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Saeki M, Yoneda H, Yamamoto M. Lateral elbow magnetic resonance imaging findings in patients without pain complaints. JPRAS Open 2024; 41:159-165. [PMID: 39040144 PMCID: PMC11261295 DOI: 10.1016/j.jpra.2024.06.005] [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] [Received: 03/09/2024] [Accepted: 06/09/2024] [Indexed: 07/24/2024] Open
Abstract
Magnetic resonance imaging (MRI) can help evaluate lateral epicondylitis; however, abnormal findings on MRI are not always consistent with the symptoms. The occurrence of such abnormal MRI findings at the lateral side of the elbow in patients without pain remains unclear. Therefore, the purpose of this study was to investigate the MRI findings of the lateral elbow joint in patients with no complaints of pain in the elbow joint. We retrospectively identified 152 patients who had undergone MRI of the area including the elbow from July 2015 to January 2022. We excluded patients with pain in the elbow area and those with diagnosis of diseases that could affect MRI findings at the lateral elbow. The presence of lateral collateral ligament complex (LCLC) and common extensor tendon (CET) lesions on MRI was assessed by two reviewers. In total, 22 patients (12 men and 10 women) were included in the analysis. The mean age of the patients was 54 years. Five patients, all ≥65 years old, had abnormal findings related to the LCLC or CET on MRI. Abnormal LCLC and CET findings on MRI can be encountered in older patients even in the absence of elbow pain.
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Affiliation(s)
- Masaomi Saeki
- Department of Human Enhancement & Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidemasa Yoneda
- Department of Human Enhancement & Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michiro Yamamoto
- Department of Human Enhancement & Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Saeki M, Yoneda H, Yamamoto M. Posterior Translation of the Radial Head in Magnetic Resonance Imaging of Lateral Epicondylitis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5746. [PMID: 38633509 PMCID: PMC11023611 DOI: 10.1097/gox.0000000000005746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/01/2024] [Indexed: 04/19/2024]
Abstract
Background Posterolateral rotatory instability is produced by disruption of the lateral collateral ligament complex (LCLC); it is commonly induced by trauma, with few cases reported due to lateral epicondylitis. We examined the amount of posterior transition of the radial head with or without LCLC injury, common extensor tendon (CET) injury, and Baker classification in lateral epicondylitis. Methods We retrospectively studied patients with lateral epicondylitis of the humerus who underwent surgery between April 2016 and July 2021. Fifteen elbows with coronal and sagittal images on preoperative magnetic resonance imaging (MRI) were included. We investigated the amount of posterior transition of the radial head in sagittal MRI images of the elbow, which were compared based on LCLC and CET lesion. Results The mean age of patients was 49 years. The lesions in four, nine, and two patients were classified as LCLC0, LCLC1, and LCLC2, respectively. The mean radio-humeral distance values among the LCLC lesions were 0.65, 2.46, and 2.22 mm in LCLC0, LCLC1, and LCLC2, respectively, with the RHD between LCLC0 and LCLC1 differing significantly. In five, six, and four patients, the lesions were classified as CET1, CET2, and CET3, respectively. The mean RHD values among the CET lesions were 1.33, 2.68, and 1.48 mm in CET1, CET2, and CET3, respectively. Conclusions Our results showed that posterior transition of the radial head is greater in patients with lateral epicondylitis with LCLC lesions on MRI than those with normal findings of LCLC.
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Affiliation(s)
- Masaomi Saeki
- From the Department of Human Augmentation and Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidemasa Yoneda
- From the Department of Human Augmentation and Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michiro Yamamoto
- From the Department of Human Augmentation and Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kamel SI, Rosas HG, Gorbachova T. Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications. AJR Am J Roentgenol 2024; 222:e2330458. [PMID: 38117096 DOI: 10.2214/ajr.23.30458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.
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Affiliation(s)
- Sarah I Kamel
- Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107
| | - Humberto G Rosas
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Ge Z, Yang M, Wei D, Wang D, Zhao R, Deng X, Tang Y, Fang Q, Xiong Z, Wang C, Wang G, Li W, Tang K. Inhibition of IKKβ via a DNA-Based In Situ Delivery System Improves Achilles Tendinopathy Healing in a Rat Model. Am J Sports Med 2023; 51:3533-3545. [PMID: 37804159 DOI: 10.1177/03635465231198501] [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: 10/09/2023]
Abstract
BACKGROUND The inhibition of IKKβ by the inhibitor 2-amino-6-[2-(cyclopropylmethoxy)-6-hydroxyphenyl]-4-(4-piperidinyl)-3-pyridine carbonitrile (ACHP) is a promising strategy for the treatment of Achilles tendinopathy. However, the poor water solubility of ACHP severely hinders its in vivo application. Moreover, the effective local delivery of ACHP to the tendon and its therapeutic effects have not been reported. PURPOSE To investigate the therapeutic effects of IKKβ inhibition via injection of ACHP incorporated into a DNA supramolecular hydrogel in a collagenase-induced tendinopathy rat model. STUDY DESIGN Controlled laboratory study. METHODS Dendritic DNA, a Y-shaped monomer, and a crosslinking monomer were mixed with ACHP and self-assembled into an ACHP-DNA supramolecular hydrogel (ACHP-Gel). The effects of ACHP-Gel in tendon stem/progenitor cells were investigated via RNA sequencing and validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). A total of 120 collagenase-induced rats were randomly assigned to 5 groups: blank, phosphate-buffered saline (PBS), DNA-Gel, ACHP, and ACHP-Gel. Healing outcomes were evaluated using biomechanic and histologic evaluations at 4 and 8 weeks. RESULTS ACHP-Gel enhanced the solubility of ACHP and sustained its release for ≥21 days in vivo, which significantly increased the retention time of ACHP and markedly reduced the frequency of administration. RNA sequencing and qRT-PCR showed that ACHP effectively downregulated genes related to inflammation and extracellular matrix remodeling and upregulated genes related to tenogenic differentiation. The cross-sectional area (P = .024), load to failure (P = .002), stiffness (P = .039), and elastic modulus (P = .048) significantly differed between the ACHP-Gel and PBS groups at 8 weeks. The ACHP-Gel group had better histologic scores than the ACHP group at 4 (P = .042) and 8 weeks (P = .009). Type I collagen expression (COL-I; P = .034) and the COL-I/collagen type III ratio (P = .015) increased while interleukin 6 expression decreased (P < .001) in the ACHP-Gel group compared with the ACHP group at 8 weeks. CONCLUSION DNA supramolecular hydrogel significantly enhanced the aqueous solubility of ACHP and increased its release-retention time. Injection frequency was markedly reduced. ACHP-Gel suppressed inflammation in Achilles tendinopathy and promoted tendon healing in a rat model. CLINICAL RELEVANCE ACHP-Gel injection is a promising strategy for the treatment of Achilles tendinopathy in clinical practice.
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Affiliation(s)
- Zilu Ge
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingyu Yang
- Department of Orthopedics/Sports Medicine Center, First Affiliated Hospital of Third Military Medical University [Army Medical University], Chongqing, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Danfeng Wei
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dong Wang
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Renliang Zhao
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiangtian Deng
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunfeng Tang
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qian Fang
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhencheng Xiong
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chengshi Wang
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research, West China Hospital, Sichuan University, Chengdu, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guanglin Wang
- Trauma Medical Center, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Li
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research, West China Hospital, Sichuan University, Chengdu, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kanglai Tang
- Department of Orthopedics/Sports Medicine Center, First Affiliated Hospital of Third Military Medical University [Army Medical University], Chongqing, China
- Investigation performed at Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Tsechelidis OB, Sabido-Sauri R, Aydin SZ. Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review. Clin Ther 2023; 45:852-859. [PMID: 37716837 DOI: 10.1016/j.clinthera.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections. METHODS The published literature was searched through PubMed as well as identifying relevant articles from their citations, for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included. FINDINGS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged. IMPLICATIONS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.
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Affiliation(s)
| | - Ricardo Sabido-Sauri
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Sibel Zehra Aydin
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.
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Atthakomol P, Manosroi W, Sathiraleela K, Thaiprasit N, Duangsan T, Tapaman A, Sripheng J. Prognostic factors related to recurrence of trigger finger after open surgical release in adults. J Plast Reconstr Aesthet Surg 2023; 83:352-357. [PMID: 37302240 DOI: 10.1016/j.bjps.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 05/02/2023] [Accepted: 05/14/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Recurrent trigger finger after surgery is one of the major adverse events. However, studies to identify factors associated with recurrence after open surgical release in adult trigger finger patients are still limited. PURPOSE To identify factors associated with recurrent trigger finger after open surgical release. METHODS This 12-year retrospective observational study included 723 patients with 841 trigger fingers who underwent open A1 pulley release. Patients were categorized into 2 groups: those with recurrent trigger finger after surgery and those without. Associations between potential predictors including age, sex, duration of symptoms, occupation status, active smoker status, number of steroid injections before surgery, and types of comorbidities and the outcome of interest, recurrence of trigger finger, were examined using univariable and multivariable analyses. The results are presented as hazard ratios (HR) with a 95% confidence interval (95% CI). RESULTS The recurrence rate after trigger finger release was 2.39% (20 of 841 fingers). After adjusting for confounders, more than 3 steroid injections before surgery and manual labor were the independent predictors of recurrent trigger finger (HR = 4.87, 95%CI = 1.06-22.35 and HR = 3.43, 95%CI = 1.15-10.23, respectively). CONCLUSIONS More than 3 steroid injections before surgery and manual labor increase the risk of recurrent trigger finger after an open A1 pulley release. There may be limited benefit in administering a fourth steroid injection.
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Affiliation(s)
- Pichitchai Atthakomol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research Center, Chiang Mai University, Chiang Mai, Thailand; Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Worapaka Manosroi
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Krittin Sathiraleela
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Nutthapong Thaiprasit
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Treephum Duangsan
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Atithep Tapaman
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Jiramate Sripheng
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Enhanced tendon healing by a tough hydrogel with an adhesive side and high drug-loading capacity. Nat Biomed Eng 2022; 6:1167-1179. [PMID: 34980903 PMCID: PMC9250555 DOI: 10.1038/s41551-021-00810-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/13/2021] [Indexed: 12/14/2022]
Abstract
Hydrogels that provide mechanical support and sustainably release therapeutics have been used to treat tendon injuries. However, most hydrogels are insufficiently tough, release drugs in bursts, and require cell infiltration or suturing to integrate with surrounding tissue. Here we report that a hydrogel serving as a high-capacity drug depot and combining a dissipative tough matrix on one side and a chitosan adhesive surface on the other side supports tendon gliding and strong adhesion (larger than 1,000 J m<sup>-2</sup>) to tendon on opposite surfaces of the hydrogel, as we show with porcine and human tendon preparations during cyclic-friction loadings. The hydrogel is biocompatible, strongly adheres to patellar, supraspinatus and Achilles tendons of live rats, boosted healing and reduced scar formation in a rat model of Achilles-tendon rupture, and sustainably released the corticosteroid triamcinolone acetonide in a rat model of patellar tendon injury, reducing inflammation, modulating chemokine secretion, recruiting tendon stem and progenitor cells, and promoting macrophage polarization to the M2 phenotype. Hydrogels with 'Janus' surfaces and sustained-drug-release functionality could be designed for a range of biomedical applications.
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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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Boone SL, Uzor R, Walter E, Elsinger E, Catanese D, Ye K, Goldberg-Stein S. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis. Skeletal Radiol 2021; 50:2471-2482. [PMID: 34019132 DOI: 10.1007/s00256-021-03783-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for retrocalcaneal bursitis. MATERIALS AND METHODS After IRB approval, all fluoroscopically guided and ultrasound-guided retrocalcaneal bursa injections (2013-2019) were retrospectively evaluated. Pre-procedure US and radiographs were scored by 2 blinded radiologists in consensus for Achilles tendinosis and retrocalcaneal bursitis (0-3 scale), Achilles enthesopathy (present/absent), and Haglund deformity (present/absent). Pre- and post-procedure pain scores (0-10 scale) evaluated short-term response at 1-4 weeks: excellent (7-10 point decline), good (4-6 point decline), fair (1-3 point decline), or no response. Paired t-test determined significance of short-term improvement. Kaplan-Meier method analyzed time to progression to surgery or complication at 6-month minimum follow-up. Logistic regression analysis evaluated for association between demographic and imaging variables and negative outcome. RESULTS Two hundred eighteen injections (181 female; mean 54.5 years) performed under ultrasonographic (157, 72%) or fluoroscopic (61, 28%) guidance were evaluated for complication and long-term outcomes. Injections with short-term follow-up (n = 62) yielded excellent or good response in 62.9% (p < 0.00001). Thirty patients (14%) had subsequent elective Achilles surgery. Bursal Doppler flow was associated with progression to surgery (p = 0.00042). No differences were identified in outcomes between US and fluoroscopic-guidance cohorts. Four Achilles ruptures (1.8%) were identified 15-59 days post-injection, each with immediately preceding acute injury. CONCLUSION Image-guided retrocalcaneal bursa corticosteroid injection yields significant short-term decrease in pain score in majority (63%) of patients. Subsequent Achilles tendon rupture rate was 1.8%. Bursa Doppler flow was significantly correlated with progression to surgery and may represent a negative prognostic indicator.
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Affiliation(s)
- Sean L Boone
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Robert Uzor
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Eric Walter
- Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Elizabeth Elsinger
- Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Dominic Catanese
- Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Kenny Ye
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Shlomit Goldberg-Stein
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
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Kholinne E, Liu H, Kim H, Kwak JM, Koh KH, Jeon IH. Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact? Am J Sports Med 2021; 49:2542-2550. [PMID: 33433240 DOI: 10.1177/0363546520980133] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Elbow instability, particularly posterolateral rotatory instability (PLRI), has been reported in patients with refractory lateral epicondylitis (LE). However, evidence of diagnostic approach and surgical outcomes is lacking. PURPOSE To identify (1) the risk factors, clinical and radiologic-diagnostic characteristics, and (2) the treatment options and clinical outcome of LE with PLRI. STUDY DESIGN Systematic review. METHODS We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, Scopus, and EMBASE databases using keywords as well as Medical Subject Headings terms and Emtree using "(lateral epicondylitis OR tennis elbow) AND (instability OR posterolateral rotatory instability)" for English-language studies. We conducted a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS In total, 8 articles comprising 6 level 4 and 2 level 3 studies were identified, including 249 patients (254 elbows). The main triggering factor was heavy labor activity (74/172; 43%). A total of 184 patients (73.9%) received either single (4/184; 2.2%) or multiple (180/184; 97.8%) steroid injections. Clinically, instability was always accompanied by pain in 9% of study individuals. Magnetic resonance imaging (MRI) revealed that radial collateral ligament (RCL) and lateral ulnar collateral ligament (LUCL) lesions were most common (18/79; 23%). The most common surgical procedure performed was arthroscopic RCL plication (62/120; 52%) followed by LUCL reconstruction (30/120; 25%). A ligament patholaxity sign was shown intraoperatively for 64% (44/69). Clinical outcomes ranged from good to excellent in all studies. The most common residual symptom was limited range of motion (11/18; 61%). CONCLUSION Instability can coexist and may be associated with refractory LE. The risk factors of instability associated with refractory LE are heavy labor and multiple steroid injections. A systematic approach to identify the clinical and MRI presentation of the condition followed by examination under anesthesia are necessary for affirmative diagnosis, as independent presentations may be misleading.
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Affiliation(s)
- Erica Kholinne
- Faculty of Medicine, Trisakti University, Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia.,Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
| | - Hua Liu
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Hyojune Kim
- Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
| | - Jae-Man Kwak
- Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
| | - Kyoung-Hwan Koh
- Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
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11
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Hsu PC, Chang KV, Wu WT, Wang JC, Özçakar L. Effects of Ultrasound-Guided Peritendinous and Intrabursal Corticosteroid Injections on Shoulder Tendon Elasticity: A Post Hoc Analysis of a Randomized Controlled Trial. Arch Phys Med Rehabil 2020; 102:905-913. [PMID: 33338463 DOI: 10.1016/j.apmr.2020.11.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The study aimed to investigate whether the shoulder tendons changed their elasticity after ultrasound-guided peritendinous or intrabursal corticosteroid injections. DESIGN Post hoc secondary analysis of a double-blinded, randomized controlled study with 3 months of follow-up. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Patients with subacromial impingement syndrome (N=60). INTERVENTIONS Patients with unilateral shoulder pain were randomly assigned to receive standard ultrasound-guided subacromial or dual-target corticosteroid injections. The supraspinatus tendons were exposed to 40 mg triamcinolone acetonide in the formal group, whereas the long head of the biceps brachii tendons (LHBT) and supraspinatus tendons were individually infiltrated by 20 mg triamcinolone acetonide in the latter group. Patients' bilateral shoulders were divided into group 1 (n=30, receiving standard subacromial injections), group 2 (n=30, receiving dual-target injections), and group 3 (n=60, without injections). MAIN OUTCOME MEASURES Strain ratio of LHBT and supraspinatus tendons using ultrasound elastography. RESULTS The repeated-measures analysis of variance revealed no intragroup difference of the strain ratio of the LHBT (P=.412 for group 1, P=.936 for group 2, P=.131 for group 3) and supraspinatus tendon (P=.309 for group 1, P=.067 for group 2, P=.860 for group 3) across the 3 time points. Treating group 3 as the reference, the linear mixed model revealed no significant changes in tendon elasticity after either the standard subacromial injection (P=.205 for the LHBT and P=.529 for the supraspinatus tendon) or the dual-target injection (P=.961 for the LHBT and P=.831 for the supraspinatus tendon). CONCLUSIONS Elasticity of the LHBT and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections. Future studies with a shorter follow-up interval are needed to validate whether corticosteroid injections can cause transient changes of the tendon's elasticity.
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Affiliation(s)
- Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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12
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Sederberg M, Cushman DM. Current Treatments of Insertional Achilles Tendinopathy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00288-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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13
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Aicale R, Bisaccia RD, Oliviero A, Oliva F, Maffulli N. Current pharmacological approaches to the treatment of tendinopathy. Expert Opin Pharmacother 2020; 21:1467-1477. [DOI: 10.1080/14656566.2020.1763306] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Rocco Domenico Bisaccia
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Department of Pharmacology, School of Medicine and Surgery, University of Salerno , Baronissi, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London , London, UK
- Keele University, Faculty of Medicine, School of Pharmacology and Bioengineering, Guy Hilton Research Centre , Stoke-on-Trent, UK
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14
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Bedi A, Trinh TQ, Olszewski AM, Maerz T, Ramme AJ. Nonbiologic Injections in Sports Medicine. JBJS Rev 2020; 8:e0052. [PMID: 32224626 DOI: 10.2106/jbjs.rvw.19.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability.
A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.
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Affiliation(s)
- Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thai Q Trinh
- Department of Orthopaedic Surgery, Genesis Healthcare, Zanesville, Ohio
| | - Adam M Olszewski
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tristan Maerz
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Austin J Ramme
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Steindler Orthopedic Clinic, Iowa City, Iowa
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15
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Stenroos AJ, Brinck T. Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate. J Am Podiatr Med Assoc 2020; 110:436389. [PMID: 32556230 DOI: 10.7547/18-014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation. METHODS We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016. RESULTS During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient). CONCLUSIONS In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.
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Affiliation(s)
- Antti J Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Tuomas Brinck
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
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16
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Ge Z, Tang H, Chen W, Wang Y, Yuan C, Tao X, Zhou B, Tang K. Downregulation of type I collagen expression in the Achilles tendon by dexamethasone: a controlled laboratory study. J Orthop Surg Res 2020; 15:70. [PMID: 32093733 PMCID: PMC7038574 DOI: 10.1186/s13018-020-01602-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/17/2020] [Indexed: 12/16/2022] Open
Abstract
Background Spontaneous Achilles tendon rupture associated with long-term dexamethasone (Dex) use has been reported. However, few studies have investigated the potential mechanism. The aim of this study was to evaluate the effects of oral Dex on type I collagen in humans and rats and its association with tendon rupture. Methods First, six Achilles tendons from patients who received long-term Dex treatment, and another six normal tendons were harvested for histological evaluation. Secondly, 8-week-old rats (n = 72) were randomly assigned to a Dex group or a control group. Type I collagen was studied at the mechanical, histological, and molecular levels after 3 and 5 weeks. Tenocytes isolated from normal human and rat tendon were used to investigate the effect of Dex on cellular scale. Results Histological analysis of human and rat tendon tissue revealed an irregular, disordered arrangement of type I collagen in the Dex group compared with the control group. In addition, In the Dex+ group, type I collagen expression decreased in comparison with the Dex− group in both human and rat tenocytes. The mechanical strength of tendons was significantly reduced in the Dex group (68.87 ± 11.07 N) in comparison with the control group (81.46 ± 7.62 N, P = 0.013) after 5 weeks. Tendons in the Dex group were shorter with smaller cross-sectional areas (10.71 ± 0.34 mm2, 1.44 ± 0.22 mm2, respectively) after 5 weeks than those in the control group (11.13 ± 0.50 mm2, P = 0.050, 2.74 ± 0.34 mm2, P < 0.001, respectively). Conclusions This finding suggests long-term use of Dex that decreases the expression of type I collagen at molecular and tissue levels both in human and rat Achilles tendons. Furthermore, Dex decreases the mechanical strength of the tendon, thereby increasing the risk of Achilles tendon rupture.
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Affiliation(s)
- Zilu Ge
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Hong Tang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Wan Chen
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China.
| | - Yunjiao Wang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Chengsong Yuan
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Xu Tao
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Binghua Zhou
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
| | - Kanglai Tang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street. 30, Shapingba District, Chongqing, 400038, China
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17
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Xu H, Li H, Hua Y, Bai L, Chang F, Chen S, Chen W, Fang Z, Gui J, Guo Q, Hu Y, Huang H, Jiao C, Li Q, Li W, Liang X, Lu H, Lu L, Miao X, Qu J, Song W, Xu T, Wang Z, Wang X, Wei M, Wei S, Xiang D, Xu H, Yang M, Zhan J, Zhang F, Zhao F, Zhu Y, Tang K. Chinese Consensus on Insertional Achilles Tendinopathy. Orthop J Sports Med 2019; 7:2325967119879052. [PMID: 31656824 PMCID: PMC6791038 DOI: 10.1177/2325967119879052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Insertional Achilles tendinopathy (IAT) is a common finding in the clinic. However, consensus on its mechanism, pathological process, diagnosis, treatment, and rehabilitation is lacking. Thus, the Chinese Society of Sports Medicine organized and invited experts representing the fields of ankle disease and tendinopathy to jointly develop an expert consensus on IAT. Study Design: A consensus statement of the Chinese Society of Sports Medicine. Methods: A total of 34 experts in the field of sports medicine and orthopaedics were invited to participate in the compilation of a consensus statement regarding IAT. Consensus was achieved according to the Delphi method. First, 10 working groups composed of 34 experts were established to compile draft statements about clinical problems related to IAT by reviewing and analyzing the available literature. An expert consensus meeting to discuss drafts was then arranged. Each statement was individually presented and discussed, followed by a secret vote. Consensus was reached when more than 50% of the experts voted in its favor. The strength of the proposed recommendation was classified based on the proportion of favorable votes: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimity, 100%. Results: Of the 10 expert consensus statements on the clinical diagnosis and treatment of IAT, there was strong consensus for 8 statements and unanimity for 2 statements. Conclusion: This expert consensus focused on the concepts, causes, pathological process, clinical diagnosis, and treatment of IAT. Accepted recommendations in these areas which will assist clinicians in carrying out standardized management of related diseases.
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Affiliation(s)
- Chinese Society of Sports Medicine
- Yinghui Hua, MD, PhD, and Kanglai Tang, MD, PhD, No 12, Wulumuqi Zhong Road, Shanghai 200040, China & Gaotanyan Str. 30, Chongqing 400038, People’s Republic of China ( and )
| | | | | | - Yinghui Hua
- Yinghui Hua, MD, PhD, and Kanglai Tang, MD, PhD, No 12, Wulumuqi Zhong Road, Shanghai 200040, China & Gaotanyan Str. 30, Chongqing 400038, People’s Republic of China ( and )
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kanglai Tang
- Yinghui Hua, MD, PhD, and Kanglai Tang, MD, PhD, No 12, Wulumuqi Zhong Road, Shanghai 200040, China & Gaotanyan Str. 30, Chongqing 400038, People’s Republic of China ( and )
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18
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Shim JW, Yoo SH, Park MJ. Surgical management of lateral epicondylitis combined with ligament insufficiency. J Shoulder Elbow Surg 2018; 27:1907-1912. [PMID: 30170794 DOI: 10.1016/j.jse.2018.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/03/2018] [Accepted: 06/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. METHODS We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. RESULTS The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. CONCLUSIONS Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.
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Affiliation(s)
- Jae Woo Shim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Si Hoon Yoo
- Department of Orthopedic Surgery, Inseong Hallym Hospital, Incheon, Republic of Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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19
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Seo J, Yeom SR, Shin HR, Park K, Kim JK, Park SJ, Lee S. Effectiveness and safety of fluoroscopy-guided acupuncture for subacromial impingement syndrome: A protocol for a randomized, patient-assessor blind, parallel clinical trial. Medicine (Baltimore) 2018; 97:e12386. [PMID: 30235704 PMCID: PMC6160190 DOI: 10.1097/md.0000000000012386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Subacromial impingement syndrome (SIS) is one of the most common diseases inducing shoulder pain. Acupuncture is a source of pain relief that has been used for SIS; however, there is no clinical study about image-guided acupuncture for SIS. The aim of this study is to evaluate the effectiveness and safety of fluoroscopy-guided acupuncture in patients with SIS. METHODS This is the protocol for a randomized, patient-assessor blind, parallel clinical trial comparing fluoroscopy-guided acupuncture to acupuncture without fluoroscopy. There will be a 1-week run-in period before random allocation to 2 groups. The total duration of the clinical trial will be 3 weeks including 2 weeks for the follow-up period. A total of 57 participants will be enrolled for the clinical trial. Acupuncture will be conducted in 2 sessions for each group, once at baseline and once at the 1-week mark. The primary outcome will be 100 mm pain visual analogue scale. Secondary outcomes will include the Neer and Hawkins test, the Modified Constant Murley Score scale, the Shoulder Pain And Disability Index, the patient satisfaction degree, and the accuracy rate of acupuncture. For the evaluation of safety, adverse events will be monitored. DISCUSSION We designed the clinical trial using image-guided acupuncture. This will be the first trial to study the effectiveness of image-guided acupuncture for SIS compared with acupuncture using the proportional measurements. TRIAL REGISTRATION Clinical Research Information Service Registration Number is KCT0002751. Registered on March 23, 2018.
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Affiliation(s)
| | - Seung-Ryong Yeom
- Department of Korean Medicine Rehabilitation, Gwangju Medical Center, College of Korean Medicine, Wonkwang University, Gwangju
| | - Hee-Ra Shin
- Department of Korean Medicine Rehabilitation, Gwangju Medical Center, College of Korean Medicine, Wonkwang University, Gwangju
| | - Kyungtae Park
- Department of Korean Medicine Rehabilitation, Gwangju Medical Center, College of Korean Medicine, Wonkwang University, Gwangju
| | - Jae Kyoun Kim
- Clinical Trial Center
- Department of Global Public Health and Korean Medicine Management, Graduate School, Kyung Hee University, Seoul
| | | | - Sangkwan Lee
- Clinical Trial Center
- Department of Internal Medicine, College of Korean Medicine, Wonkwang University, Iksan, Jeonbuk, Republic of Korea
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20
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Stenson JF, Reb CW, Daniel JN, Saini SS, Albana MF. Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis. Foot Ankle Spec 2018; 11:252-255. [PMID: 28884594 DOI: 10.1177/1938640017729497] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
UNLABELLED Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario. LEVELS OF EVIDENCE Level IV: Retrospective Case series.
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Affiliation(s)
- James F Stenson
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, New Jersey (JFS, SSS, MFA).,Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida (CWR).,Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia, Pennsylvania (JND).,Foot and Ankle Service, The Rothman Institute, Philadelphia, Pennsylvania (JND)
| | - Christopher W Reb
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, New Jersey (JFS, SSS, MFA).,Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida (CWR).,Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia, Pennsylvania (JND).,Foot and Ankle Service, The Rothman Institute, Philadelphia, Pennsylvania (JND)
| | - Joseph N Daniel
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, New Jersey (JFS, SSS, MFA).,Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida (CWR).,Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia, Pennsylvania (JND).,Foot and Ankle Service, The Rothman Institute, Philadelphia, Pennsylvania (JND)
| | - Sundeep S Saini
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, New Jersey (JFS, SSS, MFA).,Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida (CWR).,Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia, Pennsylvania (JND).,Foot and Ankle Service, The Rothman Institute, Philadelphia, Pennsylvania (JND)
| | - Mohammed F Albana
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, New Jersey (JFS, SSS, MFA).,Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida (CWR).,Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia, Pennsylvania (JND).,Foot and Ankle Service, The Rothman Institute, Philadelphia, Pennsylvania (JND)
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Abstract
RATIONALE Ptosis is a rare complication of periocular steroid use. Studies report that local injections of steroids produce ptosis. We describe the first 2 cases of ptosis because of long-term treatment with topical steroid eye drops. PATIENT CONCERNS Two cases admitted to our hospital because of ptosis of their right eye after long-term treatment with topical steroid eye drops. Both of them had uncontrolled Posner-Schlossman syndrome. DIAGNOSIS Two cases were diagnosed as steroid-related ptosis. INTERVENTIONS Regulatory anti-inflammation therapy was prescribed for case 1, and after inflammation control, phacoemulsification was done for her. Six months after steroid withdrawal, the levator resection of the right eye was performed. Case 2 refused our advice of steroid reduction and ptosis surgery. OUTCOMES After surgery, case 1 retained a symmetrical appearance during a 1-year follow-up. In the surgery, we found thin levator muscles and slack levator palpebrae superioris aponeurosis (LPSA) in the affected eye. Postoperative transmission electron microscopy revealed typical signs of apoptosis in levator muscle cells. LESSONS We suggest topical application of steroids induces levator muscle apoptosis and LPSA weakness, and results in ptosis.
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Blomgran P, Hammerman M, Aspenberg P. Systemic corticosteroids improve tendon healing when given after the early inflammatory phase. Sci Rep 2017; 7:12468. [PMID: 28963482 PMCID: PMC5622078 DOI: 10.1038/s41598-017-12657-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/19/2017] [Indexed: 12/26/2022] Open
Abstract
Inflammation initiates tendon healing and then normally resolves more or less completely. Unresolved inflammation might disturb the remodeling process. We hypothesized that suppression of inflammation during the early remodeling phase by systemic dexamethasone treatment can improve healing. 36 rats underwent Achilles tendon transection and were randomized to dexamethasone or saline on days 0-4 after surgery (early inflammatory phase), and euthanasia day 7. Another 54 rats received injections days 5-9 (early remodeling phase) and were euthanized day 12 for mechanical, histological and flow cytometric evaluation. Dexamethasone treatment days 0-4 reduced the cross-sectional area, peak force and stiffness by day 7 to less than half (p < 0.001 for all), while material properties (peak stress and elastic modulus) were not significantly affected. In contrast, dexamethasone treatment days 5-9 increased peak force by 39% (p = 0.002) and stiffness by 58% (p < 0.001). The cross-sectional area was reduced by 42% (p < 0.001). Peak stress and elastic modulus were more than doubled (p < 0.001 for both). Semi-quantitative histology at day 12 showed that late dexamethasone treatment improved collagen alignment, and flow cytometry revealed reduced numbers of CD8a+ cytotoxic T cells in the tendon callus. These results suggest that downregulation of lingering inflammation during the early remodeling phase can improve healing.
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Affiliation(s)
- Parmis Blomgran
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Malin Hammerman
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Jo CH, Lee SY, Yoon KS, Shin S. Effects of Platelet-Rich Plasma With Concomitant Use of a Corticosteroid on Tenocytes From Degenerative Rotator Cuff Tears in Interleukin 1β-Induced Tendinopathic Conditions. Am J Sports Med 2017; 45:1141-1150. [PMID: 28061032 DOI: 10.1177/0363546516681294] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A corticosteroid injection is commonly used to treat tendinopathy, but it has been associated with negative effects on tendon homeostasis. Platelet-rich plasma (PRP) is known to have proliferative and anabolic effects as well as cytoprotective effects against corticosteroids on tenocytes. However, the combined effects of a corticosteroid and PRP on the anti-inflammatory, matrix synthesis, and cytoprotective potential of tenocytes in conditions simulating tendinopathy have not been investigated. PURPOSE To assess the effects of PRP on tenocytes from degenerative rotator cuff tears with the concomitant use of a corticosteroid in interleukin 1β (IL-1β)-induced tendinopathic conditions. STUDY DESIGN Controlled laboratory study. METHODS Tenocytes were enzymatically isolated and cultured from patients with degenerative rotator cuff tears. PRP was prepared using a plateletpheresis system, and growth factor concentrations were measured. To evaluate the gene expression of proinflammatory and anti-inflammatory cytokines, enzymes and their inhibitors, and matrix molecules, cells were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) platelet-poor plasma (PPP) and PRP of 200, 1000, and 4000 × 103/μL; quantitative real-time reverse transcriptase polymerase chain reaction was also performed. Western blotting was performed to investigate the protein synthesis of degradative enzymes and their inhibitors. Cell viability, apoptosis, and senescence assays were also conducted. RESULTS PRP did not interfere with the anti-inflammatory effects of dexamethasone on tenocytes pretreated with IL-1β, but it increased the synthesis of tissue inhibitor of metalloproteinase (TIMP)-1 and -3. Meanwhile, PRP did not induce anti-inflammatory cytokines that had been suppressed with a corticosteroid. It did increase the type I/III collagen ratio mainly through the suppression of type III collagen expression. PRP reversed the decreased viability, increased apoptosis, and induced senescence with IL-1β and a corticosteroid. CONCLUSION This study shows that the addition of PRP does not interfere with the anti-inflammatory effects of a corticosteroid on IL-1β-treated tenocytes from degenerative rotator cuff tears but that it does avoid the deleterious side effects of a corticosteroid. CLINICAL RELEVANCE PRP can be clinically useful with a corticosteroid as a treatment for tendinopathy.
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Affiliation(s)
- Chris Hyunchul Jo
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Yeon Lee
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kang Sup Yoon
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sue Shin
- Department of Laboratory Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
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Yamamoto Y, Yamaguchi S, Sasho T, Fukawa T, Akatsu Y, Akagi R, Yamaguchi T, Takahashi K, Nagashima K, Takahashi K. Quantitative US Elastography Can Be Used to Quantify Mechanical and Histologic Tendon Healing in a Rabbit Model of Achilles Tendon Transection. Radiology 2017; 283:408-417. [PMID: 28145809 DOI: 10.1148/radiol.2016160695] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Purpose To determine the time-dependent change in strain ratios (SRs) at the healing site of an Achilles tendon rupture in a rabbit model of tendon transection and to assess the correlation between SRs and the mechanical and histologic properties of the healing tissue. Materials and Methods Experimental methods were approved by the institutional animal care and use committee. The Achilles tendons of 24 New Zealand white rabbits (48 limbs) were surgically transected. The SRs of Achilles tendons were calculated by using compression-based quantitative ultrasonographic elastography measurements obtained 2, 4, 8, and 12 weeks after transection. After in vivo elastography, the left Achilles tendon was harvested for mechanical testing of ultimate load, ultimate stress, elastic modulus, and linear stiffness, and the right tendons were harvested for tissue histologic analysis with the Bonar scale. Time-dependent changes in SRs, mechanical parameters, and Bonar scale scores were evaluated by using repeated-measures analysis of variance. The correlation between SRs and each measured variable was evaluated by using the Spearman rank correlation coefficient. Results Mean SRs and Bonar scale values decreased as a function of time after transection, whereas mechanical parameters increased (P < .001). SR correlated with ultimate stress (ρ = 0.68, P <.001,) elastic modulus (ρ = 0.74, P <.001), and the Bonar scale (ρ = 0.87, P <.001). Conclusion Quantitative elastography could be a useful method with which to evaluate mechanical and histologic properties of the healing tendon. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Yohei Yamamoto
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Satoshi Yamaguchi
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Takahisa Sasho
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Taisuke Fukawa
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Yorikazu Akatsu
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Ryuichiro Akagi
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Tadashi Yamaguchi
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Kenji Takahashi
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Kengo Nagashima
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
| | - Kazuhisa Takahashi
- From the Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences (Y.Y., S.Y., T.S., T.F., Y.A., R.A., Kazuhisa Takahashi), Clinical Research Center (K.N.), and Center for Frontier Medical Engineering (T.Y.), Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan; and Funabashi Orthopaedic Hospital, Funabashi, Japan (Kenji Takahashi)
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Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6492597. [PMID: 27885357 PMCID: PMC5112330 DOI: 10.1155/2016/6492597] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/20/2016] [Indexed: 12/30/2022]
Abstract
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.
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Lu H, Yang H, Shen H, Ye G, Lin XJ. The clinical effect of tendon repair for tendon spontaneous rupture after corticosteroid injection in hands: A retrospective observational study. Medicine (Baltimore) 2016; 95:e5145. [PMID: 27741145 PMCID: PMC5072972 DOI: 10.1097/md.0000000000005145] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Corticosteroid injections for hand tendinitis can lead to a rare significant complication of tendon spontaneous rupture. However, only sporadic cases were reported in the literature before. This study was designed to gauge the clinical effect of tendon repair in patients of tendon spontaneous rupture after corticosteroid injection and analyze our experience.This was a retrospective observational study of 13 patients (8 women and 5 men) operated between July 2011 and December 2015 for tendon spontaneous rupture after corticosteroid injection. Demographic data, clinical features, imaging data, and surgical treatments were carefully reviewed.The average age was 52.308 ± 15.381 years (range 29-71). The average injection times were 2.538 ± 1.664 times (range 1-6). The average rupture time (after last injection) was 10.923 ± 9.500 weeks (range 3-32). Nine patients were treated by tendon suture (69% of cases), and 4 patients were treated by tendon grafting (31% of cases). All patients received follow-up in our outpatient clinic. The sites of the tendon rupture (15 tendons of 13 patients had involved) include extensor pollicis longus (6 tendons, 40% of cases), extensor digiti quinti and extensor digiti minimi (4 tendons, 27% of cases), ring finger of extensor digitorum communis (3 tendons, 20% of cases), and middle finger of extensor digitorum communis (2 tendons, 13% of cases). Two patients who had tendon adhesion (15% of cases) were treated by tendon release. One patient who had tendon rerupture (8% of cases) was treated by tendon grafting. No patient had complications of infections, vascular, or nerve injury.Tendon spontaneous rupture is a serious complication after corticosteroid injection for tendinitis. Rigid standard of corticosteroid injection is very important. Magnetic resonance imaging was contributory to preoperative assess tendon defect and can be used to monitor healing quality of tendons during the follow-up.
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Affiliation(s)
- Hui Lu
- Department of Hand Surgery
- Correspondence: Hui Lu, Department of Hand Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79# Qingchun Road, Hangzhou 310003, Zhejiang Province, PR China (e-mail: )
| | | | | | - Ganmin Ye
- Departments of Orthopedics, Sanmen People's Hospital, Taizhou, Zhejiang Province, PR China
| | - Xiang-Jin Lin
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
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Goldberg-Stein S, Berko N, Thornhill B, Elsinger E, Walter E, Catanese D, Popowitz D. Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes. Skeletal Radiol 2016; 45:1107-12. [PMID: 27020450 DOI: 10.1007/s00256-016-2368-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe a lateral fluoroscopically guided retrocalcaneal bursa injection technique, report patient outcomes at 1-4 weeks after steroid/anesthetic retrocalcaneal bursal therapeutic injection, and correlate pre-injection diagnostic heel ultrasound variables with improvement in patient pain scores. MATERIALS AND METHODS After IRB approval, fluoroscopically guided therapeutic retrocalcaneal bursa injections performed using a lateral approach were retrospectively reviewed. Pre-injection heel ultrasound results and pre- and post-injection patient VAS pain scores (scale 0-10) were recorded. The Wilcox matched-pair test compared pain scores, and Spearman's rho assessed for correlation between pain score changes and heel ultrasound results. RESULTS Thirty-two injections were performed in 30 patients (25 females, 5 males; mean 56.5 ± 9.3 years, range 39-75 years; 21 left heel, 11 right heel) with technical success in 32 of 32 cases (100 %). Insertional Achilles tendon pathology and retrocalcaneal bursitis were present in 31 of 32 cases (97 %) and 16 of 32 cases (50 %), respectively. Median pre- and post-procedure pain scores were 8 (IQR 7, 10) and 1.75 (IQR 0, 6). A statistically significant decrease in pain score was observed following injection, with a median change of 4.75 (IQR 3, 8; p < 0.001). Clinically significant response (>50 % reduction in pain score) was present in 69 % (95 % CI, 0.52-0.86; p < 0.001). No significant correlation was identified between a decrease in pain score and a sonographically abnormal Achilles tendon or retrocalcaneal bursa. CONCLUSION Fluoroscopically guided retrocalcaneal bursal steroid/anesthetic using a lateral approach is an effective technique. This technique yielded 100 % technical success and a clinically significant decrease in patient pain scores (p < 0.001).
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Affiliation(s)
- Shlomit Goldberg-Stein
- Musculoskeletal Division, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Netanel Berko
- Musculoskeletal Division, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Beverly Thornhill
- Musculoskeletal Division, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Elizabeth Elsinger
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Eric Walter
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Dominic Catanese
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Daniel Popowitz
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
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Benazzo F, Marullo M, Indino C, Zanon G. Achilles Tendinopathies. ARTHROSCOPY AND SPORT INJURIES 2016:69-76. [DOI: 10.1007/978-3-319-14815-1_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Maman E, Yehuda C, Pritsch T, Morag G, Brosh T, Sharfman Z, Dolkart O. Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff: A Biomechanical and Imaging Study in Rats. Am J Sports Med 2016. [PMID: 26216105 DOI: 10.1177/0363546515591266] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of corticosteroids on tendons is poorly understood, and current data are insufficient and conflicting. PURPOSE To evaluate the effects of corticosteroid injections on intact and injured rotator cuffs (RCs) through biomechanical and radiographic analyses in a rat model. STUDY DESIGN Controlled laboratory study. METHODS A total of 70 rats were assigned to 7 groups. Uninjured rats (no tear) received either a single saline injection, a single methylprednisolone acetate (MTA) injection, or triple MTA injections. Injured rats (unilateral supraspinatus injury) received either a single saline injection, triple saline injections, a single MTA injection, or triple MTA injections (injections were subacromial; repeat injections were administered weekly). Rats were sacrificed 1 week after final injection. Shoulders were harvested and grossly inspected, and the supraspinatus tendon was evaluated biomechanically. Bone density at the tendon insertion site on the greater tuberosity was assessed by micro-computed tomography. RESULTS Intact RCs exposed to triple MTA injections had significantly decreased maximal load and stiffness compared with the control group (14.43 vs 21.25 N and 8.21 vs 16.6 N/mm, respectively; P < .05). Injured RCs exposed to steroid treatment had significantly lower maximal load (single saline: 10.91 N, single steroid: 8.43 N [P < .05]; triple control: 15.77 N, triple steroid: 11.65 N [P < .05]) compared with the control at 3 weeks. Greater tuberosity volume density and connectivity density were significantly lower in undamaged rats after triple MTA injection (P < .05). CONCLUSION The study results clearly showed that repeated doses of corticosteroids significantly weaken rat RC and negatively affect bone quality in addition to possibly causing deterioration of the osteotendinous junction. However, data retrieved from animals must be scrupulously analyzed before extrapolation to humans. As such, the potential benefits and harms of subacromial corticosteroid treatment must be considered before administration. CLINICAL RELEVANCE The potential benefit and detrimental effects of corticosteroid injection should be thoroughly considered before it is administered subacromially in patients with RC injuries.
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Affiliation(s)
- Eran Maman
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Chaim Yehuda
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Tamir Pritsch
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Guy Morag
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Tamar Brosh
- Biomechanics Laboratory, School of Dental Medicine Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Zachary Sharfman
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Oleg Dolkart
- Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
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Abstract
Abstract
Disorders of the Achilles tendon, the largest tendon in the human body, are common and occur in both active and sedentary persons. A thorough history and physical examination allow primary care physicians to make an accurate diagnosis and to initiate appropriate management. Mismanaged or neglected injuries markedly decrease a patient’s quality of life. A growing body of related literature is the basis for current therapeutic regimens, which use a multimodal conservative approach, including osteopathic manipulative treatment. Although primary care physicians can manage most cases of Achilles tendon disorders, specialty care may be needed in certain instances. Procedural intervention should consider any comorbid conditions in addition to patients’ lifestyle to help guide decision making. When appropriately managed, Achilles tendon disorders generally carry a favorable prognosis.
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Chen W, Tang H, Zhou M, Hu C, Zhang J, Tang K. Dexamethasone inhibits the differentiation of rat tendon stem cells into tenocytes by targeting the scleraxis gene. J Steroid Biochem Mol Biol 2015; 152:16-24. [PMID: 25906952 DOI: 10.1016/j.jsbmb.2015.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/24/2015] [Accepted: 04/08/2015] [Indexed: 11/27/2022]
Abstract
Glucocorticoid-induced tendon rupture is very common in clinical practice, and the overall outcome of surgical suture repair is rather poor. The mechanism remains unclear, and effective treatments are still lacking. In the present study, we investigated the effect of dexamethasone on the differentiation of rat tendon stem cells (TSCs) to tenocytes and the underlying molecular mechanisms and found that dexamethasone inhibits the differentiation of TSCs to tenocytes by analyzing the development of long, spindle-shaped cells and detecting the expression of tenocyte markers type I collagen and tenomodulin (TNMD) at both the mRNA and protein levels. We also discovered that after treatment with dexamethasone, the scleraxis expression level is downregulated in vitro and in human specimen. Chromatin immunoprecipitation (ChIP)-PCR showed that dexamethasone promotes glucocorticoid receptor interacted with the TGGAAGCC sequence located between -734 and -726 base pairs (bp) upstream of the start codon of the scleraxis gene. Furthermore, TSCs were transfected with scleraxis knockdown or overexpression plasmids, and the results indicated that scleraxis plays a pivotal role in the differentiation of TSCs to tenocytes. In conclusion, dexamethasone inhibits the differentiation of TSCs to tenocytes by inhibiting the scleraxis gene.
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Affiliation(s)
- Wan Chen
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Hong Tang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Mei Zhou
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Chao Hu
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Jiqiang Zhang
- Department of Neurology, Third Military Medical University, Chongqing 400038, China.
| | - Kanglai Tang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China.
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32
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Kim YC, Ahn JH, Kim MS. Infectious Achilles Tendinitis After Local Injection of Human Placental Extracts: A Case Report. J Foot Ankle Surg 2015. [PMID: 26213164 DOI: 10.1053/j.jfas.2015.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Local injections of corticosteroids or human placental extracts are sometimes used for the treatment of resistant tendinitis or fasciitis. We report a case of infectious Achilles tendinitis complicated by calcaneal osteomyelitis after injection of human placental extracts for the Achilles tendinitis. She was treated with excision of the infected bone and tendon, followed by V-Y lengthening of the proximal portion of the Achilles tendon in a single stage. At 2 years postoperative, she remained symptom free without any signs of recurrence, and the follow-up magnetic resonance imaging scan demonstrated a well-maintained Achilles tendon with normal signal intensity.
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Affiliation(s)
- Yoon-Chung Kim
- Clinical Assistant Professor, Department of Orthopaedic Surgery, St. Vincent's Hospital, Suwon, Korea
| | - Jae Hoon Ahn
- Professor, Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Man-Soo Kim
- Orthopedist, Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kim JH, Gwak HC. Adrenal Insufficiency in Patients with Rotator Cuff Tear: Prevalence, Risk Factors and Influence on Outcome. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.2.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ghellioni GV, da Silva LS, Piovezan AP, Martins RO. Effect of methylprednisolone use on the rotator cuff in rats: biomechanical and histological study. Rev Bras Ortop 2015; 50:260-5. [PMID: 26229927 PMCID: PMC4519642 DOI: 10.1016/j.rboe.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 06/13/2014] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the influence of treatment with different doses of methylprednisolone on the mechanical resistance and possible histological alterations of the rotator cuff tendon in rats. Methods Male Wistar rats were divided randomly into four treatment groups: sham, vehicle or 0.6 mg/kg or 6.0 mg/kg of methylprednisolone. Changes to mechanical resistance (in N) and histological parameters (fibrillar appearance, presence of collagen, edema and vascular proliferation) of the rotator cuff tendon were evaluated. The analyses were conducted after administration of one treatment (24 h afterwards), two treatments (7 days afterward) or three treatments (14 days afterwards), into the subacromial space. Results Seven and fourteen days after the treatments were started, it was found that in a dose-dependent manner, methylprednisolone reduced the mechanical resistance of the rotator cuff tendon (p < 0.05 in relation to the vehicle group). Modifications to the histological parameters were observed on the 7th and 14th days after the first infiltration, especially regarding the presence of collagen and vascular proliferation, for the dose of 0.6 mg/kg of methylprednisolone, and also regarding the presence of collagen, edema and vascular proliferation for the dose of 6.0 mg/kg of corticoid. Conclusion The results obtained demonstrated a relationship between methylprednisolone use through infiltration into the subacromial space and reduction of the mechanical resistance of and histological modifications to the rotator cuff tendon in rats.
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Ghellioni GV, Silva LSD, Piovezan AP, Martins RO. Efeito do uso da metilprednisolona no manguito rotador em ratos. Estudo biomecânico e histológico. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Yang SL, Zhang YB, Jiang ZT, Li ZZ, Jiang DP. Lidocaine potentiates the deleterious effects of triamcinolone acetonide on tenocytes. Med Sci Monit 2014; 20:2478-83. [PMID: 25433272 PMCID: PMC4259563 DOI: 10.12659/msm.891116] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Local anesthetics are commonly used for the treatment of a variety of tendinopathies in combination with corticosteroids injection. The goal of this study was to evaluate the effects of lidocaine and triamcinolone acetonide (TA) on cultured rat tenocytes and to determine whether there is a synergistic effect. Material/Methods Rat patellar tendon-derived tenocytes were cultured with or without TA and lidocaine, and the culture without any additive served as the control. Cell morphology and cell viability were evaluated. Expressions of tenocyte-related genes were measured by qRT-PCR. Results TA, when exposed to tenocytes in vitro, significantly decreased cell viability. The cells cultured with TA had a flattened shape. Moreover, the expressions of tenocyte-related genes in tenocytes were markedly decreased in the TA-treated group. We found that 1% lidocaine synergistically increased the deleterious effects of TA. Conclusions Our data provide evidence of the detrimental effects of these drugs on tendon tissues. Injection of TA in combination with 1% lidocaine should be used with caution.
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Affiliation(s)
- Shu-long Yang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Yu-bo Zhang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Zhi-tao Jiang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Zhao-zhu Li
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Da-peng Jiang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
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Muto T, Kokubu T, Mifune Y, Inui A, Harada Y, Yoshifumi, Takase F, Kuroda R, Kurosaka M. Temporary inductions of matrix metalloprotease-3 (MMP-3) expression and cell apoptosis are associated with tendon degeneration or rupture after corticosteroid injection. J Orthop Res 2014; 32:1297-304. [PMID: 24985902 DOI: 10.1002/jor.22681] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/10/2014] [Indexed: 02/04/2023]
Abstract
Corticosteroid injections are widely used to treat enthesopathy and tendinitis, but are also associated with possible side effects, such as tendon degeneration or rupture. However, the mechanism of tendon degeneration or rupture after corticosteroid injection remains controversial. The purpose of this study was to reveal the mechanism of tendon degeneration or rupture after injection of triamcinolone acetonide (TA) or prednisolone (PSL). Forty-two rats were divided into 3 groups: A normal saline injection group (control group), a TA injection group, and a PSL injection group; the normal saline or corticosteroid was injected around the Achilles tendon. One or 3 weeks after injection, the tendons were subjected to biomechanical testing and histological analysis. At 1 week, the biomechanical strength was significantly lower in the corticosteroid groups. Histological analysis, at 1-week post-injection, showed collagen attenuation, increased expression of MMP-3 and apoptotic cells in the corticosteroid groups. The histological changes and biomechanical weaknesses of the tendon were not seen at 3 weeks. These alterations appeared to be involved in tendon degeneration or rupture after corticosteroid injection.
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Affiliation(s)
- Tomoyuki Muto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom
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Sellon JL, Wempe MK, Smith J. Sonographically guided distal biceps tendon injections: techniques and validation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1461-1474. [PMID: 25063412 DOI: 10.7863/ultra.33.8.1461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The primary purpose of this investigation was to describe and validate sonographically guided techniques for distal biceps peritendinous/intratendinous injections using a cadaveric model. METHODS A single experienced operator completed 18 sonographically guided distal biceps peritendinous injections and 15 sonographically guided distal biceps intratendinous injections in 18 unembalmed cadaveric elbow specimens (11 male and 7 female; age, 53-100 years; body mass index, 19.4-42.2 kg/m(2)). Four different peritendinous approaches were used to inject 3 mL of diluted yellow latex: (1) anterior/superficial, (2) posterior/superficial, (3) posterior/deep/short-axis (to the distal biceps tendon), and (4) posterior/deep/long-axis (to the distal biceps tendon). Three different intratendinous approaches were used to inject 1 mL of diluted blue latex: (1) anterior, (2) anterior/pronator window, and (3) posterior. The feasibility of all 7 injections was assessed by the operator in all specimens, and execution difficulty was recorded after each injection. Specimens were subsequently dissected to assess injectate placement. RESULTS All 18 peritendinous distal biceps tendon injections accurately placed latex around the tendon without injecting into the tendon proper. All posterior/superficial peritendinous injections delivered injectate to the ulnar side of the tendon. All posterior/deep peritendinous injections delivered injectate to the radial side of the tendon, with the long-axis approach being technically easier than the short-axis approach. Anterior/superficial peritendinous injections delivered injectate predominantly to the anterior side of the tendon and resulted in 1 brachial artery injury. All but 1 of 15 distal biceps intratendinous injections (93%) accurately placed injectate into the tendon proper, with 1 of 5 anterior injections delivering injectate primarily deep to the paratenon. The posterior intratendinous approach was technically the easiest. No intratendinous injection resulted in neurovascular injury. CONCLUSIONS Sonographically guided distal biceps peritendinous/intratendinous injections are feasible and therefore may play a role in the management of patients presenting with distal biceps tendinopathy/bursopathy.
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Affiliation(s)
- Jacob L Sellon
- Departments of Physical Medicine and Rehabilitation (J.L.S., J.S.), Radiology (J.S.), and Anatomy (J.S.), Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, Minnesota USA; and Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota USA (M.K.W.)
| | - Michael K Wempe
- Departments of Physical Medicine and Rehabilitation (J.L.S., J.S.), Radiology (J.S.), and Anatomy (J.S.), Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, Minnesota USA; and Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota USA (M.K.W.)
| | - Jay Smith
- Departments of Physical Medicine and Rehabilitation (J.L.S., J.S.), Radiology (J.S.), and Anatomy (J.S.), Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, Minnesota USA; and Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota USA (M.K.W.).
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Turmo-Garuz A, Rodas G, Balius R, Til L, Miguel-Perez M, Pedret C, Del Buono A, Maffulli N. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle? Musculoskelet Surg 2013; 98:121-6. [PMID: 24222527 DOI: 10.1007/s12306-013-0305-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 11/04/2013] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of the study is to explain the cause-effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis. METHODS Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected. RESULTS An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances. CONCLUSIONS Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk-benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.
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Affiliation(s)
- A Turmo-Garuz
- High Performance Center (CAR de Sant Cugat Consorci Sanitari de Terrassa), Barcelona, Spain
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Dean BJF, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum 2013; 43:570-6. [PMID: 24074644 DOI: 10.1016/j.semarthrit.2013.08.006] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Our primary objective was to summarise the known effects of locally administered glucocorticoid on tendon tissue and tendon cells. METHODS We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines of the Medline database using specific search criteria. The search yielded 50 articles, which consisted of 13 human studies, 36 animal studies and one combined human/animal study. RESULTS Histologically, there was a loss of collagen organisation (6 studies) and an increase in collagen necrosis (3 studies). The proliferation (8 studies) and viability (9 studies) of fibroblasts was reduced. Collagen synthesis was decreased in 17 studies. An increased inflammatory cell infiltrate was shown in 4 studies. Increased cellular toxicity was demonstrated by 3 studies. The mechanical properties of tendon were investigated by 18 studies. Descriptively, 6 of these studies showed a decrease in mechanical properties, 3 showed an increase, while the remaining 9 showed no significant change. A meta-analysis of the mechanical data revealed a significant deterioration in mechanical properties, with an overall effect size of -0.67 (95% CI = 0.01 to -1.33) (data from 9 studies). CONCLUSIONS Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.
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Affiliation(s)
- Benjamin John Floyd Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK.
| | - Emilie Lostis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Thomas Oakley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Mark E Morrey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
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Muto T, Kokubu T, Mifune Y, Sakata R, Nagura I, Nishimoto H, Harada Y, Nishida K, Kuroda R, Kurosaka M. Platelet-rich plasma protects rotator cuff-derived cells from the deleterious effects of triamcinolone acetonide. J Orthop Res 2013; 31:976-82. [PMID: 23280560 DOI: 10.1002/jor.22301] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/29/2012] [Indexed: 02/04/2023]
Abstract
Triamcinolone acetonide (TA) injections are widely used to treat enthesopathy, but they may induce adverse effects such as tendon impairment and rupture. Platelet-rich plasma (PRP) is a blood fraction containing high platelet concentrations and various growth factors that play a role in tissue repair processes. The purpose of this study is to investigate whether TA has deleterious effects on human rotator cuff-derived cells, and if PRP can protect these cells from the effects of TA. Human rotator cuff-derived cells were cultured with and without TA and PRP, and the culture without any additive served as the control. Cell morphology was assessed at days 7 and 21. Cell viability was evaluated at days 1, 7, 14, and 21 by a water-soluble tetrazolium salt assay. Induction of apoptosis was measured by immunofluorescence staining and flow cytometry at day 7. Induction of cleaved caspase-3 was measured by immunofluorescence staining at day 7. The cells cultured with TA had a flattened and polygonal shape at day 7. The cells cultured with both TA and PRP were similar in appearance to control cells. Exposure to TA also significantly decreased cell viability, but cell viability did not decrease when PRP was added along with TA. The number of apoptotic cells increased with TA exposure, while addition of PRP prevented cell apoptosis. In conclusion, the deleterious effect of TA was prevented by PRP, which can be used as a protective agent for patients receiving local TA injections.
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Affiliation(s)
- Tomoyuki Muto
- Department of Orthopaedic Surgery, Kobe University, Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
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Abstract
Overuse injuries are a common and important cause of morbidity in elite and recreational athletes. They are increasingly recognized in the sedentary population. This article reviews the major classes of overuse injuries of the lower extremity. The underlying pathologic condition is correlated with the imaging appearances, and the often variable relationship between the imaging appearances and patients' symptoms are reviewed. Attempts at imaged-based grading systems and the ability of imaging to predict patients' prognosis are considered. Image-guided injection therapy for tendinopathy is an important and rapidly changing area; the indications, risks, and potential benefits of these interventions are reviewed.
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Retrospective Analysis of Postinjection Ultrasound Imaging After Platelet-Rich Plasma or Autologous Blood: Observational Review of Anatomic Distribution of Injected Material. AJR Am J Roentgenol 2012; 199:W501-5. [DOI: 10.2214/ajr.11.8075] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Dextrose prolotherapy and corticosteroid injection into rat Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2012; 20:1895-900. [PMID: 22113221 DOI: 10.1007/s00167-011-1789-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 11/14/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To assess the mechanical behavior and the histology of collagen fibers after prolotherapy with 12.5% dextrose into rat Achilles tendons and to compare with those of corticosteroid treatment. METHODS Out of 60 adult female Wistar rats (70 tendons), 15 received 12.5% dextrose (group I); 15 were treated with corticosteroid injection (group II); and 15 were given 0.9% saline injection (group III), all into the right Achilles tendon, whereas 13 animals received no injections (group IV). Three doses of each substance (groups I, II, and III) were given at a 5-day interval. Collagen fiber color was quantitatively assessed in three samples from each group and in five samples from the control group using picrosirius red staining under polarized and nonpolarized light. Twelve tendons from each group treated with the test substance and 20 tendons from the control group were submitted to the tensile strength test. RESULTS There was no statistical difference across the groups with respect to maximum load at failure (n.s.) and absorbed energy (n.s.). With respect to tendon rupture, there was no difference between the myotendinous and the tendinous regions (n.s.). However, hematoxylin-eosin staining revealed statistical significance in lymphocytic inflammatory infiltrate (P = 0.008) and in parallel fiber orientation (P = 0.003) when comparing groups to the control group, without significance for either neovascularization (n.s.) or the presence of fibroblasts (n.s.). Likewise, there was no significant difference between the percentage of mature (n.s.) and immature (n.s.) fibers. CONCLUSIONS Dextrose was not deleterious to the tendinous tissue, as it did not change the mechanical and histological properties of Achilles tendons in rats. The data obtained in this study may help clinicians in their daily work as they suggest that injections of 12.5% dextrose caused no harm to the tendons, although the clinical importance in humans still needs to be defined.
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Royall NA, Farrin E, Bahner DP, Stawicki SP. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2012. [PMID: 22474637 DOI: 10.5312/wjo.v2.i7.] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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Abstract
Bone shape is an important factor to determine the bone's structural function. For the asymmetrically shaped and anisotropically distributed bone in vivo, a surface mapping method is proposed on the bases of its geometric transformation invariance and its uniqueness of the principal axes of inertia. Using spiral CT scanning, we can make precise measurements to bone in vivo. The coordinate transformations lead to the principal axes of inertia, with which the prime meridian and the contour can be set. Methods such as tomographic reconstruction and boundary development are employed so that the surface of bone in vivo can be mapped. Experimental results show that the surface mapping method can reflect the shape features and help study the surface changes of bone in vivo. This method can be applied to research into the surface characteristics and changes of organ, tissue or cell whenever its digitalized surface is obtained.
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Affiliation(s)
- Yifang Fan
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, People's Republic of China
- * E-mail: (Yifang Fan); (Yubo Fan)
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China
- * E-mail: (Yifang Fan); (Yubo Fan)
| | - Zhiyu Li
- College of Foreign Studies, Jinan University, Guangzhou, People's Republic of China
| | - Changsheng Lv
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, People's Republic of China
| | - Bo Zhang
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, People's Republic of China
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Cho NS, Hwang JH, Lee YT, Chae SW. Tendinosis-like histologic and molecular changes of the Achilles tendon to repetitive stress: a pilot study in rats. Clin Orthop Relat Res 2011; 469:3172-80. [PMID: 21800208 PMCID: PMC3183207 DOI: 10.1007/s11999-011-2000-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 07/13/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendinopathy (pain and tendon degeneration) is associated with repetitive use and mechanical overload. However, the etiology of tendinopathy remains unclear. Clarification of histologic and molecular changes of tendon to repetitive stress could provide better understanding of Achilles tendon disorders related to repetitive stress. QUESTIONS/PURPOSES We asked whether repetitive stress simulating overuse of the Achilles tendon induced (1) histologic changes in rats similar to tendinosis (increased cellularity of fibrocytes, increased disorganization of collagen fiber, and increased roundness of the nucleus of the fibrocyte), (2) increased collagen Type III occurrence, and (3) increased inducible nitric oxide synthase (iNOS) expression. METHODS We used an exercise protocol simulating repetitive, jerky, eccentric contraction of the triceps surae in 15 rats. We conducted the exercise for 2 hours per day, three times per week using the right rear legs only and the left legs as internal controls. We harvested Achilles tendons after either 2, 4, or 6 weeks of exercise, and evaluated changes in tendon thickness, fibrocyte count, collagen fiber arrangement, collagen fiber type, and occurrence of iNOS. RESULTS Exercised Achilles tendons showed increased cellularity of fibrocytes at 4 and 6 weeks of exercise, and disorganized collagen fiber arrangement at 6 weeks of exercise. There was a trend for Type III collagen occurrence being greater in experimental groups. Expression of iNOS increased after 2 and 4 weeks of exercise when compared with that of the controls, but decreased after 6 weeks. CONCLUSIONS These observations suggest repetitive, synchronized, passive, and jerky exercise induced by electrical stimulation can lead to the tendinosis-like changes in the Achilles tendons in rats with imbalance between synthesis and degeneration after 4 weeks of exercise. CLINICAL RELEVANCE This newly designed exercise protocol may be used to design an animal model of Achilles tendon overuse. With this model, therapeutic interventions of tendinopathy could be analyzed by investigation of tendon biology and response in terms of histologic and molecular changes.
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Affiliation(s)
- Nam Soon Cho
- Department of Physical Medicine and Rehabilitation, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-do, Korea
| | - Ji Hye Hwang
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Taek Lee
- Department of Physical Medicine and Rehabilitation, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seoung Wan Chae
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Royall NA, Farrin E, Bahner DP, Stawicki SP. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2011; 2:57-66. [PMID: 22474637 PMCID: PMC3302042 DOI: 10.5312/wjo.v2.i7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 06/28/2011] [Accepted: 07/05/2011] [Indexed: 02/06/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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