#Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

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Lupine Publishers | Application of Autologous Platelet Rich Plasma to Graft Donor Sites to Reduce Pain and Augment Healing: A Randomized Controlled Trial

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Introduction

Platelet Rich Plasma has been vastly utilized in the medical field due to its property to heal the wounds and the multitude of growth factors it contains. Traditionally, donor sites are left to heal with a primary dressing which would otherwise be opened as the wound heals. Various methods of donor site management have been described such as collagen dressings, hydrocolloid, alginate, hydro fiber, silicone dressing, or paraffin gauze. However, it is often encountered that there is a delay in the healing process and accompanied by pain at donor site. Furthermore, in a relatively small population of patients who have a tendency to hypertrophic scar formation, this becomes a challenge for the plastic surgeon. It not only leads to unsightly scars but also additional problems of dryness and itching. Owing to the healing properties of PRP, we designed this study to utilize it for donor site dressings following split thickness skin grafts. This study primarily throws light on the usage of Autologous PRP over Split thickness Skin Graft donor sites to augment healing, and reduce pain.

Materials and Methods

The 100 patients enrolled in this study between January 2018- July 2019 were divided into two groups of 50 each on a randomized basis, one of which was subjected to use of Autologous PRP, which was topically applied at the donor site and the other control group where the wound was traditionally dressed. Pain scales were measured in the immediate postoperative period as well as at the time of first dressing. Dressing was opened on the 14th postoperative day and observed for healing.

Results

Patients with the PRP group showed statistically significant faster healing at the 14th postoperative day, as compared to the control group which required continuing dressing 3-4 weeks. We also measured pain scale in the postoperative period and at the time of first dressing, which was significantly less in the PRP group. It’s worthy to mention that a few of the patients who has hypertrophic scars previously, did not develop after the application of PRP.

Conclusion

Application of PRP is a safe, cost effective, easy method to achieve faster healing in graft donor site areas, which is more often than not bothersome to the patients undergoing split thickness grafts. It also reduces the postoperative pain at the donor site. We recommend its use more frequently in managing donor site for Split thickness skin grafts.

Keywords: PRP; Donor Site; Pain; Skin Grafts; Wound Healing

Introduction

Split thickness skin graft is a widely accepted technique to cover large defects. However, it is often encountered that there is a delay in healing process, which may further lead to problems such as pain, infection and hypertrophic scar formation. Autologous PRP has been used in various treatment modalities in the field of plastic surgery for its healing, adhesive and hemostatic properties owing to the growth factors that are released. Platelet-rich plasma (PRP) is an autologous product that concentrates a large number of platelets in a small volume of plasma [1]. PRP also provides an immediate surgical hemostatic agent that is biocompatible, safe, and effective. The platelet comprises granules which are released when PRP is applied to the surface. These granules have properties which:

• Accelerates endothelial, epithelial, and epidermal regeneration • Stimulates angiogenesis • Enhances collagen synthesis • Promotes soft tissue healing • Decreases dermal scarring • Enhances the hemostatic response to injury

Another concern about PRP is its method of preparation. Although a lot has been written about methods of preparing PRP, there is still confusion over terminology to classify and describe the different variations of platelet concentrations. There are several ready to use commercial devices available, which make preparation of PRP simple and easy. However, they add to the costs of treatment. They are usually able to achieve a concentration of 2-5 times above baseline. Higher Platelet count above this has not shown to cause any additional benefits contrary to the assumptions; in fact concentration of PRP above 2.5 has been shown to be detrimental[4]. Marx proposed that platelet count of 10 lakh/ml in 5 mL of PRP, as a working definition of PRP, based on the scientific proof of bone and soft tissue healing enhancement [13].Rughetti et al.[14] found that the stimulation for proliferation of endothelial cells peak at 1.25 × 106 and angiogenesis at 1.5 × 106 platelets/ mL, respectively. This signifies the fact that a PRP platelet count 1 million/mL has become the working definition for therapeutic PRP. We have our own institutional method of preparing PRP which has been rectified by our labs to achieve a high platelet concentration. In view of the properties of PRP, we have theorized its use to be expanded in donor site dressings which has been a point of concern for a long time for both patients and treating physicians. In this study we have demonstrated how application of PRP aids in donor site healing. We have also shown that it reduces pain in the immediate postoperative period. The application of autologous Platelet-Rich Plasma (PRP) to STSG application sites has been recently described and theorized to help in faster healing and treatment of hypertrophic scars.

Materials and Methods

The study was performed in the Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital, Jaipur between 2018-2020. We obtained a sample size of 100 using our institutional software to make the study statistically significant in view of the previous studies involving use of PRP for various treatments. The 100 patients taken into the study with written and informed consent were randomly divided into two groups of 50 each in cases and controls. Sealed envelopes containing a number indicative of the group assignment (even number = Cases, uneven = Controls) were used to randomly allocate patients into two groups in the operation theatre. 100 envelopes were prepared in this manner and the patients were blinded to the treatment. All the patients gave consent to be a part of this trial as well.The patients in the cases group were subjected to use of PRP at the donor site followed by the standard paraffin gauze dressing. In the patients of the control group, the donor site was managed simply by paraffin gauze dressing without the use of PRP.Intraoperatively, fentanyl in a dose of 1ug/kg was given as a pain medication and postoperatively no pain medication was administered until the patient complained of pain. If he did complain of pain a rescue drug Inj. Diclofenac in a dose 1mg/kg was given. All patients with wounds that required split thickness skin grafting were included in the study. To be a part of the study the patient had to fulfill the following inclusion criteria

Inclusion Criteria

• All patients which required harvesting of split thickness skin graft • S. Albumin above 2.5 g/dl The following patients were excluded from the study

Exclusion Criteria

• Active Infection • Age >70 years • Pus, discharge • Immunocompromised patients • Exposed ligaments/ bone/cartilage • Underlying Comorbidities uncontrolled hypertension, uncontrolled diabetes and renal disorders • Uncooperative Patients • Drug Abuse

Our Method of Preparing Prp

• Patients venous sample was taken • Blood Collected in 10 ml ACD vials • The vials were spun for 5 mins at 1500 rpm (Soft Spin) after which the supernatant was spun at 3500 rpm (Hard Spin) for 15 mins. • PRP is spread as a thin film over the area using a syringe with a 24 gauge needle • 5 ml for 100 square cm was used.

Post-Operative Care

Dressing was opened on the 14th Postoperative day to assess for healing and pain by an independent observer thereby masking the treatment allocation. The wound was said to heal well if on inspection there was complete epithelization of the donor site characterised by healthy pink tissue, there was no residual raw area or any signs of infection. Next follow up was done on the 21st day.

Primary Outcome

• Donor site healing on 14th post-operative day • Pain scale in the postoperative period at 6,10 and 16 hours and on the 14th day at the time of dressing. • A paired T test was used as a tool to assess the test of significance. • All patients adhered to follow up protocols as designed in our study.

Results

The wound healing was assessed by an independent observer at the time of the first dressing. The wound was said to heal well if on inspection there was complete epithelization of the donor site characterised by healthy pink tissue, there was no residual raw area or any signs of infection. 48 out of 50 patients had good wound healing on the 14th post operative day. In other two patients we required more dressings. The first of these was a 60 year old male with no other comorbidities who underwent grafting for post traumatic ulcer on foot. The other patient was a 55 year old male with traumatic ulcer over knee. In both these patients we required 3 additional dressings before the wound completely healed. (Table 1) shows the wound healing in both cases and controls on the day 14th post operatively. A paired T Test was applied to assess this where in a p value of <0.005 was obtained. It was observed that the patients in the PRP group had significantly higher fasted wound healing rates as compared to the controlled group.

Assessment of Pain Control

Pain at the donor site was measured at 6, 10, 16 hours post operatively by the use of VAS Scales. Further, pain was also measured at the time of first dressing. (Table 2) depicts the Mean VAS Scores at the defined intervals. Paired T test was used to define the test of significance and It was observed that the Mean VAS Score was significantly lower with a p value <0.05 at 6 hours in the Cases group. At 10hours and 16 hours the VAS Scores were similar. The Pain scores were also significantly less at the time of first dressing with a p value <0.045. (Table 2) and (Figure 2)depict Mean VAS Scores in two groups. (Figure 1) depicts pain and healing on the day of first dressing.

Discussion

PRP is defined as a biological product derived from patients own blood with the concentration of platelets above the baseline [2]. PRP has been known to have many benefits which help early vascularisation by delivering these growth factors and increasing collagen synthesis. There are other benefits like reduced hematoma, infection, and cost. Donor site care with dressing material should provide optimum healing, be cost effective and should prevent complications such as pain, infection, discomfort and scarring. It is often encountered that patients feel more pain at the donor site as compared to the recipient wound bed[3,4,5]. There have been a variety of dressings and devices that are available in the clinical practice. However, there is no single dressing that is devoid of complications or can address to all the necessary problems with donor sites. This has led to variations in choice of dressing or topical agents used by health care professionals. [6,7,8]. Gibran et al conducted a study on forty post burn patients in which they used PRP as a wound adhesive for fixing of grafts over wound beds comparing it to traditional methods like sutures and staples. [9] Schade and Roukis found PRP enhances wound healing time by releasing the growth factors it contains. [10] Kakudo et al. published a study which proved that PRP helps in revealed that PRP epithelialization and angiogenesis of graft donor sites [11]. There are many other studies that have been conducted which demonstrates that PRP aids healing and reduces pain providing growth factors to the local site. In that view this study was conducted to overcome these problems at graft donor sites.

Various methods have been described to prepare PRP. Use of different compounds in vials has also been described. In a recent study, Wanden-Berghe et al. found accelerated wound healing in chronic wound beds by PRP activated by calcium chloride [12]. In our center, after taking the venous sample in ACD tubes there are two cycles of centrifugation. The first spin step is performed at constant acceleration to separate RBCs from the remaining whole blood volume. After the first spin step, the whole blood separates into three layers: an upper layer that contains mostly platelets and WBC, an intermediate thin layer that is known as the buffy coat and that is rich in WBCs, and a bottom layer that consists mostly of RBCs. For the production of PRP the upper layer and superficial buffy coat are transferred to an empty sterile tube. The second spin step is then performed. The upper portion of the volume that is composed mostly of PPP (platelet-poor plasma) is removed. Pellets are homogenized in the lower 1/3rd (5 ml of plasma) to create the PRP (Platelet-Rich Plasma).The platelet concentrations have been classified into Low with a count of 0.5 x million/μl, Intermediate having 0.5-3 x million/μl and High with 3-5 x million/ μl. We have been able to achieve high concentration of platelets by our technique of preparation. We observed that the problem of prolonged dressings and donor site pain for which there was no definite solution. Keeping that in mind and with the proven properties of PRP, this study was conducted. It has been observed that there was significantly faster healing rates and that the donor site in most of the cases had healed when the dressing was opened on day 14. We observed that our study showed lower pain scales at 6 hours. At 10 and 16 hours the similarity in pain scales was due to the rescue medication which was given to patients that complained of pain. Pain scales were also significantly lower on the day of first dressing in coherence with Previous studies that correlate regular application of PRP with pain reduction during gauze changes [15,16,17,18,19,20] We also followed up 8 patients (5 in PRP group and 3 in Control group) who had history of hypertrophic scar formation in donor sites. It was observed that patients in PRP group did not develop Hypertrophy in donor sites as compared to the control group where hypertrophy occurred at the end of 1st year. Although no statistical analysis was done on these patients we found it worthy enough for its mention and that a study could be done to prove this hypothesis.

Conclusion

Application of PRP is a safe, cost effective, easy method to promote faster healing in donor site areas from where split thickness skin grafts have harvested. It also reduces the postoperative pain at the donor site. We recommend its use more frequently in managing donor site for split thickness skin grafts.

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Lupine Publishers | SMART Technology and Orthopedic Treatment and Rehabilitation

Lupine Publishers |  Orthopedics and Sports Medicine Mini Review

There is a growing recognition in orthopedics of the use and benefit of SMART technology. SMART stands for Self-Monitoring Analysis and Re¬porting Technology. Recent clinical research [1- 3] has identified the value and benefits of wearable technology for various popula¬tions raising the question as to whether there may be beneficial use with individuals in treatment for orthopedic related conditions. Wear¬able SMART technology employs digital technologies to collect health data from individuals in one location, such as a patient’s home, and electronically transmit the information to health¬care providers in a different location for assessment, monitoring and compliance [4]. The orthopedic devices industry continues to be a promising area in the global medical technology area, and is expected to rank third in sales after cardiology and in-vitro diagnostics in the next decade. The growing number of orthopedic patients are aging and can benefit from SMART technology available for both their orthopedic injury as well as the collateral issues the aging population faces when adjusting to an orthopedic condition.

Clinical orthopedic interventions and procedures that reduce both time and expense are improving orthopedic recovery. These interventions are expected to increase as innovative technologies continue to shape the industry. Intelligent orthopedics, which involves a combination of traditional techniques and SMART technology, will be the future of the industry [5,3]. SMART sensor-enabled technologies and implants have provided realtime information to orthopedic surgeons for positioning and post-operative evaluation for better patient care throughout the treatment pathway. These implants have the potential to reduce periprosthetic infection, which is a growing problem in orthopedic practice. Sensor-enabled technologies have given health care providers a choice of unique, cost-effective products. Orthopedic patients will benefit as well from remote monitoring types of technology to aid them in having quick access to emer¬gency networks. These devices can help foster a safe and indepen¬dent living environment. Personal wearable smart technology devices are al¬ready available and the subject of research beneficial to a growing geriatric population. Among these is the Apple “iWatch” which of¬fers close to a dozen different sensors, tracking the wearers’ health and fitness metrics in terms of steps taken, calories burned, blood glucose, sleep quality and heart rate. There are several customized services available for families who have a senior family member needing monitoring. Applications to create a “Smart Medical Home” is impacting the care and treatment of orthopedic patients and aid caregivers who may benefit from computer based technology in their homes to provide necessary monitoring of be¬havior and maintain health and wellness for the rehabilitating orthopedic patient.

Sport Medicine specialists are engaging biomedical professionals in recognizing the value and benefits of utilizing SMART tech¬nology options in providing clinical care. E-health is a relatively recent term for healthcare practice utilizing technology-based as¬sessment and treatment strategies that have the potential to deliver benefit to a broad array of individuals who experience anxiety related to their medical conditions [6]. SMART technology is a form of synchronous or asynchronous healthcare delivery that may serve as an adjunct to standardized forms of clinical treatment intervention. Contemporary models of medically supervised healthcare in¬clude integrated clinical models that emphasize multidisciplinary teams treating patients. Mental health professionals are recognized as bringing specialized skills to the multidisciplinary integrated health care teams. In treating the whole person, contemporary care often requires an integrated team approach that addresses both physical and mental health components involving intervention models that require a limited number of appointments that demonstrate mea¬surable improvements in the current managed care environment. Wearable SMART technology provides a potential adjunct for use in assessing the therapeutic progress of some behavioral activities of patients.

University research centers should support greater joint efforts of sport medicine clinicians, scientists and engineers from multiple sites internationally to frame our expanding knowledge and evidence based research studies for SMART healthcare on a multidisciplinary level. Neuro-restoration involves lost neurological function due to the traumatic or ischemic damage to the brain and the associ¬ated neurological deficits. SMART technology can contribute to the rehabilitation of orthopedic patients. Within the SMART medical home [7], a computer tracks the location of preprogrammed items such as eyeglasses, coffee cups, or car keys throughout the house so aging person can locate such items when needed. The SMART technology can aid the person in restoring some lost skills due to brain injury. A camera and scanning system can take three-dimensional textured images of one’s skin, automat¬ically checking for carefully watched skin features such as moles or skin irritation. Other trackers are smart monitors that use cameras located around the home, the personal item. When a picture of the sought-after item is touched on a monitor, the system pinpoints where the item was last recorded, an especially helpful tool for aging persons suffering from forgetfulness brought on by some diseases. Gait Monitors have been developed to track the way the aging person ambulates on various surfaces and in different locations. The system’s computers make comparisons over time, checking for any indications of shuffling or limping that may be the precur¬sor to a stroke or for the trembling that may indicate Parkinson’s disease. By identifying these ailments early, the hope is that a dis¬ease’s full effects can be prevented or ameliorated. Utilization of SMART technology along with an effective diet and exercise program can make all the difference for these patients in achieving improved and recommended health goals in¬cluding weight, diet, sleep, exercise, self-esteem and an improved quality of life. The use of wearable technology devices like the popular Fitbit [8] has become an enormously popular health & fitness gauge for about a decade. Health and wellness prone individuals’ benefit from self-tracking using such a device as they provide a variety of self-monitoring information and biomarkers.

Within the rehabilitation process the development of the TracPatch is an effective SMART medical device worn by the patient that facilitates healthy post-surgical healing by monitoring range of motion, exercise compliance, and ambulation [5]. TracPatch may be used for both pre and post-op patient monitoring, engagement and critical data analytics. Such wearable devices are easily used by patients as they adhere to the skin above and below the knee. The TracPatch dashboard offers the healthcare provider anytime, anywhere data assessing the patient’s recovery. Such technology facilitates for immediate care adjustments that can improve efficiency in the recovery process. With Bluetooth connectivity allows the device to be paired with any smartphone and the HIPAA compliant TracPatch cloud allows for unlimited data collection and storage. The SMART wearable devices are applied before total knee surgery to determine a patient’s baseline activity levels, and then again post-surgery to allow the patient and surgeon to stay connected by monitoring activity, pain levels, range of motion and physical therapy progress.

Multiple research efforts have used different terminology to capture the essence of e-health and the overall language used to describe the benefits of wearable SMART technologies. There is clear evidence that the utility and benefits of such technology is being established and beneficial to aging individuals [4]. SMART technology advances for improving healthcare delivery, wearable appliances that form an integral part of our personal life have emerged. The use of 21st century technology is shaping the delivery of biomedical clinical care for orthopedic patients. On the positive side, tech¬nology’s integration with specific counseling skills is inevitable and show favorable potential to assist with improved patient self-management. Because of the early investigations into this modality, single case study design has served as a pilot with the realization that there are a number of limitations. Lacking are certain models or analysis that might include a multiple subject design model and randomization to assess the ef¬fectiveness of multiple models of the wearable technology. What it represents is an introduction to the use of SMART wearable tech¬nology in monitoring and promoting self-management among aging orthopedic patients who experience anxiety related to medical condition that could benefit from life style changes [9].

SMART technology incorporated into the collaborative efforts of orthopedic science and practice clinicians provides a significant pathway with the use of SMART technology in self-monitoring compliance, health and behavior change with a patient mo¬tivated to utilize smart technology in complying with prescribed clinical treatment continues to contribute to rehabilitation and recovery. Employing available SMART technology for both pre and post-op patient monitoring, engagement and critical data analytics offers both the orthopedic provider and the orthopedic patient improved healthcare efficiency in the treatment and recovery process for orthopedic injury and repair.

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Lupine Publishers | Resident Investigators Excel

Lupine Publishers |  Orthopedics and Sports Medicine

Introduction

On September 5, 2018, the fifth iteration of the Orthopaedic Research and Education Foundation (OREF)/Orthopaedic Research Society (ORS) Southwest Region Resident Research Symposium was held in San Diego, California. The event showcased resident researchers from University of California, San Diego, Stanford University, University of California, San Francisco, Naval Medical Center San Diego, Cedars-Sinai Medical Center, the San Francisco Orthopaedic Residency Program, the University of California, Davis the University of Arizona and Loma Linda University. Papers were judged by clinical and basic science faculty members from the University of California, San Diego; Naval Medical Center San Diego; and by OREF Visiting Professor, Nicholas M. Bernthal MD, Assistant Professor in Residence, Department of Orthopaedic Surgery, University of California, Los Angeles. Hosted by Reid A. Abrams, MD, Interim Chairman and Professor, Department of Orthopaedic Surgery, University of California, San Diego, the OREF ORS Southwest Region Resident Research Symposium has continued to grow since its inception in 2009. This year, 26 residents were selected to present at the symposium. “We were impressed by the number of excellent abstracts. The winners in both the clinical and basic science categories presented impressive, high-quality research,” according to D.C. Covey, MD, the local event coordinator.

Participating residents found the event both rewarding and thought-provoking. According to Stephanie Wong, MD, “The OREF has long been dedicated to those in orthopaedics early in their careers which is underscored by the Resident Research Symposiums. The 2018 Southwest Resident Research Symposium was a well-organized conference exhibiting excellent research with renowned faculty speakers and judges. The OREF award is an important recognition of resident research. I am grateful to the OREF for its support of my research and for advancing musculoskeletal research and innovation.” Dylan Kluck, MD added that, “Having the opportunity to present this research in front of a regional conference and field questions from an impressive guest speaker was a truly inspiring experience and highlighted the role that we, even as residents, can have in advancing the orthopedic field. In particular, winning the 2nd place Clinical Science OREF award was a true honor and one of the highlights of my career thus far.” Trevor Shelton, MD, stated that, “Winning one of the research awards meant a lot as far as validating the time invested in this project and other research projects to hopefully bring forth clinically useful research.” “This award helps to advance my goal of becoming a surgeon-scientist studying novel ways to prevent muscle degeneration and fatty infiltration following rotator cuff tears,” according to Michael Davies, MD.

Congratulations to the winners!

The judges named the following winners, each of whom received an honorarium:

Basic Science

1st Place: Michael Davies MD, University of California, San Francisco. Altering Stem Cell Fate to Decrease Muscle Degeneration After Rotator Cuff Tears. Study significance:

Our group used a mouse model of rotator cuff tear to replicate the pathology seen after cuff tears in humans and to study the muscle stem cell populations that play a role in the pathogenesis of fatty infiltration. Our recent work suggests that adipogenic differentiation of fibro-adipogenic progenitors present in muscle can be inhibited by histone deacetylase inhibitors, leading to less fat both in vitro and in vivo using our injury model.

2nd Place: Mario Vargas-Vila MD PhD, University of California, San Diego. Transcriptional Profile of Supraspinatus Muscle in Rabbit Model of Rotator Cuff Tear Over Time. Study significance:

Our study aimed to better characterize muscle degeneration in rotator cuff disease. We used a rabbit model to do this at both the cellular and molecular level.

3rd Place: Derek Ju MD, Cedars-Sinai Medical Center, Electrospun Synthetic Bone Scaffold Promotes Mesenchymal Stem Cell Function and rhBMP-2 Mediated Spinal Fusion. Study significance: My research focuses on osteoinductive synthetic bone scaffolds for spinal fusion.

Clinical Science

1st Place: Stephanie Wong MD, University of California, San Francisco. Effect of Gender on Outcomes After Reverse Total Shoulder Arthroplasty. Study significance:

In this study, we showed that males achieve significantly higher SF-12 PCS and ASES function scores postoperatively compared to females. This may be attributed to differences in ADLs, especially those that require shoulder rotation. All patients experienced improvements in forward elevation and abduction, decrease in pain, and improvement in function. However, patients should be aware that shoulder arthroplasty alone may not change their shoulder rotation. Addressing gender differences in outcomes after surgery will further our understanding of how musculoskeletal conditions affect males and females differently and would help optimize evaluation and treatment of orthopaedic conditions.

2nd Place: Dylan Kluck MD, University of California, San Diego. A Novel 3D Parameter Can Guide Concave Rod Contour for the Correction of Lost Kyphosis in Adolescent Idiopathic Scoliosis. Study significance:

“As part of my UCSD research year I was fortunate enough to work in Dr. Peter Newton’s lab at Rady Children’s Hospital where I was involved in several projects centering primarily around adolescent idiopathic scoliosis. As part of his lab I worked on a longstanding project analyzing intra-op rod contours during posterior spinal fusion to quantify the ideal amount of rod contour required to achieve a desired amount of surgical correction. During my research year, our biomechanical engineer was instrumental in identifying a new 3D parameter which we found to strongly correlate with restoration of thoracic kyphosis. Using 3D spinal reconstructions, this parameter represents an exciting step in being able to estimate a starting point for ideal rod contour.

3rd Place: Trevor Shelton MD, University of California, Davis. ACL Graft with Hamstring Tendons: Optimal Location for Pre- Operative MRI Measurement of Cross Sectional Area. Study significance:

The goal of my research project was to determine where along the hamstring tendons had the best correlation to intraoperative graft size for autograft hamstring ACL reconstruction. Using this, we created a model to predict whether hamstring autograft would be of sufficient size for ACL reconstruction.

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Lupine Publishers | Continuous Spinal Anesthesia with Spinocath® Catheter. A Retrospective Analysis of 455 Orthopedic Elderly Patients in the past 17 years

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Background and Objectives: Database analysis in general cost less and require less time as compared to large randomized controlled trials. This retrospective study with a catheter outside the cutting-tip needle for continuous spinal anesthesia for femur and hip surgery in elderly patients from 1998 to 2015, with the aim of determine possible advantages and disadvantages of this technique.

Methods: Anesthetic records of 455 patients receiving continuous spinal anesthesia over a 17-year period were analyzed retrospectively. All blockades were performed with patients in the left lateral position and by the two authors. Doses of 0.5% isobaric bupivacaine were administered according to the patient’s height. Evaluated parameters were: puncture success, highest level of anesthesia, lower limb motor block, quality of anesthesia, need for additional doses, failures incidence, paresthesia, postdural puncture headache, cardiovascular changes, mental confusion and delirium, blood transfusion and mortality.

Results: Seven patients were excluded for failure to puncture and accidental perforation of the duramater. The mean time for puncture and placement of the catheter was 2.66±1.03 min. The kit was easy to use in 376 patients and difficult in 42 patients. In all patients the catheter was inserted from 1 to 2 cm in the subarachnoid space. The mode of dispersion cephalad analgesia was T12. In 360 patients, the initial dose was sufficient to reach T12 and 88 patients required to supplement the dose. Mean isobaric bupivacaine initial dose was 7.74±1.78 mg and total dose was 8.58±2.60 mg. Hypotension occurred in 32 patients and bradycardia in 21 patients. Low intensity headache lasting for 3 days has been observed in seven patients. There has been no cauda equina syndrome or transient radicular irritation. Mental confusion occurred in 29 patients.

Conclusions: Our results with 455 patients over 17 years suggest that continuous spinal anesthesia with the catheter outside the needle for elderly orthopedic patient’s shows minor insertion problem, a low incidence of hypotension, paresthesia and headache. No neurological complications were observed, such as cauda equina syndrome or transient neurological symptoms.

Keywords: Anesthetics; Local: Isobaric Bupivacaine; Anesthetic Techniques; Regional: Continuous Spinal Block; Surgery; Orthopedic

Introduction

With the appearance of microcatheters (calibers 28 to 32G) in 1990 there was a resurgence of interest in continuous spinal anesthesia (CSA) [1]. Microcatheters are difficult to handle, the appearance CSF is slow or impossible, injection of the local anesthetic is slow, can break and provide inadequate blocks due to poor anesthetic distribution hyperbaric in the subarachnoid space, which can cause cauda equina syndrome [2, 3]. In 1995, a new spinal anesthesia catheter was used in Europe [4]. This 22G and 24G caliber catheter, 73 cm long, is mounted outside a spinal anesthesia needle caliber 27G and 29G, with Quincke point. It has terminal opening and only one side hole 0.5 cm from the tip, requiring only an inch of your length is introduced into the subarachnoid space. Three years after its initial use in Germany, it arrived in Brazil and one year after, the first article was published with this new catheter for CSA in 40 patients with orthopedic lower limb surgery, suggesting CSA with the catheter outside the needle shows minor insertion problems and a low incidence of hypotension [5]. Subsequently, we compared CSA with combined spinal-epidural anesthesia and sing shot spinal anesthesia (SSA) in a retrospective study [6] and compared with combined spinal-epidural anesthesia in a prospective study [7], provided good surgical conditions with a low mortality rate in the first postoperative month and to a low incidence of complications. And finally in 2006, we used it for labor analgesia with the 29G needle and 24G catheter set in five pregnant patients [8]. The catheter to perform CSA arrived in Brazil in 1998 and was discontinued in 2016 by the company that marketed it. In Brazil our group published several articles with the kit for CSA. Thus, we retrospectively assessed the number of CSA performed by our study group. Our objectives were to evaluate the use of CSA, its efficacy, ease to use and safety over the 17 year period.

Method

After obtaining institutional approval and informed consent from the subjects, this retrospective analysis was conducted the period from June 1998 to December 2015. All patients who submitted to femur osteosyntesis and partial or total hip replacement and received CSA carried out in this period were noted in an Excel spreadsheet designed for this monitoring and were reviewed. Patients’ demographic profiles, ASA physical status, comorbidities and clinical outcome were noted in the Excel spreadsheet. Details of the CSA, performance parameters, duration of surgery, intraoperative hemodynamic status and the usage of vasopressor and atropine were obtained from the anesthesia records. Inclusion criteria are shown in (Table 1). Associated diseases and drugs in use were also recorded. No patient was premedicated. Monitoring in the operating room consisted of continuous ECG in CM5, non-invasive blood pressure and pulse oximetry. All patients had an upper limb vein punctured with an 18G venous catheter and a 3 L.min-1 oxygen catheter or Hudson mask installed. After venous puncture, patients were given intravenous midazolam (0.5-1 mg). To place the patient in the blockade position, 0.1 mg/kg dextroketamine IV were injected, or anterior plexus lumbar blockade was performed with 20 mL of 2% lidocaine with epinephrine 1:200.000 + 20 mL of 0.5% bupivacaine. In patients operated for partial or total hip arthroplasty, they received dextroketamine and posterior lumbar plexus block with 40 mL of 0.25% bupivacaine for postoperative analgesia. Using the previously described technique [5], the epidural puncture was paramedially performed in the left lateral position at L2-L3 or L3-L4 interspace with an 18G Crawford needle. After that, dura was punctured with a Spinocath® device (B. Braun Melsungen AG) with a 27G needle and 22G catheter set. With the patient still in the puncture position, 5 to 10mg of 0.5% isobaric bupivacaine was injected, depending on patient’s height, when they were immediately placed in the supine position (Table 2). The following data were recorded: time taken for catheter insertion, perception of dural puncturing by spinal needle, difficulty of technique (“easy”, “difficult”, “impossible” or “perforation duramater”), highest level of sensory blockade, quality of motor blockade according to the Bromage scale, incidence of paresthesia, duration of the surgical procedure and neurologic complications. In case of pain or inadequate level, 2.5 mg of 0.5% bupivacaine were injected through the spinal catheter, until problem correction, which was removed at the end of surgery.

If accidental dural puncture were to occur during attempts to use an epidural approach with Crawford or Tuohy needles, the catheter would have to be introduced into the subarachnoid space and such patients would be excluded from the study. In the event of failure to access the epidural space within 15 minutes, singleshot spinal anesthesia would be administered with 15 mg of 0.5% isobaric bupivacaine and such patients would be excluded. All anesthesia’s were performed by or in the presence of the two authors (LEI, MAG). Hypotension (defined as a 30% decrease in systolic blood pressure, in comparison with preoperative control levels) was treated with ethylphenylephrine 1 mg intravenously. Bradycardia (defined as HR less than 50beats/min) was treated with atropine 0.5 mg intravenously. The patients were followed up by telephone regarding the appearance of cauda equina syndrome or transient neurological symptoms. The results were evaluated by the descriptive analysis of studied variables (frequencies, percentages, scatter plots and concentration ellipses) and, when possible, by the mean and standard deviation

Results

Four hundred and fifty-five underwent patient’s surgery using CSA during 17 years of the studied period. Of these, 298 (65.9%) were females. All of these CSA were carried out by the two authors. The 27G needle and 22G catheter were used in all patients. Only seven patients had to be excluded because of unintended dural perforation with the epidural needle in two patients or failure to access the epidural space with the Crawford needle in five patients. Demographic data are shown in (Table 3) and (Figure 1). The different doses used in the 448 patients are shown in (Table 4). Mean isobaric bupivacaine initial dose was 7.74±1.78 mg and total dose was 8.58±2.60 mg. The time to perform CSA was 2.36±1.03 minutes and the duration of surgery was 2.17±0.82 hours. In 376 patients, epidural puncture with Crawford needle was easy; in 72 patients it was difficult. The subarachnoid catheter was inserted easily in 407 patients and with difficulty in 42 and in all patients the catheter was inserted only 1 to 2 cm in the subarachnoid space. Paresthesia was observed in only 27 patients. In the seven patients where there was accidental perforation of the dura mater or failure to identify the epidural space, simple spinal anesthesia was performed with 15 mg of 0.5% isobaric bupivacaine (Table 5).

Discussion

This retrospective study has shown that for femur and hip surgeries in elderly patients, CSA with catheter designed for this procedure provides less cephalad dispersion (mode T12), lower incidence of arterial hypotension and less local anesthetic requirement, without any neurological complications. The failure rate was low (1.5%) and need for complementation of the initial dose of 19.6%. Femur and hip fractures are major issues for health services. Incidence increases with age, with predominance of women due to association to osteoporosis. In our study, this was confirmed by the 65.9% presence of women in the groups. The utilization rate of CSA technique only in elderly patients with hip or hip fracture by our group for 17 years averaged 30 patients per year [5-7]. In 2006, we used the set (24G catheter and 29G needle) for labor analgesia in five parturients, with excellent results [8]. In 2016 we stopped using CSA with Spinocath® has been discontinued from the market. In a previous study comparing CSA with continuous epidural anesthesia (CEA), the time to perform it was significantly shorter with CSA (2.6±0.9 min) than with CEA (2.9±1.2 min) [7]. In this retrospective study with 448 patients, the time to perform the CSA was shorter (2.36±1.03 min) than that obtained in the previous article. Using the same kit for CSA (n=50) compared to CEA, the performance time was significantly longer with CSA (6.09±2.20 min) and practically three times that obtained in our studies [9]. In most of our patients, they received an inguinal lumbar plexus block before CSA. For this reason, we do not evaluate the latency time of the first dose of 0.5% isobaric bupivacaine. In a study comparing CSA versus CEA, the time to reach sensory level T10 was significantly lower with CSA (8.40±3.96 min x 18.80±6.59 min) [9]. Sensory block level and motor blockade may be easily obtained and controlled with CSA, in the same way allows early recognition of insufficient level or insufficient time for the surgical procedure. Because of the incremental doses in 19.6% of the patients, either to produce the required analgesia or to extend analgesia, it would be useless to study the final dermatome level of analgesia. CSA was introduced in 1907 [10]. It is a well-established technique that has been used successfully in orthopedic surgical procedures [5-7]. The technique allows titration of the local anesthetic dose according to surgical needs and provides safe anesthesia, particularly for elderly or high-risk patients with unstable hemodynamic status [5, 11]. CSA depends on how the catheter is introduced into the subarachnoid space. It is more difficult when a microcatheter is used [1-3]. We found difficulties during catheter insertion in 9.2% of the patients in the CSA group, an incidence 3.6 times higher than in a previous study [7]. In three studies comparing CSA with CEP, it showed a significantly lower dose in the CSA group [6, 7, 9]. The total mean dose of 0.5% isobaric bupivacaine was similar in the three studies and practically the same in this group of 448 patients (8.58±2.60 mg). In a recent study, it was found that CSA took longer with a Spinocath® with 29G Quincke needle and 24G catheter (6.3±3.2 min) than with a microcatheter 22G Sprotte needle and 27G catheter (3.9±1.2 min) [12]. This time was 2.6 times longer than what we found in our study, using the Spinocath® with 27G Quincke needle and 22G catheters. It is well known that the time taken for cerebrospinal fluid to flow through a 29G needle with Quincke bevel (80.45 seconds) is three times longer than through a 27G needle (27.21 seconds) [13]. The use of different types and sizes of needles may explain this difference. Some studies used the CSA for post-operative analgesia for abdominal, vascular, hip surgery [14] and severe aortic stenosis with hip fracture [15]. Because we used lumbar plexus block (anterior and posterior) with neurostimulator, the use of CSA for postoperative analgesia was not practiced in our routine and all catheters were removed at the end of surgery. CSA using small titrated dose provides better hemodynamic stability than SSA [6] and CEA [6, 7] in elderly orthopedic patients. Although transoperative hypotension (7.1%) may occur, it was easily treated with small doses of vasopressors without any major adverse event reported. Because it has a larger diameter than the needle 27G and the catheter 22G occludes the duramater orifice and prevents CSF loss and develops a reaction with fibrin deposit at the puncture site, which has already been shown to be animal [11]. There was no presence of CSF in the dressing during the removal of the catheter from the subarachnoid space. The direction of the catheter introduced into the subarachnoid space cannot be predicted. In this work, with professionals over 45 years of practice and introduction of less than 2 cm of the catheter, a 6% incidence of paresthesia was observed. Post dural-puncture headache (PDPH) is a commonly reported complication of spinal anesthesia. A decrease in the size of the puncture needle and an increasing age of the patient are thought to reduce its incidence, but also factors such as thickness of the dura, a thicker dura tends to retract more rapidly than thin dura and gender of the patient, females have a higher incidence, are to be taken into consideration [16]. In a 1999 study with a catheter outside the needle, there were two patients with mild post dural-puncture headache after CSA, who did not require any invasive therapy, and two patients who received a blood-patch [11]. In another study with the same kit for CSA in 50 patients, no case of PDPH was observed [9]. In our study with 448 patients, PDPH was observed in only 7 patients (1.5%) of medium intensity and short duration (3 days). Postoperative urinary retention is a common event following surgical procedures. As criteria for inclusion in the study, patients who had a bladder catheter were automatically excluded from the study. Likewise, no patient received opioids subarachnoid ally and analgesia was performed with lumbar plexus block. In this study, only 1.7% of patients needed a urinary catheter during the postoperative period.

Conlusion

The main advantage of CSA is the possibility to gradually inject the local anesthetic and control dispersion in the CSF, providing security and control over the needs of each patient. This objective was achieved in this study. The frequency of headache with this technique and in this age group is very low. No serious neurological complications were observed, especially cauda equina syndrome. Thus, we can say that CSA when correctly used with a catheter outside the needle is a safe technique, especially in elderly patients with hip or hip fractures. The CSA with high doses of hyperbaric anesthetics through the catheter outside the needle, poor distribution was not observed or risk of cauda equina syndrome were not observed. 17 Unfortunately this catheter was discontinued by the manufacturer and we anesthetists have lost an excellent product in our therapeutic arsenal.

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Lupine Publishers | Athletic Training and Adaptation

Lupine Publishers |  Orthopedics and Sports Medicine

Introduction

In the field of sports and games, we understand the sport training in general sense that the preparation of sportsmen for acquiring top class performances. If we go on the particular sense of sports training it is the Physical, technico-tactical, intellectual, Psychic and moral preparation of the sportsman by physical exercises that is by physical load. In the training process different laws are practicable mainly the biological educational and psychological as well as the theoretical knowledge of the trainer and coach. But the above laws have to be correctly utilized at the time of sports training. The task to be solved by the coach and trainer which is facilitated by the formation of generally accepted principles. The above principles are valid for all pedagogical processes and also for sports training. In addition, following the laws of training, further principles were formulated which so far have been called principles of load.

Principles and Methods

The principles indicates to all branches and task of training, they find out the contents, the means and method as well as the organization of training which becomes a binding instruction for the activity of the coach because they determine the conscious and complex application of the laws of uniform sensible process because of the fact that the common experiences of the successful practice are reflected by them [1]. Standard or moderate loads lose their training effect step by step and create only insufficient or even not at all to the development of physical and psychical faculties. Interruption of loading causes stagnation of the capacity of performance for all level of athletes. The widely ratified opinion that the load after reaching high level performances can stopped or even be reduced cannot be proved. In training it must always be in a certain relation to the individual performance capacity and loading capacity. Top-level performance may be obtained by increasing the training load more quickly and who trained harder than former record holder’s in particular sports events, according to training analysis a gradual increase in loading is not as effective for the improvement of training condition as an increase in form of steps after certain intervals. Here the increased load definitely causes real contradictory reactions to the actual capacity and it must disturb the psycho-physiological balance to enforce the organism to form new regulation and adaptation process. However exact recording of the load, permanent observation of the athletes during training and the regular checking of performance development are the essential and important pre-requisites for the realization of the principles of the increasing demand. On the other hand we have year round loading principles hi the training system for a continuous development of training condition [2]. Throughout the year training guarantees a high total load which helps for performance development. Year long training should be arranged according to perspective aim, stabilization of adaptation that an athlete can able to achieve best possible results in decisive competitions of the year. In most codes of sports we can subdivide the whole year to carry out the specific aim and objective from which tasks, the means and structure of load can be derived. Volume and intensity of outer load is a key-factor for making training schedule. The training means and methods may be variable in different countries but one should follow the theory and basics of training in regard to onward effective progression. One has to point out that it is a definitely not optimum or sufficient if the main competitions are evently spread over a whole year. By this the coaches and athletes attention is directed to the subsequent qompetition in almost each case. Thus the training is not satisfaction determined according to perspective aim and there is no systematic development of the fundamental that determine the performance. For reasons of inadequacy of material pre-reqmsite, climatic adverseness and the organization defects the organizer and sports officials especially of the developing countries may plan the training according to its capabilities and the availability of the resources. For the cause of climate and other organization, a further subdivision of longer stages into section which can be better assessable. This is also important for better understanding of training methodical indexes, the trainer and coaches should be aware regarding methodical approach to training by the energy system.

Conclusion

In sports training the coaches and trainers must be concerned with other branches of training science for example the knowledge on sports psychology, sports biology, biomechanics and sports nutrition as well. Training is a bi responsibility for a coach because upcoming and potential trainees are coming to his coach with a strong conviction for developing his sporting performance, so if the coach do wrong in the methodical process in his instruction and workouts then the results will not be satisfactory or not even effective. One should always remember that the success of the coach depends on the expected performance of his athlete.

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Lupine Publishers | Radiographic Accuracy in Scaphoid Waist Fractures

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Objectives: We compared CT scanning and radiographic imaging to determine the relationship between measurements of displacement and angulation of the fracture.

Design: X-ray review.

Methods: All patients with acute scaphoid fractures treated at our hospital in a 4-year period that had a CT scan and plain radiographs were evaluated. The maximum displacement seen on either AP or lateral X-rays was measured as well as the amount of palmar flexion through the fracture as seen on the lateral X-ray. The differences were calculated and the mean of the sum of the differences was calculated.

Results: 103 patients radiographic files were evaluated and 43 were found to have CT scans through the longitudinal axis of the scaphoid as well as AP and lateral plain radiographs taken within one week of the CT in acute fractures. The average displacement seen on the CT was 1.85mm with an average of 50.9 degrees of palmar flexion through the fracture. The average displacement and angulation on the plain radiographs were .93mm and 33.2 degrees respectively. The mean difference in displacement and angulation between the CT scan and plain radiographs was 1.39mm (p=0.003) and 17.9 degrees (p=0.013) respectively. These were statistically significant using paired t-test comparison.

Conclusion: We believe that the accurate assessment of scaphoid fractures is essential to ensure the most appropriate treatment is rendered. We feel that CT scanning should be used to evaluate all acute scaphoid fractures to ensure that the most reliable determination of displacement can be made, and the most effective treatment rendered.

Introduction

Radiographs are routinely used to diagnose and evaluate scaphoid fracture displacement and angulation [1-9]. The amount of angulation and displacement is used to determine whether or not a patient would benefit from non-operative or operative management [10-12]. The accuracy of plain radiographs is often taken for granted and has not been validated with other imaging modalities that are more accurately utilized for fracture displacement and angulation. We compared CT scanning and radiographic imaging to determine the relationship between measurements.

Materials and Methods

All patients with acute scaphoid fractures treated at our hospital over a 4-year period that had a CT scan and plain radiographs were evaluated. The maximum displacement and angulation of the scaphoid fracture was measured in the sagittal plane (Figure 1) using the dorsal cortical angle (Figure 2) [13,14]. The maximum displacement seen on either AP or lateral X-rays was measured as well as the amount of palmar flexion through the fracture as seen on the lateral X-ray. The differences were calculated and the mean of the sum of the differences was calculated.

Results

103 patients’ radiographic files were evaluated and 43 were found to have CT scans through the longitudinal axis of the scaphoid as well as AP and lateral plain radiographs taken within one week of the CT in acute fractures. The average displacement seen on the CT was 1.85mm with an average of 50.9 degrees of palmar flexion through the fracture. The average displacement and angulation on the plain radiographs were .93mm and 33.2 degrees respectively. The mean difference in displacement and angulation between the CT scan and plain radiographs was 1.39mm (p=0.003) and 17.9 degrees (p=0.013) respectively. These were statistically significant using paired t-test comparison.

Discussion

Scaphoid fractures are one of the most troublesome injuries about the wrist. The propensity for suboptimal outcomes with these injuries should make the treating physician particularly suspicious when dealing with wrist injuries that may involve the scaphoid. Radiographic determination of displacement and angulation of scaphoid fractures is quite difficult at times. Displacement and angulation of 1mm and 60-70 degrees is generally accepted as indications for operative stabilization of scaphoid fractures [15,16]. Hence, it is extremely important to evaluate the scaphoid using the most accurate modality available.

Conclusion

In our series of patients, we have found a significant discrepancy in the amount of displacement and angulation between plain X-rays and CT scanning. Based on this data we recommend CT scanning for all scaphoid fractures that have displacement and angulation. The CT scan will better delineate the fracture characteristics and facilitate pre-operative planning.

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Lupine Publishers | The Effect of two Surgical Approach Lordosis Correction in Degenerative Lumbar Diseases: Minimally Invasive Oblique Lumbar Interbody Fusion (OLIF) Versus Transforminal Lumbar Interbody Fusion (TLIF)

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Background: The present study aimed to compare clinical outcomes and radiographic results of oblique lumbar interbody fusion (OLIF) with transforaminal lumbar interbody fusion (TLIF) in patients with lumbar spondylolisthesis.

Methods: We retrospectively reviewed and compared 28 patients who underwent OLIF (OLIF group) and 35 who underwent TLIF (TLIF group). The operation time, intraoperative hemorrhage, bed rest duration, and length of hospital stay were compared between the 2 groups. Clinical results were evaluated with the ODI and VAS for back and leg pain. Radiological results were evaluated with disc height (DH), foraminal height (FH), fused segment lordosis (FSL) and lumbar lordosis (LL).

Results: The OLIF group had less intraoperative blood loss, shorter operative time, bed rest time, and hospital stay than TLIF group (P<0.05). The OLIF group had lower VAS scores for back pain and lower VAS scores for leg pain after surgery compared with before surgery (P<0.05), The OLIF group had lower ODI after surgery compared with before surgery (P<0.05) .The was no significant difference in decrease value in VAS and ODI after surgery between the two groups (P>0.05). No significant differences were found in DH, FH and LL between the 2 groups preoperatively (P>0.05). The OLIF group showed higher DH and FH than the TLIF group at all time points (P<0.05). No significant differences were found in FSH between the 2 groups at any time point.

Conclusions: OLIF has similar good long-term clinical outcomes of TLIF with the additional benefits of less initial postoperative pain, early rehabilitation, shorter hospitalization, and fewer complications.

Keywords: Lumbar Spondylolisthesis; Oblique Lumbar Interbody Fusion; Transforaminal Lumbar Interbody Fusion; Sagittal Balance

Introduction

Lumbar spondylolisthesis describes a forward displacement of a lumbar vertebra. The most common types are degenerative or isthmic lumbar spondylolisthesis. It is a common pathology, often causing lumbar canal stenosis. Symptoms of lumbar spondylolisthesis may include intermittent neurogenic claudication, lumbar radiculopathy and back pain [1]. The primary treatment for lumbar spondylolisthesis is non-surgical. When unsuccessful, surgery can be considered in order to decompress neural structures and stabilize the spine. Lumbar fusion has become an accepted treatment to treat degenerative diseases of the lumbar spine. There is a growing body of evidence that consistently demonstrates improved clinical outcomes with lumbar fusions for patients who fail conservative care [2]. Transforaminal lumbar interbody fusion (TLIF) is one of the widely used techniques for spinal fusion. The first attempt for TLIF was by Harms and Rolinger, who reported on the use of bone graft packed in titanium mesh that was inserted via a unilateral transforaminal route into the anterior part of the disc space. Harms and Blumes developed the TLIF technique further, and Harms described this in detail together with Jeszensky in 1998 [3-5] It is a posterior approach that uses a facetectomy corridor and has benefits of safety, good outcomes, and high fusion rate. Surgeons prefer this approach because they can reduce dural retraction and enable direct neural decompression. However, characteristic complications include posterior spinal muscle injury and cerebrospinal fluid (CSF) leakage [6, 7]. The OLIF was first described by Mayer et al in 1997, and the term was later coined by Silvestre et al in 2012. This approach aims to avoid the morbidity of the transpsoas approach by translating the incision anteriorly and dissecting around the psoas [8, 9] Oblique lateral interbody fusion (OLIF) is a new technique in spine surgery, through oblique lateral retroperitoneal approach, it can establish a work corridor direct access to the intervertebral space between the psoas muscles and the abdominal vessels sheath. Through the retroperitoneal work corridor, OLIF can complete intervertebral fusion of anterior and middle column, restore the height of intervertebral space and foramen, and make the spinal canal or nerve root indirect decompression. OLIF is applicable to degenerative lumbar spine diseases, spinal tuberculosis, tumor, kyphosis, postoperative renovation and trauma, etc. OLIF conforms to the current trend of minimally invasive spinal surgery, which has many advantages like less surgical trauma, less surgical bleeding loss, shorter hospital stay, faster recovery, less damage to the abdominal organs, no stimulation of the spinal nerve and less damage to the psoas and lumbosacral plexus [10-12]. The aim of this study was to compare OLIF and TLIF for the treatment of lumbar spondylolisthesis in terms of clinical outcomes and radiographic results.

Methods

Patients

The study enrolled patients who underwent TLIF (TLIF group) or OLIF (OLIF group) in our department between January 2018 and October 2019. The surgery apporach was deteminated by the patien’s desirement. The inclusion criteria were as follows: all patients were operated for a single lumbar level and they had complaints of low back pain and lower limb pain unresponsive to conservative therapy for over 3 months, radicular symptom and/ or intermittent claudication before the operation. Preoperative examination included a detailed physical examination and radiological imaging. Patients with previous spinal instrumentation, spinal tumor pathologies, spinal infections, and acute spinal trauma or fractures were excluded. Among them, 28 patients underwent OLIF (OLIF group) and 35 patients underwent TLIF (TLIF group). The health records and radiographic data of the 64 patients were summarized and analyzed. This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Soochow University.

Operative Procedure

Oblique lumbar interbody fusion

After induction of general anesthesia, the patient was placed in lateral decubitus position on the right side. The operating segment was marked on the skin via a C-arm machine. A 5 cm skin incision was made on the marked disc level at the left abdomen. Then carry out blunt finger dissection of the abdominal oblique muscles, which includes the external oblique, internal oblique, and transversalis abdominis muscles. The surgeon uses the index finger to confirm the anterior border of the psoas muscle, sliding from the quadratus lumborum muscle to reach there. The retroperitoneal space was accessed by blunt dissection, and the peritoneal content was mobilized anteriorly. Place a Kirschner wire into the disc space from the antero-laterl corner to confirm the target disc space again. Sequential dilators were placed over the Kirschner wire. After the final tubular retractor was placed over the anterior onethird of the disk under illumination, the entire visualized area was made clearly. A lateral annulotomy was performed followed by a complete discectomy by using pituitary rongeurs and curettes, then removing the focus by using curette. After that, an appropriate-sized cage filled with autologous bone graft was inserted orthogonally in a press-fit fashion into the disc spaces. The above procedures were done step by step under C-arm fluoroscopic guidance. After completing the anterior procedure, the patient was turned to the prone position, and supplemental posterior instrumentation was then placed with a midline incision to sustain the stability of spine.

Transforaminal lumbar interbody fusion

After induction of general anesthesia, the patient was placed in a prone position on a carbon table. Then mark the target level under the C-arm guidance. A midline incision was made. The skin and subcutaneous tissue were incised layer by layer and the paravertebral muscles were dissected from the spine. Pedicle screw-rod was inserted bilaterally. The facet joint and part of the vertebral lamina were removed by osteotome and the disk was then removed. After resection of ligamentum flavum and osteophyte, a cage filled with autologous bone was inserted in the disc space. The wound was copiously irrigated and closed in layers.

Assessment of Clinical and Radiographic Outcomes

The duration of the operation, volume of intraoperative hemorrhage, length of bed rest, length of hospital stay and complications were recorded for all patients. Clinical and radiographic outcomes were evaluated preoperatively and at 1 week, 3 months and 6 months postoperatively. We used the visual analog scale (VAS) for leg pain (VAS-LP) and back pain (VAS-BP) and the Oswestry Disability Index (ODI) to compare clinical outcomes between the two groups. Lumbar lordosis (LL), disc height (DH), foraminal height (FH), LL was defined as the angle between the upper endplate of the L1 and S1 vertebra using the Cobb method. DH was calculated as the mean value of the anterior and posterior margin heights of the affected disc. FH was measured as the maximal interval between the lower border of the upper pedicle and the upper border of the lower pedicle. Two observations were made at an interval of at least 2 weeks by two neurosurgeons, and the mean values were used for the study.

Statistical Analysis

The data analysis were performed by Statistical Package for the Social Sciences (version 19.0 SPSS, Chicage, IL) and Microsfot Excel 2016 (Microsoft, Seattle, WA). All quantitative variables are presented as means±standard deviations. Student’s t-test and the chisquared test were used to compare radiological and clinical outcomes of OLIF and TLIF. The difference between the two groups were assessed by using Chi-square test. P<.05 was considered statistically significant.

Results

No significant differences were found between the 2 groups in terms of baseline patient characteristics, including age, sex, body mass index and operated levels (Table1). The operative duration was shorter and intraoperative hemorrhage was less in the OLIF group compared with the TLIF group (186.44±36.5 vs. 199±59.64min; 55.94±57.37 vs. 190±66.33mL; respectively). The OLIF group had a shorter bed rest time and shorter hospital stay than did the TLIF group (P<0.05) (Table1). VAS scores of both groups decreased postoperatively (Table2). No significant differences in VAS（BP）scores were found at preoperative and postoperative 3 months between the 2 groups (P>0.05). Statistical difference was found at 1 week after surgery (P<0.05). No significant differences in VAS（LP）scores were found at any follow up time. Preoperative ODI were 54.88±8.13 and 53.93±6.06 points in the OLIF and TLIF groups, respectively (P>0.05), which both decreased postoperatively. No significant differences in ODI scores were found at preoperative and postoperative 3 months between the 2 groups (P>0.05). Statistical difference was found at 1 week after surgery (P<0.05). No significant differences in DH and FH between the 2 groups were seen preoperatively (P>0.05). The postoperative FH and DH was significantly greater than the preoperative value in each group (p<0.01). The postoperative DH was significantly greater in the OLIF group than in the TLIF group (p<0.01). The postoperative FH and DH was significantly greater than the preoperative value in each group (p<0.05). The OLIF showed higher DH and FH than the TLIF group at all time points after surgery (p<0.05). There was no statistically difference found in LL between the two groups before surgery (P > 0.05), but the recovery of LL in OLIF group was significantly greater than that in TLIF group (P < 0.05). Both groups showed increased FSL after surgery, while no significant differences in FSL were found between the 2 groups at any follow-up time point (Table 3). For patients in TLIF group with a combination of supplemental fixation at a given level, there was 8.6% (3 of 35) rate of cage subsidence. Of the 3 patients with radiographical subsidence, only 1 was symptomatic. Besides, for patients in OLIF group with a combination of unilateral fixation, there was 7.1% (2 of 28) of cage sedimentation. In OLIF group, two patients showed ileus on the first postoperative day which improved spontaneously the next several days. One patient experienced thigh and numbness postoperatively, which alleviated within 7 days after surgery. There was no ureteral injury or lesion to sympathetic chain. In the TLIF group, CSF leakage due to thecal sac injury and root injury was confirmed in three cases. The drainage tube was removed 7 days after the operation. Superficial incision infection occurred in 3 patients in the TLIF group, which was treated with dressing change and antibiotics.

Discussion

Lumbar spondylolisthesis is a common pathology accompanied with lumbar canal stenosis, displaying a certain degenerative imbalance and thus presentinga risk factor for degenerative scoliosis in later life. This is due to conservative treatment options being relatively inferior, thus indicating that surgical treatments offer a more meaningful approach [13]. Lumbar fusion has become an accepted treatment to treat degenerative diseases of the lumbar spine [14]. Both PLIF and TLIF are the most widely used posterior fusion techniques, which can fully expose to nerve roots. However, several literatures demonstrated that there is a risk of iatrogenic lesions of the dural sac and nerve roots as well as epidural bleeding in PLIF. For the limitations of PLIF, TLIF was introduced. TLIF is a variant of the PLIF technique described by Cloward in the 1950s [15]. It is usually performed by unilateral approach preserving the interlaminar surface on the contralateral side, which can be used as a site for additional fusion. Compared with PLIF, TLIF retains ligamentous complex, contralateral lamina and facet joints, thus maintaining spinal stability [16-17]. OLIF is a modification of the retroperitoneal approach for microsurgical anterolateral lumbar interbody fusion, which was first described by Mayer in 1997[18]. In this study, we found that the OLIF group had less intraoperative blood loss and shorter operative time, bed rest duration, and hospital stay than the TLIF group. Potentially because of the absence of back muscle injury in OLIF, we also found that the OLIF group had lower VAS scores for back pain and ODI than the TLIF group at 1 week postoperatively. In contrast to transforaminal lumbar interbody fusion, OLIF technique is performed through the retroperitoneal space and accessed by blunt dissection. Both separation of paravertebral and tissue removal of bone mass near the canal are not necessary in procedure. The separation of the paravertebral tissue and the large incision are key reasons that accounts for the high level of intraoperative blood loss and high incidence of postoperative incision complications. Altogether, both OLIF and PLIF display obvious differences in terms of the surgical procedure. Compared with TLIF, OLIF had the advantages of less blood loss, shorter operative time and preservation of the posterior longitudinal ligament complex, which presented as a key reason in affecting post-operative efficacy. It has been reported that no significantly improvement was found in lumbar lordosis in TLIF [19]. However, the lumbar lordosis (LL) recovered significantly in both groups in our study. We noted that the TLIF was effective in restoring normal lumbar lordosis, which is probably because that we place the interbody graft as anterior as possible to maximize the lordotic potential, and it is within the construct in combination with compression from the posterior column. Other studies show that the effect of TLIF in restoring normal lumbar lordosis depends on compression of posterior structure of the lumbar vertebrae [20]. Several literatures demonstrated that LL is restored well in lateral lumbar interbody fusion. Thus far, we expect that OLIF will do better in deformity correction. Luckily, differences were found in LL in two groups after surgery. In OLIF group, the mean improved Cobb angle is larger than that of TLIF, demonstrating that the correction in lumbar lordosis is better in OLIF. Kepller et al. demonstrated that more lumbar lordosis was associated with more back and leg pain as assessed by VAS [21]. Fujibayashi demonstrated that clinical results are related more to the effect of deformity correction than to indirect neural decompression [13]. This may be explained that why the VAS scores is less in OLIF group after the surgery. In addition, restoration of DH in the fusion segment significantly improved the compression of nerve canal by reduction of disc bulging and elongation of the hypertrophied ligamentum flavum. Both surgical procedures increase DH of the diseased segment. Moreover, the OLIF group showed higher restoration of DH and FH than TLIF group postoperatively. This is reasonable, because we inserted a relatively larger cage into the target disc in OLIF. The height and width of OLIF cage are 8-14 mm and 55 mm respectively while the cage in TLIF is 8-12 mm in height and 30 mm in width [23]. The height of intervertebral can be increased by using larger and wider cage, the same as intervertebral foramen height and vertebral canal area. The wide cage allows it to rest on the hard epiphyseal ring around the vertebral body, rather than on the relatively weak area of the cortical bone in the central depression of the endplate.

For patients in TLIF group with a combination of supplemental fixation at a given level, there was 8.6% (3 of 35) rate of cage subsidence. Of the 3 patients with radiographical subsidence, only 1 was symptomatic. Besides, for patients in OLIF group with a combination of unilateral fixation, there was 7.1% (2 of 28) of cage sedimentation. It may prove that the effect on avoiding subsidence in unilateral fixation is good enough. Besides, as mentioned by Tien V, the inferior endplate is 40% stronger than the superior endplate [24]. In 5 cases of our study, the cage was inserted superior endplate, which did consistent the theory mentioned above. In the current reports, the complication rates of TLIF were range from 7.1 to 21.6% [25-29] including rod-broken and cage migration. The complication incidences of OLIF were varied in literatures, ranging from 3.7% to 58.3% [13-31]. Ohtori et al. demonstrated that segmental artery injury occurred in 1 patient and the surgery was converted to open surgery. Zeng et al. reported that the complication incidence of OLIF was 13.62%, such as cerebral infraction and reoperation, both of which were only one case. Except for several serious complications mentioned above, the rest are all transient symptoms. In this study, two patients who underwent OLIF showed ileus on the first postoperative day. The postoperative ileus improved spontaneously in the next several days. One patient experienced thigh and numbness postoperatively in the OLIF group, which alleviated within 7 days after surgery. There was no ureteral injury or lesion to sympathetic chain. In the TLIF group, CSF leakage due to thecal sac injury and root injury was confirmed in three cases. The drainage tube was removed 7 days after the operation. Superficial incision infection occurred in 3 patients in the TLIF group, which was treated with dressing change and antibiotics. However, several disadvantages can’t be ignored in OLIF technique. In the process of disc removal, repeated fluoroscopy is needed and patients are exposed to more radiation than TLIF. Besides, the larger cage may lead to iatrogenic injury to nerve root, especially to the upper nerve root of the oblique side of the kambin triangle. What’s more, the cage is more expensive than traditional one and some patients in poor family can’t afford it.

Limitations

A limitation of the study was that it was a retrospective study with a relatively small sample size. Moreover, the inclusion criteria were rather restrictive and may have contributed to a selection bias that may have led to an underestimation of incidence rates for nonunion, subsidence, and surgical approach-related complications. The intention is to follow up this study in the future to obtain further information aimed at improving the deficiencies identified in this article. In addition, increase the number of followup cases in an attempt to reduce the error of follow-up data to further improve the accuracy of this study.

Conclusion

Both OLIF and TLIF can achieve satisfactory clinical results in the treatment of lumbar spondylolisthesis accompanied with lumbar stenosis. However, compared with TLIF, a smaller incision, shorter ansthesia time, less blood loss and earlier postoperative activities in OLIF did exhibit a greater advantage, attracting more and more attention in surgeons.

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Lupine Publishers | Neglected Posterior Shoulder Dislocation with a Large Bone Defect in a young Active Patient Treated with Osteochondral Allograft

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Background: Posterior glenohumeral joint dislocation is a rare injury. Despite positive clinical signs is often underdiagnosed and undertreated. The presence of a large bone humeral defect could worsen the outcome.

Case Report: We report a case of 45 years-old man with a neglected posterior shoulder dislocation with a large segmental bone defect involving 40% of the articular surface of the humeral head. We decided to treat the patient with an open reduction of the shoulder dislocation and reconstruction of the articular surface with fresh-frozen humeral head allograft. Our patient showed improved shoulder mobility and ROM on all planes that positively affected the patient daily activities; no pain was registered at follow-ups.

Conclusion: Our case report demonstrates that neglected posterior shoulder dislocations with a large bone defect and viable humeral head can be treated using allograft, obtaining optimal clinical results and avoiding the need for early prosthetic replacement surgery.

Keywords: Neglected Posterior Shoulder Dislocation; Reverse Hill-Sachs Lesion; High-Demand Patient; Humeral Head Allograft; Anatomic Shoulder Restoration

Abbreviations: GHJ: Glenohumeral Joint; MRI: Magnetic Resonance Imaging; MVA: Motor Vehicle Accident; LHB: Long Head Of Biceps Brachii; XR: X-Rays

Introduction

Posterior glenohumeral joint (GHJ) dislocation is a rare injury and accounts for only 2% to 5% of all dislocations of the shoulder [1]. GHJ posterior dislocation has a prevalence of 1.1 per 100,000 inhabitants per year, with the first peak in male patients aged between 20-49 years old, and the second one in the elderly over the age of seventy [2]. Posterior shoulder dislocation is often underdiagnosed and undertreated in up to 50% of cases admitted to the E.R. [3]. A dislocation is defined chronic when left untreated for more than 3 weeks. Diagnosis of posterior GHJ dislocations is often delayed, becoming chronic and leading to a locked joint and decreased functional outcome [4]. Typically, posterior shoulder dislocation can be traumatic or atraumatic: the first might be due to direct high-energy trauma or it can also develop insidiously through a repetitive minor injury. A major trauma with a force applied to the arm with the shoulder in adduction, flexion and internal rotation is the most frequent cause (e.g. A direct blow to the anterior shoulder or by a fall on a forward-flexed upper limb)[5]. On the other hand, seizures and electrocution are the major causes of atraumatic dislocations, by contraction of the internal rotators and disruption of the joint static and dynamic posterior stabilizers [1]. Associated injuries include humeral neck or tuberosity fractures, impaction fractures of the anterior humeral head (i.e. reverse Hill–Sachs lesion), posterior labrum capsular complex lesions (i.e. reverse Bankart lesion) and rotator cuff tears [2, 6]. Reverse Hill-Sachs lesions can be associated with posterior GHJ dislocation in up to 86% of cases, requiring open or arthroscopic surgical therapy [1, 7, 8].

Missed, late or incorrect diagnosis is a significant clinical problem, as it can predispose to serious complications, such as chronic instability, osteonecrosis, post-traumatic osteoarthritis, persistent joint stiffness and functional instability [4, 8]. Treatment management of chronic posterior shoulder dislocation associated with a large articular defect is strongly debated due to lack of studies with significant clinical records: operative treatment is usually preferred based on the type and the extension of injury, age, medical history and functional demand of the patient. The patient gave consent for case report.

Case Report

A 45-year-old deaf man, involved in an MVA, sustained a direct blunt trauma to his dominant right shoulder. The patient was employed as a warehouse worker. At the time of the accident, he has been admitted to the ER of another hospital where he has been discharged with the diagnosis of “right shoulder contusion”. The patient was admitted to our clinic three months after the trauma, complaining severe pain and functional limitation of the right shoulder. At physical examination the patient showed functional limitation of the shoulder motion on all planes, in particular: abduction 30°, flexion 30°, internal rotation at the iliac spine, external rotation 0°. At palpation the shoulder was painful. The patient was neurovascular intact. X-Ray and CT scan were carried out, showing posterior GHJ dislocation with an osteocartilagineous lesion about 40% of the humeral head surface, localized on its antero-medial edge (a reverse Hill-Sachs lesion; type I according to Randelli’s classification of posterior shoulder dislocation) (Figure 1) [9]. Based on clinical (i.e. not reducible dislocation after conservative treatment) and radiological evaluation (i.e. complete dislocation of the shoulder with important bone loss of the humeral head), the patient was subsequently scheduled for surgery. Considering the young age of the patient, his high functional demand and the extension of the lesion, we decided to perform a humeral head allograft reconstruction. We requested it to the bone bank communicating the size of the humerus of the patient to obtain the best matching allograft. The procedure was performed under general anaesthesia with the patient placed in a beach-chair position. A deltopectoral approach was used with release of the pectoralis major tendon insertion to improve the exposure of the surgical field. After finding and isolating the anterior humeral circumflex artery and vein, the subscapularis tendon was exposed and cut through its insertion. After detaching the subscapularis muscle from the lesser tuberosity, as the long head of biceps brachii (LHB) tendon tended to dislocate from the bicipital groove we decided to tenotomize it. We proceeded to perform lysis of the posterior adhesions and then the posteriorly dislocated locked humeral head was gently reduced with the aid of a Schanz pin inserted in the lateral aspect of the humeral shaft used as a joystick. Subsequently a large 40% reverse Hill–Sachs lesion was exposed. With an appropriate burr, an accurate regularization of the Hill-Sachs lesion was made, obtaining a viable bony surface. The fresh-frozen humeral allograft was then carefully prepared aside to obtain an anatomic restoration of the cephalic anatomy. The size-matched osteocartilaginous allograft was press-fit into the humeral defect and fixed with 3 4.0mm lag screws reaching a stable construct – (Figure 3). The subscapularis tendon was reinserted by two anchors (JuggerKnot® SoftAnchor - 2.9 mm, Zimmer-Biomet, Jacksonville, FL, USA), (ALLthread™ Suture Anchor – 5mm Zimmer-Biomet, Jacksonville, FL, USA), on his anatomical site. The LHB was sutured on the pectoralis major tendon with non-absorbable suture. The arm was kept in a 30° of abduction and 30° of external rotation using a shoulder brace for 4 weeks post-operatively. Passive range of motion was started at 4 weeks following surgery and active range of movement was started 6 weeks post-operatively. A shoulder CT scan was performed at 1-year follow-up showing no signs of allograft bone resorption, screw loosening or avascular necrosis (Figure 4 A-B). Also 1 year after surgery the patient reported no painful symptoms showing excellent ROM on all planes (Figure 5 A-D); he was able to perform normal daily and work-related activities. A 95 points Constant- Murley Score was recorded at this time.

Discussion

The aim of this paper is to present the clinical results using a fresh-frozen osteochondral humeral head allograft in a young active patient affected by a chronic GHJ dislocation with reverse Hill-Sachs lesions about 40%. Scientific literature shows scarce consensus about the treatment of this rare injury: there is an ongoing debate about the different treatment options. Moreover there is not an agreement on the best allograft that has to be used. The reverse Hill-Sachs lesion size is the most influencing factor for choosing the type of treatment [3]. The reverse Hill-Sachs (also called McLaughlin lesion) is a wedge-shaped impaction fracture on the antero-medial aspect of the humeral head [7]. Any significant lesion should be treated operatively [8]. According to Guehring et al., for defects involving less than 25% of the articular surface closed reduction is the first choice of treatment; patients with unstable joints and bone defects >25% could benefit of operative treatment, with arthroplasty being recommended if the bone defect is >40% [9,10]. For defects between 25% and 40% a plethora of treatment modalities can be adopted including the classical or the modified McLaughlin technique, bone grafts, etc. [11.12]. In our patient, we opted for a humeral head allograft to obtain an anatomic restoration. We preferred this procedure to non-anatomic procedures as subscapularis tendon transfer (i.e. classic McLaughlin) or the lesser tuberosity transfer (i.e. modified McLaughlin) because, according to authors, a non-anatomic restoration of the humeral head sphericity can lead to a decreased internal rotation of the shoulder and can complicate a foreseeable prosthetic reconstruction [3, 4, 5]. Our patient had borderline indications for hemiarthroplasty. Considering his relatively young age and global clinical assessment, we decided to perform an allograft procedure to respect the patient’s high functional demand of the affected limb. Furthermore, we agree with authors which alert on the difficulty to manage the moderate-sized Hill Sachs lesions (i.e. sizing between 40-55%), even for experienced shoulder surgeons: young and middle-aged individuals with high functional demand can benefit of a delay in the hemiarthroplasty surgery by preserving the sphericity of the humeral head [6]. Concerning the graft type, most literature focus on cancellous allograft or autograft to treat acute posterior shoulder dislocation. These grafts are used as a void filler after lifting off the previous impacted articular surface to better stabilized the lesion gap and promote bone healing [1]. For defect between 25% and 40% some authors report reconstruction of the articular surface with fresh-frozen osteochondral allograft [1, 5, 13, 22, 23]. No specific guideline has been proposed for the choice of the allograft. Some authors used a fresh-frozen femoral head allograft. In particular, authors report good functional outcomes using a femoral head allograft for treating locked chronic posterior shoulder dislocation in patients having 25-50% articular surface bony defects [5,13]. The same good results are described in a case report by Patrizio et al. [22]. The most frequent possible complications recorded with this procedure are graft resorption, articular surface flattening and arthritis [5, 13]. Other authors. Proposed the use of a fresh-frozen talus allograft in case of limited accessibility of humeral head graft. They described a similar congruency between the radii of curvature observed with the taller dome and with the humeral head, allowing for application to broader category of patients [23]. The use of fresh-frozen humeral head allograft has been described by Martinez et al. in 5 patients affected by GHJ instability after posterior GH dislocation and in 1 patient with chronic GH dislocation. All patients had a 40% humeral defect. The study had a follow-up period of 10 years; 4 patients had satisfying outcomes while 2 suffered collapsing of the graft [1]. When comparing our case with the aforementioned paper, we obtained from the bone bank an accurate sized humerus matching the patient’s one. By doing so we were able to better fill the gap and restore the precise curvature of the humeral head of the patient, rather than with the use of femoral head, achieving an anatomical restoration. By filling the defect using a humeral head allograft we aimed at preserving both shoulder stability and function, while maintaining the integrity of anatomic soft tissue attachments and preserving the remaining articular surface. Our case report showed how operative treatment options must be patient-targeted according to each intrinsic factors (e.g. age, functional demand, comorbidities, etc.), to the type of injury (e.g. extension of bone defects) and its severity [14, 15]. Our patient had a high functional demand influencing his work-related activities and reported consistent pain for up to three months. Patients with posterior GHJ dislocation suffer a diagnosis delay and often report aspecific symptoms during healthcare evaluation [16, 17]. Our patient as well had aspecific symptoms; apart from significant pain and loss of motion, patients with chronic GHJ dislocation may show shoulder muscle atrophy and prominent acromion on the opposite side, while the dislodged humeral head can be palpated on the back of the shoulder [18]. XR findings can mislead clinicians as the AP view could show no sign of posterior GHJ dislocation: axillary-lateral or Y views (hard to obtain if consistent pain is present), CT scan and/or, as in our case, an MRI can unmask the dislocation [7, 19]. Diagnosis delay pivots the treatment: in a case series study it is highlighted how patients promptly treated for acute dislocation have a better outcome and are easier to treat [20]. During follow-up, our patient has undergone rehabilitation therapy; post-operative recovery consists of strengthening exercise neuromuscular re-education, while educating the patients to avoid flexion, adduction and internal rotation movements [19, 21]. We acknowledge the limitations of this paper due to limited follow-up.

Conclusion

Posterior GHJ dislocation greatly benefits early diagnosis. If a reverse Hill-Sachs lesion is associated, there is the need of standardized treatment protocols for management of this condition. An important limit we faced when searching the literature is the paucity of studies with a large number of cases treating GHJ dislocation with a reverse Hill-Sachs lesion: we strongly recommend for future studies to unveil possible benefits and limitations, especially involving the benefits of bone grafts. We want to emphasize the importance of preserving the GHJ anatomy in the young, active patient by delaying prosthetic replacement only once necessary. We want to point out how, even if the graft procedure fails there is still the possibility to proceed with a salvage procedure (i.e. prosthetic replacement), that will be found easier to perform over a preserved humeral head anatomy.

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Lupine Publishers | Haglund Syndrome – A Case of Bilateral Involvement

Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Haglund syndrome is a cause of posterior heel pain and occurs commonly in adolescent girls who wear high heels with restrictive heel counters and may occur in people with rheumatoid arthritis. Is characterized clinically by thickening of the soft tissues at the Achilles tendon insertion or a painful “pump bump” and retrocalcaneal bursitis, Achilles tendinitis, and a prominent posterosuperior calcaneal border or bursal projection. We report a case of a 59 years-old woman with bilateral Haglund syndrome which did not needed surgical treatment, being the conservative treatment enough to improve the patient’s quality of life.

Keywords: Calcaneus; Magnetic resonance imaging; Foot diseases

Introduction

Haglund syndrome is a cause of posterior heel pain and was first described by Patrick Haglund, in 1928, to occur in patients who had a prominence of the posterosuperior surface of the calcaneus [1]. It occurs commonly in adolescent girls who wear high heels with restrictive heel counters and may occur in people with rheumatoid arthritis [1]. Haglund syndrome has also been termed “pump bump,” “winter heel,” “knobby heels,” “calcaneal altus,” “highbrow heels,” and “cucumber heels” [1]. Haglund syndrome is characterized clinically by thickening of the soft tissues at the Achilles tendon insertion or a painful “pump bump” and retrocalcaneal bursitis, Achilles tendinitis, and a prominent posterosuperior calcaneal border or bursal projection [1-4].

Case Presentation

59 years-old woman with pain and swelling in both feet for four months that get worse when use slippers and when she wake up and put her feet in the floor for the first time in the day. The patient denies other complaints and surgeries. At physical examination refers pain at the palpation of in the posterior and inferior regions of the ankle. The Magnetic Resonance Imaging (MRI) demonstrates posterior and plantar calcaneal spurs, liquid in retrocalcaneal and subcutaneous calcaneous bursa, and calcaneal tendon with heterogeneous signal and thickened (1.4cm at left and 1.2cm at right), markedly in their insertion with adjacent bone edema (Figures 1 & 2). The set of findings are compatible with Haglund syndrome. The patient started conservative treatment with non-steroidal anti-inflammatories, change of footwear and physiotherapy, presenting a good response, not requiring surgery.

Discussion

Haglund syndrome is caused by mechanically induced inflammation of the Achilles tendon and its bursa, from abnormally high pressure between the bursal projection of the calcaneus, the Achilles tendon, and the bursa [1,5]. Patients with bursitis have erythema and swelling over the bursa and tenderness to direct palpation [2] besides pain with dorsiflexion of the foot [6]. Clinically, by physical examination alone, it may be difficult to distinguish Haglund’s syndrome from other causes of hindfoot pain such as Reiter’s disease, rheumatoid arthritis, or isolated local conditions such as superficial tendon Achilles bursitis secondary to poor shoe fit [7]. Plain radiograph in a lateral standing position is useful to assess the presence of a prominent bursal projection of the calcaneum, the Haglund deformity [3]. Loss of a lucent retrocalcaneal recess is an important indication of underlying retrocalcaneal bursitis [3]. The Achilles tendon is swollen, and dystrophic calcifications may also be seen [3].

MRI may be required for ambiguous or clinically equivocal cases [3]. The cardinal soft tissue abnormalities, namely Achilles tendinopathy, and retrocalcaneal and retroachilles bursitis are more easily and directly depicted by MRI [3]. The detection of marrow oedema within the prominent bursal projection is likely to support the repetitive mechanical compression and inflammation as the pathological mechanism in this condition [3]. Treatment of Haglund deformity, with or without bursitis, targets decreasing the pressure and inflammation with openheeled shoes, anti-inflammatory or analgesic medications, and corticosteroid injections [2]. Physical therapy may also help reduce pain. In recalcitrant cases, surgery to remove the Haglund deformity may be necessary [2].

The nonsurgical treatment, combined with modifications in daily shoe wear, is an appropriate initial treatment for pain relief of Haglund’s syndrome [7]. Using ultrasound guidance to inject the retrocalcaneal bursa is a simple, reliable method of ensuring accurate delivery of medication into the bursa and avoiding intratendinous injection [7].

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Lupine Publishers | Effects of Applying A Circuit Training Program During the Warm-Up Phase of Practical Physical Education Classes

Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

This study aimed to analyze the effect of a training circuit, applied for 3 weeks, during the warm-up phase of practical physical education classes, and to verify the resulting effects on the analyzed variables. Twenty-five students participated in the study (mean ± age = 15.67 ± 1.02), weight (67.31 ± 9.29 kg), height (1.72 ± 0.08 m). The training program in circuit was applied twice a week, for 3 weeks, and it was containing burpees, jumping together, squats, sit-ups, push-ups, countermovement jumps, sprints with change direction. The students were analyzed in two different moments (i.e., pre/post application of the training program). The results indicated that the application of the training program induced positive effects in the optimization of aerobics fitness, specifically in the shuttle test. The study also concluded that the circuit training program, in addition to inducing positive changes in the shuttle test, is also a viable alternative for warming up in the physical education class.

Introduction

Physical education plays a fundamental role in the integral development of the student, enabling cognitive, psychomotor, and affective development while also encouraging healthy lifestyles, socialization, team spirit, and sports practice. The benefits of regular physical activity are diverse; namely, improvements in cardiovascular and respiratory function, decreased levels of anxiety and depression, and increased sense of well-being, and the development of cognitive and social valences [1-43]. In contrast, a sedentary lifestyle in adults is associated with a decrease in functional capacity, an increase in morbidity and mortality, and chronic diseases [19-32]. Therefore, it is essential to promote healthy living habits and physical activity during childhood, which, when prolonged during adolescence until adulthood, can be useful in combating physical inactivity and also have a beneficial influence on health in general [22-24]. Currently, and in the face of an increasingly challenging and stimulating world, it would be expected that there would be concerns regarding the development of motor, social, and cognitive abilities from an early age [5-35]. However, the reality is that an increase in sedentary lifestyle, interaction problems, and less contact with nature is exponential and endangering the development of children’s motor skills [40]. The daily recommendation for physical activity for young people is 60 minutes of moderate to vigorous activity, 5 times a week [42]. However, in most cases, this is not the case, as most adolescents practice exercise only in a school context, particularly during physical education classes, hence its exponential importance in children’s development [28]. Therefore, the school can be characterized as the perfect location to implement health promotion strategies and promote healthy lifestyle habits [18]. In particular, with regard to physical education classes, one of the strategies that can increase their efficiency, and which has been increasingly implemented in the school context, is circuit training, which, when properly adapted, enables the inclusion of various content and the development of several individual skills [10] as well as the enhancement of physical exercise practices [17]. In fact, the need for training and increased strength in children and young people has gained greater significance, as well as the knowledge that there are significant improvements associated with the application of these programs, provided that they be run in sufficient quantities-with functional loads that exceed the usual muscular activity-and are adequate, in that they strictly follow the methodological recommendations for the development of strength in children and young people [21].

This type of training program is carried out through interval training and consists of several stations that involve work on strength, balance, resistance, and coordination, depending on the objectives [37]. This type of training program has several advantages: it is easy to adapt to the target audience and existing resources; it enables the stimulation of several muscle groups in each season and the application of different loads, and allows results to be obtained in a short period of time [12]. In this regard, recent studies indicate that children and adolescents could benefit from this type of training program in a school context [2-30]. A recent study [7] showed significant improvements in all investigated physical capacities after the application of this type of program. Efficiency was demonstrated even in a short period, and these conclusions have been corroborated by a previous investigation [29]. Another study [2] also found improvements in the physical fitness of the students, although the program application time was different. Emphasizing these results [11] considered that physical fitness is an important health marker that should be monitored from a young age and be assessed through aptitude tests, which are easy to apply, do not require many resources, and enable an evaluation in little time, therefore offering an excellent alternative for schools in symbiosis with the training programs mentioned above [36] mentioned the importance of physical education teachers using this type of test, given that, in addition to being a vehicle for promoting physical activity, it also detects certain health problems. Based on the evidence that indicates that physical fitness has a fundamental role in our society and health, at any age [34] as well as the indicators pointed out by some studies regarding the relevance of the application of programs of training in the school context, it is important to consolidate this idea and continue to investigate the effects of the application of training programs in the school context, in order to analyze the potential of application to the alternative development of students’ physical condition in physical education classes. Despite the variability of studies on this subject, which emphasize the improvements resulting from the application of various training programs, there is still no consensus regarding the characteristics they should have, namely with regard to their duration, intensity, type of training, exercise, and ideal application time. Thus, the objective of this study was to analyze the effect of a training circuit, applied for 3 weeks, at the beginning of each physical education class, and to verify the resulting effects on the analyzed variables. As a study hypothesis, it was considered that the varied program may have positive effects on the physical condition of the participants across determined variables, including the horizontal thrust, reciprocating, abdominals, and push-ups.

Methods

Participants

A group of 25 students belonging to a Portuguese school-mean age (15.67 ± 1.02), weight (67.31 ± 9.29 kg), height (1.72 ± 0.08 m) and index of body mass (BMI) (22.50 ± 2.65%)-participated in the study. None of the participants had regular strength training habits. Before the study began, students underwent a physical examination by a doctor, and each was considered free from any disorder that would prevent full participation in the investigation. All participants and the teacher were fully informed verbally and in writing about the nature of the study. As for the nature and requirements of the study, as well as the known health risks, the participants filled out a questionnaire about their health history and were informed that they could withdraw from the study at any time. All guardians provided their consent through informed consent, attesting to their children’s voluntary participation in the study. The study was approved by the school’s Ethical Advisory Committee and conducted in accordance with the Declaration of Helsinki.

Experimental Design This study aimed to verify the effects of applying a circuit training program during the warm-up phase of practical physical education classes on specific physical fitness variables (i.e., the shuttle test, sit-up test, push-up test, and horizontal impulse test). A varied circuit training program was applied, with the aim of stimulating increments in four indicators of physical fitness (i.e., shuttle, horizontal thrust, extension of arms, and abdominals). These were evaluated at two different points: before the start of the training program (pre-test) (T1) and after applying the training program (post-test) (T2). The training program lasted for 3 weeks and was run during the academic year, between February and March, during the warm-up period of physical education classes. In addition, on a weekly timetable of 3 hours per week, divided into 2 classes of 1h 30m, the students took part in a training program that included exercises lasting 15 minutes. All experimental procedures were performed in coordination with the teachers and, therefore, did not cause any change in the individuals’ routine. Pre and posttests were carried out in the internal space to eliminate the effect of climatic conditions on the results. These tests were chosen because they could be applied quickly and because they did not influence the normal course of activities in the classroom.Procedures

Four specific variables were analyzed with adaptations to previously used protocols: the shuttle test [14], sit-up test [9], pushup test [4], and horizontal impulse test [31]. These were evaluated in 2 distinct phases: before the application of the training program (i.e. pre-test) and after the application of the training program (i.e. post-test). The values for each test were recorded for subsequent analysis. The anthropometric variables of height and body mass were measured for each subject, on a levelled platform scale (Año Sayol, Barcelona, Spain), with an accuracy of 0.001 m and 0.01 kg, respectively.

Training Program

The training program was applied twice a week for a total of 3 weeks. The program had a weekly increment of one repetition. The exercises applied contained strength exercises: burpees, jumping together, squats, sit-ups, push-ups, and countermovement jumps. The program was also composed of sprints, with changes in direction (5 m) and speed (20 m), as shown in Table 1, and were performed according to the protocol described in Figure 1 [15].

Statistical Analysis

The calculation of means, standard deviations, and 95% confidence intervals (95% CI) was performed using standardized statistical methods. The normality of the distribution was examined using the Shapiro-Wilk test (n <30) and, depending on the existence of normality, parametric or nonparametric tests were adopted for data analysis. To compare the physiological variables at rest in the two assessment sessions and to compare the responses to the exercises, the paired T-test and the non-parametric correspondent, the Wilcoxin test, were used. The level of statistical significance was found to be p≤0.05. The effect size (TDE), with a 90% CI, was calculated using the Hedge’s g formula, as it produces more reliable results when n <20 [20]. To classify the TDE, a modified classification system was used (trivial: 0.0–0.2; small: 0.2–0.6; moderate: 0.6–1.2; large: 1.2–2 , 0; very large:> 2.0; extremely large:> 4.0) (Hopkins et al., 2009). Percentage variations between the initial evaluation (pre) and the evaluation after the academic period (post) [(posttraining - pre-training) / pre-training) x100] were also calculated and considered statistically significant when 95% of the difference confidence did not include the zero value.

Results

The two moments of evaluation were analyzed and paired, as shown in Table 2 (pre- vs post-training test). The results showed that there were no statistically significant differences (p> 0.05) for the push-up test, sit-up test, and horizontal impulse test (p = 0.085; p = 1.0; p = 0.052) respectively. Regarding the effect size, the results showed a small effect for the push-up test (d = 0.18) a moderate effect for the sit-up test (d = 0.9), and a trivial effect for the horizontal push test (d = 0). With regard to the shuttle test, there were statistically significant differences between the 2 evaluation moments (p <0.05) with a small effect size (d = 0.25). The difference between the pre and post-workout for the push-up test was 6.60%, whereas for the sit-up test it was 4.27%; the shuttle test, however, had a variation of 7.26%, whereas for the horizontal impulse it was 0%.

Table 2: Comparison between Pre- and Post-test Training.

Discussion

Go to

This study aimed to analyze the effects of applying a training circuit on the physical condition of a school community. This circuit consisted of exercises such as burpees, sit-ups, squats, sprints, pushups, and changes in direction. The findings indicate that it induced positive effects in the optimization of aerobic fitness. The results of this study demonstrate that the training program has a positive effect for the shuttle test only. The shuttle test variable was the only one that showed significant differences after the application of a training circuit in the school context, manifesting changes between the pre-and the post-test, which contradicts previous studies [27- 29]. In this regard, another study [2] also found improvements in the performance of the shuttle test, concluding that circuit training could be an effective way to develop resilience in school. In fact, these results contradict a previous investigation [23], where benefits resulting from the application of training circuits were evidenced, such as an increase in muscular strength and muscular endurance capacity as well as a reduction in the risk of occurrences of injuries during the practice of physical and recreational activities. The analysis of the push-up variable showed that there were no significant changes, probably due to the limited time of application of the circuit, although there was a slight variation between the pretraining and post-training moments. In addition, previous studies have shown that push-up tests are those with the highest failure rates [6-41]. Regarding the horizontal impulse test, it was found that the present study contradicts the data found in previous investigations [8], as there were no significant changes. However, it was expected that there would be an improvement in the results based on the regular use of the muscles of the lower limbs during the daily activities [2]. Other investigations that evaluated the horizontal impulse [38,39] found average values of 177.89 cm after application of the training program, whereas the results of this study show average values of 196.6 cm, a much higher value that may be related to the height of the participants, based on the strong correlation between height and the force of the impulse [38]. The lack of evolution in this variable may also be related to the fact that the students have not assimilated the correct mechanics of the exercises and, therefore, there may be a deficiency in the technique that will not translate into exercise efficiency [44]. Likewise, there were also no significant differences between the moments of analysis (i.e., pre-workout and post-workout) in the sit-up test. In this regard, other investigations that have investigated this variable [13-33] obtained mean values of 35.6 cm, but the current investigation obtained a considerably higher value (i.e., 46.8 cm); in fact, this result may be related to the practice of physical activity outside the school context, which was previously considered decisive for the test result [26]. A study of characteristics similar to ours [25] found significant differences in the variables considered after the application of the training program, which consisted of a training circuit applied weekly, where the degree of difficulty of the exercises increased each week. The fact that the training program had a significant effect only on the variable of aerobic fitness may also be due to the fact that the students do not yet have an established action plan. In other words, the action scheme is enhanced and developed using repeated action, which occurs in all sports movements. This same scheme is kept in memory and can be evoked later. In this specific case, students had little time to assimilate the circuit diagram, which helps to justify the results found. It is also important to note that comparison with other investigations becomes a little reductive due to the methodological differences verified between the studies, such as circuit duration, distinct and adapted circuits, and the sample size, as well as their characteristics.

Conclusion

Go to

This investigation aimed to investigate the effects of the application of a training program in circuit format in the initial part of physical education classes, and to verify its impact on physical fitness variables in students aged between 15 and 18. After 3 weeks of application of the training circuit, the results indicate that despite the short time of exercise applied, significant improvements were obtained in the variable of aerobic fitness (the shuttle test). However, and most likely due to the short period of application of the training program, the remaining analyzed variables did not show statistically significant differences, which also allows for the possibility that if the training program was applied over a longer period, the results of the analyzed variables could show a significant increase. Nevertheless, it appears that the development of similar programs in the school context and during the teaching of teaching units may be beneficial for students in terms of improving their physical fitness and implementing training habits, as well as regular and healthy lifestyles. This investigation also presents a different proposal for the initial part of the physical education class that may be more motivating for the student, in addition to guaranteeing a different practical utility in relation to the time traditionally dedicated to warming up. With regard to study limitations, the fact that only one female member participated in the investigation prevented the results from being compared between genders, which would have been an interesting and enriching route for the study and is therefore recommended for further research. Finally, food and sleep hours were not controlled during pre-training and post-training and are variables that can affect students’ performance.

Disclosure Statement

The authors declare that there are no conflicts of interest.

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Lupine Publishers | Locked Bridge Plating is a Suitable Option for Forearm Fractures Secondary to Civilian Low Velocity Gunshot Injuries

Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Introduction: The purpose of this retrospective study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods: A 10 year IRB approved retrospective review of our national trauma database was conducted. Initial treatment consisted of wound care and sterile dressing. Forearm radiographs were acquired to determine bony involvement. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. Patients were placed into two categories of operative or nonoperative treatment. Those placed into operative treatment were further divided into the subcategories of formal debridement and plating or minimal debridement and plating.

Results: 94 patients were included in the study. 29 were treated nonoperatively and 65 were treated operatively. Of those 65, 30 underwent minimal debridement and bridge plating and 35 were treated with formal debridement and bridge plating. All patient radiographs displayed fracture healing at latest follow-up with no evidence of infection or osteomyelitis. Nerve injuries were found among 15 patients and vascular injuries were present in 7.

Conclusions: Both methods of irrigation and debridement resulted in reliable osseous union with no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

Keywords: Irrigation; Debridement; Forearm; Gunshot; Fracture; Minimal

Introduction

There are 300,000 injuries and 30,000 hospitalizations from gunshot wounds annually in the United States [1-3] primarily from low-velocity handguns. These weapons produce less soft-tissue injury than high-velocity rifles or shotguns attributed to lower mass, velocity and energy transfer of the projectiles to surrounding tissues [4, 5]. Gunshot wounds of the forearm have been reported in several small series in the literature; however, no treatment guidelines backed by adequate scientific evidence exist. Prior studies with limited numbers have recommended debridement irrigation, antibiotics and compression plating for displaced fractures of one or both bones, and immobilization for undisplaced simple fractures of single bones. We feel that aggressive debridement and conventional compression plating may not be practical for these injuries which often have boney comminution but minimal soft tissue injury. A potential alternative is limited debridement and bridge plating. The purpose of this study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods

An IRB approved 10-year retrospective review of our hospital trauma database revealed one-hundred and one patient admitted to the hospital with forearm fractures following gunshot wound (2000-2010). Seven patients were excluded from the study as their injuries were the result of a high-velocity firearm, leaving ninety-four patients treated for gunshot wounds of the forearm with hospitalization. Patients who were discharged from the emergency room with gunshot wounds with or without fractures and patients who left the hospital against medical advice prior to treatment were not captured in this database. There were eightythree males and eleven females. The average age was 27.7 years with a range of 16-52 years. The average duration of follow-up of all patients was 27.3 months with a range of 9 to 105 months. Treatment was initiated with wound care by applying a sterile dressing in the emergency department. Forearm radiographs were acquired to determine bony involvement. Clinical suspicion of limb ischemia by physical exam was an indication for angiography. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. The initial antibiotic selected was cefazolin with or without gentamicin, and some patients with concomitant thoracic or abdominal injuries received additional antibiotics for greater time periods. Patients with non-displaced or minimally displaced fractures were treated non-operatively with local wound care, antibiotics, and casting. Displaced fractures were divided into 2 groups. During the first 5 years 35 patients underwent aggressive debridement and irrigation of wounds, fracture stabilization using compression plating techniques when feasible and bridge plating when there was bone loss. Antibiotic cement spacers were placed where there was bone loss followed by delayed grafting using iliac crest bone. Eight were stabilized with initial external fixation followed by plating and 27 had immediate plate fixation. The second 5 years included 30 patients treated with open reduction and internal fixation (ORIF) with a bridge plating technique, limited irrigation and debridement of entry and exit wounds locally at the level of skin and subcutaneous tissue without debridement of bone. This was intended to minimize soft tissue stripping around the fracture site. Bullet fragments were not disturbed unless they were superficial and easily removed without further damaging the surrounding soft tissues. Entrance and exit wounds were not closed primarily. Patients with non-displaced or minimally displaced fractures (29) were treated non-operatively with local wound care, antibiotics and casting. These were often admitted for concomitant injuries and thus were picked up in our database. We reviewed all radiographic images obtained at presentation and during treatment. Fractures were classified as radius, ulna or both (Figure 1). The fracture location was noted whether they were proximal, midshaft or distal and if they were non-displaced or minimally displaced versus comminuted and displaced. Radiographic data were used to determine the status of fracture healing or hardware failure. Patients were examined in the clinic (Figure 2) to assess for fracture healing, infection, presence of deformity, sensory or motor deficits, and range of motion. Range of motion was classified as good (<10 degrees flexion extension loss and <25 degree pronation/ supination loss), satisfactory (<30 degree flexion extension loss and <50 degree pronation/supination loss) or poor (>30 degree flexion extension loss or >50 degree pronation/supination loss).

Results

Operative Treatment

Sixty-five patients were treated operatively. Thirty patients underwent bridge plating and minimal debridement of the gunshot wounds without excision of only frankly necrotic tissue and minimal to no bone debridement and no bone grafting (Figure 3). Thirtyfive patients were treated with formal irrigation and debridement of the wounds and stabilization (Figure 4). Of the thirty patients with bridge plating and limited debridement twenty-nine patients displayed fracture healing at their latest follow up and one patient required revision surgery for delayed union. There were no signs of infection or osteomyelitis at final follow up. Of the thirty-five patients treated with more aggressive irrigation and debridement with fracture stabilization, seven patients were determined to have more extensive soft tissue injury requiring multiple surgeries and more aggressive debridement and eventual soft tissue coverage. Five of these seven required early bone grafting after original damage control surgery and prior to soft tissue reconstruction. All patients displayed radiologic evidence of healing at their latest follow up with no patient showing signs of infection or osteomyelitis.

Non-Operative Treatment

Twenty nine patients were treated non-operatively with local wound care and casting for forearm fractures. All patients had a single bone non-displaced or minimally displaced fracture. All patients displayed radiographic evidence of fracture healing at their latest follow up with no patient showing signs of infection or osteomyelitis. Range of motion in this subset was determined to be satisfactory or good at final follow up.

Nerve Injuries

There were fifteen patients with an associated nerve injury. The ulnar and median nerve were the most common nerves injured (six patients each) followed by the radial nerve in four patients and the palmar cutaneous nerve and anterior interosseous nerves in one patient each. Three patients had multiple nerve injuries. In seven patients the nerve injury resolved completely and in five patients a partial nerve deficit was observed. Three patients showed no recovery with one patient displaying a classical ulnar claw hand deformity.

Vascular Injury

Seven patients presented with signs of associated vascular injury of the forearm. There were four radial artery injuries and four ulnar artery injuries. One patient had both arteries injured and repaired. All patients had a viable limb on follow up. Three patients had nerve injury associated with vascular injury. One patient developed a compartment syndrome requiring fasciotomy.

Discussion

Early stabilization of forearm fractures is important after a gunshot injury and the management of the open wound and soft tissue injury is always an important consideration for surgical planning. In this study, we showed that minimal irrigation and debridement of the entrance and exit wounds is adequate for low velocity gunshot injuries to the forearm with minor visible soft tissue injury, and that bridge plating with minimal surgical dissection through the zone of injury is sufficient to achieve reliable union of these fractures. Dicpinigaitis, et al. showed that most non-displaced fractures of the radius or ulna can be effectively managed with casting al in their review of the literature addressing gunshot wounds to the extremities, but displaced fractures should be treated operatively with compression plating [4]. reported superior results in patients treated with delayed primary ORIF with displaced forearm fractures secondary to gunshot wounds [12]. In the same study, no patients treated by delayed ORIF went on to melanin or delayed union, but all patients did have decreased range-of-motion, particularly pronation and supination. Rodrigues, et al. recommended a treatment protocol involving early wound care and provisional stabilization followed by definitive treatment with internal fixation within one week [18-20]. In our review, thirty five patients were successfully treated with a more extensive soft tissue debridement with fracture stabilization, and thirty patients with comminuted and displaced fractures were effectively treated with local wound care followed by internal fixation with bridge plating. Several studies have also examined the effectiveness of nonsurgical treatment in non-displaced or minimally displaced forearm fractures resulting from low-velocity firearms. Elstrom, et al. reported on fourteen patients that were treated with casting [12]. In eight non-displaced single bone fractures, seven had good outcomes. In six displaced fractures, closed reduction and casting lead to poor outcomes in four patients. Lenihan ,et al. reported on thirty-seven patients with civilian gunshot wounds to the radius and ulna [13]. Twenty-three patients with non-displaced fractures were treated by closed means with twenty-one showing good outcomes. However, in the fourteen patients with displaced fractures, the outcomes of the eight patients who had closed reduction were worse than the six patients treated surgically. Dickson, et al. prospectively evaluated patients with non-displaced fractures treated as outpatients with closed reduction and casting [3]. Only one patient in their study went on to delayed union [3]. also reported excellent results in patients of non-displaced fractures treated with closed reduction in a long arm cast, with seven of eight patients showing evidence of fracture healing and good functional outcome. The same study reported that four out of six patients with comminuted and displaced fractures treated with casting went on to malunion or delayed union resulting in a poor functional outcome. The authors concluded that closed reduction has satisfactory results in non-displaced fractures while displaced fractures require internal fixation to achieve superior outcomes. In our retrospective review we found similar results and agree that patients with minimally displaced or non-displaced extra-articular fractures can be adequately treated with closed reduction and casting without surgical debridement. We add to these findings that extensive surgical debridement can also be withheld with low risk of infection or nonunion after bridge plating for fracture stabilization. Past studies have shown that bullets are not sterilized during discharge of the weapon and may act as a vector introducing pathogenic bacteria into the wound4. Controversy exists, however, as to the necessity of administering prophylactic antibiotics to this patient population. Patzakis, et al. demonstrated an infection rate of 13.9% in patients with open fractures resulting from gunshot wounds not treated with antibiotics and an infection rate of 2.3% in patients treated with cephalothin [7]. The study also showed no statistically significant difference in infection rate between the control group (13.9%) and a group treated with penicillin and streptomycin (9.7%) [7]. Conversely investigated the efficacy of antibiotics in a similar patient population and showed no significant difference in infection rate between the control group and the experimental group treated with at least twenty-four hours of intravenous cefazolin [2]. concluded in a prospective study that short-term intravenous antibiotics did not decrease the risk of infection [9]. recommended the use of prophylactic antibiotics in high-velocity and intra-articular injuries but did not support the use of prophylactic antibiotics for low-velocity injuries [10]. Howland and Ritchey in a retrospective analysis concluded that prophylactic antibiotics were unnecessary in the treatment of lowvelocity gunshot fractures [11-20]. In our study, all patients were treated with intravenous first generation cephalosporin antibiotics, and in some cases additional antibiotics to treat other concurrent injuries. As no patient in our review developed osteomyelitis even with a large subset undergoing limited debridement, we support the use of a first-generation cephalosporin for 48 hours in patients reporting with open forearm fractures secondary to low-velocity gunshot wounds. We recognize the following limitations of our study. First, it is retrospective in nature and carries all the associated risks of bias. It is additionally possibly biased towards more severe injuries since all included patients were admitted for at least 48 hours. Patients with minor gunshot forearm injuries and treated as outpatients had variable antibiotic regimens or no antibiotics and were not captured in this database. Thirdly, the patient population of this study is small, although it is larger than previously published studies. Furthermore, we had difficulty in contacting patients in our study for longer term follow up.

Conclusion

Forearm fractures caused by low velocity gunshot wounds in a civilian setting are often comminuted single bone injuries with minor soft tissue injury. Both the aggressive and limited debridement regimens resulted in reliable osseous union and no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

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Lupine Publishers | A literature review of the treatment options for Idiopathic Adhesive Capsulitis of the Shoulder

Orthopedics and Sports Medicine Open Access Journal (OSMOAJ) Abstract

Goal: Systematic review of current therapeutic options for Idiopathic Adhesive Capsulitis of the shoulder (IAC).Materials and Methods: Research carried out in the MEDLINE / Pubmed database using MeshTerms: “adhesive capsulitis”, “frozen shoulder”, “treatment”. The articles in Portuguese or English published were selected, after which non-relevant articles were excluded based on the title, reading of the abstract and full article.Results: Physical therapy has proven to be beneficial, either isolated or concomitantly with other therapeutic approaches. Options like capsular distention, manipulation under anesthesia and arthroscopic surgery have reported good results, especially in refractory cases. No significant benefits were found with the use of oral corticosteroids, NSAIDs or acupuncture. New treatment options are currently being tested with promising results.Conclusions: There are several effective options for the treatment of Adhesive Capsulitis. In the early stages, conservative measures should be chosen, with special emphasis on physical therapy within the limits of pain associated with low-dose intraarticular injection of corticosteroids. In refractory cases, more invasive treatment options should be suggested namely capsular distension and manipulation under anesthesia.Keywords: Adhesive Capsulitis; Frozen Shoulder; Diagnosis; TreatmentIntroductionGo toAdhesive capsulitis is a pathology characterized by a spontaneous onset of insidious and diffuse pain in the shoulder associated with progressive restriction of active and passive motion of the glenohumeral joint [1]. Almost 150 years after its first description, it remains an uncertain entity. The proper terminology, used for the first time in 1945, is also controversial, since this condition is related to the contraction and thickening of the glenohumeral capsule, in particular the coracohumeral ligament in the rotator’s interval [1, 2]. The disease is classified as primary and secondary. The primary entity has an unknown etiology and will be addressed in this review [3]. Secondary adhesive capsulitis is caused by an event or triggering condition such as trauma, surgery or a systemic condition such as diabetes mellitus, thyroid abnormalities, etc. [2]. Diabetes mellitus has the most established connection, with an estimated incidence of adhesive capsulitis in 20% of this population [4]. The prevalence of this pathology in the general population is believed to be 2-5%. However, it is believed that the true prevalence is actually inferior and difficult to determine, not only because vague and insidious symptoms lead to numerous diagnostic errors, but also because most studies include specific comorbidities with a greater incidence of IAC than within the general population [2, 3, 5, 6]. This pathology occurs mainly between the 4th and 6th decade of life and is thought to be more frequent in women [7]. Some argue that it affects the non-dominant side more often and that in about 20-30% of cases it recurs on the contralateral shoulder, usually in the first 5 years after the resolution of the primary condition [1, 3, 7-10]. Although considered a benign condition, with a self-limiting pattern and resolution within 2 to 3 years, it is estimated that 20-50% of the cases continue with mild to moderate pain and restricted movement over a period of up to 10 years [4, 11]. The etiology of adhesive capsulitis also remains uncertain and theories vary. However, the evidence points to a chronic inflammatory response with subsequent capsular fibrosis that possibly involves increased deposition of cytokines such as TGF-β, PDGF, TNF-α and IL-1 [1-3, 7]. There are also studies that advocate an association with Dupuytren’s contracture that may involve the same abnormalities. The changes found include: contraction and fibrosis of the coracohumeral ligament, thickening and fibrosis of the rotator’s interval, contraction of the anterior and inferior capsule, decrease in joint volume, obliteration of the axillary recess and neovascularization [2, 3]. The evolution of this pathology can be divided into three phases. The acute initial phase (freezing phase) is characterized by the insidious appearance of diffuse pain and restriction of the range of motion of the glenohumeral joint, which lasts for about 10 to 36 weeks (Figure1). In the second phase (frozen phase), for about 4 to 12 months, the pain slightly decreases but the movement restriction continues, with almost total loss of external rotation. In the resolution phase (thawing phase) there is spontaneous progressive improvement in the range of motion and resolution of pain. This last phase has an average duration of 30 months (12 to 42 months) [3, 6-8]. Numerous studies have attempted to determine which treatment is the most effective for adhesive capsulitis. However, currently, despite the various options, there is still no consensus among the authors regarding the most advantageous treatment and at what stages of the disease it should be performed [4, 12, 13]. Most of the evidence is inconclusive due to the precarious methodology of the studies [14].

Diagnosis

There is no standard diagnostic method for this condition, which is based on clinical examination, exclusion of differential diagnosis, normal radiographic appearance and findings on ultrasound, magnetic resonance imaging (MRI) and arthrographic magnetic resonance imaging (arthroMRI) [2, 15]. The early diagnosis of adhesive capsulitis is extremely important since it allows the institution of therapy before the progression of thickening and contracture of the capsule observed in advanced stages [15]. Clinically, an insidious diffuse pain with at least four weeks that interferes with the activities of daily life should be investigated. Night pain is also common, with the patient complaining of more severe pain while sleeping on the affected side. Painful restriction of active and passive motion of the glenohumeral joint is also frequent, with special emphasis on external rotation (more than 50% of restriction) and elevation (less than 100ᴼ) [1, 3]. Radiographs do not normally show any changes, except for a slight periarticular osteopenia of the humeral head and neck, which can occasionally be found [1, 3, 7,15]. The most important role of radiography is the possibility of ruling out other pathologies such as calcifying tendinitis of the rotator cuff, osteoarthritis, avascular necrosis or fractures that can also cause painful movement restriction and be misdiagnosed as adhesive capsulitis [15, 16]. For a more accurate diagnosis, ultrasound, MRI or ArtroRM are usually necessary [15]. With the use of ultrasound, the diagnosis can be suspected by a thickening of the structures in the rotator’s interval, namely of the coracoumeral ligament, and restriction of the motion of the supraspinatus tendon during abduction. With echodoppler, synovial inflammation can be readily detected (Figure 2), which has advantages when compared with MRI and ArtroMRI since it is less expensive, faster, more dynamic and easily accessible [2, 3, 15]. MRI is an effective non-invasive diagnostic tool, not only for cases where this condition is suspected, but also provides information that can help the surgeon differentiate between the different stages of the disease [3,15,17]. Although it is not diagnostic, some argue that the degree of capsular thickening, measured in the axillary recess, can be correlated with the clinical stage of adhesive capsulitis [16]. Among other findings, several characteristics of this condition can be seen: thickening of the coracohumeral and capsular ligament in the rotator’s interval and axillary recess (greater than 4 mm) and obliteration of the subcoracoid space by the thickened capsule (Figure 3). Thus, MRI allows for early diagnosis, determining the pathophysiological stage and ruling out differential diagnosis [15]. ArtroMRI allows for visualization of basic disease characteristics, namely the thickening of the coracohumeral ligament and the capsule, possibly with greater precision than the MRI, but also to detect decreased joint volume [1,3,15]. However, some claim that both MRI and ArtroMRI, despite the useful findings, are not indicated as a means of diagnosis for adhesive capsulitis and should only be used as a method of excluding other intra-articular pathologies [3]. TreatmentA great variety of therapeutic options are available for the treatment of adhesive capsulitis. During the early stages, where pain predominates, treatment should be directed towards pain relief and patients should be advised to limit activities according to their tolerance [7]. The secondary objective is to improve the range of motion [4] and restore the ability to perform the daily activities.Conservative TreatmentConservative treatment, such as physical therapy, is recommended in the freezing phase [4, 6]. Most patients will recover with this initial management [16, 18, 63]. The conservative approach has a wide range of modalities, with well documented results.PhysiotherapyIsolated physiotherapy is a widely accepted treatment option, which can also be used as a complement to other therapeutic modalities [1, 3], with some reports considering it to be crucial for success [4]. Currently, various techniques are used, such as the application of moist heat, strengthening exercises, stretching and manual exercises [7, 19, 20]. Several studies have compared these modalities with different conclusions, making it difficult to determine which is the most beneficial [4, 9,20]. Most studies in which comparisons were made between two interventions did not detect significant differences between the techniques [21]. In several investigations, the techniques of high and low grade glenohumeral mobilization were compared, with significant improvement after 12 months for both approaches. Some authors concluded that the intensive approach was significantly more effective in restoring mobility and reducing disability [20-22]. In contrast, others argue that the amount of force applied should be adjusted to the patient’s condition, limited to their tolerance, because if excessive force is applied, it can produce extreme pain, periarticular injury or abandonment of treatment, thus, one should opt for prolonged progressive low-load stretches, a method considered safe and effective [7, 9, 23]. In a study with level I evidence, the effectiveness of three different physical therapy modalities was compared: group physiotherapy, individual physiotherapy and home exercise program. Not only was there a greater degree of symptomatic improvement in the shoulder, but also better anxiety control with group physiotherapy. There were also benefits in relation to costeffect and self-management in this group. However, standard physical therapy remains a good alternative and has been shown to be significantly better than unsupervised home exercises [6]. In another study with level II evidence in which regular physical therapy was compared with a new contraction technique, the new approach demonstrated greater recovery of the function of the glenohumeral joint when compared to the group of normal physical therapy. However, further studies are needed to validate this conclusion [24]. Some authors advise a Multimodal Care program that includes mobilization, shoulder orthoses and stretches with strengthening exercises, which appears to be beneficial for symptomatic relief, although the evidence seems limited [25, 26]. Horst, et al. compared structural-oriented (conventional) physical therapy with an activity-oriented physiotherapeutic treatment, concluding that therapy based on performing activities appears to be more effective for pain reduction and the ability to perform daily life activities than conventional treatment methods [64]. When compared to ad initium arthroscopy, physical therapy produces similar results, but without surgical aggression and with a better cost-benefit ratio [27]. Lamplot, et al. in a level III cohort study [57] found a decrease in the need of a second intra-articular injection in the patients who underwent physical therapy following the first injection, underlining the major role of physiotherapy in the treatment of IAC. Intra-Articular Injection of CorticosteroidsCorticosteroids have been administered to the glenohumeral joint in several ways, namely anterior, lateral and / or posterior approach [4, 28]. Although clinically it is common practice to use an injection via an anterior or posterior approach, studies comparing different techniques have not found significant differences in the improvement of pain or range of motion [11, 29]. Cho, et al. [60] in a randomized trial study found that the efficacy of corticosteroid injection into the subacromial space in IAC was inferior to intraarticular injection up to 12 weeks. However, a combination of injection sites had an additive effect on the benefits in the internal rotation angle There is no agreement regarding the optimal dose of intra-articular corticosteroids. Yoon et al. did not detect a significant difference between the low (20 mg) or high (40 mg) dose groups, indicating, due to its side effects, the preferential use of low dose corticosteroids for the treatment of adhesive capsulitis [30]. A limitation of the use of intra-articular corticosteroids is the fact that blind injections can be inaccurate in about 60% of cases. The current use of ultrasound or fluoroscopy-guided injection can overcome this problem [8, 16]. It has been shown in several studies that this practice improves accuracy and results compared to the “blind-technique” [3, 31]. There is evidence that the initial corticosteroid injection can reduce pain and improve range of motion in the short term and that its benefit can be increased in the short and medium term when these injections are followed by physical therapy [11, 21, 57]. Kraal et al. in a two center, randomized controlled trial, found that additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage IAC up to the first three months, underlining the good results of these techniques combined [61]. When compared as isolated treatments, there is strong evidence in benefit of corticosteroid injection in the short term (4-6 weeks), compared to isolated physical therapy, but not in the long term [11, 22, 30, 32, 33]. In a study that compared the injection of corticosteroids and the benefit of isolated intra-articular analgesics, significant improvements were found with the administration of corticosteroids [22]. Hettrich et al. showed that corticosteroid injections decreased fibromatosis and myofibroblasts in the shoulders with IAC [58]. On the other hand, some studies conclude that this form of treatment has results similar to isolated physical therapy or more invasive treatments such as MUA and arthroscopy [29, 32, 34], confirming the high degree of controversy surrounding this disease.Echography-Guided Capsular DistensionUltrasound-guided interventions have several strong points like the lack of radiation and the possibility of real time visualization of the needle’s trajectory. This technique has advantages when compared to fluoroscopy, CT and MRI since these are less practical, more time consuming and involve radiation or a specific needle [35]. One of the modalities of capsular distention is based on the use of hyaluronic acid. The ideal time between injections is one week and the effects are usually seen after the second injection [36]. In a study comparing this approach with the injection of corticosteroids, it was found to be more effective in favor of distension with hyaluronic acid in passive external rotation (10ᴼ) at 2 and 6 weeks, with no significant differences in pain relief or in function recovery. This study also concluded that this approach is a good alternative to intra-articular injection of corticosteroids and can be especially useful in patients with diabetes mellitus or contraindicated to the use of corticosteroids [37]. Calis et. al. also concluded that this approach is effective in the treatment of adhesive capsulitis when compared to isolated corticosteroid injection, physical therapy and exercise [36]. Ultrasound-guided capsular hydrodistension is a procedure that aims to distend the capsule contracted by increasing pressure by injecting large amounts of sodium chloride into the glenohumeral joint [9]. There is evidence that it provides relief from pain and improves range of motion, especially when it is followed by physical therapy [29, 38]. Other studies have found that saline distension with or without concomitant corticosteroids are more effective than MUA, describing better results after 6 months with this procedure, with less risk, and resulting in a higher level of satisfaction on the part of patients. However, the effects do not seem to persist beyond 6-12 weeks [9, 29, 39, 40].Artrographic Capsular DistensionThis technique can be performed with sodium chloride, local anesthetic, steroids, contrast or air. It should be reserved for patients who do not improve despite physical therapy [22]. It is also considered a good therapeutic option for rapid symptom relief. Better results were observed when followed by physical therapy [38]. There was no significant difference in the efficacy of capsular distention with or without corticosteroids in most investigations [39, 41]. However, Rysns et al. when comparing distension with corticosteroid injection with placebo saline injection to determine whether the results were due only to the increase in volume, found a significant improvement with the concomitant use of corticosteroids [32].Extracorporeal Shockwave TherapyThe use of Extracorporeal Shock Wave Therapy (ESWT) in the treatment of several shoulder diseases, namely in calcific tendinopathy of the rotators cuff, is well documented. Several studies evaluate its usefulness in IAC, with positive effects such as a quicker return to daily activities and quality-of-life improvement [66, 67], at least in the short-term. El Naggar, et al. compared the effectiveness of radial extracorporeal shock-wave therapy versus ultrasound-guided low-dose intra-articular steroid injection in in diabetic patients, concluding that in the short-term follow-up ESWT was superior to a low-dose intra-articular steroid injection in improving function and pain in diabetic patients with shoulder IAC [68], therefore validating it as an alternative to steroid injections in diabetic patients with this pathology. This particular usefulness of ESWT in diabetic patients has also been documented in other studies [69, 70]. Many prospective randomized trials are underway to further validate ESWT as a treatment option in IAC, especially in the diabetic population.OtherOral non-steroidal anti-inflammatory drugs, although widely used in the initial / inflammatory phases for pain relief in the short term, did not prove their benefit when compared with placebo [3, 7, 9]. Prednisone at a dose of 40 to 60 mg / day for two to three weeks provides faster relief of symptoms in the short term, but their effects are not significant after 6 weeks and there is no evidence that they shorten the duration of disease [28]. Some studies have concluded that there may be a moderate short-term benefit with acupuncture associated with exercise [22], however the usefulness of this therapeutic approach remains undetermined [21]. Calcitonin is a polypeptide hormone secreted from parafollicular cells of the thyroid that has been used for pain control in several pathologies. Although its pathophysiology is not totally clear, it is thought to diminish the inflammatory response and increase endorphins’ release [71, 72]. Rouhani, et al. in a double-blinded randomized controlled trial compared intranasal calcitonin versus placebo for 6 weeks and found great improvement of shoulder pain, ROM, and functional scores in the calcitonin group [71]. Currently the dose recommendation is 200 U (1 puff) daily [73]. Regarding future approaches, Badalamente, et al. [53, 54] published two papers evaluating the applicability of extra-articular collagenase injections in the anterior shoulder capsule. In a placebo controlled doubleblind RCT, they found improvements in shoulder motion, functional score and pain control in the collagenase group in their 1.8 years follow up. In a randomized pilot study comparing subcutaneous adalimumab with local corticosteroids, Schydlowsky et al. found no benefits with the anti-TNF agent in the treatment of frozen shoulder [55] These new treatment approaches for IAC must undergo further investigation, but, if developed, could also play a role in the management of other arthrofibrosis [56].Surgical TreatmentSurgical treatment of adhesive capsulitis is considered after failure of conservative treatment. It is estimated that 10% of patients do not respond to non-invasive treatment [25, 26]. There are no defined guidelines for this transition. However, regardless of the chosen conservative treatment, a surgical approach is only considered after about 6 months of non-surgical treatment without clinical improvement [3, 4, 8, 12, 16, 42]. Its benefit in refractory / severe adhesive capsulitis is proven and well documented [43], and some studies have found that in patients with high risk factors such as diabetes mellitus, and those who suffer chronic symptoms or bilaterally affected, early surgery is beneficial [65]. In a recent questionnaire to health professionals, only 3% recommended surgical treatment in the acute phase, while 47% recommended it in the second and third stages of the disease [4]. Surgical treatments should be complemented with an appropriate physical therapy scheme [63]. Some advocate the initiation of immediate postoperative physiotherapy, with light isometric exercises after 1-2 weeks and isotonic exercises in the following 2-3 weeks. Ideally the range of motion without complete restriction should be achieved in 12 to 16 weeks [4].Manipulation Under AnesthesiaThis procedure involves stabilizing the shoulder blade with flexion, abduction and adduction, followed by maximum internal and external rotation. Some studies advocate good results with this technique, mainly in terms of range of motion [44], others have not found significant differences in comparison with other treatments [45]. There is modest evidence of the benefit of MSA in relieving pain and recovering mobility when followed by physical therapy [46]. However, some authors have not found significant differences in the improvement of pain, function, disability or range of motion in the short, medium or long term between isolated MUA and exercise-associated MUA when compared to physical therapy alone [21, 45]. When compared with arthroscopy, better results were observed with arthroscopic distention at 6 months [21]. However, more recently, Schoch et al. in a study with the largest series of patients undergoing surgical treatment of adhesive capsulitis with a direct comparison between MUA, MUA/Capsular release (CR), and CR alone, found significant improvement of the ROM in all surgical modalities, however, the MUA group had the greatest external rotation, postoperatively [59]. MUA has been associated with several intra-articular iatrogenic complications such as humeral fracture, glenohumeral dislocation, brachial plexus injury rotator cuff injury and hemarthrosis [4, 46, 47]. Nonetheless, some argue that these lesions have no clinical relevance or that they can be minimized by performing the technique properly [44, 47]. Others advise that this procedure should be avoided in patients with osteoporosis, osteopenia or previous MUA recurrence [46]. Another limitation of manipulation is the fact that stretching the tissues can cause severe pain after the end of the anesthesia effect, leading to delays in recovery [8].ArthroscopyArthroscopy allows the distension of the glenohumeral joint to be combined with a series of other procedures, such as adhesions release, opening of the rotator’s interval, circular capsulotomy and section of the coracohumeral ligament. This procedure must be followed by physiotherapy [2]. Several studies have supported the role of this approach as safe and effective in the treatment of adhesive capsulitis [27, 48, 49]. Several authors support the use of arthroscopy, claiming that, in addition to the good results obtained, it makes it possible to deepen and confirm the diagnosis by a complete assessment of the shoulder joint during the procedure [4, 8]. Some, on the contrary, argue that currently the evidence does not support the use of this technique [50], underlining the prevalent controversy in the treatment of this pathology. Recent investigations have not shown greater benefits in range of motion with more extensive release of the capsule (anterior release vs. Anterior plus posterior release) [9, 62]. Sivasubramanian et al. made a systematic review and meta-analysis which suggests that less extensive releases may result in better functional and pain scores. The addition of a posterior release appears to increase early internal rotation, but doesn’t maintain that benefit over time. No benefit was found with the complete 360 release [62]. Some authors suggest that arthroscopic distension can be associated with concomitant manipulation, with improved outcomes [8]. In a study comparing arthroscopy plus manipulation against isolated intraarticular corticosteroid injection, both approaches were effective in improving pain and range of motion. However, the objectives were achieved sooner by the group that underwent arthroscopy (6 weeks vs 12 weeks) [51]. Grant, et al. compared arthroscopic distention with MUA finding a small benefit in favor of arthroscopy alone or in association with manipulation, advising this technique due to the lower number of complications [52]. On the other hand, Jerosch et al. concluded that this therapy has a greater benefit in reducing pain and improving movement, even in the long term, being a valuable, more precise, controlled option with fewer complications than manipulation [12].Open SurgerySurgical treatments have changed from open to arthroscopic procedures and, therefore, the open technique, although effective, has fallen into disuse [4]. It is rarely used nowadays, but may be beneficial in cases refractory to MUA and arthroscopy [9].ConclusionGo toIdiopathic adhesive capsulitis is an extremely painful and limiting pathology of the shoulder, which, despite the abundant published literature, remains controversial in many aspects. Its etiology is unknown, but synovial inflammation of the glenohumeral joint and subsequent progressive capsular fibrosis is believed to occur. The correct diagnosis of this condition is a crucial step in patient orientation. Although the diagnosis is mostly clinical, ultrasound, MRI and ArtroMRI have gained increasing importance, as they more accurately allow ruling out other conditions. Despite the various therapeutic options available, there is still no global consensus among authors regarding the most appropriate approach for the treatment of IAC of the shoulder and there is a need for high-level, definitive evidence to elaborate definitive approach guidelines. Initially, conservative measures should always be chosen, with the majority of patients recovering with non-surgical treatment. There is evidence that demonstrates the effectiveness of physical therapy, being considered by many authors as an essential component of treatment. Corticosteroid injection is an effective form of treatment, especially when guided by ultrasound, with evidence of its benefit in the short, but not long term (after 6 weeks). Lower dosages have been advised in order to minimize its possible adverse effects. ESWT is gaining popularity in the treatment of diabetic and refractory cases, with many studies underway to further validate its importance. Calcitonin and collagenase are two relatively new approaches to the disease, with promising results. Ultrasound-guided capsular distention with hyaluronic acid appears to be useful in the treatment of adhesive capsulitis, being mainly suitable in patients with Diabetes Mellitus or in those with contraindications to corticosteroids. Hydrodistension is an effective method, with results similar to MUA, but with a lower rate of complications, although its effect does not seem to last beyond 6-12 weeks. Arthrographic capsular distention is considered a good option for rapid pain relief, especially in cases refractory to physical therapy. Oral corticosteroids, while providing short-term pain relief, do not appear to shorten the duration of the disease. The association of corticosteroid injection guided by ultrasound with physiotherapy, demonstrated a statistically significant improvement, being advocated by many as the ideal approach for early stages.Surgical treatment should be reserved for cases with unsatisfactory results with conservative approaches, that is, after about 6 months without clinical improvement. Regardless of the surgical therapeutic option, it should be followed by rehabilitation physiotherapy.MUA and arthroscopy are effective in the treatment of idiopathic adhesive capsulitis, especially in severe and complicated cases. MUA, although very popular in the past, has recently gained some skepticism because of the frequently associated complications. For more Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

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Lupine Publishers | Best Position and Duration for Immobilization in Primary Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Background: Anterior shoulder dislocation is the most common injury of the glenohumeral joint and primarily caused by traumatic event and shoulder instability. Recurrent dislocation of anterior shoulder dislocation is a common occasion following the primary anterior shoulder dislocation. Generally, anterior shoulder dislocations are treated with closed reduction, stages of immobilization, and series of physical exercise treatment. This systematic and meta-analysis study were conducted to consider the best duration and position of immobilization after primary anterior shoulder dislocation reduction to reduce the risk of anterior shoulder dislocation recurrence.

Methods: PubMed, Cochrane, NCBI, Elsevier were used to searched randomized controlled trials. Two reviewers selected studies for inclusion, assessed methodological quality, and extracted data. The studies were peer-reviewed by two consultant, then selected based on inclusion criteria.

Study Design: Systematic review and meta-analysis; Level of evidence, I, II.

Result: A total of seven randomized controlled trials (635 patients) included in this systematic review and meta-analysis. In these studies, the recurrence rate of instability in ER group was 23.45% (76/324) versus IR group was 33.44% (104/311). Pooled data showed that ER immobilization significantly reduced the recurrence rate of instability (risk ratio, 1.83; P= 0.0001) compared to IR immobilization. Pooled data also summarized that immobilization in 3 weeks significantly reduced the risk of recurrence compared to ER immobilization in 4 weeks (risk ratio, 2.35; P=0.01). The subgroup analysis has been made and there was no significant difference between ER immobilization and IR immobilization in patient aged <30 years (P=0.29). Analysis on 3 studies showed that there was no significant difference in WOSI score between both groups (p=0.32).

Conclusion: Best position and duration for primary anterior shoulder dislocation is ER immobilization in 3 weeks. This study found it significantly reduces the risk of recurrence instability. Furthermore, more studies needed to support the result of our studies to determine best assessment for anterior shoulder dislocation and the risk of recurrence instability.

Keywords: Anterior Shoulder Dislocation; Immobilization; External Rotation; Recurrence Rate; Meta-Analysis

Introduction

The glenohumeral joint has its large arc of motion, making them prone to mild or even severe injury [6,12]. The most common injury to the glenohumeral joint is anterior shoulder dislocation [12], which possibly the cause of a traumatic event or the shoulder instability itself.9 Anterior shoulder dislocation contributes 96% of total shoulder dislocations [11, 19]. The incidence of primary anterior shoulder dislocation is between 11.2 to 26.2 per 100,000 people. Recurrent dislocation is caused by a lesion in the glenoid labrum; the primary stabilizer of the shoulder. The prevalence of primary anterior shoulder dislocation is high in athletic activities, with the mechanism of apprehension position of shoulder abduction and external rotation [29]. Traditionally, anterior shoulder dislocations are treated with closed reduction, stages of immobilization in external or internal rotation for 2-6 weeks, and a series of physical exercise treatment, perhaps reducing the risk of recurrent dislocation and enhance the soft tissue healing [12, 18, 20] Despite its protocol to treat the anterior shoulder dislocation, the most advantageous time and position of immobilization yet the best position has to be proven. Therefore, we conducted a systematic review and meta-analysis from the available literature to consider the best duration and position for immobilization after the reduction of anterior shoulder dislocation.

Materials and Methods

Literature Search

Electronic databases (PubMed, NCBI, Cochrane, and Elsevier) were searched without limit. This study was conducted strictly following the methods established in the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We independently reviewed the titles and abstracts and strictly followed the inclusion criteria12: [1] the patient must be diagnosed with primary anterior shoulder dislocation; [2] direct comparison between internal and external rotation immobilization with recurrence rate in result for comparison; [3] more than 1-year follow up; [4] must be randomized controlled trials (RCTs). Exclusion criteria included studies where: [1] retrospective study, case reports, reviews, observational studies; [2] the outcome data were not available; [3] follow up time less than 1 year. Publications were excluded by title review, and abstracts, of all studies that were not excluded by title were reviewed to meet the criteria mentioned above. Then publications that have been reviewed were retrieved in full text and were read in detail.

Literature Search

We reviewed and extracted independently all the studies. Especially year of publication, study design, patient demographics (age, sex, sample size), type of immobilization, duration of immobilization, mean follow-up time, loss to follow up rate, recurrences rate, and WOSI Score. We used data from the analysis of treatment from the available data from the studies. If the data were not reported, we extracted them from the accompanying graphs.

Statistical Analysis

To perform the meta-analysis, we used RevMan version 5.3 software (Cochrane Collaboration). We used the risk ratio (RR) and a 95% CI as a pooled measure for dichotomous data. Inconsistency index [I2] test which ranges from 0% to 100% was used to assess heterogeneity across studies. A value above 50% or P <0.05 indicates statistically significant heterogeneity. We used the Mantel-Haenzsel method with a fixed-effect model for meta-analysis and a random effect model was used in case of heterogeneity. All P values were 2-tailed with a statistical significance set at 0.05 or below.

Source of Funding

No external funding support was received for this study.

Results

The literature search identified 138 studies. Among these 138 studies, 41 were excluded by titles (duplicates), 36 were excluded by abstract. Leaving 61 studies to be screened, and after we reviewed all the studies, we did consult with our consultant and 54 have been excluded by peer-reviewed, leaving 7 RCT in total to be included in our study.

Description of Studies

We included 7 RCTs comparing ER and IR immobilization after primary shoulder dislocation. Overall, there were 635 patients included in this study, with a mean age of 29.2 years across the 7 included studies. The overall follow-up time for the included studies was 23.6 months. Male to female ratio was 288:68 in the ER group, and 262:65 in the IR group. Duration of immobilization ranged from 3 to 4 weeks. The characteristics, main outcomes, and patient demographics included in the studies are shown in Tables 1 to 3. Itoi, et al [1] Itoi et al. reported in a clinical trial that immobilization in ER was shown to reduce the risk of recurrence shoulder dislocation compared to the IR groups. There were 198 participants (104 were treated in ER and 94 in IR). The average patient age reported was 37 years. The inclusion criteria included [1] firsttimer dislocation, [2] within 3 days after dislocation, [3] no associated fracture based on radiograph findings. They reported that recurrent dislocation was 25% in the ER group (22/85), and 42% in the IR group (31/74). Taskoparan, et al. [2] performed a randomized clinical trial comparing 3 weeks of immobilization in 10o of external rotation and internal rotation. The inclusion criteria of this study were primary anterior shoulder dislocation, no hyperlaxity of the shoulder, and admission on the first day of reduction after a dislocation. However, the exclusion criteria were not stated in this study, but it was stated that 2 patients were excluded from the study with, respectively, brachial plexus injury and hyperlaxity of the shoulder. A total of 33 met the inclusion criteria with 20 patients who encountered the dominant side. To be noted, 1 from 16 patients (6.3%) in external rotation group and 5 from 17 patients (29.4%) in internal rotation group experience anterior shoulder dislocation recurrence (p>0.05). While patients aged between 21-30 in the ER group did not fall on anterior shoulder dislocation recurrence, 5 patients in the IR group did (p=0.035). Hence, this study showed that external rotation is an effective preference to prevent recurrence of anterior shoulder dislocation rather than traditional internal rotation sling Liavaag, et al. [3] enrolled in a multicenter clinical trial from 13 hospitals, comparing immediate 3 weeks immobilization of both internal rotation; sling and swathe; and 15o external rotation; external rotation immobilizer. The inclusion criteria were [1] patients aged 16 – 40 years old and [2] successful reduction of primary traumatic anterior glenohumeral dislocations which were documented with a conventional radiograph. Furthermore, glenoid fracture with large osseous defect, greater tuberosity fracture with malalignment after repositioning, nerve injury-prone to the dislocation or even the reduction, and the unwillingness or ineptitude to take part in the study were excluded. Afterward, the outcome of the intervention was measured with a minimum of 24 months (2 years) of follow-up after the first anterior shoulder dislocation. A total of 188 patients; 93 randomized to ER and 95 randomized to IR; were acquired in the study with the mean age of 26.8 ±7.1 years old, ranging from 16-40 years old. It was shown that the recurrence rate (primary outcome) of internal rotation immobilization was 24.7% and 30.8% for external rotation immobilization with p = 0.37. Moreover, the secondary outcome measures the Western Ontario Shoulder Instability Index (WOSI) with a median score for the ER group was 238 and 375 for the IR rotation group, the difference was not significant (p=0.32). From the study, it was concluded that immobilization in the external rotation did not reduce the rate of recurrence for patients with primary anterior shoulder dislocation Heidari, et al [4] performed a prospective, randomized, controlled, clinical trial to compare the effectiveness of immobilization in external rotation (15o abduction and 10o external rotation) and internal rotation. The subjects were picked from the ED within 6 hours after the primary unilateral anterior shoulder dislocation, ranging from 15-55 years old and inclining to be followed up. Patients with previous shoulder issues, surgical joint repair, multidirectional instability, shoulder injuries requiring surgical intervention, associated with fractures of the shoulder upon routine radiographic examination, and unwilling to be followed up for the next 24 months were excluded. Afterward, all the patients included were assigned in a ratio of 1:1, respectively, in the adduction – internal rotation (AdIR) group and abduction – external rotation (AbER) group. The primary outcome was a recurrent dislocation, measured with WOSI. From the results, it was shown that the recurrence rate was significantly higher in AdIR group (33.33%) rather than the AbER group (3.9%), with p < 0.001. Hence, the abducted and externally rotated stabilization for primary anterior shoulder dislocation has more benefit in reducing the risk of anterior shoulder dislocation recurrence Whelan, et al. [5] Prospective multicenter randomized control trial with singleblinded evaluations was a study conducted by Whelan et al to 2 study groups. They are external rotation brace (90o elbow flexion, 0o shoulder abduction and flexion, and 0o- 5o external rotation at the shoulder), and internal rotation sling (90o of elbow flexion, 0o of shoulder abduction and flexion, and 70o-80o of internal rotation at the shoulder). Both groups were obligated to wear the fixator for a total of 4 weeks. Furthermore, the exclusion criteria of this study including previous instability of the affected shoulder with significantly associated fractures of the proximal humerus, glenoid, or scapula (except Hill-Sachs lesion and/ or small bony Bankart lesions) or those who were unwilling to participate in the study. The result was 37% (10/27) of ER group experienced recurrent dislocation and subluxation, while 40% (10/25) of the IR group (p=0.41 for recurrent instability between groups). The WOSI scores were not different between the groups respectively 87% and 84% for external rotation and internal rotation (p=0.74). Hence, it was concealed from this study that there was no significant difference in the rate of recurrent dislocation or instability between the groups of external and internal rotation Chan, et al. [6] A prospective, multi-center randomized control trial was conducted by Chan, et al. between 2006 and 2010. This study looked into the better outcome between using the conventional sling/ Polysling (internally rotated shoulder) or external rotation brace (30o externally rotated shoulder and 30o abduction) in the first occurrence of anterior shoulder dislocation for 4 weeks after the incidence. Starting from September 2006, patients with primary anterior shoulder dislocation ranging from 14-45 years old were put into the study. Exclusion criteria included an associated fracture, an indication for surgery (as determined by the recruiting surgeon), inability to provide informed consent, learning difficulties, mental illness, dementia, significant co-morbidities, or if the patient was unwilling to participate. After 24 months, the follow-up data showed that 30% of subjects who were put in internal rotation sling experienced recurrence of anterior shoulder dislocation, while 24% of subjects of external rotation and abduction did come through anterior shoulder dislocation recurrence. From the study by Chan et al, it can be concluded that ER bracing is unlikely more superior to provide advantages in traumatic first-time anterior shoulder dislocation Murray, et al. [7] A report from Murray, et al found that there is no significant difference between the ER and IR groups. Fifty patients were included in the study, which 25 patients allocated in the IR group and others [25] in the ER group. One patient refused to be treated in external rotation, and three patients were lost to follow-up. This study also reported that 38.3% of the patients had recurrent shoulder dislocation within two years. The recurrence rate was 47.8% (11 of 23) in IR group and 29.2% (7 of 24) in the ER group. They also report that in the subgroup aged between 20 and 40 years, the recurrence rate was 50% (9 of 18) in the IR group and 17.6% (3 of 17) in the ER group (p=0.044). For the patient aged under 20 or over 40 years found that no significant difference was found between IR and ER groups.

Recurrence Rates

We included 6 studies for the recurrence rate at all ages. All data were pooled to make a meta-analysis. We found that ER immobilization was significantly reduce the recurrence rate at all ages (RR: 1.83 (1.35, 2.48); p=<0, 0001; I2=42%) (Figure 2). Moreover, in sub-group analysis we found no significant difference in recurrence rate based on age, <30 years (RR: 1.50 (0.70, 3.18); p= 0.29; I2=67%) (Figure 3), and >30 years (RR: 1.81 (0.45, 7.24); p=0.32; I2=59%).

Duration of Immobilization

We included 6 studies for the duration of immobilization which separated into two groups, inclusive of 3 weeks and 4 weeks. We pooled all the data to make a meta-analysis. From the forest plot, we found that 3 weeks of immobilization in ER significantly reduce the recurrence rates (RR of 2.35 (1.18, 4.67); p= 0.01; I2=53%). In contrast, 4 weeks immobilization showed no significant difference to reduce the recurrence rate of anterior shoulder dislocation (RR=1.14 (0.65, 2.01); p= 0.64; I2=0%).

The Western Ontario Shoulder Instability Index (WOSI) Scores

The WOSI scores analysis was obtained from 3 studies to value the disease-specific quality of life (QoL) deficits between both IR and ER groups. It was found that there was no significant difference in the WOSI scores between both groups (p = 0.32, I2 = 0%).

Discussion

Recently, several studies showed reports about preferences in immobilization. Yet its duration, after a primary anterior shoulder dislocation, remains questionable, controversial, and debatable [25]. In our study that includes a meta-analysis of level I and II trials, we added 2 RCTs that had not been included in the previous meta-analysis [6, 7]. We pooled recurrence rates by age (all ages, <30 years, and >30 years) to evaluate the effectiveness of immobilization for reducing the risk of recurrence rate objectively. We also pooled the duration of immobilization of primary anterior shoulder dislocation to conclude the significance duration for reducing recurrence rate, WOSI score also being pooled to evaluate the better immobilization position. The previous systematic review and meta-analysis studies reported that there was no statistically significant difference between ER and IR immobilization to reduce the risk of recurrence [21,31]. In contrast, one of the recently published systematic review and meta-analysis showed that there is a statistically significant difference in recurrence rate based on immobilization, the investigator found that ER immobilization is superior to IR immobilization based on pooled data that has been shown in their study (p = 0.007)8.

The summary of our review and meta-analysis based RCTs with the highest-level evidence (level I or II trials) found that ER immobilization is statistically significant to reduce the recurrence rate (P<0.0001) at all ages, although we did not find any statistically significant difference in group ages <30 years (P=0.29), and >30 years (P=0.40). Even though we found a significant difference between the groups, still more RCTs are needed to prove the efficacy and preferred immobilization position [21]. According to our study, ER immobilization after primary anterior shoulder dislocation was preferably superior to IR immobilization, perhaps reducing the risk of recurrence and shoulder instability [1,17]. It was found no detachable contact force when the arm placed in IR immobilization after anterior shoulder dislocation. ER immobilization has been suggested based on an MRI study which stated that external rotation would maintain the labrum and capsule in close contact to the glenoid and enhance the tension on the subscapularis muscle [19,32]. Moreover, a biomechanical study on cadaver proved that gleno-labral contact was much wider when the shoulder was externally rotated in 450. [2,19,22,32] However, 45o in the external rotation will increase the contact force and seem difficult to be tolerated by the patients, therefore, most of the studies performed 10o external rotation to increase the cooperation rate in immobilization [2,22]. A radiologic study also confirmed that immobilization in external rotation had a positive impact in decreasing the hemarthrosis and reduction of anterior capsule detachment and labral lesions [1, 2, 17, 32]. Regarding to its superiority, some studies also reported the conflicting results on patients’ acceptance to use external rotation brace [23]. In 2010, Paterson, et al made an analysis for preference duration of immobilization in primary anterior shoulder dislocation. 25 The analyst showed that duration of immobilization <1 week and >3 weeks had no statistically significant difference in reducing the risk of recurrence. Since then, no reports have been showing about preferred durations of immobilization of primary anterior shoulder dislocation. Two comparisons had been made in our study to conclude the best duration of immobilization. Pooled data from 3 weeks of immobilization showed a statistically significant difference to reduce the recurrence rate (p=0.01). Otherwise, we found no statistically significant difference in the duration of immobilization in 4 weeks (p=0.64). One of the most common complications of anterior shoulder dislocation is hemarthrosis of the glenohumeral joint which would maintain the anterior capsule detachment.21,28,33 Hemarthrosis itself would resolve and be absorbed only after 3 to 7 weeks, which why 3 weeks are considered as the minimum compliance time of immobilization 21,33.

Conclusion

This meta-analysis study summarized that ER immobilization in 3 weeks is the best position and duration for immobilization after primary shoulder dislocation based on recent RCTs (Level I; II Evidence). We suggest more meritorious and thorough prospective randomized controlled trials with long-term follow-ups to be conducted, perhaps cutting off the biases in meta-analysis study and annotate an objective outcome.

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Lupine Publishers | The Effect of Aerobic Exercise on The Cardiorespiratory Endurance and Skeletal Muscle of Metabolic Syndrome

Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

This study examined the influence of aerobic exercise on the cardiorespiratory endurance and skeletal muscle of metabolic syndrome. An experimental research method was adopted, sampling community health service center people participating in health examination, 15 middle-aged men with waist circumference greater than 90cm (age 49.11±3.32) as subjects. Participants received 60-min aerobic exercise sessions two times a week for 10 weeks (20 sessions in total). The research tool uses a body composition analyzer (In Body) to detect skeletal muscle and basal metabolic rate; a three-minute cardiorespiratory endurance test (Harvard Step Test) is used to understand the subject’s cardiorespiratory endurance index after aerobic training. The results of the study found that weight loss, skeletal muscle rate t = -6.58*, and basal metabolic rate t = -5.77* all improved, and the cardiopulmonary endurance index increased from 52.64 to 58.31, from “poor” to “average” “within. The study concluded that aerobic exercise can consume more deep fat, reduce the risk of suffering from metabolic syndrome, help improve cardiorespiratory endurance and skeletal muscles, and achieve the results of rehabilitation and health improvement.

Keywords: Metabolic Syndrome; Cardiorespiratory Endurance; Aerobic Exercise; Skeletal Muscle Rate; Basal Metabolic Rate

Introduction

Metabolic syndrome (MS) is a group of metabolic diseases that appear in the same person. Its main metabolic abnormalities include obesity, dyslipidemia, hyperglycemia, hypertension, insulin resistance or glucose intolerance and other risk factors [1-4], one person At the same time, as long as there are more than three risk factors, it can be presumed to be metabolic syndrome [5], that is, MS is not a disease but a warning sign of the body [6,7], it is also a “predisease state” in which the body begins to experience metabolic abnormalities. MS is an aggregation of risk factors that increase the incidence of cardiovascular events and diabetes mellitus (DM). Population aging is accompanied by higher prevalence of MS [8,9]. The prevalence of MS increases with age, with about 40% of people older than 60 years meeting the criteria [10]. Now days MS can no longer be considered a disease of only adult populations. Alarmingly, MS and DM are increasingly prevalent in the pediatric population, again in parallel with a rise in obesity [11]. Most middleaged people have abdominal obesity, and thus constitute a high-risk group for MS. Statistics have indicated that people with visceral obesity have a 50% chance of developing MS [12]. Middle-aged people who belong to the high-risk group of MS can easily lead to chronic diseases such as diabetes, heart disease, and hypertension if they do not control their diet and exercise [13-15]. General body composition is composed of body fat mass, body fat percentage, skeletal muscle rate (SMR) and basal metabolic rate (BMR) [16]. Among them, the MS is closely related to its own BMR [17], and because the BMR is positively correlated with SMR growth and exercise [18]. One of the most critical elements of physical fitness is cardiorespiratory endurance. Relying on the kinetic functions of the heart and lungs, cardiorespiratory endurance refers to the body’s ability to continue supplying energy to the human circulatory system and muscles over extended periods [17]. There had been positive reports [19,21] about how advanced cardiorespiratory endurance not only enables one to engage in aerobic exercises, such as walking and jogging for a longer time. From the above literature, we could see the feasibility of this study. After a long period of aerobic exercise, people with metabolic syndrome and generally healthy people should be able to improve the growth rate of skeletal muscle and improve cardiorespiratory endurance [22,25]. This was also the focus of this research. In addition to dietary control, frequent exercise is the best method for staving off MS, where daily exercise invigorates the body [26]. Evidence has indicated that aerobic exercise is an effective method of improving cardiorespiratory endurance, aerobic exercise can significantly improve health [27,30]. Relevant studies have indicated that starting from 30 years old, lack of exercise is the primary driver of aging-related loss of muscle mass [31,32]. Some other studies have indicated that exercise can enhance bone density, reduce body fat, enhance metabolism, and prevent chronic diseases [33,34]. Aerobic exercise can strengthen the muscles surrounding and supporting the joints can help maintain a good body shape and enhance the integrity of the joints, thereby helping to prevent injuries [35,36]. Aerobic exercise will strengthen the skeletal muscles and help the bones to stay strong. Just like your brain, skeletal muscles need to be exercised to maintain muscle strength [37]. Some MS become obese, muscle strength deteriorates, physical vitality decreases, and even chronic diseases are caused by lack of exercise [38]. MS is a symptom produced by modern society and civilization, and because aerobic exercise has a positive effect on the physical composition of individuals, this study uses middle-aged people with MS as the research object, and uses aerobic exercise to understand the cardiorespiratory endurance and skeletal muscles of MS.

Materials and Methods

Experimental Approach to the Participants

An experimental research method was adopted, in cooperation with the community health service center, and implemented in the school gym. The subjects were people who participated in the health checkup at the community health service center. Middleaged men with a waist circumference greater than 90cm were the sample objects, a total of 15 people were sampled (age = 47.89 ± 6.24 years). Participants received 60-min aerobic exercise training sessions two times a week for 10 weeks (20 sessions in total). All training and testing are performed by the research team. This study did not involve personal privacy and strictly adhered to research ethics. As for the subjects’ psychological symptoms, disease history, family factors and other potential variables, they were listed as control variables. Aerobic training courses are shown in Table 1[39].

Experimental Detection Tools

A body composition analyzer (InBody 230) was used to measure SMR, and BMR. The mechanism underlying the InBody analyzer is the method of bioelectrical impedance analysis, which utilizes the impedance of current flow; specifically, the lower the conductivity of the muscles, blood, body fat, and skin, the higher the impedance is [40]. Take a 3-minute test of cardiorespiratory endurance (Harvard step test) to learn about the subjects’ cardiorespiratory endurance index after aerobic training. Use a 35cm high step, 96 beats per minute metronome, a total of three minutes of operation, after completing the test, measure 1 minute to 1.5 minutes, 2 minutes to 2.5 minutes, 3 minutes to 3.5 minutes, three 30-second wrist pulse rates. The cardiorespiratory endurance index score is then determined by the following equations. Cardiorespiratory Endurance Index = (100 x test duration in seconds) divided by (2 x sum of heart beats in the recovery periods). And consider the male cardiorespiratory endurance index norm [41], as shown in Table 2.

Statistical Analysis

Pre-test and post-test data were obtained and analyzed in SPSS (version 23.0). Descriptive statistics (specifically, the mean and standard deviation) were used to summarize the participants’ characteristics, and t tests were used to analyze after aerobic training changes in cardiorespiratory endurance (CRE), SMR and BMR.

Results

The results of this study are divided into two parts: First, Descriptive statistics of SMR, BMR, CRE before and after aerobic exercise; Second, Difference analysis of SMR, BMR, CRE before and after aerobic exercise for subjects.

Descriptive Statistics of SMR BMR CRE Before and After Aerobic Exercise

In this study, 15 men (age 49.11±3.32) were the subjects. These subjects were middle-aged men with waist circumference greater than 90 cm. According to the data in Table 3, the weight of the subjects was overweight or obese, and the cardiorespiratory endurance did not reach the standard average value. The data in Table 4 shows that the average weight of the subjects decreased significantly after aerobic exercise training, while the skeletal muscle, basal metabolism, and cardiopulmonary endurance were significantly improved.

Pre-test results: The average weight of the subjects was 84.47 kg, the SMR was 29.30%, which was slightly too low, the BMR was 1585 kcal/day, and the cardiorespiratory endurance index was 52.64, which was a poor state.

Post-test results: The average weight of the subjects was 78.67 kg, the SMR was 34.98% above the normal range (32~34% of the normal range), and the BMR was 1623 kcal/day, which was in the normal range (the male is 1400~1700) Card) [42], cardiorespiratory endurance index (cardiorespiratory endurance index) of 58.31 belongs to average state. According to the above data, aerobic exercise can increase the body’s BMR [43,44], and improve the effect of cardiopulmonary endurance [45,46], and the BMR is positively correlated with skeletal muscle [47]. Increasing skeletal muscle can increase the BMR, which not only helps burn calories and avoid weight gain, so the metabolic rate is low, and the risk of weight gain is low higher.

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Lupine Publishers | Vicryl or Ethibond for open Surgical Achilles Tendon Repair

Lupine Publishers |  Orthopedics and Sports Medicine

Mini Review

The strongest tendon in the body is the Achilles tendon. Acute tendon rupture can occur and is found most commonly in males. Management of rupture can be conservative or surgical. Surgical management is often associated with wound complications that can occur early or later. By contrast, conservative management is associated with a higher rate of re-rapture. Various suturing open techniques have been reported [1]. Krakow, Kessler and Bunnel suture techniques are commonly used [1,2]. Cadaveric study has shown that the three techniques have no strength differences [3]. The surgeon should be aware of the risk of developing wound complications. Bruggeman et al. have reported that females, tobacco use, and steroid use are risk factors for developing wound complications following open Achilles tendon repair [4]. Nonathletic patients tend to have poor outcomes following Achilles tendon surgery because of a higher body mass index, greater calf circumference, smoking, and greater subcutaneous body fat than athletic patients[5]. The surgeon is often the one who chooses which material to use to suture the tendon. This selection could be based on experience or on how the surgeon was taught. Suture materials can be divided into absorbable and non-absorbable. The absorbable suture commonly used in orthopaedics is vicryl, while ethibond and fibre wire are non-absorbable [6]. The reasons why surgeons use a non-absorbable suture include a higher knot and suture security and holding resistance, and also a belief that this type of suture is stronger [7]. But in biochemical test, it has been found that there was no knot slippage for either type of suture [6]. Kocaoglu et al. reported comparable clinical scores for both suture types, however, the non-absorbable had higher complication rates following Achilles tendon repair. Common complications for a non-absorbable suture include delayed wound healing, wound dehiscence, and at a later stage granulation formation which can present as a chronic sinus [7, 8, 9]. Patients may then require oral antibiotics or surgical debridement that involves removal of the non-absorbable material. When surgically treating Achilles tendon rupture, the absorbable suture material can be used.

Ethical Approval

Not applicable.

Data Availability

Not applicable.

Funding

No specific funding was received for this work.

Transparency Declarations

The author declares that there is no conflict of interest.

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