The Effect of Intra-articular Injection of Hyaluronic Acid in Frozen Shoulder: a Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Frozen shoulder (FS) is a common progressive disorder that causes restricted motion and refractory pain undermining quality of life. Intra-articular hyaluronic acid (HA) injection is a widely adopted conservative therapy relieving symptomatic FS, whereas the effect of which were contradictory and unclear in current literatures. The aim of the present study is to investigate whether intra-articular HA administration facilitates symptomatic pain relief and functional improvements in patients diagnosed with shoulder FS. METHODS: The PubMed, Embase, Cochrane Library electronic databases and Google scholar were searched, from inception to 15th Jan 2022. Randomized controlled trials (RCTs) comparing intra-articular HA administration with any other non-surgical treatment in patients with FS were included. Risk of bias was evaluated using the Cochrane risk-of-bias tool and meta-analyses were undertaken to pool the data of visual analog scale for pain, range of motion (ROM) in external rotation, abduction, and flexion, as well as Shoulder Pain and Disability Index (SPADI), Constant score and American Shoulder and Elbow Surgeons (ASES). RESULTS: The present study included 7 RCTs involving 504 patients. The results provided no support for superior pain control in patients undergoing HA injection compared with any other treatment (p = 0.75). Furthermore, HA group failed to exert superior improvements to other treatments in ROM concerning abduction (p = 0.69) and flexion (p = 0.33). However, HA injection was observed to facilitate functional recovery in external rotation (p = 0.003). In addition, the pooled data showed a significant higher SPADI score in control group than in HA group (p = 0.01), while no statistical significance between two groups was observed in Constant score (p = 0.36) and ASES (p = 0.76). CONCLUSIONS: The current meta-analysis suggested that HA is a beneficial treatment procedure in improving the ROM of the shoulder for patients with FS, whereas the effect in relieving pain may be equal to the existing therapy. In conclusion, Intra-articular HA injection is recommended for FS patients.

Impact of Collagen Crosslinking on Dislocated Human Shoulder Capsules-Effect on Structural and Mechanical Properties.

Classical treatments of shoulder instability are associated with recurrence. To determine whether the modification of the capsule properties may be an alternative procedure, the effect of crosslinking treatment on the structure and mechanical properties of diseased human shoulder capsules was investigated. Joint capsules harvested from patients during shoulder surgery (n = 5) were treated or not with UV and/or riboflavin (0.1%, 1.0% and 2.5%). The structure and the mechanical properties of the capsules were determined by atomic force microscopy. The effect of treatments on cell death was investigated. Collagen fibrils were well-aligned and adjacent to each other with a D-periodicity of 66.9 ± 3.2 nm and a diameter of 71.8 ± 15.4 nm in control untreated capsules. No effect of treatments was observed on the organization of the collagen fibrils nor on their intrinsic characteristics, including D-periodicity or their mean diameter. The treatments also did not induce cell death. In contrast, UV + 2.5% riboflavin induced capsule stiffness, as revealed by the increased Young's modulus values (p < 0.0001 for each patient). Our results showed that the crosslinking procedure changed the biomechanics of diseased capsules, while keeping their structural organisation unchanged at the single fibril level. The UV/riboflavin crosslinking procedure may be a promising way to preserve the functions of collagen-based tissues and tune their elasticity for clinically relevant treatments.

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial.

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

The effect of injection volume on long-term outcomes of US-guided subacromial bursa injections.

PURPOSE: Limited data exist on the efficacy of high- compared to low-volume US-guided corticosteroid injections (CI) in the subacromial-subdeltoid (SA-SD) bursa. Our purpose was to compare the short- and long-term efficacy of low- and high-volume injections, by using a capacity reference of SA-SD bursa volume, as assessed on cadaveric specimens. METHOD: Within two years, 136 patients (63 males, 73 females; mean age: 46.11 ±â€¯10.28 years) who underwent SA-SD bursa US-guided CI for subacromial impingement, rotator cuff tendinopathy or shoulder overuse were prospectively included. Patients were randomly assigned to low-volume (1 mL triamcinolone acetonide/40 mg) or high-volume (1 mL triamcinolone acetonide/40 mg, 9 mL anaesthetic agents) groups (67 and 69 patients, respectively). Visual Analogue Scores (VAS) were recorded at baseline, 30 min, 3 weeks, 3 months, 6 months and 1 year post-treatment. Predictors of complete recovery (VAS ≤ 2) at 1 year were analysed with multivariate Cox regression analysis. SA-SD bursa cadaveric dissection in 10 specimens was performed for volume assessment. RESULTS: Injection volume was the only predictor of complete pain resolution at 1 year. High-volume CI yielded higher chances of early pain recovery (2.837 HR, 95% CI 1.737-4.633, P < .001). Mean VAS scores at baseline and subsequent time-points were 6, 2.6, 2.2, 2, 1.6 and 1 for the high-volume and 7.8, 7.3, 4.7, 3.2, 2.5 and 1.8 for the low-volume group, respectively (P < .001, at all time-points). Cadaveric measurements showed a minimum SA-SD bursa volume of approximately 6.9 mL. CONCLUSIONS: High-compared to low-volume US-guided CI are superior for achieving early pain recovery.

Voxel-based Three-dimensional Segmentation of the Capsulo-synovium from Contrast-enhanced MRI Can Represent Clinical Impairments in Adhesive Capsulitis.

The purposes were to calculate total voxel volume of the entire capsulo-synovial enhanced portion on contrast-enhanced (CE) MRI in adhesive capsulitis, and to investigate its association with glenohumeral joint volume and passive range of motions (ROMs), which are a well-known diagnostic reference standard and clinical hallmark of this condition. Medical records of 169 consecutive patients who underwent ultrasound-guided intraarticular injection with adhesive capsulitis and CE-MRI to exclude other mimicking shoulder diseases were retrospectively reviewed. To calculate total voxel volume of entire capsulo-synovial enhanced portion on CE-MRI, voxel-based 3-dimensional (3D) segmentation was obtained semi-automatically using Fiji, an open-source image processing software. Pearson's correlation coefficients were analyzed. Sixty patients who met eligibility criteria were included. Total voxel volume showed a significant inverse correlation with the glenohumeral joint volume (r = -0.528, P < 0.001), forward elevation, external rotation, and abduction (r = -0.407, P = 0.001; r = -0.342, P = 0.007; r = -0.275, P = 0.034, respectively). Intra-observer and inter-observer reliabilities, measured by intraclass correlation coefficients (ICC), were excellent (ICC = 0.87 and 0.77, respectively). This study's results indicate that voxel-based 3D segmentation of entire capsulo-synovial enhanced portion from CE-MRI can represent the severity of clinical impairments, such as obliterated joint volume and limited passive ROMs in adhesive capsulitis.

Accuracy of unguided and ultrasound guided Coracohumeral ligament infiltrations - a feasibility cadaveric case series.

BACKGROUND: Coracohumeral ligament (CHL) thickening, contracture, and fibroplasia have been identified in glenohumeral idiopathic adhesive capsulitis (GHIAC). The CHL is the main structure responsible for the range of motion limitations. Favorable outcomes have been reported with CHL surgical release. Intra-articular glenohumeral joint corticosteroid infiltrations are utilized to disrupt the inflammatory process and reduce pain in GHIAC. The aim of this study was to investigate whether the CHL could be accurately targeted with a periligamentous infiltration. METHODS: A convenience sample of 12 unembalmed cadaver shoulders (mean age: 74.5 years, range 66-87 years) without evidence of previous injury or surgery were utilized in this exploratory double factor feasibility cadaveric (unguided and ultrasound (US) guided) case series. Two clinicians trained in musculoskeletal infiltration techniques carried out the infiltrations on each shoulder with colored latex. One clinician infiltrated without guidance, the other with US-guidance. The injecting clinicians were blinded to the others infiltration procedure and the order was randomized. An anatomist blinded to the infiltration order performed a shoulder dissection and recorded the infiltrate location. Percentage calculation for accuracy of infiltration and a chi-square evaluation of the difference between unguided and US-guided infiltrations was applied. RESULTS: An accuracy of 75% was achieved for unguided infiltration and 80% for US-guided infiltration techniques. Chi-squared indicated there was no significant difference (p = 0.82) between the unguided and US-guided techniques. CONCLUSION: US-guided and unguided infiltrations achieved good accuracy targeting the CHL, suggesting infiltrations can specifically and accurately target the CHL. In vivo investigation using such infiltration techniques are warranted.

Tuina for periarthritis of shoulder: A systematic review protocol.

BACKGROUND: Periarthritis of shoulder (PAS) symptom is one of the leading causes prompting many patients to seek treatment. Tuina is a common treatment for PAS in China. But at present, there is no systematic evaluation report on its therapeutic effectiveness and safety. This protocol aims to reveal the efficacy and safety of Tuina for treating PAS. METHODS: The following databases will be searched by electronic methods: PubMed, EBASE, WHO International Clinical Trials Registry Platform, Embase, the Chinese Biomedical Literature Database (CBM), Wan-fang Data (WANFANG), the China National Knowledge Infrastructure (CNKI), and other sources from inception to December 2019. Bias risk, subgroup analysis, data synthesis, and meta-analyses will be assessed with RevMan V.5.3 software if the data is met inclusion conditions. RESULTS: This study will present a quality evidence of Tuina for the treatment of PAS patients. CONCLUSION: The systematic review will present reliable evidence to judge whether or not Tuina is a safe and effective intervention for PAS patients. PROSPERO REGISTRATION NUMBER: CRD42019147445.

Descripción histológica de los daños ocasionados por monoiodo acetato de sodio en articulación humeral de rata / Histologyc description of monosodium iodoacetate damage in rat humeral joint

La inyección con monoiodo acetato de sodio (MIA) es ampliamente utilizada para producir osteoartritis en diversas articulaciones. El objetivo fue describir los daños histológicos provocados por MIA en la articulación humeral de rata. Se inyectó 0,1 mL de mezcla de 0,5 mg de MIA disuelto en 10 mL de solución fisiológica en la articulación humeral izquierda de 21 ratas SpragueDawley. Como control se utilizó la articulación derecha de cada rata. Se realizó la eutanasia a las 4, 8 y 12 semanas post inyección en grupos de 7 ratas. Los miembros mantenidos en formalina tamponada al 10% fueron descalcificados con EDTA por tres meses. Para la evaluación histológica se realizó la inclusión en parafina y se realizaron cortes coronales de 5 µm de espesor, para posterior tinción con azul de toluidina. En el cartílago sano, se observó una superficie lisa sin fisuras, todas las células de las zonas del cartílago se observaron normales. Se observaron cambios en el cartílago articular a partir de las 4 semanas post inyección, los condrocitos de la zona radial hipertróficos con gran producción de proteoglicanos. A las 12 semanas post inyección, se observa un gran deterioro, el espacio articular se ve disminuido, La superficie del cartílago se observa con fisuras y grietas que llegan hasta la zona radial. Las células alrededor de estas fisuras han desaparecido. Se observa una pérdida prominente de proteoglicanos debido a la débil tinción con azul de toluidina. La inyección articular con MIA produce lesiones similares a la OA. La gran ventaja de la OA inducida por MIA, es la facilidad de su aplicación y la rapidez en la progresión de OA.

Injection with monoiode sodium acetate (MIA) is widely used to produce osteoarthritis in various joints. The aim of this work was to describe the histological damage caused by MIA in the rat humeral joint; 0.1 mL of 0.5 mg mixture of MIA dissolved in 10 mL of physiological solution was injected into the left humeral joint of 21 Sprague-Dawley rats. As a control, the right joint of each rat was used. Euthanasia was performed at 4, 8 and 12 weeks post injection in groups of 7 rats. The samples maintained in 10 % buffered formalin were descaled with EDTA for three months. For histological evaluation, paraffin inclusion was performed and 5 µm thick coronal cuts were made for subsequent staining with toluidine blue. In the healthy cartilage, a smooth surface was observed, all cells in the cartilage areas were normal. Changes in articular cartilage were observed after 4 weeks post injection, hypertrophic radial chondrocytes with high proteoglycan production. At 12 weeks post injection, a great deterioration was observed, the articular space was diminished. The surface of the cartilage was observed with fissures and cracks that reach the radial zone. The cells around these fissures have disappeared. A prominent loss of proteoglycans was observed due to weak toluidine blue staining. Joint injection with MIA produced lesions similar to OA. The great advantage of the OA induced by MIA, is the ease of its application and the rapidity in the progression of OA.

Intra-Articular versus Subacromial Corticosteroid Injection for the Treatment of Adhesive Capsulitis: A Meta-Analysis and Systematic Review.

BACKGROUND: Adhesive capsulitis is one of the most well-known causes of pain and stiffness of the shoulder. Corticosteroid injections have been used for many years. However, it is still controversial where corticosteroid should be injected, whether subacromial or intra-articular. OBJECTIVE: The objective of this meta-analysis was to compare the effects of intra-articular (IA) and subacromial (SA) corticosteroid injections for the treatment of adhesive capsulitis. MATERIALS AND METHODS: Four foreign databases and two Chinese databases were searched for RCTs and quasi-RCTs involving the comparison of IA and SA corticosteroid injection for the treatment of adhesive capsulitis. The Cochrane risk of bias tool and PEDro score were used to evaluate the quality of the studies. The primary clinical outcomes including VAS, Constant score, ASES score, and ROM were collected. The secondary outcome of corticosteroid-related adverse reactions was also compared between the two groups. The results were evaluated and compared at five time points. Subgroup analyses were performed to further explore the differences between groups. RESULTS: Eight RCTs and one quasi-RCT, involving 512 participants, were identified and included in this meta-analysis. All studies were of low risk of bias and medium-high quality with the PEDro score ≥5 points. The pooled effect showed that there was no significant difference in the primary outcomes between IA injection and SA injection, with an exception of VAS at 2-3 weeks (P=0.02) and ROM of internal rotation at 8-12 weeks (P=0.02). According to the results of subgroup analyses, the differences of VAS and ROM of internal rotation did not last beyond the 2-3-week time period. Additionally, SA injection had the advantage of avoiding adverse reactions from the corticosteroid, especially in avoiding a large fluctuation of serum blood glucose levels. CONCLUSIONS: When corticosteroid injection is used to treat adhesive capsulitis, both injection sites can be selected. However, due to the scarcity of related studies, more rigorous trials are needed to confirm the current findings.

Proresolving Mediators LXB4 and RvE1 Regulate Inflammation in Stromal Cells from Patients with Shoulder Tendon Tears.

Tendon stromal cells isolated from patients with chronic shoulder rotator cuff tendon tears have dysregulated resolution responses. Current therapies do not address the biological processes concerned with persistent tendon inflammation; therefore, new therapeutic approaches that target tendon stromal cells are required. We examined whether two specialized proresolving mediators (SPMs), lipoxin B4 (LXB4) and resolvin E1 (RvE1), modulate the bioactive lipid mediator profiles of IL-1ß-stimulated tendon cells derived from patients with shoulder tendon tears and healthy volunteers. We also examined whether LXB4 or RvE1 treatments moderated the proinflammatory phenotype of tendon tear stromal cells. Incubation of IL-1ß-treated patient-derived tendon cells in LXB4 or RvE1 up-regulated concentrations of SPMs. RvE1 treatment of diseased tendon stromal cells increased 15-epi-LXB4 and regulated postaglandin F2α. LXB4 or RvE1 also induced expression of the SPM biosynthetic enzymes 12-lipoxygenase and 15-lipoxygenase. RvE1 treatment up-regulated the proresolving receptor human resolvin E1 compared with vehicle-treated cells. Incubation in LXB4 or RvE1 moderated the proinflammatory phenotype of patient-derived tendon tear cells, regulating markers of tendon inflammation, including podoplanin, CD90, phosphorylated signal transducer and activator of transcription 1, and IL-6. LXB4 and RvE1 counterregulate inflammatory processes in tendon stromal cells, supporting the role of these molecules as potential therapeutics to resolve tendon inflammation.

Effect of antioxidants on BPA-induced stress on sperm function in a mouse model.

In the past few years, bisphenol A, (BPA) an endocrine-disrupting chemical, has received increasing attention because of its detrimental health effects. There is ample evidence to support that BPA interferes with the reproductive health of humans and animals. In spermatozoa, BPA-induced adverse effects are mostly caused by increased oxidative stress. Using an in vitro experimental model, we examined whether antioxidants (glutathione, vitamin C, and vitamin E) have defensive effects against BPA-induced stress in spermatozoa. The results showed that antioxidants inhibit the overproduction of reactive oxygen species (basically cellular peroxides) and increase intracellular ATP levels, thereby preventing motility loss and abnormal acrosome reaction in BPA-exposed spermatozoa. In particular, glutathione and vitamin E reduced the protein kinase A-dependent tyrosine phosphorylation in spermatozoa and, thus, prevented the precocious acrosome reaction from occurring. Furthermore, we found that the compromised fertilisation and early embryo development mediated by BPA-exposed spermatozoa can be improved following their supplementation with glutathione and vitamin E. Based on these findings, we suggest that antioxidants reduce oxidative stress in BPA-exposed spermatozoa, thus preventing detrimental effects on their function and fertility.

Intraarticular injection of relaxin-2 alleviates shoulder arthrofibrosis.

Arthrofibrosis is a prevalent condition affecting greater than 5% of the general population and leads to a painful decrease in joint range of motion (ROM) and loss of independence due to pathologic accumulation of periarticular scar tissue. Current treatment options are limited in effectiveness and do not address the underlying cause of the condition: accumulation of fibrotic collagenous tissue. Herein, the naturally occurring peptide hormone relaxin-2 is administered for the treatment of adhesive capsulitis (frozen shoulder) and to restore glenohumeral ROM in shoulder arthrofibrosis. Recombinant human relaxin-2 down-regulates type I collagen and α smooth muscle actin production and increases intracellular cAMP concentration in human fibroblast-like synoviocytes, consistent with a mechanism of extracellular matrix degradation and remodeling. Pharmacokinetic profiling of a bolus administration into the glenohumeral joint space reveals the brief systemic and intraarticular (IA) half-lives of relaxin-2: 0.96 h and 0.62 h, respectively. Furthermore, using an established, immobilization murine model of shoulder arthrofibrosis, multiple IA injections of human relaxin-2 significantly improve ROM, returning it to baseline measurements collected before limb immobilization. This is in contrast to single IA (sIA) or multiple i.v. (mIV) injections of relaxin-2 with which the ROM remains constrained. The histological hallmarks of contracture (e.g., fibrotic adhesions and reduced joint space) are absent in the animals treated with multiple IA injections of relaxin-2 compared with the untreated control and the sIA- and mIV-treated animals. As these findings show, local delivery of relaxin-2 is an innovative treatment of shoulder arthrofibrosis.

Value of MR arthrography findings for pain relief after glenohumeral corticosteroid injections in the short term.

OBJECTIVES: This study was conducted in order to determine the predictive value of MR arthrography findings for pain relief after glenohumeral corticosteroid injection. METHODS: This study prospectively enrolled 212 patients (mean age 51.4 years; range 15-90) who underwent fluoroscopy-guided glenohumeral corticosteroid injection. All patients received MR arthrography of the shoulder less than 3 months prior to the infiltration and returned questionnaires which assessed patients' shoulder pain using the 11-point numeric rating scale (NRS), covering a 1-month follow-up period. MR arthrograms were retrospectively assessed for abnormalities of the rotator cuff, long biceps tendon, glenohumeral bone, cartilage, and labrum as well as for synovitis, bursitis, and signs of adhesive capsulitis. MR arthrography findings were compared to patients' NRS change using the Mann-Whitney U and Kruskal-Wallis tests for univariate analysis and multiple linear regression for multivariate analysis. RESULTS: Pain reduction of ≥ 2 points was considered to represent clinically relevant improvement, which was seen in 71% of patients 1 week and in 74% of patients 1 month after glenohumeral injection. Univariate analysis of MR findings showed that signs of adhesive capsulitis and an intact labrum were associated with significantly higher NRS reductions after 1 month in comparison to patients without these findings (median 4 vs. 3, p = 0.007 and 4 vs. 2, p = 0.003, respectively). Multivariate analysis proved both factors to be independent predictors of improved outcome after 1 month (beta = 0.176, p = 0.039 and beta = 0.212, p = 0.001, respectively). CONCLUSIONS: Glenohumeral corticosteroid injections for pain relief have a high success rate with 74% of patients reporting clinically relevant improvement after 1 month. Signs of adhesive capsulitis and an intact labrum on MR arthrography are independent predictors of a better outcome. KEY POINTS: • Seventy-four percent of patients report clinically relevant improvement 1 month after glenohumeral corticosteroid injection. • Signs of adhesive capsulitis and an intact labrum on MR arthrography are independent predictors of a high pain level decrease.

[Frozen shoulder].

Frozen shoulder, or adhesive capsulitis, is a painful inflammatory disorder with an unknown pathogenesis characterised by progressive fibrosis of the capsule. Frozen shoulder presents clinically with intense pain at rest and passive restricted motion. In general, treatment modalities seem to relieve pain and improve the range of movement, but no single treatment modality has been shown to affect the long-term outcome. Initially, a non-operative approach is traditionally recommended. Oral or intraarticular injection of cortisone relieves short-term pain. In refractory cases, arthroscopic capsular release is suggested.

Preoperative bisphosphonate treatment may adversely affect the outcome after shoulder arthroplasty.

AIMS: The aim of this study was to investigate the effects of preoperative bisphosphonate treatment on the intra- and postoperative outcomes of arthroplasty of the shoulder. The hypothesis was that previous bisphosphonate treatment would adversely affect both intra- and postoperative outcomes. PATIENTS AND METHODS: A retrospective cohort study was conducted involving patients undergoing arthroplasty of the shoulder, at a single institution. Two patients with no previous bisphosphonate treatment were matched to each patient who had received this treatment preoperatively by gender, age, race, ethnicity, body mass index (BMI), and type of arthroplasty. Previous bisphosphonate treatment was defined as treatment occurring during the three-year period before the arthroplasty. The primary outcome measure was the incidence of intraoperative complications and those occurring at one and two years postoperatively. A total of 87 patients were included: 29 in the bisphosphonates-exposed (BP+) group and 58 in the non-exposed (BP-) group. In the BP+ group, there were 26 female and three male patients, with a mean age of 71.4 years (51 to 87). In the BP- group, there were 52 female and six male patients, with a mean age of 72.1 years (53 to 88). RESULTS: Previous treatment with bisphosphonates was positively associated with intraoperative complications (fracture; odds ratio (OR) 39.40, 95% confidence interval (CI) 2.42 to 6305.70) and one-year postoperative complications (OR 7.83, 95% CI 1.11 to 128.82), but did not achieve statistical significance for complications two years postoperatively (OR 3.45, 95% CI 0.65 to 25.28). The power was 63% for complications at one year. CONCLUSION: Patients who are treated with bisphosphonates during the three-year period before shoulder arthroplasty have a greater risk of intraoperative and one-year postoperative complications compared with those without this previous treatment.

Polydeoxyribonucleotide injection in the patients with partial-thickness tear of supraspinatus tendon: a prospective and pilot study using ultrasound.

OBJECTIVE: Polydeoxyribonucleotide as adenosine receptor (A2A) agonist has been used in plastic surgery and dermatology related to its regenerative property. The aim of this pilot study is to evaluate the safety and efficacy of polydeoxynucleotide injection in patients with rotator cuff tears by a variety of outcomes including pain, disability, physical performance test, and ultrasonography (US). METHODS: Seventeen patients (9 men, 8 women, age: 57.9 ± 9.1) with partial-thickness tear of supraspinatus tendon were evaluated in a prospective, open-label, and pre-and-post study. Seventeen patients underwent 3 times intra-lesional polydeoxynucleotide injection under ultrasound (US) guidance on weeks 0, 2 and 4. The safety and efficacy were assessed on weeks 0, 6 and 12. Main outcome measures included shoulder pain on Visual Analogue Scale (VAS) and DASH (disabilities of arm, hand, shoulder) score, range of motion in shoulder, shoulder strength and tear volume (cm3) by US. Adverse events were monitored. (CRIS: https://www.cris.nih.go.kr , KCT0000767). RESULTS: Active shoulder pain on VAS reduced from 5.53 to 3.53 (P = 0.016), and acting pain, one of DASH questionnaires, reduced from 3.35 to 2.00 (P < 0.001). However, resting shoulder pain on VAS and total DASH scores were not significantly different. Forward flexion and internal rotation in range of motion improved significantly (from 169.41 to 178.13 degrees [P = 0.004] and from 83.53 to 88.75 degrees [P = 0.014], respectively). The volume of torn lesion decreased during the study period, however it was not significant. There were no significant adverse events leading to hospitalization. CONCLUSIONS: Minimally invasive procedure through polydeoxynucleotide injection into torn area of supraspinatus tendon on US could be candidate for the safe and effective treatment on shoulder pain and limited range of motion in patients with rotator cuff tear.

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy.

BACKGROUND: Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. METHODS: Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. RESULTS: Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. CONCLUSIONS: Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. LEVEL OF EVIDENCE: Level IV-therapeutic.

The Effect of Corticosteroid Injection Into Rotator Interval for Early Frozen Shoulder: A Randomized Controlled Trial.

BACKGROUND: Corticosteroid injection is a common treatment for frozen shoulder, but controversy still exists regarding the injection site with the best outcome. HYPOTHESIS: To treat the frozen shoulder in the freezing stage with corticosteroid injection, a single injection into the rotator interval (RI) could yield better effects in terms of improvement in pain, passive range of motion (ROM), and function than would an injection into the intra-articular (IA) or subacromial (SA) space. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with primary frozen shoulder in the freezing stage were randomized into 3 groups: RI injection, IA injection, or SA injection with corticosteroid. Clinical outcomes were documented at baseline and at 4, 8, and 12 weeks after intervention, including visual analog scale (VAS) for pain; passive ROM measurements, including external rotation, internal rotation, forward flexion, and abduction; and evaluation with the Disability of Arm, Hand, and Shoulder (DASH) score and Constant score. RESULTS: There were no significant differences in the basic properties of the 3 groups (27 in RI group, 24 in IA group, and 26 in SA group) before injection. Improvements in pain VAS, passive ROM, Constant score, and DASH score were faster and significant in the RI group from 4 weeks after injection, followed by those in the IA group. Passive ROM decreased and DASH score did not change significantly in the SA group, although pain VAS and Constant score improved significantly. CONCLUSION: To treat frozen shoulder in the freezing stage with corticosteroid injection, a single injection into the RI yielded better effects in terms of improvement in pain, passive ROM, and function than did injections into the IA or SA space.

Ibuprofen impairs capsulolabral healing in a rat model of anterior glenohumeral instability.

BACKGROUND: Failure of glenoid labrum and capsular healing after glenohumeral dislocation can lead to persistent shoulder instability. The purpose of this study was to determine the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on the healing glenoid labrum and capsule after glenohumeral dislocation in a rat model. METHODS: Sixty-six rats had surgically induced anterior-inferior labral tears and anterior glenohumeral dislocation. Postoperatively, the animals were assigned to either normal (n = 32) or ibuprofen drinking water (n = 31). Animals were euthanized at 2 and 4 weeks postoperatively for biomechanical testing and histologic analysis. RESULTS: The maximum load increased from 2 to 4 weeks after injury in the NSAID groups but not in the control groups. At 2 weeks, the maximum load was lower in the NSAID group compared with the control group. In a matched comparison between injured and uninjured limbs, the maximum load was significantly decreased in the injured limb of the 2-week NSAID group. At 4 weeks, the NSAID group had decreased stiffness compared with the 4-week control group. CONCLUSIONS: In a new rat model of glenohumeral instability, the postinjury administration of ibuprofen resulted in decreased capsulolabral healing. A matched pair analysis of injured to uninjured limbs supported the findings of impaired healing in the NSAID-treated animals. These findings demonstrate that the use of NSAIDs after glenohumeral dislocation may impair capsulolabral healing and should be limited or avoided to optimize glenohumeral stability.