Jiwu Chen

Combination of modified Broström procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms.

PURPOSE To evaluate the effectiveness of the modified Broström procedure combined with ankle arthroscopy for chronic ankle instability (CAI) accompanied by intra-articular symptoms. METHODS We identified 85 consecutive patients with CAI (87 ankles). There were 58 male patients (58 ankles) and 27 female patients (29 ankles) with a mean age of 24.4 years (range, 14 to 36 years). All the patients had intra-articular symptoms. Ankle arthroscopic surgery was performed initially to manage any intra-articular lesions. This was followed by the modified Broström procedure, including shortening of the anterior talofibular ligament and/or calcaneofibular ligament, as well as extensor retinaculum augmentation. All the intra-articular lesions found during surgery were recorded. American Orthopaedic Foot & Ankle Society (AOFAS) scores were obtained before surgery and at follow-up. RESULTS Intra-articular lesions were found in 79 ankles (90.8%), including 75 with synovitis and soft-tissue impingement, 33 with chondral injuries, 23 with anterior tibial osteophytes, 7 with loose bodies, and 6 with distal tibiofibular syndesmosis injuries. A total of 79 patients (92.9%) (81 ankles) were followed up for a mean of 29 months (range, 12 to 47 months). The mean AOFAS score improved from 46.6 +/- 8.1 preoperatively to 86.5 +/- 7.6 postoperatively (P < .05). Mean postoperative AOFAS scores were significantly higher in patients without chondral lesions than in those with chondral lesions (89.76 +/- 5.88 and 81.35 +/- 7.18, respectively; P < .05). Improvements in AOFAS scores after surgery were significantly greater in patients without chondral lesions than in those with chondral lesions (42.28 +/- 9.04 and 36.06 +/- 11.85, respectively; P < .05). CONCLUSIONS The modified Broström procedure combined with ankle arthroscopy produced satisfactory surgical outcomes in patients with CAI and intra-articular symptoms. Accompanying chondral injuries were associated with poorer surgical outcomes. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Is the Extended Release of the Inferior Glenohumeral Ligament Necessary for Frozen Shoulder

PURPOSE The aims of our study were to assess effects of the extent of capsular release and to define the benefit of additional release of the inferior glenohumeral ligament (IGHL) from inferior to posterior in frozen shoulder. METHODS Seventy-four consecutive patients with refractory frozen shoulder underwent arthroscopic capsular release and were divided into 2 groups randomly. The release of anterior capsular structures, including the anterior band of the IGHL, was performed in group 1. In group 2 the release extended inferiorly and posteriorly. Constant functional scores were used to assess the outcome. The range of motion (ROM) in various directions was also recorded preoperatively and postoperatively. RESULTS Follow-up was obtained in 41 patients in group 1 and 29 patients in group 2, and it averaged 28 months. At the last follow-up, there was a significant improvement in Constant score (P < .01) postoperatively in all patients. There was a significant and rapid reduction in the visual analog scale score in both groups postoperatively. No statistical difference in the visual analog scale score was found between the 2 groups at the corresponding time points. Overall, patients had restored shoulder ROM at the last follow-up without difference between group 1 and group 2. Abduction, flexion, external rotation at 90 degrees of abduction, internal rotation at 0 degrees of abduction, and internal rotation at 90 degrees of abduction recovered more rapidly in group 2 within 3 months after surgery; however, there was no significant difference in ROM after 6 months. CONCLUSIONS In this broad group of patients with recalcitrant adhesive capsulitis, the addition of the posterior capsular release did not improve patient function or ROM over anterior capsular release alone at 6 months. The extended release of the inferior and posterior IGHL would improve ROM more rapidly within the first 3 months postoperatively. LEVEL OF EVIDENCE Level I, therapeutic randomized controlled trial.

Biologic Failure of a Ligament Advanced Reinforcement System Artificial Ligament in Anterior Cruciate Ligament Reconstruction: A Report of Serious Knee Synovitis

A ligament advanced reinforcement system (LARS) artificial ligament has been proposed for use in anterior cruciate ligament reconstruction in some cases, and an emerging body of reports has shown its success in the short term. However, there are great concerns about the potential risks of complications, which might prevent its extensive use. We report a rare case of serious synovitis 3 years postoperatively in a 26-year-old man who underwent LARS artificial ligament reconstruction. During revision arthroscopy, we observed a large amount of synovial hyperplasia in the knee joint, containing a large amount of hemosiderin deposition. In addition, the femoral tunnel was placed too anteriorly, and the ligament was ruptured near the tibial tunnel. Histologically, there was thick fibrous scar tissue around the graft, and poorly organized fibrous scar tissue infiltrated into the graft fibers, which could cause loss of structural integrity of the ligament and eventual graft failure. Collectively, our findings might arouse further in-depth research on the development of artificial ligament.

Quantitative Magnetic Resonance Imaging Assessment of Cartilage Status: A Comparison Between Young Men With and Without Anterior Cruciate Ligament Reconstruction

PURPOSE To assess the cartilage status of the knee joints using magnetic resonance imaging at least 2 years after anterior cruciate ligament reconstruction (ACLR) in young adult men. METHODS Thirty young male patients with unilateral ACLR and 15 age-matched and body mass index--matched healthy men (controls) participated in this study. All participants underwent quantitative magnetic resonance imaging scans. Three-dimensional dual-echo steady-state sagittal images were segmented using solid model software to calculate the mean cartilage thickness, and multi-echo sagittal images were segmented with Siemens software (Siemens, Erlangen, Germany) to determine the T2 relaxation time of each cartilage plate. RESULTS There was no statistically significant difference in the mean thickness of each cartilage plate between the ACLR and control groups (P = .9616 for lateral femoral cartilage, P = .5962 for lateral tibial cartilage, P = .9328 for patellar cartilage, P = .9712 for trochlear cartilage, P = .4408 for medial femoral cartilage, and P = .1933 for medial tibial cartilage). The ACLR group had significantly higher T2 values than the control group in the lateral femoral cartilage (P < .001), lateral tibia (P = .0011), trochlea (P = .0028), medial femur (P < .001), and medial tibia (P < .001). In addition, the patella showed no difference in T2 values between the 2 groups (P = .2152). The medial compartment cartilage showed a much higher percentage change in cartilage T2 values in the ACLR group. CONCLUSIONS Although no difference in cartilage thickness was detected between the ACLR group and the control group, the mean T2 relaxation time in the ACLR patients was significantly longer than that in control subjects. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Delayed Early Passive Motion Is Harmless to Shoulder Rotator Cuff Healing in a Rabbit Model

Background: Postoperative passive motion is the most widely accepted rehabilitation protocol after rotator cuff repair; however, a rotator cuff retear remains a frequent surgical complication. Clinical outcomes indicate that early passive motion is harmless to rotator cuff healing, but no laboratory evidence supports this proposition. Hypotheses: (1) Immediate postoperative immobilization improves rotator cuff healing in rabbits. (2) Early passive motion after short-term immobilization does not harm rotator cuff healing in rabbits. Study Design: Controlled laboratory study. Methods: An injury to the supraspinatus tendon was created and repaired in 90 New Zealand White rabbits, after which they were randomly separated into 3 groups: (1) nonimmobilization (NI; n = 30), (2) continuous immobilization (IM; n = 30), and (3) immobilization with early passive motion (IP; n = 30). At 3, 6, and 12 weeks postoperatively, 5 rabbits from each group were sacrificed for histological evaluation, biomechanical testing, and magnetic resonance imaging. Results: The histological study demonstrated better postoperative healing in the IM and IP groups, with clusters of chondrocytes accumulated at the tendon-bone junction. Magnetic resonance imaging illustrated that the tendon-bone junction was intact in the IM and IP groups. The magnetic resonance quantification analysis showed that the signal-to-noise quotient (SNQ) of the NI group was not significantly higher than that of the immobilization groups at 3 weeks (P = .232) or 6 weeks (P = .117), but it was significantly different at 12 weeks (NI vs IM, P = .006; NI vs IP, P = .009). At 12 weeks, the failure load was significantly higher in the IM and IP groups than in the NI group (NI vs IM, P = .002; NI vs IP, P = .002), but no difference was found between the IM and IP groups (P = .599). Conclusion: Immediate postoperative immobilization led to better tendon-bone healing than immediate postoperative mobilization, and under immobilization, early passive motion was harmless to tendon-bone healing in this study. Clinical Relevance: The results have an implication in supporting the rehabilitation protocol of early passive motion after rotator cuff repair.

Ultrasound-Guided Establishment of Hip Arthroscopy Portals

We describe ultrasound-guided establishment of hip arthroscopy portals. The surface projections of anatomic structures around the hip joint (including the nerve, vessels, femoral neck, and acetabulum) were marked. The entry points were then planned for the anterolateral and anterior portals and, if necessary, the posterolateral portal. The anterolateral portal was first placed. Through the use of real-time ultrasound guidance, a pin was inserted into the hip joint and 20 mL of normal saline solution was injected. A K-wire was then inserted into the joint space over the needle. The arthroscopic trocar was introduced along the K-wire, and the arthroscope was inserted to confirm the establishment. The anterior portal was then established. The hip joint was flexed slightly. The previous procedure was duplicated to insert the K-wire. The path of the pin was confirmed by viewing from the arthroscope in the anterolateral portal. If necessary, the posterolateral portal was established by the same procedure.

Mussel-Inspired Artificial Grafts for Functional Ligament Reconstruction.

The development of an artificial graft with distinct osteogenetic activity to enhance osseointegration and to induce the formation of biomimetic tissue structure for ligament reconstruction remains a significant challenge. Inspired by mussels, biomimetic calcium phosphate apatite/polydopamine hybridized-polyethylene terephthalate (APA/PDA-PET) grafts were successfully prepared. The efficacy and mechanism of APA/PDA-PET grafts to induce osseointegration were systematically investigated. The results from the in vitro study indicated that the prepared APA/PDA-PET grafts support the attachment of bone marrow stromal cells (BMSCs) and stimulate the proliferation and osteogenic/angiogenic differentiation of BMSCs via activation of the PKC/p-ERK1/2 signaling pathway. In vivo, histological and radiological results further demonstrate that the APA/PDA-PET grafts significantly improve osseointegration by inducing the formation of new bone tissue and the fibrocartilage transitional zone compared with pure PET grafts. In addition, the pull-out strength of the APA/PDA-PET grafts is significantly higher than that of the pure PET grafts 12 weeks after surgery. These results suggest that this mussel-inspired biomimetic method is an effective strategy for modifying artificial grafts, and the prepared APA/PDA-PET grafts, which possess a beneficial interface, can significantly improve in vivo osseointegration for ligament reconstruction via the synergistic effect of polydopamine and apatite.

Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis

Background: Intra-articular steroid injection is a common intervention for frozen shoulder (FS). Purpose: This review aimed to illustrate the effects of intra-articular steroid injection for FS. Study Design: Systematic review and meta-analysis. Methods: PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) comparing intra-articular steroid injection with no injection or sham injections for FS. Visual analog scale (VAS) pain scores were the primary outcome measure. Secondary outcome measures included passive external rotation, abduction, flexion, internal rotation, and functional scores. Complication rates were the safety outcome measure. Comparisons were performed with mean differences (MDs) and 95% confidence intervals (95% CIs). Three time intervals were analyzed: 4 to 6 weeks, 12 to 16 weeks, and 24 to 26 weeks postintervention. Trial sequential analysis was used to verify the pooled results. Line charts were drawn to view the recovery trend in both the intervention and control groups. Results: Eight RCTs with 416 patients were included. Compared with controls, patients who received intra-articular steroid injection had significantly reduced VAS pain scores at 4 to 6 weeks (MD, 1.28 cm [95% CI, 0.75 to 1.82]), 12 to 16 weeks (MD, 1.00 cm [95% CI, 0.47 to 1.52]), and 24 to 26 weeks (MD, 0.65 cm [95% CI, 0.19 to 1.10]) postinjection. Trial sequential analysis confirmed the pooled results at 4 to 6 weeks and 12 to 16 weeks but not at 24 to 26 weeks. Patients who received intra-articular steroid injection had improved passive external rotation, abduction, and flexion and Shoulder Pain and Disability Index (SPADI) scores at all 3 time intervals, as well as improved American Shoulder and Elbow Surgeons (ASES) scores at 12 to 16 weeks (MD, 12.20 [95% CI, 2.55 to 21.85]). No difference was noticed in Constant scores (MD, 5.70 [95% CI, –0.59 to 11.99]) or internal rotation except at 12 to 16 weeks (MD, 0.81° [95% CI, 0.18° to 1.44°]) and 24 to 26 weeks (MD, 3.88° [95% CI, 0.51° to 7.25°]) between steroid injection and placebo. Complication rates were 1.78% for facial flushing, 0.71% for dizziness owing to vasovagal reactions during injection, 1.07% for chest or shoulder pain, and 0.36% for nausea. Line charts improved in both groups. Conclusion: Intra-articular steroid injection is effective and safe for FS and relieves pain, improves functional performance, and increases range of motion. The effects are significant at 4 to 6 and 12 to 16 weeks postintervention and may last as long as 24 to 26 weeks.

Steroid Injection and Nonsteroidal Anti-inflammatory Agents for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of Randomized Controlled Trials

AbstractAdvantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for shoulder pain are not fully understood.To compare the efficiency and safety of steroid injection versus NSAIDs for patients with shoulder pain.PubMed, Embase, and the Cochrane Library were searched through July 2015.Study eligibility criteria, participants, and interventions: randomized controlled trials (RCTs) that assessed steroid injection versus NSAIDs for patients with shoulder pain.Study appraisal and synthesis methods: predefined primary efficacy outcome was functional improvement; and secondary efficacy outcomes included pain relief and complications. Relative risks (RRs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model accounting for clinical heterogeneity.Eight RCTs involving 465 participants were included in the meta-analysis. Five trials compared steroid injection with oral NSAIDs, and 3 compared steroids injection with NSAIDs injection. Compared with steroid injection, oral NSAIDs were less effective in 4 or 6 weeks for functional improvement (SMD 0.61; 95% CI, 0.08–1.14; P = 0.01), while there was no significant difference in pain relief (SMD 0.45; 95% CI, −0.50–1.40; P < 0.00001) or complication rate (RR 1.10; 95% CI, 0.26–4.58; P = 0.29). Meta-analysis was not performed for NSAIDs injection due to considerable heterogeneity. Conflicting results were observed in favor of either steroid or NSAIDs injection.Not all diseases that can lead to shoulder pain were included, detailed intervention protocols were inconsistent across studies, and some estimated data were input into comparison while some data were lost, which could exert an influence on pooled results.Steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks.Treatment decision should be made based on diseases. NSAIDs injection might be a treatment method for shoulder pain.

Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS). An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement. Nine RCTs including 453 patients were identified. From 6–7 weeks to 24–26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI −0.01–0.58; P = 0.06) or pain relief (SMD −0.10; 95% CI −0.70–0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11–0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36–0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD −0.07; 95% CI −0.79–0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67–1.31). Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.