Effect of radiosynoviorthesis on the progression of arthropathy and haemarthrosis reduction in haemophilic patients.

INTRODUCTION: Repeated haemarthrosis is widely accepted as the triggering cause of synovitis and haemophilic arthropathy. A first-line treatment of chronic synovitis is radiosynoviorthesis (RS). The aim of this study was to evaluate the RS effects on the progression of arthropathy and on a reduction in bleeding in patients with haemophilia. METHODS: An observational-retrospective study was performed. Bleeding episodes in the 12 months following and in the 12 months preceding RS was compared. The arthropathy was clinically and radiologically analysed by age range, joint and subject, comparing those undergoing RS (Radiosynoviorthesis Group, RSG) against those not undergoing this treatment (Non-Radiosynoviorthesis Group, Non-RSG). RESULTS: One hundred and seventy-four RS were performed in 71 patients (90 Y in Knees and 186 Re in elbows/ankles/shoulder). RS resulted in significant reduction in bleeding (582 preintervention and 168 postintervention, P < .001). In general, the level of arthropathy measured clinically and radiologically was greater with age increase in both groups (RSG and Non-RSG), especially in the 25-40 age range. A significant increase (P < .05) in the progression of arthropathy was also observed, both globally by patient and specifically for each joint, in non-RSG and RSG group. CONCLUSION: RS is an effective method to reduce the number of haemarthrosis episodes in chronic synovitis. Moreover, RS can positively affect arthropathy by slowing down its progression. However, the results obtained suggest that arthropathy may be conditioned by the subject's age, regardless of whether or not the joint has undergone RS.

Subacromial temperature profile during bipolar radiofrequency use in shoulder arthroscopy. Comparison of Coblation® vs. VAPR®.

BACKGROUND: The use of bipolar electrodes for arthroscopic procedures carries a theoretical ex vivo risk of inducing burn injuries. Few studies have measured the in vivo temperatures produced by bipolar electrodes during arthroscopy, and their results are conflicting. The objective of this study was to evaluate the temperature profile within the subacromial space during shoulder arthroscopy with two different electrode systems. HYPOTHESIS: The primary hypothesis was that the two electrode systems produced similar temperature variations and peak temperatures. The secondary hypothesis was that neither electrode system produced irrigation-fluid temperatures above the tissue-damage threshold. MATERIAL AND METHODS: A comparative, prospective, single-centre, single-surgeon, single-blind study was conducted to compare the Coblation® system (Smith&Nephew, Andover, MA, USA) and the VAPR® system (DePuy Synthes Mitek Sports Medicine, Raynham, MA, USA) in 13 patients undergoing shoulder arthroscopy. A temperature probe inserted into the subacromial space was used to record temperatures at 10-second intervals for 60seconds during continuous radiofrequency application. RESULTS: Mean baseline temperature was 21.4±0.7°C with VAPR® and 23.0±2.2°C with Coblation®. No significant between-group differences were found during the first 40seconds. The mean peak temperature reached after 60seconds was 25.0±1.9°C with VAPR® and 27.9±2.8°C with Coblation® (P<0.05). DISCUSSION: Few studies have compared the in vivo temperatures produced during arthroscopy by different electrode systems. In vivo studies have established that temperature increases can cause tissue damage, particularly to chondrocytes, and that the irrigation flow rate plays a key role in lowering the in vivo temperatures. Our study showed a significant difference between the two electrode systems after 50seconds of use, with lower temperatures with the VAPR®. Nevertheless, neither system increased the irrigation-fluid temperatures above the tissue-damage threshold. Both systems can be used safely, provided the manufacturer instructions are followed and the irrigation system is effective. LEVEL OF EVIDENCE: II (prospective randomized trial).

Heterotopic ossification of the shoulder joint following spinal cord injury: an analysis of 21 cases after single-dose radiation therapy.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Heterotopic ossification (HO) affecting the hips is a common complaint of patients suffering traumatic spinal cord injury. However, the incidence of HO of the shoulder is considerably rare. In this context, we report on our results of 13 patients with a total of 21 cases of shoulder HO and single-dose radiation therapy. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: The study group consists of 12 male and 1 female patient with a mean age of 55.5 years (range from 24 to 81 years; s.d.=14.5). Primary outcome measures were defined as the number of HO relapses and the number of side or adverse effects in relation to the radiation therapy. RESULTS: At the time of latest follow-up during hospitalization, the mean shoulder flexion was 92.1° while mean abduction was 94.5°. The average external rotation was 26.4°. No HO recurrence occurred and none of the patients suffered any adverse effects related to radiation therapy. CONCLUSIONS: In conclusion, single-dose radiation therapy in the treatment of shoulder HO due to spinal cord injury is an effective and reliable method, although the risk of secondary side effects related to the radiation therapy remain unknown.

[Operative treatment of the rheumatic shoulder]. / Operative Therapie der rheumatischen Schulter.

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

Shoulder Dysfunction After Radiotherapy in Surgically and Nonsurgically Treated Necks: A Prospective Study.

Our goal was to evaluate the shoulder dysfunction after radiotherapy in surgically and nonsurgically treated necks.A prospective pair matched design was performed. A total of 96 patients from 3 groups were enrolled in the study. The patients were asked to complete the shoulder domain section of the University of Washington Quality of Life questionnaire on 2 occasions: preoperatively and 12 months postoperatively.None of the patients had a shoulder impairment before the operation. At the follow-up session, 4 patients who had received radiotherapy only reported mild shoulder dysfunction, the mean score was 96.3, the difference was significant compared with the preoperative score (P = 0.046). For patients who had received neck dissection, 7 patients reported that the impaired shoulder function caused them to change their work and 14 patients reported that their shoulder function was affected a little; the mean score was 71.6. For patients who had received both neck dissection and postoperative radiotherapy, 9 patients reported that they had changed their work due to shoulder dysfunction and 16 patients reported mild shoulder impairment; the mean score was 65.3 and the difference was not significant (P = 0.304).Radiotherapy does not increase shoulder dysfunction in surgically treated necks, but it could induce shoulder impairment in nonsurgically treated necks.

The efficacy of low-level laser therapy for shoulder tendinopathy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND PURPOSE: Low-level laser therapy (LLLT) is proposed as a treatment for tendinopathies. This is the first systematic review focusing solely on LLLT treatment effects in shoulder tendinopathy. METHODS: A systematic review with meta-analysis and primary outcome measures pain relief on 100-mm visual analogue scale (VAS) and relative risk for global improvement. Two independent assessors rated the included studies according to the PEDro scale. Intervention quality assessments were performed of LLLT dosage and treatment procedures according to World Association for Laser Therapy guidelines. The included trials were sub-grouped by intervention quality and use of other physiotherapy interventions. RESULTS: Seventeen randomized controlled trials (RCTs) met the inclusion criteria, and 13 RCTs were of high and 4 RCTs of moderate methodological quality. Significant and clinically important pain relief was found with weighted mean differences (WMD) over placebo, for LLLT as monotherapy at 20.41 mm (95% CI: 12.38 to 28.44) and as adjunct to exercise therapy at 16.00 mm (95% CI: 11.88 to 20.12). The WMD when LLLT was used in a multimodal physiotherapy treatment regime reached statistical significance over placebo at 12.80 (95% CI: 1.67-23.94) mm pain reduction on VAS. Relative risks for global improvement were statistically significant at 1.96 (95% CI: 1.25-3.08) and 1.51 (95% CI: 1.12-2.03), for laser as monotherapy or adjunctive in a physiotherapy regime, respectively. Secondary outcome measures of shoulder function were only significantly in favour of LLLT when used as monotherapy. Trials performed with inadequate laser doses were ineffective across all outcome measures. CONCLUSION: This review shows that optimal LLLT can offer clinically relevant pain relief and initiate a more rapid course of improvement, both alone and in combination with physiotherapy interventions. Our findings challenge the conclusions in previous multimodal shoulder reviews of physiotherapy and their lack of intervention quality assessments.

Use of X-rays to treat shoulder tendonitis/bursitis: a historical assessment.

This article assesses the therapeutic efficacy of ionizing radiation for the treatment of shoulder tendonitis/bursitis in the USA over the period of its use (human 1936-1961; veterinary 1954-1974). Results from ~3,500 human cases were reported in the clinical case studies over 30 articles, and indicated a high treatment efficacy (>90 %) for patients. Radiotherapy was effective with a single treatment. The duration of treatment effectiveness was prolonged, usually lasting until the duration of the follow-up period (i.e., 1-5 years). Therapeutic effectiveness was reduced for conditions characterized as chronic. Similar findings were reported with race horses in the veterinary literature. These historical findings are consistent with clinical studies over the past several decades in Germany, which have used more rigorous study designs and a broader range of clinical evaluation parameters. Radiotherapy treatment was widely used in the mid twentieth century in the USA, but was abandoned following the discovery of anti-inflammatory drugs and the fear of radiation-induced cancer. That X-ray treatment could be an effective means of treating shoulder tendonitis/bursitis, as a treatment option, and is essentially unknown by the current medical community. This paper is the first comprehensive synthesis of the historical use of X-rays to treat shoulder tendonitis/bursitis and its efficacy in the USA.

Bi-tangential hybrid IMRT for sparing the shoulder in whole breast irradiation.

BACKGROUND AND PURPOSE: A bi-tangential technique is proposed to reduce undesired doses to the shoulder produced by standard tangential irradiation. PATIENTS AND METHODS: A total of 6 patients affected by shoulder pain and reduced functional capacity after whole-breast irradiation were retrospectively analysed. The standard tangential plan used for treatment was compared with (1) a single bi-tangential plan where, to spare the shoulder, the lateral open tangent was split into two half-beams at isocentre, with the superior portion rotated by 10-20° medially with respect to the standard lateral beam; (2) a double bi-tangential plan, where both the tangential open beams were split. The planning target volume (PTV) coverage and the dose to the portion of muscles and axilla included in the standard tangential beams were compared. RESULTS: PTV95 % of standard plan (91.9 ± 3.8) was not significantly different from single bi-tangential plan (91.8 ± 3.4); a small but significant (p < 0.01) decrease was observed with the double bi-tangential plan (90.1 ± 3.7). A marked dose reduction to the muscle was produced by the single bi-tangential plan around 30-40 Gy. The application of the double bi-tangential technique further reduced the volume receiving around 20 Gy, but did not markedly affect the higher doses. The dose to the axilla was reduced both in the single and the double bi-tangential plans. CONCLUSION: The single bi-tangential technique would have been able to reduce the dose to shoulder and axilla, without compromising target coverage. This simple technique is valuable for irradiation after axillary lymph node dissection or in patients without dissection due to negative or low-volume sentinel lymph node disease.

The deltoid, a forgotten muscle of the shoulder.

The deltoid is a fascinating muscle with a significant role in shoulder function. It is comprised of three distinct portions (anterior or clavicular, middle or acromial, and posterior or spinal) and acts mainly as an abductor of the shoulder and stabilizer of the humeral head. Deltoid tears are not infrequently associated with large or massive rotator cuff tears and may further jeopardize shoulder function. A variety of other pathologies may affect the deltoid muscle including enthesitis, calcific tendinitis, myositis, infection, tumors, and chronic avulsion injury. Contracture of the deltoid following repeated intramuscular injections could present with progressive abduction deformity and winging of the scapula. The deltoid muscle and its innervating axillary nerve may be injured during shoulder surgery, which may have disastrous functional consequences. Axillary neuropathies leading to deltoid muscle dysfunction include traumatic injuries, quadrilateral space and Parsonage-Turner syndromes, and cause denervation of the deltoid muscle. Finally, abnormalities of the deltoid may originate from nearby pathologies of subdeltoid bursa, acromion, and distal clavicle.

Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer.

BACKGROUND: Shoulder dysfunction is a common problem in patients treated for head and neck cancer. Both neck dissections and radiotherapy can cause morbidity to the shoulder joint. Exercise interventions have been suggested as a treatment option for this population. OBJECTIVES: To evaluate the effectiveness and safety of exercise interventions for the treatment of shoulder dysfunction caused by the treatment of head and neck cancer. SEARCH METHODS: We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 7 July 2011. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing any type of exercise therapy compared with any other intervention in patients with shoulder dysfunction due to treatment of head and neck cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed risk of bias and extracted data from studies. We contacted study authors for information not provided in the published articles. MAIN RESULTS: Three trials involving 104 people were included. We classified one study as having low risk of bias; the others had some limitations and we classified them as having high risk of bias.Two studies (one with low risk of bias and the other with high risk of bias) applied progressive resistance training (PRT) combined with range of motion exercises and stretching; the comparison group received standard care. Pooled data demonstrated that PRT can improve shoulder pain (mean difference (MD) -6.26; 95% confidence interval (CI) -12.20 to -0.31) and shoulder disability (MD -8.48; 95% CI -15.07 to -1.88), both measured using the Shoulder Pain and Disability Index (SPADI) (range 0 to 100). Similarly, secondary outcomes were also improved: active range of motion for external rotation (MD 14.51 degrees; 95% CI 7.87 to 21.14), passive range of motion for abduction (MD 7.65 degrees; 95% CI 0.64 to 14.66), forward flexion (MD 6.20 degrees; 95% CI 0.69 to 11.71), external rotation (MD 7.17 degrees; 95% CI 2.20 to 12.14) and horizontal abduction (MD 7.34 degrees; 95% CI 2.86 to 11.83). Strength and resistance of scapular muscles was assessed in one study and the results showed a statistically significant benefit of PRT. The studies did not demonstrate a statistically significant difference in quality of life. Only two non-serious adverse events were described in the PRT group compared with none in the standard care group.One study with high risk of bias used a broad spectrum of techniques including free active exercises, stretching and postural care for a period of three months following surgery. This study did not demonstrate a difference between the exercise group and routine postoperative physiotherapy care in shoulder function and quality of life, but serious methodological limitations could explain this. No serious adverse events were reported. AUTHORS' CONCLUSIONS: Limited evidence from two RCTs demonstrated that PRT is more effective than standard physiotherapy treatment for shoulder dysfunction in patients treated for head and neck cancer, improving pain, disability and range of motion of the shoulder joint, but it does not improve quality of life. However, although statistically significant the measured benefits of the intervention may be small. Other exercise regimes were not shown to be effective compared to routine postoperative physiotherapy. Further studies which apply other exercise interventions in head and neck cancer patients in the early postoperative and radiotherapy period are needed, with long-term follow-up.

Calcifying tendonitis of the shoulder joint : predictive value of pretreatment sonography for the response to low-dose radiotherapy.

BACKGROUND AND PURPOSE: Calcifying tendonitis is a degenerative inflammatory joint disorder. Pain relief can be successfully achieved with low-dose radiotherapy. It is actually unknown which types of calcifying tendonitis respond to radiotherapy and which do not. The authors tried to get predictive objectives for the response to radiotherapy on the basis of different morphological patterns of calcifications evaluated by X-ray and ultrasound. PATIENTS AND METHODS: Between August 1999 and September 2002, a total of 102 patients with 115 painful shoulder joints underwent low-dose radiotherapy. At the beginning of radiotherapy, every shoulder joint was examined with a radiograph in two planes. In addition, sonography was performed before and during therapy. This examination was repeated 6 and 18 months after irradiation. Radiotherapy consisted of two series with a total dose of 6.0 Gy. 29 joints with calcifying tendonitis could be further divided using the sonographic and radiographic classification according to Farin and Gärtner, respectively. RESULTS: Pain relief was achieved in 94/115 joints (82%) at a follow-up of 18 months (median). A different response to radiotherapy was found using the sonographic classification of Farin: calcifying tendonitis type III (n = 18) responded well in contrast to a significantly worse result in type I (n = 11). The radiologic classification did not provide a predictive value. CONCLUSION: Sonographic classification of calcifying tendonitis is predictive for the outcome after radiotherapy. Especially patients with Farin type III calcification will benefit from low-dose radiotherapy.

[Radiotherapy for shoulder impingement]. / Bestrahlung beim Impingementsyndrom des Schultergelenks.

BACKGROUND AND PURPOSE: Up to now, degenerative shoulder diseases were summarized by the term "periarthritis humeroscapularis". Actual shoulder diseases can be differentiated etiopathologically according to a primary and secondary impingement syndrome. Narrowing of the subacromial space, which is caused by an osseous shape variant, leads to primary impingement. Secondary impingement develops, when the subacromial space is reduced by swelling tissue below the osseous shoulder roof. This study aimed for the exact diagnosis to indicate therapy and to classify the results according to the Constant score. PATIENTS AND METHODS: From August 1999 to September 2002, 102 patients with 115 shoulder joint conditions underwent radiation therapy (RT). All joints received two RT series (6 x 0.5 Gy/series) applied in two to three weekly fractions, totaling a dosage of 6.0 Gy (250 kV, 15 mAs, 1-mm Cu filter). The second RT course started 6 weeks after the end of the first. 115 shoulders were examined before RT, 6 weeks after the second RT course and, finally, during the follow-up from January to May 2003. RESULTS: Pain relief was achieved in 94/115 shoulder joints (82%) after 18-month follow-up (median). A significant difference existed between secondary impingement and primary/non-impingement according to response. Tendinosis calcarea, bursitis subdeltoidea, tendovaginitis of the long biceps tendon, and capsulitis adhaesiva responded well to therapy. CONCLUSION: Shoulder diseases of secondary impingement demonstrate a good response to RT. Less or no benefit was found in primary impingement syndrome or complete rotator cuff disruption and acute shoulder injuries, respectively.

Long-term results of radiotherapy for periarthritis of the shoulder: a retrospective evaluation.

BACKGROUND: To evaluate retrospectively the results of radiotherapy for periarthritis of the shoulder METHODS: In 1983-2004, 141 patients were treated, all had attended at least one follow-up examination. 19% had had pain for several weeks, 66% for months and 14% for years. Shoulder motility was impaired in 137/140 patients. Nearly all patients had taken oral analgesics, 81% had undergone physiotherapy, five patients had been operated on, and six had been irradiated. Radiotherapy was applied using regular anterior-posterior opposing portals and Co-60 gamma rays or 4 MV photons. 89% of the patients received a total dose of 6 Gy (dose/fraction of 1 Gy twice weekly, the others had total doses ranging from 4 to 8 Gy. The patients and the referring doctors were given written questionnaires in order to obtain long-term results. The mean duration of follow-up was 6.9 years [0-20 years]. RESULTS: During the first follow-up examination at the end of radiotherapy 56% of the patients reported pain relief and improvement of motility. After in median 4.5 months the values were 69 and 89%, after 3.9 years 73% and 73%, respectively. There were virtually no side effects. In the questionnaires, 69% of the patients reported pain relief directly after radiotherapy, 31% up to 12 weeks after radiotherapy. 56% of the patients stated that pain relief had lasted for "years", in further 12% at least for "months". CONCLUSION: Low-dose radiotherapy for periarthropathy of the shoulder was highly effective and yielded long-lasting improvement of pain and motility without side effects.

The effect of mastectomy and radiotherapy for breast carcinoma on soft tissues of the shoulder and its joint mobility among Egyptian patients.

Patients with post mastectomy soft tissue shoulder disorders usually benefit from various lines of physiotherapy treatment. However, the controversy about their efficacy persists. The aim of this work was to study and assess the efficacy of each, and to identify the best intervention. One hundred female patients with ipsilateral post mastectomy shoulder problems were enrolled in the study, from September 2003 until December 2004. They were followed up for 32 weeks. Mastectomy, both radical and conservative and axillary lymph node clearance, was the standard surgery applied for operable breast carcinoma in this series. Clinical examination was followed by testing for the shoulder complaint by measuring maximal protrusion at the inferior scapular angle, scapular stabilization and the lift-off tests. Approved physiotherapy modalities were then applied, viz: no treatment (randomly chosen 12 patients), passive and active motion therapy (14 patients), oral diclofenac sodium (19 patients), local triamcinilone injection (40 patients) and manually applied low intensity laser therapy (15 patients). Assessment was by determining overall success rate for each intervention modality. Intervention outcome was assessed at 8, 16, and 32 weeks as shown by physical examination using the healthy shoulder as a reference, and by measuring restricted mobility during passive lateral rotation and glenohumeral abduction. "Success rate" was determined separately for each group at the end of the intervention period. The applied surgery was followed by radiotherapy in 96%, chemotherapy in 24% and both in 11%. The presenting post mastectomy symptoms at the shoulder were pain (100%), shoulder weakness (88%), winging of the scapula (11%) and inability to perform everyday shoulder movements (23%). Evaluation was by overall improvement score. The results were: 14.3% for untreated patients, 43.3% for those treated by motion therapy, 42% for diclofenac therapy, 80.7% for local triamcinolone, and lastly 68% for low intensity laser therapy. All treatment regimens for shoulder disabilities in those patients gave little long-term advantage, local steroid injections were the most effective. Low level laser therapy may augment its effect. It is concluded that all treatment regimens provide little long-term advantage; however, trimcinilone local injections may be the most useful in terms of pain relief and improvement in shoulder movement.

Comparison in the effect of linear polarized near-infrared light irradiation and light exercise on shoulder joint flexibility.

OBJECTIVE: This study aimed at comparing the effect of linear polarized near-infrared light irradiation (PL irradiation) and bicycle exercise with 50%HRreserve on the flexibility of the shoulder joint. DESIGN: Placebo-controlled trial. SETTING: Twenty-four healthy young adults (10 males: mean+/-SD, age 20.9+/-3.1 y, height 171.0+/-3.9 cm, body mass 63.4+/-3.5 kg and 14 females: age 21.2+/-1.7 y, height 162.0+/-7.8 cm, body mass 56.2+/-7.2 kg). INTERVENTIONS: PL-irradiation (100%, 1800 mW), placebo-irradiation (10%,180 mW), and light exercise (50%HRreserve) for 10 minutes. OUTCOME MEASUREMENTS AND RESULTS: The shoulder joint angles were measured twice-before and after each intervention. We measured the angles when the right shoulder joint extended forward and flexed backward maximally without support, and analyzed these shoulder joints and range of motion. Trial-to-trial reliability (intraclass correlations) of each joint angle was very high, over 0.98. All joint angles showed significant changes, and values in post-PL-irradiation and postlight exercise were significantly greater than that in postplacebo-irradiation. Shoulder forward flexion and backward extension angles had significantly greater change rates in PL-irradiation and light exercise than placebo-irradiation, and their range of motion angle was in the order of PL-irradiation, light exercise, and placebo-irradiation. CONCLUSIONS: It is suggested that PL-irradiation produces almost the same effect on shoulder joint range of motion as light exercise.

The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer: a randomized study.

The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer was examined through a randomized controlled trial. One hundred and thirty-nine patients with newly diagnosed breast cancer were enrolled in the study. Sixty-two (45%) had Breast Conserving Therapy and 77 (55%) had Modified Radical Mastectomy (Axillary dissection of level I and II was included in both procedures). Enrolled patients were randomized to either group A or group B. Group A was offered, team instructed physiotherapy consisting of 12 sessions of 60 min, two sessions a week. The treatment was instituted between the sixth and eight postoperative week. Group B was also offered team instructed physiotherapy, consisting of 12 sessions of 60 minute two sessions a week, but not until the 26th postoperative week. The patients were seen for follow-up examinations four times during the first postoperative year (after 7, 13, 26 and 56 weeks). Shoulder function was assessed by the Constant Shoulder Score preoperatively and at the four follow-up examinations. Team instructed physiotherapy was found to improve the shoulder function significantly in patients treated surgically for breast cancer. The effect of the treatment was influenced by the type of surgery performed, and in mastectomised patients, also by the application of radiation therapy. Compromised shoulder function is a less frequent and less severe side effect to breast conserving therapy as compared to modified radical mastectomy.

[Results of radiation therapy in periarthritis humeroscapularis]. / Ergebnisse der Strahlentherapie bei Periarthropathia humeroscapularis.

BACKGROUND: Radiation therapy is applied in painful degenerative shoulder diseases. Aim of this work was to evaluate the contribution of radiation therapy to symptomatic improvement in periarthritis humeroscapularis. METHODS: Ninety-four patients with periarthritis humeroscapularis were treated in two institutions. Mean age was 68 years, sex distribution were 32 men and 62 women. In 58 cases the right side was affected, left in 36 cases. At single doses of 0.75 Gy once a week a total dose of 6 Gy was applied (Fig. 1). The treatment effect was evaluated by the standardized von Pannewitz-score at the end of the treatment up to 6 months thereafter. RESULTS: The treatment results of all the 94 patients were documentated at the end of therapy. Seventy-one patients were followed at least for further 4 months. Radiogenic side-effects were not noticed. The symptoms of 54 patients (57.4%) were improved or vanished, in 40 cases the symptoms were not significantly affected (42.6%) (Table 1). Four months after therapy 42 of 71 patients were improved (59.2%), 29 unchanged (40.8%) (Table 2). The treatment effect occured typically up to 2 months after therapy, there were no age-related differences. Also in recurrent radiation therapies the symptoms improved, in 80 percent after one preceding therapy (Table 3), however only in 31.2 percent after multiple prior radiotherapies (Table 4). CONCLUSION: Radiation therapy is effective in the symptomatic treatment of periarthritis humeroscapularis. Treatment should be performed early after initial conservative treatment prior to any invasive therapy.

Thermal profile of radiofrequency energy in the inferior glenohumeral ligament.

PURPOSE: Currently, two different methods of applying radiofrequency (RF) energy (monopolar and bipolar) are available to the surgeon for thermal shortening of the shoulder capsule. The objective of this study was to investigate the temperature changes and the thermal conduction across the human inferior glenohumeral ligament (IGHL) during radiofrequency energy application. METHODS: Thermistors were secured onto both the intra-articular and extra-articular surfaces of human IGHL. Monopolar RF energy and bipolar RF energy were delivered to the intra-articular surface at the manufacturer's recommended settings. Pre-treatment and post-treatment ligament lengths, widths, heating times, and temperatures were measured and compared. RESULTS: For the monopolar devices, temperature spikes to 89 degrees C were recorded for the set temperature of 67 degrees C, averaging 77 degrees C +/- 10 degrees C. Temperatures across the ligament averaged 48 degrees C +/- 3 degrees C. For both devices, the IGHL became thicker with higher RF settings. Recorded temperatures decreased as distance increased from the point of application. Maximum temperatures occurred at least 6 to 7 seconds after cessation of energy application. CONCLUSIONS: The bipolar and monopolar devices had similar conduction times across the ligament, suggesting that this occurs by simple diffusion of heat. Bipolar and monopolar devices were equally efficacious for capsular shrinkage if the extent of the shortening is tightly defined. CLINICAL RELEVANCE: The thermal probe should not rest in one position for an extended period of time during RF energy application because, as our study showed, the monitoring of temperature or the visualization of tissue change is not efficacious for determining the end point of thermal shrinkage of the shoulder capsule.

Is chronic lymphocytic leukemia a contraindication for radon and thermotherapy?--a case report.

A growing number of patients presenting for radon-thermotherapy have a history of malignant disease. The question as to whether malignancies in general are a contraindication for radon treatment or mild hyperthermia during spa therapy is still a subject of controversy. We report a patient with osteoarthritis and a frozen shoulder who repeatedly underwent speleotherapeutic radon and hyperthermia treatment in the gallery of the Gasteiner Heilstollen, Austria, despite concomitant chronic lymphocytic leukemia (B-CLL, Rai stage 0). After nine courses of radon-thermotherapy over eight years, no apparent negative impact on CLL was noted. The purpose of this case report is to encourage discussion as to whether CLL or other past or present malignancies must be considered a contraindication for spa treatment such as radon-thermotherapy.

The biologic response to laser thermal modification in an in vivo sheep model.

The purpose of this study was to evaluate the effect of nonablative laser energy on mechanical, histologic, ultrastructural, and biochemical properties of joint capsular tissue in an in vivo sheep model. Femoropatellar joint capsule was treated with the holmium:yttrium-aluminum-garnet laser via an arthroscope, and tissues were harvested immediately after surgery, or at 3, 7, 14, 30, 60, 90, and 180 days after surgery (n = 8/group). Laser treatment caused significant decreases in tissue stiffness from 0 to 7 days after surgery, then stiffness gradually increased after 14 days. Tissue strength was lowest 3 days after laser treatment. Histologic examination revealed immediate collagen hyalinization and cell necrosis, followed by active cellular response characterized by extensive fibroblast migration and capillary sprouting. Tissue appeared to be normal histologically 60 days after surgery; however, collagen fibrils remained uniformly small. This study showed an active tissue response secondary to thermal modification with concomitant recovery of mechanical properties by 30 days after surgery. Whether the shrinkage or joint stability was maintained with time remains to be evaluated. To clarify the advantages and disadvantages of this technique, a carefully controlled clinical trial with long term followup should be performed.