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Lui PPY, Liang Z, Tan RM, Yung PSH. Establishment of a Mouse Degenerative Model of Patellar Tendinopathy with Upregulation of Inflammation. Int J Mol Sci 2024; 25:3847. [PMID: 38612656 PMCID: PMC11011606 DOI: 10.3390/ijms25073847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
There is no mouse model of patellar tendinopathy. This study aimed to establish a mouse inflammatory and degenerative patellar tendon injury model, which will facilitate research on patellar tendinopathy using advanced molecular tools including transgenic models. Collagenase at different doses (low dose (LD), medium dose (MD), high dose (HD)) or saline was injected over the mouse patellar tendon. At weeks 1, 2, 4, and 8 post-injection, the tendons were harvested for histology and further examined by micro-computed tomography (microCT) imaging at week 8. The optimal dose group and the saline group were further evaluated by immunohistochemical staining, gait pattern, and biomechanical properties. The histopathological score increased dose-dependently post-collagenase injection. Ectopic mineralization was observed and increased with collagenase dose. The LD group was selected for further analysis. The expression of IL-10, TNF-α, and MMP-1 significantly increased post-injection. The changes of limb idleness index (ΔLII) compared to preinjury state were significantly higher, while the ultimate load, stiffness, ultimate stress, and maximum Young's modulus were significantly lower in the LD group compared to the saline group. A mouse inflammatory degenerative model of patellar tendon injury resembling tendinopathy was established as indicated by the dose-dependent increase in tendon histopathology, ectopic calcification, decrease in biomechanical properties, and pain-associated gait changes.
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Affiliation(s)
- Pauline Po Yee Lui
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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2
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Arias-Vázquez PI, Guzzardo MN, Guzzardo DR, Castillo-Avila RG, Tovilla-Zárate CA, Ake Montiel MAN. Efficacy of ozone injections for reducing musculoskeletal pain in comparison with corticosteroid injections: A systematic review and meta-analysis. J Back Musculoskelet Rehabil 2024; 37:821-838. [PMID: 38277280 DOI: 10.3233/bmr-230173] [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] [Indexed: 01/28/2024]
Abstract
BACKGROUND Corticosteroid injections are frequently used in the short-term treatment of musculoskeletal pain, but their use is controversial as repeated exposures to corticosteroids can lead to deleterious effects on musculoskeletal tissue. Ozone injections have been proposed as a possible treatment for musculoskeletal pain; however, their effectiveness has not been compared with corticosteroids. OBJECTIVE To evaluate the effectiveness of ozone injections for reducing pain in individuals with musculoskeletal pain in comparison with corticosteroid injections through a meta-analysis. METHODS An online systematic search was performed using electronic databases up to September 2023. We searched for studies that compared corticosteroid injections with ozone injections in the treatment of musculoskeletal pain of diverse origins. RESULTS Eleven studies were included comprising a total of 534 individuals. In the overall pooled analysis, a pain reduction in favor of corticosteroid injections was found in the short term (d= 0.31, 95% CI 0.01 to 0.60, p (z) 0.04, I2 = 32%). In the medium term, no significant differences were found in reducing pain between groups (d=-0.17, 95% CI -0.42 to 0.07, p (z) 0.15, I2 = 0%). CONCLUSIONS Our results suggest that corticosteroids injections are more effective in reducing musculoskeletal pain in the short term, but equally effective in the medium term when compared with ozone injections. Nonetheless, better-quality clinical trials are necessary to corroborate these results.
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Affiliation(s)
| | - Mauro Nicolás Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
| | - Duilio Román Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
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Bafaloukos D, Gazouli I, Koutserimpas C, Skarlos PD, Samonis G. Bilateral Spontaneous Supraspinatus Tendon Rupture Under Prolonged BRAF/MEK Targeting Treatment in a Melanoma Patient. Cureus 2023; 15:e50567. [PMID: 38222175 PMCID: PMC10788042 DOI: 10.7759/cureus.50567] [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: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
The B-Raf proto-oncogene, serine/threonine kinase (BRAF)/ mitogen-activated protein kinase kinase (MEK) targeting agents have become the treatment of choice for BRAF-mutated melanoma during the last decade. However, it is possible that some long-term adverse events of these drugs have not yet been reported. A case of bilateral spontaneous, non-traumatic, supraspinatus tendon rupture in a 65-year-old Caucasian male suffering metastatic melanoma under prolonged and successful combination treatment with dabrafenib plus trametinib is presented. These damages could not be attributed to some other probable cause. The ruptured tendons were promptly restored arthroscopically. Oncologists should remain vigilant for the early detection of potential side effects of BRAF/MEK targeting agents that have not been systematically recorded yet but may appear and affect patients in the long run.
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Affiliation(s)
| | - Ioanna Gazouli
- Department of Medical Oncology, Metropolitan Hospital, Athens, GRC
| | - Christos Koutserimpas
- Department of Orthopedics and Traumatology, 251 Air Force General Hospital, Athens, GRC
- Department of Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | | | - George Samonis
- Department of Medicine, University of Crete, Heraklion, GRC
- Department of Medical Oncology, Metropolitan Hospital, Athens, GRC
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Lemme NJ, Yang D, Lama C, Testa EJ, Dworkin M, Modest JM, Owens BD, Daniels AH, DeFroda SF. The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty. Shoulder Elbow 2023; 15:87-94. [PMID: 37692872 PMCID: PMC10492524 DOI: 10.1177/17585732221114647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 09/12/2023]
Abstract
Background Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.
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Affiliation(s)
- Nicholas J Lemme
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Daniel Yang
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Christopher Lama
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Edward J Testa
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Myles Dworkin
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Jacob M Modest
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Providence, RI, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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5
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Feng S, Li H, Zhong Y, Xie Y, Chen J, Chen Y, Chen S. Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections. Am J Sports Med 2023; 51:733-742. [PMID: 36734466 DOI: 10.1177/03635465221145949] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair. PURPOSE To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes-including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness-were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9. RESULTS Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy. CONCLUSION No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.
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Affiliation(s)
- Sijia Feng
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Huizhu Li
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuting Zhong
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuxue Xie
- Department of Radiology and Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuzhou Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiyi Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Pang L, Xu Y, Li T, Li Y, Zhu J, Tang X. Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials. Arthroscopy 2023; 39:402-421.e1. [PMID: 35810976 DOI: 10.1016/j.arthro.2022.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To explore whether platelet-rich plasma (PRP) injection can be a viable alternative to corticosteroid (CS) injection for conservative treatment of rotator cuff disease. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, The Cochrane Library, and Web of Science were searched from January 1, 1990, to March 20, 2022, for English-language randomized controlled trials that compared PRP and CS injections for patients with rotator cuff disease. Two evaluators independently screened the literature, extracted data, and assessed the level of evidence and methodologic quality of the enrolled studies. The meta-analysis was conducted using RevMan software (version 5.3.3). RESULTS Thirteen nonsurgical randomized controlled trials with 725 patients were included. Compared with CS, PRP provided statistically worse short-term (<2 months) changes in American Shoulder and Elbow Surgeons (ASES) assessment scores, Simple Shoulder Test scores, and Disabilities of the Arm, Shoulder and Hand questionnaire scores but provided better medium-term (2-6 months) changes in Disabilities of the Arm, Shoulder and Hand scores, as well as long-term (≥6 months) changes in Constant-Murley scores, ASES scores, and Simple Shoulder Test scores. No statistically significant differences regarding pain reduction were found between the 2 groups. PRP injections led to worse short-term changes in forward flexion and internal rotation but better medium-term changes in forward flexion and external rotation. PRP showed significantly lower rates of post-injection failure (requests for subsequent injections or surgical intervention prior to 12 months) than CS. No outcome reached the minimal clinically important difference. After sensitivity analyses excluding studies with substantial clinical and/or methodologic heterogeneity, PRP showed better medium-term changes in ASES scores and visual analog scale scores and long-term changes in visual analog scale scores that reached the minimal clinically important difference. CONCLUSIONS Without the drawbacks of CS injection, PRP injection is not worse than CS injection in terms of pain relief and function recovery at any time point during follow-up. PRP injection may reduce rates of subsequent injection or surgery, and it might provide better improvements in pain and function in the medium to long term. PRP injection can be a viable alternative to CS injection for conservative treatment of rotator cuff disease. LEVEL OF EVIDENCE Meta-analysis of Level I and II studies.
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Affiliation(s)
- Long Pang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China; West China Medical School, Sichuan University, Chengdu, China
| | - Yang Xu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China; West China Medical School, Sichuan University, Chengdu, China
| | - Tao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yinghao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Zhu
- West China Hospital, Sichuan University, Chengdu, China.
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
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Nudelman B, Song B, Higginbotham DO, Piple AS, Montgomery WH. Platelet-Rich Plasma Injections Are at Least Equivalent to Corticosteroid Injections for Adhesive Capsulitis: A Systematic Review of Prospective Cohort Studies. Arthroscopy 2023; 39:1320-1329. [PMID: 36708748 DOI: 10.1016/j.arthro.2023.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the role of platelet-rich plasma (PRP) for adhesive capsulitis (AC) as compared with other injectables. METHODS A literature search of the PubMed and Embase online databases was performed to identify articles evaluating injection therapy for the treatment of AC. The inclusion criteria included prospective studies comparing PRP against alternative injectables with a minimum of 15 patients in each treatment arm and a minimum 12-week follow-up period. Pain scores, range of motion, and function scores were the primary outcomes assessed. RESULTS Five articles comparing PRP with corticosteroid or saline solution injections met the inclusion criteria. A total of 157 patients were treated with PRP, with a follow-up duration ranging from 3 to 6 months. All 5 studies showed statistically significant improvements in pain scores, motion, and function scores in patients receiving PRP, corticosteroid, and saline solution injections. However, PRP was consistently superior on intergroup analyses in all but 1 study. In 4 studies, pain and function scores favored PRP over control at final follow-up (range in mean difference, -2.2 to 0.69 for visual analog scale pain score [n = 5] and -50.5 to -4.0 for Shoulder Pain and Disability Index score [n = 3]), whereas 3 studies found greater improvement in shoulder motion after PRP (range in mean difference, 0.7° to 34.3° for forward flexion and -2.3° to 20.4° for external rotation [n = 4]). One study found no significant difference between PRP and corticosteroid injections but noted that the results were comparable. CONCLUSIONS According to a limited number of prospective studies, PRP injections for AC are at least equivalent to corticosteroid or saline solution injections and often lead to improved pain, motion, and functional outcomes at 3- to 6-month follow-up. Given the small number of studies, with design heterogeneity, there is insufficient evidence to routinely recommend PRP for AC. However, the results are promising and do support considering PRP as an adjunct treatment option for AC, especially for patients refractory and/or averse to corticosteroids or alternative treatment modalities. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
- Brandon Nudelman
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California, U.S.A..
| | - Bowen Song
- St. Mary's Medical Center, San Francisco, California, U.S.A
| | | | - Amit S Piple
- The Taylor Collaboration, San Francisco, California, U.S.A
| | - William H Montgomery
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California, U.S.A
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8
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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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9
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Atar MÖ, Korkmaz N, Aslan SG, Tezen Ö, Köylü SU, Demir Y, Kesikburun S. Comparison of ultrasound-guided subacromial corticosteroid and ozone (O 2-O 3) injections in the treatment of chronic rotator cuff tendinopathy: a randomized clinical trial. Korean J Pain 2023; 36:128-136. [PMID: 36533317 PMCID: PMC9812695 DOI: 10.3344/kjp.22221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
Background : The authors aimed to compare the effects of a one-time ultrasound (US)-guided subacromial corticosteroid injection and three-time ozone (O2-O3) injection in patients with chronic supraspinatus tendinopathy. Methods : Participants were randomly assigned to the corticosteroid group (n = 22) or ozone group (n = 22). Injections in both groups were administered into subacromial bursa with an US-guided in-plane posterolateral approach. Primary outcome measure was the change in the Western Ontario Rotator Cuff Index (WORC) score between baseline and 12-weeks post-injection. Secondary outcome measures included visual analog scale and Shoulder Pain and Disability Index scores. Assessments were recorded at baseline, and 4-weeks and 12-weeks post-injection. Results : Forty participants completed this study. Based on repeated measurement analysis of variance, a significant effect of time was found for all outcome measures in both groups. Both the groups showed clinically significant improvements in shoulder pain, quality of life, and function. Baseline, 4-week post-injection, and 12-week post-injection WORC scores (mean ± standard deviation) were 57.91 ± 18.97, 39.10 ± 20.50 and 37.22 ± 27.31 in the corticosteroid group, respectively and 69.03 ± 15.89, 39.11 ± 24.36, and 32.26 ± 24.58 in the ozone group, respectively. However, no significant group × time interaction was identified regarding all outcome measures. Conclusions : Three-time ozone injection was not superior to a one-time corticosteroid injection in patients with chronic supraspinatus tendinopathy. It might be as effective as corticosteroid injection at 4-weeks and 12-weeks post-injection in terms of relieving pain and improving quality of life and function.
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Affiliation(s)
- Merve Örücü Atar
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey,Correspondence: Merve Örücü Atar Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Universiteler Mahallesi, Lodumlu Yolu 29, Ekim Sk. No:1, 06800 Çankaya, Ankara, Turkey, Tel: +90 312 291 2443, Fax: +90 312 291 1009, E-mail:
| | - Nurdan Korkmaz
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Sefa Gümrük Aslan
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Özge Tezen
- Department of Physical Medicine and Rehabilitation, Ankara City Hospital, Ankara, Turkey
| | - Sinem Uyar Köylü
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Yasin Demir
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Serdar Kesikburun
- Department of Physical Medicine and Rehabilitation, Gaziler Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
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Anti-inflammatory and Tendon-Protective Effects of Adipose Stem Cell-Derived Exosomes with Concomitant Use of Glucocorticoids. Stem Cells Int 2022; 2022:1455226. [PMID: 35646125 PMCID: PMC9142315 DOI: 10.1155/2022/1455226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/21/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022] Open
Abstract
Glucocorticoid (GC) injections are commonly used in clinical practice to relieve pain and improve function in patients with multiple shoulder disabilities but cause detrimental effects on rotator cuff tendons. Adipose stem cell-derived exosomes (ASC-Exos) reportedly recover impaired tendon matrix metabolism by maintaining tissue homeostasis. However, it is unclear whether additional treatment with ASC-Exos overrides the detrimental effects of GCs without interfering with their anti-inflammatory effects. Thus, we aimed to investigate the anti-inflammatory effect of ASC-Exos with GCs and protective effect of ASC-Exos against GC-induced detriments. The present study comprised in vitro and in vivo studies. In vitro inflammatory analysis revealed that ASC-Exos exerted a synergic anti-inflammatory effect with GCs by significantly decreasing secretion of proinflammatory cytokines by RAW cells and increasing secretion of anti-inflammatory cytokines. In vitro cytoprotective analysis showed that ASC-Exos overrode GC-induced detrimental effects on tenocytes by significantly improving GC-suppressed cellular proliferation, migration, and transcription of tenocytic matrix molecules and degradative enzyme inhibitors and significantly decreasing GC-induced cell senescence, apoptosis, and transcription of ROS and tenocytic degradative enzymes. In vivo studies revealed that additional ASC-Exo injection restored impairments in histological and biomechanical properties owing to GC administration. Collectively, these results suggest that ASC-Exos exert a stronger anti-inflammatory effect in combination with GCs, overriding their detrimental effects on rotator cuff tendons.
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11
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Huang SH, Hsu PC, Wang KA, Chou CL, Wang JC. Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears. J Chin Med Assoc 2022; 85:723-729. [PMID: 35507030 DOI: 10.1097/jcma.0000000000000736] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Partial-thickness rotator cuff tears (PTRCTs) is not uncommon, and various nonsurgical injection therapy for PTRCTs emerged. Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection were proposed for treating PTRCTs; however, the relation of dose among injectates was still lacking. METHODS This was a prospective, nonrandomized, comparative study. The aim of the study was to compare the effects of ultrasound-guided single PRP injection with three doses of HA injection, combination of postinjection rehabilitation, for treating PTRCTs. Subjects received either ultrasound-guided PRP injection and rehabilitation exercise, or ultrasound-guided subacromial HA injection and rehabilitation exercise. Shoulder Pain and Disability Index (SPADI), range of motion (ROM), pain visual analog scale (VAS), and Constant-Murley Shoulder Score (CMSS) were recorded before injection, and at 1 and 3 months after injection. RESULTS Forty-eight patients were enrolled. They received either ultrasound-guided single PRP (n = 24) intralesional and peritendinous injection or three doses of HA (n = 24) subacromial injection plus rehabilitation exercise. In the PRP group, SPADI scores, VAS scores, CMSS significantly improved at 1-month and 3-month follow up; flexion and abduction ROM significantly increased at 3-month follow up. In the HA group, SPADI scores, VAS during overhead activities, VAS night pain, and CMSS significantly improved in the first and third months; flexion and active abduction ROM significantly increased in the third month. The PRP group revealed significantly better passive abduction ROM and CMSS at third month than HA group. CONCLUSION Ultrasound-guided single PRP injection exhibited comparable benefit to three doses of HA injection in patients with PTRCTs short-termly, with an extended effect regarding passive shoulder abduction ROM and CMSS.
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Affiliation(s)
- Shou-Hsien Huang
- Department of Physical Medicine and Rehabilitation, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Kevin A Wang
- Divison of General Surgery, Department of Surgery, Shin-Kong Memorial Hospital, Taipei, Taiwan, ROC
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Chen-Liang Chou
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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12
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Lin CY, Huang SC, Tzou SJ, Yin CH, Chen JS, Chen YS, Chang ST. A Positive Correlation between Steroid Injections and Cuff Tendon Tears: A Cohort Study Using a Clinical Database. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084520. [PMID: 35457390 PMCID: PMC9031762 DOI: 10.3390/ijerph19084520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/06/2023]
Abstract
This cohort study aimed to investigate the association between steroid injections for shoulder diseases and the increased incidence of cuff tendon tears. The Kaohsiung Veterans General Hospital clinical database was used in this study. Patients were enrolled using the corresponding diagnostic codes for shoulder diseases. Patients who received steroid injections were included in the case group, and those without steroid injections were included in the control group. The outcome measure was the occurrence of cuff tendon tears during the study period. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis adjusted for sex, age, and comorbidities. Of the 1025 patients with shoulder disease, 205 were in the case group and 820 were in the control group. The incidence of cuff tendon tears was 9.8% in patients who received steroid injections (p < 0.001). The adjusted hazard ratios for steroid injections, smoking, and chronic liver disease were 7.44 (p < 0.001), 2.40 (p = 0.046), 3.25 (p = 0.007), respectively. Steroid injections on the shoulder were associated with a raised risk of cuff tendon tears by 7.44 times compared to non-injection. The incidence of cuff tendon tears increased by 3.25 times with concurrent chronic liver disease and by 2.4 times with smoking.
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Affiliation(s)
- Ching-Yueh Lin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Armed Forces General Hospital, Kaohsiung 802301, Taiwan;
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114202, Taiwan
| | - Shih-Chung Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung 802301, Taiwan;
- Teaching and Researching Center, Kaohsiung Armed Forces General Hospital, Kaohsiung 802301, Taiwan;
- Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung 804201, Taiwan
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114202, Taiwan
| | - Shiow-Jyu Tzou
- Teaching and Researching Center, Kaohsiung Armed Forces General Hospital, Kaohsiung 802301, Taiwan;
- Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung 804201, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan;
- Institute of Health Care Management, National Sun Yat-sen University, Kaohsiung 804201, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan; (J.-S.C.); (Y.-S.C.)
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan; (J.-S.C.); (Y.-S.C.)
| | - Shin-Tsu Chang
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114202, Taiwan
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan
- Correspondence: ; Tel.: +886-7-3422121 (ext. 78204)
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Wang C, Zhou Z, Song W, Cai Z, Ding Z, Chen D, Xia F, He Y. Inhibition of IKKβ/NF-κB signaling facilitates tendinopathy healing by rejuvenating inflamm-aging induced tendon-derived stem/progenitor cell senescence. MOLECULAR THERAPY. NUCLEIC ACIDS 2022; 27:562-576. [PMID: 35036066 PMCID: PMC8738957 DOI: 10.1016/j.omtn.2021.12.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/15/2021] [Indexed: 02/08/2023]
Abstract
Degenerative rotator cuff tendinopathy (RCT) is a chronic tendon disease caused by degeneration and inflammation, which often affects the elderly population. Mesenchymal stem cell senescence is generally recognized as an important pathophysiological mechanism in many age-related skeletal diseases. Herein, we collected human tendon-derived stem/progenitor cells (TSPCs) from degenerative supraspinatus tendons and found that TSPC senescence is closely related to RCT. We further identified that nuclear factor κB (NF-κB) pathway activation is involved in age-related inflammation (inflamm-aging) of degenerative RCT. Moreover, whole genome RNA sequencing revealed that in vitro inhibition of the I kappa B kinase β (IKKβ)/NF-κB signaling pathway could reverse the aged TSPC phenotype with decreased TSPC senescence and increased tenogenic potential. To achieve effective in vivo inhibition of IKKβ/NF-κB signaling, we fabricated IKKβ small interfering RNA (siRNA)-loaded gold nanoclusters (AuNC-siRNA) for efficient and convenient intra-articular delivery of IKKβ siRNA. We found that AuNC-siRNA prevented inflamm-aging-induced TSPC senescence and dysfunction in a degenerative RCT aged rat model. Together, these data show that inflamm-aging causes degenerative RCT through inducing TSPC senescence, which can be reversed by blocking the IKKβ/NF-κB pathway in vivo. Thus, our study provides a promising therapeutic strategy for degenerative RCT via intra-articular delivery of IKKβ siRNA using AuNCs.
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Affiliation(s)
- Chongyang Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Zhekun Zhou
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Wei Song
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Zhuochang Cai
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Zhenyu Ding
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Daoyun Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Fangfang Xia
- Department of Instrument Science and Engineering, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai 200240, China
| | - Yaohua He
- Department of Orthopaedics, Jinshan Branch of Shanghai Sixth People's Hospital affiliated to Shanghai University of Medicine & Health Sciences, 147 Jiankang Road, Shanghai 201503, China
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Khan M, Shanmugaraj A, Prada C, Patel A, Babins E, Bhandari M. The Role of Hyaluronic Acid for Soft Tissue Indications: A Systematic Review and Meta-Analysis. Sports Health 2022; 15:86-96. [PMID: 35114853 PMCID: PMC9808833 DOI: 10.1177/19417381211073316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
CONTEXT Soft tissue injuries are often treated with injectables such as corticosteroids and platelet-rich plasma (PRP) to reduce inflammation and promote healing. There is increasing evidence examining the use of hyaluronic acid (HA) for the management of soft tissue injuries. OBJECTIVE To evaluate the treatment effect and role of HA for available soft tissue indications. DATA SOURCES A search of PubMed, MEDLINE, EMBASE, and CENTRAL from the inception date of each database through February 24, 2021, was conducted for all randomized controlled trials (RCTs) involving the use of HA for soft tissue indications. Two reviewers independently screened articles for eligibility and extracted data from included studies for analysis. We assessed risk of bias for all included studies and pooled outcomes using a fixed-effects model. Outcomes (ie, function and pain relief) were categorized to short-term (<6 weeks, 6-12 weeks) and mid-term (>12 weeks) data. We present effect estimates as mean differences (MDs) and standardized mean differences (SMDs) and present the estimate of effect of HA for available indications in relation to available comparators. STUDY DESIGN Meta-analysis of RCTs. LEVEL OF EVIDENCE Level 1. RESULTS Of the 6930 articles screened, 19 RCTs (n = 1629 patients) were eligible and included in this review. HA was evaluated across a variety of soft tissue indications including rotator cuff disease, elbow pain, ankle sprains, Achilles tendinopathy, patellar tendinopathy, and trigger finger. Of the 19 RCTs, 11 were placebo-controlled and 9 used active comparators (PRP, cortisone, prolotherapy, or extracorporeal shockwave therapy). The pooled treatment effect of HA across most soft indications against placebo and active comparators demonstrated benefit in short-term pain <6 weeks (MD visual analogue scale [VAS] 2.48, 95% CI 2.31-2.65) and 6 to 12 weeks (MD VAS 2.03, 95% CI 1.86-2.20). Mid-term pain relief also favored HA over comparators across indications >12 weeks from administration (MD VAS 3.57, 95% CI 3.35-3.78). High heterogeneity was present with rotator cuff (10 trials, I2 = 94%), and elbow tendinopathy (2 trials, I2 = 99%). We identified uncertain benefit for trigger finger (2 trials, I2 = 67%). Heterogeneity for ankle sprains, patellar tendinopathy and Achilles tendinopathy could not be assessed as they only had 1 trial each. CONCLUSION This systematic review and meta-analysis support HA's efficacy in the treatment of a variety of soft tissue indications. Understanding the relative effects of HA to other injectable modalities requires additional, large trials.
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Affiliation(s)
- Moin Khan
- Division of Orthopaedic Surgery,
Department of Surgery, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods,
Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada,Moin Khan, MD, MSc, FRCSC,
McMaster University, St Joseph’s Healthcare Hamilton, 50 Charlton Avenue East,
Mary Grace Wing, Room G807, Hamilton, Ontario, L8N 4A6, Canada (
) (Twitter: @moinkhan_md)
| | - Ajaykumar Shanmugaraj
- Division of Orthopaedic Surgery,
Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Carlos Prada
- Division of Orthopaedic Surgery,
Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ashaka Patel
- Schulich School of Medicine, Western
University, London, Ontario
| | - Eric Babins
- University of Calgary, Calgary,
Alberta, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery,
Department of Surgery, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods,
Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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15
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Soderlund M, Boren M, O’Reilly A, San Juan A, Mahylis JM. Arthroscopic debridement for management of massive, irreparable rotator cuff tears: a systematic review of outcomes. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:1-7. [PMID: 37588294 PMCID: PMC10426654 DOI: 10.1016/j.xrrt.2021.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Surgical management of massive irreparable rotator cuff tears remains controversial. Arthroscopic debridement (AD) has shown promising results especially in the population older than 65 years; however, there is no consensus on the benefits of various AD procedures. The aim of this systematic review was to evaluate the functional midterm to long-term outcomes in patients treated with AD in combination with subacromial decompression, biceps tenotomy, tuberoplasty, or bursectomy, without repair of the rotator cuff tear. Methods A comprehensive search was performed in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane databases for studies reporting clinical outcomes of AD of massive rotator cuff tears. Quality was determined using the Methodological Index for Nonrandomized Studies (MINORS) criteria by two independent reviewers. Pooled frequency-weighted means and standard deviations were calculated for patient-reported outcomes. Results Sixteen articles containing 643 patients and 662 shoulders met the eligibility criteria. The mean age at the time of surgery was 65.9 ± 4.4 years with a mean follow-up period of 46.5 ± 27.3 months. There was notable clinically significant improvement across all patient-reported outcome scores postoperatively: Constant 70.4 ± 8.9 (P value = .06), University of California, Los Angeles ultrasonography 26.7 ± 5.2 (P value = .001), American Shoulder and Elbow Surgeons score 71.7 ± 2.1 (P value = .12), Disabilities of the Arm, Shoulder, and Hand score 35.3, and visual analog score 1.7 ± 0.9. Forty-nine patients (7%) required reoperation, which most commonly was a reverse total shoulder arthroplasty for the development of rotator cuff arthropathy. Conclusion Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy, for treatment of massive irreparable rotator cuff tears, produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function.
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Affiliation(s)
- Matthew Soderlund
- Department of Orthopaedic Surgery, Midwestern University/Franciscan Health-Olympia Fields, Olympia Fields, IL, USA
| | - Morgan Boren
- Department of Orthopaedic Surgery, Midwestern University/Franciscan Health-Olympia Fields, Olympia Fields, IL, USA
| | - Andrew O’Reilly
- Department of Orthopaedic Surgery, Midwestern University/Franciscan Health-Olympia Fields, Olympia Fields, IL, USA
| | - Angielyn San Juan
- Department of Orthopedic Surgery, Northshore University Health System, Evanston, IL, USA
| | - Jared M. Mahylis
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, MI, USA
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16
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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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17
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Oudelaar BW, Huis In 't Veld R, Ooms EM, Schepers-Bok R, Nelissen RGHH, Vochteloo AJH. Efficacy of Adjuvant Application of Platelet-Rich Plasma After Needle Aspiration of Calcific Deposits for the Treatment of Rotator Cuff Calcific Tendinitis: A Double-Blinded, Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med 2021; 49:873-882. [PMID: 33566629 DOI: 10.1177/0363546520987579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD. PURPOSE To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL). STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures. RESULTS Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P < .001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P = .003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P < .001; DASH, P = .002; OSS, P = .010; EQ-5D, P < .001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P = .081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P = .036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P = .11). CONCLUSION NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT. REGISTRATION NCT02173743 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Bart W Oudelaar
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Edwin M Ooms
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Rob G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands
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Kwong CA, Woodmass JM, Gusnowski EM, Bois AJ, Leblanc J, More KD, Lo IKY. Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial. Arthroscopy 2021; 37:510-517. [PMID: 33127554 DOI: 10.1016/j.arthro.2020.10.037] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a randomized controlled trial comparing platelet-rich plasma (PRP) with standard corticosteroid (CS) injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears (PTRCTs). METHODS This double-blind randomized controlled trial enrolled patients with ultrasound-proven or magnetic resonance imaging-proven PTRCTs who received either an ultrasound-guided PRP or CS injection. Patients completed patient-reported outcome assessments at baseline and at 6 weeks, 3 months, and 12 months after injection. The primary outcome was improvement in the visual analog scale (VAS) score for pain. Secondary outcomes included changes in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) scores. Treatment failure was defined as subsequent injection, consent to undergo surgery, or operative intervention. RESULTS We followed up 99 patients (47 in the PRP group and 52 in the CS group) until 12 months after injection. There were no differences in baseline patient demographic characteristics including age, sex, or duration of symptoms. Despite randomization, patients in the PRP group had worse baseline VAS (46.0 vs 34.7, P = .01), ASES (53.9 vs 61.8, P = .02), and WORC (42.2 vs 49.5, P = .03) scores. At 3 months after injection, the PRP group had superior improvement in VAS (-13.6 vs 0.4, P = .03), ASES (13.0 vs 2.9, P = .02), and WORC (16.8 vs 5.8, P = .03) scores. There were no differences in patient-reported outcomes at 6 weeks or 12 months. There was no difference in the rate of failure (P = .31) or conversion to surgery (P = .83) between groups. CONCLUSIONS Patients with PTRCTs or tendinopathy experienced clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided CS and PRP injections. Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months). There was no sustained benefit of PRP over CS at longer-term follow-up (12 months). LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Cory A Kwong
- Department of Surgery, Section of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Jarret M Woodmass
- Pan Am Clinic, Department of Orthopedics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eva M Gusnowski
- Department of Surgery, Section of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Aaron J Bois
- Department of Surgery, Section of Orthopedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Justin Leblanc
- Department of Surgery, Section of Orthopedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Kristie D More
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
| | - Ian K Y Lo
- Department of Surgery, Section of Orthopedic Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
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Gleich J, Milz S, Ockert B. [Principles of tendon healing at the shoulder and consequences for their treatment : Importance of platelet-rich plasma and regenerative medicine]. Unfallchirurg 2020; 124:89-95. [PMID: 33346862 DOI: 10.1007/s00113-020-00941-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 11/30/2022]
Abstract
Tendon pathologies are a frequent cause of shoulder pain and can lead to significant decline in the quality of life. Conservative treatment is suitable for most tendon pathologies. In addition to classical conservative treatment options, such as physiotherapy, oral analgesia and infiltrations, there are a number of additive treatment options to promote structural tendon healing and clinical outcome. Furthermore, there are approaches to improve the results of the surgical treatment of tendon injuries by biological augmentation. The objective of this article is to give an overview of biological and regenerative therapeutic options in the treatment of tendon injuries of the shoulder. Therefore, the anatomical and molecular biological principles of the tendon structure and their importance for tendon healing are explained in order to highlight the various therapeutic options for daily practice. Biological augmentation procedures and regenerative medicine represent a promising therapeutic option for tendon injuries of the shoulder, however, the benefits are so far supported by little or no evidence at all.
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Affiliation(s)
- J Gleich
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität München, Nussbaumstr. 20, 80336, München, Deutschland.
| | - S Milz
- Anatomische Anstalt, Ludwig-Maximilians-Universität, München, Deutschland
| | - B Ockert
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität München, Nussbaumstr. 20, 80336, München, Deutschland
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20
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How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthop Traumatol Surg Res 2020; 106:1159-1166. [PMID: 32826188 DOI: 10.1016/j.otsr.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair. HYPOTHESIS The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair. METHODS This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848). RESULTS Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197). CONCLUSION This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery. LEVEL OF EVIDENCE II, low-powered placebo-controlled, randomized study.
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21
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Sullivan SN, Altmann NN, Brokken MT, Durgam SS. In vitro Effects of Methylprednisolone Acetate on Equine Deep Digital Flexor Tendon-Derived Cells. Front Vet Sci 2020; 7:486. [PMID: 32851046 PMCID: PMC7419577 DOI: 10.3389/fvets.2020.00486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/29/2020] [Indexed: 11/25/2022] Open
Abstract
Primary deep digital flexor tendon (DDFT) pathologies and those accompanying degenerative changes of navicular bone fibrocartilage are major causes of lameness associated with navicular disease. Intrasynovial corticosteroids are mainstay in the treatment due to the anti-inflammatory effects, but their effect on DDFT cell biosynthesis are unknown. The objective of this in-vitro study was to investigate the effects of methylprednisolone acetate (MPA) on cells isolated from the dorsal fibrocartilaginous region of forelimb DDFTs (DDFT-derived cells) of 5 horses (aged 11–17 years). Non-adherent aggregate cultures were established from third passage cells over a 72 to 96-h duration prior to treating with medium containing 0 (control), 0.05 and 0.5 mg/mL MPA for 24 h. Tendon and cartilage extracellular matrix (ECM) related gene expression, cell aggregate and culture medium GAG contents, culture medium collagen and MMP-3 and−13 concentrations were measured. After 24 h of treatment, only the higher MPA concentration (0.5 mg/mL) significantly down-regulated tendon ECM related genes; whereas, both MPA doses significantly down-regulated cartilage ECM related genes. MPA treatment did not affect the total GAG content of DDFT-derived cells or total GAG, soluble collagen and MMP-3 and−13 contents in culture medium compared to untreated controls. Future studies to determine the response of DDFT-derived cells with longer exposure times to corticosteroids and in the presence of inflammatory cytokines are necessary. These results are a first step in assessing the effects of intrasynovial medications on equine DDFT, for which currently no information exists.
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Affiliation(s)
- Stasia N Sullivan
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, United States
| | - Nadine N Altmann
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, United States
| | - Matthew T Brokken
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, United States
| | - Sushmitha S Durgam
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, United States
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22
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Cimino AM, Veazey GC, McMurtrie JT, Isbell J, Arguello AM, Brabston EW, Ponce BA, Momaya AM. Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review. Arthroscopy 2020; 36:2334-2341. [PMID: 32389769 DOI: 10.1016/j.arthro.2020.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs). METHODS A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies. CONCLUSIONS CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Addison M Cimino
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Garrison C Veazey
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - James T McMurtrie
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Jonathan Isbell
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Alexandra M Arguello
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Eugene W Brabston
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Brent A Ponce
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Amit M Momaya
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A.
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Kunze KN, Mirzayan R, Beletsky A, Cregar W, Skallerud W, Williams BT, Verma NN, Cole BJ, Chahla J. Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis. Arthroscopy 2020; 36:1476-1484. [PMID: 32035175 DOI: 10.1016/j.arthro.2020.01.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/01/2019] [Accepted: 01/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections. METHODS The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed. RESULTS A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls. CONCLUSIONS The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR. LEVEL OF EVIDENCE Level III, systematic review of Level I and III studies.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Raffy Mirzayan
- Department of Orthopaedic Surgery, Kaiser Permanente, Baldwin Park, California, U.S.A
| | - Alexander Beletsky
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - William Cregar
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - William Skallerud
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brady T Williams
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brian J Cole
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois.
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Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review. Arthroscopy 2020; 36:1468-1475. [PMID: 31862292 DOI: 10.1016/j.arthro.2019.12.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 12/08/2019] [Accepted: 12/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR). METHODS A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon. RESULTS A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]). CONCLUSION Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months. LEVEL OF EVIDENCE IV, systematic review of Level III and IV studies.
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Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies. Arthrosc Sports Med Rehabil 2020; 2:e161-e169. [PMID: 32368753 PMCID: PMC7190543 DOI: 10.1016/j.asmr.2020.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT). Methods A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT. Results Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent. Conclusions On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI. Clinical Relevance Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.
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Hohmann E, Shea K, Scheiderer B, Millett P, Imhoff A. Indications for Arthroscopic Subacromial Decompression. A Level V Evidence Clinical Guideline. Arthroscopy 2020; 36:913-922. [PMID: 31882271 DOI: 10.1016/j.arthro.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 02/02/2023]
Abstract
Since the introduction of acromioplasty by Neer in 1971 and arthroscopic subacromial decompression (SAD) by Ellman in 1987, the outcomes have been reported to be consistently good. Recently it was suggested that supervised physical therapy is comparable with SAD, which was contested by other studies claiming that SAD is clearly superior to nonoperative treatment. Before consideration for treatment, the diagnosis of impingement with an intact rotator cuff must be determined by clinical history, a detailed and structured clinical examination, and appropriate imaging. In favor of SAD are published long-term studies with a minimum of 10 years outlining significant functional and clinical improvement. The main factor for failure reported was workers compensation, calcific tendinopathy, and high-grade partial-thickness tears. Studies nonsupportive of SAD suffer from bias, crossover from the nonoperative group to the operative group following failure of conservative treatment, and loss of follow-up. Recently, lateral acromion resection has been suggested as a viable alternative, effectively reducing the critical shoulder angle. Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. Care should be taken to avoid resection of the acromioclavicular ligament. Five millimeters of lateral acromion resection is the recommended amount of resection. Patients with chronic calcific tendinitis, workers compensation, and partial-thickness tears should not be treated by SAD alone.
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Affiliation(s)
- Erik Hohmann
- Department of Orthopaedic Surgery and Sports Medicine, Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates; School of Medicine, University of Pretoria, South Africa.
| | - Kevin Shea
- Division of Sports Medicine and Shoulder Surgery, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Bastian Scheiderer
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | | | - Andreas Imhoff
- Department of Orthopaedic Sports Medicine, School of Medicine and Sports Science, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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27
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Lee W, Kim SJ, Choi CH, Choi YR, Chun YM. Intra-articular injection of steroids in the early postoperative period does not have an adverse effect on the clinical outcomes and the re-tear rate after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2019; 27:3912-3919. [PMID: 30980117 DOI: 10.1007/s00167-019-05486-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/11/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes and structural integrity following arthroscopic rotator cuff repair, either with intra-articular injection of corticosteroids in the early postoperative period using ultrasound guidance or without it. METHODS This study included 318 patients who underwent arthroscopic repair for either a partial-thickness or small-to-medium-sized full-thickness rotator cuff tear from 2012 to 2015. Patients were divided into two groups based on the administration of an intra-articular corticosteroids injection at 3 months after the surgery: group A (with corticosteroid injection, n = 56) and group B (without corticosteroid injection, n = 262). Functional outcomes were evaluated using the visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, and active range of motion (ROM). Postoperative magnetic resonance arthrography (MRA) was performed 6 months postoperatively to assess structural integrity. RESULTS At the 2-year follow-up, both groups showed no significant differences in VAS pain score (group A/B, 1.1 ± 0.9/1.1 ± 1.1), functional scores including SSV (88.5 ± 10.8/88.3 ± 10.0), ASES (90.8 ± 6.6/90.4 ± 6.9), and UCLA scores (30.2 ± 5.6/30.7 ± 5.2), and active ROM including forward flexion (151° ± 8°/153° ± 7°), external rotation (54° ± 5°/55° ± 7°), and internal rotation (10 ± 1/10 ± 2). Follow-up MRA imaging collected 6 months after surgery showed no significant difference in the re-tear rate (n.s.) between group A and B (n = 10/56, 17.9% and 45/262, 17.2%, respectively). CONCLUSIONS Intra-articular corticosteroids injection in the early postoperative period after arthroscopic rotator cuff repair provided satisfactory pain relief and ROM improvement without increasing the re-tear rate or deteriorating clinical outcomes at the 2-year follow-up. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Wonyong Lee
- The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Sung-Jae Kim
- The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Chong-Hyuk Choi
- The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Yun-Rak Choi
- The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, CPO Box 8044, Seoul, 120-752, Republic of Korea
| | - Yong-Min Chun
- The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, CPO Box 8044, Seoul, 120-752, Republic of Korea.
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Liu CT, Yang TF. Intra-substance steroid injection for full-thickness supraspinatus tendon rupture. BMC Musculoskelet Disord 2019; 20:569. [PMID: 31775808 PMCID: PMC6882333 DOI: 10.1186/s12891-019-2952-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 11/18/2019] [Indexed: 12/29/2022] Open
Abstract
Background The use of steroid injection for treatment of a full-thickness rotator cuff tear is still controversial. This study aimed to evaluate the effectiveness and safety of this treatment method. Methods Twelve patients in Group 1 received an intra-substance injection into rupture area of supraspinatus tendon with Diprospan 1 cc (betamethasone disodium phosphate 2 mg and betamethasone dipropionate 5 mg) and 1% xylocaine 1 cc. Twelve patients in Group 2 received an injection with normal saline 1 cc and 1% xylocaine 1 cc. The rupture size was measured by sonography before the injection, 3 months after the injection, and 6 months after the injection. Shoulder Pain and Disability Index (SPADI) score and Pain Visual Analogue Scale (VAS) score were measured and compared between the two groups before the injection, 1 week after the injection, 3 months after the injection, and 6 months after the injection. Results Pain and function improved more in Group 1 than in Group 2. The therapeutic effect lasted for at least 6 months in both groups. The size of the supraspinatus tendon rupture was not increased after injection in either group. Conclusions Intra-substance injection into rupture area of supraspinatus tendon with steroid and xylocaine is effective to reduce pain and improve function in patients with full-thickness supraspinatus tendon rupture without increasing the size of the rupture. Trial registration Current Controlled Trials ChiCTR1900026376, data of registration: 2019/10/05 retrospectively registered.
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Affiliation(s)
- Chung-Ting Liu
- Degree Program of Biomedical Science and Engineering, National Chiao Tung University, Hsinchu, Taiwan.,Department of Orthopaedics, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ten-Fang Yang
- Degree Program of Biomedical Science and Engineering, National Chiao Tung University, Hsinchu, Taiwan. .,College of Biological Science and Technology, National Chiao-Tung University, Hsinchu, Taiwan. .,Graduate Institute of Medical Informatics, Taipei Medical University and Hospital, Taipei, Taiwan.
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29
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Burnier M, Elhassan BT, Sanchez-Sotelo J. Surgical Management of Irreparable Rotator Cuff Tears: What Works, What Does Not, and What Is Coming. J Bone Joint Surg Am 2019; 101:1603-1612. [PMID: 31483405 DOI: 10.2106/jbjs.18.01392] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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30
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Darrieutort-Laffite C, Varin S, Coiffier G, Albert JD, Planche L, Maugars Y, Cormier G, Le Goff B. Are corticosteroid injections needed after needling and lavage of calcific tendinitis? Randomised, double-blind, non-inferiority trial. Ann Rheum Dis 2019; 78:837-843. [PMID: 30975645 DOI: 10.1136/annrheumdis-2018-214971] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Steroid injections are common after an ultrasound-guided puncture and lavage (UGPL) of calcific tendonitis of the rotator cuff. However, steroids may prevent calcification resorption and negatively affect tendon healing. Our study was designed to determine whether saline solution was non-inferior to steroids in the prevention of acute pain reactions in the week following UGPL. METHODS This was a randomised, double-blinded, controlled non-inferiority trial with 12-month follow-up. We included 132 patients (66 in each group) with symptomatic calcification measuring more than 5 mm. Patients received 1 mL of saline or steroid (methylprednisolone 40 mg) in the subacromial bursa at the end of UGPL. Primary outcome was the maximal pain during the week following the procedure with a prespecified non-inferiority margin of 10 mm (0-100 visual analogue scale). Secondary outcomes included pain at rest and during activity, function (disabilities of the arm, shoulder and hand score) and radiological evolution of the calcification over the 12-month follow-up. RESULTS The estimated mean difference in the first week's maximal pain between these two groups was 11.76 (95% CI 3.78 to 19.75). Steroids significantly improved VAS pain at rest and during activities, as well as function at 7 days and 6 weeks. They did not change the rate of calcification resorption, which occurred in 83% and 74% of patients at 12 months in the saline and steroid groups. CONCLUSION Non-inferiority of saline when compared with steroids could not be established. However, steroid injection improved pain in the 6 weeks following the procedure, and function in the 3 months after, with no significant effect on calcification resorption. TRIAL REGISTRATION NUMBER NTC02403856.
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Affiliation(s)
| | - Stephane Varin
- Department of Rheumatology, CHD Vendée, La Roche sur Yon, France
| | | | | | - Lucie Planche
- Biometrics and Statistic Platform, CHU Nantes, Nantes, France
| | - Yves Maugars
- Department of Rheumatology, CHU Nantes, Nantes, France
| | - Grégoire Cormier
- Department of Rheumatology, CHD Vendée, La Roche sur Yon, France
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Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair-Is It Time to Rethink a Conservative Treatment Paradigm? Arthroscopy 2019; 35:714-716. [PMID: 30827425 DOI: 10.1016/j.arthro.2018.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 02/02/2023]
Abstract
The standard of care for most rotator cuff conditions over the past half century or longer has been a trial of nonoperative treatment including nonsteroidal anti-inflammatory agents, physiotherapy, and steroid injections prior to surgery. There is compelling basic science data to suggest a negative effect of corticosteroids on tissue quality. Chronicity of the tear is a risk factor for unsuccessful repair, but other factors including use of tobacco products, repair technique, and postoperative management all have an impact. Evidence either in favor of or against use of steroid injections as a treatment option is limited or weak at best. Given advances in rotator cuff repair techniques and successful long-term outcomes, treating surgeons should be mindful of how injections might affect surgical outcomes owing to either delayed surgical intervention or a direct effect on tissue quality.
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Weber AE, Trasolini NA, Mayer EN, Essilfie A, Vangsness CT, Gamradt SC, Tibone JE, Kang HP. Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates. Arthroscopy 2019; 35:717-724. [PMID: 30733024 DOI: 10.1016/j.arthro.2018.10.116] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/21/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes. METHODS Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates. RESULTS Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P = .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group. CONCLUSIONS This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Alexander E Weber
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A..
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Anthony Essilfie
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - C Thomas Vangsness
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Seth C Gamradt
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - James E Tibone
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Hyunwoo Paco Kang
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
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Agarwalla A, Puzzitiello RN, Mascarenhas R, Sumner S, Romeo AA, Forsythe B. Preoperative Injections May Be an Iatrogenic Cause of Reoperation After Arthroscopic Rotator Cuff Repair. Arthroscopy 2019; 35:325-331. [PMID: 30611584 DOI: 10.1016/j.arthro.2018.08.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine whether an association exists between preoperative shoulder injections and reoperations in patients undergoing arthroscopic rotator cuff repair (aRCR). METHODS The PearlDiver Patient Records Database was reviewed for Humana-insured patients undergoing aRCR after a shoulder injection. Two matched groups were created: aRCR within 1 year of injection (n = 12,054) and aRCR without prior injection within 1 year of surgery (n = 12,054). Reoperation rates within 3 months, at 3 to 6 months, and at 6 to 12 months postoperatively were assessed. Statistical analysis was performed with the χ-square test. RESULTS The rate of reoperation within 3 months of the index procedure was higher in the control group (3.7% vs 3.1%, P = .01); however, 3 to 6 months after the index procedure, the rate of reoperation was higher in patients who received an injection within 1 year of the index procedure (1.8% vs 1.4%, P = .03). During the same intervals, the rate of revision rotator cuff repair (RCR) within 3 months of the index procedure was higher in the control group (2.9% vs 2.6%) and the rate of revision RCR 3 to 6 months after the index procedure was higher in patients who received an injection within 1 year of the index procedure (1.1% vs 0.9%); however, these results were not statistically significant (P = .3 and P = .8, respectively). The incidence of revision RCR (1.6% vs 1.1%; odds ratio, 1.4; P = .003) and incidence of subacromial decompression (1.5% vs 1.1%; odds ratio, 1.3; P = .01) 6 to 12 months after the index procedure were significantly higher in patients receiving an injection within 1 year before surgery. CONCLUSIONS Preoperative shoulder injections may increase the risk of revision RCR and subacromial decompression by up to 150% in patients 6 to 12 months after index surgery compared with patients who did not receive a preoperative injection. However, the absolute increase in these revision procedures is only 0.5%. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Avinesh Agarwalla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Richard N Puzzitiello
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Shelby Sumner
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, The Rothman Institute, Philadelphia, Pennsylvania, U.S.A
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Desai VS, Camp CL, Boddapati V, Dines JS, Brockmeier SF, Werner BC. Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery. Arthroscopy 2019; 35:45-50. [PMID: 30473453 DOI: 10.1016/j.arthro.2018.07.043] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. METHODS Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. RESULTS A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations. CONCLUSIONS A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Vishal S Desai
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Venkat Boddapati
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Joshua S Dines
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Stephen F Brockmeier
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia, U.S.A..
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Kim IB, Jung DW. An Intra-articular Steroid Injection at 6 Weeks Postoperatively for Shoulder Stiffness After Arthroscopic Rotator Cuff Repair Does Not Affect Repair Integrity. Am J Sports Med 2018; 46:2192-2202. [PMID: 29924633 DOI: 10.1177/0363546518777739] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shoulder stiffness is a common complication after arthroscopic rotator cuff repair. However, there is no consensus on the treatment of stiffness after repair. Although one treatment option is an intra-articular steroid injection, it may negatively affect repair integrity, and there is a paucity of literature regarding the timing of intra-articular injections for stiffness after repair and its effect on repair integrity. PURPOSE To compare repair integrity and clinical outcomes after an intra-articular steroid injection administered at 6 weeks and 12 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 (6-week group) and 12 weeks (12-week group) postoperatively. The control group had rotator cuff tears but neither stiffness nor injections. Shoulder range of motion (ROM), the Korean Shoulder Scoring System (KSS) score, and the University of California, Los Angeles (UCLA) shoulder score were assessed preoperatively with a minimum of 2-year follow-up. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively. RESULTS Seventy-four of 209 patients (35.4%) who underwent arthroscopic rotator cuff repair developed stiffness. There were no significant differences in retear rates among the 6-week (5.7%, 2/35 patients), 12-week (10.3%, 4/39 patients), and control groups (14.1%, 19/135 patients) ( P = .374). Both the 6- and 12-week groups showed significant improvement in ROM (both P < .001), KSS scores (both P < .001), and UCLA scores (both P < .001) at the final follow-up. The 6-week group showed significantly better ROM ( P < .001), KSS scores ( P < .001), and UCLA scores ( P < .001) than the 12-week group at 3 months postoperatively. However, both the 6- and 12-week groups showed significantly lower KSS (81.3 ± 12.0 [ P = .004] and 83.4 ± 8.6 [ P = .035], respectively) and UCLA (29.3 ± 4.6 [ P = .006] and 30.0 ± 3.3 [ P = .042], respectively) scores than the control group (90.4 ± 13.6 and 32.3 ± 4.7, respectively) at the last follow-up. CONCLUSION An intra-articular steroid injection administered at 6 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair may be effective for reducing patients' pain and improving shoulder ROM at 3 months postoperatively without compromising repair integrity.
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Affiliation(s)
- In-Bo Kim
- Department of Orthopedic Surgery, Busan Bumin Hospital, Busan, Republic of Korea
| | - Dong Wook Jung
- Department of Orthopedic Surgery, Busan Bumin Hospital, Busan, Republic of Korea
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Oh JH, Park MS, Rhee SM. Treatment Strategy for Irreparable Rotator Cuff Tears. Clin Orthop Surg 2018; 10:119-134. [PMID: 29854334 PMCID: PMC5964259 DOI: 10.4055/cios.2018.10.2.119] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/11/2018] [Indexed: 12/18/2022] Open
Abstract
Recently, patients with shoulder pain have increased rapidly. Of all shoulder disorders, rotator cuff tears (RCTs) are most prevalent in the middle-aged and older adults, which is the primary reason for shoulder surgery in the population. Some authors have reported that up to 30% of total RCTs can be classified as irreparable due to the massive tear size and severe muscle atrophy. In this review article, we provide an overview of treatment methods for irreparable massive RCTs and discuss proper surgical strategies for RCTs that require operative management.
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Affiliation(s)
- Joo Han Oh
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Suk Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung Min Rhee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Lansdown DA, Cole BJ, Verma NN. Decision-Making for Managing Complex Rotator Cuff Tears. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2017.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Baverel L, Boutsiadis A, Reynolds RJ, Saffarini M, Barthélémy R, Barth J. Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair? JSES OPEN ACCESS 2017; 2:54-59. [PMID: 30675568 PMCID: PMC6334978 DOI: 10.1016/j.jses.2017.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Rotator cuff tears are associated with capsular contraction and stiffness that should be restored before surgical repair. Corticosteroid injections (CSIs) are frequently used as conservative treatments before surgical repair. This study aimed to determine the influence of preoperative and postoperative CSIs on clinical and anatomic outcomes after rotator cuff repair. Methods The authors analyzed the records of 257 patients who had arthroscopic rotator cuff repair, of whom 212 were evaluated at 3.1 ± 1.0 years (median, 2.9 years; range, 1.4-7.1 years) by clinical (Constant score) and ultrasound (Sugaya classification) examinations. Univariable and multivariable regressions were performed to determine associations between outcomes and administration of preoperative and postoperative CSIs, patient characteristics, and tendon characteristics. Results The Constant scores improved from 56.4 ± 15.1 to 80.8 ± 12.5. Multivariable regression confirmed that postoperative scores were associated with postoperative CSIs (P < .001), preoperative scores (P < .001), gender (P < .001), and fatty infiltration (P < .005). Retears (Sugaya types IV-V) were observed in 27 shoulders (13%). Multivariable regression clarified that retear rates were associated only with postoperative CSIs (P = .007) and stage 3 fatty infiltration (P = .001). Adjusting for confounders, an additional postoperative CSI would decrease scores by 4.7 points and double retear risks. Discussion Preoperative CSIs had no influence on clinical scores and retear rates, whereas postoperative CSIs were associated with lower scores and more retears. Although we can infer that preoperative CSIs do not affect outcomes, we cannot determine whether postoperative CSIs compromised outcomes or were administered in patients who had already poor outcomes. Our findings may resolve controversies about the administration of preoperative CSIs.
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Affiliation(s)
- Laurent Baverel
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Achilleas Boutsiadis
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | | | | | | | - Johannes Barth
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
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Dolkart O, Chechik O, Bivas A, Brosh T, Drexler M, Weinerman Z, Maman E. Subacromial corticosteroid injections transiently decrease suture anchor pullout strength: biomechanical studies in rats. J Shoulder Elbow Surg 2017; 26:1789-1793. [PMID: 28689827 DOI: 10.1016/j.jse.2017.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/06/2017] [Accepted: 05/08/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthroscopic rotator cuff (RC) repair incorporates suture anchors to secure torn RC tendons to the greater tuberosity (GT) bone. RC repair strength depends on the anchor-bone interface and on the quality of the GT. We evaluated the effect of single and multiple corticosteroid injections on the pullout strength of suture anchors. METHODS Fifty rats were divided into those receiving saline solution injection (control group), a single methylprednisolone acetate (MTA) injection (MTA1 group), or 3 once-weekly MTA injections (MTA3 group). Rats were killed humanely at 1 or 4 weeks after the last injection. A mini-suture anchor was inserted into the humeral head through the GT. Specimens were tested biomechanically. RESULTS At 1 week after the last injection, the mean maximal pullout strength was significantly reduced in the MTA1 group (63.5%) and MTA3 group (56%) compared with the control group (P < .05 for both). Mean stiffness decreased significantly in both treatment groups compared with controls (P < .05). At 4 weeks after the last injection, there was a significant increase in the mean maximal pullout strength after single and triple MTA injections compared with values recorded at the 1-week time point (P < .05). At 4 weeks, the mean maximal pullout strength after a single MTA injection was 92.8% of the pullout strength measured in the control group. CONCLUSIONS We showed a significant detrimental effect of corticosteroid exposure on the pullout strength of a suture anchor at 1 week. However, this effect was transient and resolved within a relatively short period. These findings indicate that a waiting period is required between subacromial corticosteroid injection and RC repair surgery that involves the use of suture anchors.
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Affiliation(s)
- Oleg Dolkart
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ofir Chechik
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Bivas
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Brosh
- Biomechanics Laboratory, School of Dental Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Drexler
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zachary Weinerman
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Maman
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Donohue NK, Prisco AR, Grindel SI. Pre-operative corticosteroid injections improve functional outcomes in patients undergoing arthroscopic repair of high-grade partial-thickness rotator cuff tears. Muscles Ligaments Tendons J 2017; 7:34-39. [PMID: 28717609 DOI: 10.11138/mltj/2017.7.1.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Subacromial corticosteroid injections (CSI's) are a common non-surgical treatment for rotator cuff tears. Few studies have assessed the effects of pre-operative CSI's on postoperative functional outcomes. METHODS A retrospective analysis was conducted of 132 patients with high-grade, partial-thickness rotator cuff tears (PTRCT's). The subjects were divided into two groups based on whether they received a CSI or not. The CSI group was further divided into three subgroups based on when they received a pre-operative injection: 0-3 months, 3-6 months, >6 months before surgery. The Visual Analog Scores (VAS), American Shoulder and Elbow Surgeon scores (ASES), and Constant scores were recorded prior to surgery and at a one-year post-operative follow-up appointment for each subject. RESULTS Patients who received a pre-operative CSI (n=92) improved significantly more than the non-injection group (n=40) in all outcome measures. The 0-3 months injection subgroup experienced a significant increase in ASES and Constant score (p=0.019 and 0.014, respectively) compared to the other two subgroups, but the VAS score decrease only trended toward significance (p=0.091). The sample as a whole experienced significant improvement in all three outcome measures. CONCLUSION Patients undergoing arthroscopic repair of a high-grade PTRCT may benefit from a pre-operative CSI 0-3 months before surgery. LEVEL OF EVIDENCE IIb.
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Affiliation(s)
- Nicholas K Donohue
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Anthony R Prisco
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Steven I Grindel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
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Rothrauff BB, Pauyo T, Debski RE, Rodosky MW, Tuan RS, Musahl V. The Rotator Cuff Organ: Integrating Developmental Biology, Tissue Engineering, and Surgical Considerations to Treat Chronic Massive Rotator Cuff Tears. TISSUE ENGINEERING PART B-REVIEWS 2017; 23:318-335. [PMID: 28084902 DOI: 10.1089/ten.teb.2016.0446] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The torn rotator cuff remains a persistent orthopedic challenge, with poor outcomes disproportionately associated with chronic, massive tears. Degenerative changes in the tissues that comprise the rotator cuff organ, including muscle, tendon, and bone, contribute to the poor healing capacity of chronic tears, resulting in poor function and an increased risk for repair failure. Tissue engineering strategies to augment rotator cuff repair have been developed in an effort to improve rotator cuff healing and have focused on three principal aims: (1) immediate mechanical augmentation of the surgical repair, (2) restoration of muscle quality and contractility, and (3) regeneration of native enthesis structure. Work in these areas will be reviewed in sequence, highlighting the relevant pathophysiology, developmental biology, and biomechanics, which must be considered when designing therapeutic applications. While the independent use of these strategies has shown promise, synergistic benefits may emerge from their combined application given the interdependence of the tissues that constitute the rotator cuff organ. Furthermore, controlled mobilization of augmented rotator cuff repairs during postoperative rehabilitation may provide mechanotransductive cues capable of guiding tissue regeneration and restoration of rotator cuff function. Present challenges and future possibilities will be identified, which if realized, may provide solutions to the vexing condition of chronic massive rotator cuff tears.
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Affiliation(s)
- Benjamin B Rothrauff
- 1 Department of Orthopaedic Surgery, Center for Cellular and Molecular Engineering, University of Pittsburgh , Pittsburgh, Pennsylvania.,2 McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Thierry Pauyo
- 3 Division of Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Richard E Debski
- 2 McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Mark W Rodosky
- 3 Division of Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Rocky S Tuan
- 1 Department of Orthopaedic Surgery, Center for Cellular and Molecular Engineering, University of Pittsburgh , Pittsburgh, Pennsylvania.,2 McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Volker Musahl
- 2 McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,3 Division of Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
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Gelber JD. CORR Insights ®: Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res 2017; 475:244-246. [PMID: 27572298 PMCID: PMC5174046 DOI: 10.1007/s11999-016-5044-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/15/2016] [Indexed: 01/31/2023]
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Burger M, Africa C, Droomer K, Norman A, Pheiffe C, Gericke A, Samsodien A, Miszewski N. Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2016; 72:318. [PMID: 30135893 PMCID: PMC6093128 DOI: 10.4102/sajp.v72i1.318] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 08/12/2016] [Indexed: 11/18/2022] Open
Abstract
Background Subacromial impingement syndrome (SIS) is one of the most common causes of shoulder pain. Limited research has been conducted into the efficacy of corticosteroid injections (CSIs) compared to physiotherapy in the management of SIS. Objective To critically appraise and establish the best available evidence for the effectiveness of CSI in comparison with physiotherapy for the management of pain, shoulder range of motion (ROM) and shoulder function in patients with SIS. Methodology Seven databases were searched from inception to February 2016, namely PubMed, Science Direct, EBSCO Host: SPORTDiscus, EBSCO Host: CINAHL, Cochrane, Scopus and PEDro. The main search terms were shoulder impingement syndrome and/or subacromial impingement syndrome, corticosteroid injections and/or steroid injections, physical therapy and/or physiotherapy. Only randomised controlled trials (RCTs) were considered for inclusion. The articles were appraised according to the PEDro scale. The Revman© Review Manager Software was used to combine the results of shoulder function and the data were illustrated in forest plots. Results The PEDro scores of the three RCTs that qualified for this review ranged from 7 to 8/10. There is Level II evidence suggesting that besides a significant improvement in shoulder function in favour of CSI at 6–7 weeks follow-up (p < 0.0001), no evidence was found for the superiority of CSIs compared with physiotherapy for pain, ROM and shoulder function in the short- (1–3 months), mid- (6 months) and long term (12 months). Conclusion In patients with SIS only a short term significant improvement in shoulder function was found in favour of CSIs.
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Affiliation(s)
- Marlette Burger
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Carly Africa
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Kara Droomer
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Alexa Norman
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Chloé Pheiffe
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Anrich Gericke
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Adeeb Samsodien
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Natasha Miszewski
- Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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Marks D, Bisset L, Comans T, Thomas M, Ng SK, O’Leary S, Conaghan PG, Scuffham PA. Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon. PLoS One 2016; 11:e0162679. [PMID: 27631987 PMCID: PMC5025143 DOI: 10.1371/journal.pone.0162679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 08/23/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon. METHODS A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs. RESULTS 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive. CONCLUSIONS Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry 12612000532808.
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Affiliation(s)
- Darryn Marks
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Leanne Bisset
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Tracy Comans
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
- Metro North Hospital and Health Service, 112 Alfred Street, Fortitude Valley, QLD 4006, Brisbane, Australia
| | - Michael Thomas
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia
| | - Shu Kay Ng
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Shaun O’Leary
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, St Lucia, QLD 4072, Australia
- Physiotherapy Department, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, QLD 4006, Australia
| | - Philip G. Conaghan
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, United Kingdom
| | - Paul A. Scuffham
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
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Shin SJ, Do NH, Lee J, Ko YW. Efficacy of a Subacromial Corticosteroid Injection for Persistent Pain After Arthroscopic Rotator Cuff Repair. Am J Sports Med 2016; 44:2231-6. [PMID: 27268240 DOI: 10.1177/0363546516648326] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase. PURPOSE To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively. RESULTS In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04). CONCLUSION A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.
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Affiliation(s)
- Sang-Jin Shin
- Global Top 5 Research Program, Department of Orthopedic Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Nam-Hoon Do
- Joint Center, Department of Orthopedic Surgery, Baro Hospital, Incheon, Korea
| | - Juyeob Lee
- Global Top 5 Research Program, Department of Orthopedic Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Young-Won Ko
- Global Top 5 Research Program, Department of Orthopedic Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
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