The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome.

Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score.

Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001).

Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.

Femoroacetabular Impingement (FAI) syndrome, characterised by abnormal hip contact causing symptoms and osteoarthritis, is measured using the International Hip Outcome Tool (iHOT). This study uses machine learning to predict patient outcomes post-treatment for FAI, focusing on achieving a minimally clinically important difference (MCID) at 52 weeks. A retrospective analysis of 6133 patients from the NAHR who underwent hip arthroscopic treatment for FAI between November 2013 and March 2022 was conducted. MCID was defined as half a standard deviation (13.61) from the mean change in iHOT score at 12 months. SKLearn Maximum Absolute Scaler and Logistic Regression were applied to predict achieving MCID, using baseline and 6-month follow-up data. The model's performance was evaluated by accuracy, area under the curve, and recall, using pre-operative and up to 6-month postoperative variables. A total of 23.1% (1422) of patients completed both baseline and 1-year follow-up iHOT surveys. The best results were obtained using both pre and postoperative variables. The machine learning model achieved 88.1% balanced accuracy, 89.6% recall, and 92.3% AUC. Sensitivity was 83.7% and specificity 93.5%. Key variables determining outcomes included MCID achievement at 6 months, baseline iHOT score, 6-month iHOT scores for pain, and difficulty in walking or using stairs. The study confirmed the utility of machine learning in predicting long-term outcomes following arthroscopic treatment for FAI. MCID, based on the iHOT 12 tools, indicates meaningful clinical changes. Machine learning demonstrated high accuracy and recall in distinguishing between patients achieving MCID and those who did not. This approach could help early identification of patients at risk of not meeting the MCID threshold one year after treatment

Interstitial supraspinatus tears can cause persistent subacromial impingement symptoms despite non operative treatment. Autologous tendon cell injection (ATI) is a non-surgical treatment for tendinopathies and tear. We report a randomised controlled study of ATI compared to corticosteroid injection (CS) as treatment for interstitial supraspinatus tears and tendinopathy.

Inclusion criteria were patients with symptom duration > 6 months, MRI confirmed intrasubstance supraspinatus tear, and prior treatment with physiotherapy and ≥ one CS or PRP injection. Participants were randomised to receive ATI to the interstitial tear or corticosteroid injection to the subacromial bursa in a 2:1 ratio, under ultrasound guidance. Assessments of pain (VAS) and function (ASES) were performed at baseline, and 1, 3, 6 and 12 months post treatment.

30 participants (19 randomised to ATI) with a mean age of 50.5 years (10 females) and a mean duration of symptoms of 23.5 months. Baseline VAS pain and ASES scores were comparable between groups. While mean VAS pain scores improved in both groups at 3 months after treatment, pain scores were superior with ATI at 6 months (p=0.01). Mean ASES scores in the ATI group were superior to the CS group at 3 months (p=0.026) and 6 months (p=0.012). Seven participants in the CS group withdrew prior to 12 months due to lack of improvement. At 12 months, mean VAS pain in the ATI group was 1.6 ± 1.3. The improvements in mean ASES scores in the ATI group at 6 and 12 months were greater than the MCID (12.0 points). At 12 months, 95% of ATI participants had an ASES score > the PASS (patient acceptable symptom state).

This is the first level one study using ATI to treat interstitial supraspinatus tear. ATI results in a significant reduction in pain and improvement in shoulder function.

The purpose of this study was to compare the outcomes of arthroscopic unilateral surgery and simultaneous bilateral surgery for posterior ankle impingement syndrome (PAIS) in athletes and to evaluate the usefulness of simultaneous bilateral surgery.

A total 48 hindfeet of 41 athletes (14 hindfeet of 14 males, 34 hindfeet of 27 females) who underwent arthroscopic surgery for PAIS were studied. Japanese society for surgery of the foot (JSSF) score and visual analogue scale (VAS) were compared before and after surgery, using Wilcoxon signed-rank test. The operation time and the time to return to sports activity were compared in 10 hindfeet of 5 patients who underwent simultaneous bilateral surgery and 38 hindfeet of 36 patients who underwent unilateral surgery, using Wilcoxon rank sum test.

Classic ballet was the most common type of sport that caused PAIS (59%, 24/41 athletes). Soccer (10%, 4/41 athletes), baseball (10%, 4/41 athletes), badminton (5%, 2/41 athletes), volleyball (5%, 2/41 athletes), and athletics (5%, 2/41 athletes) followed. The JSSF score improved significantly from 72.7 preoperatively to 98.9 postoperatively in unilateral surgery, and significantly improved from 75.2 preoperatively to 99.0 postoperatively in simultaneous bilateral surgery. VAS significantly decreased from 64.7 preoperatively to 4.8 postoperatively in unilateral surgery, and significantly decreased from 72.7 preoperatively to 1.0 postoperatively in simultaneous bilateral surgery. The operating time was 53.7 minutes on average for unilateral surgery and 101.0 minutes for simultaneous bilateral surgery, significantly longer in bilateral simultaneous surgery. The mean time to return to sports activity was 4.8 weeks for unilateral surgery and 9.6 weeks for simultaneous bilateral surgery, significantly longer in simultaneous bilateral surgery.

Both unilateral and simultaneous bilateral surgeries for PAIS in athletes were useful. It should be noted that the operating time and the time to return to sports will be longer. However, considering the 2 times hospitalizations and 2 times surgeries, simultaneous bilateral surgery is one of the treatment options for PAIS.

The pathology of the posterior acetabular legion in femoroacetabular impingement (FAI) syndrome, so called “contre-coup region”, is still unclear. ¹⁸F-fluoride positron emission tomography (PET) is a functional imaging modality, which reflects the osteoblast activity. Recent technological advances in PET combined with computed tomography (CT) imaging allowed us to obtain detailed 3-dimensional (3D) morphological information. We evaluated the abnormal uptake of ¹⁸F-fluoride PET/CT on posterior acetabular lesion in FAI syndrome cases. We enrolled forty-one hips from 41 patients who were diagnosed as FAI syndrome and were performed ¹⁸F-fluoride PET/CT between October 2014 and October 2016. In each hip, the maximum standardized uptake value (SUV_max) on the posterior acetabular was measured. The cases were divided into 4 groups; cam-type (11 cases), pincer-type (7), combined-type (11), dysplastic developmental hip (DDH) with cam morphology (12). The average SUV_max of the pincer-type was significantly smaller than that of the other 3 groups (p < .05). The percentage of the cases with SUV_max ≥ 6 was 81.8% in cam-type, 28.6% in pincer-type, 90.9% in combined-type, 91.7% in DDH with cam morphology. Furthermore, the average degree of α angle of the cases of SUV_max ≥ 6 was significantly higher than that of the cases of SUV_max < 6 (p = .005). Although actual biomechanical mechanism in contre-coup region is still controversial, this result indicated that the cam morphology related to the posterior acetabular lesion with accelerated bone metabolism.

Purpose

Femoroacetabular impingement syndrome (FAI) is a common cause of hip and groin pain in young adults. Physiotherapy and surgery have both been used to treat FAI syndrome, but there is no robust evidence of comparative effectiveness. UK FASHIoN compared the clinical and cost-effectiveness of arthroscopic hip surgery (HA) versus best conservative care in patients with FAI syndrome.

Introduction. Subacromial corticosteroid injection is widely used in the treatment of Subacromial Impingement Syndrome (SIS). There is increasing interest in using ultrasound (US) to improve the accurate placement of injections. This study investigated whether the accuracy of placement of US-guided subacromial corticosteroid injections influences patients' outcome of pain and function. Method. Secondary analysis of data from a 2−2 factorial randomised controlled trial investigating exercise and corticosteroid injection for pain and function in SIS. US-guided injections were delivered according to a pre-defined protocol. Video images were reviewed to categorise accuracy of injection into the subacromial bursa into 3 accuracy groups using pre-defined criteria: 1) not in the subacromial bursa; 2) probably in the subacromial bursa; and 3) definitely in the subacromial bursa. The primary outcome measure was the self-reported Shoulder Pain and Disability Index (SPADI) total score, compared at 6 weeks and 6 months. Secondary outcomes included SPADI pain and function subscales and participant global rating of overall change from baseline. A mixed effects model was used to compare accuracy groups' outcomes at 6 weeks and 6 months, adjusted for baseline covariates. Results. US-guided injection accuracy data were available for 114 participants; with 22 participants in group 1, 21 in group 2 and 71 in group 3. There were no significant differences in mean SPADI scores among the three injection accuracy groups at 6 weeks (group 2 vs. 1: 8.22 (95% CI −4.01, 20.50); group 3 vs. 1: −0.57 (−10.27, 9.13)) and 6 months (group 2 vs. 1: 12.38 (−5.34, 30.10); group 3 vs. 1: 3.10 (−11.04, 17.23)). Similarly, no differences between accuracy groups were seen in SPADI pain, SPADI function or participant global rating of change. Conclusion. The accuracy of US-guided subacromial corticosteroid injection in SIS does not influence clinical response to the injection, questioning the need for guided injections. Larger, adequately powered studies are required to explore this further

Background

Shoulder impingement syndrome (SIS) is a common debilitating condition, treated across multiple health disciplines including Orthopaedics, Physiotherapy, and Rheumatology. There is little consistency in diagnostic criteria with ‘Shoulder impingement syndrome’ being used for a broad spectrum of complex pathologies. We assessed patterns in diagnostic procedures for SIS across multiple disciplines.

Introduction. Health Economists in Denmark have recently reported low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). Surgeons however are reporting that patients achieve good pain relief and a high standard of activities of daily living (ADL) after surgery. Aim. To evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work. Methods. Prospective cohort study and retrospective review of data from the Nottingham Shoulder database (presentation: 01/04/2008–30/06/2011). Inclusion criteria: Patients diagnosed clinically with SAIS by an experienced shoulder surgeon, who have failed conservative treatment (physiotherapy and sub-acromial injection), undergoing ASAD. Pre-operative and 6-month follow-up Oxford Shoulder Score (OSS) and Constant Score (CS) were compared. The rates of return to pre-operative level of work were also analysed. Statistical analysis: Wilcoxon signed rank test. Results. 73 patients with OSS (51 also with CS documentation) were included. The improvement in median OSS between pre-operative (24) and 6-month follow-up (39) was +15 (Z = −6.726, ∗∗∗, T=6, r=0.55). The difference in median CS between pre-operative (39) and 6-month follow-up (67) was +28 (Z=−5.435, T=6, r=0.59, ∗∗∗). Improvement in median pain score was +5 (7,12, ∗∗∗) median ADL was +5.5 (10.5,16, ∗∗∗) median ROM was +13 (18,31, ∗∗∗) and median strength was +4 (3,7, ∗∗∗). 76% returned to their pre-operative level of work (mean time = 11.5 weeks post surgery). 79% returned to their pre-operative hobbies (mean time = 11.8 weeks post surgery). Conclusion. There is a significant improvement in OSS and CS, 6 months after ASAD in patients with SAIS who have had previous failed conservative treatment. The rate of return to work was good for these patients in contrast to that reported for Danish patients. (∗∗∗ = p< 0.0001 = Highly statistically significant)

Introduction. The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically. Methods. Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test. Results. The median OSS pre-injection was 29 (range 2–43) and post-injection was 40 (range 2–48) (p=< 0.001; z=−6.0; r=−0.5). 45/69 (71%) of patients benefited significantly from subacromial injection at 6 to 12 weeks post-injection. However only 28/53 (53%) benefited significantly from injection by 6 months post-injection. These results support the continued use of sub-acromial corticosteroid injections in the treatment of SAIS. 31% of these patients were subsequently treated with an arthroscopic subacromial decompression operation. Previous injection history had no impact on the results. Conclusions. We recommend that all patients with SAIS should be offered at least one subacromial injection before being considered for an arthroscopic subacromial decompression operation

A total of 92 patients with symptoms for over six months due to subacromial impingement of the shoulder, who were being treated with physiotherapy, were included in this study. While continuing with physiotherapy they waited a further six months for surgery. They were divided into three groups based on the following four clinical and radiological criteria: temporary benefit following steroid injection, pain in the mid-arc of abduction, a consistently positive Hawkins test and radiological evidence of impingement. Group A fulfilled all four criteria, group B three criteria and group C two criteria. A total of nine patients improved while waiting for surgery and were excluded, leaving 83 who underwent arthroscopic subacromial decompression (SAD). The new Oxford shoulder score was recorded pre-operatively and at three and 12 months post-operatively.

A total of 51 patients (group A) had a significant improvement in the mean shoulder score from 18 (13 to 22) pre-operatively to 38 (35 to 42) at three months (p < 0.001). The mean score in this group was significantly better than in group B (21 patients) and C (11 patients) at this time. At one year patients in all groups showed improvement in scores, but patients in group A had a higher mean score (p = 0.01). At one year patients in groups A and B did better than those in group C (p = 0.01).

Arthroscopic SAD is a beneficial intervention in selected patients. The four criteria could help identify patients in whom it is likely to be most effective.

Introduction

Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique.

Purpose: The purpose of this study was to investigate the difference in the level of pre and 6 months post operative objective and subjective measures of disability between patients with full-thickness rotator cuff tears and those with impingement syndrome/partial thickness rotator cuff tears.

Method: This study involved a review of prospectively collected data from a consecutive series of patients who had undergone surgery related to rotator cuff pathology (acromioplasty with or without resection of clavicle for impingement syndrome/partial thickness rotator cuff tears or repair for full-thickness rotator cuff tears). Exclusion criteria included previous surgery, concomitant pathologies, and work-related injuries with an active compensation claim related to the shoulder. Standardized pre and post-operative data (history and clinical examination, including strength assessment) were collected. To measure symptoms and functional levels, all patients completed a disease-specific outcome measure, the Western Ontario Rotator Cuff (WORC) Index which explores five domains of physical symptoms, life style, work, sports, and emotions. Paired and independent non-parametric (Wilcoxon two sample tests, and Wilcoxon signed rank tests) statistics were used where normality of data were violated.

Results: Three hundred and five patients (130 women and 175 men) with a mean age of 58 years (range, 21–82) met inclusion criteria. One hundred and ninety eight (65%) patients had full-thickness rotator cuff tears and 107(35%) had impingement [59 (55%)] or partial thickness rotator cuff tears [48 (45%)]. Patients with full-thickness tears complained of greater weakness, had a higher prevalence of a specific injury such as fall on an outstretched hand, and reported a higher frequency of insidious onset of pain. The full-thickness tear group was significantly weaker in elevation both pre and post-operatively. Patients with impingement syndrome expressed more severe symptoms and more emotional disability prior to surgery and had more physical disability related to lifting and performing activities of daily living and more emotional disability 6 months after surgery. Both groups showed a statistically significant improvement in overall pain, WORC score, and strength 6 months following surgery.

Conclusion: Our results indicate that the extent of rotator cuff pathology and level of physical and emotional disability do not necessarily correlate positively in the early phase of recovery. Patients with less severe rotator cuff pathology tend to be more disabled both before and after surgery. This needs to be considered when planning for return to work and other activities and when assessing treatment outcomes.

Hip arthroscopy has gradually evolved over the past two decades. Recently hip arthroscopy has an increasing role in diagnosis and treatment for specific intra articular and extra articular hip injuries and especially for soft tissue injuries. February 2002 – May 2009. 18 athletes. 5 football players. 8 basketball players. 2 weight lifters. 3 gymnasts. Mean age: 32 y.o. (19–39 y.o.). Undiagnosed hip pain, Osteoarthritis, Labral pathology, Loose bodies, Osteochondral defects, Sepsis, Liga-mentum Teres, Trauma, Synovitis. Symptoms: Deep dull ache pain during hip flexion and external or internal rotation. Decreased R.O.M. 12/18 Cam sign + (positive), 11/18 Pincher sign + (positive), 14/18 Impingement syndrome in adduction and in flexion. Instrumentation and Equipment: 30°, 70°, 4,5mm arthroscope, High flow rate mechanical pump, 15 gauge 6" cardiac needle, Convex full radius chondroplasty blades, Special electrocautery (Philippon), Distraction apparatus, Mechanical water pump unit, Image intensifier. Surgery: Standard orthopaedic traction table, Supine position, Hip is extended and abducted 25°. Portals: Anterior, Anterolateral, Posterolateral. Intraoperative Findings – Results. Detachment of the labrum, 2/18 erosion of the articular cartilage of the acetabulum and drilling of the bare area, 12/18 Cam sign excision. The athletes with symptoms of an internal hip pain and impingement signs after a clinical exam of their hip will get a benefit from an arthroscopic procedure for treating any existing cetabulo-femoral pathology, especially for the athletes with femoraloacetabular impingement syndrome (FAI)

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify ‘neuropathic’ and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively. A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation). The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively). These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests. The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88). The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%). Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°). Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03. An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome. Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis). Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available.

An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly.

Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.

The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.

The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.

Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.

58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)

In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Introduction: Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique.

Methods: Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively.

Results: Since January 2003, 36 hips in 34 patients (average age of 43 years (14–65)) underwent surgical hip dislocation for treatment of FAI. In 9 hips, grade 4 osteoarthritis was present in greater than 10 x 10mm regions after reshaping of the abnormal anatomy. In these cases, hip resurfacing was performed.

Of the 27 hips preserved, 14 had chondral ‘carpet’ flaps debrided, 17 underwent recession of the acetabular rim at the site of impingement, 6 had removal of medial osteophytes, 6 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft.

Oxford Hip Score improved from an average 36 (range 17–59) to 23 (12–45) and McCarthy hip score from 43 (9–74) to 62 (36–72) in the preserved hips at an average 15 months following surgery (range 6–33 months).

Discussion: The early results of surgical hip dislocation are encouraging. Careful patient selection is important in order to exclude patients with hip osteoarthritis. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis.