Glenohumeral joint injections: a review

Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Comparison of triamcinolone and methylprednisolone efficacy and steroid flare reaction rates after shoulder corticosteroid injection: a prospective interrupted time series study

BACKGROUND

A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions.

METHODS

In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection.

RESULTS

MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection.

Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: A systematic review and meta-analysis

Symptomatic primary glenohumeral (GH) joint osteoarthritis (OA) can be challenging to treat. Hyaluronic acid (HA) has emerged as a promising treatment for the nonsurgical management of GH-OA. In this systematic review with meta-analysis, we aimed to evaluate the current evidence regarding the efficacy of intra-articular HA on pain relief in patients suffering from GH-OA. A total of 15 studies (only randomized controlled trials providing data at the end of the intervention) were included. The relevant studies were selected based on the following PICO model: P: patients with diagnosis of shoulder OA; I: HA infiltrations as therapeutic intervention administered; C: no restriction for comparators assessed; O: pain, in terms of visual analog scale (VAS) or numeric rating scale. The risk of bias among the included studies was estimated using the PEDro scale. A total of 1023 subjects were analyzed. Comparing HA injections combined with physical therapy (PT) compared to PT alone resulted in superior scores, showing an overall effect size (ES) of 4.43 (p = 0.00006). Moreover, pooled analysis of VAS pain scores demonstrated a significant improvement in the ES of the HA in comparison with corticosteroid injections (p = 0.002). On average, we reported a PEDro score of 7.2. A total of 46.7% of studies showed probable signs of a randomization bias. The findings of this systematic review and meta-analysis showed that IA injections of HA might be effective on pain relief with significant improvements compared to baseline and compared to corticosteroid injections in patients affected by GH-OA.

The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty

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.

Factors impacting time to total shoulder arthroplasty among patients with primary glenohumeral osteoarthritis and rotator cuff arthropathy managed conservatively with corticosteroid injections

BACKGROUND

The purpose of this study was to identify predictors of the time from initial presentation to total shoulder arthroplasty (TSA) in patients with primary glenohumeral osteoarthritis (OA) and rotator cuff (RTC) arthropathy who were conservatively managed with corticosteroid injections.

METHODS

We conducted a retrospective cohort study of patients who underwent TSA from 2010 to 2021. Kaplan-Meier survival analysis was used to estimate median time to TSA for primary OA and RTC arthropathy patients. The Cox proportional hazards model was used to identify significant predictors of time to TSA and to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Statistical significance was set at P&lt;0.05.

RESULTS

The cohort included 160 patients with primary OA and 92 with RTC arthropathy. In the primary OA group, median time to TSA was 15 months. Significant predictors of shorter time to TSA were older age at presentation (HR, 1.02; 95% CI, 1.00-1.04; P=0.03) and presence of moderate or severe acromioclavicular joint arthritis (HR, 1.45; 95% CI, 1.05-2.01; P=0.03). In the RTC arthropathy group, median time to TSA was 14 months, and increased number of corticosteroid injections was associated with longer time to TSA (HR, 0.87; 95% CI, 0.80-0.95; P=0.003).

CONCLUSIONS

There are distinct prognostic factors for progression to TSA between primary OA patients and RTC arthropathy patients managed with corticosteroid injections. Multiple corticosteroid injections are associated with delayed time to TSA in RTC arthropathy patients.

Interventional Radiology Procedures of the Shoulder

Using imaging guidance to perform procedures around the shoulder girdle has become established practice in musculoskeletal radiology. Whether it be therapeutic injections for intra-articular pathology, rotator cuff or subacromial/subdeltoid bursal pathology, or injections for diagnostic purposes, such as magnetic resonance or computed tomography arthrography, a range of techniques and imaging modalities can be used. This article discusses the techniques for commonly performed procedures.

Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty

AIMS

Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures.

METHODS

Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes.

RESULTS

In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036).

CONCLUSION

There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620-626.

Review of Extraosseous Applications of Thermal Ablation in the Treatment of Moderate to Severe Large Joint Osteoarthritis

Osteoarthritis (OA) is the most common joint disease worldwide, leading to significant pain, restricted range of motion, and disability. A gap exists between short- and long-term symptom-relieving therapies. Although arthroplasty is an effective treatment for symptomatic end-stage disease, most patients ultimately do not receive a joint replacement due to suboptimal surgical qualifications, comorbidities, or an aversion to surgery. The lack of additional treatment options in this setting makes opioid agonists a commonly used pharmacologic agent, contributing to the addiction epidemic that greatly afflicts our communities. Cooled radiofrequency ablation (CRFA) has arisen as a treatment modality in the setting of moderate to severe OA among patients refractory to conservative management, generally showing greater efficacy compared with other existing strategies. This review focuses on the benefits of CRFA and its technical feasibility as a management option among patients experiencing debilitating large joint OA with limited clinical options.

Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities

Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Intra-articular steroid injections in large joint arthritis: A survey of current practice

INTRODUCTION

Intra-articular corticosteroid injections are widely used as a management modality for mild large joint osteoarthritis (OA). In contrast, there is little guidance or consensus on the use of steroids in moderate to severe disease. The aim of this study is to explore the current practice of surgeons in relation to the use of therapeutic intra-articular steroid injections in patients awaiting large joint arthroplasty for OA.

METHODS

An anonymous questionnaire was distributed to consultants performing large joint arthroplasty in four National Health Service Trusts. Participants were questioned on their use of intra-articular therapeutic steroid injections in patients listed for elbow, shoulder, hip or knee arthroplasty. Data was collected over 6 months and analysed using Microsoft Excel.

RESULTS

A total of 42 surgeons were included in the study with the majority performing lower limb arthroplasty (73%). About 21 (50%) surgeons indicated they would perform injections in the patient group of interest. Two would perform an unlimited number of injections, whilst the remainder would perform between one and three injections. Respondents most commonly indicated they would tell patients that an injection would provide between 6 and 12 weeks of benefit (14 of 39 surgeons, 36%). Most injecting surgeons (88%) leave 4 months between an injection and subsequent arthroplasty due to increased risk of infection if surgery is performed sooner.

CONCLUSION

This study demonstrates variation in practice in the use of intra-articular steroids in the analysed patient group, and the way surgeons council their patients. National or specialist society guidelines may help to reduce this variation in practice.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

Ultrasound practice for chronic pain procedures: A comprehensive review

Chronic pain management techniques have evolved in recent years. With regard to this, ultrasound (US) technology has become a standard for most acute pain procedures and essential for postsurgical pain relief and enhanced recovery after surgery protocols. This manuscript summarizes clinical studies evaluating US use for chronic pain management and compares efficacy with standard techniques including fluoroscopy (FL). US possesses several unique benefits when compared with FL, including elimination of radiation exposure while providing similar clinical outcomes. In summary, US use for chronic pain procedures is emerging as a viable, safe, and effective modality. Additional studies are needed to best appreciate US and its role in chronic pain management.

[Osteoarthritis of the shoulder: pathogenesis, diagnostics and conservative treatment options]

PATHOGENESIS

Osteoarthritis of the shoulder is characterized by a progressive degenerative process, which is based on chronic inflammation with intra-articular release of different cytokines and proteolytic enzymes. The main predisposing factors are a history of trauma or surgery, as well as chronic overuse or instability of the glenohumeral joint. Affected patients especially suffer from impaired joint function and pain, which are often associated with cognitive and psychosocial restrictions.

DIAGNOSTICS

Possible co-pathologies have to be evaluated carefully both clinically and radiologically as they must be taken into account in the therapeutic procedure. If arthroplasty of the shoulder is planned, a pre-operative CT scan is mandatory in order to evaluate the bone stock of the glenoid, which has a decisive influence on the choice of implant.

TREATMENT

Conservative treatment options are oral pain medication, physical therapy, and intra-articular injections, whereby, in comparison to corticosteroids, hyaluronic acid seems to be advantageous especially with respect to the duration of a positive clinical effect.

[Shoulder Osteoarthritis-pathogenesis, classification, diagnostics and treatment]

Primary osteoarthritis of the shoulder represents a destructive joint disease with associated synovitis, which in the first line seems to be genetically determined. Clinically, patients suffer from shoulder pain with progressive impairment of both active and passive range of motion. The diagnostics include a clinical examination, imaging by native radiography and magnetic resonance imaging (MRI) for assessment of the rotator cuff. Current classification systems consider the formation of humeral osteophytes, glenoid morphology and loss of humeral sphericity. Non-surgical measures include, apart from topical and oral analgesics, injection of corticosteroids and hyaluronic acid supported by physiotherapeutic measures. After failure of non-surgical therapeutic measures, arthroscopic joint-preserving arthroplasty in terms of the comprehensive arthroscopic management (CAM) procedure can be performed in young patients with early stage osteoarthritis, whereas in advanced stages endoprosthetic joint replacement is indicated.

Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Hyaluronic acid (HA) is an analgesic and chondroprotective agent often used for the nonoperative treatment of osteoarthritis (OA). The effects of HA injections are well studied in the treatment of knee OA, but the effects in glenohumeral OA remain unclear. This study evaluated the efficacy of HA to reduce pain in patients with glenohumeral OA.

METHODS

PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through January 16, 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of risk of bias. The primary outcome was change in visual analog scale for pain. The secondary outcomes were functional outcome and adverse events.

RESULTS

In the HA arm, the reduction of visual analog scale pain score at 3 months was 26.2 mm (95% confidence interval, 22.0-30.3 mm; I² = 31%) and at 6 months was 29.5 mm (95% confidence interval, 25.5-33.4 mm; I² = 19%). All studies reported an improvement in functional outcome. Similar clinical improvements were reported in the intervention and control groups, suggesting that these improvements may not be directly related to HA. Commonly reported adverse events were rare and included swelling and mild pain at the injection site, local effusion, lethargy, and face rash.

CONCLUSION

Intra-articular HA injection is safe and improves pain for patients with glenohumeral OA. Pain improvements also reported in the control group suggest that a significant placebo effect may be present with respect to intra-articular shoulder injection. Further randomized controlled trials are necessary to evaluate the efficacy of HA and identify optimal dosing and route of administration.

Corticosteroids and Hyaluronic Acid Injections

Osteoarthritis is a common condition that affects many individuals resulting in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment. Studies have shown that they provide short-term pain improvement and can be used for osteoarthritis flares. Hyaluronic acid injections have extensively been studied in knee osteoarthritis but to a lesser degree in other joints. Despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function.

A comparison of one-year treatment utilization for shoulder osteoarthritis patients initiating care with non-orthopaedic physicians and orthopaedic specialists

Background

In this paper we investigate patients seeking care for a new diagnosis of shoulder osteoarthritis (OA) and the association between a patient’s initial physician specialty choice and one-year surgical and conservative treatment utilization.

Methods

Using retrospective data from a single large regional healthcare system, we identified 572 individuals with a new diagnosis of shoulder OA and identified the specialty of the physician which was listed as the performing physician on the index shoulder visit. We assessed treatment utilization in the year following the index shoulder visit for patients initiating care with a non-orthopaedic physician (NOP) or an orthopaedic specialist (OS). Descriptive statistics were calculated for each group and subsequent one-year surgical and conservative treatment utilization was compared between groups.

Results

Of the 572 patients included in the study, 474 (83%) received care from an OS on the date of their index shoulder visit, while 98 (17%) received care from a NOP. There were no differences in baseline patient age, gender, BMI or pain scores between groups. OS patients reported longer symptom duration and a higher rate of comorbid shoulder diagnoses. Patients initiating care with an OS on average received their first treatment much faster than patients initiating care with NOP (16.3 days [95% CI, 12.8, 19.7] vs. 32.3 days [95% CI, 21.0, 43.6], Z = 4.9, p < 0.01). Additionally, patients initiating care with an OS had higher odds of receiving surgery (OR = 2.65, 95% CI: 1.42, 4.95) in the year following their index shoulder visit.

Conclusions

Patients initiating care with an OS received treatment much faster and were treated with more invasive services over the year following their index shoulder visit. Future work should compare patient-reported outcomes across patient groups to assess whether more expensive and invasive treatments yield better outcomes for patients with shoulder OA.

Injectable Corticosteroids in Sport

OBJECTIVE

To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes.

DATA SOURCES

An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles.

MAIN RESULTS

Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits.

CONCLUSIONS

Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

Glenohumeral Osteoarthritis in the Young Patient

Glenohumeral osteoarthritis in the young patient (aged <60 years) is a difficult condition, given both age and functional demands. Primary osteoarthritis is the most common etiology in this patient demographic, but secondary causes include osteonecrosis, previous trauma (eg, fracture-dislocation), previous infection (eg, septic arthritis), previous capsulorrhaphy, previous arthroscopic surgery (eg, chondrolysis), and glenoid dysplasia. Nonsurgical modalities, including activity modification, pharmacotherapy, physical therapy, and intra-articular injections, are the mainstay of management; however, in young patients who have exhausted nonsurgical management, surgical options include arthroscopic débridement, humeral head replacement with or without glenoid treatment (ie, biologic glenoid resurfacing, glenoid reaming), and total or reverse total shoulder arthroplasty. Unfortunately, failure rates after surgical management are considerably higher in young patients compared with those observed in older, more sedentary patients. Here, we focus on the etiology, evaluation, and management of young patients with glenohumeral osteoarthritis, with a focus on clinical outcomes.

Osteoarthritis treatment: Decreasing pain, improving mobility

Osteoarthritis (OA) is the most common articular disease. The condition results in bone-on-bone contact, stiffness, pain, and decreased mobility. By the year 2050, 40 million individuals will be severely disabled because of OA, and there will be over 130 million individuals suffering from OA worldwide.

Optimal management of glenohumeral osteoarthritis

Glenohumeral osteoarthritis (OA) is defined as progressive loss of articular cartilage, resulting in bony erosion, pain, and decreased function. This article provides a gross overview of this disease, along with peer-reviewed research by experts in the field. The pathology, diagnosis, and classification of this condition have been well described. Treatment begins with non-operative measures, including oral and topical anti-inflammatory agents, physical therapy, and intra- articular injections of either a corticosteroid or a viscosupplementation agent. Operative treatment is based on the age and function of the affected patient, and treatment of young individuals with glenohumeral OA remains controversial. Various methods of surgical treatment, ranging from arthroscopy to resurfacing, are being evaluated. The roles of hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty are similarly reviewed with supporting data.

Irreparable Rotator Cuff Tears Without Arthritis Treated With Reverse Total Shoulder Arthroplasty

Background:

Irreparable rotator cuff (RC) tears without arthritis is a challenging clinical problem in young adults. Reverse total shoulder arthroplasty (RTSA) has been proposed as one of the surgical treatment options for this condition.

Methods:

In this review, we discuss the current understanding of the role of RTSA for the management of irreparable RC tears without arthritis based on authors personal experience and available scientific literature.

Results:

Reverse total shoulder arthroplasty (RTSA) is a constrained arthroplasty system that can allow the deltoid and remaining rotator cuff to substitute for the lost function of irreparable RC. Furthermore, the pain relief is consistent with often a dramatic improvement in patient comfort, shoulder function and stability. In patients with pseudoparalysis of the shoulder without advanced arthritis, RTSA effectively restores forward elevation above the shoulder but may not dramatically improve external (ER) or internal rotation (IR). However, due to concerns over implant longevity, caution has to be exercised when using RTSA for symptomatic irreparable RC tears with preserved active forward elevation (AFE) and in patients less than 65 years of age.

Conclusion:

RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis. However, caution should be exercised when offering RTSA to young patients and patient without pseudoparalysis because they can have a higher complication and dissatisfaction rate. In addition, longevity of RTSA and subsequent need for revision surgery remains a significant concern in this population.

Evolving Role of Ultrasound in Therapeutic Injections of the Upper Extremity

Ultrasound machines are creating more refined pictures and becoming more user-friendly and readily accessible. As a result, ultrasound is being increasingly used for therapeutic purposes. One example involves the use of ultrasound guidance in musculoskeletal interventional procedures, such as joint injections, tendon sheath injections, and peripheral nerve blocks. Technical considerations and therapeutic results have been described for multiple locations about the upper extremities, with varying levels of success. The implementation of ultrasound-guided injections in the orthopedist's clinic has therapeutic, financial, and provider role implications. Given these potential benefits, orthopedic providers, both in practice and residency, would benefit from increased exposure and education in ultrasound use. Ultrasound provides the benefit of real-time, dynamic imaging without the radiation exposure of fluoroscopy, and ultrasound-guided injections can be performed in the office, as opposed to the operating room, which is frequently required when using fluoroscopy. A basic knowledge of the principles and terms used in ultrasound is required. With these simple principles, a practitioner can review techniques for specific areas of the musculoskeletal system and begin using ultrasound to guide injections. Many locations for diagnostic and/or therapeutic injections in the upper extremities have improved accuracy and benefit with the use of ultrasound vs blind techniques, although a few have not been shown to have a significant difference in the literature. The educational and professional implications can be significant, but these potential benefits need to be carefully weighed against costs by each orthopedic practice.