Introduction: Intra-articular steroid injection has long been used to treat osteoarthritis of the knee and hip by orthopaedic surgeons, rheumatologists and general practitioners. Recent literature has shown conflicting results with regard to its safety. We aimed to investigate whether a relationship exists between preoperative intra-articular steroid injection and postoperative infection in total knee arthroplasty (TKA). Patients and Methods: We reviewed the records of all patients having TKA between April 2005 and April 2007 in University Hospital Aintree, Liverpool. The operations were carried out by 6 consultants. Exclusion criteria for analysis were: previous knee infection, revision knee surgery, fracture around the knee, skin disorders, diabetes, blood transfusion, rheumatoid arthritis and immunosuppressive medication. Eligible patients were divided into two groups: group I had received intra-articular steroid injection (each subject receiving 1–3 (mean 1.6) injections between 1–12 (mean 5) months before TKA); group II had received no injection. Mean follow-up was 17 months. Results: 425 patients had TKA, of which 361 met our criteria. 121 patients in group I and 240 patients in group II. No-one in group I developed acute infection. In group II, 7 patients developed acute infection (5 superficial and 2 deep) between 1 and 6 weeks (mean 3.7 weeks) post-operatively. There were no late infections. The difference in infection rate between groups I and II was not statistically significant (P=0.1, Fisher’s exact test). Conclusion: We found no evidence that intra-articular steroid injection prior to TKA increased the incidence of postoperative infection

Objective: To assess the possible effect of intra-articular steroid injections to future TKA. Materials-Method: We retrospectively studied all 231 patients who underwent AGC (Biomet) TKR in our hospital from February 2002 to October 2004. Twenty notes were not available in medical records and were excluded from the study. Other exclusion criteria were previous surgery (other than knee arthroscopy) on the affected site, a diagnosis of inflammatory arthritis, immunosu-pressed patients, a previous history of infection around the knee, smoking, diabetic patients. Applying these criteria we excluded a further sixty-seven patients. The remaining 144 patients were separated in to two groups. Group I (n=54) consisted of those patients that received one or more recorded I/A steroid injections in their operated knee in an orthopaedic clinic, rheumatology clinic or general practice setting prior to surgery. Group II (n=90) consisted of those patients with no record of receiving an I/A steroid injection prior to surgery. Results: We found that all the deep infections (3) were from Group I and had received an I/A steroid injection up to 11 months prior to surgery. The incidence of superficial infection was not significantly different from the control group (Group II). In addition to those patients with confirmed deep infections, five patients underwent post-operative investigations for suspected deep infection, due to symptoms of persistent swelling or pain. All had received an I/A steroid injection pre-operatively. The length of time between injection and subsequent post-operative infection leads us to speculate that the steroid agent might not fully dissolve, becoming trapped within the soft tissues or cystic areas of degeneration in the knee joint. Such steroids may become re-activated during operation, leading to catastrophic results. Indeed, there is experimental evidence to suggest an increased risk of infection with the intra-operative administration of steroids. Conclusion: We conclude that the decision to administer intra-articular steroids to a patient who may be a candidate for knee replacement surgery should not be taken lightly because of a risk of post operative deep infection

Steroids are known to have an adverse effect on the blood glucose levels in diabetics. Intra-articular steroids are commonly used in Orthopaedic and Rheumatology practice. However we have failed to identify any studies to date that have been carried out on the short-term effect of intra-articular steroids in diabetics who are taking insulin. This study was carried out to establish the effects of intra-articular (IA) steroid injections on the blood glucose levels and insulin requirements for insulin dependant diabetic patients treated for a “Frozen Shoulder”. Methods: Insulin-dependant diabetic patients suffering from a “Frozen Shoulder” who were referred to our out patient clinics were recruited prospectively for this study. Each patient received 40 mg of long acting steroid plus 9 mls of 0.5% Marcain injected intra-articularly into the glenohumeral joint. They were each asked to record their subsequent blood glucose levels and insulin requirements on a form, four times a day for seven days post injection. Each patient was seen again at 6 weeks and, when appropriate, they were offered a second intra-articular injection according to the recommendations of Jacobs et al. 1. (1991). Results: Fifteen patients were recruited into the study. All patients reported a disturbance of their blood glucose control in the post injection period lasting for a variable period up to seven days. Approximately one third of patients found it necessary to increase their daily insulin requirements during the first two days after the injection. Conclusion: IA steroid injections cause disturbance of the blood glucose control in insulin dependant diabetics. Patients must be warned regarding this side effect when IA steroid injections are given

Aim. The purpose of the study was to assess the safety of Intra-articular steroid hip injections (IASHI), prior to ipsilateral total hip arthroplasty (THA). Method. We investigated whether there was an excess of infection in such a group 7–10 years after total hip arthroplasty. A database of 49 patients who had undergone IASHI followed by ipsilateral THA was reviewed. Results. The mean length of time between injection and arthroplasty was 12.1 months (5.1–19 months). We found 7 major complications. Ten patients died with no further hip surgery at a mean of 28 months from surgery; 3 were lost to follow-up. The remaining group (36) were contacted by telephone at a mean of 97.8 (85–117) months from their surgery. No objective signs of joint infection were found. Conclusion. We believe our results show that ipsilateral steroid injection does not confer an increased risk of complications following subsequent THA, over an extended follow up

Introduction: Intra-articular steroid injection has been widely used for relief of pain in osteoarthritis. Recent studies show an increasing rate of infection in these patients following hip arthroplasty. We have reviewed our cohort of patients to see if they are susceptible to higher infection rate. Methods: We reviewed a cohort of 167 consecutive hips that had at least one injection with a 40mg triamcinolone acetonide and 4ml 0.5% bupivacaine mixture to relieve the symptoms of hip osteoarthritis or to clarify a diagnosis of hip arthritis between January 1997 and November 2004 were reviewed. A total of 37 hips (36 patients) that subsequently proceeded to have a total hip arthroplasty were selected as our study group. There was a minimum of a one-year follow up. Results: The rate of infection in our initial cohort of patients following a hip injection was 0.60% (1 hip) which resulted in repeated washouts and a subsequent total hip arthroplasty with a good outcome. On review of the 37 hips, one was revised due to a deep infection secondary to staphylococcus epidermidis. Four were revised for continued instability and pain with no evidence of infection either prior to or during revision. When deep infection is taken as an endpoint, cumulative survival at 7.5 years is 0.968 (95% confidence interval of 1 to 0.905). The total survivorship of this cohort if all revisions are included is 0.852 at 7.5 years (95% confidence interval of 0.730 to 0.974). The revision rate due to a deep infection in our study is 2.7%. Discussion: We conclude that patients who have a total hip arthroplasty after a hip injection do not have an adversely high rate of deep infection

Intra-articular steroid injection has been widely used for relief of pain in Osteoarthritis. Recent studies show an increasing rate of infection in these patients following hip arthroplasty. We have reviewed our cohort of patients to see if they are susceptible to higher infection rate. We reviewed a cohort of 167 consecutive hips that had at least one injection with a 40mg triamcinolone acetonide and 4ml 0.5% bupivacaine mixture to relieve the symptoms of hip osteoarthritis or to clarify a diagnosis of hip arthritis between January 1997 and Novem-ber 2004 were reviewed. A total of 37 hips (36 patients) that subsequently proceeded to have a total hip arthroplasty were selected as our study group. There was a minimum of a one-year follow up. The rate of infection in our initial cohort of patients following a hip injection was 0.60% (1 hip) which resulted in repeated washouts and a subsequent total hip arthroplasty with a good outcome. On review of the 37 hips, one was revised due to a deep infection secondary to staphylococcus epidermidis. Four were revised for continued instability and pain with no evidence of infection either prior to or during revision. When deep infection is taken as an endpoint, cumulative survival at 7.5 years is 0.968 (95% confidence interval of 1 to 0.905). The total survivorship of this cohort if all revisions are included is 0.852 at 7.5 years (95% confidence interval of 0.730 to 0.974). The revision rate due to a deep infection in our study is 2.7%. We conclude that patients who have a total hip arthroplasty after a hip injection do not have an adversely high rate of deep infection

We present a unique prospective study which estimates the median sustained stage related improvement in pain and hand function predicting symptomatic relief period with high accuracy with a single steroid injection.

Patients were grouped into stages, I to IV according to the Eaton and Glickel radiological criteria. The steroid injection contained 40mg triamcelone and 1% lido-caine. The response was assessed by DASH and a visual analogue score before and at six-week interval. We used the Kaplan-Meier method to estimate median length of sustained improvement by grade of disease, with 95% confidence interval. All the patients were injected by an upperlimb physiotherapist (DD). Post injection review was carried out by an independent observer(MK).

Forty patients were studied: 33 females and 7 males. The age ranged from 53 to 81 years, (mean 65years). No patient was lost to follow-up. Mean duration of symptoms were 36 months. Six patients has stage I disease(15%), eighteen patients had stage II disease (45%), ten patients had stage III disease (25%) and six patients has stage IV disease (15%). Pain score ranged from 4 to 9 on visual analogue score. Reduction in pain visual analogue score was noticed in all but 3 patients. With the exception of Grade III patients, DASH scores decreased significantly at 6 weeks (Grade I 14.9, Grade II 19.3, Grade III 6.2 and Grade IV 10.0.). With the exception of Grade IV patients, pain scores decreased significantly at 6 weeks. In Grade II patients, over half had sustained symptomatic relief at 6 months. So on average, we can expect grade I patients to sustain symptomatic relief for an average of 17 weeks. The true average is likely to be between 13 and 21 weeks. For grade II patients, most will still have improved at 6 months. Grade III and IV patients have an identical prognosis of 4 weeks, though the true prognosis may be between 2 and 6 weeks.

In conclusion it is possible to predict the period of symptomatic improvement in each of the four disease stages. This allows the treating clinician to discuss the outcome of treatment with reasonable accuracy.

Image-guided intra-articular hip injection of local-anaesthetic and steroid is commonly used in the management of hip pain. It can be used as a diagnostic and/or therapeutic tool and is of low cost (£75). The aim of this study was to assess how often a hip injection has a therapeutic effect.

This is a retrospective, consecutive, case series of intra-articular hip injections performed in a tertiary referral hospital over a 2-year period (2013–4). Patients were identified from the radiology department's prospectively entered database. Clinical information, reason for injection and subsequent management was obtained from hospital records. All patients prospectively reported their pain levels in a numeric pain scale diary (out of 10) at various time points; pre-, immediately post-, 1st day-, 2nd day- and 2 weeks- post-injection. Only patients with complete pain scores at all time points were included (n=200, of the 250 injections performed over study period, 80%).

The majority of injections were performed for osteoarthritis (OA) treatment (82%). The pain was significantly reduced from a pre-injection score of 7.5 (SD:2) to 5.0 (SD:3) immediately post-injection(p<0.001); only 24 (11%) reported any worsening of pain immediately post-injection. Pain significantly reduced further to 3.8(SD:3) at 2-weeks post-injection (p<0.001). 50% of patients had at least a 3 point drop in reported pain. No improvement was seen in 18 patients and 10 (5%) reported worse pain at 2-weeks compared to pre-injection. Of the OA cohort, 10% have required repeat injections, 45% required no further intervention and 45% underwent or are due for hip replacement. No immediate complications occurred.

Intra-articular hip injection reduced pain in 86% of cases and has delayed any further surgical treatment for at least 2 years in over 50% of OA cases. It is hence a cost-effective treatment modality. Further work is necessary to describe factors predicting response.

An intra-articular steroid injection can be a useful diagnostic tool in patients presenting with debilitating hip pain and radiographically mild osteoarthritis. The clinical and patient reported outcomes associated with patients who have radiographically mild osteoarthritis and undergo total hip arthroplasty (THA) remain poorly studied. Patients undergoing primary, elective THA at a single academic medical center by a fellowship-trained adult reconstruction surgeon between 2017–2023 were identified. Only those patients who underwent an intra-articular corticosteroid injection into the operative hip within one year of surgery were included. Patients were divided into two cohorts based on the severity of their osteoarthritis as determined by preoperative radiographs; those with Kellgren-Lawrence (KL) grade I-II arthritis were classified as “mild” whereas those with KL grade III-IV arthritis were classified as “severe”. Clinical and patient reported outcomes at final follow-up were compared between cohorts. The final cohorts included 25 and 224 patients with radiographically mild and severe osteoarthritis, respectively. There were no baseline differences in age, gender or time between intra-articular corticosteroid injection and THA between cohorts. There were no significant differences in the preoperative or postoperative HOOS JR values between patients with mild or severe arthritis (all p>0.05). There were no significant differences in the change in HOOS JR scores from the preoperative to final follow-up timepoints between cohorts. There were no significant differences in the percentage of patients who achieved the minimal clinically important difference (MCID) on the HOOS JR questionnaire between cohorts. Patients with radiographically mild osteoarthritis who feel relief of their hip pain following an intra-articular corticosteroid injection report similar preoperative debility and demonstrate similar improvements in patient reported outcome scores following THA compared to patients with radiographically severe osteoarthritis

Purpose: Intra-articular (IA) steroid injections have been widely used by orthopedic surgeons as symptomatic relief for severe hip OA, and with the addition of local anesthetic, they can be used to differentiate pain from the hip, knee and lumbar spine. This technique has come under some question as of late however due to inconsistencies in the literature. It has been reported that there is an association between infection post Total Hip Arthroplasty (THA) and prior IA steroid injections (Kaspar & de Beer, 2005). Additionally, the incidence of infections has been noted to particularly rise when the injections occur within six weeks of the operation (McIntosh et al, 2006). This study was used to analyze the risk of intra-articular steroid injections with respect to infection following THA. Method: We retrospectively reviewed 96 hips of patients who underwent total hip arthroplasty between 2001 and 2007 by one surgeon. Matched cohorts of 48 hips were established: one group in which patients received an injection prior to THA and one in which patients did not. Statistical analysis was performed using SPSS V14. Exclusion criteria included previous ipsilateral fracture or surgery, malignancy and immunosuppression. Results: There was no significant difference found between groups and there was no correlation found with regards to time of injection prior to surgery and infection. Within the injected group, two patients developed a UTI while one other had a pulmonary embolism. There were zero infections with regards to the hip, and there were no dislocations or revisions. The non-injected group included one patient who developed cholelethiasis, another patient with Norfolk virus and one patient with a superficial infection which was contributed to a dental procedure. There were no dislocations or revisions. Conclusion: These findings suggest that the administration of intra-articular steroid prior to THA does not increase risk of infection, and therefore our study does not find such an injection to be a contra-indicator

There has never been a study of whether intra-articular steroid injections of arthritic hips can alter the outcomes of subsequent arthritis management, particularly total hip arthroplasty (THA). In this study forty patients with a history of steroid injection of the hip and subsequent THA are examined retrospectively for infections, revisions, and prospectively-gathered hip scores, as compared to matched non-steroid controls. The steroid group had an increased incidence of pain, infectious workup under usual care, and two revisions for deep infection within three years. We suggest that steroid injections of hips should be avoided in patients who are candidates for THA. Despite the lack of demonstrated efficacy of intra-articular steroid injections for hip arthritis, the procedure is often utilized for diagnostic differentiation from spine pain, and attempted therapeutic management of painful hip arthritis. However, in the era of total hip arthroplasty (THA) the safety of this practice must be evaluated in the context of whether the injections pose any potential for complicating subsequent surgery, particularly with regard to infection. In this study, forty patients who underwent THA and had a history of previous steroid injection were compared retrospectively to forty carefully-matched patients who underwent THA in the same time period but had no history of prior steroid injection. Outcome measures included whether there was a septic workup under usual care, and this occurred in 20% of steroid patients within the first thirty-six months post-THA, as opposed to 0% in the controls. Furthermore, in a detailed analysis of Harris and Oxford scores, there was in the steroid group a higher incidence of night pain, increased severity of pain, and reduced function with activities of daily living at one year. There were two revisions for deep infection in the steroid group, and one revision for dislocation in each of the steroid and control groups. Pending the completion of the study, we provisionally suggest that steroid injection of hips may be ill-advised in a patient who will be a candidate for THA in the future. This suggestion is based primarily on the incidence of pain and infectious complications in the first postoperative year. Funding Dr Kaspar holds academic research grants from McMaster University and from The Physicians’ Services Incorporated (PSI) Foundation, the latter of which was used to finance this study and the continuation thereof. There are no commercial grants or conflicts of interest

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Introduction and Aims: Intra-articular steroid hip injection (IASHI) for osteoarthritis of the hip has not been well studied. The immunosuppressive nature of steroids may be hypothesised to interfere with asepsis in subsequent total hip arthroplasty (THA). We evaluate the infectious complications and functional outcomes of THA performed in patients who previously received IASHI. Method: This is a retrospective cohort study of functional outcomes (Harris and Oxford hip scores), and infectious complications in the first year following THA, in patients without (n=40 controls) or with (n=40) a history of ipsilateral IASHI. Functional scores had been compiled in our database, at one tertiary care centre, and infectious complications (wound infection, deep infection, work-up with bone scans, revision surgery) were retrospectively reviewed from hospital records. Results: The IASHI group had worse post-THA function (p=0.0008 ANOVA for Oxford functional hip scores across time, with mean one-year scores being worse by seven points out of 60). In the IASHI group there were five revision surgeries, four of which were for deep infection of the hip replacement (10%, versus 0% in controls, versus 1.02% in our database of 979 THA primaries, p < 0.001 by Log-Rank testing of Kaplan-Meier survivor-ship analysis). Additionally, each group had two superficial wound infections. Six additional IASHI patients underwent infectious work-ups for ongoing hip problems (compared to one patient worked-up in the control group). The total rate of culture-proven infection (either superficial or deep), or problems leading to negative infectious work-up, was 12/40 (steroid, 30%) versus 3/40 (control, 7.5%, p = 0.010 by Fisher’s Exact test). Conclusion: IASHI should now be considered as relatively contra-indicated in patients who are (or will become) candidates for THA. IASHI appears to compromise the functional results of subsequent THA, with much higher infection and revision rates. We suggest a multi-centre review of infected THA post-IASHI

Introduction and Aims: Intra-articular steroid hip injection (IASHI) has been extensively administered for painful hip arthritis since the 1950s, but with advances in medical and surgical management, its role is less certain today. There is very little published data on the utility or prescribing patterns of IASHI. Method: A questionnaire seeking expert opinions on IASHI was developed and distributed to practising Ontario-based members of the Canadian Orthopaedic Association. Initial phone calls identified those who perform hip replacements, and subsequent faxed forms had a 73% response rate (99 surgeons). We systematically describe the current practices and expert opinions of 99 hip surgeons, on the use of IASHI, focusing on indications, current usage, and complications. Results: Only 56% of surgeons felt that IASHI was actually useful therapeutically, though four in five surgeons cited the usefulness of hip injection for differentiating hip-spine co-morbidity in diagnostically challenging patients. Therapeutic benefit from IASHI was perceived to be poor, with 72% of surgeons estimating that between zero and 60% of their patients achieved any benefit at all from the injections, with duration of benefit uniformly estimated as being between zero and six months. Infection rates were considered to be less than 2% by most surgeons. One quarter of the surgeons felt that IASHI accelerates arthritis progression, most of whom had stated that it would be no great loss if IASHI was no longer available. Nineteen percent of the surgeons believed that there may be increased infection rate of THA after IASHI, and this was associated with lower numbers of IASHI ordered per year, compared to those who did not feel that infection rates would increase. The opinions of this large group of experts is consistent with efficacy studies, and forms a context for our ongoing studies of infected hip arthroplasty post-IASHI. Conclusion: Opinions were mixed, with substantial numbers of surgeons stating that the procedure is not therapeutically helpful, may accelerate arthritis progression, or may increase infections after subsequent total hip arthroplasty. This information provides a systematic collection of expert opinions, as well as a context for forthcoming studies on effectiveness and complications

Aims

To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation.

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Aims

The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.