Magnetic resonance imaging-based diagnosis of aortitis preceding development of a thoracic aneurysm in a patient with giant cell arteritis: a case report

Background Inflammatory manifestation in the aortic arch can be a complication of giant cell arteritis (GCA), potentially requiring surgical therapy in the case of aneurysmatic dilatation. Case summary We report the case of a 73-year-old female patient with GCA in whom a typical appearance of arteritis was visualized on magnetic resonance imaging of the superficial temporal arteries. Additionally, ectasia (4.7 cm) of the ascending aorta with a mural rim of increased contrast media uptake was detected at the time of the initial diagnosis, which is an indicator of aortitis. While the diameter had only minimally increased in a computed tomography angiography (CTA) examination after 8 months, a subsequent CTA revealed an increased diameter of 5.8 cm and maximum at the level of the ascending aorta another 22 months later, indicating urgent surgery to replace the ascending aorta. Discussion Magnetic resonance imaging can detect silent, generalized manifestations of GCA such as severe aortitis, which may possibly lead to aneurysmatic dilatation, urging closer follow-up imaging. Detection of the ongoing process and subsequent follow-up imaging protects patients by avoiding rupture

Percutaneous aortic valve replacement: valvuloplasty studies in vitro

Objective: Valvuloplasty of the aortic valve is currently used in selected patients for severe calcified aortic valve disease, but clinical effectiveness is low and complication rate remains high. In this study, the total particle load after valvuloplasty and the embolization risk of calcific debris into the coronary arteries was analyzed in an in vitro model. Methods: Three highly calcified human aortic leaflets have been sutured into a porcine annulus (N=9). Both coronary arteries were separated and each was anastomized to a silicon line, which was drained off into a measuring beaker. Then valvuloplasty was performed (Thyshak II, 20mm, 1.5atm). After removal of the balloon, 100ml of sodium chloride solution irrigated the ascending aorta. After passing through the separated coronary arteries, the solution was filtered (filter size 0.45μm), dried, and the total amount of particles was analyzed microscopically. Results: Nine experiments were analyzed. After valvuloplasty, all hearts showed a median of 18 particles larger than 1mm in the coronary arteries (range 0-307). The amount of particles smaller than 1mm was 6574 (median, range 2207-14200). In five cases, coronary arteries were completely occluded by bulky particles. Conclusion: This study demonstrated a large amount of calcific particles after valvuloplasty with a consequently high risk for coronary embolic events in case of highly calcified aortic valves. In times of valvuloplasty rediscovering as part of transcatheter valve implantation, the risk of embolization should be taken into consideration and filtering techniques have to be develope

Lumbrical muscle tear: clinical presentation, imaging findings and outcome

The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I–III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries (p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy

Accelerating Recovery from Exercise-Induced Muscle Injuries in Triathletes: Considerations for Olympic Distance Races

The triathlon is one of the fastest developing sports in the world due to expanding participation and media attention. The fundamental change in Olympic triathlon races from a single to a multistart event is highly demanding in terms of recovery from and prevention of exercise-induced muscle injures. In elite and competitive sports, ultrastructural muscle injuries, including delayed onset muscle soreness (DOMS), are responsible for impaired muscle performance capacities. Prevention and treatment of these conditions have become key in regaining muscular performance levels and to guarantee performance and economy of motion in swimming, cycling and running. The aim of this review is to provide an overview of the current findings on the pathophysiology, as well as treatment and prevention of, these conditions in compliance with clinical implications for elite triathletes. In the context of DOMS, the majority of recovery interventions have focused on different protocols of compression, cold or heat therapy, active regeneration, nutritional interventions, or sleep. The authors agree that there is a compelling need for further studies, including high-quality randomized trials, to completely evaluate the effectiveness of existing therapeutic approaches, particularly in triathletes. The given recommendations must be updated and adjusted, as further evidence emerges

Evaluation of a Diagnostic-Therapeutic Algorithm for Finger Epiphyseal Growth Plate Stress Injuries in Adolescent Climbers

Background: Finger epiphyseal growth plate stress injuries are the most frequent sport-specific injuries in adolescent climbers. Definitive diagnostic and therapeutic guidelines are pending. Purpose: To evaluate a diagnostic-therapeutic algorithm for finger epiphyseal growth plate stress injuries in adolescent climbers. Study Design: Case series; Level of evidence, 4. Methods: On the basis of previous work on diagnostics and treatment of finger epiphyseal growth plate stress injuries (EGPIs) in adolescent climbers, we developed a new algorithm for management of these injuries, which was implemented into our clinical work. During a 4-year period, we performed a prospective multicentered analysis of our patients treated according to the algorithm. Climbing-specific background was evaluated (training years, climbing level, training methods, etc); injuries were analyzed (Salter-Harris classification and UIAA MedCom score [Union Internationale des Associations d’Alpinisme]); and treatments and outcomes were recorded: union, time to return to climbing, VAS (visual analog scale), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder, and Hand), and a climbing-specific outcome score. Results: Within the observation period, 27 patients with 37 independent EGPIs of the fingers were recorded (mean ± SD age, 14.7 ± 1.5 years; 19 male, 8 female; 66.7% competitive athletes). Regarding maturity at time of injury, the mean age at injury did not differ by sex. Average UIAA climbing level was 9.5 ± 0.8, with 6 ± 4.6 years of climbing or bouldering and 14 ± 9.1 hours of weekly climbing-specific training volume. Among the 37 injuries there were 7 epiphyseal strains, 2 Salter-Harris I fractures, and 28 Salter-Harris III fractures (UIAA 1, n = 7; UIAA 2, n = 30). Thirty-six injuries developed through repetitive stress, while 1 had an acute onset. Twenty-eight injuries were treated nonoperatively and 9 surgically. Osseous union was achieved in all cases, and there were no recurrences. The time between the start of treatment and the return to sport was 40.1 ± 65.2 days. The climbing-specific outcome score was excellent in 34 patients and good in 3. VAS decreased from 2.3 ± 0.6 to 0.1 ± 0.4 after treatment and QuickDASH from 48.1 ± 7.9 to 28.5 ± 3.3. Conclusion: The proposed management algorithm led to osseous union in all cases. Effective treatment of EGPIs of the fingers may include nonsurgical or surgical intervention, depending on the time course and severity of the injury. Further awareness of EGPI is important to help prevent these injuries in the future

Double-Level Torsional Osteotomy in Severe Torsional Malalignment: A Surgical Technique

Background: Torsional malalignment of the femur and/or tibia is associated with patellar maltracking, and torsional osteotomies have shown to improve clinical symptoms. In patients with severe torsional malalignment, a double-level torsional osteotomy may be necessary. Indications: Symptomatic torsional malalignment leading to patellofemoral maltracking associated with anterior knee pain and/or patellofemoral instability. Technique Description: A double-level torsional osteotomy correcting both increased internal femoral torsion and increased external tibial torsion, is described. Meticulous preoperative deformity analysis and planning of the osteotomy is mandatory. An arthroscopy of the knee is performed first to evaluate the patellofemoral joint and patellar tracking. Tibial torsional correction is performed by a lateral approach. A biplanar osteotomy is performed, and the amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis can be done via a bended 5-hole DC-Plate or an angle-stable plate. The femoral osteotomy is performed by a medial approach. A uniplanar osteotomy is performed perpendicular to the mechanical axis of the femur. The amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis is achieved by an angle-stable plate. Results: Double-level torsional osteotomy has been shown to be an effective treatment for patients with patellar dislocation or subluxation associated with severe torsional malalignment. In a series of 18 patients, double-level osteotomy led to improved patellofemoral stability, decreased pain, and increases subjective outcome scores. Discussion/Conclusion: In patients with patellofemoral problems caused by a combined increased tibial external torsion and increased femoral internal torsion, a double-level torsional osteotomy is able to correct torsional angles to normal. Available clinical data on this procedure are promising. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.This is a visual representation of the abstract

Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes

Background: There is limited insight into the mechanisms of knee injuries in rock climbing and bouldering in noncompetitive and competitive athletes. Purpose: To examine the traumatic mechanisms of injury, demographics, distribution, and severity of knee injuries in affected athletes. Study Design: Case series; Level of evidence, 4. Methods: During a 4-year period, we performed a retrospective multicenter analysis of acute knee injuries in competitive and noncompetitive climbing athletes. Traumatic mechanisms were inquired and severity levels, therapies, and outcomes recorded with visual analog scale, Tegner, Lysholm, and climbing-specific outcome scores. Results: Within the observation period, 71 patients (35% competitive athletes, 65% noncompetitive athletes) with 77 independent acute knee injuries were recorded. Four trauma mechanisms were identified: high step (20.8%), drop knee (16.9%), heel hook (40.3%), and (ground) fall (22.1%). The leading structural damage was a medial meniscal tear (28.6%), found significantly more often in the noncompetitive group. A specific climbing injury is iliotibial band strain during the heel hook position. Most injuries resulted from indoor bouldering (46.8%). Surgical procedures were predominantly necessary in noncompetitive climbers. One year after the injury, the Tegner score was 5.9 ± 0.8 (mean ± SD; range, 3-7); the Lysholm score was 97 ± 4.8 (range, 74-100); and the climbing-specific outcome score was 4.8 ± 0.6 (range, 2-5). Conclusion: Increased attention should be placed on the climber’s knee, especially given the worldwide rise of indoor bouldering. Sport-specific awareness and training programs for noncompetitive and competitive climbing athletes to reduce knee injuries should be developed, and sports medical supervision is mandatory

CSF Metabolic and Proteomic Profiles in Patients Prodromal for Psychosis

BACKGROUND: The initial prodromal state of psychosis (IPS) is defined as an early disease stage prior to the onset of overt psychosis characterized by sub-threshold or more unspecific psychiatric symptoms. Little is known regarding the biochemical changes during this period. METHODOLOGY/PRINCIPAL FINDINGS: We investigated the metabolic/proteomic profiles of cerebrospinal fluid (CSF) of first-onset drug naïve paranoid schizophrenia patients (n = 54) and individuals presenting with initial prodromal symptoms (n = 24), alongside healthy volunteers (n = 70) using proton nuclear magnetic resonance ((1)H-NMR) spectroscopy and surface enhanced laser desorption ionization (SELDI) mass spectrometry, respectively. Partial least square discriminant analysis (PLS-DA) showed that 36%/29% of IPS patients displayed proteomic/metabolic profiles characteristic of first-onset, drug naïve schizophrenia, i.e., changes in levels of glucose and lactate as well as changes in a VGF-derived peptide (VGF23-62) and transthyretin protein concentrations. However, only 29% (n = 7) of the investigated IPS patients (who to date have been followed up for up to three years) have so far received a diagnosis of schizophrenia. The presence of biochemical alterations in the IPS group did not correlate with the risk to develop schizophrenia. CONCLUSIONS/SIGNIFICANCE: Our results imply that schizophrenia-related biochemical disease processes can be traced in CSF of prodromal patients. However, the biochemical disturbances identified in IPS patients, at least when measured at a single time point, may not be sufficient to predict clinical outcome

MRI of Finger Pulleys at 7T—Direct Characterization of Pulley Ruptures in an Ex Vivo Model

The aim of this study was to evaluate 7 Tesla (7T) magnetic resonance imaging (MRI) for direct visualization and specific characterization of the finger flexor pulleys A2, A3, and A4 before and after ex vivo pulley rupture. Thirty fingers of human cadavers were examined before and after pulley disruption with a 26 min clinical 7T pulse sequence protocol. Images were assessed by two experienced radiologists for the presence of pulley rupture. Injury characterization included definition of rupture location, morphology, and complications. Image quality was evaluated according to a 4-point Likert-type scale from “not evaluable” to “excellent”. Macroscopic preparations were used as the reference standard. Direct characterization of intact A2, A3, and A4 pulleys and the corresponding pulley lesions was possible in all cases. The rupture location was distributed equally at the radial, ulnar, and central parts of the pulleys. A dislocation and intercalation of the pulley stump between the flexor tendon and finger phalanges was observed as a complication in 62.5% of cases. The average Likert score for direct visualization of pulleys was 2.67 before rupture and 2.79 after rupture creation, demonstrating adequate image quality for routine application. 7T MRI enables a direct characterization of A2, A3, and A4 pulleys before and after artificial disruption, including the definition of rupture morphology and location as well as the detection of rupture complications. This promises a precise presurgical evaluation of pulley injuries and complicated pulley stump dislocations

Dynamic study of the finger interphalangeal joint volar plate—motion analysis with magnetic resonance cinematography and histologic comparison

Objective We aimed to further improve knowledge about volar plate (VP) motion of the finger proximal interphalangeal joint (PIP), by analyzing the dynamic VP shape during a full range of finger flexion using magnetic resonance cinematography of the fingers (MRCF), and to compare the results with anatomical cross sections from cadaver specimens. Materials and methods The dynamic sagittal VP shape was visualized with MRCF in a total number of 23 healthy volunteers. The length, angle, and thickness as well as the contact length of the VP to the PIP joint base were measured. Statistical analysis included t -test or rank-sum testing. Anatomical cross sections with differing degrees of PIP joint flexion were obtained from 12 cadaver specimens (fingers) for comparison. Results Significant positive correlations between PIP joint flexion angle and VP area, length, depth and the VP contact length were found. This matched histologically to fiber rearrangements especially within the loose third VP layer. Conclusion Our study analyzed the full range of motion dynamic VP shape of the PIP joint using MRCF. This contributes to a more precise understanding of the complex interaction of the VP with the PIP joint and may facilitate evaluation of clinical cases such as VP avulsion or pulley rupture.Open Access funding enabled and organized by Projekt DEAL.Universitätsmedizin Rostock (8980