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Lee J, Lho T, Lee J, Lee J, Chung SW. Influence of Frequent Corticosteroid Local Injections on the Expression of Genes and Proteins Related to Fatty Infiltration, Muscle Atrophy, Inflammation, and Fibrosis in Patients With Chronic Rotator Cuff Tears: A Pilot Study. Orthop J Sports Med 2024; 12:23259671241252421. [PMID: 38840789 PMCID: PMC11151761 DOI: 10.1177/23259671241252421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/09/2023] [Indexed: 06/07/2024] Open
Abstract
Background The effect of local corticosteroid (CS) injections on rotator cuff muscles remains poorly defined, despite the significance of muscle quality as a crucial prognostic factor for patients with rotator cuff tears (RCTs). Purpose To compare alterations in gene and protein expression patterns in the rotator cuff muscles of patients with RCTs who received frequent joint CS injections with alterations in those without a history of CS injections. Study Design Controlled laboratory study. Methods A total of 24 rotator cuff muscle samples with medium-sized tears from 12 patients with a frequent joint CS injection history (steroid group; 7 men and 5 women who had received ≥5 injections with at least 1 within the previous 3 months; mean age, 63.0 ± 7.2 years) and 12 age- and sex-matched control patients without a history of CS injections (no-steroid group) were acquired. Alterations in the expression of genes and proteins associated with adipogenesis, myogenesis, inflammation, and muscle fibrosis were compared between the groups using quantitative reverse transcription-polymerase chain reaction, Western blotting, and immunohistochemistry. Statistical analysis included comparison of group means using the Mann-Whitney U test, chi-square test, or Fisher exact test and logistic regression for multivariate analysis. Results In the steroid group, the mRNA expression levels of adipogenic CCAAT/enhancer-binding protein alpha (C/EBPα; P = .008) and muscle atrophy-related genes (atrogin; P = .019) were significantly higher, and those of myogenic differentiation 1 (MyoD; P = .035), inflammatory interleukin 6 (IL-6; P = .035), and high mobility group box 1 (P = .003) were significantly lower compared with the no-steroid group. In addition, MyoD (P = .041) and IL-6 (P = .026) expression were decreased in the steroid versus no-steroid group. Immunohistochemistry revealed increased expression of C/EBPα and atrogin and decreased expression of MyoD and IL-6 in the steroid versus no-steroid group. Conclusion Patients with RCTs and a history of frequent CS injections exhibited an upregulation of adipogenic and muscle atrophy-related genes and proteins within the rotator cuff muscles and a downregulation in the expression of myogenic and inflammatory genes and proteins in the same muscles. Clinical Relevance These altered gene and protein expressions by frequent local CS injections may cause poor outcomes in patients with RCTs.
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Affiliation(s)
- JiHwan Lee
- Department of Medicine, Korea University Graduate School, Seoul, Republic of Korea
| | - Taewoo Lho
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jongwon Lee
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jeongkun Lee
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Republic of Korea
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Aamer S, Tokhi I, Asim M, Akhtar M, Razick DI, Wen J, Shelton TJ. Postoperative Infection Following Hip Arthroscopy in Patients Receiving Preoperative Intra-articular Injections: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e61649. [PMID: 38966473 PMCID: PMC11223719 DOI: 10.7759/cureus.61649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/06/2024] Open
Abstract
Intra-articular injections prior to hip arthroscopy are often used to diagnose and conservatively manage hip pathologies, such as femoroacetabular impingement, labral tears, and chondral lesions. As a diagnostic tool, the relief of hip pain following an intra-articular injection helps pinpoint the primary source of pain and assists surgeons in recommending arthroscopic intervention for underlying intra-articular pathologies. However, when injections are not sufficiently spaced apart in time prior to hip arthroscopy, there is an elevated risk of postoperative infection. This systematic review aims to assess whether preoperative intra-articular injections prior to hip arthroscopy are associated with an increased risk of postoperative infection and to determine the safety timeframe for administering such injections prior to the procedure. A comprehensive search was conducted in the PubMed, Embase, and Cochrane Library databases to identify studies examining the relationship between preoperative intra-articular injections and postoperative infection following hip arthroscopy. A meta-analysis was conducted to compare the risk of infection between patients who received injections prior to hip arthroscopy at varying intervals and those who did not receive any preoperative injections. Five studies were included (four level III and one level IV), which consisted of 58,576 patients (58.4% female). Injections administered anytime prior to hip arthroscopy posed a significantly higher risk of infection compared to no history of prior injections (risk ratio: 1.45, 95% confidence interval: 1.14-1.85, P = 0.003). However, upon subanalysis, the risk of infection was significantly higher among patients who received injections within three months prior to hip arthroscopy compared to those who did not receive injections (risk ratio: 1.55, 95% confidence interval: 1.19-2.01, P = 0.001). Additionally, no significant difference in infection risk was observed when injections were administered more than three months before hip arthroscopy compared to no injections (risk ratio: 1.05, 95% confidence interval: 0.56-1.99, P = 0.87). The findings suggest that patients undergoing hip arthroscopy who have previously received intra-articular injections may face a statistically higher risk of postoperative infection, particularly when the injection is administered within three months prior to hip arthroscopy. Consequently, surgeons should exercise caution and avoid administering intra-articular injections to patients scheduled for hip arthroscopy within the subsequent three months to mitigate the increased risk of infection.
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Affiliation(s)
- Sonia Aamer
- Orthopedic Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Ilham Tokhi
- Orthopedic Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Maaz Asim
- Orthopedic Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Muzammil Akhtar
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Daniel I Razick
- Orthopedic Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Jimmy Wen
- Physical Medicine and Rehabilitation, California Northstate University College of Medicine, Elk Grove, USA
| | - Trevor J Shelton
- Orthopedic Surgery, Utah Valley Orthopedics and Sports Medicine, Provo, USA
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Kamel SI, Rosas HG, Gorbachova T. Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications. AJR Am J Roentgenol 2024; 222:e2330458. [PMID: 38117096 DOI: 10.2214/ajr.23.30458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.
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Affiliation(s)
- Sarah I Kamel
- Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107
| | - Humberto G Rosas
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Rhim HC, Ruiz J, Taseh A, Afunugo W, Crockett Z, Schon J, Pan X, Shin J, Schowalter S, Jang KM, Robinson DM. Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis. J Clin Med 2024; 13:1132. [PMID: 38398445 PMCID: PMC10889729 DOI: 10.3390/jcm13041132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. METHODS Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. RESULTS A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. CONCLUSION NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.
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Affiliation(s)
- Hye Chang Rhim
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02115, USA; (A.T.); (J.S.)
| | - Joseph Ruiz
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
| | - Atta Taseh
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02115, USA; (A.T.); (J.S.)
| | - Wilma Afunugo
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
| | - Zack Crockett
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
| | - Jason Schon
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
| | - Xiaoyu Pan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Jaehyung Shin
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02115, USA; (A.T.); (J.S.)
| | - Sean Schowalter
- Department of Sports Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - David M Robinson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA 02115, USA; (H.C.R.); (J.R.); (W.A.); (Z.C.); (J.S.); (D.M.R.)
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5
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Saithna A. Editorial Commentary: Corticosteroid Injections Administered Within 4 Weeks Before Shoulder Arthroscopy Are Associated With an Increased Risk of Infection. Arthroscopy 2024; 40:284-286. [PMID: 38296435 DOI: 10.1016/j.arthro.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 02/08/2024]
Abstract
Corticosteroid injections are a frequently used modality for addressing shoulder pain. The widespread utilization of corticosteroid injections is supported by clinical practice guidelines and consensus statements including the 2019 American Academy for Orthopaedic Surgeons (AAOS) guidelines for the management of rotator cuff injuries. However, steroids may be detrimental to healing potential following cuff repair and increase the risk of re-tear. In addition, corticosteroid injections administered within 4 weeks prior to shoulder arthroscopy are associated with an increased risk of infection. The degree of risk is dependent on the timing of surgery with longer time intervals between injection and shoulder arthroscopy being associated with less risk. The next version of the AAOS clinical practice guidelines for managing rotator cuff tears should incorporate commentary on the specific risk of surgical site infection following pre-operative corticosteroid injections, as well as on the timing of injections, with the aim of increasing awareness of these potentially devastating adverse effects.
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Livadas N, Cuff A, Loughran I, Chesterton P. United Kingdom physiotherapists injection therapy practice for musculoskeletal complaints: A cross-sectional survey. Musculoskelet Sci Pract 2024; 69:102889. [PMID: 38056376 DOI: 10.1016/j.msksp.2023.102889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/09/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Physiotherapists in the United Kingdom (UK), who have received additional training can adopt injection therapy for the treatment of musculoskeletal (MSK) disorders. OBJECTIVES The objective of this practice survey was to explore (i) the frequency of use of injection therapy by UK physiotherapists for MSK disorders; and (ii) the clinical reasoning for selection of injectate, dose and pre/post injection practice. DESIGN Cross-sectional online survey. METHODS The online survey was disseminated via social media and professional networks over a 3-month period. Responses to closed multiple choice survey questions were analysed with descriptive data, with reporting of confidence intervals at 95%. Open questions were analysed using content analysis. RESULTS The survey received 320 responses. The majority (86.6%, n = 277) used landmark guided approaches. The highest frequency of injections administered were for trigger digits, sub acromial pain and the knee joint. Corticosteroid drugs were widely used (99.7%, n = 319, CI 95% 98 to 100) with Triamcinolone (Kenalog) being the most frequently utilised for both joints (58.8%, n = 160, 53 to 65) and soft tissues (46.3%, n = 126, 40 to 52). Drug choice was largely based on availability in clinic (47.1%, n = 128, 41 to 53). Drug doses for common injection sites varied among the respondents with variation also evident in pre and post-injection practice. CONCLUSION Marked variation across some elements of injection therapy practice was evident. Notable differences in corticosteroid preparation used, the doses of drug injected, and the use of local anaesthetic were reported by respondents. Injecting physiotherapists should endeavour to ensure practice is aligned to best available evidence.
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Affiliation(s)
- Nick Livadas
- Connect Health, Floor 3, The Lightbox, Q2, Quorum Business Park, Benton Lane, Newcastle upon Tyne, Tyne and Wear, NE12 8EU, UK; School of Health and Life Sciences, Teesside University, TS1 3BX, UK.
| | - Andrew Cuff
- Connect Health, Floor 3, The Lightbox, Q2, Quorum Business Park, Benton Lane, Newcastle upon Tyne, Tyne and Wear, NE12 8EU, UK; Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Brooks Building, 53 Bonsall Street, M15 6GX, UK
| | | | - Paul Chesterton
- School of Health and Life Sciences, Teesside University, TS1 3BX, UK
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Remily E, Dubin J, Bains SS, Monarrez R, Livesey MG, Weir TB, Hameed D, Ingari JV, Gilotra MN, Hasan SA. Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates. Arthroscopy 2024; 40:277-283.e1. [PMID: 37689159 DOI: 10.1016/j.arthro.2023.08.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection. METHODS An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P < .05. RESULTS Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P < .001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P = .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P = .03), 1 year (1.82, 95% CI 1.13-2,82, P = .01), and 2 years (1.62, 95% CI 1.10-2.47, P = .012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P = .48) 1 year (OR 1.18, 95% CI 0.85-1.63 P = .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P = .54), compared with the control cohort. CONCLUSIONS The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery. LEVEL OF EVIDENCE Level III, retrospective comparative, prognosis study.
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Affiliation(s)
- Ethan Remily
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - Ruben Monarrez
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - Michael G Livesey
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Tristan B Weir
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Daniel Hameed
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - John V Ingari
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - Mohit N Gilotra
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A
| | - S Ashfaq Hasan
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, U.S.A..
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Smith JT, Pill SG, Eggert KA, Brignull CG, Adams KJ, Wyland DJ, Tolan SJ, Thigpen CA, Kissenberth MJ. Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair. JSES Int 2024; 8:75-79. [PMID: 38312263 PMCID: PMC10837736 DOI: 10.1016/j.jseint.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI. Methods An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05). Results There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05). Conclusion Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.
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Affiliation(s)
- Justin T. Smith
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Stephan G. Pill
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | | | | | - Kyle J. Adams
- Department of Orthopedics, Prisma Health Upstate, Greenville, SC, USA
| | - Douglas J. Wyland
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Stefan J. Tolan
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Charles A. Thigpen
- ATI Physical Therapy, Greenville, SC, USA
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
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Moretti L, Bizzoca D, Cassano GD, Coviello M, Franchini A, Moretti B. One-shot platelet-rich plasma (PRP) injection is non-inferior to extracorporeal shockwave therapy in the management of supraspinatus tendinosis. Musculoskelet Surg 2023; 107:455-462. [PMID: 36905574 PMCID: PMC10709471 DOI: 10.1007/s12306-023-00778-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/26/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Supraspinatus tendinosis (ST) refers to the intratendinous degeneration of the supraspinatus tendon. Platelet-Rich Plasma (PRP) is one of the possible conservative treatments for supraspinatus tendinosis. This prospective observational study aims to evaluate the efficacy and safety of a single ultrasound-guided PRP injection in the treatment of supraspinatus tendinosis and to assess its non-inferiority to the widely used shockwave therapy. METHODS Seventy-two amateur athletes (35 male, mean age: 43.75 ± 10.82, range 21-58 years old) with ST were finally included in the study. All the patients underwent clinical evaluation at baseline, (T0) and at 1-month (T1), 3-month (T2) and 6-month (T3) follow-up using the following clinical scales: the Visual Analogue Scale for pain (VAS), Constant Score and the Disabilities of the Arm, Shoulder and Hand Score (DASH). A T0 and T3 ultrasound examination was also performed. The findings observed in the recruited patients were compared to the clinical results observed in a retrospective control group made up of 70 patients (32 male, mean age = 41.29 ± 13.85, range 20-65 years old) treated by extracorporeal shockwave therapy (ESWT). RESULTS VAS, DASH and Constant scores significantly improved from T0 to T1; the improvement in clinical scores was kept until T3. No local nor systemic adverse events were observed. An improvement in the tendon structure was observed on ultrasound examination. PRP showed a non-statistical inferiority, in terms of efficacy and safety, compared to ESWT. CONCLUSION The PRP one-shot injection is a valid conservative treatment to reduce pain, and improve both quality of life and functional scores in patients with supraspinatus tendinosis. Furthermore, the PRP intratendinous one-shot injection showed a non-inferiority in terms of efficacy at the 6-month follow-up, compared to ESWT.
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Affiliation(s)
- L Moretti
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - D Bizzoca
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy.
- PhD Course in Public Health, Clinical Medicine, and Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100, Bari, Italy.
| | - G D Cassano
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - M Coviello
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - A Franchini
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - B Moretti
- Department DiBraiN, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Piazza Giulio Cesare 11, 70124, Bari, Italy
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Fernández-Matías R, García-Pérez F, Requejo-Salinas N, Gavín-González C, Martínez-Martín J, García-Valencia H, Flórez-García MT. Content reporting and effectiveness of therapeutic exercise in the management of massive rotator cuff tears: A systematic review with 490 patients. Shoulder Elbow 2023; 15:92-107. [PMID: 37974611 PMCID: PMC10649485 DOI: 10.1177/17585732221140113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2023]
Abstract
Background Massive rotator cuff tears (MRCT) account for a substantial fraction of tears above the age of 60 years. However, there are no clear criteria for prescription parameters within therapeutic exercise treatments. The aim of this study was to evaluate the effects and characteristics of therapeutic exercise treatments in patients with MRCT. Methods A systematic search was conducted in MEDLINE/PubMed, Web of Science, SPORTDiscus, SciELO, Scopus and EMBASE from inception to August 2022. Studies were included if they evaluated the effects of exercise on patients with MRCT. The risk of bias was evaluated and the Consensus on Exercise Reporting Template (CERT) was also used. A narrative synthesis without meta-analysis was performed. Results One randomized controlled trial, two non-randomized studies, six non-controlled studies, one case series and four retrospective studies were included. They ranged from serious to moderate risk of bias. The CERT reflected a poor description of the exercise programmes. Studies showed a pattern of improvements in most patient-reported outcome measures (PROM) surpassing the MCID, and active elevation range of motion. Conclusions There is limited evidence that exercise and co-interventions are effective in the management of some patients with MRCT, based on a systematic review without meta-analysis. Future research should improve content reporting. Level of evidence IV.
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Affiliation(s)
- Rubén Fernández-Matías
- Research Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain
- Physiotherapy and Rehabilitation Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain
| | - Fernando García-Pérez
- Physiotherapy and Rehabilitation Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain
| | - Néstor Requejo-Salinas
- Department of Physical Therapy, Superior Center for University Studies La Salle, Autonomous University of Madrid, Madrid, Spain
- Motion in Brains Research Group, Institute of Neuroscience and Movement Sciences (INCIMOV). Superior Center for University Studies La Salle. Autonomous University of Madrid, Madrid, Spain
| | - Carlos Gavín-González
- Orthopedic Surgery and Traumatology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain
| | - Javier Martínez-Martín
- Orthopedic Surgery and Traumatology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain
| | - Homero García-Valencia
- Orthopedic Surgery and Traumatology Unit, Hospital Universitario Fundación Alcorcon, Madrid, Spain
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Velasquez Garcia A, Ingala Martini L, Franco Abache A, Abdo G. Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy. World J Orthop 2023; 14:505-515. [PMID: 37485430 PMCID: PMC10359750 DOI: 10.5312/wjo.v14.i7.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/11/2023] [Accepted: 05/15/2023] [Indexed: 07/18/2023] Open
Abstract
Shoulder pain is a common musculoskeletal complaint, and rotator cuff (RC) pathologies are one of the main causes. The RC undergoes various tendinopathic and avascular changes during the aging process. Other degenerative changes affecting its healing potential make it an appealing target for biological agents. Platelet-rich plasma (PRP) has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators, and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle, ligaments, and tendinous cells. This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence. Due to the different characteristics and conflicting outcomes, clinicians should use PRP with moderate expectations until more consistent evidence is available. However, it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing. Its autologous origin makes it a safe treatment, and its characteristics make it a promising option for treating RC tendinopathy, but the efficacy has yet to be established.
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Affiliation(s)
| | - Liborio Ingala Martini
- Department of Orthopedic Surgery, Hospital IVSS Dr. Luis Ortega, Porlamar 6301, Venezuela
- Department of Orthopedic Surgery, Hospital Clinicas del Este, Los Robles 6301, Venezuela
| | - Andres Franco Abache
- Department of Orthopedic Surgery, Hospital de Especialidades Guayaquil MSP, Guayaquil 090101, Ecuador
| | - Glen Abdo
- Department of Graduate Medical Education, Internal Medicine Residence Program, New York Medical College at St. Mary’s and St. Clare’s, Passaic, NJ 07055, United States
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Tanpowpong T, Thepsoparn M, Numkarunarunrote N, Itthipanichpong T, Limskul D, Thanphraisan P. Effects of Platelet-Rich Plasma in Tear Size Reduction in Partial-Thickness Tear of the Supraspinatus Tendon Compared to Corticosteroids Injection. SPORTS MEDICINE - OPEN 2023; 9:11. [PMID: 36752928 PMCID: PMC9908802 DOI: 10.1186/s40798-023-00556-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Corticosteroid (CS) injection is commonly used in partial-thickness rotator cuff tears to decrease pain. However, this could result in unwanted side effects, such as tendon rupture. Alternatively, platelet-rich plasma (PRP) injection is frequently used to treat tendinopathies because it enhances healing. This study aimed to compare the differences in tear size and functional scores between intralesional PRP and subacromial CS injections. METHODS Patients with symptomatic partial-thickness tears of the supraspinatus tendon who underwent conservative treatment for ≥ 3 months were enrolled. All patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis. Fourteen and 15 patients were randomized to receive intralesional PRP and subacromial CS injections, respectively. Tears were measured in the coronal and sagittal planes. The patients underwent another MRI 6 months after the injection. Tear size was compared between the two MRI results. The American Shoulder and Elbow Surgeons Shoulder score (ASES) and Constant-Murley score (CMS) were also obtained. RESULTS The baseline data were similar between the groups. In the coronal plane, PRP and CS showed tear size reductions of 3.39 mm (P = 0.003) and 1.10 mm (P = 0.18), respectively. In the sagittal plane, PRP and CS showed tear size reductions of 2.97 mm (P = 0.001) and 0.76 mm (P = 0.29), respectively. Functional scores improved 6 months after injection in both groups, but PRP showed better functional scores than CS (P = 0.002 for ASES, P = 0.02 for CS). CONCLUSION Intralesional PRP injection can reduce the tear size in partial-thickness tears of the supraspinatus tendon. Subacromial steroid injection did not significantly affect the tear size. While CS improved functional scores compared with baseline, PRP resulted in better improvement 6 months post-injection. Trial registration Thai Clinical Trials Registry, TCTR20210428004. Registered 28 April 2021-retrospectively registered, TCTR20210428004 .
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Affiliation(s)
- Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Marvin Thepsoparn
- Pain Management Research Unit, Department of Anesthesia, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Rama IV Rd, Bangkok, 10330, Thailand.
| | - Numphung Numkarunarunrote
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Phark Thanphraisan
- Pain Management Research Unit, Department of Anesthesia, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Rama IV Rd, Bangkok, 10330 Thailand
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13
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Brand JC, Hardy R. Editorial Commentary: Platelet-Rich Plasma May Be Superior to Corticosteroid Injection for Rotator Cuff Disease Because of Improved Chance of Healing, Longer-Lasting Pain Relief, and No Detriment if Surgery Is Needed. Arthroscopy 2023; 39:422-424. [PMID: 36604005 DOI: 10.1016/j.arthro.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 01/04/2023]
Abstract
Both corticosteroid and platelet-rich plasma (PRP) injections have benefits for patients with rotator cuff tendinopathy. Currently, the published clinical differences are small, and statistical differences aren't as significant without a clinical difference, so the answer is personal. PRP is expensive, but rotator cuff healing is possible, resulting in the best chance to avoid surgery. And, if surgery is required, PRP results in no detriment, unlike corticosteroid. PRP may result in lasting pain relief. Based on the current literature, we prefer PRP despite the cost.
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14
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Johnson AJ, Bradsell H, Frank RM. Use of Injections and Biologics for the Nonoperative Treatment of Rotator Cuff Pathology. Clin Sports Med 2023; 42:53-68. [DOI: 10.1016/j.csm.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Adra M, El Ghazal N, Nakanishi H, Smayra K, Hong SS, Miangul S, Matar RH, Than CA, Tennent D. Platelet-rich plasma versus corticosteroid injections in the management of patients with rotator cuff disease: A systematic review and meta-analysis. J Orthop Res 2023; 41:7-20. [PMID: 36250611 PMCID: PMC10092782 DOI: 10.1002/jor.25463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/22/2022] [Accepted: 10/08/2022] [Indexed: 02/04/2023]
Abstract
Platelet-rich plasma (PRP) is an alternative to corticosteroid (CS) injections in managing rotator cuff disease. This meta-analysis investigated differences between PRP and CS for function and pain scores in significance and minimal clinical important difference (MCID). A literature search of Ovid Cochrane Library, Medline, Embase, Epub, and Scopus was conducted from inception to October 28, 2021. Eligible studies reported patients older than 18 years with a diagnosis of rotator cuff disease. This review was registered in PROSPERO (ID: CRD42021278740). Twelve studies met eligibility criteria (n = 639) of patients receiving either PRP or CS. At short-term follow-up, a difference favored CS compared to PRP in baseline change for disability of arm, shoulder, and hand (DASH) score (MD = -5.08, 95% CI: -8.00, -2.15; p = 0.0007; I2 = 0%) and simple shoulder test (SST) (MD = 1.25, 95% CI: 0.33, 2.18; p = 0.008; I2 = 0%). At intermediate follow-up, a difference favored PRP to CS baseline change of the DASH score (MD = 3.41, 95% CI: 0.67, 6.15; p = 0.01; I2 = 0%). At medium-term, a difference favored PRP to CS baseline change of the American Shoulder and Elbow Surgeons Shoulder (ASES) score (MD = -4.42, 95% CI: -8.16, -0.67; p = 0.02; I2 = 0%). Both treatments achieved individual MCID for each score. Despite favoring CS at short-term follow-up and PRP at intermediate- and medium-term follow-up, functional and pain scores did not demonstrate any clinical difference between the two treatment modalities in management of rotator cuff disease at all follow-up periods.
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Affiliation(s)
- Maamoun Adra
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Nour El Ghazal
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Hayato Nakanishi
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Karen Smayra
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Sam S. Hong
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Shahid Miangul
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
| | - Reem H. Matar
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
- Division of Gastroenterology and HepatologyMayo ClinicRochesterNew YorkUSA
| | - Christian A. Than
- St George's University of LondonLondonUK
- University of Nicosia Medical SchoolUniversity of NicosiaNicosiaCyprus
- School of Biomedical SciencesThe University of QueenslandBrisbaneQueenslandAustralia
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16
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Jou E, Zhou AK, Ho JSY, Thahir A. Perioperative use of intra-articular steroids during the COVID-19 pandemic. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022; 32:1225-1235. [PMID: 34468841 PMCID: PMC8408365 DOI: 10.1007/s00590-021-03105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted. METHODS A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities. RESULTS ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications. CONCLUSION Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.
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Affiliation(s)
- Eric Jou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- MRC Laboratory of Molecular Biology, Cambridge Biomedical Campus, Cambridge, UK.
| | | | | | - Azeem Thahir
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. J Orthop Sports Phys Ther 2022; 52:647-664. [PMID: 35881707 DOI: 10.2519/jospt.2022.11306] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306.
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18
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Comparison of the efficacy of physiotherapy, subacromial corticosteroid, and subacromial hyaluronic acid injection in the treatment of subacromial impingement syndrome: a retrospective study. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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van Doorn PF, Schiphof D, Rozendaal RM, Ottenheijm RPG, van der Lei J, Bindels PJE, de Schepper EIT. The use and safety of corticosteroid injections for shoulder pain in general practice: a retrospective cohort study. Fam Pract 2022; 39:367-372. [PMID: 34623417 PMCID: PMC9155165 DOI: 10.1093/fampra/cmab116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Guidelines for shoulder pain in general practice recommend treatment with corticosteroid injections (CSI) if initial pain management fails. However, little is known about the actual use and safety of CSIs in treatment by general practitioners (GP). OBJECTIVE The objective of this study was to gain insight into the use and safety of CSIs for patients with a new episode of shoulder pain in general practice. METHODS A retrospective cohort study was conducted using a healthcare database containing the electronic medical records of approximately 200,000 patients in general practice. A search algorithm was constructed to identify patients with a new episode of shoulder pain between January 2012 and December 2017. Data on the use of CSIs in 2 random samples (n = 1,000) were manually validated for a 12-month period after the diagnosis. RESULTS In total, 26% of the patients with a new episode of shoulder pain received a CSI. The patient's age (OR 1.03, 95% CI 1.02-1.04) and a history of shoulder pain (OR 1.52, 95% CI 1.13-2.12) were significantly associated with the administration of a CSI. Half of the patients received the CSI in the first consultation. The patient's age was positively associated with the likelihood of receiving the CSI in the first consultation (OR 1.01, 95% CI 1.00-1.02). No serious adverse reactions were recorded by the GP. CONCLUSION In contrast to the guidelines, CSIs were frequently administered in the first consultation. Older patients and patients with a history of shoulder pain were more likely to receive a CSI for shoulder pain.
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Affiliation(s)
- Pieter F van Doorn
- Department of General practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dieuwke Schiphof
- Department of General practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rianne M Rozendaal
- Department of General practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ramon P G Ottenheijm
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General practice, Erasmus Medical Center, Rotterdam, The Netherlands
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20
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Effectiveness of Ultrasound-Guided Corticosteroid Injections, Prolotherapy, and Exercise Therapy on Partial-Thickness Supraspinatus Tears. J Sport Rehabil 2022; 31:869-875. [PMID: 35453118 DOI: 10.1123/jsr.2021-0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT To investigate the effects of steroid injection (STE), prolotherapy (PRO), and exercise therapy in the treatment of partial tears of the supraspinatus. DESIGN A retrospective cohort study. METHODS A total of 64 patients with clinically and radiologically diagnosed partial-thickness supraspinatus tear who received either a cortisone injection (STE), dextrose PRO, or physical therapy combined with home-based exercise therapy were included. Main outcome measures were patients' visual analog scale scores, Western Ontario Rotator Cuff (WORC) Index scores, and the Shoulder Pain and Disability Index scores at the baseline, 3 weeks, and 3 months. RESULTS The effect of group, time, and group-time interaction on visual analog scale, WORC, and Shoulder Pain and Disability Index scores was statistically significant (P < .001). Visual analog scale and Shoulder Pain and Disability Index scores were the lowest in the STE group at week 3, and the lowest in the PRO group at month 3 (P < .001). WORC scores of the STE group were the highest at week 3 (P < .001). At month 3, WORC scores of STE and PRO groups were similar (P = .089), but significantly higher than exercise therapy. CONCLUSIONS Corticosteroids provide a fast pain-relieving effect and improvement in function in partial-thickness rotator cuff tears, but these effects diminish over time, whereas PRO provides a long-lasting effect.
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21
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Puzzitiello RN, Patel BH, Lavoie-Gagne O, Lu Y, Nwachukwu BU, Forsythe B, Salzler MJ. Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e763-e774. [PMID: 35494258 PMCID: PMC9042756 DOI: 10.1016/j.asmr.2021.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/11/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects. Methods A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications. Results Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month. Conclusions Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events. Level of Evidence Systematic review of level I-IV studies.
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22
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Annaniemi JA, Pere J, Giordano S. Platelet-rich plasma versus corticosteroid injections for rotator cuff tendinopathy: a comparative study with up to 18 months follow-up. Clin Shoulder Elb 2022; 25:28-35. [PMID: 35086189 PMCID: PMC8907507 DOI: 10.5397/cise.2021.00486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Given the complications involved in corticosteroid (CS) injections, subacromial platelet-rich plasma (PRP) injections may provide a valid alternative to CS in the treatment of rotator cuff (RC) tendinopathy. Methods We retrospectively reviewed a total of 98 patients affected by RC tendinopathy who were treated with either subacromial injection of PRP or CS. The PRP group received three injections of autologous PRP at 2 weeks interval, and the CS group received one injection of CS. The Western Ontario Rotator Cuff Index (WORC) was the primary outcome measure, while the secondary outcome measures were the visual analog scale (VAS), range of motion (ROM), and need for cuff repair surgery, which were analyzed at intervals of 6, 12, and 18 months. Results A total of 75 patients were included in the analysis (PRP, n=35; CS, n=40). The mean follow-up for PRP was 21.1±8.7 months and for CS was 33.6±16.3 months (p<0.001). Both groups showed improvement in WORC, VAS, and ROM. No significant differences were detected between the two groups in any of the primary (WORC) or secondary outcomes over 6, 12, and 18 months (all p>0.05). No adverse events were detected. Conclusions Both treatments improved patient symptoms, but neither resulted in a significantly better outcome in this series of patients. PRP can be a safe and feasible alternative to CS, even at long-term follow-up, to reduce local and systemic effects involved with CS injections.
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Bedrin MD, Putko RM, Dickens JF. Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities. Sports Med Arthrosc Rev 2021; 29:e71-e76. [PMID: 34730120 DOI: 10.1097/jsa.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.
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Eliason A, Harringe M, Engström B, Sunding K, Werner S. Bilateral ultrasound findings in patients with unilateral subacromial pain syndrome. Physiother Theory Pract 2021; 38:2568-2579. [PMID: 34402715 DOI: 10.1080/09593985.2021.1962462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Subacromial pain syndrome is a common musculoskeletal shoulder problem. The accuracy of clinical tests is low and techniques such as ultrasound and magnetic resonance imaging have been added to set up a diagnosis. Previous researchers have usually only examined the symptomatic shoulder. However, there might be similar findings in the asymptomatic shoulder. Objective:The aim of the present study was to investigate the prevalence of structural abnormalities of both shoulders in patients with clinically diagnosed unilateral subacromial pain syndrome using diagnostic ultrasound. Methods: Bilateral ultrasound examinations were performed in 115 consecutive patients, 54 men and 61 women. The patients were recruited from primary care centers in the area of Stockholm, Sweden. Results: Abnormal ultrasound findings were found in both shoulders and increased with age (p = .0004). Bursitis was the most common ultrasound finding and significantly more prevalent in the symptomatic shoulder compared to the asymptomatic shoulder (90%:74%; p = .0021), though 73% of the bursitis were bilateral. Supraspinatus is the most vulnerable tendon of the rotator cuff in both shoulders. In terms of partial-thickness tears and tendinosis, the tendon was affected more commonly in the symptomatic shoulder compared to the asymptomatic shoulder (30%:14%: 14%; p = .0026) and (24%:10%; p = .0054), respectively, but for calcification no significant difference between the shoulders was found (18%:12%; 0.1988). Conclusion: Ultrasound detected shoulder abnormalities were present in both symptomatic and asymptomatic shoulders. Bursitis and partial-thickness tears were more common in the affected shoulder when compared to the unaffected shoulder. Ultrasound as well as clinical examination findings and patient´s history should be taken into consideration when diagnosing patients with subacromial pain syndrome.
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Affiliation(s)
- Anna Eliason
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Health Care Services Stockholm County (SLSO), Region Stockholm
| | - Marita Harringe
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Aleris Sports Medicine & Ortopedi Sabbatsberg Hospital, Stockholm, Sweden
| | - Björn Engström
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Capio Artro Clinic, Stockholm, Sweden
| | - Kerstin Sunding
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Aleris Sports Medicine & Ortopedi Sabbatsberg Hospital, Stockholm, Sweden
| | - Suzanne Werner
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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25
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Arvind V, Huang AH. Reparative and Maladaptive Inflammation in Tendon Healing. Front Bioeng Biotechnol 2021; 9:719047. [PMID: 34350166 PMCID: PMC8327090 DOI: 10.3389/fbioe.2021.719047] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 12/26/2022] Open
Abstract
Tendon injuries are common and debilitating, with non-regenerative healing often resulting in chronic disease. While there has been considerable progress in identifying the cellular and molecular regulators of tendon healing, the role of inflammation in tendon healing is less well understood. While inflammation underlies chronic tendinopathy, it also aids debris clearance and signals tissue repair. Here, we highlight recent findings in this area, focusing on the cells and cytokines involved in reparative inflammation. We also discuss findings from other model systems when research in tendon is minimal, and explore recent studies in the treatment of human tendinopathy to glean further insights into the immunobiology of tendon healing.
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Affiliation(s)
- Varun Arvind
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Alice H. Huang
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Orthopedic Surgery, Columbia University, New York, NY, United States
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26
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Wang C, Zhang Z, Ma Y, Liu X, Zhu Q. Platelet-rich plasma injection vs corticosteroid injection for conservative treatment of rotator cuff lesions: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24680. [PMID: 33607808 PMCID: PMC7899870 DOI: 10.1097/md.0000000000024680] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To explore the effectiveness of platelet-rich plasma (PRP) injection regarding functional recovery, pain relief, and range of motion (ROM) of shoulder compared with the corticosteroid injection in patients with rotator cuff lesions treated non-operatively. METHODS An electronic literature search was performed by 2 authors in the PubMed, Embase, Cochrane Library, and Web of Science databases to identify relevant randomized controlled trial (RCTs) that were published up to July 20, 2020. The quality of the included RCTs was evaluated using the approach recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Standardized mean differences (SMDs) or mean differences (MDs) with 95% confidence intervals (CIs) were applied to calculate the pooled effect sizes. RESULTS Six RCTs were included in this systematic review. Meta-analysis revealed that corticosteroid injection yielded statistically significant superior functional recovery (SMD = -0.80; 95% CI, -1.42 to -0.18; P = .01) and pain relief (MD = 1.59; 95% CI, 0.30-2.89; P = .02) compared with PRP injection for rotator cuff lesions during the short-term follow-up period. However, at the medium-term and long-term follow-up, no statistically significant difference was identified between the 2 groups. Regarding the ROM of shoulder, no statistically significant difference was found between the 2 groups during the whole follow-up period. CONCLUSIONS The current clinical evidence revealed short-term efficacy of corticosteroid injection and no significant medium- to long-term difference between corticosteroid and PRP injection in the treatment of rotator cuff lesions. Additional studies with longer follow-ups, larger sample sizes, and more rigorous designs are needed to draw more reliable and accurate conclusions.
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27
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Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers 2021; 7:1. [PMID: 33414454 DOI: 10.1038/s41572-020-00234-1] [Citation(s) in RCA: 293] [Impact Index Per Article: 97.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.
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Affiliation(s)
- Neal L Millar
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
| | | | - Kristian Thorborg
- Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Paul D Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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28
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Hurd JL, Facile TR, Weiss J, Hayes M, Hayes M, Furia JP, Maffulli N, Winnier GE, Alt C, Schmitz C, Alt EU, Lundeen M. Safety and efficacy of treating symptomatic, partial-thickness rotator cuff tears with fresh, uncultured, unmodified, autologous adipose-derived regenerative cells (UA-ADRCs) isolated at the point of care: a prospective, randomized, controlled first-in-human pilot study. J Orthop Surg Res 2020; 15:122. [PMID: 32238172 PMCID: PMC7110715 DOI: 10.1186/s13018-020-01631-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background This study tested the hypothesis that treatment of symptomatic, partial-thickness rotator cuff tears (sPTRCT) with fresh, uncultured, unmodified, autologous adipose-derived regenerative cells (UA-ADRCs) isolated from lipoaspirate at the point of care is safe and more effective than corticosteroid injection. Methods Subjects aged between 30 and 75 years with sPTRCT who did not respond to physical therapy treatments for at least 6 weeks were randomly assigned to receive a single injection of an average 11.4 × 106 UA-ADRCs (in 5 mL liquid; mean cell viability: 88%) (n = 11; modified intention-to-treat (mITT) population) or a single injection of 80 mg of methylprednisolone (40 mg/mL; 2 mL) plus 3 mL of 0.25% bupivacaine (n = 5; mITT population), respectively. Safety and efficacy were assessed using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), RAND Short Form-36 Health Survey, and pain visual analogue scale (VAS) at baseline (BL) as well as 3 weeks (W3), W6, W9, W12, W24, W32, W40, and W52 post treatment. Fat-saturated T2-weighted magnetic resonance imaging of the shoulder was performed at BL as well as at W24 and W52 post treatment. Results No severe adverse events related to the injection of UA-ADRCs were observed in the 12 months post treatment. The risks connected with treatment of sPTRCT with UA-ADRCs were not greater than those connected with treatment of sPTRCT with corticosteroid injection. However, one subject in the corticosteroid group developed a full rotator cuff tear during the course of this pilot study. Despite the small number of subjects in this pilot study, those in the UA-ADRCs group showed statistically significantly higher mean ASES total scores at W24 and W52 post treatment than those in the corticosteroid group (p < 0.05). Discussion This pilot study suggests that the use of UA-ADRCs in subjects with sPTRCT is safe and leads to improved shoulder function without adverse effects. To verify the results of this initial safety and feasibility pilot study in a larger patient population, a randomized controlled trial on 246 patients suffering from sPTRCT is currently ongoing. Trial registration Clinicaltrials.gov ID NCT02918136. Registered September 28, 2016, https://clinicaltrials.gov/ct2/show/NCT02918136. Level of evidence Level I; prospective, randomized, controlled trial.
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Affiliation(s)
- Jason L Hurd
- Sanford Orthopedics & Sports Medicine Sioux Falls, 1210 W. 18th St., Suite G01, Sioux Falls, SD, 57104, USA.
| | | | | | | | | | - John P Furia
- SUN Orthopedics of Evangelical Community Hospital, Lewisburg, PA, USA
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, UK.,School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University School of Medicine, Stoke on Trent, UK
| | | | | | - Christoph Schmitz
- Institute of Anatomy, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Eckhard U Alt
- Sanford Health, Sioux Falls, SD, USA.,InGeneron, Inc., Houston, TX, USA.,Isar Klinikum, Munich, Germany
| | - Mark Lundeen
- Sanford Orthopedics & Sports Medicine Fargo, Fargo, ND, USA
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