Wen-Yi Chou

Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo-controlled study.

HYPOTHESIS A randomized, double-blind, placebo-controlled study of sodium hyaluronate (ARTZ Dispo) treatment was performed in 51 patients with rotator cuff lesions without complete tears. We hypothesized that ARTZ Dispo would render better results than the placebo. MATERIALS AND METHODS Twenty-five patients (ARTZ Dispo group) had injections of 25 mg/wk of sodium hyaluronate into the subacromial bursa for 5 consecutive weeks. Twenty-six patients (placebo group) were given 2.5 mL of normal saline solution with the same injection protocol as the ARTZ Dispo group. No significant difference in age, height, weight, gender, vocation, involved shoulder, duration of symptoms, baseline Constant score, or visual analog scale (VAS) score existed between the 2 groups. RESULTS The 2 groups did not significantly differ with regard to Constant scores, VAS scores, or global improvement assessments 1 week after injections. The ARTZ Dispo group had a better Constant score (P = .0095) and VAS score (P = .0018) than the placebo group 6 weeks after treatment. Patients in the placebo group were given 5 sodium hyaluronate injections, rather than placebo, after disclosure of the blind list, if they wished. Forty-one patients who underwent hyaluronate injection exhibited a significantly improved Constant score, from 64.0 +/- 11.7 at baseline to 88.9 +/- 10.4 (P < .0001), and a significantly improved VAS score, from 6.4 +/- 1.3 to 1.5 +/- 1.6 (P < .0001), at a mean follow-up of 33.1 months. No significant adverse effect was noted. CONCLUSIONS Subacromial injections of sodium hyaluronate are effective in treating rotator cuff lesions without complete tears.

Increased Dickkopf-1 expression accelerates bone cell apoptosis in femoral head osteonecrosis.

Intensive bone cell apoptosis contributes to osteonecrosis of femoral head (ONFH). Dickkopf-1 (DKK1) reportedly mediates various types of skeletal disorders. This study investigated whether DKK1 was linked to the occurrence of ONFH. Thirty-nine patients with various stages of ONFH were recruited. Bone specimens were harvested from 34 ONFH patients underwent hip arthroplasty, and from 10 femoral neck fracture patients. Bad, Bcl2 TNFalpha, DKK1, Wnt3a, LRP5, and Axin1 expressions were analyzed by quantitative RT-PCR and ELISA. Apoptotic cells were assayed using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end-labelling (TUNEL). Primary bone-marrow mesenchymal cells were treated with DKK1 RNA interference and recombinant DKK1 protein. ONFH patients with the histories of being administrated corticosteroids and excessive alcohol consumption had significantly higher Bad and DKK1 mRNA expressions in bone tissue and DKK1 abundances in serum than femoral neck fracture patients. Bone cells adjacent to osteonecrotic bone displayed strong DKK1 immunoreactivity and TUNEL staining. Increased DKK1 expression in bone tissue and serum correlated with Bad expression and TUNEL staining. Serum DKK1 abundance correlated with the severity of ONFH. The DKK1 RNA interference and recombinant DKK1 protein regulated Bad expression and apoptosis of primary bone-marrow mesenchymal cells. Knock down of DKK1 reduced dexamethasone-induced apoptosis of mesenchymal cells. Taken together, promoted DKK1 expression was associated with bone cell apoptosis in the occurrence of ONFH patients with the histories of corticosteroid and alcohol intake and progression of ONFH. DKK1 expression in injured tissue provides new insight into ONFH pathogenesis.

Surgical Results in Rotator Cuff Tears with Shoulder Stiffness

BACKGROUND/PURPOSE Little has been mentioned about the treatment of rotator cuff tears and associated shoulder stiffness. We prospectively treated a series of patients with rotator cuff tears associated with shoulder stiffness concomitantly and reported the outcomes. METHODS A combined procedure of manipulation, lysis of adhesions, anterior acromioplasty and repair of rotator cuff was performed on 43 patients (47 shoulders) who were available for follow-up for a minimum of 2 years. Ten patients (11 shoulders) had diabetes mellitus and 33 patients (36 shoulders) were non-diabetic. Partial tear of the rotator cuff was noted in 27 shoulders, complete tears in 15 shoulders and massive tears in five shoulders. A functional score of Constant and Murley was used to evaluate the overall outcomes, the results between patients with and without diabetes mellitus and the results among different types of rotator cuff tears. RESULTS At a mean (+/- SD) of 48.61 +/- 18.0 months (range, 24-85 months) after the operation, each patient showed a significant improvement in subjective score, objective score and strength score as well as in the total score of Constant and Murley. There was no statistical difference in postoperative total Constant scores between patients with and without diabetes mellitus (p = 0.123). Comparison of the scores among the three types of rotator cuff tears revealed that all had a significant improvement in the total scores of Constant and Murley (44.6 +/- 7.7 vs. 91.7 +/- 4.9, p < 0.001 for a partial cuff tear; 42.9 +/- 11.3 vs. 86.0 +/- 9.6, p = 0.001 for a complete tear; and 44.2 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.043 for a large tear), but patients with partial tears of the rotator cuff had significantly better total scores than did those with complete tears (92.6 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.018) or large tears (92.6 +/- 4.8 vs. 86.1 +/- 9.7, p = 0.041). CONCLUSION A combined procedure of manipulation, lysis of adhesions, acromioplasty and repair of rotator cuff is a satisfactory procedure for patients with rotator cuff tears and associated shoulder stiffness.

Navigation-assisted total knee arthroplasty for a knee with malunion of the distal femur.

Conventional total knee arthroplasty (TKA) has been developed for several decades. However, very few previous reports describe TKA with less invasive modality for extra-articular angular deformity. Herein, we report a case of navigation-assisted TKA for severe osteoarthritis associated with malunited distal femoral fracture. Fourteen months after navigation TKA surgery, satisfactory alignment, diminished length discrepancy, and improved range of motion were noted. Our report reveals that navigation system without intramedullary reaming is a feasible and less invasive alternative for TKA surgery for complex arthritic knee disorders.

Extracorporeal shockwave therapy shows time-dependent chondroprotective effects in osteoarthritis of the knee in rats.

BACKGROUND Recent studies reported that extracorporeal shockwave therapy (ESWT) has a chondroprotective effect on the initiation and regression of osteoarthritis of the knee in rats. However, the time course effects of ESWT in the osteoarthritic knee are not fully understood. The purpose of this study was to evaluate the effects of ESWT over time on osteoarthritis of the knee in rats. METHODS We used 72 8-week-old male Sprague-Dawley rats with body weights ranging from 245 to 265 g. We randomly divided the rats into three groups, with 24 rats in each group. The control group received neither surgery nor ESWT. The anterior cruciate ligament transected (ACLT) group underwent anterior cruciate ligament transection but received no ESWT. The ACLT plus ESWT group underwent ACL transection and received ESWT at 1 wk after surgery. The animals were killed at 2, 4, 8, and 12 wk, 6 rats from each group at each time course. Evaluation parameters included Mankin score, Safranin O stain, and collagen II for the articular cartilage; and vascular endothelial growth factor (VEGF), bone morphogenetic-2 (BMP-2), and osteocalcin for the subchondral bone using histopathological examination and immunohistochemical analysis. RESULTS The ACLT group showed significant increases in Mankin score and Safranin O stain, and a decrease in collagen II in the articular cartilage, and significant decreases in VEGF, BMP-2, and osteocalcin in the subchondral bone compared with the control (P < .05). The ACLT + ESWT group showed significant decreases in Mankin score and Safranin O stain and an increase in collagen II in the articular cartilage, and significant increases in VEGF, BMP-2, and osteocalcin in the subchondral bone compared with the control group. The changes in the ACLT + ESWT group appeared to correlate with the time courses of treatment; the most beneficial effects were noticed 4 weeks after ESWT. CONCLUSION Extracorporeal shockwave therapy is effective in preventing osteoarthritis of the knee in rats. The beneficial effects of ESWT appear to be time-dependent beginning at 4 weeks after treatment.

Preoperative Templating and Computer-Assisted Total Knee Arthroplasty for Arthritic Valgus Knee

We reported the functional outcomes, component alignment and optimal thickness of the tibial inserts and joint line changes of 21 arthritic valgus knee deformities using preoperative templating and computer-assisted total knee arthroplasty(TKA). The osseous cut was modified using a novel preoperative templating technique. Soft tissue balance and component implantation were implemented with the aid of a computed tomography-free navigation system. The arthritic valgus knees had clinical, and functional improvement of the knee Society scores and Lysholm scores postoperatively, at an average of 37.8 ± 7.2 months. The mean anatomic axis (15.2° ± 4.5° vs. 6.1° ± 1.4°) and mechanical axis (8.3° ± 5.2° vs. 0.28° ± 1.6°) were also significantly improved postoperatively. The mean thickness of tibial inserts and joint line changes was 10.7 ± 1.46 mm and 0.1 ± 1.4 mm. This computer-assisted technique with preoperative radiographic templating is an alternative strategy to improve TKA results in arthritic valgus knees.

Changes of articular cartilage and subchondral bone after extracorporeal shockwave therapy in osteoarthritis of the knee.

We assessed the pathological changes of articular cartilage and subchondral bone on different locations of the knee after extracorporeal shockwave therapy (ESWT) in early osteoarthritis (OA). Rat knees under OA model by anterior cruciate ligament transaction (ACLT) and medial meniscectomy (MM) to induce OA changes. Among ESWT groups, ESWT were applied to medial (M) femur (F) and tibia (T) condyles was better than medial tibia condyle, medial femur condyle as well as medial and lateral (L) tibia condyles in gross osteoarthritic areas (p<0.05), osteophyte formation and subchondral sclerotic bone (p<0.05). Using sectional cartilage area, modified Mankin scoring system as well as thickness of calcified and un-calcified cartilage analysis, the results showed that articular cartilage damage was ameliorated and T+F(M) group had the most protection as compared with other locations (p<0.05). Detectable cartilage surface damage and proteoglycan loss were measured and T+F(M) group showed the smallest lesion score among other groups (p<0.05). Micro-CT revealed significantly improved in subchondral bone repair in all ESWT groups compared to OA group (p<0.05). There were no significantly differences in bone remodeling after ESWT groups except F(M) group. In the immunohistochemical analysis, T+F(M) group significant reduced TUNEL activity, promoted cartilage proliferation by observation of PCNA marker and reduced vascular invasion through observation of CD31 marker for angiogenesis compared to OA group (P<0.001). Overall the data suggested that the order of the effective site of ESWT was T+F(M) ≧ T(M) > T(M+L) > F(M) in OA rat knees.

Extracorporeal shockwave therapy for treatment of keloid scars: Extracorporeal shockwave therapy for treatment of keloid scars

The purpose of this investigation was to study the effectiveness of extracorporeal shockwave therapy (ESWT) for the treatment of keloid scars, and compared the results with intralesional steroid injection. Thirty‐nine patients were randomly divided into 22 in ESWT group and 17 in steroid group. The ESWT group received 3 ESWT treatments in 6 weeks. The steroid group received three intra‐lesional triamcinolone injections in 6 weeks. The evaluations included gross morphology, functional outcome, local blood flow perfusion, biopsy for histopathological examination, and immunohistochemical analysis. Both groups showed significant improvements in appearance with less discoloration, flattening and softer consistency, and more elasticity of the lesions. There is a significant reduction in keloid height after treatment in both groups, and significant differences are noticed between two groups after treatment. The volume of keloid was decreased after treatment but there is no statistically significant difference between two groups. Both groups showed comparable functional scores, POSAS patient, and observer scales. The blood flow perfusion rates were statistically not significant between two groups before and after treatments. Histopathological findings revealed no significant difference in cell count, cell activity, and cell concentration between two groups. After ESWT, the significant decreases in collagen type I, type III, and Masson Trichrome stain were observed as compared with steroid group. However, very little changes were noticed in angiogenesis, inflammatory cytokines, proliferating and regeneration, and apoptosis, with no statistical significance noticed between two groups before and after treatment. This study revealed that ESWT showed comparable functional outcome and POSAS patient and observer scales as compared with steroid injection for keloid scars. Treatment of keloid scars with ESWT resulted in significant decreases in collagen fibers and increases in MMP‐13 enzyme.

High power Doppler ultrasound score is associated with the risk of triangular fibrocartilage complex (TFCC) tears in severe rheumatoid arthritis

In the distal radioulnar joint, the triangular fibrocartilage complex (TFCC) is an important stabilizer and are frequently found in patients with rheumatoid arthritis (RA) with wrist pain. This study was designed to predict TFCC tears using high-resolution ultrasound in severe RA. We retrospectively reviewed patients with severe RA. MRI and ultrasound were performed at baseline and after 1 year of follow-up. TFCC tears were recorded. The predictive factors for TFCC tears were analyzed by logistic regression. During the 1-year follow-up period, 54 patients were enrolled (42 females and 12 males), of whom 21 (38.9%) developed TFCC tears. The body mass index was 22.81±2.59 kg/m2 in the TFCC tear group compared with 23.61±2.76 kg/m2 in the non-tear group (p=0.136). The mean age was 55.14±9.54 years in the TFCC tear group compared with 56.45±14.04 years in the non-tear group (p=0.596). The tear group had a higher Disease Activity Score in 28 joints (DAS28) (6.36±0.47 vs 5.58±0.65, p=0.011) and higher power Doppler (PD) ultrasound score at the dorsal radiocarpal joint (1.90±1.30 vs 1.33±0.99, p=0.011) than the non-tear group. We found that high DAS28 (OR 2.96, 95% CI 1.95 to 4.50; p=0.001) and higher baseline PD score (OR 1.51, 95% CI 1.07 to 2.14; p=0.019) were significantly associated with a higher risk of TFCC tears by logistic regression. So we conclude a higher wrist PD score in severe RA predicted future TFCC tears. Therefore, we suggest to use PD score in such patients to monitor the risk of future TFCC tears.

Comparative outcomes of extracorporeal shockwave therapy for shoulder tendinitis or partial tears of the rotator cuff in athletes and non-athletes: Retrospective study

BACKGROUND Refractory shoulder tendinitis or partial thickness rotator cuff tears (PTRCTs) are common findings in overhead athletes. Previous studies have examined the effectiveness of extracorporeal shockwave therapy (ESWT) for shoulder tendinitis. MATERIALS AND METHODS In the current study, we recruited 36 shoulders and performed a comparison between the professional athletes (13 shoulders, athletic group; AG) and the non-athletic population (23 shoulders, non-athletic group, NAG) with PTRCTs or shoulder tendinitis of the shoulder after ESWT. Patients with symptomatic tendinitis of the shoulder with or without a partial tear of the rotator cuff tendon and failed oral medication and physical therapy for more than 3 months were treated with electrohydraulic mode of ESWT. All patients that met the inclusion criteria were categorized into two groups according to their pre-treatment activity level. RESULTS We found that NAG exhibited significant aging and degenerative change around the glenohumeral joint and subacromial space. After ESWT treatment, the patients in AG were with 53.8% high satisfaction rating and patients in NAG were 52.1% by one-year followed up. CONCLUSION The results showed ESWT was equally effective treatment in both AG and NAG. In light of its efficacy and less-invasive nature, we suggest ESWT can be used to treat athletes with refractory tendinitis or PTRCTs before proceeding to arthroscopic intervention.