyx limb region, but it differs in terms of degree, surface texture, color, and angle, as well as leaf morphology. This species, discovered and known only from one region, is assessed as Critically Endangered (CR) according to IUCN categories and criteria. This publication includes detailed morphological illustrations of A. pulvinata, with comparative photo plates and a table that highlights distinguishing features relative to similar species.

The ventricular septal defect in tetralogy of Fallot: A multi-centre morphological and statistical shape analysis study

Abstract Background Ventricular septal defects (VSDs) in Tetralogy of Fallot (TOF) are often thought to be ‘large and unrestricted’ but experience suggests they have a more heterogenous morphology. Understanding the morphological variations and dimensions is the first step in modifying surgical closure or optimising potential device design. Purpose The objective of this study was to perform a comprehensive multi-center morphological analysis of the characteristics of the VSD in TOF. Additionally, we sought to perform a preliminary 2D shape analysis and principal component analysis (PCA) on standardised photos of the VSDs. Through this multi-dimensional approach, we aim to elucidate the morphological variations and structural characteristics of the VSD in TOF as a basis for future 3D shape analysis. Methods Of 495 specimens analysed, 460 were included in the morphological analysis. Standardised protocol was applied to assess the characteristics of the VSD: basic measurements of the height, width, inferior limb, and length of the inferior fibrous rim (if perimembranous) were taken and indexed to ventricular length. The degree of aortic override and presence of aorto-mitral continuity were also documented with double outlet right ventricle (DORV) being defined as more than 50% of aorta supported by the right ventricle. Statistical analysis was performed to assess variations in TOF morphology across different age groups and disease phenotypes. Standardised photographs of 130 VSDs were taken from the right ventricle and traced for PCA, in order to assess shape variations among the VSDs. Results Both the length of the inferior limb of the PM VSD and the length of the fibrous rim increased with ventricular length but the rate of change was lower for the fibrous rim. A chi-square analysis comparing the presence of double outlet right ventricle and the presence of a fibrous continuity between the aortic and mitral valves showed no association between these features (p = 0.89). The results of PCA in the indexed datasets showed that the largest variation was in the size of the VSD and then from the shape of the VSD where two distinct morphologies emerged: a classic V-shaped VSD and wide but shallow variant. Discussion Our study challenges conventional definitions and assumptions regarding the morphological characteristics of the VSD in TOF and suggests that components may change size at differing rates. Our study conclusively shows that DORV and TOF can co-exist and the definition of DORV should be made independently of the presence of aorto-mitral continuity. Contrary to the traditional view of TOF featuring large unrestricted VSDs, our findings suggest wide shallow VSDs are common. These findings challenge paradigms and underscore a necessity for the continuing morphological re-evaluation of TOF utilising large datasets with a diverse phenotypic spread.

MiRNA in the Diagnosis and Treatment of Critical Limb Ischemia.

Chronic threatening limb ischemia of the inferior limbs (CLTI) is the final stage of peripheral arterial disease (PAD) and is one of the most feared atherosclerotic manifestations because if left untreated, in time, it can lead to amputation. Although there are currently numerous treatment techniques, both open and endovascular, it is a pathology that has no underlying treatment. Therefore, current studies are very much focused on new therapeutic possibilities that can be applied in the early stages of the atherosclerotic process. In numerous studies in the literature, miRNAs have been identified as important markers of atherosclerosis. The present study aims to identify the expression of three miRNAs-miR-199a, miR-20a, and miR-30c-in patients with chronic limb-threatening ischemia in the pre- and post-revascularization periods. The aim of the study is to identify whether these three markers play a role in critical ischemia and whether they have the potential for future use in new treatments of this pathology.

Life expectancy in cancer patients with pulmonary thromboembolism: From clinical prognostic biomarkers and paraclinical investigations to therapeutic approaches (Review).

Pulmonary embolisms (PEs) are obstructions of the pulmonary arteries by thrombi, which are emboli and they most frequently originate from the deep venous system of the inferior limbs. Emboli can also come from the inferior vena cava, abdominal and pelvic veins, or the upper body venous system from the right atrium or ventricle of the heart. Thrombi can form in situ inside pulmonary arteries as well. A cancer patient is at a higher risk for thromboembolic phenomena given both the oncological pathological context and also due to the associated medical or surgical treatment they receive. PE is a high-risk medical emergency that is associated with an increased risk of early mortality, with sudden death occurring in 25% of patients. The long-term presence of this condition can result in thromboembolic pulmonary hypertension. The risk of mortality, both in the acute and long-term, is dependent on the severity of the acute form, the recurrence of the embolism and the associated conditions. The majority of deaths associated with PE can be prevented by early diagnosis. The aim of the present review was to describe the various biological and cellular parameters, together with known paraclinical investigations, to assist in the rapid diagnosis of PE. Mortality in patients with PE and neoplastic conditions may be reduced by initiating anticoagulant treatment as soon as possible. PE may be the first manifestation of an underlying silent malignancy or may represent a complication of an already diagnosed malignancy. Exclusion or confirmation of the diagnosis is of utmost importance to avoid unnecessary anticoagulant treatment associated with a high risk of bleeding or to start immediate anticoagulant treatment if required.

The ultrasonographic diagnosis of lymph node varicose veins in the groin - an overlooked missing link in chronic venous disease?

Chronic venous disease is a common pathology characterized by valvular incompetence and venous hypertension. The venous network of the lymph nodes at the Scarpa triangle connects the superficial and the deep venous systems. This study aimed to describe infrainguinal intranodal venous dilatations and to evaluate the connection with peripheral venous disease. The study included 183 subjects (116 women, 67 men) who underwent Doppler ultrasound examinations of the venous system of the inferior limb in the context of chronic venous disease. The diagnosis of lymph node varices was based on well-defined criteria and the severity of the lymph node varices was established using an original classification. There was a statistically significant, moderately strong association, between the presence of intranodal varices and the great saphenous vein reflux (φ=0.341, p=0.000). There was a moderate-to-high positive correlation between intranodal varices and the chronic venous disease stage (rrb=0.457, p=0.000). Patients with more advanced stages of chronic venous insufficiency have a higher probability of presenting intranodal varices. Lymph node venous network identification could considerably impact clinical decision-making and treatment choices.

HALF DOSE THROMBOLYSIS IN INTERMEDIATE – HIGH RISK PULMONARY EMBOLISM WITH TRICUSPID VALVE MOBILE MASS: A BAIL OUT STRATEGY

Abstract A 82–year–old previously healthy male was referred to the emergency department complaining sudden onset dyspnea and witnessed syncope complicated by head trauma. Recurrent dizziness occurred previously. No history or drug consumption noted. On admission: heart rate 90 beats/min, blood pressure 110/60 mmHg, respiratory rate 25 breaths/min, oxygen saturation 87% in room air, normal body temperature. No lower extremities tenderness or swelling reported. Consistent with peripheral blood oxygen saturation levels, arterial blood gas analysis showed hypoxemia and respiratory alkalosis. Laboratory exams were significant for thrombocytopenia (89.000 cells/L), elevated cardiac troponin T levels (222 ng/L) and natriuretic peptide (NT pro–BNP 3944 pg/mL). Head CT excluded acute cerebral hemorrhage. At the electrocardiogram, signs of RV strain were present (biphasic T–waves in V1–V3 leads, S1–Q3–T3). Transthoracic echocardiography (TTE) showed dilated RV with hypokinetic free wall, “D–shaped” LV, “60/60” sign and a mobile filiform mass crossing the tricuspid valve plan in the right atrium (fig. 1). The patient did not present structural valvular abnormalities or endocarditis–related risk factors. CT pulmonary angiography detected a “saddle” PE and extensive thrombosis in inferior vena cava. After unfractioned heparin (UFH) bolus, the patient was transferred to our intensive care unit and balancing risks and benefits the chosen treatment option consisted in half dose systemic thrombolysis (50 mg rtPA in 60’’; 10 mg as loading dose in 2’). Because of potential harmful effects in thrombocytopenia and recent head trauma, UFH was temporarily withheld and started again after 1 hour. The day after, a beside TTE showed complete tricuspid thrombus resolution, a significant decrease in RV/LV ratio and systolic pulmonary artery pressure (fig. 2). Apart from small hematomas, no bleedings were reported. The patient was shifted to the ward on the next day and following course was uneventful. On day 4 a direct oral anticoagulant (Dabigatran 110 mg) was started. Abdominal and inferior limb–deep–venous ultrasound were both negative for pathological reports. A total body CT was scheduled to exclude silent malignancies at discharge. Take home message: in intermediate–high risk PE, half dose systemic fibrinolysis strategy is controversial since its potential benefit is counterbalanced by concerns about major bleedings, but increasing data suggest its efficacy with low risk profile.

Sudden Loss of Motor Evoked Response Followed by Clinical Recovery After Resection of an Intradural Dorsal Meningioma: A Unique Case of a ClinicalNeurophysiological Dissociation

In the neuromonitoring era, resection surgery of spinal intradural lesions is guided by Intraoperative Neurophysiological Monitoring (IONM) of Motor Evoked Potentials (MEP). We describe a single case of a 70s-year-old patient who underwent surgery as a treatment for a voluminous dorsal intradural juxtamedullary meningioma: during surgery, we observed a sudden loss of bilateral lower limbs muscle MEPs, followed by a rapid recurrence of normal responses exclusively in the right side, but not in the left one. After awakening, the patient presented a transitory complete monoplegia of the left inferior limb for 30 minutes, and then it was resolved with rapid restoration of the neurological status.

Diplopia as the presenting symptom of a post‐transplant lymphoproliferative disorder in a bilateral inferior lim transplanted young adult

Aims/Purpose: To present a unique case of post‐transplant lymphoproliferative disorder (PTLD) after bilateral inferior limb transplantation, which is still controversial due to the absence of precedents in the literature and the unclear risk–benefit ratio.Methods: Case report.Results: A 22‐year‐old male presented to the emergency room complaining of double vision. He had a history of bilateral inferior limb amputation 8 years ago and received a bilateral lower limb transplantation 2 years later. He had normal graft function and was receiving cytomegalovirus prophylaxis. During neurological examinations left abducens nerve (CN VI) palsy was noted. Other cranial nerves affected produced facial hypoesthesia (CN V) and mild paresis (CN VII), hearing loss and tinnitus in left side (CN VIII) and soft palate asymmetry (CN X). He was otherwise neurologically intact, alert and orientated. MRI revealed a lesion located at the facial colliculus at the floor of 4th ventricle. In the context of immunosuppression, the differential diagnosis included abscess versus PTLD. Biopsy of the lesion was performed. Morphologically atypical lymphocytic cells suggestive of B lymphoma were identified. Monoclonal rearrangement for heavy chain Igen and immunoglobulins were identified with molecular biology techniques. The histology features were consistent with a diagnosis of CNS B lineage primary lymphoma. Two days later, bilateral supracondylar amputation was performed. Following the explant, immunosuppression was withdrawn. His underlying condition was finally diagnosed as PTLD, for which he started a chemotherapeutic regimen with radical intention (methotrexate and cytosine arabinoside). The patient recovered fully and up to date, 10 years later, is doing well.Conclusions: Due to its diverse aetiologias, a proper workup must be done of the patients presenting with diplopia to the emergency room. PLTD must be a condition to always be considered in patients with history of solid organ transplant; since the early diagnosis is crucial for a successful management of this often‐fatal condition.

A novel case of yamaguchi syndrome in the Saudi population

Background: Apical hypertrophic cardiomyopathy (ApHCM) known as Yamaguchi syndrome, is an uncommon variant of hypertrophic cardiomyopathy, with higher incidence reported in the Asian populations. The clinical presentation of ApHCM is vague thus can mimic other conditions, which can lead to a delayed or a missed diagnosis. Only a few reports have described the incidence of Yamaguchi syndrome in other populations other than Asians. Case Presentation: A 46-year-old male, heavy smoker, with unremarkable past medical history was presented to the emergency department with severe central chest pain that radiates to the left side, exacerbated by excretion, and relived by rest not associated with shortness of breath or palpitation. Additionally, the patient reported two similar episodes that occurred the past 4 days. However, physical examination was unremarkable. Initially the patient was labeled as high-risk acute coronary syndrome (unstable angina vs non-ST segment myocardial infarction). Cardiac markers including troponin I and Creatine kinase-MB were within normal range. ECG revealed deep T wave inversion in the inferior limb leads and pericardial leads suggestive of right coronary and left anterior descending artery or left main coronary lesion. The patient underwent for urgent cardiac catheterization which revealed normal coronary arteries. Transthoracic echocardiograph (TTE) showed isolated apical hypertrophy with preserved LV function, suggestive of ApHCM. The patient was advised on smoking cessation and discharged on beta blocker. Conclusion: There is an imminent need to establish further research investigating the prevalence of Yamaguchi syndrome among the Saudi population.

Neuromuscular imaging in clinical practice: an ESNR survey of 30 centers.

We assessed the current clinical imaging practice in the primary evaluation of neuromuscular disorders (NMD), with respect to standardized imaging, evaluation and reporting through a European and extra-European-wide survey. An online questionnaire was emailed to all European Society of Neuroradiology (ESNR) members (n = 1662) who had expressed their interest in NMD. The questionnaire featured 40 individual items. Information was gathered on the context of the practices, available and preferred imaging modalities, applied imaging protocols and standards for interpretation, reporting and communication. A total of 30 unique entries from European and extra-European academic and non-academic institutions were received. Of these, 70% were neuroradiologists, 23% general radiologists and 7% musculoskeletal radiologists. Of the 30 responding institutes, 40% performed from 20 to 50 neuromuscular scans per year for suspected NMD. The principal modality used for a suspected myopathy was magnetic resonance imaging (MRI) (50%) or "mainly MRI" (47%). The primary imaging modality used for the evaluation of patients suspected of a neuropathy was MRI in 63% of all institutions and "mainly MRI" in 37%. For both muscle and nerve pathology, pelvic girdle and inferior limbs are the most scanned parts of the body (28%), followed by the thigh and leg (24%), whole body MR (24%), scapular girdle (16%), and the thigh in just 8% of institutions. Multiplanar acquisitions were performed in 50% of institutions. Convectional sequences used for muscle MRI included T2-STIR (88%), 2D T1weighted (w) (68%), T1 Dixon or equivalent (52%), T2 Dixon (40%), DWI (36%), 2D T2w (28%), T1 3D and T2 3D (20% respectively). For nerve MRI conventional sequences included T2-STIR (80%), DWI (56%), T2 3D (48%), 2D T2w (48%), T1 3D (44%), T1 Dixon or equivalent (44%), 2D T1 (36%), T2 Dixon (28%). Quantitative sequences were used regularly by 40% respondents. While only 28% of institutions utilized structured reports, a notable 88% of respondents expressed a desire for a standardized consensus structured report. Most of the respondents (93%) would be interested in a common MRI neuromuscular protocol and would like to be trained (87%) by the ESNR society with specific neuromuscular sessions in European annual meetings. Based on the survey findings, we can conclude that the current approach to neuromuscular imaging varies considerably among European and extra-European countries, both in terms of image acquisition and post-processing. Some of the challenges identified include the translation of research achievements (related to advanced imaging) into practical applications in a clinical setting, implementation of quantitative imaging post-processing techniques, adoption of structured reporting methods, and communication with referring physicians.

Syndesmosis Evaluation Under WBCT: 3rd Base to Get a Cut-Off Point to Diagnosis

Category: Sports; Arthroscopy Introduction/Purpose: Evaluation of syndesmal injury remains challenging for Foot & Ankle Surgeons. As objective data to provide an accurate preoperative diagnosis of syndesmal instability is lacking, arthroscopy has remained the Gold Standard. However, the costs and risks associated with surgery make arthroscopy challenging to indicate in all cases. Therefore, significant interest exists in determining objective criteria to safely indicate surgery. Comparative WBCT is a valuable tool, allowing a precise evaluation of the healthy and injured joints. Specifically, the difference in the syndesmal area correlates with diastasis at the inferior tibiofibular joint, while the cut value for diagnostic instability remains undetermined. Objective: To compare the difference in syndesmal area between healthy patients and patients with syndesmal sprains under WBCT. Methods: IRB approval was obtained for a retrospective case-control study. Patients with suspected syndesmal injuries from April 2019 to August 2022 were included in the case group. Patients with chronic ankle instability, age over 55 years, or surgery of the inferior limb were excluded. The control group was obtained from a previous study of comparative WBCT of the ankle joint, obtained for reasons different than trauma or instability. All patients were evaluated under WBCT by a fellowship-trained MSK radiologist. After evaluating the syndesmal area at 1 cm from the ankle joint line in an axial WBCT slice, the percentage difference from the injured to the healthy side was recorded. Demographic data were obtained from the patient chart. For those patients undergoing surgical stabilization, the operative note was examined. Statistical evaluation was performed by an independent statistician using SPSSv27 using the ANOVA test. Results: Thirty-nine patients were recruited for the study group, and a control group of 25 patients with healthy ankles was obtained. Demographics data for both groups were comparable Arthroscopy was indicated in 7/39 patients (17,9%), which confirmed diagnosis and warranted stabilization of the joint. The mean percentage area difference of the confirmed injured syndesmosis was 15,14% (IC 4,89-25,39), suspected injured syndesmosis was 9,25% (IC 3,11-15,39), and the healthy syndesmosis was 1,54 (IC 1,08-2,01). Statistically significant differences were obtained for healthy, operated, and non-operated patients with a p=0,021. Conclusion: A comparative WBCT scan and the percentage difference in the syndesmal area between the healthy, confirmed, and suspected syndesmal injury demonstrated a handy diagnostic tool. Although the limitations of this study, our results suggest that a 15% difference in the syndesmal area between healthy and injured sides might be used as the cut-off point to indicate diagnostic arthroscopy.

Gaucher disease type 3 presenting with deformation of inferior limbs and bone infarction: A case report

Introduction: Gaucher disease (GD) is a lysosomal storage disorder characterized by the accumulation of glucocerebroside in various cells throughout the body. Bone infarction is a common and fearsome complication. Case Report: We present the case of a 5-year-old child diagnosed with Gaucher disease type 3, who exhibited deformation of the inferior limbs and bone pain. Upon evaluation, radiographic examination of the limbs revealed a characteristic triangular appearance of the metaphysis and a serpiginous sclerotic area. A magnetic resonance imaging was performed to confirm the diagnosis of bone infarction. Conclusion: Gaucher disease is a complex genetic disorder. Bone involvement is a significant manifestation causing pain, bone crises, deformities. Various imaging techniques can help for an accurate diagnosis and for a timely intervention and prevention of the disease progression.

Electromyographic signals analysis to assess the response of a proprioceptive neuromuscular facilitation pattern execution.

Proprioceptive Neuromuscular Facilitation is a rehabilitation technique that consists of the stimulation of a healthy muscle in one extremity of the body to produce an activation effect of a damaged muscle in another extremity, laterally or contralaterally. The use of the analysis of the electromyographic response during the process allows us to describe and evaluate if the damaged muscle produces an activation. This paper presents the progress of the results of a clinical protocol where PNF is explored in healthy subjects, manipulating the upper limb, and recording the electromyographic response of the lower limbs in three different muscles in both inferior limbs. Four activation patterns (movement sequence) with three different stages with different intensities of resistance are considered. Lateral plane video recording analysis is performed to extract the trajectory of the manipulated limb and correlate this information with electromyography signals. The electromyography signals are analyzed in their temporal response by integrating the rectified and smoothed signal according to the beginning and end of the trajectory of the manipulated superior limb. Additionally, the spectrogram analysis of the signals is performed. The partial results of the protocol allow us to establish that the response in the most distal muscles to the manipulated upper limb has been non-significant for the subjects, compared to the response of the proximal muscles, where a relationship with activation and trajectory of the arm is observed. particularly in the process with greater resistance. The observed changes in signal frequency across the spectrogram correspond to low-frequency changes in the 15 to 20Hz band.Clinical Relevance- This work presents a strategy to assess the rehabilitation process based on proprioceptive neuromuscular facilitation by analyzing the time and time-frequency response of the electromyographic signal.

Buerger's Disease - A Clinical Case.

Buerger's disease is a distal segmental nonatherosclerotic vasculopathy that involves the inferior and superior limbs of smoker males younger than 45 years old. This article aims to describe a clinical case and revise the literature about Buerger's disease. A 45-year-old smoker male repeatedly visited the emergency department for refractory pain and inflammatory signs in the right hallux. After developing ulcers in the right foot, Doppler ultrasonography revealed segmental occlusion of distal arteries of that limb. It was also observed in arteriography "corkscrew" collaterals. Autoimmune, thrombophilic and cardiovascular diseases were excluded. Analgesia, antibiotics and alprostadil were implemented. As a result, the patient stopped smoking and was submitted to minor amputation with complete healing, after which he remained asymptomatic. Buerger's disease is a diagnosis of exclusion. Therefore, smoking cessation is the most effective treatment and is crucial to prevent disease progression.

Cardiovascular magnetic resonance in neuromuscular disorders: looking ahead

Abstract Funding Acknowledgements Type of funding sources: None. Background Neuromuscular disorders (NMD) have a wide range of different cardiac presentations. Cardiac magnetic resonance (CMR) has an established role in diagnosis and risk stratification. We sought to access how CMR performs in predicting events in a real cohort of NMD patients (pts). Methods We included consecutive pts followed in a tertiary clinical center with NMD from January 2012 to December 2018. Clinical and CMR data were collected. During follow-up (FUP), we considered major adverse cardiovascular events (MACE) as a composite of device implantation, ventricular tachycardia/appropriate shock therapy and death. Results A total of 65 patients (pts) were included, 33 (51%) women, with mean age of 32 ± 16 years. Most patients had myotonic dystrophy (34, 52%), followed by limb–girdle muscular dystrophy (22; 34%); the remained 9 (13%) had other NMD. About half had inferior limbs predominantly affected and 74% had none, mild or moderate functional impairment. Regarding cardiac manifestations, 18% had cardiac symptoms, 97% were in sinus rhythm, median PR and QRS duration were 169 (IQR 47) ms and 101 (IQR 11) ms, respectively; median BNP was 26 (IQR 25) mg/dl. Regarding CMR, 43,3% of pts had ≥ one abnormality. Six pts had left ventricle dilation and 7 had left ventricle ejection fraction (LVEF) 55%. Three pts had significant hypertrophy (>12 mm) and there were isolated cases of hypertrabeculation, segmental alterations or right ventricle dilation. Regarding tissue characterization, 2 pts had T2 hyperintensity, 8 had early gadolinium enhancement (EGE) and 22 had late gadolinium enhancement (LGE). LGE was located mainly intramyocardium (45%) or subepicardial (36%) and the most affected segments were basal and medium inferolateral (40%). During a median FUP of 77 (IQR 33) months there were 7 deaths, 8 implanted devices (4 pacemakers and 4 CRT-D, 3 in primary prevention) and one sustained ventricular tachycardia in holter; there were no shock therapies. Table 1 describes some CMR parameters according to the occurrence of events. Using Kaplan Meier curves, there were associations between LVEF<55% and presence of LGE with occurrence of allevents (log rank test, p = 0,002 and p = 0,045, respectively), but no association were found with age, LGE pattern nor number/distribution of affected segments. Using Cox Regression, we found that the LVEF<55% was associated with 6 fold higher risk of events (HR crude 6,15; 95% CI 1,65–22,93), that remained significant after adjusting for LGE (HR adjusted 4,81, 95% CI 1,07–15,9). Conclusion In our cohort, CMR LVEF<55% and the presence of LGE were significantly associated with events during FUP, reinforcing the role of this technique on risk stratification of NMD populations

Comparison of Patient-Reported Outcomes, Strength, and Functional Performance in Primary Versus Revision Anterior Cruciate Ligament Reconstruction

Background: Clinical outcomes after revision anterior cruciate ligament reconstruction (ACLR) are not well understood. Hypothesis: Patients undergoing revision ACLR would demonstrate worse patient-reported outcomes and worse limb symmetry compared with a cohort undergoing primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: 672 participants (373 with primary ACLR, 111 with revision ACLR, and 188 uninjured) completed functional testing at a single academic medical center. Descriptive information, operative variables, and patient-reported outcomes (International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Tegner Activity Scale score) were assessed for each patient. Quadriceps and hamstring strength tests were conducted using a Biodex System 3 Dynamometer. Single-leg hop for distance, triple hop test, and the 6-m timed hop test were also assessed. Limb symmetry index (LSI) between the ACLR limb and contralateral limb was calculated for strength and hop testing. Normalized peak torque (N·m/kg) was calculated for strength testing. Results: No differences were found in group characteristics, excluding body mass (P < .001), or in patient-reported outcomes. There were no interactions between revision status, graft type, and sex. Knee extension LSI was inferior (P < .001) in participants who had undergone primary (73.0% ± 15.0%) and revision (77.2% ± 19.1%) ACLR compared with healthy, uninjured participants (98.8% ± 10.4%). Knee flexion LSI was inferior (P = .04) in the primary group (97.4% ± 18.4%) compared with the revision group (101.9% ± 18.5%). Difference in knee flexion LSI between the uninjured and primary groups, as well as between the uninjured and revision groups, did not reach statistical significance. Hop LSI outcomes were significantly different across all groups (P < .001). Between-group differences in extension in the involved limb (P < .001) were noted, as the uninjured group exhibited stronger knee extension (2.16 ± 0.46 N·m/kg) than the primary group (1.67 ± 0.47 N·m/kg) and the revision group (1.78 ± 0.48 N·m/kg). As well, differences in flexion in the involved limb (P = .01) were found, as the revision group exhibited stronger knee flexion (1.06 ± 0.25 N·m/kg) than the primary group (0.97 ± 0.29 N·m/kg) and the uninjured group (0.98 ± 0.24 N·m/kg). Conclusion: At 7 months postoperatively, patients who had undergone revision ACLR did not demonstrate inferior patient-reported outcomes, limb symmetry, strength, or functional performance compared with patients who had undergone primary ACLR. Patients who had undergone revision ACLR exhibited greater strength and LSI than their counterparts with primary ACLR, but these parameters were still inferior to those of uninjured controls.

Stenting performs better than drug-coated balloon angioplasty in popliteal lesions

BackgroundPeripheral arterial disease (PAD) is a common and highly morbid disease. Although there have been recent advancements in the endovascular modalities to treat PAD, comparisons of these strategies, especially in the popliteal region, remain underinvestigated. The objective of this study was to compare midterm outcomes in patients with PAD undergoing treatment with both novel and SS compared with drug-coated balloon (DCB) angioplasty. MethodsAll patients at a multi-institution health system treated for PAD in the popliteal region from 2011 to 2019 were identified. Presenting features, operative details, and outcomes were included in the analysis. Patients who underwent popliteal revascularization with stents were compared with DCB. SS were compared separately with novel dedicated stents. Two-year primary patency was the primary outcome. ResultsWe included 408 patients (72.7 ± 11.8 years old; 57.1% men) in the analysis. There were 221 (54.7%) patients who underwent popliteal stenting and 187 (45.3%) who underwent popliteal DCB. There were high rates of tissue loss in both groups (57.9% vs 50.8%; P = .14). Stented patients had longer lesions (112.4 ± 3.2 vs 100.2 ± 5.8 mm; P = .03) and higher rates of concomitant superficial femoral artery treatment (88.2% vs 39.6%; P < .01). Chronic total occlusions accounted for the majority of lesions treated (stent 62.4%, DCB 64.2%). Perioperative complications were similar between groups. Primary patency for the stented group was higher at two years than the DCB group (61.0% vs 46.1%; P = .03). When evaluating stented patients only, SS had higher 2-year patency than novel stents in the popliteal segment (69.6% vs 51.4%; P = .04). On multivariable analysis, stenosis, as opposed to chronic total occlusion, was associated with improved patency (hazard ratio, 0.49; 95% confidence interval, 0.25-0.96; P = .04), whereas novel stents were associated with worse primary patency (hazard ratio, 2.01; 95% confidence interval, 1.09-3.73; P = .03). ConclusionsIn a population of patients with severe vascular disease, stents do not have inferior patency and limb salvage rates compared with DCB angioplasty when treating the popliteal region. For patients with advanced vascular disease, and especially tissue loss, stents and DCB are both beneficial when treating popliteal lesions.

Rotator cuff muscle degeneration in a mouse model of glenohumeral osteoarthritis induced by monoiodoacetic acid.

Osteoarthritis (OA) is a disease of joint degeneration and impaired function. Muscle atrophy, fatty infiltration (FI), and fibrosis are degenerative features of muscle injury and predict poor outcomes in some degenerative and exercise-related injuries. Patients with glenohumeral joint OA are usually accompanied by rotator cuff muscle degeneration, even though the rotator cuff is intact. However, the mechanism and correlation between OA and degeneration of muscles around joints are still unknown. Forty-five 12-month-old C57BL/6J mice received a single injection of monoiodoacetic acid(MIA)into the right glenohumeral joint. The sham group was injected with saline on the same day in the right glenohumeral joint. 3 and 6 weeks after the operation, gait analysis was conducted to evaluate the function of the forelimb. Then, the shoulder joint and supraspinatus muscle (SS) were collected for histological staining, RT-qPCR, and biomechanics test. Correlations between fat area fraction in muscle, percentage wet muscle weight change or OARSI score and gait analysis,/muscle mechanics tests were assessed using Pearson's correlation coefficient or Spearman's correlation coefficient. Compared with the sham group, the MIA group developed significant glenohumeral joint OA, and the SS developed significant FI and muscle atrophy. Shoulder function correlated with glenohumeral joint OA/rotator cuff muscle severity, weight loss, and FI. In mice, glenohumeral joint OA can lead to rotator cuff degeneration and inferior limb function. The small animal model could be a powerful tool to further study the potential mechanisms between glenohumeral OA and rotator cuff muscle degeneration. Basic Science Study; In-Vivo Animal Model.

Angiotensin II type 1a receptor deficiency alleviates muscle atrophy after denervation

The study aim was to determine if suppressed activation of angiotensin II type 1 receptor (AT1) prevents severe muscle atrophy after denervation. The sciatic nerves in right and left inferior limbs were cut in AT1a knockout homo (AT1a−/−) male mice and wild-type (AT1a+/+) male mice. Muscle weight and cross-sectional areas of type IIb muscle fibers in gastrocnemius muscle decreased at 7 and 21 days postdenervation in both AT1a−/− mice and AT1a+/+ mice, and the reduction was significantly attenuated in the denervated muscles of AT1a−/− mice compared to the AT1a+/+ mice. Gene expressions in the protein degradation system [two E3 ubiquitin ligases (muscle RING-finger protein-1 and Atrogin-1)] upregulated at 7 days postdenervation in all denervated mice were significantly lower in AT1a−/− mice than in AT1a+/+ mice. Activations of nuclear factor κB and Forkhead box subgroup O1, and protein expression of monocyte chemoattractant protein-1 were significantly suppressed in the AT1a−/− mice compared with those in the AT1a+/+ mice. In addition, suppressed apoptosis, lower infiltration of M1 macrophages, and higher infiltration of M2 macrophages were significantly observed at 21 days postdenervation in the AT1a−/− mice compared with those in the AT1a+/+ mice. In conclusion, the AT1 receptor deficiency retarded muscle atrophy after denervation.

Elsberg Syndrome Secondary to Cytomegalovirus Infection in an Immunocompetent Patient: A Case Report.

Infectious lumbosacral radiculitis and myelitis, a clinical entity called Elsberg syndrome, is classically linked to HSV-2 and VZV. Here, we report a case of an Elsberg syndrome caused by primary cytomegalovirus (CMV) infection in an immunocompetent patient. Here is a case report at an academic medical center. Cerebral and spinal cord MRI, electroneuromyography, and serum and CSF analysis were performed. We investigated a 31-year-old healthy woman presenting with acute paresthesia of both feet ascending to the pelvic region, urinary retention, and constipation. Neurologic examination revealed symmetrical hyperesthesia of both inferior limbs up to the pelvic region, with patellar and Achilles hyporeflexia. Although MRI was normal, a dysfunction of the S1 left nerve root was observed on electroneurography. CSF analysis was inflammatory. Blood CMV PCR was positive, and anti-CMV IgG/IgM values indicated seroconversion. Taken together, these results strongly suggested an Elsberg syndrome caused by CMV primary infection. After a course of ganciclovir, a marked improvement of the symptoms was observed. This case highlights that CMV primary infection can be a cause of Elsberg syndrome in immunocompetent patients. CMV testing should be discussed in these patients to initiate adequate antiviral therapy.