Platelet-Rich Plasma Injections for Shoulder Adhesive Capsulitis Are at Least Equivalent to Corticosteroid or Saline Solution Injections: A Systematic Review of Prospective Cohort Studies.

PURPOSE: To evaluate the role of platelet-rich plasma (PRP) for adhesive capsulitis (AC) as compared with other injectables. METHODS: A literature search of the PubMed and Embase online databases was performed to identify articles evaluating injection therapy for the treatment of AC. The inclusion criteria included prospective studies comparing PRP against alternative injectables with a minimum of 15 patients in each treatment arm and a minimum 12-week follow-up period. Pain scores, range of motion, and function scores were the primary outcomes assessed. RESULTS: Five articles comparing PRP with corticosteroid or saline solution injections met the inclusion criteria. A total of 157 patients were treated with PRP, with a follow-up duration ranging from 3 to 6 months. All 5 studies showed statistically significant improvements in pain scores, motion, and function scores in patients receiving PRP, corticosteroid, and saline solution injections. However, PRP was consistently superior on intergroup analyses in all but 1 study. In 4 studies, pain and function scores favored PRP over control at final follow-up (range in mean difference, -2.2 to 0.69 for visual analog scale pain score [n = 5] and -50.5 to -4.0 for Shoulder Pain and Disability Index score [n = 3]), whereas 3 studies found greater improvement in shoulder motion after PRP (range in mean difference, 0.7° to 34.3° for forward flexion and -2.3° to 20.4° for external rotation [n = 4]). One study found no significant difference between PRP and corticosteroid injections but noted that the results were comparable. CONCLUSIONS: According to a limited number of prospective studies, PRP injections for AC are at least equivalent to corticosteroid or saline solution injections and often lead to improved pain, motion, and functional outcomes at 3- to 6-month follow-up. Given the small number of studies, with design heterogeneity, there is insufficient evidence to routinely recommend PRP for AC. However, the results are promising and do support considering PRP as an adjunct treatment option for AC, especially for patients refractory and/or averse to corticosteroids or alternative treatment modalities. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

The role of Wnt/ß-catenin signaling in proliferation and regeneration of the developing basilar papilla and lateral line.

Canonical Wnt/ß-catenin signaling has been implicated in multiple developmental events including the regulation of proliferation, cell fate, and differentiation. In the inner ear, Wnt/ß-catenin signaling is required from the earliest stages of otic placode specification through the formation of the mature cochlea. Within the avian inner ear, the basilar papilla (BP), many Wnt pathway components are expressed throughout development. Here, using reporter constructs for Wnt/ß-catenin signaling, we show that this pathway is active throughout the BP (E6-E14) in both hair cells (HCs) and supporting cells. To characterize the role of Wnt/ß-catenin activity in developing HCs, we performed gain- and loss-of-function experiments in vitro and in vivo in the chick BP and zebrafish lateral line systems, respectively. Pharmacological inhibition of Wnt signaling in the BP and lateral line neuromasts during the periods of proliferation and HC differentiation resulted in reduced proliferation and decreased HC formation. Conversely, pharmacological activation of this pathway significantly increased the number of HCs in the lateral line and BP. Results demonstrated that this increase was the result of up-regulated cell proliferation within the Sox2-positive cells of the prosensory domains. Furthermore, Wnt/ß-catenin activation resulted in enhanced HC regeneration in the zebrafish lateral line following aminoglycoside-induced HC loss. Combined, our data suggest that Wnt/ß-catenin signaling specifies the number of cells within the prosensory domain and subsequently the number of HCs. This ability to induce proliferation suggests that the modulation of Wnt/ß-catenin signaling could play an important role in therapeutic HC regeneration.

Optimal screw placement for base plate fixation in reverse total shoulder arthroplasty.

HYPOTHESIS: Scapular cortical thickness has not been fully characterized from the perspective of determining optimal screw placement for securing the glenoid base plate in reverse shoulder arthroplasty. MATERIALS AND METHODS: Twelve fresh frozen cadaveric scapulae underwent high resolution CT scans with 3-dimensional reconstructions and wall thickness analysis. Digital base plates were positioned and virtual screws were placed according to 2 scenarios: A - intraosseous through the entire course and exits a "safe region" with no known neurovascular structures; B - may leave and re-enter the bone and penetrates the thickest cortical region accessible regardless of adjacent structures. RESULTS: For scenario A, the optimal screw configurations were: (superior screw) length = 35 mm, 9° superior, 2° posterior; (inferior screw-A) length = 34 mm, 16° inferior, 5° anterior; (inferior screw-B) length = 31 mm, 31 inferior, 4 posterior; (posterior screw) length 19 mm, 29° inferior, 3° anterior. For scenario B: (superior screw) length = 36 mm, 28° superior, 10° anterior; (inferior screw) length = 35 mm, 19° inferior, 4° anterior; (posterior screw) length 37 mm, 23° superior, 3° anterior. The anterior screw was consistent between scenarios A and B, averaged 29 mm in length and was directed 16° inferior and 14° posterior. CONCLUSION: Thicker cortical regions were present in the lateral aspect of the suprascapular notch, scapular spine base, anterior/superior aspect of inferior pillar and junction of glenoid neck and scapular spine. Regions with high cortical thickness were accessible for both scenarios except for the posterior screw in scenario A.

Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial.

BACKGROUND: Loss of meniscal tissue leads to increased pain and decreased clinical function and activity levels. We hypothesized that patients receiving a collagen meniscus implant would have better clinical outcomes than patients treated with partial medial meniscectomy alone. METHODS: Three hundred and eleven patients with an irreparable injury of the medial meniscus or a previous partial medial meniscectomy, treated by a total of twenty-six surgeon-investigators at sixteen sites, were enrolled in the study. There were two study arms, one consisting of 157 patients who had had no prior surgery on the involved meniscus (the "acute" arm of the study) and one consisting of 154 patients who had had one, two, or three prior meniscal surgical procedures (the "chronic" arm). Patients were randomized either to receive the collagen meniscus implant or to serve as a control subject treated with a partial meniscectomy only. Patients underwent frequent clinical follow-up examinations over two years and completed validated outcomes questionnaires over seven years. The patients who had received a collagen meniscus implant were required by protocol to have second-look arthroscopy at one year to determine the amount of new tissue growth and to perform a biopsy to assess tissue quality. Reoperation and survival rates were determined. RESULTS: In the acute group, seventy-five patients received a collagen meniscus implant and eighty-two were controls. In the chronic group, eighty-five patients received the implant and sixty-nine were controls. The mean duration of follow-up was fifty-nine months (range, sixteen to ninety-two months). The 141 repeat arthroscopies done at one year showed that the collagen meniscus implants had resulted in significantly (p = 0.001) increased meniscal tissue compared with that seen after the original index partial meniscectomy. The implant supported meniscus-like matrix production and integration as it was assimilated and resorbed. In the chronic group, the patients who had received an implant regained significantly more of their lost activity than did the controls (p = 0.02) and they underwent significantly fewer non-protocol reoperations (p = 0.04). No differences were detected between the two treatment groups in the acute arm of the study. CONCLUSIONS: New biomechanically competent meniscus-like tissue forms after placement of a collagen meniscus implant, and use of the implant appears safe. The collagen meniscus implant supports new tissue ingrowth that appears to be adequate to enhance meniscal function as evidenced by improved clinical outcomes in patients with a chronic meniscal injury. The collagen meniscus implant has the utility to be used to replace irreparable or lost meniscal tissue in patients with a chronic meniscal injury. The implant was not found to have any benefit for patients with an acute injury.

Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming.

BACKGROUND: Active and young individuals with glenohumeral arthritis who are treated with total glenohumeral arthroplasty are at risk for loosening or wear of the prosthetic glenoid component. This study tests the hypothesis that patients with severe glenohumeral arthritis have improvement in self-assessed shoulder comfort and function at two to four years after treatment with the combination of humeral hemiarthroplasty and concentric glenoid reaming without tissue or prosthetic component interposition. METHODS: Thirty-seven consecutive patients (thirty-eight shoulders), with a mean age of fifty-seven years, who were managed by one surgeon were enrolled in this prospective study. The procedure consisted of an uncemented humeral hemiarthroplasty combined with reaming of the glenoid to a diameter 2 mm larger than that of the prosthetic humeral head. The duration of follow-up ranged from two to four years (average, 2.7 years) for thirty-five shoulders. Self-assessed comfort and function was documented with use of the Simple Shoulder Test, and radiographs were evaluated. RESULTS: Thirty-two shoulders demonstrated improved comfort and function according to patient self-assessment, one demonstrated no change, and two had worse function following the procedure. The total number of Simple Shoulder Test functions that could be performed increased from 4.7 (of a possible 12.0) before surgery to 9.4 at the time of the final follow-up. The patients demonstrated significant improvement in ten of the twelve individual functions of the Simple Shoulder Test (p < 0.022 to p < 0.00001). With the numbers studied, gender, diagnosis, age, glenoid wear, and preoperative glenoid erosion did not significantly affect final shoulder function or overall improvement. The range of motion was significantly improved for all individuals (p < 0.00001). Radiographically, twenty-two patients had a joint space between the glenoid bone and the humeral prosthesis at the time of final follow-up. These shoulders had significantly better function than those without a preserved joint space (p < 0.017). There were no surgical complications and no revisions to total shoulder arthroplasty. CONCLUSIONS: At a minimum follow-up of two years, a selected series of patients who had humeral hemiarthroplasty with concentric glenoid reaming for the treatment of glenohumeral arthritis showed significant improvement in self-assessed shoulder comfort and function. Further study, however, is needed before routine application of this procedure can be recommended. LEVEL OF EVIDENCE: Therapeutic Level IV.

Simultaneous ipsilateral posterior knee and hip dislocations: case report, including a technique for closed reduction of the hip.

In isolation, dislocations of the hip and knee require emergent reduction to minimize the risks of serious complications, including vascular and neurologic injury, osteonecrosis of the femoral head, and loss of motion and function. With simultaneous dislocation of the ipsilateral hip and knee, as in the situation of hip dislocation with concomitant femoral shaft fracture, reduction of the hip may prove difficult because of the inability to control the femoral segment. In this setting, general anesthesia is commonly required. We present the case of a patient who sustained an ipsilateral hip and knee dislocation who underwent closed reduction of the knee in the emergency department but required general anesthesia and the insertion of Schanz pins in the femur to reduce the hip dislocation.

Anteroinferior bone-grafting can restore stability in osseous glenoid defects.

BACKGROUND: Glenohumeral instability associated with a large osseous defect of the glenoid can be treated with bone graft to restore the glenoid concavity. The shape and positioning of the graft is critical: a graft that encroaches on the extrapolated glenoid curvature can prevent the head from seating completely in the glenoid, whereas a graft that is too far from the curvature does not restore the glenoid concavity. The purpose of the present study was to investigate how the intrinsic stability that is provided by the glenoid is affected by (1) a standardized anteroinferior glenoid defect and (2) different configurations of anteroinferior glenoid bone graft. METHODS: The anteroinferior stability provided by the glenoid was quantitated by measuring the balance stability angle in that direction. The balance stability angle is the maximal angle that the direction of the net humeral joint-reaction force can make with the glenoid centerline before dislocation takes place. The anteroinferior stability was assessed in each of four fresh-frozen, grossly normal cadaveric glenoids in (1) the unaltered state, (2) after the creation of a standardized defect of a magnitude that has been reported by other investigators to be sufficient to require a bone graft, and (3) after each step of a series of bone-grafting procedures involving grafts of varying height and contour. RESULTS: The anteroinferior glenoid defect significantly diminished the anteroinferior stability by almost 50% (p = 0.006). Bone-grafting significantly increased the stability provided by the glenoid. The increase in stability as compared with that of the glenoid with the standardized defect was particularly marked for contoured graft heights of 6 and 8 mm, for which the increases were 150% (p = 0.0001) and 229% (p < 0.00025), respectively. Contouring of the graft minimized the potential for unwanted contact between the ball and the graft. CONCLUSIONS: Anteroinferior shoulder instability caused by an osseous defect in the glenoid can be corrected with bone-grafting. The effectiveness of the graft in restoring the lost stability is related both to its height and to the extent to which it is contoured as long as the graft is not so prominent that it forces the ball posteriorly from the center of the glenoid.

Intraoperative thyroid storm: a case report.

An 18-year-old woman being treated for Graves disease underwent elective thyroidectomy. Tachycardia was noted before surgery. The patient's heart rate and temperature started to rise 30 minutes into surgery. Malignant hyperthermia was excluded on clinical grounds, and treatment with beta blockers was started. The patient's conditions stabilized, and surgery was completed. A review of the patient's laboratory test results revealed a high free thyroxine level before surgery. Diagnosis and management of thyroid storm are discussed.