Accuracy of shoulder joint injections with ultrasound guidance:Confirmed by magnetic resonance arthrography

BACKGROUND Intra-articular glenohumeral joint injections are essential procedures for treating various shoulder disorders. Fluoroscopy-guided injections have been extensively used;however, they pose a risk of radiation exposure and are expensive and timeconsuming. Recently, it has been suggested that ultrasound-guided injections are accurate and cost effective procedures.AIM To evaluate the accuracy of ultrasound-guided glenohumeral injections using a posterior approach that is confirmed using magnetic resonance arthrography(MRA).METHODS The study included 179 shoulders of patients with recurrent anterior instability(150 patients;103 and 76 right and left shoulders, respectively;160 males and 19 females;average age = 20.5 years;age range: 14-63 years) who underwent MRA for preoperative diagnosis. They were injected with 12 m L lidocaine(1%) using the ultrasound-guided posterior approach and then underwent magnetic resonance imaging. Two shoulder surgeons, except for the injector, evaluated the transverse relaxation(T2)-weighted images of axial planes and classified the intraarticular condition of injected contrast into three groups based on one of the three following scenarios: no leakage, injection into the glenohumeral joint without leakage;minor leakage, practical intra-articular injection with some leakage outside the posterior rotator cuffs;and major leakage, inaccurate injection with mass leakage without any contrast into the joint. The inter-rater reliability between two assessors was also evaluated by calculating Cohen’s kappa coefficient. The learning curve was assessed regarding the inaccurate injection rate by analyzing Spearman’s rank correlation coefficient.RESULTS Of the 179 injections, 163 shoulders(91.0%) had no leakage, 10 shoulders(5.6%) had minor leakage, and six shoulders(3.4%) had major leakage. In total, 173 shoulders(96.6%) were intraarticularly injected;thus, we could detect anterior labrum and capsular pathologies. Regarding the inter-rater reliability, the kappa coefficient was 0.925, indicating consistency in the evaluations by both examiners. Regression analysis of the inaccurate injection rate for assessingtechnical learning showed a logarithmic curve with a downward trend(R;= 0.887, P < 0.001). Three(50%) of the six inaccurate injections classified into “major leakage” were observed in the first 30 injections, indicating that the accurate injection showed a leaning effect.CONCLUSION Ultrasound-guided intra-articular glenohumeral injections using a posterior approach had high accuracy;however, injection accuracy depends on clinical experience.

Strategies to prevent hypertrophic scar formation:a review of therapeutic interventions based on molecular evidence

Once scar tissues mature,it is impossible for the surrounding tissue to regenerate normal dermal tissue.Therefore,it is essential to understand the fundamental mechanisms and establish effective strategies to inhibit aberrant scar formation.Hypertrophic scar formation is considered a result of the imbalance between extracellular matrix synthesis and degradation during wound healing.However,the underlying mechanisms of hypertrophic scar development are poorly understood.The purpose of this review was to outline the management in the early stage after wound healing to prevent hypertrophic scar formation,focusing on strategies excluding therapeutic agents of internal use.Treatment aimed at molecular targets,including cytokines,will be future options to prevent and treat hypertrophic scars.More basic studies and clinical trials,including combination therapy,are required to investigate the mechanisms and prevent hypertrophic scar formation.

Advances in surgical applications of growth factors for wound healing

Growth factors have recently gained clinical importance for wound management.Application of recombinant growth factors has been shown to mimic cellmigration,proliferation,and differentiation in vivo,allowing for external modulation of the healing process.Perioperative drug delivery systems can enhance the biological activity of these growth factors,which have a very short in vivo half-life after topical administration.Although the basic mechanisms of these growth factors are well understood,most have yet to demonstrate a significant impact in animal studies or small-sized clinical trials.In this review,we emphasized currently approved growth factor therapies,including a sustained release system for growth factors,emerging therapies,and future research possibilities combined with surgical procedures.Approaches seeking to understand wound healing at a systemic level are currently ongoing.However,further research and consideration in surgery will be needed to provide definitive confirmation of the efficacy of growth factor therapies for intractable wounds.

Surgical treatment algorithms for post-burn contractures

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.

The neck burn scar contracture:a concept of effective treatment

A neck scar contracture can severely and negatively affect the function of mastication, phonic, or breathing and result in neck pain and issues with esthetics. The best way is of course to avoid such contracture by means of non-surgical treatment such as use of a growth factor. The basic fibroblastic growth factor is clinically well proven in decreasing scar formation and improving healing. There are numerous reconstructive methods for neck contracture, especially when the lesions are relatively limited in part of the neck. However, a very severe and full circumferential scar contracture requires extensive reconstruction. The thin groin flap is one of the answers and well matches with the tissue texture and maintains the flexibility. Even with extensive burns and delayed reconstructions due to resuscitation first, the groin area is well preserved and can be safely harvested by dual vasculature systems of the superficial circumflex iliac artery and superficial epigastric artery, which warrant more reliability compared to the perforator flaps in this area. More demanding and stringent forms of the neck burn scar contracture are the sequelae of radiation. A radiation burn or radiation injury can be progressing and hard to heal. Adipose-derived stem cells can reverse the scar contracture as the surrounding tissue is softened and can accelerate wound healing. In this review, different types of neck burn scar contracture and reconstructive methods are summarized, including innovative use of bFGF and ADSCs in the management of difficult wound healing and scar contracture.

Topical odour management in burn patients

Preventing microbial colonization or infections that cause offensive smells may lead to odor reduction.As both anaerobic and aerobic bacteria cause the release of malodor from wounds,the most direct way of avoiding or eliminating wound odor is to prevent or eradicate the responsible infection through the debridement of necrotic tissues.However,some burn patients with malodorous wounds are unable to undergo debridement due to systemic conditions,especially in the acute stage.Moreover,the optimal drug doses and dressings to ensure the efficacy and cost-effectiveness of odorous burn wound management is unclear.The purpose of this commentary is to outline the odor management options available for burn patients,focusing on topical strategies.Numerous potential therapies for treating odorous wounds after burn injuries are suggested.

Dorsal hand reconstruction with radial artery perforator-based adipofascial flap

Reconstruction of dorsal hand soft tissue defects after severe injury is challenging for surgeons.Depending on the degree of defect,extensor tendon reconstruction may also be necessary.Various reconstruction methods are commonly performed to cover dorsal hand defects,such as skin grafting and distant,free,or local flaps.Among them,free vascularized flap transplantation is an ideal procedure because the major vessels that feed the local flap may have been damaged,and the affected limb can be reconstructed using a flow-through method.Although free flap surgery has advanced,few surgeons can choose this option due to its technical difficulty and uncertainty.On the other hand,distant flaps have been commonly used for the reconstruction of dorsal hand defects,and local flaps,such as reverse forearm flaps and retrograde posterior interosseous flaps,do not require microvascular anastomosis.However,they have some problems;distant flaps require at least two surgeries,reverse forearm flaps sacrifice major vessels and leave a scar at the donor site,and retrograde posterior interosseous flaps require meticulous dissection of the vascular pedicle.The radial artery perforator-based adipofascial flap is a versatile flap that is safe and easy to elevate without sacrificing the radial artery.In addition,elevating it as an adipofascial flap enables surgeons to avoid an unacceptable donor scar.We present two cases,demonstrating the usefulness of this pedicled perforator flap.