Osteonecrosis of Humeral Head after Arthroscopic Capsular Release for Postoperative Shoulder Joint Stiffness: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for allowing to review the manuscript. I read the manuscript with great interest.

The authors described the osteonecrosis of the humeral head after arthroscopic capsular release. However, I would like to raise some concerns regarding the article.

 

Major point

The manuscript is well written regarding case presentation and discussion; the biggest concern is the etiology of osteonecrosis of the humeral head. Given that the patient received intra-articular glucocorticoid injection postoperatively, the reason of the necrosis may have been glucocorticoid injection, not the ACR. Although the authors mentioned this point, this is the big limitation of this case report, and the authors should emphasize this point in this manuscript.

 

Minor point

L71-72: It would be preferable to point out that there was no sign of necrosis in the preoperative MRI.

 

Figure3B: It looks like the image focused on the clavicle, not the shoulder. Is there any imaging of the shoulder at 6 months of follow-up?

 

L116-117:

What was the reason of glucocorticoid injection during the 15 months?

 

L147-170:

The patient developed osteonecrosis of the humeral head at least 6 months after the ACR. What was the time frame of osteonecrosis of the humeral head in the previous literature?

Perhaps the time of onset can be a clue to consider the etiology of osteonecrosis.

 

 

 

 

Author Response

Comments 1: Major point
The manuscript is well written regarding case presentation and discussion; the biggest concern is the etiology of osteonecrosis of the humeral head. Given that the patient received intra-articular glucocorticoid injection postoperatively, the reason of the necrosis may have been glucocorticoid injection, not the ACR. Although the authors mentioned this point, this is the big limitation of this case report, and the authors should emphasize this point in this manuscript.

Response 1: I completely agree with your point. Accurate information was obtained by verbally confirming the matter with the patient. Based on this, additional information was described.

The patient regained right shoulder pain at the time post operative 15 months. He went to local orthopedic hospital and received two times of glucocorticoid injections (postop 15 months and 21 months) and 4 times of prolotherapy injections which are mixed with saline, dextrose, and lidocaine during 6 months of period, a treatment method that's quite popular in Korea, postoperative 15 to 21 months. 
We hypothesized that the recurrence of shoulder pain preceded the glucocorticoid injections, indicating a possibility of pain arising from osteonecrosis following the ACR. We anticipate that the occurrence of osteonecrosis takes place within the first year postoperatively. (Connection to response 5)

We changed Abstract 
However, at 15 months postoperative, the patient experienced a recurrence of shoulder pain and subsequently underwent triamcinolone injections at both the 15th and 21st postoperative months. (L20-22)

We changed case report
At 15 months postoperative, the patient developed recurring right shoulder pain. Sub-sequently, he sought treatment at another orthopedic hospital. He received two tri-amcinolone intra-articular injections and underwent four prolotherapy injections using a mixture of saline, dextrose, and lidocaine over a six-month period from 15 to 21 months postoperative. (L110-114)

Comments 2: Minor point
L71-72: It would be preferable to point out that there was no sign of necrosis in the preoperative MRI.
Response 2: Agree. We changed the words.
“without bony structural abnormality” (L72-73)

Comments 3: Minor point
Figure3B: It looks like the image focused on the clavicle, not the shoulder. Is there any imaging of the shoulder at 6 months of follow-up?

Response 3: Agree. We did not perform shoulder x-rays at this time, and only clavicle x-rays were obtained, so we had no choice but to use these x-rays as figures.

Comments 4: Minor point
L116-117:
What was the reason of glucocorticoid injection during the 15 months?

Response 4: The patient had discomfort for shoulder movement at postop 15 months. He came to local orthopedic doctor and had several injections. He received a couple of traimcinolone injections and several other injections, including prolotherapy injections mixed with saline, dextrose, and lidocaine. It is assumed that the patient visited several hospitals for persistent shoulder pain and stiffness and received repeated glucocorticoid injections without considering previous injection history.

Comments 5: Minor point
L147-170:
The patient developed osteonecrosis of the humeral head at least 6 months after the ACR. What was the time frame of osteonecrosis of the humeral head in the previous literature?
Perhaps the time of onset can be a clue to consider the etiology of osteonecrosis.

Response 5: There is no osteonecrosis report after the ACR. However, there are some osteonecrosis report after rotator cuff repair using anchors. Beauthier et al. reported osteonecrosis of the humeral head eight months after arthroscopic RCR. Goto et al. reported RDON after 3 months of arthroscopic RCR. Kim et al. reported ON within one year of arthroscopic RCR.
We presumed it would be around 3 months to 1 year.

Reference.
Kim JK, Jeong HJ, Shin SJ, Yoo JC, Rhie TY, Park KJ, Oh JH. Rapid Progres‑ sive Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery. Arthroscopy. 2018;34(1):41–7.
Beauthier V, Sanghavi S, Roulot E, Hardy P. Humeral head osteonecrosis following arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2010;18(10):1432–4.
Goto M, Gotoh M, Mitsui Y, Okawa T, Higuchi F, Nagata K. Rapid collapse of the humeral head after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):514–6.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript describes a case o humeral necrosis in a course of the treatment of the stiff shoulder. My main concern is if the AVN has been developed due to surgery or corticosteroid injections. The authors don’t provide clear evidence for this, moreover the information about injections used in another department is missing.

My remarks:

-         -  the title suggest the surgery as the cause tending to be innovative as a first described case

-          - complete range of motion description is missing in the abstract

-          - the authors don’t distinguish between active an passive range of motion both in the abstract and in the main text

-          - in the line 59 they mention medication but don’t clarify what kind

-          - Fig 3B is inadequately cropped

-          - lines 116-118 – the sentences about injections are contradictionary and the exact information is missing – this is crucial for this paper so the more effort should be done to clarify this

Author Response

Comments 1: The manuscript describes a case of humeral necrosis in a course of the treatment of the stiff shoulder. My main concern is if the AVN has been developed due to surgery or corticosteroid injections. The authors don’t provide clear evidence for this, moreover the information about injections used in another department is missing.

Response 1: I completely agree with your point. Accurate information was obtained by verbally confirming the matter with the patient. Based on this, additional information was described.   The patient regained right shoulder pain at the time post operative 15 months. He went to local orthopedic hospital and received two times of glucocorticoid injections (postop 15 months and 21 months) and 4 times of prolotherapy injections which are mixed with saline, dextrose, and lidocaine during 6 months of period, postoperative 15 to 21 months.   We hypothesized that the recurrence of shoulder pain preceded the glucocorticoid injections, indicating a possibility of pain arising from osteonecrosis following the ACR. We anticipate that the occurrence of osteonecrosis takes place within the first year postoperatively. Perhaps the time of onset can be a clue to consider the etiology of osteonecrosis.   There is no osteonecrosis report after the ACR. However, there are some osteonecrosis reports after rotator cuff repair using anchors. Beauthier et al. reported osteonecrosis of the humeral head eight months after arthroscopic RCR. Goto et al. reported RDON after 3 months of arthroscopic RCR. Kim et al. reported ON within one year of arthroscopic RCR. We presumed it would be around 3 months to 1 year.   Reference. Kim JK, Jeong HJ, Shin SJ, Yoo JC, Rhie TY, Park KJ, Oh JH. Rapid Progres‑ sive Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery. Arthroscopy. 2018;34(1):41–7. Beauthier V, Sanghavi S, Roulot E, Hardy P. Humeral head osteonecrosis following arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2010;18(10):1432–4. Goto M, Gotoh M, Mitsui Y, Okawa T, Higuchi F, Nagata K. Rapid collapse of the humeral head after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):514–6.   We changed Abstract However, at 15 months postoperative, the patient experienced a recurrence of shoulder pain and subsequently underwent triamcinolone injections at both the 15th and 21st postoperative months. (L20-22) We changed case report At 15 months postoperative, the patient developed recurring right shoulder pain. Sub-sequently, he sought treatment at another orthopedic hospital. He received two tri-amcinolone intra-articular injections and underwent four prolotherapy injections using a mixture of saline, dextrose, and lidocaine over a six-month period from 15 to 21 months postoperative. (L110-114)

Comments 2:  -  the title suggest the surgery as the cause tending to be innovative as a first described case

Response 2: We think we can keep the title.     Comments 3: - complete range of motion description is missing in the abstract   Response 3: We changed the abstract as you asked. Preoperative ROM was 90° for active forward flexion, 90° for abduction, 40° for external rotation, and sacral level for internal rotation. (L13-14)   Comments 4:  - the authors don’t distinguish between active a passive range of motion both in the abstract and in the main text   Response 4: The patient had much discomfort for shoulder movement before surgery. Our measurements showed that both active and passive ranges of motion were similar, likely due to the significant pain the patient was experiencing.   Passive and active ranges of motion were identical, attributed to the predominant cause of pain being stiffness rather than weakness. (L66-67)   Comments 5: - in the line 59 they mention medication but don’t clarify what kind   Response 5: It is typical pain control PO medication, celecoxib, oral nonsteroidal anti-inflammatory drug. We clarified about it   including the use of Celebrex oral nonsteroidal anti-inflammatory drugs and physiotherapy. (L59-60)   Comments 6: - Fig 3B is inadequately cropped   Response 6: That x-ray was our best radiograph showing intact glumerohumeral joint. We did not perform shoulder x-rays at this time, and only clavicle x-rays were obtained, so we had no choice but to use these x-rays as figures.   Comments 7:  - lines 116-118 – the sentences about injections are contradictionary and the exact information is missing – this is crucial for this paper so the more effort should be done to clarify this   Response 7: We made clear about injections as we said in response 1

Reviewer 3 Report

Comments and Suggestions for Authors

Please see the attached file.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

None.

Author Response

Comments 1: 
Thank you for the opportunity to review this case report. Unfortunately, the cause of osteonecrosis of the humeral head cannot be attributed to only ACR because of the patient’s several risk factors of the osteonecrosis and limited clinical data of the presented case. The comments are described below:
The presented case had several risk factors of osteonecrosis of the humeral head including alcohol consumption, chronic hepatitis and history of ORIF of the dislocation of the acromioclavicular joint. In addition, he had experienced many times of intraarticular injections after ACR. The information concerning the content of injections is lacking, suggesting that multiple steroid injections after ACR would cause the osteonecrosis. Therefore, it cannot be concluded that ACR itself caused the osteonecrosis of humeral head in this case.
Several authors have reported the occurrence of osteonecrosis of the humeral head following arthroscopic rotator cuff repair. The common characteristics in these cases included rapid progressive humeral head necrosis (within one year after arthroscopic rotator cuff repair) in the aged women. The presented case was 56-year-old male and the onset of the osteonecrosis was not within 12months after ACR (21 months after ACR). These factors additionally make the reviewer wonder if the ACR itself was the cause of osteonecrosis of the humeral head in the presented case. 

Response 1: I completely agree with your point. Accurate information was obtained by verbally confirming the matter with the patient. Based on this, additional information was described.

The patient regained right shoulder pain at the time post operative 15 months. He went to local orthopedic hospital and received two times of glucocorticoid injections (postop 15 months and 21 months) and 4 times of prolotherapy injections which are mixed with saline, dextrose, and lidocaine during 6 months of period, a treatment method that's quite popular in Korea, postoperative 15 to 21 months. 

We hypothesized that the recurrence of shoulder pain preceded the glucocorticoid injections, indicating a possibility of pain arising from osteonecrosis following the ACR. We anticipate that the occurrence of osteonecrosis takes place within the first year postoperatively. Perhaps the time of onset can be a clue to consider the etiology of osteonecrosis. 

There is no osteonecrosis report after the ACR. However, there are some osteonecrosis reports after rotator cuff repair using anchors. Beauthier et al. reported osteonecrosis of the humeral head eight months after arthroscopic RCR. Goto et al. reported RDON after 3 months of arthroscopic RCR. Kim et al. reported ON within one year of arthroscopic RCR. We presumed it would be around 3 months to 1 year.

Reference.
Kim JK, Jeong HJ, Shin SJ, Yoo JC, Rhie TY, Park KJ, Oh JH. Rapid Progres‑ sive Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery. Arthroscopy. 2018;34(1):41–7.
Beauthier V, Sanghavi S, Roulot E, Hardy P. Humeral head osteonecrosis following arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2010;18(10):1432–4.
Goto M, Gotoh M, Mitsui Y, Okawa T, Higuchi F, Nagata K. Rapid collapse of the humeral head after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):514–6.

We changed Abstract 
However, at 15 months postoperative, the patient experienced a recurrence of shoulder pain and subsequently underwent triamcinolone injections at both the 15th and 21st postoperative months. (L20-22)
We changed case report
At 15 months postoperative, the patient developed recurring right shoulder pain. Sub-sequently, he sought treatment at another orthopedic hospital. He received two tri-amcinolone intra-articular injections and underwent four prolotherapy injections using a mixture of saline, dextrose, and lidocaine over a six-month period from 15 to 21 months postoperative. (L110-114)

Comments 2: 
Line 53-61:
How long did this patient receive medications and PT after ORIF?
What was the treatment history concerning chronic hepatitis B?
Did this patient have a history of hyperlipidemia? 

Response 2: 
How long did this patient receive medications and PT after ORIF?
    During the metal removal surgery and ACR, there was a six-month interval. Following these procedures, the patient underwent six months of conservative care.

What was the treatment history concerning chronic hepatitis B?
    He took telbivudine (Sebivo) 600mg 1 TA, PO, qd for chronic hepatitis B, and took           Amlodipine/Losartan (Cozaar XQ) 5mg/100mg 1 TA, PO,qd for hypertension. He was checked for HBV DNA titer, and it was negative. Even though hepatitis B virus is not officially acknowledged as a risk factor, its influence on bone quality can be significant, especially in the presence of liver cirrhosis.

Konarski W, Pobozy T, Konarska K, et al. Osteonecrosis Related to Steroid and Alcohol Use-An Update on Pathogenesis. Healthcare (Basel). 2023;11(13).

Did this patient have a history of hyperlipidemia? 
    He was regularly monitored for hepatitis B virus (HBV) in our hospital, and he did not exhibit dyslipidemia.

Comments 3:
Line 83-93:
Did the authors regard ACR as the cause of osteonecrosis of the humeral head? If so, which surgical procedures during ACR had detrimental influence on the blood supply to the humeral head?

Response 3: 
We believe that the issue lies not solely with ACR but rather with multiple perioperative steroid injections and inherent risk factors. Nevertheless, clinicians should exercise caution, as these outcomes are events that patients may perceive as surgery-related results.

Comments 4:
   - Line 111-122:
The clinical information between 6 months and 21 months after ACR was lacking, hampering the speculation of the cause of osteonecrosis of the humeral head. The component of each injection needs to be confirmed. 

Response 4: We clarified it as we said in response 1. Thank you.

Comments 5: 
- Line 161-166: These sentences are merely speculations.

Response 5: Surgery has the potential to impact the condition of soft tissues and the surrounding blood supply. Reports indicate occurrences of pseudoaneurysm after arthroscopic subacromial decompression and distal clavicle excision. We are currently investigating which artery may have been damaged during the operation.
Webb, B.G.; Elliott, M.P. Pseudoaneurysm after arthroscopic subacromial decompression and distal clavicle excision. Orthopedics 2014, 37, e596–e599. DOI:10.3928/01477447-20140528-63.

Comments 6: 
- Line 202-206: A careful observation is mandatory for subjects with risk factors of osteonecrosis of the humeral head regardless of type of surgery.

Response 6: 
We fully support your comments. Regardless of the type of surgery performed on patients with inherent risk factors for avascular necrosis, it is believed that both clinicians and patients should share the risks of indiscriminate pre- and post-operative steroid injection. 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the explanations and improvements.

Author Response

Thank you

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your revised version. As pointed out in the first round, the cause of osteonecrosis of the humeral head cannot be attributed to only ACR because of the patient’s several risk factors of the osteonecrosis and limited clinical data of the presented case. In addition, the cause of developing osteonecrosis after ACR cannot be explained by reading this present case. Why did the osteonecrosis develop after ACR?

Comments on the Quality of English Language

No comments.

Author Response

Thank you for your review. We attached file.

Author Response File: Author Response.pdf

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your re-revised version. The reviewer appreciated the authors’s hardworking to answer the comments by the reviewer. The cause of osteonecrosis of the humeral head cannot be attributed to only ACR because of the patient’s several risk factors of the osteonecrosis and limited clinical data of the presented case. In addition, the cause of developing osteonecrosis after ACR cannot be explained by reading this present case. There are several papers reporting the development of osteonecrosis of the humeral head after shoulder arthroscopic surgery. As described by the authors, this may be the first case reporting the osteonecrosis of the humeral head after ACR. However, the specific cause of osteonecrosis caused by ACR is not unclear. If the injury to ACHA during surgery was a cause, this knowledge is not novel as many studies have shown the association between the circulation of the shoulder and osteonecrosis. Lines 150-171 summarize the previous studies findings. What is the new evidence supported by the present case? The reviewer cannot find novel findings that are worth publication as a case report.

The decision to this paper is same, rejection.

Comments on the Quality of English Language

None.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses in the attachment.

Author Response File: Author Response.pdf