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Ultrasound-guided versus blind subacromial corticosteroid injection for subacromial impingement
Thursday 16 October Papers / Journal of Science and Medicine in Sport 18S (2014) e23–e71
17 Ultrasound-guided versus blind subacromial corticosteroid injection for subacromial impingement L. Hackett 1,∗ , K. Peters 2 , G. Murrell 1 1
Orthopaedic Research Institute, St George Hospital, Australia 2 Kliniek Klein Rosendael, Netherlands Introduction: Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder. To improve accuracy of injection, ultrasound can be used. The aim of this study was to assess the clinical outcome of ultrasound guided subacromial injection compared to blind subacromial injection for subacromial impingement syndrome. Methods: A prospective, randomized, double blinded trial was conducted. Fifty-six patients with subacromial impingement syndrome were randomized into 2 groups: 28 patients received a subacromial corticosteroid injection with ultrasound guidance (ultrasound group) and 28 patients received a subacromial corticosteroid injection without ultrasound guidance (blind group). The Visual Analog Scale (VAS) for pain with overhead activities and the American Shoulder and Elbow Surgeons (ASES) score were obtained before injection and at 6 weeks post injection. Results: The VAS for pain with overhead activities decreased from 59 ± 5 mm (mean ± SEM) pre-injection to 33 ± 6 mm six weeks post-injection in the ultrasound group (p < 0.001) and from 63 ± 4 mm to 39 ± 6 mm in the blind group (p < 0.001). The mean VAS decrease was not significantly different between the groups (p = 1). The mean ASES score increased from 57 ± 2 pre-injection to 68 ± 3 six weeks post-injection in the ultrasound group (p < 0.01) and from 54 ± 3 pre-injection to 65 ± 4 post-injection in the blind group (p < 0.01), with no significant difference in mean increase between the groups (p = 0.7). Four patients (14%) in the ultrasound group and six patients (21%) in the blind group eventually needed surgery (p = 0.7). Conclusions: No significant differences were found in clinical outcome when comparing ultrasound guided subacromial injection to blind subacromial injection for subacromial impingement syndrome. http://dx.doi.org/10.1016/j.jsams.2014.11.207 18 Effect of glenohumeral abduction on supraspinatus repair tension J. Hawthorne ∗ , E. Carpenter, P. Lam, G. Murrell Orthopaedic Research Institute, St George Hospital, Australia Background: The re-tear rate post-rotator cuff repair is reported to be 11–94%. Some surgeons insist the use of slings and abduction pillows (large or small) post-operatively to unload or protect the repair while others do not. The aim of this study was to: (1) determine what position the shoulder is placed in when wearing a sling with large abduction pillow, a sling with small abduction pillow, a sling with no pillow and no sling, and (2) in an cadaver rotator cuff repair model, evaluate the tension on the supraspinatus tendon at each of these shoulder positions, with the ultimate aim to determine which type of sling places the repaired rotator cuff in the best position to heal without re-tearing. Method: An X-ray study was performed on three asymptomatic subjects using fluoroscopy in true anterior–posterior (AP) view, to
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determine what position the shoulder is placed in when wearing a sling only (Ultrasling II (DJO, Australia)), sling with small abduction pillow (Ultrasling II (DJO)) and sling with large abduction pillow (ProCare (DJO)). These positions were reproduced in four human cadaveric shoulders using a custom made testing jig. A rotator cuff repair using a single row inverted mattress technique was performed on each shoulder and the tension in the supraspinatus were evaluated both in the repaired tendon itself and the sutures used in the repair. Results: The sling with no abduction pillow placed the glenohumeral (GH) joint in 4◦ ± 1◦ (mean ± SEM) of abduction and 29◦ ± 4◦ internal rotation, a sling with small abduction placed the joint in 13◦ ± 2◦ abduction and 20◦ ± 1◦ internal rotation and a sling with large abduction pillow placed the joint in 25◦ ± 3◦ abduction and 11◦ ± 0◦ internal rotation. Placing the human cadaveric shoulders in the position of a sling with small abduction pillow caused a reduction in tension on the supraspinatus of 27% anteriorly (p < 0.05) and 55% posteriorly (p < 0.006) compared to placing the shoulder in the position of a sling with no abduction pillow. Placing the shoulder in the position of a sling with large abduction pillow caused a further reduction in tension on the supraspinatus of 42% anteriorly (p < 0.0005) and 56% posteriorly (p < 0.0001). Discussion: Placing the at positions consistent with wearing small and large abduction pillows reduced tension on the repaired supraspinatus tendon by approximately 27–56%. http://dx.doi.org/10.1016/j.jsams.2014.11.208 19 Are the symptoms of calcific tendonitis due to neoinnervation and/or neovascularisation? L. Hackett 1,∗ , N. Millar 2 , P. Lam 1 , G. Murrell 1 1
Orthopaedic Research Institute, St George Hospital, Australia 2 Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary & Life Sciences, University of Glasgow, United kingdom Aim: The aim of this study was to determine whether there is evidence of neoinnervation and/or neovascularisation in calcific tendinitis lesions of the shoulder. Methods: This was a prospective case control study. At arthroscopy a breast biopsy localisation needle was utilized to identify and subsequently remove the calcium from the supraspinatus tendon. Small 2 mm samples were taken from the supraspinatus tendon adjacent to the calcific lesion (calcific tendonitis, n = 7), torn supraspinatus tendon of patients undergoing rotator cuff repair (RCT, n = 6) and the subscapularis of patients undergoing stabilisation surgery (control, n = 6). Samples were paraffin embedded, sectioned and stained with hematoxylin and eosin. The following antibodies were used for immunohistochemical evaluation; macrophages (CD68), M2 macrophages (CD202), mast cells (mast cell tryptase), Tcells (CD3), vascular endothelium (CD34) and general nerve marker (PGP9.5) utilising the appropriate isotype controls. Results: The calcific tendonitis and RCT group had 5–6 fold higher T-cell counts compared to the control group (p < 0.001; p < 0.004). There was a 3–8 fold increase of nerve markers, neovascularisation, macrophages, M2 macrophages, and mast cells in the calcific tendonitis group compared to the RCT group (p < 0.0002) and control group (p < 0.0001). There were approximately three times more of each markers in tendon from patients with calcific tendonitis compared to tendon from patients with rotator cuff tears. Increase nerve counts positively correlated with more
17 Ultrasound-guided versus blind subacromial corticosteroid injection for subacromial impingement L. Hackett 1,∗ , K. Peters 2 , G. Murrell 1 1
Orthopaedic Research Institute, St George Hospital, Australia 2 Kliniek Klein Rosendael, Netherlands Introduction: Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder. To improve accuracy of injection, ultrasound can be used. The aim of this study was to assess the clinical outcome of ultrasound guided subacromial injection compared to blind subacromial injection for subacromial impingement syndrome. Methods: A prospective, randomized, double blinded trial was conducted. Fifty-six patients with subacromial impingement syndrome were randomized into 2 groups: 28 patients received a subacromial corticosteroid injection with ultrasound guidance (ultrasound group) and 28 patients received a subacromial corticosteroid injection without ultrasound guidance (blind group). The Visual Analog Scale (VAS) for pain with overhead activities and the American Shoulder and Elbow Surgeons (ASES) score were obtained before injection and at 6 weeks post injection. Results: The VAS for pain with overhead activities decreased from 59 ± 5 mm (mean ± SEM) pre-injection to 33 ± 6 mm six weeks post-injection in the ultrasound group (p < 0.001) and from 63 ± 4 mm to 39 ± 6 mm in the blind group (p < 0.001). The mean VAS decrease was not significantly different between the groups (p = 1). The mean ASES score increased from 57 ± 2 pre-injection to 68 ± 3 six weeks post-injection in the ultrasound group (p < 0.01) and from 54 ± 3 pre-injection to 65 ± 4 post-injection in the blind group (p < 0.01), with no significant difference in mean increase between the groups (p = 0.7). Four patients (14%) in the ultrasound group and six patients (21%) in the blind group eventually needed surgery (p = 0.7). Conclusions: No significant differences were found in clinical outcome when comparing ultrasound guided subacromial injection to blind subacromial injection for subacromial impingement syndrome. http://dx.doi.org/10.1016/j.jsams.2014.11.207 18 Effect of glenohumeral abduction on supraspinatus repair tension J. Hawthorne ∗ , E. Carpenter, P. Lam, G. Murrell Orthopaedic Research Institute, St George Hospital, Australia Background: The re-tear rate post-rotator cuff repair is reported to be 11–94%. Some surgeons insist the use of slings and abduction pillows (large or small) post-operatively to unload or protect the repair while others do not. The aim of this study was to: (1) determine what position the shoulder is placed in when wearing a sling with large abduction pillow, a sling with small abduction pillow, a sling with no pillow and no sling, and (2) in an cadaver rotator cuff repair model, evaluate the tension on the supraspinatus tendon at each of these shoulder positions, with the ultimate aim to determine which type of sling places the repaired rotator cuff in the best position to heal without re-tearing. Method: An X-ray study was performed on three asymptomatic subjects using fluoroscopy in true anterior–posterior (AP) view, to
e29
determine what position the shoulder is placed in when wearing a sling only (Ultrasling II (DJO, Australia)), sling with small abduction pillow (Ultrasling II (DJO)) and sling with large abduction pillow (ProCare (DJO)). These positions were reproduced in four human cadaveric shoulders using a custom made testing jig. A rotator cuff repair using a single row inverted mattress technique was performed on each shoulder and the tension in the supraspinatus were evaluated both in the repaired tendon itself and the sutures used in the repair. Results: The sling with no abduction pillow placed the glenohumeral (GH) joint in 4◦ ± 1◦ (mean ± SEM) of abduction and 29◦ ± 4◦ internal rotation, a sling with small abduction placed the joint in 13◦ ± 2◦ abduction and 20◦ ± 1◦ internal rotation and a sling with large abduction pillow placed the joint in 25◦ ± 3◦ abduction and 11◦ ± 0◦ internal rotation. Placing the human cadaveric shoulders in the position of a sling with small abduction pillow caused a reduction in tension on the supraspinatus of 27% anteriorly (p < 0.05) and 55% posteriorly (p < 0.006) compared to placing the shoulder in the position of a sling with no abduction pillow. Placing the shoulder in the position of a sling with large abduction pillow caused a further reduction in tension on the supraspinatus of 42% anteriorly (p < 0.0005) and 56% posteriorly (p < 0.0001). Discussion: Placing the at positions consistent with wearing small and large abduction pillows reduced tension on the repaired supraspinatus tendon by approximately 27–56%. http://dx.doi.org/10.1016/j.jsams.2014.11.208 19 Are the symptoms of calcific tendonitis due to neoinnervation and/or neovascularisation? L. Hackett 1,∗ , N. Millar 2 , P. Lam 1 , G. Murrell 1 1
Orthopaedic Research Institute, St George Hospital, Australia 2 Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary & Life Sciences, University of Glasgow, United kingdom Aim: The aim of this study was to determine whether there is evidence of neoinnervation and/or neovascularisation in calcific tendinitis lesions of the shoulder. Methods: This was a prospective case control study. At arthroscopy a breast biopsy localisation needle was utilized to identify and subsequently remove the calcium from the supraspinatus tendon. Small 2 mm samples were taken from the supraspinatus tendon adjacent to the calcific lesion (calcific tendonitis, n = 7), torn supraspinatus tendon of patients undergoing rotator cuff repair (RCT, n = 6) and the subscapularis of patients undergoing stabilisation surgery (control, n = 6). Samples were paraffin embedded, sectioned and stained with hematoxylin and eosin. The following antibodies were used for immunohistochemical evaluation; macrophages (CD68), M2 macrophages (CD202), mast cells (mast cell tryptase), Tcells (CD3), vascular endothelium (CD34) and general nerve marker (PGP9.5) utilising the appropriate isotype controls. Results: The calcific tendonitis and RCT group had 5–6 fold higher T-cell counts compared to the control group (p < 0.001; p < 0.004). There was a 3–8 fold increase of nerve markers, neovascularisation, macrophages, M2 macrophages, and mast cells in the calcific tendonitis group compared to the RCT group (p < 0.0002) and control group (p < 0.0001). There were approximately three times more of each markers in tendon from patients with calcific tendonitis compared to tendon from patients with rotator cuff tears. Increase nerve counts positively correlated with more