Glenohumeral versus subacromial steroid injections for impingement syndrome with mild stiffness: a randomized controlled trial

Background@#The subacromial (SA) space is a commonly used injection site for treatment of impingement syndrome. For shoulder stiffness, glenohumeral (GH) injections are commonly performed. However, in cases of impingement syndrome with mild shoulder stiffness, the optimal site of steroid injection has yet to be identified. @*Methods@#This prospective, randomized study compared the short-term outcomes of ultrasound-guided GH and SA steroid injections in patients who were diagnosed with impingement syndrome and mild stiffness. Each group comprised 24 patients who received either a GH or SA injection of 40 mg of triamcinolone. Range of motion and clinical scores were assessed before and 3, 7, and 13 weeks after the injection. @*Results@#GH and SA injections significantly improved the range of motion and clinical scores after 13 weeks of follow-up. Notably, targeting the GH joint resulted in an earlier gain of forward elevation, external rotation, and internal rotation in 3 weeks (P<0.001, P=0.012, and P=0.002, respectively) and of internal rotation and a Constant-Murley score in 7 weeks (P<0.001 and P=0.046). Subsequent measurements were similar between the groups and showed a steady improvement in all ranges of motion and clinical scores. @*Conclusions@#GH injections may be more favorable than SA injections for treatment of impingement syndrome with mild stiffness, especially in improving the range of motion in the early period. However, the procedures showed similar outcomes after 3 months.Level of evidence: I.

Protocatechuic acid impacts rotator cuff healing and reduces fatty degeneration in a chronic rotator cuff tear model in rats

The purpose of this study was to verify the effect of protocatechuic acid (PCA) on tendon healing and fatty degeneration in a chronic rotator cuff model. Methods: Twenty-eight Sprague-Dawley male rats were randomly allocated into two groups: Saline+repair (SR) and PCA+repair (PR). The right shoulder was used for experimental interventions, and the left served as a control. PCA (30 mg/kg/day) was administered intraperitoneally at the site of infraspinatus tendon detachment in rats in the PR group, and the same volume of saline was administered to the same site in the SR group. The torn tendon was repaired 4 weeks after infraspinatus detachment. Four weeks after repair, hematoxylin and eosin (H&E), S100, and CD68 stains were performed to evaluate the degree of fatty degeneration and H&E and Masson trichrome stains were performed to assess tendon healing. Superoxide dismutase (SOD) was measured to test the efficacy of PCA as an antioxidant. Results: Results from histological evaluation indicated that SOD and CD68 levels at the musculotendinous region and collagen fiber parallel to the orientation at the tendon-to-bone junction were not significantly different between the SR and PR groups. The mean load-to-failure of the PR group (20.32±9.37 N) was higher than that of the SR group (16.44±6.90 N), although this difference was not statistically significant (p=0.395). The SOD activity in the operative side infraspinatus muscle of the PR group was higher than that of the SR group, but the difference was not statistically significant (p=0.053). Conclusions: The use of PCA could improve tendon healing and decrease fatty degeneration after rotator cuff repair.

Regional nerve blocks for relieving postoperative pain in arthroscopic rotator cuff repair

Rotator cuff tear is the most common cause of shoulder pain in middle-age and older people. Arthroscopic rotator cuff repair (ARCR) is the most common treatment method for rotator cuff tear. Early postoperative pain after ARCR is the primary concern for surgeons and patients and can affect postoperative rehabilitation, satisfaction, recovery, and hospital day. There are numerous methods for controlling postoperative pain including patient-controlled analgesia, opioid, interscalene block, and local anesthesia. Regional blocks including interscalene nerve block, suprascapular nerve block, and axillary nerve block have been successfully and commonly used. There is no difference between interscalene brachial plexus block (ISB) and suprascapular nerve block (SSNB) in pain control and opioid consumption. However, SSNB has fewer complications and can be more easily applied than ISB. Combination of axillary nerve block with SSNB has a stronger analgesic effect than SSNB alone. These regional blocks can be helpful for postoperative pain control within 48 hours after ARCR surgery.

Comparison of the effectiveness of extensor muscle strengthening exercise by itself, exercise with polydeoxyribonucleotide injection, and exercise with extracorporeal shockwave therapy in lateral epicondylitis: a randomized controlled trial

Extensor muscle strengthening exercises with counterforce braces (EX) is a conventional conservative treatment for lateral epicondylitis (LE) of the elbow. In addition, polydeoxyribonucleotide (PDRN) or extracorporeal shockwave therapy (ESWT) has been recently used for LE. Methods: Sixty-three patients with chronic LE participated in this study and randomly allocated in three groups (G1: EX, G2: EX+PDRN injection, and G3: EX+ESWT). All of the three groups were taught to perform EX at the first out-patient department (OPD) visit. Group 2 was injected with 3 mL PDRN (5.625 mg/3 mL), while group 3 received ESWT at the first OPD visit. Visual analog scale pain score, Mayo elbow performance score (MEPS), and ultrasonographic examination were checked before, 6 weeks, and 12 weeks after the treatments. Results: Overall functional scores and ultrasonographic findings in all three groups improved after treatment. The mean MEPS in group 2 improved more than groups 1 and 3 at 6 weeks (G1, 56.9>62.4; G2, 54.3>65.0; G3, 55.7>62.6), and more than group 1 at 12 weeks (G1, 56.9>67.9; G2, 54.3>73.6). The mean common extensor tendon depth (CETD) on ultrasonography in group 2 increased more than groups 1 and 3 at 6 and 12 weeks (6 weeks: G1, 0.385>0.386; G2, 0.332>0.392; G3, 0.334>0.357; 12 weeks: G1, 0.385>0.409; G2, 0.332>0.438; G3, 0.334>0.405 [cm]). Conclusions: PDRN injections combined with EX exhibited a greater improvement in mean MEPS and mean CETD compared to EX only or EX combined with ESWT for LE within the 12 weeks follow-up.

Polydeoxyribonucleotide and Polynucleotide Improve Tendon Healing and Decrease Fatty Degeneration in a Rat Cuff Repair Model

BACKGROUND@#After surgical repair of chronic rotator cuff tears, healing of the repaired tendons often fails and is accompanied by high-level fatty degeneration. Our purpose was to explore the effects of polydeoxyribonucleotide (PDRN) and polynucleotide (PN) on tendon healing and the reversal of fatty degeneration in a chronic rotator cuff tear model using a rat infraspinatus. @*METHODS@#Sixty rats were randomly assigned to the following three groups (20 rats per group: 12 for histological evaluation and 8 for mechanical testing): saline + repair (SR), PDRN + repair (PR), and PN + repair (PNR). The right shoulder was used for experimental intervention, and the left served as a control. Four weeks after detaching the infraspinatus, the torn tendon was repaired. Saline, PDRN, and PN were applied to the repair sites. Histological evaluation was performed 3 and 6 weeks after repair and biomechanical analysis was performed at 6 weeks. @*RESULTS@#Three weeks after repair, the PR and PNR groups had more CD168-stained cells than the SR group. The PR group showed a larger cross-sectional area (CSA) of muscle fibers than the SR and PNR groups. Six weeks after repair, the PR and PNR groups showed more adipose cells, less CD68-stained cells, and more parallel tendon collagen fibers than the SR group. The PR group had more CD 68-stained cells than the PNR group. The PR group showed a larger CSA than the SR group. The mean load-to-failure values of the PR and PNR groups were higher than that of the SR group, although these differences were not significant. @*CONCLUSION@#PDRN and PN may improve tendon healing and decrease fatty degeneration after cuff repair.

PHILOS plate fixation with polymethyl methacrylate cement augmentation of an osteoporotic proximal humerus fracture

PHILOS plate fixation in osteoporotic proximal humerus fracture of old age is well-known for high complication rate, especially metal failure, providing various augmentation techniques, such as calcium phosphate cement, allogenous or autologous bone graft. We report a case of PMMA augmentation to provide appropriate reduction with a significant mechanical support. This can be a treatment option for displaced unstable osteoporotic proximal humerus fracture with marked bony defect.

Prevalence of rotator cuff diseases in adults older than 40 years in or near Chuncheon city, Korea

Background@#To determine the prevalence of rotator cuff diseases in a population older than 40 years in or nearby Chuncheon city, Republic of Korea. @*Methods@#Sixty shoulders of 30 people older than 40 years who participated in a health lecture were examined for free by an orthopedic surgeon. Visual analog scale of pain and American Shoulder and Elbow Surgeons scores were assigned, and routine physical examination was performed. Ultrasonography was performed on the shoulder. @*Results@#On ultrasonographic examination, there were one shoulder with full thickness rotator cuff tear, 20 of 60 (33%) with partial thickness rotator cuff tear, five of 60 (8%) with calcific tendinitis, one of 60 (2%) with tear of the long head of the biceps, and five of 50 (8%) with tendinitis of the long head of the biceps. Participants older than 60 years showed significantly high proportions of lesion of the long head of the biceps and rotator cuff diseases (P=0.019 and P=0.015, respectively). Participants who performed physical labor had high proportions of rotator cuff tear and rotator cuff disease (P=0.001 and P<0.001, respectively). @*Conclusions@#Rotator cuff diseases showed a high prevalence in elderly persons and resulted in a decrease in shoulder function.

Scapular Dyskinesis Assessment with Low Dose Three-Dimensional Wing Computer Tomography after Anatomical Union of Clavicle Fracture / 대한스포츠의학회지

PURPOSE: Malunions after clavicle fractures are generally considered to cause scapular dyskinesis. This study aims to verify the incidence of scapular dyskinesis following anatomically reduced clavicle fracture and to verify the usefulness of low-dose three-dimensional (3D) scapular wing computed tomography (3D-scapula wing-CT) analysis.METHODS: Twenty-four patients with mid-clavicle fracture and four patients with distal clavicle fracture were recruited. After anatomical reduction and bony union, scapular dyskinesis was assessed by history taking and physical examination by two orthopedic doctors. The mean follow-up period for the assessment was 14.3±10.1 months. Low-dose 3D-scapular wing-CT analysis in prone position was performed with calculated effective dose 2.35 mSv, which means approximately 25% dose of conventional setting. Four observers evaluated five angles (upward rotation, internal rotation, anterior tilting, superior translation, protraction) from 3D-reconstructed images on both shoulders of a patient. Authors analyzed the results between injured to normal shoulder.RESULTS: Scapular dyskinesis or significant shortening of injured clavicle (mean clavicle length difference, − 1.77±6.36 mm) were not observed among the included 28 subjects. The difference values of the five angles between the fractured side and normal side showed no statistical significance (upward rotation: 1.51, p=0.13; superior translation: 0.89, p=0.327; anterior tilting: 1.7, p=0.096; protraction: 0.83, p=0.374; internal rotation: 0.98, p=0.406). As the interclass correlation coefficients of four observers was 0.988 (p=0.00), images from low-dose 3D-wing-CT are clear enough to assess scapular dyskinesis (interclass correlation coefficient, 0.996; p=0.00).CONCLUSION: It is important to make anatomical reduction and length restoration of clavicle fracture for preventing scapular dyskinesis. Low-dose 3D-scapular wing-CT is an effective tool for assessing scapular dyskinesis, which provides images of sufficient quality with little increase in morbidity from radiation hazard.

Usefulness of Arthroscopic Treatment of Painful Hip after Acetabular Fracture or Hip Dislocation

BACKGROUND: Painful hip following hip dislocation or acetabular fracture can be an important signal for early degeneration and progression to osteoarthritis due to intraarticular pathology. However, there is limited literature discussing the use of arthroscopy for the treatment of painful hip. The purpose of this retrospective study was to analyze the effectiveness and benefit of arthroscopic treatment for patients with a painful hip after major trauma. METHODS: From July 2003 to February 2013, we reviewed 13 patients who underwent arthroscopic treatment after acetabular fracture or hip dislocation and were followed up for a minimum of 2 postoperative years. The degree of osteoarthritis based on the Tonnis classification pre- and postoperatively at final follow-up was determined. Clinical outcomes were evaluated using visual analogue scale for pain (VAS) and modified Harris hip score (MHHS), and range of motion (ROM) of the hip pre- and postoperatively at final follow-up. RESULTS: There were nine male and four female patients with a mean age at surgery of 28 years (range, 20 to 50 years). The mean follow-up period of the patients was 59.8 months (range, 24 to 115 months), and the mean interval between initial trauma and arthroscopic treatment was 40.8 months (range, 1 to 144 months). At the final follow-up, VAS and MHHS improved significantly from 6.3 and 53.4 to 3.0 and 88.3, respectively (p = 0.002 and p < 0.001, respectively). However, there were no significant differences in hip flexion, abduction, adduction, external rotation, and internal rotation as minor improvements from 113.1°, 38.5°, 28.5°, 36.5°, and 22.7° to 118.5°, 39.0°, 29.2°, 38.9°, and 26.5° were observed, respectively (p = 0.070, p = 0.414, p = 0.317, p = 0.084, and p = 0.136, respectively). None of the patients exhibited progression of osteoarthritis of the hip at the final follow-up. CONCLUSIONS: Arthroscopic treatment after acetabular fracture or hip dislocation is effective and delays the progression of traumatic osteoarthritis.

Charcot Spine Treated Using a Single Staged Posterolateral Costotransversectomy Approach in a Patient with Traumatic Spinal Cord Injury

Charcot spine is a progressive and destructive process that affects the vertebral bodies, intervertebral discs, and posterior facets. It is the result from repetitive microtrauma in patients who have decreased joint protective mechanisms due to loss of deep pain and proprioceptive sensation, typically because of spinal cord injury. The objective of the study is to report an unusual case of Charcot spine, as a late complication of traumatic spinal cord injury, treated by a circumferential arthrodesis performed with a single staged posterolateral costotransversectomy approach.

Surgical Treatment of Multiple Rice Bodies in Chronic Subacromial and Subdeltoid Bursitis: A Case Report / 대한골관절종양학회지

Multiple rice body formation is a complication of chronic bursitis frequently associated with seronegative rheumatoid arthritis or tuberculosis. It resembles synovial chondromatosis on imaging and clinically. We report on a pathologically diagnosed multiple rice body formation in subacromial and subdeltoid bursitis in a 44-year-old man who was treated by surgical removal and bursectomy. At 16 months after the removal, range of motion of affected shoulder was normal. No evidence of recurrence of rice body in plain X-ray and ultrasonography. Multiple rice body formed in chronic subacromial and subdeltoid bursitis could be treated with surgical removal and bursectomy successfully.

Arthroscopic Percutaneous Repair of Anterosuperior Rotator Cuff Tear Including Biceps Long Head: A 2-Year Follow-up

BACKGROUND: To report the results of an arthroscopic percutaneous repair technique for partial-thickness tears of the anterosuperior cuff combined with a biceps lesion. METHODS: The inclusion criteria were evidence of the upper subscapularis tendon tear and an articular side partial-thickness tear of the supraspinatus tendon, degeneration of the biceps long head or degenerative superior labrum anterior-posterior, above lesions treated by arthroscopic percutaneous repair, and follow-up duration > 24 months after the operation. American Shoulder and Elbow Surgeons (ASES) score, constant score, the pain level on a visual analogue scale, ranges of motion and strength were assessed. RESULTS: The mean (+/- standard deviation) age of the 20 enrolled patients was 56.0 +/- 7.7 years. The forward flexion strength increased from 26.3 +/- 6.7 Nm preoperatively to 38.9 +/- 5.1 Nm at final follow-up. External and internal rotation strength was also significantly increased (14.2 +/- 1.7 to 19.1 +/- 3.03 Nm, 12.3 +/- 3.2 to 18.1 +/- 2.8 Nm, respectively). Significant improvement was observed in ASES and constant scores at 3 months, 1 year and the time of final follow-up when compared with preoperative scores (p < 0.001). The mean subjective shoulder value was 86% (range, 78% to 97%). CONCLUSIONS: The implementation of complete rotator cuff repair with concomitant tenodesis of the biceps long head using arthroscopic percutaneous repair achieved full recovery of normal rotator cuff function, maximum therapeutic efficacy, and patient satisfaction.

Treatment of Femoral Neck Fractures in Patients with Ischemic Heart Disease by Cemented Hemiarthroplasty

PURPOSE: There is a controversy about whether the use of polymethylmethacrylate (PMMA) in orthopedic reconstructive surgery can increase the possibility of cardiovascular dysfunction. This study was undertaken to determine if cemented hemiarthroplasty is safe for treating femoral neck fracture in patients with ischemic heart disease. MATERIAL AND METHODS: Between March 1999 and February 2004, we performed cemented hemiarthroplasties for displaced femoral neck fractures in 158 consecutive patients. This retrospective study consisted of 44 patients with ischemic heart disease (group 1) and 58 age matched control patients (group 2). We compared the mortality rate, the incidence of deep vein thrombosis (DVT), pulmonary embolism, cerebrovascular disease, dislocation and deep infection, the amount of postoperative blood loss and the grade of cementation according to the schema of Barrack on the radiograph between the two groups. RESULTS: No difference was found in the perioperative mortality rate, the deep infection rate, the incidence of DVT or pulmonary embolism, the newly developed heart ischemic events or brain hemorrhagic lesions between the two groups. But there was a greater incidence of dislocation related to weakness from past brain ischemic lesion and the newly developed brain ischemia in group 1 than in group 2 (p<0.05). More importantly, six patients in group 1 had transient symptoms of dyspnea, signs of hypotension and bradycardia within two days postoperatively, which raises suspicions of embolic phenomenon, even though this was not confirmed. CONCLUSION: Close and careful observations should be done for the occurrence of dislocation related to previous brain ischemia, or newly developed brain ischemic lesion or embolic phenomenon. Appropriate thromboprophylaxis is necessary in patients with ischemic heart disease after cemented hemiarthroplasty for the treatment of femoral neck fracture.