The role of acetic acid in orthopaedic surgery

Acetic acid has become more commonly used in orthopaedic surgery. The purposed roles include biofilm eradication and surgical debridement, postoperative scar reduction and managing soft tissue injuries. Current research is scarce and does not provide conclusive evidence behind acetic acid’s efficacy in orthopaedic procedures such as biofilm eradication or acetic acid iontophoresis in soft tissue injuries. Current literature on acetic acid’s effects on biofilm eradication is composed of in-vitro studies, which do not demonstrate the potential clinical efficacy of acetic acid. Acetic acid iontophoresis is a novel technique which is now more commonly accepted for soft tissues injuries. Our literature search identified calcifying tendonitis of the shoulder, rotator cuff tendinopathy, heel pain syndrome, plantar fasciitis, achilles tendonitis, calcifying tendonitis of the ankle, myositis ossificans and cervical spondylosis as documented clinical uses. In this narrative review, we present the current uses of acetic acid and acetic acid iontophoresis, while evaluating the evidence revolving around its efficacy, benefits and risks.

Algorithm of management based on treatment goals for calcifying tendonitis of the shoulder: rigidity, pain and size of calcification

Purpose: The objective of the present manuscript is to propose a step-by-step algorithm for the management of calcifying tendonitis (CT) of the shoulder based on treatment goals, from conservative to surgical approaches. Method: A clinical note to present the main treatments for the management of calcifying tendonitis of the shoulder based on pain, rigidity and size of calcification based on the clinical experience and previous publications of the authors has been performed. Arguments: Treatment is conservative and surgical although there is controversy on the most adequate treatment. Kinesiotherapy is the recommended therapy for shoulder rigidity. For pain management after NSAIDs; microwaves, short waves, TENS, ultrasounds and Interferentials are effective. For the management of size of calcification, Iontophoresis, Electroshock wave therapy, Ultrasound needle guided aspiration and arthroscopic surgeries are the recommended alternatives, in that order. Conclusions: CT of the shoulder must be treated based on specific goals, mainly pain, rigidity or size of calcification. The proposed step-by-step algorithm of treatment is suggested based on the effectiveness of available techniques. If rigidity is present, kinesiotherapy is the recommended technique. For pain management, physical therapy such as microwaves, short waves, TENS, Ultrasound and Interferentials are effective techniques. For the treatment of calcification, iontophoresis is the most common, safe and inexpensive technique. If all previous conservative techniques failed, advanced techniques such as ESWT, US guided aspiration and arthroscopy are recommended, although they are not exempt of risk factors and complications.

Extracorporeal shock wave therapy: an update

Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended. Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection. The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process. The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another. In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems. Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067