Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder

BACKGROUND

Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease.

METHODS

Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated.

RESULTS

The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases.

CONCLUSIONS

Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

[Proteome of extracellular vesicles from synovial fluid and their possible function in periprosthetic infections]

Bevezetés: A periprotetikus infekciók ellátása jelentős kihívás elé állítja az operáló orvost, mind diagnosztikai, mind terápiás tekintetben. Az utóbbi években a mozgásszervi kutatások során egyre növekvő figyelmet kaptak az extracellularis vesiculák. Az extracellularis vesiculák által szállított fehérjék tömegspektrometrián alapuló azonosítása fontos lépés, mely segíthet megérteni a védekezési folyamatban betöltött biológiai funkcióikat. Célkitűzés: Vizsgálatunk célja volt az akut és a krónikus fertőzött mintákból izolált extracellularis vesiculák fehérjetartalmának megismerése, azonosságok és különbségek keresése – az „egy legjobb biomarker” megtalálása helyett a lehető legtöbb, detektálható mennyiségben jelen lévő extracellularis vesiculába zárt fehérje vizsgálata és biológiai folyamatokba illesztése. Módszer: Prospektív, monocentrikus vizsgálatot végeztünk, a beválasztási kritériumok a 2018-as MSIS-kritériumokon alapultak. A vizsgálatba 13 (n = 13) beteget vontunk be, minden beteg periprotetikus infekció miatt került műtétre. 6 (n = 6) betegnél akut purulens (akut csoport) folyamatot, míg 7 (n = 7) betegnél ’low-grade’ infekciót (krónikus csoport) igazoltunk. Az extracellularis vesiculák izolálása minden esetben a protézist körülvevő synovialis folyadékból történt. A tömegspektrometriai vizsgálattal azonosított fehérjék funkcionális alapú klaszterezésére a STRING, KEGG, Gene Ontology adatbázisokat használtuk. A végleges vizualizáció Cytoscape 3.9.1. szoftverrel történt. Eredmények: Az extracellularis vesiculák feltárása után 222 db fehérjét azonosítottunk, melyek vagy az akut, vagy a krónikus minták valamelyikének több mint felében fordultak elő. Csak az akut minták több mint felében 50 db fehérjét; csak a krónikus minták több mint felében 33 db fehérjét; egyszerre mindkét csoport több mint felében 86 db fehérjét azonosítottunk. Ezek alapján készültek a funkcionális klaszterek. Megbeszélés: A protézisfertőzések diagnosztikájában régóta megvan a törekvés, hogy megtalálják az „egy legjobb biomarkert”, amely biztosan különbséget tud tenni fertőzött és nem fertőzött protézislazulás között. Következtetés: Vizsgálatunk célja nem egy újabb biomarker kiválasztása volt, hanem az extracellularis vesiculákban szállított fehérjék biológiai folyamatokban betöltött szerepének ábrázolása, leírása, amellyel jobban betekinthetünk a periprotetikus infekció során zajló folyamatokba. Orv Hetil. 2024; 165(3): 98–109.

Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection

BACKGROUND

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR).

METHODS

We reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%).

CONCLUSIONS

Based on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.

Rifampicin resistance and risk factors associated with significantly lower recovery rates after two stage revision in patients with prosthetic joint infection

PURPOSE

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favorable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing two-stage revision.

METHODS

We reviewed medical records and microbiology reports of 73 patients (41 males and 32 females) undergoing two-stage revision due to PJI between 2017 and 2019. Patient-specific data, co-morbidities and the antibiotic resistance of microbiological isolates were registered. 48 patients had hip, 22 had knee, 2 had shoulder and 1 had elbow joint infection. Obtained data were statistically analyzed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 53 cases (72.6%). Recovery rate was 92.5% in the sensitive and 60.0% in the resistant group. We observed that rifampicin resistance significantly reduced the probability of recovery. Furthermore, in the rifampicin-sensitive group, the probability of recovery decreased with advancing age with a significant drop above the age of 60 years. The effect of age is negligible in the rifampicin-resistant group. We also found that type 2 diabetes mellitus has a negative effect on recovery. Coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (50% of the isolates) and Gram-negative rods in the resistant group (40%).

CONCLUSIONS

Rifampicin resistance was associated with lower recovery rates among patients undergoing two-stage revision due to PJI. Higher age and type 2 diabetes mellitus had negative impact on clinical outcome.

Our initial experiences with MR arthrography

INTRODUCTION

The gold standard method for shoulder surgery imaging is magnetic resonance imaging (MRI). The sensitivity of the conventional MRI for full thickness tears is way above 85%, for partial rotator cuff lesions this number is less than 40%. Diagnostic accuracy is equally low in detecting different variations of anterior labrum lesion and also in injury of the glenohumeral ligaments. Contrast agent given directly into the joint can improve these diagnostic inaccuracies.

METHOD

We made the first shoulder joint related MR arthrography in February 2018 at the Semmelweis University. The studied period lasted for 17 months; during that time 29 examinations were performed. For the injection we used gadolinium-based contrast substance.

RESULTS

In the case of 26 patients (89.9%), the contrast substance had a good position and distended well. From all of the shoulder MRI examinations, 9 (31%) surgical interventions were made, and 8 surgical findings had the same diagnosis as the radiologic description.

CONCLUSION

The contrast substance given into the intraarticular space makes it easier to identify and detect the structures in the joint. The injection under X-ray screening is safe, it is absorbed from the joint in short time, and so far - based on our experience - there has not been any complication. It can help to identify injuries which are difficult to diagnose with conventional MRI, and helps planning before surgery. Orv Hetil. 2020; 161(36): 1514-1521.

[Prevalence of blood transfusion after primary total hip arthroplasty]

Introduction: Total hip arthroplasty is one of the most common surgical procedures that requires blood transfusion, with the possible risk of significant complications. Aim: A retrospective study was performed to analyze the predictors of blood transfusion after primary total hip arthroplasty. Method: We collected the data of 210 consecutive patients undergoing total hip arthroplasty. Patient's data, preoperative hemoglobin and hematocrit level, the type of the prosthesis, the use of a suction drain, tranexamic acid or anticoagulants and the type and amount of blood transfusion were recorded. Results: A total of 41% of our patients required transfusion, 8.6% receiving allogenic blood. Significant predictors of allogenic blood transfusion were preoperative hemoglobin and hematocrit levels, the type of prosthesis, the use of suction drainage and the use of tranexamic acid. Patients with pre-donated autologous blood did not require allogenic blood transfusion. Conclusion: Based on our study, total hip arthroplasty necessitates allogenic blood transfusion in 8.6%. Major predictors associated with the need for transfusion are preoperative hemoglobin and hematocrit levels, the type of prosthesis, the use of suction drainage and the use of tranexamic acid. Pre-donated autologous blood helps to reduce allogenic transfusion rate. Orv Hetil. 2020; 161(8): 290-294.

[The role of multimodal postoperative analgesia after primary hip arthroplasty]

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.

[The change of fatty degeneration in the rotator cuff muscles after repair in patients over 65]

INTRODUCTION

In the case of rotator cuff tears, the severity of the muscle atrophy and fatty degeneration has an effect on the success of the repair and on the functional outcome after surgery.

AIM

The ability of regeneration reduces with ageing; therefore, the study examined the atrophy and the fatty degeneration after rotator cuff repair in patients over 65.

METHOD

Eleven patients over 65 years of age were involved whose surgery was performed at the Department of Orthopaedics of Semmelweis University between 2012 and 2015. Their average age was 71.9 years and the average follow-up period was 39.9 months. Tear sizes were C1 in 3 cases, C2 in 3 cases, C3 in 4 cases, and C4 in 1 case. Each patient had magnetic resonance examination before and after the repair; the muscle atrophy and fatty degeneration were evaluated together with the type of the tear. Visual analogue scale and Constant score were used for the assessment of the pain and the shoulder function.

RESULTS

The average Constant score was 75 points. The occupancy ratio - referring to the severity of the atrophy - did not show significant improvement. The change in fatty degeneration and the atrophy were examined in different groups according to the size of the tears. In each group, the results showed progression.

CONCLUSIONS

After rotator cuff repair in patients over 65, fatty degeneration and muscle atrophy also show progression. No significant relationship was found between the size of the tear and fatty degeneration or between the size of the tear and muscle atrophy. Orv Hetil. 2019; 160(14): 533-539.

[Comparative functional outcome of reverse shoulder prostheses implanted on degenerative and oncological indications]

INTRODUCTION

Several methods (bone graft, endoprosthesis) are used to reconstruct proximal humerus resections due to primary and metastatic tumours. One of the new procedures is the replacement of the joint surfaces and the removed proximal humerus end with reverse shoulder prosthesis, optionally supplemented with bone implantation (composite procedure) in the hope of achieving better shoulder function.

AIM

The aim of this study was to compare the shoulder function of the patient group operated by the above procedure with reverse prosthesis to a patient group operated by indication of degenerative shoulder disease (rotator cuff arthropathy).

METHOD

The study involved 23 patients (13 men, 10 women) who were operated between 2012 and 2016 in our institution. Among them, 15 had rotator cuff arthropathy indication of reverse prosthesis, while in 8 cases, resection of the humerus and prosthesis implantation were performed due to tumour lesions. The average age of our patients was 62.5 years (17-82) and the average follow-up was 23.5 months (5-57). We performed physical examination, X-ray pictures on their operated arm, and data were recorded and analysed based on functional score systems.

RESULTS

The level of postoperative pain was almost the same in the two groups, but only the rotator cuff arthropathy group needed pain medications. In line with our expectations, we received slightly lower values by each of the three scoring systems in case of tumorous patients. The tumorous patients were satisfied with the results achieved.

CONCLUSIONS

Following proximal humerus resections, reversed prosthesis implantation with occasional bone allografts is a reliable method of reconstruction, which approaches available functions and reliability as compared to non-tumour-indicating patients. Orv Hetil. 2018; 159(45): 1838-1843.

[Periprosthetic joint infection caused by Rhodococcus equi. Case report]

Rhodococcus equi is a rare pathogen in humans causing infections mostly in immunocompromised hosts. We present the first case of periprosthetic joint infection caused by Rhodococcus equi. An 88-year-old male patient was referred to our clinic with a history of fever and right hip pain. The patient had multiple hip surgeries including total joint arthroplasty and revision for aseptic loosening on the right side. He was immunocompetent, but his additional medical history was remarkable for diabetes mellitus, diabetic nephropathy and stroke with hemiplegia resulting in immobilization. Radiography showed stable components, joint aspirate yielded Rhodococcus equi. Irrigation and debridement was proposed, but the patient refused any surgical intervention. Therefore antibiotic therapy was administered. At the last follow-up the patient is free of complaints but the C-reactive protein level is still elevated. This case illustrates the possible role of Rhodococcus equi in medical device-associated infections. Orv Hetil. 2017; 158(27): 1071-1074.

[Functional outcome of arthroscopic rotator cuff repair]

INTRODUCTION

Functional outcome after rotator cuff reconstruction is influenced by several factors of which re-rupture is probably the most important.

AIM

The aim of the study was to evaluate the postoperative outcome including re-rupture rate after arthroscopic rotator cuff reconstruction.

METHOD

23 shoulders of 22 patients were examined prospectively. Physical examination, ultrasound and radiography were performed. Quality of life and functional outcome were evaluated using Constant Score and Visual Analog Scale.

RESULTS

Excellent or good results were found in 80% of the patients. The Constant Score has increased from 45 to 79, and the level of pain decreased from 6.6 to 2.5. Full-thickness rotator cuff tear was absent, but partial tear occurred in 7 cases (30%). Average acromiohumeral distance in the operated side was 8.5 mm compared to 9.5 mm measured on the contralateral shoulder.

CONCLUSIONS

Arthroscopic rotator cuff repair is a safe and reliable procedure that provides good results.