Objectives. Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade. Methods. A total of 60 patients were included in this prospective randomised study: 30 patients received 2 ml autologous blood drawn from contralateral upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received 2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral epicondyle. Outcome was measured using a pain score and Nirschl staging of lateral epicondylitis. Follow-up was continued for total of six months, with assessment at one week, four weeks, 12 weeks and six months. Results. The corticosteroid injection group showed a statistically significant decrease in pain compared with autologous blood injection group in both visual analogue scale (VAS) and Nirschl stage at one week (both p < 0.001) and at four weeks (p = 0.002 and p = 0.018, respectively). At the 12-week and six-month follow-up, autologous blood injection group showed statistically significant decrease in pain compared with corticosteroid injection group (12 weeks: VAS p = 0.013 and Nirschl stage p = 0.018; six months: VAS p = 0.006 and Nirschl p = 0.006). At the six-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in autologous blood injection group were completely relieved of pain. Conclusions. Autologous blood injection is efficient compared with corticosteroid injection, with less side-effects and minimum recurrence rate

Aims. Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome. Cite this article: Bone Jt Open 2024;5(9):729–735

Aims. Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. Methods. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder. Cite this article: Bone Jt Open 2023;4(3):205–209

Aims. Ultrasound (US)-guided injections are widely used in patients with conditions of the shoulder in order to improve their accuracy. However, the clinical efficacy of US-guided injections compared with blind injections remains controversial. The aim of this study was to compare the accuracy and efficacy of US-guided compared with blind corticosteroid injections into the glenohumeral joint in patients with primary frozen shoulder (FS). Methods. Intra-articular corticosteroid injections were administered to 90 patients primary FS, who were randomly assigned to either an US-guided (n = 45) or a blind technique (n = 45), by a shoulder specialist. Immediately after injection, fluoroscopic images were obtained to assess the accuracy of the injection. The outcome was assessed using a visual analogue scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the subjective shoulder value (SSV) and range of movement (ROM) for all patients at the time of presentation and at three, six, and 12 weeks after injection. Results. The accuracy of injection in the US and blind groups was 100% (45/45) and 71.1% (32/45), respectively; this difference was significant (p < 0.001). Both groups had significant improvements in VAS pain score, ASES score, SSV, forward flexion, abduction, external rotation, and internal rotation throughout follow-up until 12 weeks after injection (all p < 0.001). There were no significant differences between the VAS pain scores, the ASES score, the SSV and all ROMs between the two groups at the time points assessed (all p > 0.05). No injection-related adverse effects were noted in either group. Conclusion. We found no significant differences in pain and functional outcomes between the two groups, although an US-guided injection was associated with greater accuracy. Considering that it is both costly and time-consuming, an US-guided intra-articular injection of corticosteroid seems not always to be necessary in the treatment of FS as it gives similar outcomes as a blind injection. Cite this article: Bone Joint J 2021;103-B(2):353–359

Aims. To describe the incidence of adverse clinical outcomes related to COVID-19 infection following corticosteroid injections (CSI) during the COVID-19 pandemic. To describe the incidence of positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing, positive SARS-COV2 IgG antibody testing or positive imaging findings following CSI at our institution during the COVID-19 pandemic. Methods. A retrospective observational study was undertaken of consecutive patients who had CSI in our local hospitals between 1 February and 30June 2020. Electronic patient medical records (EPR) and radiology information system (RIS) database were reviewed. SARS-CoV-2 RT-PCR testing, SARS-COV2 IgG antibody testing, radiological investigations, patient management, and clinical outcomes were recorded. Lung findings were categorized according to the British Society of Thoracic Imaging (BSTI) guidelines. Reference was made to the incidence of lab-confirmed COVID-19 cases in our region. Results. Overall, 1,656 lab-confirmed COVID-19 cases were identified in our upper tier local authority (UTLA), a rate of 306.6 per 100,000, as of 30June 2020. A total of 504 CSI injections were performed on 443 patients between 1 February and 30June 2020. A total of 11 RT-PCR tests were performed on nine patients (2% of those who had CSI), all of which were negative for SARS-CoV-2 RNA, and five patients (1.1%) received an SARS-CoV-2 IgG antibody test, of which 2 (0.5%) were positive consistent with prior COVID-19 infection, however both patients were asymptomatic. Seven patients (1.6%) had radiological investigations for respiratory symptoms. One patient with indeterminate ground glass change was identified. Conclusion. The incidence of positive COVID-19 infection following corticosteroid injections was very low in our cohort and no adverse clinical outcomes related to COVID-19 infection following CSI were identified. Our findings are consistent with CSI likely being low risk during the COVID-19 pandemic. The results of this small observational study are supportive of the current multi-society guidelines regarding the judicious use of CSI. Cite this article: Bone Joint Open 2020;1-9:605–611

Aims. The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy. Methods. Participants were recruited from two community musculoskeletal treatment centres in the UK. Patients were eligible if aged 18 years or older, and had a clinical diagnosis of subacromial impingement syndrome which the treating clinician thought was suitable for treatment with a subacromial injection. Consenting patients were randomly allocated 1:1 to a patient-blinded subacromial injection of CSI (standard care) or APS. The primary outcome measures of this study relate to rates of recruitment, retention, and compliance with intervention and follow-up to determine feasibility. Secondary outcome measures relate to the safety and efficacy of the interventions. Results. A total of 53 patients were deemed eligible, and 50 patients (94%) recruited between April 2022 and October 2022. Overall, 49 patients (98%) complied with treatment. Outcome data were collected in 100% of participants at three months and 94% at six months. There were no significant adverse events. Both groups demonstrated improvement in patient-reported outcome measures over the six-month period. Conclusion. Our study shows that it is feasible to recruit to a patient-blinded randomized controlled trial comparing APS and CSI for subacromial pain in terms of clinical outcomes and health-resource use in the UK. Safety and efficacy data are presented. Cite this article: Bone Jt Open 2024;5(7):534–542

Aims. The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton’s neuroma (MN). . Patients and Methods. In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (. sd. ) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis. . Results. The mean visual analogue score for pain improved significantly in both groups (Group A – from 64 mm, . sd. 25 mm to 29 mm, . sd. 27; Group B – from 69 mm, . sd. 23 mm to 37 mm, . sd. 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months. . Conclusion. This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN. Take home message: In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results. Cite this article: Bone Joint J 2016;98-B:498–503

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (. sd. 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (. sd. 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (. sd. 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group. We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results

Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

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

Aims. Intra-articular (IA) injection may be used when treating hip osteoarthritis (OA). Common injections include steroids, hyaluronic acid (HA), local anaesthetic, and platelet-rich plasma (PRP). Network meta-analysis allows for comparisons between two or more treatment groups and uses direct and indirect comparisons between interventions. This network meta-analysis aims to compare the efficacy of various IA injections used in the management of hip OA with a follow-up of up to six months. Methods. This systematic review and network meta-analysis used a Bayesian random-effects model to evaluate the direct and indirect comparisons among all treatment options. PubMed, Web of Science, Clinicaltrial.gov, EMBASE, MEDLINE, and the Cochrane Library were searched from inception to February 2023. Randomized controlled trials (RCTs) which evaluate the efficacy of HA, PRP, local anaesthetic, steroid, steroid+anaesthetic, HA+PRP, and physiological saline injection as a placebo, for patients with hip OA were included. Results. In this meta-analysis of 16 RCTs with a total of 1,735 participants, steroid injection was found to be significantly more effective than placebo injection on reported pain at three months, but no significant difference was observed at six months. Furthermore, steroid injection was considerably more effective than placebo injection for functional outcomes at three months, while the combination of HA+PRP injection was substantially more effective at six months. Conclusion. Evidence suggests that steroid injection is more effective than saline injection for the treatment of hip joint pain, and restoration of functional outcomes. Cite this article: Bone Joint J 2024;106-B(6):532–539

Aims. The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection. Methods. The medical records of 500 patients (754 fingers) treated for one or more trigger fingers with a steroid injection or with surgical release, between 1 January 2016 and 1 April 2020 with a follow-up of 12 months, were analyzed. Conversion to surgical release was recorded as an unsuccessful treatment after an injection. The effect of patient- and trigger finger-related characteristics on the outcome of an injection was assessed using stepwise manual backward multivariate logistic regression analysis. Results. Treatment with an injection was unsuccessful in 230 fingers (37.9%). Female sex (odds ratio (OR) 1.87 (95% confidence interval (CI) 1.21 to 2.88)), Quinnell stage IV (OR 16.01 (95% CI 1.66 to 154.0)), heavy physical work (OR 1.60 (95% CI 0.96 to 2.67)), a third steroid injection (OR 2.02 (95% CI 1.06 to 3.88)), and having carpal tunnel syndrome (OR 1.59 (95% CI 0.98 to 2.59)) were associated with a higher risk of conversion to surgical release. In contrast, an older age (OR 0.98 (95% CI 0.96 to 0.99)), smoking (OR 0.39 (95% CI 0.24 to 0.64)), and polypharmacy (OR 0.39, CI 0.12 to 1.12) were associated with a lower risk of conversion. The regression model predicted 15.6% of the variance found for the outcome of the injection treatment (R. 2. > 0.25). Conclusion. Factors associated with a worse outcome following a steroid injection were identified and should be considered when choosing the treatment of a trigger finger. In women with a trigger finger, the choice of treatment should take into account whether there are also one or more patient- or trigger-related factors that increase the risk of conversion to surgery. Cite this article: Bone Joint J 2022;104-B(10):1142–1147

Aims. Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures. Methods. Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes. Results. In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036). Conclusion. There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620–626

Aims. We aimed to establish the short- and long-term efficacy of corticosteroid injection for coccydynia, and to determine if betamethasone or triamcinolone has the best effect. Methods. During 2009 to 2016, we treated 277 patients with chronic coccydynia with either one 6 mg betamethasone or one 20 mg triamcinolone cortisone injection. A susequent injection was given to 62 (26%) of the patients. All were reviewed three to four months after injection, and 241 replied to a questionnaire a mean of 36 months (12 to 88) after the last injection. No pain at the early review was considered early success. When the patient had not been subsequently operated on, and indicated on the questionnaire that they were either well or much better, it was considered a long-term success. Results. At the three- to four-month review, 22 (9%) reported that they had no pain. The long-term success of one injection was 15% and rose to 29% after a second injection. Logistic regression tests showed that both early success (odds ratio (OR) 5.5, 95% confidence interval (CI) 2.1 to 14.4; p = 0.001) and late success (OR 3.7, 95% CI 1.7 to 8.3; p = 0.001) was greater with triamcinolone than with betamethasone. Late success was greater for patients with symptoms for less than 12 months (OR 3.0, 95% CI 1.4 to 6.7; p = 0.006). We saw no complications of the injections. Conclusion. We conclude that the effect of corticosteroid injection for coccygodynia is moderate, possibly because we used modest doses of the drugs. Even so, they seem worthwhile as they are easily and quickly performed, and complications are rare. If the choice is between injections of betamethasone or triamcinolone, the latter should be selected. Cite this article: Bone Joint Open 2020;1-11:709–714

Introduction. Liposomal bupivacaine has been shown to be effective in managing post-operative pain in hallux valgus and hemorrhoid surgery. However, non-industry-supported and well-powered randomized studies evaluating its efficacy in Total Knee Arthroplasty (TKA) are lacking. Our hypothesis was that liposomal bupivacaine would not decrease post-operative visual analog pain scores (VAS) or narcotic consumption in the acute post-operative period. Methodology. Two hundred seven consecutive patients were enrolled into a single-blinded prospective randomized study. We included patients undergoing unilateral TKA by five fellowship-trained surgeons with a diagnosis of osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis. Patients were excluded for any other diagnosis necessitating TKA, allergy to the medications, or pre-operative opiate use. Participants received standardized pain management, anesthesia, and physical therapy. Patients were randomized intra-operatively to one of three groups: an intra-articular (IA) injection of bupivacaine and morphine at the conclusion of the procedure, a peri-articular (PA) injection of a bupivacaine and morphine, or a PA injection of liposomal bupivacaine. Post-operative pain VAS and mean morphine equivalents (MME) consumed were recorded and compared utilizing analysis of variance (ANOVA). A power analysis demonstrated that 159 patients were needed for 80% power to detect a 25% difference in VAS or MME. Results. Patients in each study group had a mean VAS score of 3.95 (SD 2.1), 3.97 (SD 1.9). and 3.86 (SD 1.8) (p=0.94), respectively. MME consumed per day in each group was 100.7 (SD 48.4), 100.1 (SD 42.2), and 98.9 (SD 41.6) (p=0.97). Conclusion. Liposomal bupivacaine does not alter mean pain scores or post-operative narcotic consumption in patients undergoing unilateral TKA. Further, no difference was noted in comparing patients who received a single IA injection versus a PA injection. To our knowledge, this is the first reported study to evaluate post-operative pain control between identical IA and PA injections in patients undergoing unilateral TKA

Aims. There is conflicting evidence on the safety of intra-articular injections of hyaluronic acid (HA) or corticosteroids (CSs) before total knee arthroplasty (TKA). We performed a meta-analysis of the relationship between intra-articular injections and subsequent infection rates after TKA. Methods. We searched PubMed, EMBASE, and the Cochrane Library for cohort studies that assessed the effect of preoperative injection of drugs into the joint cavity on the infection rate after TKA. The outcomes analyzed included the total infection rate, as well as those for different preoperative injection time periods and different drugs. Results. Eight studies, including 73,880 in the injection group and 126,187 in the control group, met the inclusion criteria. The injection group had a significantly higher postoperative infection rate than the control group (risk ratio (RR) 1.16; 95% confidence interval (CI) 1.07 to 1.27; p < 0.001; I. 2. = 32%). For patients who received injections up to three months preoperatively, the postoperative infection risk was significantly higher than that in the control group (RR 1.26; 95% CI 1.18 to 1.35; p＜0.001; I. 2. = 0%). There was no significant difference in the infection rates between the four-to-six-month injection and control groups (RR 1.12; 95% CI 0.93 to 1.35; p = 0.240; I. 2. = 75%) or between the seven-to-12-month injection and control groups (RR 1.02; 95% CI 0.94 to 1.12; p = 0.600; I. 2. = 0%). Conclusion. Current evidence suggests that intra-articular injections of CSs or HA before TKA increase the risk of postoperative infection. Injections administered more than three months before TKA do not significantly increase the risk of infection. Cite this article: Bone Joint Res 2022;11(3):171–179

Aims. Recent studies have suggested that corticosteroid injections into the knee may harm the joint resulting in cartilage loss and possibly accelerating the progression of osteoarthritis (OA). The aim of this study was to assess whether patients with, or at risk of developing, symptomatic osteoarthritis of the knee who receive intra-articular corticosteroid injections have an increased risk of requiring arthroplasty. Methods. We used data from the Osteoarthritis Initiative (OAI), a multicentre observational cohort study that followed 4,796 patients with, or at risk of developing, osteoarthritis of the knee on an annual basis with follow-up available up to nine years. Increased risk for symptomatic OA was defined as frequent knee symptoms (pain, aching, or stiffness) without radiological evidence of OA and two or more risk factors, while OA was defined by the presence of both femoral osteophytes and frequent symptoms in one or both knees. Missing data were imputed with multiple imputations using chained equations. Time-dependent propensity score matching was performed to match patients at the time of receving their first injection with controls. The effect of corticosteroid injections on the rate of subsequent (total and partial) knee arthroplasty was estimated using Cox proportional-hazards survival analyses. Results. After removing patients lost to follow-up, 3,822 patients remained in the study. A total of 249 (31.3%) of the 796 patients who received corticosteroid injections, and 152 (5.0%) of the 3,026 who did not, had knee arthroplasty. In the matched cohort, Cox proportional-hazards regression resulted in a hazard ratio of 1.57 (95% confidence interval (CI) 1.37 to 1.81; p < 0.001) and each injection increased the absolute risk of arthroplasty by 9.4% at nine years’ follow-up compared with those who did not receive injections. Conclusion. Corticosteroid injections seem to be associated with an increased risk of knee arthroplasty in patients with, or at risk of developing, symptomatic OA of the knee. These findings suggest that a conservative approach regarding the treatment of these patients with corticosteroid injections should be recommended. Cite this article: Bone Joint J 2020;102-B(5):586–592

A promising application of Mesenchymal stem cells (MSCs) is the treatment of non-unions. Substituting bone grafts, MSCs are directly injected into the fracture gap. High cell viability seems to be a prerequisite for therapeutic success. Administration of the MSCs via injection creates shear stresses possibly damaging or destroying the cells. Aim of this study was to investigate the effect of the injection process on cell viability. MSCs were isolated and cultivated from femoral tissue of five subjects undergoing arthroplasty. Prior to injection, the cells were identified as MSCs. After dissolving to a concentration of 1 Million cells/ml, 1 ml of the suspension was injected through a cannula of 200 mm length and 2 mm diameter (14 G) with flow rates of 38 and 100 ml/min. The viability of the MSCs at different flow rates was evaluated by staining to detect the healthy cell fraction. It was analyzed statistically against a control group via the Kruskal-Wallis-test and for equivalence via the TOST procedure. Significance level was set to 5 %, equivalence margin to 20 %. The healthy cell fraction of the control group was 85.88 ± 2.98 %, 86.04 ± 2.53 % at 38 ml/min and 85.48 ± 1.64 % at 100 ml/min. There was no significant difference between the fraction of healthy cells (p = 0.99) for different volume flows, but a significant equivalence between the control group and the two volume flows (38 ml/min: p = 0.002, 100 ml/min: p = 0.001). When injecting MSC solutions, e.g. into a non-union, the viability of the injected cells does not deterioriate significant. The injecting technique is therefore feasible

Introduction and Objective. Total shoulder replacement is a common elective procedure offered to patients with end stage arthritis. While most patients experience significant pain relief and improved function within months of surgery, some remain unsatisfied because of residual pain or dissatisfaction with their functional status. Among these patients, when laboratory workup eliminates infection as a possibility, corticosteroid injection (CSI) into the joint space, or on the periprosthetic anatomic structures, is a common procedure used for symptom management. However, the efficacy and safety of this procedure has not been previously reported in shoulder literature. Materials and Methods. A retrospective chart review identified primary TSA patients who subsequently received a CSI into a replaced shoulder from 2011 – 2018 by multiple surgeons. Patients receiving an injection underwent clinical exam, laboratory analysis to rule out infection, and radiographic evaluation prior to CSI. Demographic variables were recorded, and a patient satisfaction survey assessed the efficacy of the injection. Results. Of the 43 responders, 48.8% remembered the injection. The average time from index arthroplasty to injection was median 16.8 months. Overall, 61.9% reported decreased pain, 28.6% reported increased motion, and 28.6% reported long term decreased swelling. Improvement lasted greater than one month for 42.9% of patients, and overall 52.4% reported improvement (slight to great) in the shoulder following CSI. No patient developed a periprosthetic joint infection (PJI) within 2 years of injection. Conclusions. This study suggests that certain patients following TSA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI. Given these findings, further study in a large, prospective trial is warranted to fully evaluate the benefits of CSI following TSA

Purpose. Intra-articular corticosteroid injection is widely used for symptomatic relief of knee osteoarthritis. However, if pain is not improved which consequences a total knee arthroplasty (TKA), there is a potential risk of post-operative periprosthetic joint infection (PJI). The aim of this study is to investigate whether the use of preoperative intra-articular corticosteroid injection increases the risk of PJI and to investigate a time frame in which the risk of subsequent infection is significantly increased. Methods. A systematic search was performed in PubMed (Medline), Scopus, and the Cochrane Library. Inclusion criteria were original studies investigating the rate of PJI in patients receiving pre-operative intra-articular corticosteroid injection compared to controls. Results. A total of 380 unique articles were screened. Six studies met the inclusion criteria with 255,627 patients in total. Overall, no statistical significance was observed in the intra-articular infection rate in corticosteroid compared to controls groups. However, intra-articular corticosteroid injections within 3 months prior to TKA were associated with a significantly increased risk of infection (OR: 1.52, 95% CI 1.37–1.67, p < 0.01); this was not observed in the 6-month period (OR: 1.05, 95% CI 0.80–1.39, p = 0.72). Conclusions. Performing an intra-articular corticosteroid injection within 3 months prior to TKA is associated with a significantly increased risk of PJI. The current evidence supports the safe use of intra-articular corticosteroid injection more than 6 months before TKA. However, additional studies are needed to clarify the risk of PJI after TKA implantation between 3 and 6 months after the last corticoid injection

Lumbar steroid injection can be endorsed as a treatment component for lumbrosacral radicular pain syndrome resulting from disc herniation. The facet joint steroid injection seems to be beneficial for patients with chronic backache due to the facet joint arthritis and in the lumbar Spondylosis. We did a retrospective review of 31 patients whom we treated between 2004 and 2005 with follow up of 6 months to 24 months. There were 19 females and 12 males, aged between 29–81 years. Five patients had previous surgery for simple discectomy to posterior spinal fusion. Four patients had multiple disc prolapse at 3–4 levels, 2 patients had a severe lumbar spondylosis and spinal stenosis. The remaining 20 patients had a single level disc prolapse. All these patients were given caudal and facet joint blocks. The pre and post steroid injection Oswestry score was done. After steroid injection the Oswestry score improved by 30%. Majority of the patients had pain relief for 2–18 months. The pain relief was much better in the non operative group with single level disc pro-lapse and those patients with lumbar spondylosis. In patients with chronic back pain there is an inflammatory basis for pain generation. Lumbar steroid injection seems to be beneficial in patients with disc prolapse and lumbar spondylosis. In the literature various randomized trials have been done and their results are controversial. Our study showed definitive improvement in terms of pain and function of our patient

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

As the intervertebral disc is largely avascular, needle injection is the most practical method for delivery of therapeutic agents used in treatments for degenerative disc disease. Intradiscal pressure increases during injection, and insufficient recovery time prior to needle retraction may result in injectate leakage. In order to determine the maximum pressure and post-injection recovery time for a given injection volume and rate, an analytical model of intradiscal injection was developed and calibrated experimentally. A governing equation was derived defining intradiscal pressure as a function of effective permeability, initial elastic stiffness, nonlinear stiffness term, and injection rate. The equation was solved using a fourth order Runge-Kutta routine with a 0.05s time step and a ramp-dwell injection. The model was calibrated by performing controlled intradiscal injections on five bovine caudal intervertebral discs. Three had adjacent vertebrae intact, while two were separated from vertebrae and constrained between porous stainless steel platens. A syringe driven by a linear actuator was used to inject phosphate buffered saline through a 21g hypodermic needle inserted radially into the disc to a depth of one half of the disc diameter. Injection was performed at a rate of 75μL/s to a volume of 250μL followed by a 240s dwell. Fluid pressure was recorded during both the injection phase and subsequent recovery phase. For each experimental pressure vs time trace, model parameters were varied in order to obtain an optimal fit. The model was run with the average parameter values across a grid of possible injection protocols, with injection volume ranging from 30 to 300μL and injection time ranging from 0.1 to 5s. For each case, peak pressure and time required to reach a 1kPa threshold were recorded. Experimentally measured peak pressure ranged from 68 to 88kPa. Pressure at the end of the 240s dwell ranged from 49 to 69kPa. There was no apparent difference between discs with and without endplates. Leakage of fluid following needle retraction was observed in all specimens. Experimental data were well fit by the analytical model, which predicted higher peak pressure and longer recovery time with increasing volume, from approximately 1500s at 30μL to nearly 3000s at 300μL. The model was nearly insensitive to injection rate. The experimental data confirm pressurization of the disc during injection and injectate leakage resulting from insufficient recovery time. The model predicts that the time required to recover to below threshold leakage pressure is impractically long for both laboratory and clinical injection protocols. Similar behavior with and without endplates confirms that fluid flow is limited by permeability of the tissue itself, not the boundary conditions. Slow recovery is likely attributable to the fact that peak injection pressures were lower than the hydraulic swelling pressure of the nucleus pulposus, which has been reported to be approximately 140kPa. Due to the high swelling pressure of the nucleus pulposus, it is unlikely that intradiscal injection procedures can be performed without substantial injectate leakage following needle retraction

Aims. Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. Methods. OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. Results. Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. Conclusion. There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567–574

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Surgeon-performed periarticular injection and anesthesiologist-performed femoral nerve or adductor canal block with local anesthetic have been used in multimodal pain management for total knee arthroplasty (TKA) patients. Anesthesiologist-performed adductor canal blocks are costly, time consuming, and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve (“adductor-canal”) block from within the knee joint. A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. Using a blunt tip 1.5cm needle, we injected 10 ml each of two different colored solutions at two different intra-articular medial injection locations, and after 30 minutes, dissected the femoral and saphenous nerve and femoral artery from the hip to the knee to determine the location of the injections. Based upon the MRI analysis, the saphenous nerve was located (and had exited the adductor canal) at a mean of 1.5 times the epicondylar width in females, and mean 1.3 times the epicondylar width in males, proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in 8 of 11 specimens. The proximal blunt needle and solution was adjacent, but did not puncture, the femoral artery and vein in only one specimen. This study suggests that a surgeon-performed injection of the saphenous nerve from within the knee is a feasible procedure. This technique may be a useful alternative to ultrasound guided block. A trial comparing surgeon and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure. Our anecdotal use of this intra-articular injection over the past year has been favorable. Newer, extended release anesthetic agents should be investigated with this technique

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery

Aims. The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results. A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days . (sd. 46.5) and 47 days . (sd. 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm . (sd. 10.3) and a mean VAS for arm pain of 6.3 mm . (. sd. 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (. sd. 12.4; p < 0.001); mean NPAD, 19.3 (. sd. 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (. sd. 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (. sd. 6.8; p = 0.103). Conclusion. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71

Purposes: To determine the effect of gravity on outcome in sacral epidurals injected in the prone compared to the lateral position in patients with unilateral back related leg pain. Methods: A randomised controlled trial with 2 arms. This pilot study was conducted to determine the standard deviation (SD) of the primary outcome measure to allow calculation of a final sample size. Forty patients who met the inclusion/exclusion criteria were randomly allocated to prone or lateral sacral epidural injection. Twenty patients were allocated to the prone and 20 to the left or right lateral position dependent on their radicular back pain. The primary outcome measure of back and leg pain severity was assessed using a visual analogue scale (VAS) (0= none, 10 = worst imaginable). The Oswestry disability index, SF-36 and straight leg raise were also measured. Outcomes were assessed at baseline and at 6 and 12 week follow-up. A repeated measures analysis using mixed model methodology was used to determine statistical significance. Results: The 2 groups were comparable in gender and age. The prone group had a mean improvement in VAS back pain score at 6 weeks follow-up of 0.5 compared to 1.6 in the lateral group. At 12 weeks follow-up there was a negative response of 0.1 compared to baseline in the prone group and 1.4 improvement in the lateral group. Repeated measures analysis showed no significant difference in back pain scores between the groups at the 5% level (F2,38 = 3.24; P = 0.0797). Similarly mean improvement in VAS leg pain scores at 6 weeks follow-up were 1.4 in the prone group and 1.7 in the lateral group. At 12 weeks follow-up the scores were 1.1 for the prone and 2.4 for the lateral group. Repeated measures analysis showed no significant difference in leg pain scores between the groups (F1,38= 0.76; P = 0.3898). A post-hoc power calculation using the sample VAS SD showed we had reached only 65% power. Conclusion: This pilot study has shown that sacral epidural injection for sciatica in the lateral position gives superior pain relief compared to the prone position but the difference is not statistically significant. More patients will now be recruited in order to minimise a type II error that may have occurred

Aims. Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA. Methods. We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. A total of 187 patients were randomly assigned to receive periarticular injection containing either a corticosteroid (CS group) or without corticosteroid (no-CS group). Other perioperative interventions were identical for all patients. The primary outcome was postoperative pain at rest during the initial 24 hours after surgery. Pain score was recorded every three hours until 24 hours using a 100 mm visual analogue scale (VAS). The primary outcome was assessed based on the area under the curve (AUC). Results. The CS group had a significantly lower AUC postoperatively at 0 to 24 hours compared to the no-CS group (AUC of VAS score at rest 550 ± 362 vs 392 ± 320, respectively; mean difference 158 mm; 95% confidence interval (CI) 58 to 257; p = 0.0021). In point-by-point evaluation, the CS group had significantly lower VAS scores at 12, 15, 18, 21, 24, and 48 hours. There were no significant differences in complication rates, including surgical site infection, between the two groups. Conclusion. The addition of corticosteroid to periarticular injections reduces postoperative pain without increasing complication rate following THA. Cite this article: Bone Joint J 2020;102-B(10):1297–1302

Introduction and Objective. Osteoarthritis (OA) is the most common inflammatory and degenerative joint disease. Mesenchymal Stromal Cells (MSCs), with their chondro-protective and immune-regulatory properties, have been considered as a new approach to treat OA. Considering the risk of cell leakage outside the articular space and the poor survival rate after intra-articular (IA) injection, we hypothesized that cell encapsulation in cytoprotective hydrogels could overcome these limitations and provide cells with a suitable 3D microenvironment supporting their biological activity. We previously generated micromolded alginate particles (diameter 150 μm) and demonstrated the long-term viability of microencapsulated MSCs isolated from human adipose tissue (hASCs). Encapsulated cells maintained their in vitro ability to sense and respond to a pro-inflammatory environment (IFN-γ/TNF-α or synovial fluids from OA patients) by secreting PGE. 2. , IDO, HGF and TGF-β. In this study, we evaluated the anti-OA efficacy of these microencapsulated hASCs in a post-traumatic OA model in rabbits. Materials and Methods. OA was surgically induced by anterior cruciate ligament transection (ACLT)-mediated destabilization of the right knee in rabbits (n=24). Eight weeks after surgery, destabilized joints were injected (IA, 26G needle) with 200 μL of either PBS, blank microparticles, non-encapsulated or microencapsulated cells (5×10. 5. cells). Six weeks after injection, rabbits were euthanized and all destabilized (right) and sham-operated (left contralateral) joints were dissected and analyzed for OA severity. Tibial subchondral bone histomorphometric parameters were measured by quantitative micro-computed tomography (micro-CT). Histological sections of samples were analyzed after Safranin-O staining and quantitatively assessed according to a modified Osteoarthritis Research Society International (OARSI) scoring system. Immunohistochemical detection of NITEGE was performed to assess the extracellular matrix degradation. Results. Micro-CT analysis of destabilized joints confirmed that the rabbit ACLT significantly affected the tibial subchondral bone architecture as early as eight weeks, as revealed by significant changes of the subchondral bone parameters of operated joints compared to the sham operated joints. In particular, destabilized joints exhibited a Bone Volume/Tissue Volume ratio (BV/TV) ranging from 53.4% to 56.6%, compared to a mean BV/TV of 65.4% for sham operated joints. All destabilized joints also exhibited a significantly increased modified OARSI score, ranging from 7.4±0.4 for those injected with encapsulated cells to 8.9±0.2 for those injected with PBS, as compared to 4.8±0.4 for sham-operated joints. Of interest, we identified a slight, while not significant, reduction of the severity of OA lesions after injection of microencapsulated cells using the modified OARSI scoring. Finally, semi-quantitative analysis of NITEGE immunostaining revealed a significant increase in all destabilized joints that were injected with PBS or blank microparticles, in comparison with sham ones. On the contrary, NITEGE immunostaining in destabilized joints that were injected with non-encapsulated or encapsulated hASC revealed a significant reduced NITEGE immunostaining, indicating a decreased matrix degradation. Conclusions. Our data suggest that the microencapsulated hASCs exerted their anti-OA properties after IA injection in rabbit knees, as evidenced by the tendency toward a reduced modified OARSI score, and most importantly a significant reduction in NITEGE immunostaining associated matrix degradation. Further studies are now warranted to investigate the anti-OA efficacy of microencapsulated hASCs in the long-term

To compare the efficacy of local steroid injection with surgical decompression in treatment of carpal tunnel syndrome (CTS) in terms of frequency of pain. This randomized controlled study was conducted at the Department of Orthopaedics for a duration of 01 year, i.e. from 20th April 2016 to 19th April 2017. 130 patients with carpal tunnel syndrome with moderate (Grade 2) and severe (Grade 3) pain were included. Lottery method was used to allocate the patients randomly into two groups. Group A contained 65 patients who were subjected to surgical decompression and 65 patients were in Group B who were injected with local steroid injection. Complete history was obtained from all patients. All the surgical decompressions through mini incision technique and injections procedures were performed. Information were recorded in a pre designed Performa. Efficacy was observed significantly high in group B as compared to group A (87.7% vs. 72.3%, p=0.028). Carpal Tunnel syndrome symptoms were alleviated with surgical decompression as well as local steroid injection at a follow up done after 1 month. However the steroid injections seem to have greater efficacy than surgical decompression, hence we suggest it for routine treatment of all patients with CTS. For any reader queries, please contact . virgo_r24@hotmail.com

Introduction. Recovery after total knee arthroplasty (TKA) may take longer than patients expect. Furthermore, there are a subset of patients who still experience pain and dissatisfaction despite normal physical examination, radiographs, and laboratory analysis. Corticosteroid injection (CSI) is commonly used nonsurgical treatment for painful knee arthritis. However, the efficacy of CSI in patients with a painful TKA remains unknown. Methods. A retrospective charge review was performed to identify a cohort of patients who had a primary TKA performed between 2015 and 2016 and later received a CSI. All TKAs and CSIs were performed by a fellowship-trained arthroplasty surgeon. Patients receiving a CSI underwent a clinical exam, laboratory analysis to rule out infection, and radiographic evaluation prior to injection. Patient variables were recorded and a survey assessed the efficacy of the injection. The survey response rate was 63.6%. Results. Of the 119 responders, 81.5% remembered the injection. The average time from index arthroplasty injection was 16.9 months (range 1–133) and patients received 1.3 averaged CSIs (range 1–4). Overall, 77.3% reported decreased pain, 54.6% reported increased motion, and 60.8% reported decreased swelling. The relief lasted greater than three months for 53.6% of patients, and 84.6% reported improvement (slight to great) in the knee. The rate of patient reported adverse events was 5.0% and included pruritus, pain, decreased energy, swelling, and clicking. No patients developed PJI as a result of the injection. Conclusions. The results of this survey suggest that patients with a painful and/or swollen TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out recognizable etiologies (i.e. infection, loosening, instability). This study certainly has its limitations but it is the only study of its kind. The authors hope that this provides impetus for further research regarding this investigation

Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure. A total of 76 cadaver acromioclavicular joints were injected with a solution containing methyl blue and subsequently dissected to distinguish intra- from peri-articular injection. In order to assess the importance of experience in achieving accurate placement, half of the injections were performed by an inexperienced resident and half by a skilled specialist. The specialist injected a further 20 cadaver acromioclavicular joints with the aid of an image intensifier. The overall frequency of peri-articular injection was much higher than expected at 43% (33 of 76) overall, with 42% (16 of 38) by the specialist and 45% (17 of 38) by the resident. The specialist entered the joint in all 20 cases when using the image intensifier. Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection

Introduction. Ostochondral lesion of the knee is a common cause of chronic knee pain. Arthroscopic treatment with subcondral microfracture is a widespread technique leading to noticeable improvement of knee function and pain. To improve the effectiveness of this treatment options, we thought to add intra (PRF) or post-operative (PRP) growth factors. Platelet rich plasma (PRP) is obtained by centrifugation of the blood to produce a plasma with high concentration of platelets and growth factors. This latter represents a promising method to manage degenerative cartilage lesion and can be used postoperatively to improve clinical results of patients treated arthroscopically. Platelet Rich Fibrin (PRF) has been presented as a second-generation platelet concentrate, and it is used intraoperatively to cover the microfracuteres’ holes. No literature was found about using of PRF intraoperative in association with arthroscopic microfracture technique. The aim of this study is to compare clinical outcomes of the treatment of knee osteochondral lesion using arthroscopic microfracture technique alone or in association with PRF Intraoperative application using “Vivostat” system or with PRP “ReGen Lab” postoperative injection. Patients & Methods. 90 patients with clinical and radiographic evidence of osteochondral lesion of the medial or lateral compartment of the knee were enrolled. All patients received arthroscopic debridement and Microfractures and were randomised into 3 groups: 30 patients received microfractures and intraoperative PRF “Vivostat” injection(Group A), 30 patients received microfracture and 3 intra-articular injections of 5.5 mL PRP “Regen”(Group B), 30 patients received microfracture only. IKDC, KOOS and VAS score were administered to all patients before starting the treatment, at 1, 6 and 12 months from the end of the management. Results. Patients who received microfracture and PRF intraoperative application provided the best outcomes, showing a significant higher clinical scores (P<0.001) compared to the other two groups. Patients underwent PRP postoperative administration reported significant higher score than those undergoing arthroscopic microfracture alone (P<0.005), but lesser than Intraoperative PRF group at 6 months and 1 year follow up. Discussion/Conclusion. Treatment of osteochondral lesions of the knee using microfracture technique significantly improved functional and pain scores from the pre- to postoperatively time in the overall cohort. Intraoperative application of PRF shows significantly better outcome than postoperative PRP injections. However, additional treatment with intra-articular PRP injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone

Introduction. Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures. Materials & Methods. Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-G. TM. (bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing. Results. Follow-up at 6 months showed all fractures had healed with no defect or gaps with evidence of new trabecular bone and significant resorption of Cerament-G. TM. at final follow-up. There was no evidence of residual infection with restoration of normal limb function. Fractures with no internal fixation showed a mild deformity that had developed during the course of the healing, presumed due to mild collapse in the absence of fixation. These were less than 10 degrees in sagittal and coronal planes and were clinically felt to be insignificant by the patients. Conclusions. Cerament-G's unique combination of high dose antibiotics and hydroxy apatite matrix provided by calcium sulphate might help provide an osteoconductive environment to allow these stiff non-unions to heal. The matrix appears to provide a scaffold-like structure that allows new bone in-growth with local release of antibiotics helping reduce deep-seated infections. The final deformation at fracture site underlines the need for fixation- and it is very unlikely that this technique will work in mobile nonunions. Whilst similar fractures may heal without the use of bone substitute injections, the speed of healing in presence of significant fracture gap suggests the use of these bone substitutes did help in our cases. Further studies with a larger cohort, including RCTs, to evaluate the effectiveness of this technique compared to other methods are needed

Aims. Using a systematic review, we investigated whether there is an increased risk of post-operative infection in patients who have received an intra-articular corticosteroid injection to the hip for osteoarthritis prior to total hip arthroplasty (THA). Methods. Studies dealing with an intra-articular corticosteroid injection to the hip and infection following subsequent THA were identified from databases for the period between 1990 to 2013. Retrieved articles were independently assessed for their methodological quality. Results. A total of nine studies met the inclusion criteria. Two recommended against a steroid injection prior to THA and seven found no risk with an injection. No prospective controlled trials were identified. Most studies were retrospective. Lack of information about the methodology was a consistent flaw. Conclusions. The literature in this area is scarce and the evidence is weak. Most studies were retrospective, and confounding factors were poorly defined or not addressed. There is thus currently insufficient evidence to conclude that an intra-articular corticosteroid injection administered prior to THA increases the rate of infection. High quality, multicentre randomised trials are needed to address this issue. Cite this article: Bone Joint J 2016;98-B:1027–35

Objectives. Recent studies have shown that systemic injection of rapamycin can prevent the development of osteoarthritis (OA)-like changes in human chondrocytes and reduce the severity of experimental OA. However, the systemic injection of rapamycin leads to many side effects. The purpose of this study was to determine the effects of intra-articular injection of Torin 1, which as a specific inhibitor of mTOR which can cause induction of autophagy, is similar to rapamycin, on articular cartilage degeneration in a rabbit osteoarthritis model and to investigate the mechanism of Torin 1’s effects on experimental OA. Methods. Collagenase (type II) was injected twice into both knees of three-month-old rabbits to induce OA, combined with two intra–articular injections of Torin 1 (400 nM). Degeneration of articular cartilage was evaluated by histology using the Mankin scoring system at eight weeks after injection. Chondrocyte degeneration and autophagosomes were observed by transmission electron microscopy. Matrix metallopeptidase-13 (MMP-13) and vascular endothelial growth factor (VEGF) expression were analysed by quantitative RT-PCR (qPCR).Beclin-1 and light chain 3 (LC3) expression were examined by Western blotting. Results. Intra-articular injection of Torin 1 significantly reduced degeneration of the articular cartilage after induction of OA. Autophagosomes andBeclin-1 and LC3 expression were increased in the chondrocytes from Torin 1-treated rabbits. Torin 1 treatment also reduced MMP-13 and VEGF expression at eight weeks after collagenase injection. Conclusion. Our results demonstrate that intra-articular injection of Torin 1 reduces degeneration of articular cartilage in collagenase-induced OA, at least partially by autophagy activation, suggesting a novel therapeutic approach for preventing cartilage degeneration and treating OA. Cite this article: N-T. Cheng, A. Guo, Y-P. Cui. Intra-articular injection of Torin 1 reduces degeneration of articular cartilage in a rabbit osteoarthritis model. Bone Joint Res 2016;5:218–224. DOI: 10.1302/2046-3758.56.BJR-2015-0001

Objective . Dunkin Hartley guinea pigs, a commonly used animal model of osteoarthritis, were used to determine if high frequency ultrasound can ensure intra-articular injections are accurately positioned in the knee joint. Methods. A high-resolution small animal ultrasound system with a 40 MHz transducer was used for image-guided injections. A total of 36 guinea pigs were anaesthetised with isoflurane and placed on a heated stage. Sterile needles were inserted directly into the knee joint medially, while the transducer was placed on the lateral surface, allowing the femur, tibia and fat pad to be visualised in the images. B-mode cine loops were acquired during 100 µl. We assessed our ability to visualise 1) important anatomical landmarks, 2) the needle and 3) anatomical changes due to the injection. . Results. From the ultrasound images, we were able to visualise clearly the movement of anatomical landmarks in 75% of the injections. The majority of these showed separation of the fat pad (67.1%), suggesting the injections were correctly delivered in the joint space. We also observed dorsal joint expansion (23%) and patellar tendon movement (10%) in a smaller subset of injections. Conclusion. The results demonstrate that this image-guided technique can be used to visualise the location of an intra-articular injection in the joints of guinea pigs. Future studies using an ultrasound-guided approach could help improve the injection accuracy in a variety of anatomical locations and animal models, in the hope of developing anti-arthritic therapies. Cite this article: Bone Joint Res 2015;4:1–5

Abstract. Introduction. To compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI) with bupivacaine in total knee arthroplasty. Methods. 90 patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine) and ACB + PAI. Primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physiotheraphy, length of hospital stay and ROM. Results. Mean VAS pain score was significantly higher with ACB alone, compared with the score after use of ACB+PAI, on POD1 and POD3. Total opioid consumption through POD3 was significantly higher when ACB alone had been used compared with PAI alone and ACB+PAI. Opioid consumption in the ACB-alone group was significantly higher than that in the ACB + PAI group on POD2 and POD3 and significantly higher than that in the PAI alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB + PAI. The activity level during physiotherapy on POD0 was significantly lower after use of ACB alone than after use of PAI alone or ACB + PAI. Conclusion. Higher pain scores after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between ACB alone, PAI alone and ACB + PAI inparameters measured

Introduction. Peri-articular local anesthetic injections reduce post-operative pain in total knee arthroplasty and assist recovery. It is inconclusive whether intra-operative injection of peri-articular morphine is locally effective. The aim of this study is whether the addition of morphine to peri-articular injections in only unilateral knee improves post-operative pain, range of motion, swelling in patients with simultaneous bilateral total knee arthroplasty. Materials and Methods. A prospective single-center double-blinded randomized controlled trial was undertaken to assess the local efficacy of adding morphine to intra-operative, peri-articular anesthesia in simultaneous bilateral total knee arthroplasty. Twenty eight patients with 56 TKAs were randomly divided into 2 groups, unilateral TKA with intraoperative peri-articular injection with adding morphine and the other side TKA without adding morphine. The morphine group received an intraoperative, peri-articular injection of local anesthetic (Ropivacaine 150mg), epinephrine (50μg), ketoprofen (25mg) and methylpredonisolone sodium (20mg) plus 0.1mg/kg of morphine. The no-morphine group received the same amount of local anesthetic, epinephrine, ketoprofen and methylpredonisolone sodium without morphine. The operating surgeon, operating staff, patients, physiotherapists, ward nursing staff and data collectors remained blinded for the duration of study. All surgeries were performed by the same operating team. A standard medial parapatellar approach was used in all operations. Post-operative analgesia was standardized to all participants with celecoxib daily for 3 weeks. Primary outcomes included visual analog pain scores (VAS), ROM and swelling of the thigh. Secondary outcomes included WOMAC and adverse outcomes. Result. There were no significant differences between two groups for pre-operative ROM, pre-operative pain VAS or the circumference of the thigh. There were no statistically significant differences in primary and secondary outcomes between two groups (Figure 1, 2, 3). Discussion. Multiple studies have demonstrated the clinical efficacy of multimodal peri-articular injection of analgesics in TKA for pain relief. However, the opioids often lead to nausea as an adverse effect, which is reported from 25% to 56%. The mechanism of pain relief by morphine is mainly the efficacy through the opioid receptor in central nerve system, and the other mechanism through local opioid receptor (μ-receptor) is rarely revealed for pain relief. Our study used morphine in unilateral TKA and no-morphine in the other side TKA and showed no significant difference in primary and secondary outcomes. These results revealed that the efficacy for pain relief in peri-articular injection without morphine is the same as that in no-morphine group. In conclusion, adding morphine in peri-articular injection could not be locally effective for pain relief

Background. Clinical guidelines recommend epidural steroid injection (ESI) as a treatment option for severe disc-related sciatica, but there is considerable uncertainty about its effectiveness. Currently, we know very little about factors that might be associated with good or poor outcomes from ESI. The aim of this systematic review was to synthesize and appraise the evidence investigating prognostic factors associated with outcomes following ESI for patients with imaging confirmed disc-related sciatica. Methods. The search strategy involved the electronic databases Medline, Embase, CINAHL Plus, PsycINFO and reference lists of eligible studies. Selected papers were quality appraised independently by two reviewers using the Quality in Prognosis Studies (QUIPS) tool. Between study heterogeneity precluded statistical pooling of results. Results. 2726 citations were identified; 11 studies were eligible. Overall study quality was low with all judged to have moderate or high risk of bias. Forty-five prognostic factors were identified but were measured inconsistently. The most commonly assessed prognostic factors were related to pain and function (n=7 studies), imaging features (n=6 studies), health and lifestyle (n=5 studies), patient demographics (n=4 studies) and clinical assessment findings (n=4 studies). No prognostic factor was found to be consistently associated with outcomes following ESI. Most studies found no association or results that conflicted with other studies. Conclusions. There is little, and low quality, evidence to guide practice in terms of factors that predict outcomes in patients following ESI for disc-related sciatica. The results can help inform some of the decisions about potential prognostic factors that should be assessed in future well-designed prospective cohort studies. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery. There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar

Introduction. Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic. Materials and methods. We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections. Results. Overall 410/446 (92%) patients reported a significant improvement in symptoms and 227 (62%) reported complete resolution of their pain, with 127 (28%) remaining asymptomatic at two year follow-up. The mode time of recurrence of pain was three months. 59 (13%) underwent a further injection and 102 (23%) underwent operative intervention within the follow-up period. There were no reported infections. Complications occurred in two percent of patients, including steroid flare, pain and plantar plate ruptures. Conclusion. Injections are a safe and effective option for treating a variety of foot and ankle conditions and reduce the need for surgery. They are particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than three months in conditions such as plantar fasciitis and hallux rigidus

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

In atrophic non-union models, a minimally invasive technique is used to deliver stem cells into the fracture site via percutaneous injection. This technique is significantly affected by a backflow leakage and the net number of cells might be reduced. The Z-track method is a technique used in clinical practice for intramuscular injections to prevent backflow leakage. We evaluated the potential of the Z-track injection technique for preventing cell loss in non-union models by determining the behaviour of observable marker fluids. Firstly, toluene blue stain was used as an injection material to allow visual detection of its distribution. Rat's cadaver legs were used and tibias were kept unbroken to ensure intact skin and overlying soft tissue. Technique includes pulling the skin over the shin of tibia towards the ankle and injection of the dye around the mid-shaft. The needle was then partially pulled back, the skin was returned to its normal position and a complete extraction of the needle was followed. Secondly, a mixture of contrast material and toluene blue was used to allow direct visual and radiological detection of the injected material into the fracture site. Ante-grade nailing of tibia via tibial tuberosity was carried out followed by a 3 point closed fracture. Injection was performed into the fracture gap similarly to the steps above. X-rays were taken to visualise the location and distribution of the injected material. Observation revealed no blue stain could be detected over the skin, X -rays revealed that the radiopaque dye remained around the tibia with no escape of the material into the superficial layers or onto the skin surface. Therefore, the number of cells delivered and maintained at a target site could be increased by the Z-track method and therefore, the therapeutic benefit of stem cell injections could be optimised with this simple technique

Aim. Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model. Materials and Methods. Two months after bilateral section of the ACL of Japanese white rabbits aged nine months or more, either phosphate buffered saline (PBS) or 1 x 10. 6. MSCs were injected into the knee joint in single or three consecutive doses. After two months, the articular cartilage and meniscus were assessed macroscopically, histologically, and immunohistochemically using collagen I and II. Results. Within the PBS injection (control group), typical progressive degenerative changes were revealed in the various knee structures. In the single MSC injection (single group), osteoarthritic changes were attenuated, but still appeared, especially in the medial compartments involving fibrillation of the articular cartilage, osteophyte formation in the medial plateau, and longitudinal tear of the meniscus. In the multiple-injections group, the smoothness and texture of the articular cartilage and meniscus were improved. Histologically, absence or reduction in matrix staining and cellularity were noticeable in the control and single-injection groups, respectively, in contrast to the multiple-injections group, which showed good intensity of matrix staining and chondrocyte distribution in the various cartilage zones. Osteoarthritis Research Society International (OARSI) scoring showed significantly better results in the multiple-injections group than in the other groups. Immunohistochemically, collagen I existed superficially in the medial femoral condyle in the single group, while collagen II was more evident in the multiple-injections group than the single-injection group. Conclusion. A single injection of MSCs was not enough to restore the condition of osteoarthritic joints. This is in contrast to multiple injections of MSCs, which had the ability to replace lost cells, as well as reducing inflammation. Cite this article: Bone Joint J 2019;101-B:824–831

Aims. The aim of this study was to compare the efficacy of a corticosteroid injection for the treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud’s phenomenon. Patients and Methods. In a prospective study, 139 patients with CTS were treated with a corticosteroid injection (10 mg triamcinolone acetonide); 34 had Raynaud’s phenomenon and 105 did not (control group). Grip strength, perception of touch with a Semmes-Weinstein monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the injection

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA. . A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve. . The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively. . The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection. Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA. Cite this article: Bone Joint J 2016;98-B:194–200

Aims. This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients. Methods. With informed owner consent, adipose tissue collected from adult dogs diagnosed with degenerative joint disease was enzymatically digested and cultured to passage 1. A small portion of cells (n = 4) surplus to clinical need were characterized using flow cytometry and tri-lineage differentiation. The impact and degree of osteoarthritis (OA) was assessed using the Liverpool Osteoarthritis in Dogs (LOAD) score, Modified Canine Osteoarthritis Staging Tool (mCOAST), kinetic gait analysis, and diagnostic imaging. Overall, 28 joints (25 dogs) were injected with autologous AdMSCs and PRP. The patients were followed up at two, four, eight, 12, and 24 weeks. Data were analyzed using two related-samples Wilcoxon signed-rank or Mann-Whitney U tests with statistical significance set at p < 0.05. Results. AdMSCs demonstrated stem cell-like characteristics. LOAD scores were significantly lower at week 4 compared with preinjection (p = 0.021). The mCOAST improved significantly after three months (p = 0.001) and six months (p = 0.001). Asymmmetry indices decreased from four weeks post-injection and remained significantly lower at six months (p = 0.025). Conclusion. These improvements in quality of life, reduction in pain on examination, and improved symmetry in dogs injected with AdMSCs and PRP support the effectiveness of this combined treatment for symptom modification in canine OA for six months. Cite this article: Bone Joint Res 2021;10(10):650–658

Intra-articular injections of steroid into the hip are used for a variety of reasons in current orthopaedic practice. Recently their safety prior to ipsilateral total hip replacement has been called into question owing to concerns about deep joint infection. We undertook a retrospective analysis of all patients who had undergone local anaesthetic and steroid injections followed by ipsilateral total hip replacement over a five-year period. Members of the surgical team, using a lateral approach to the hip, performed all the injections in the operating theatre using a strict aseptic technique. The mean time between injection and total hip replacement was 18 months (4 to 50). The mean follow-up after hip replacement was 25.8 months (9 to 78), during which time no case of deep joint sepsis was found. In our series, ipsilateral local anaesthetic and steroid injections have not conferred an increased risk of infection in total hip replacement. We believe that the practice of intra-articular local anaesthetic and steroid injections to the hip followed by total hip replacement is safer than previously reported

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

To study in resolution of triggering 12 months after injection with either a soluble methylprednisolone acetate or dexamethasone for idiopathic trigger finger. Twenty-eight patients were enrolled in a prospective randomized controlled trial comparing methylprednisolone acetate and dexamethasone injection for idiopathic trigger finger. Twenty-seven patients completed the 6-week follow-up (11 methylprednisolone acetate arm, 16 dexamethasone arm) and thirteen patients completed the 3-month follow-up (4 methylprednisolone acetate arm, 9 dexamethasone arm). Outcome measures included resolution of triggering, recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up. Eight patients were repeated a second injection (3 methylprednisolone acetate arm, 5 dexamethasone arm) at 6-week follow-up. To preserve autonomy, patients were permitted operative treatment any time. The analysis was according to intention to treat principles. Six weeks after injection. Absence of triggering was documented in 6 of 11 patients in the methylprednisolone cohort and in 6 of 16 patients in the dexamethasone cohort. The rate 3-month after injection were 2 of 4 patients in the methylprednisolone cohort and in 8 of 9 patients in the dexamethasone cohort. There were no significant difference between recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) scores and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up. Although there were no differences 3months after injection, our data suggest that in the dexamethasone cohort was better in resolution of triggering than the methylprednisolone cohort at 12-week follow-up

Immunosuppression following intra-articular injections of steroid into the hip may interfere with asepsis in a subsequent total hip arthroplasty (THA). We have undertaken a retrospective, matched, cohort study of infective complications after THA, in 40 patients who had received such an injection and 40 who had not. In the injection group there were five revisions, four of which were for deep infection. There were none in the matched group. The overall rate of revision in our database of 979 primary THAs was 1.02%. Six additional patients who had received injections underwent investigation for infection because of persistent problems in the hip as compared with one in the control group

This in vivo controlled laboratory study was performed to evaluate various intra-articular clinical injection regimes that might be less toxic than some in vitro studies suggest. We hypothesised that low-concentration, preservative-free, pH-balanced agents would be less toxic than high-concentration non-pH-balanced agents with preservatives, and that injections of individual agents are less toxic than combined injections. The left knees of 12- to 13-week-old Sprague–Dawley rats were injected once with eight different single agents, including low and high concentrations of ropivacaine and triamcinolone, alone and in combination, as well as negative and positive controls. The rats were killed at one week or five months, and live–dead staining was performed to quantify the death of chondrocytes. All injections except pH-balanced 0.2% ropivacaine combined with preservative-free 1 mg/ml triamcinolone acetonide resulted in statistically significant decreases in chondrocyte viability, compared with control knees, after one week and five months (p < 0.001). After one week there was no significant difference in viability between 0.2% and 0.5% ropivacaine; however, 4 mg/ml triamcinolone resulted in a lower viability than 1 mg/ml triamcinolone. Although many agents commonly injected into joints are chondrotoxic, in this in vivo study diluting preservative-free 10 mg/ml triamcinolone 1:9 in 0.2% pH-balanced ropivacaine resulted in low toxicity. Cite this article: Bone Joint J 2015; 97-B:933–8

Background. Greater trochanteric pain syndrome (GTPS) is a common problem affecting 10–25% of the population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, all with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential management option for this difficult presentation. Method. We ran a prospective, 2 arm, single blinded, randomised control trial comparing focused shockwave therapy to an ultrasound guided corticosteroid injection. The primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris hip score and Trendelenburg test for function; the SF-36 for quality of life (QoL); and a Likert scale question for a subjective assessment of symptom improvement. Results. 104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image guided injection. 11 patients were lost to follow up. Baseline scores were equal between the groups. At 3 months, pain, function and QoL scores had improved in both groups. The Trendelenburg test was significantly improved in the ESWT group with 80% patients being negative compared to 80% positive at baseline (p<0.001). At 12 months, the improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline. Across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 3.71 versus 5.50 (p=0.007, 95% confidence interval 0.63 to 3.08), HHS 69.7 vs 57.5 (p=0.002, 95% confidence interval −20.0to −4.6) and SF-36 52.4 vs 47.7 (p=0.048, 95% confidence interval −9.31 to −0.04). Conclusions. We have shown focused ESWT is an effective treatment for patients with GTPS. We hope to advocate ESWT as an effective non-invasive treatment modality for this challenging patient population

Introduction Cortisone injection for radicular leg pain may be useful in treating patients with lumbar foraminal pathology based on accurate CT/MRI diagnosis and operator-controlled biplanar fluoroscopy in an angiography suite. Methods Patient details were collected from operative records and angiography suite records. Demographic data, diagnosis and level of injection were recorded. Low Back Outcome Scores were collected prospectively for most patients. Patients were telephoned and then posted a questionnaire including the LBOS. Taranaki Ethics Committee approval was obtained. Patients were excluded from further analysis, following a single fluoroscopically-controlled foraminal injection of 80 mg triamcinolone for radiculopathy, if further injection or surgery was required. Results Between 1995 and 2004, 58 patients, all with CT or MRI diagnosis, underwent lumbar foraminal steroid injection. Thirty-seven had disc protrusion (64%) and twenty-one had stenosis (36%). Eighteen (31%) required further intervention (six: repeat injection, 3: discectomy, 8: decompression), in eleven patients with stenosis (52%) and seven patients with disc protrusion (19%). Forty patients had no further intervention. Thirty-two patients (80%) completed follow-up questionnaires, one patient had died, one was lost to follow-up, and six patients declined to complete the questionnaires despite being contacted. The average LBOS for the thirty-two patients who completed the questionnaires was 41.8 (±17.5). Twenty-three patients with pre-treatment LBOS improved on average from 25.1 (±13.5) to 45.9 (±16.1) following injection (p=0.050). The eight patients with stenosis improved on average 24.9 points from 28.8 (±12.3) to 41.6 (±15.9). This is not statistically significant (p=0.95). The fifteen patients with disc protrusion improved significantly from 23.2 (±14.1) to 48.1 (±16.3) at follow-up (p< 0.01). This difference in improvement between the two groups was significant (p=0.016). Discussion Weiner and Fraser (Weiner BK, et al; J Bone Joint Surg Br. 1997) recommended foraminal steroid injection as the primary treatment for foraminal or extraforaminal disc protrusions, describing 79% patients having long term pain relief with an average follow-up LBOS score of 54 out of a possible 75 points. This present study reports 81% of patients with disc protrusions not requiring further treatment, with an overall average improvement in the follow-up LBOS score to 48. However the results in patients with foraminal stenosis were significantly less satisfactory

The trapeziometacarpal joint (TMJ) is the most commonly involved arthritic joint in the hand and is often injected in the outpatient setting. This study assesses the accuracy of TMJ injections. Six pairs of thawed, fresh-frozen cadaveric upper limbs were placed in the anatomic position. The limbs were randomized to be injected by one of two clinicians (a senior and a junior orthopaedic trainee). The TMJ of these specimens was palpated and injected with 0.5mls aqueous jelly dyed with methylene blue. An independent investigator dissected the specimens and the location of the dye was recorded. A Posterior-Anterior radiograph was then taken to assess the bony anatomy of the joint and graded according to Eaton's classification. Dye was found inside the joint capsule in 10 (83%) of the 12 specimens. Using Fishers Exact test no significant difference was found between the 2 injectors (p=0.46). The 2 joints where the dye was extra-articular had grade III and IV arthritis, whereas all other joints were graded I. This study shows that good accuracy of TMJ injection can be achieved using palpation in the earlier stages of TMJ arthritis, when surface anatomy is accurate enough for an intra-articular injection. This is also when synovitis is more prevalent and injections are more relevant. However the failure rate of injections increases as the disease advances

Aging has been associated with decreases in muscle strength and bone quality. In elderly patients, paravertebral muscle atrophy is accompanied by vertebral osteoporosis. The purpose of this study was to use paravertebral injection of botulinum toxin-A (BTX) to investigate the effects of paravertebral muscle atrophy on lumbar vertebral bone quality. Forty 16-week-old female SD rats were randomly divided into four groups: (1) a control group (CNT); (2) a resection of erector spinae muscles group (RESM); (3) a botulinum toxin-A group (BTX) that was treated with local injection of 5U BTX into the paravertebral muscles bilaterally; and (4) a positive control group (OVX) that underwent bilateral ovariectomy. At 3 months post-surgery the lumbar vertebrae (L3 – L6) were collected. The BMDs of the RESM and BTX groups were significantly lower than that of the CNT group (P < 0.01). Micro-CT scans showed that rats in the three experimental groups had fewer trabeculae and trabecular connections than rats in the CNT group. The bone loss trend of the trabecular networks was most obvious in the OVX rats. Vertebral compression testing revealed that the three experimental groups had significantly lower maximum load, energy absorption, maximum stress, and elastic modulus values than the CNT group (P < 0.01), and these parameters were lowest in the OVX group (P < 0.05). Our results demonstrate that the new paravertebral muscle atrophy model using local BTX injection causes sufficient muscle atrophy and dysfunction to result in local lumbar vertebral bone loss and quality deterioration

Objectives. This study aimed to examine the effects of SRT1720, a potent SIRT1 activator, on osteoarthritis (OA) progression using an experimental OA model. Methods. Osteoarthritis was surgically induced by destabilization of the medial meniscus in eight-week-old C57BL/6 male mice. SRT1720 was administered intraperitoneally twice a week after surgery. Osteoarthritis progression was evaluated histologically using the Osteoarthritis Research Society International (OARSI) score at four, eight, 12 and 16 weeks. The expression of SIRT1, matrix metalloproteinase 13 (MMP-13), a disintegrin and metalloproteinase with thrombospondin motifs-5 (ADAMTS-5), cleaved caspase-3, PARP p85, and acetylated nuclear factor (NF)-κB p65 in cartilage was examined by immunohistochemistry. Synovitis was also evaluated histologically. Primary mouse epiphyseal chondrocytes were treated with SRT1720 in the presence or absence of interleukin 1 beta (IL-1β), and gene expression changes were examined by real-time polymerase chain reaction (PCR). Results. The OARSI score was significantly lower in mice treated with SRT1720 than in control mice at eight and 12 weeks associated with the decreased size of osteophytes at four and eight weeks. The delayed OA progression in the mice treated with SRT1720 was also associated with increased SIRT1-positive chondrocytes and decreased MMP-13-, ADAMTS-5-, cleaved caspase-3-, PARP p85-, and acetylated NF-κB p65-positive chondrocytes and decreased synovitis at four and eight weeks. SRT1720 treatment partially rescued the decreases in collagen type II alpha 1 (COL2A1) and aggrecan caused by IL-1β, while also reducing the induction of MMP-13 by IL-1β in vitro. Conclusion. The intraperitoneal injection of SRT1720 attenuated experimental OA progression in mice, indicating that SRT1720 could be a new therapeutic approach for OA. Cite this article: K. Nishida, T. Matsushita, K. Takayama, T. Tanaka, N. Miyaji, K. Ibaraki, D. Araki, N. Kanzaki, T. Matsumoto, R. Kuroda. Intraperitoneal injection of the SIRT1 activator SRT1720 attenuates the progression of experimental osteoarthritis in mice. Bone Joint Res 2018;7:252–262. DOI: 10.1302/2046-3758.73.BJR-2017-0227.R1

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

Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis. However, despite long historical experience with this procedure, there remains no guide in the literature as to the optimal dose of steroid. Furthermore, the accuracy of these injections has not been well established. Using a prospective, randomized, blinded design, this study compares the outcomes of high (20 mg) and low (10 mg) dose depomedrol injection. Furthermore, the accuracy of tendon sheath injections was assessed radiographically. The findings demonstrate increased effectiveness of the higher steroid dose and a significant learning curve associated with intra-thecal injections. Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis (trigger finger). However, despite long historical experience with this procedure, there remains no guide in the literature as to the safe and effective dose of steroid to be administered. Furthermore, the accuracy of digital tendon sheath injections has not been well established. One study has suggested that steroid injected outside the tendon sheath was as effective as intra-thecal injection and may result in reduced complications of infection and tendon rupture. Using a prospective, blinded design, patients were randomized to receive either high (20 mg) or low (10 mg) dose depomedrol injection. The accuracy of the steroid injections was determined radiographically using non-ionic radio-opaque dye. Outcome measures included pain, tenderness, presence of a palpable nodule, triggering, and limitation of activities (work, hobbies, ADLs). Complications such as pain, stiffness, bruising, thinning of the fat or skin, infection and tendon rupture were also recorded. Higher dose depomedrol (20 mg) was found to be more effective for relieving pain and triggering than lower dose depomedrol (10 mg). No increase in complication rate was encountered. Stenosing tenosynovitis in diabetic patients was markedly less responsive to treatment. Injection accuracy was found to increase with clinical experience from approximately 50% for beginners to over 90% for experienced hand surgeons. At the time of submission of this abstract, patient numbers (currently forty-one participants) do not allow analysis regarding the effect of injection accuracy on clinical outcome

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

We have performed a prospective double-blind, randomised controlled trial over two years to evaluate the efficacy and safety of an intra-operative peri-articular injection of triamcinolone acetonide in patients undergoing medial unicondylar knee replacement. We randomised 90 patients into two equal groups. The study group received an injection of triamcinolone acetonide, bupivacaine, and epinephrine into the peri-articular tissues at the end of the operation. The control group received the same injection mixture but without the addition of triamcinolone. The peri-operative analgesic regimen was standardised. The study group reported a significant reduction in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and had a better range of movement (p = 0.023 at three months). There was no significant difference in the rate of infection and no incidence of tendon rupture in either group. The addition of corticosteroid to the peri-articular injection after unicondylar knee replacement had both immediate and short-term benefits in terms of relief from pain, and rehabilitation with no increased risk of infection

Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed. Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were. much better,. better,. un changed or. worse after treatment; was obtained at 3 months. Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test. Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003). Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW). Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61. Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks

Background. Carpometacarpal osteoarthritis is a degenerative disease of the hand that causes pain, stiffness and weakness. Currently, no drugs are available to prevent progression or cure this disease. Ultimately, the last treatment option is the surgical removal of the trapezium bone. In order to this limited treatment options, the utilization of autologous fat injections or adipose-derived stem progenitor cells (ADSPCs) provides a novel treatment option to inhibit the progression of this disease and potentially regenerate the damaged tissue. Objective. By utilizing next-generation-sequencing (NGS), we aim to uncover novel factors, released by ADSPCs or whole-fat aspirates, that might be involved into the metabolism of osteoarthritic cartilage. Materials and Methods. Human fat tissue was collected from five patients undergoing abdominal liposuction. Fat- and ADSPCs-conditioned medium was prepared by incubating fat and ADSPCs for 48 h in culture medium with and without TNFα to stimulate the secretion of immunomodulatory factors. The transcriptome of stimulated and non-stimulated fat and ADSPCs was analyzed by NGS. Chondrocytes from osteoarthritic cartilage from seven patients undergoing trapeziectomy were isolated, expanded and pooled. Chondrocytes were treated with six different conditions for 72 h. While standard culture medium with and without TNFα served as control groups. Fat-conditioned medium with and without TNFα, as well as ADSPCs-conditioned medium with and without TNFα served as experimental groups. Before and after cultivation of osteoarthritic chondrocytes with conditioned medium, chondrocytes were analyzed by NGS to evaluate the effect of fat- and ADSPCs-conditioned medium onto transcriptional changes in osteoarthritic chondrocytes. Results. To determine which factors might be involved in the anti-inflammatory effect of fat- and ADSPCs- conditioned medium, stimulated and non-stimulated fat and ADSPCs were analyzed by NGS. The most promising genes are cytokines, tissue inhibitors of matrix metalloproteinases and growth factors. In order to see the effect of conditioned medium from fat and ADSPCs on chondrocytes before and after cultivation with conditioned medium, NGS was performed. The gene expression of matrix metalloproteinases, cytokines, suppressors of cytokine signaling and cartilage specific proteins is of special interest. Conclusion. We aimed to investigate in our study if the clinically approved fat injection into osteoarthritic joints has the same therapeutical effect as the not yet clinically approved injection of isolated ADSPCS. Since the use of autologous fat injections is not only clinically approved but also much more convenient for a clinical approach, it is of utmost interest to know if both injection methods have a sufficient treatment effect on osteoarthritis

There has been a widespread appreciation on the part of both patients and surgeons that pain control following total knee replacement is an important goal. The concepts of both preemptive analgesia and multimodal pain protocols have become increasingly popular. In addition to these ideas, surgeons continue to utilise adjunctive treatments such as peripheral nerve blocks and periarticular injections. Multiple studies demonstrate the efficacy of these therapies. Several authors have published different “cocktails” for their periarticular injections in an attempt to help delineate which components of the cocktail are most important. In addition to deciding on a correct cocktail, how it is delivered is important. This video will demonstrate a technique that increases the likelihood that the injected solution is placed in the appropriate areas and does not simply bath the tissues. Important components of the technique include the use of a small gauge needle (22) and a control syringe to insure proper placement as well as an aim to target the injections into the periosteum of the femur and tibia and the posterior capsule primarily

Aims. This study aimed to investigate whether human umbilical cord mesenchymal stem cells (UC-MSCs) can prevent articular cartilage degradation and explore the underlying mechanisms in a rat osteoarthritis (OA) model induced by monosodium iodoacetate (MIA). Methods. Human UC-MSCs were characterized by their phenotype and multilineage differentiation potential. Two weeks after MIA induction in rats, human UC-MSCs were intra-articularly injected once a week for three weeks. The therapeutic effect of human UC-MSCs was evaluated by haematoxylin and eosin, toluidine blue, Safranin-O/Fast green staining, and Mankin scores. Markers of joint cartilage injury and pro- and anti-inflammatory markers were detected by immunohistochemistry. Results. Histopathological analysis showed that intra-articular injection of human UC-MSCs significantly inhibited the progression of OA, as demonstrated by reduced cartilage degradation, increased Safranin-O staining, and lower Mankin scores. Immunohistochemistry showed that human UC-MSC treatment down-regulated the expression of matrix metalloproteinase-13 (MMP13) and a disintegrin and metalloproteinase with thrombospondin motifs 5 (ADAMTS-5), and enhanced the expression of type II collagen and ki67 in the articular cartilage. Furthermore, human UC-MSCs significantly decreased the expression of interleukin (IL)-1β and tumour necrosis factor-α (TNF-α), while increasing TNF-α-induced protein 6 and IL-1 receptor antagonist. Conclusion. Our results demonstrated that human UC-MSCs ameliorate MIA-induced OA by preventing cartilage degradation, restoring the proliferation of chondrocytes, and inhibiting the inflammatory response, which implies that human UC-MSCs may be a promising strategy for the treatment of OA. Cite this article: Bone Joint Res 2021;10(3):226–236

Introduction. There are conflicting reports about the efficacy of injection to the thumb carpometacarpal joint (CMCJ) for osteoarthritis (OA). The accuracy of joint injection without radiological control is unclear. We investigated the accuracy of blind injection and recorded their immediate and short term efficacy. Materials/Methods. We injected 25 consecutive patients between March 2010-January 2011. The CMCJ was palpated, manually distracted and a 23 gauze needle introduced blindly. Image intensifier was then used to visualize and redirect needle if necessary. Radio-opaque dye was injected to confirm intra-articular placement. We recorded patient demographics, number of attempts required for correct needle placement, pre and 10 minutes post-injection visual analogue scale (VAS) pain score, and Nelson Score (NS)before and six weeks after injection. NS is a validated thumb CMCJ specific patient administered questionnaire. Results. Mean age was 60 (range 46–90). M:F ratio was 23:2. CMC J OA ranged from grade 2–4.1. st. attempt was successful in 6 cases. Mean attempts required for accurate injection was 3 (range 0–4). Mean pain pre- injection VAS was 7 (range 4–10), 10 minutes following injection 0.5 (range 0–4) and at 6 weeks 5 (range 3–10). Mean pre-operative NS was 29.6 (range 14–65) and at 6 weeks 32.4 (range 14–55). The difference was not statistically significant (paired t test, p=0.24). Conclusion. Our results suggest that blind injection of thumb CMCJ may not be accurate. Accuracy can be improved by X-ray guided injection. The procedure afforded excellent immediate pain relief but was not effective over six weeks follow up

The effect of timing of a manipulation under anaesthetic (MUA) and injection of corticosteroid and local anaesthetic for the treatment of frozen shoulder has attracted little attention to date. All studies describe a period of conservative treatment before proceeding to an MUA. Delay has been associated with a poorer outcome. We present a retrospective review of a prospectively collected, single-surgeon, consecutive series of 246 patients with a primary frozen shoulder treated by MUA within four weeks of presentation. The mean duration of presenting symptoms was 28 weeks (6 to 156), and time to initial post-operative assessment was 26 days (5 to 126). The Oxford shoulder score (OSS) improved by a mean of 16 points (Wilcoxon signed-ranks test, p < 0.001) with a mean OSS at this time of 43 (7 to 48). Linear regression analysis showed no correlation between the duration of presenting symptoms and OSS at initial follow-up (R2 < 0.001) or peri-operative change in OSS (R2 < 0.001) or OSS at long-term follow-up (R2 < 0.03). Further analysis at a mean of 42 months (8 to 127) revealed a sustained improvement with a mean OSS of 44 (16 to 48). A good outcome follows an MUA and injection of corticosteroid and local anaesthetic in patients with primary frozen shoulder, independent of the duration of the presenting symptoms, and this improvement is maintained in the long term

Osteoarthritis (OA) is a degenerative and inflammatory joint disease that affects the whole joint. Mesenchymal stem cells ability to secrete anti-inflammatory and immuno-modulatory factors represents an attractive tool in the treatment of OA. Considering the risk of cell leakage and the massive cell death upon intra-articular injection, we developed a micromolding protocol of encapsulation that allows to obtain particles that (i) could be injected with a 26G needle into a mouse joint and (ii) could provide a 3D microenvironment supporting cell biological activity. Polydimethylsiloxane (PDMS) chips containing circular micromolds were manufactured and a solution of alginate (2% w/v) containing human adipose stem cells (3 millions/mL) was deposited on the chips. Cell loading into the micromolds was performed either by sedimentation or by centrifugation. Following Ca2+ crosslinking, alginate particles (diameter 150±0.7μm) were obtained. The number of cells per particle was 5 times higher when the micromolds were loaded by centrifugation. Cell number and metabolic activity remained stable for 7 days after encapsulation and injection through a 26G needle had no impact on cell viability. When cells were stimulated with TNF-alpha and INF-gamma, prostaglandin E2 (PGE2) concentration in the supernatant was multiplied by 13 and 7 and indoleamine2,3-dioxygenase (IDO) activity was 2 and 4 times higher when cell loading was performed by sedimentation or centrifugation, respectively. We have demonstrated that encapsulated cells were able to sense and respond to an inflammatory stimulus and their therapeutic potential will be evaluated in a murine model of osteoarthritis

Background. Evidence from recent trials has supported the efficacy of periarticular analgesic injection for pain control following total knee arthroplasty (TKA). However, no randomized controlled trial has compared the efficacy of periarticular analgesic injection with that of other regimens for simultaneous bilateral TKA. Methods. We conducted a randomized controlled trial in which patients scheduled for simultaneous bilateral TKA were randomly assigned to receive periarticular analgesic injection or epidural analgesia. In the periarticular analgesic injection group, the injection contained 7.5 mg/ml ropivacaine 40 ml, 10 mg/ml morphine hydrochloride hydrate 1.0 ml, 1.0 mg/ml epinephrine 0.6 ml, methylprednisolone 80 mg, and ketoprofen 50 mg. These agents were mixed with normal saline to a combined volume of 120 ml. The 60 ml of the cocktail was injected into each knee. In the epidural analgesia group, the catheter was placed at the L2–3 or L3–4 level, and connected to an infusion pump delivering continuous infusion (flow rate: 4 ml/h) of 100 ml of 2 mg/ml ropivacaine plus 1.0 ml of 10 mg/ml morphine hydrochloride hydrate. Surgery was managed under spinal anaesthesia. Surgical techniques and postoperative medication protocols were identical in both groups. The primary endpoint was postoperative pain at rest, quantified as the area under the curve (AUC) of the score on a visual analogue scale. Results. Seventy-one patients with 142 knees were randomly assigned to receive periarticular analgesic injection or epidural analgesia. The flow chart presented in Figure 1 outlines the trial. The periarticular analgesic injection group had a significantly lower AUC at 4–24 hour compared with the epidural analgesia group (174.9 ± 181.5 versus 360.4 ± 360.6; p = 0.0073), while no difference in the AUC was noted at 24–72 hour (1388.1 ± 727.2 versus 1467.3 ± 810.1; p = 0.67). The consumption of diclofenac sodium suppositories as rescue analgesia was significantly lower in the periarticular analgesic injection group than in the epidural analgesia group on the night of surgery (0.16 ± 0.4 versus 0.70 ± 0.9; p = 0.0013). The incidence of nausea on the night of surgery and postoperative day 1 and that of pruritus were significantly lower in the periarticular analgesic injection group than in the epidural analgesia group (7.4 % versus 45.5 %; p = 0.0031, 7.4 % versus 54.5 %; P = 0.0003, and 0 % versus 15.2 %; p = 0.014, respectively). Conclusions. Compared with epidural analgesia, periarticular analgesic injection following simultaneous bilateral TKA was associated with better postoperative pain relief and decreased opioid-related side-effects. Periarticular analgesic injection is preferable to epidural analgesia for postoperative pain relief after simultaneous bilateral TKA

The aim of this study is to assess the long-term results of Ethibloc (Ethnor Laboratories/ Ethicon, Norderstedt, Germany) injection in aneurysmal bone cysts (ABC). 33 patients with aneurysmal bone cysts were treated with computed tomographic (C.T) guided percutaneous injection of Ethibloc into the cyst cavity. 22 patients had Ethibloc injection as primary treatment and 11 patients had presented to us with recurrence following previous procedures including steroid injection, bone marrow injection, curettage bone grafting and various other surgical procedures. The mean follow-up was 54 (22-90) months. Symptoms were relieved in all patients. 2 patients were lost to follow up. 18 (58%) of the 31 patients followed, had complete resolution of the lesion, 11 (35.5%) patients had partial healing (asymptomatic residual non progressive lytic areas). 2 (6.5%) patients showed recurrence in the proximal humerus during the follow-up. They are under follow-up but asymptomatic. 2 patients encountered more significant complications after the procedure. Ethibloc injection is a relatively simple, minimally invasive alternative procedure for the treatment of ABC, and makes open operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of ABCs excluding spinal lesions as shown by this long-term follow-up study

Our aim was to evaluate the effect of adding inhibitory casting to the treatment of young children with cerebral palsy who received injections of botulinum neurotoxin A (BoNT-A) to gastrocnemius for equinus gait. Of the 20 patients in the series, 11 in group A had inhibitory casts applied on the day of the first set of BoNT-A injections and nine in group B did not have casting. Both groups received another BoNT-A injection four months later. The patients were followed for eight months and examined at five intervals. Both groups showed significant improvement in gait parameters and function (p < 0.0001) and selective motor control (p = 0.041, − 0.036) throughout the study. Group A had significantly better passive dorsiflexion of the ankle (p = 0.029), observational gait score (p = 0.006) and selective motor control (p = 0.036). We conclude that the addition of inhibitory casting enhances and prolongs the results of treatment and mainly influences the passive range of movement, while BoNT-A mostly influences the dynamic motion. The second injection further improved the results of most parameters. The gross motor function measure, the selective motor control test and the modified Tardieu scale correlated well with the results of treatment. We recommend the use of inhibitory casting whenever augmentation of the effect of treatment with BoNT-A is needed

Background. Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). We have developed an injectable hydrogel (NPgel), which following injection into bovine IVD explants, integrates with IVD tissue and promotes disc cell differentiation of delivered mesenchymal stem cells (MSCs) without growth factors. Here, we investigated the injection of NPgel+MSCs into IVD explants under degenerate culture conditions. Methods and Results. The NPgel integrated with bovine and human degenerate Nucleus Pulposus (NP) tissue and hMSCs produced matrix components: aggrecan, collagen type II and chondroitin sulphate in standard and degenerate culture conditions. Significantly increased cellular immunopositivty for aggrecan was observed within native NP cells surrounding the site where NPgel+MSCs were injected (P≤0.05). In NP explants a significant decrease in catabolic factors were observed where NPgel+MSCs was injected in comparison to controls. Conclusions. In agreement with our previous findings NPgel was sufficient alone to induce NP cell differentiation of MSCs following injection into NP tissue explants. Here, we have shown that viability is maintained even in degenerate conditions. Injection of NPgel with MSCs increased aggrecan expression and reduced MMP3 and IL-1R1 expression by native NP cells. The NPgel with incorporated MSCs has the potential to regenerate the NP and provide mechanical support, whilst reducing the catabolic phenotype of degenerate NP cells, as a treatment strategy for IVD degeneration. No conflicts of interest. Sources of funding: Funded by ARUK and MRC

Aims. To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder. Patients and methods. Ethical approval was obtained and 50 patients (23 women and 27 men) with mean age of 64.5 years (42-87 years) and clinical diagnosis of subacromial impingement were recruited. Patients with old or recent shoulder fracture, bleeding disorders, and allergy to iodine were excluded. All injections were given by the consultant or an experienced registrar after obtaining informed consent. Patients were randomised into posterior and anterolateral groups and the method of injection was revealed by opening sealed envelopes just before the injection. A combination of 3mls 0.5% bupivacaine and 2mls of radiographic dye (Niopam) was injected in the subacromial space (SAS) using either anterolateral (n-22) and posterior approaches (28). AP and lateral radiographs of shoulder were taken after injection and were reported by a Consultant Radiologist blinded to the method of injection. Visual analogue scale (VAS) and Constant-Murley shoulder score was used to assess pain and function respectively. Both scores were determined before and 30 minutes after the injection. Results. 22 injections (78.5%) were accurately placed in SAS with the posterior approach and in 14 patients (63.6%) with anterolateral approach. This difference was statistically significant (P< 0.05). Only patients who received injection accurately in SAS with either method had a reduction in pain of an average of 4 points on VAS, and improvement in the Constant score of average 14 points. Conclusions. The posterior approach of SAS injection is more accurate than anterolateral approach. Injections that are correctly placed in the SAS lead to better reduction of pain and improvement in the Constant score

This study was done to determine the effectiveness of percutaneous autologous bone marrow injection in fracture healing and to determine if centrifuged bone marrow is more effective in bone healing as compared to uncentrifuged marrow. This is a randomized interventional trial of 106 patients who had bone marrow injection. The study was done in 2 parts. In the first part, 51 patients were divided into three groups – a) Fresh fractures,(within 6 weeks of injury) b) Delayed union – (8 to 12 weeks after injury) c) Non union – more than 16 weeks after injury. All patients in the first part of the study underwent percutaneous autologous bone marrow injection and were followed up at 6,8,10 and 12 weeks and every 4th week thereafter. Forty seven out of 51 patients united. The second part of the study was done to compare centrifuged and uncentrifuged bone marrow injections. Fifty five patients having either tibial or femoral fractures were divided into two groups, centrifuged and uncentri-fuged and appropriate marrow injection was done. All patients were followed up every 6 weeks till 36 weeks. 48 patients out of 55 united. Equal number of patients united in the centrifuged and uncentrifuged group. We conclude that percutaneous autologous bone marrow injection is a simple and effective tool which can be used for fracture healing and centrifugation of bone marrow yields no added advantage in bone healing

Summary Statement. There are no standardised methods for assessing the cement flow behaviour in vertebroplasty. We propose a novel methodology to help understand the interaction of cement properties on the underlying displacement of bone marrow by bone cement in porous media. Introduction. Concerns related to cement extravasation in vertebroplasty provide the motivation for the development of methodologies for assessing cements (novel and commercially available) and delivery systems. Reproducible and pathologically representative three-dimensional bone surrogates are used to understand the complex rheology underlying the two-phase flow in porous media. Patients & Methods. The bone surrogates were achieved by first developing CAD models then manufacturing the physical models through a suitable rapid prototyping technique. MicroCT 100 (Scanco Medical, Switzerland) was used to assess the variability in the model morphology (n=8). Contact angle measurements were performed on the material to compare the surface wettability to that of bone. The surrogates were filled with bone marrow substitute (Carboxymethyl cellulose 2.5 % in water, 0.4 Pa.s) then 5 ml of silicone oil (Dow Corning Corp. 200® Fluid, 60 Pa.s) was injected at a constant flow rate (3mL/min) using a syringe pump. The injection was radiographically monitored and the video sequences were captured. Experiments were repeated three times. The displacement of the syringe plunger and the force applied on the plunger were recorded. Image processing was performed on the video sequences to quantitatively describe the resulting flow patterns and calculate parameters including the time of leakage and the mean spreading distance. Results. The variability in the model morphology was very low with a strut thickness of 0.253 ± 0.010 mm and a pore spacing of 0.83 + 0.01 mm. The surface wettability was very similar between all materials with a contact angle around 65°. The measured displacement of the syringe plunger confirmed the flow rate to be constant at 3 ml/min. The peak injection pressure was 0.443 ± 0.013 MPa which is well below the reported clinical measurement of injection pressure during vertebroplasty. 1. Anterior oil leakage occurred at 34.6 ± 4.71 seconds. The oil never reached the posterior wall and the mean spreading distance at the end of the injection was 23.39 ± 1.11 mm. Discussion/Conclusion. These complex three-dimensional bone surrogates provide a clinically relevant representation of the in vivo situation in terms of geometry, porosity and permeability. They overcome limitations of previous models by being constant in terms of both porosity and geometry which is crucial to reduce the variability, render the experiments reproducible and shift the focus onto understanding the cement flow behaviour. The proposed methodology will help study cement-fluid interaction to get better representation of in vivo cement flow patterns and provide a tool for validating computational simulations. Funding was provided by the EU under the FP7 Marie Curie Action (PITN-GA-2009-238690-SPINEFX)

Background. Steroid injections can be used safely to treat trigger fingers. We aimed to determine the accuracy of referring General Practitioner (GP) diagnoses of trigger finger made to an upper limb surgeon. We also aimed to determine the efficacy of a serial two steroid injection then surgery technique in the management of trigger fingers. Methods. Data was collected prospectively from a “one-stop” trigger finger clinic (based in a district general hospital). 200 trigger fingers identified from September 2005 to November 2008, giving a minimum 1 year follow-up. Data was analysed for correct referring diagnosis, resolution/recurrence rate following injection and the effect of age, injector grade, diabetes on the rate of recurrence. Results. GP diagnoses were correct in 94% of referrals. Recurrence free resolution after one steroid injection was achieved in 74% of cases, rising to 84% after a second injection. The grade of injector did not influence the rate of resolution (p=0.967) or recurrence (p=0.818). Age was the only statistically significant factor, with recurrences being 8.3 years younger (95% CI 4.1–12.6 yrs; p=0.0002). 15% required surgical release after failure of two steroid injections. Conclusions. Steroid injection for trigger finger is a safe, easily performed technique that can give recurrence free resolution in up to 84% using a serial two steroid injection technique. This is an easily acquired technique that has obvious potential to be performed in the primary care setting, thus reducing the burden on hospital based specialist upper limb services, as only 15% required surgical intervention

High-pressure injection injuries occur infrequently but are usually work-related and involve the non-dominant hand. The neck is a very rare site for such an injury. We describe the management of a 36-year-old man with a high-pressure grease-gun injection injury to his neck causing a cervical spinal cord injury. He developed severe motor and sensory changes which were relieved by surgical removal of the grease through anterior and posterior approaches

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

We reviewed 231 patients who had undergone total knee replacement with an AGC (Biomet) implant over a period of 2.5 years. After applying exclusion criteria and with some loss to follow-up, there were 144 patients available for study. These were divided into two groups; those who had received intra-articular steroid in the 11 months before surgery and those who had not. There were three deep infections, all of which occurred in patients who had received a steroid injection. The incidence of superficial infection was not significantly different in the two groups. Five patients had undergone investigation for suspected deep infection because of persistent swelling or pain and all of these had received an intra-articular injection pre-operatively. We conclude that the decision to administer intra-articular steroids to a patient who may be a candidate for total knee replacement should not be taken lightly because of a risk of post-operative deep infection

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

In 79 consecutive patients with unicameral bone cysts we compared the results of aspiration and injection of bone marrow with those of aspiration and injection of steroid. All were treated by the same protocol. The only difference was the substance injected into the cysts. The mean radiological follow-up to detect activity in the cyst was 44 months (12 to 108). Of the 79 patients, 14 received a total of 27 injections of bone marrow and 65 a total of 99 injections of steroid. Repeated injections were required in 57% of patients after bone marrow had been used and in 49% after steroid. No complications were noted in either group. In this series no advantage could be shown for the use of autogenous injection of bone marrow compared with injection of steroid in the management of unicameral bone cysts

Aim: To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles. Methods: In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months. Results: Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001). Conclusions: The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection

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

Introduction. Without intervention 80% of hips with osteonecrosis (ON) will progress. Core decompression has shown favorable results (60–80% survivorship) in early stage ON, and recently, bone marrow aspirate concentration (BMAC) injection into the decompressed femoral head has been proposed to stimulate healing of the necrotic lesion and improve outcomes and survivorship. Methods. We retrospectively reviewed the clinical and radiographic outcomes of 42 hips in 26 patients who underwent core decompression with BMAC for ON with a minimum of 1 year follow up. We evaluated pre-op visual analog pain scores (VAS), Steinberg class based on radiographs, as well as Kerboul angle as measured on MRI. Clinical outcomes were reported as change in VAS at final follow up, advancement in Steinberg classification based on radiographs at final follow up, or decision to proceed with THA. Results. At final follow up, VAS scores had improved from 7 to 2.6 (P<0.05). A total of 33 of 42 hips (78.5%) had stable radiographs without collapse or progression to a higher Steinberg class, while a total of 9 of 42 hips (21.4%) went on to THA. Of the patients that went on to THA, all had a pre-operative Steinberg classification of 2C or higher, and the pre-op Kerboul angle in this cohort was 243, compared to 171 in the group that did not go on to THA (p<0.05). In patients with pre-op Steinberg class 2B or less, there was no advancement in radiographic grade, whereas 61% of patients with pre-op Steinberg grade 2C or higher progressed on to a more advanced stage. Conclusion. Core decompression with BMAC significantly improves clinical symptoms and helps prevent the advancement of ON when performed on patients in whom ON is classified as Steinberg class 2B or less, or in whom the Kerboul angle is 180 or less. For any tables or figures, please contact the authors directly

Introduction and Aims: Adequacy of post-operative pain control can effect total knee arthroplasty (TKA) outcomes. We examine the effectiveness of a simple and inexpensive method using long-acting local anesthetic (bupivacaine) with epinephrine and morphine injection on controlling pain, blood loss, and motion in primary TKA. Method: We retrospectively reviewed 170 patients who underwent 208 primary TKA, by a single surgeon between October 2001 and December 2002. The control group of 75 patients (99 knees) had received no intra-operative injections. The study group of 95 patients (109 knees) had received intra-operative injection of 0.25 percent bupivacane with epinephrine and morphine divided two-thirds soft-tissue injection and one-third intra-articular injection. Bilateral simultaneous TKA in the study group received a divided anaesthetic dose. Results: The control group required significantly more breakthrough narcotic (85 percent vs 67 percent; p=0.004); and required more narcotic reversal for over-sedation. The study group had significantly higher ROM at discharge 63 degrees vs 52 degrees. Lower ROM at discharge was associated with manipulation (p equals 0.001). The study group required less transfused blood (mean 0.03 vs 0.1 units), and had significantly lower bleeding indices 2.7 vs 3.5. Conclusion: Preemptive analgesia with intra-articular and soft-tissue injection of long-acting local anesthetic with epinephrine and morphine appears to decrease need for rescue narcotics and reversal agents. The use of the injection also increases ROM at discharge, which reduces the need for manipulation. Lastly, the bleeding index and transfusion requirements are significantly reduced. This inexpensive method is effective in improving the post-operative course of primary TKA

When performing an intraarticular injection in the clinic setting the skin must first be cleaned with an antiseptic. This is typically done by spraying the skin with an alcohol based solution and allowing it to dry. Bony landmarks are then palpated to identify the correct insertion point for the needle. In the busy clinic setting this is sometimes done wearing sterile gloves, non-sterile gloves or no gloves at all. Potentially organisms from the palpating hand could contaminate the injection field and be introduced into the joint leading to a septic arthritis. We therefore looked at different scenarios often seen during intraarticular injections in clinic to see which was the least likely to contaminate the injection site. In order to investigate the safest method of palpating bony landmarks whilst preventing infection we sprayed the entire volar surfaces, of both forearms, of fifty volunteers with alcohol. After the alcohol had dried, the subjects then palpated their own forearms in three separate areas with a naked digit, an unsterile-gloved digit and a digit itself sprayed with alcohol. Microbiology samples were taken using contact agar plates in each of the three areas as well as a control area, which had been sprayed but not touched. The number of bacterial colonies on the plates after incubation was then counted. During transit to the incubator, three of the contact plate lids became dislodged. It could not be determined if further contamination had occurred and so all the samples from those volunteers were discarded. This left 188 contact plates (47 volunteers x 4 samples). The average number of colonies were, 14.5 for a naked digit, 3.5 for an unsterile glove, 2.0 for an alcohol sprayed digit and 1.7 for the control. Kolmogrov-Smirnov and Shapiro-Wilk tests were performed to assess the data for normality. The data was found to be highly skewed and therefore a Wilcoxon signed ranks test was performed comparing the three arms of the study with the control. There was a highly significant difference in the number of colonies between the naked digit and the control (p=0.0001) and to a lesser degree between the gloved digit and the control (p=0.030). No significant difference was found between the alcohol sprayed digit versus the control group (p=0.805). In order to prevent contamination of an injection site after skin preparation the area should never be touched with a naked digit. We would also not recommend unsterile gloves often found in clinics. However, spraying your own fingers with antiseptic before palpating the injection site causes as much contamination as not touching it at all. This would seem to be a cheap and effective method as it avoids the cost of sterile gloves in clinic. We intend to extend the study further by adding an unsterile glove, which has been sprayed with alcohol. This may be the best solution of all

Background. We compared platelet rich plasma (PRP) injection to cortisone (40mg triamcinolone) injection in the treatment of chronic plantar fasciitis resistant to traditional nonoperative management. The aims were to compare early and long term efficacy of PRP to that of Steroid (3, 6 and 12 months after injection). Methods. 60 heels with intractable plantar fasciitis with failed conservative treatment were randomized to either PRP or Steroid injection. All patients were assessed with Roles-Maudsley (RM) Score, Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Data was collected prospectively on the cohort, pre-treatment, at 3, 6 and 12 months post injection. The mean scores of the two groups were compared using Student t test. Results. Pre-injection, the two groups were well matched with no statistically significant difference in the values. At 3 months, all three outcome scores in both groups had significantly improved from their pretreatment level with no significant difference between the groups (PRP: RM 3.7 to 2.0, VAS 8.3 to 3.5, AOFAS 58 to 84; Steroid: RM 3.6 to 1.9, VAS 8.3 to 2.8, AOFAS 57 to 86). At 6 months, improvement was maintained in both groups with no significant difference between groups (PRP: RM 2.1, VAS 3.7, AOFAS 89; Steroid: RM 2.2, VAS 3.3, and AOFAS 84). At 12 months, all outcome measures were significantly better for the PRP group as response in the steroid group had deteriorated (PRP: RM 1.9, VAS 3.3 and AOFAS 89; Steroid: RM 2.6, VAS 5.1 and AOFAS 77: p = 0.008, 0.02 and 0.002 respectively). Conclusions. PRP is better for the treatment of chronic plantar fasciitis as compared to steroid. It shows no statistical difference in effectiveness early on, but unlike steroid, its effectiveness does not wear off with time, making it more durable

Segmental bone transport (SBT) using an external fixator is currently a standard treatment for large-diameter bone defects at the donor site with low morbidity. However, long-term application of the device is needed for bone healing. In addition, patients who received SBT treatment sometimes fail to show bone repair and union at the docking site, and require secondary surgery. The objective of this study was to investigate whether a single injection of recombinant human bone morphogenetic protein 2 (rhBMP-2)-loaded artificial collagen-like peptide gel (rhBMP-2/ACG) accelerates consolidation and bone union at the docking site in a mouse SBT model. Six-month-old C57BL/6J mice were reconstructed by SBT with external fixator that has transport unit, and a 2.0-mm bone defect was created in the right femur. Mice were divided randomly into four treatment groups with eight mice in each group, Group CONT (immobile control), Group 0.2mm/d, Group 1.0mm/d, and Group BMP-2. Mice in Group 0.2mm/d and 1.0mm/d, bone segment was moved 0.2 mm per day for 10 days and 1.0 mm per day for 2 days, respectively. Mice in Group BMP-2 received an injection of 2.0 μg of rhBMP-2 dissolved in ACG into the bone defect site immediately after the defect-creating surgery and the bone segment was moved 1.0 mm/day for 2 days. All animals were sacrificed at eight weeks after surgery. Consolidation at bone defect site and bone union at docking site were evaluated radiologically and histologically. At the bone defect site, seven of eight mice in Group 0.2mm/d and two of eight mice in Group 1.0mm/d showed bone union. In contrast, all mice in Group CONT showed non-union at the bone defect site. At the docking site, four of eight mice in Group 0.2 mm/d and three of eight mice in Group 1.0 mm/d showed non-union. Meanwhile, all mice in Group BMP-2 showed bone union at the bone defect and docking sites. Bone volume and bone mineral content were significantly higher in Group 0.2mm/d and Group BMP-2 than in Group CONT. HE staining of tissue from Group 0.2mm/d and Group BMP-2 showed large amounts of longitudinal trabecular bone and regenerative new bone at eight weeks after surgery at the bone defect site. Meanwhile, in Group CONT and Group 1.0mm/d, maturation of regenerative bone at the bone defect site was poor. Differences between groups were analyzed using one-way ANOVA and a subsequent Bonferroni's post-hoc comparisons test. P < 0.05 was considered significant. rhBMP-2/ACG combined with SBT may be effective for enhancing bone healing in large bone defects without the need for secondary procedures

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

Poly-ether-ether-ketone (PEEK) is a biomaterial commonly used for spinal implants and screws. It is often desirable for orthopaedic implants to osseointegrate, but as PEEK is biologically inert this will not occur. The aim of this project was to determine if injection mould nanopatterning can be used to create a make PEEK bioactive and stimulate osteogenesis in vitro. PEEK substrates were fabricated by injection mould nanopatterning to produce near-square (NSQ) nanopatterned PEEK and planar (FLAT) PEEK samples. Atomic force microscopy (AFM) and scanning electron microscopy were used to characterize the surface topography. Human bone marrow stromal cells (hBMSCs) were isolated from patients undergoing primary hip replacement operations and seeded onto the PEEK substrates. After 6 weeks the cells were stained using alizarin red S (ARS) stain (to detect calcium) and the von Kossa technique (to detect phosphate) and analyzed using CellProfiler image analysis software to determine: surface coverage; cell number; and expression of either calcium (ARS stain) or phosphate (von Kossa technique). ARS stain showed calcium expression (quantified relative to the number of cells) was increased on NSQ PEEK compared to FLAT PEEK (not statistically significant) and the surface coverage was similar. Von Kossa staining revealed more surface coverage on FLAT PEEK (69.1% cf. 31.9%), cell number was increased on FLAT PEEK (9803 ± 4066 cf. 4068 ± 1884) and phosphate expression relative to cell number was also increased (seven-fold) on NSQ PEEK (P < 0.05) compared to FLAT PEEK. Although hBMSCs may adhere to NSQ PEEK in smaller numbers, the cells expressed a relatively larger amount of calcium and phosphate. This indicates that the cells adopted a more osteoblastic phenotype and that nanopatterning PEEK induces hBMSC differentiation and stimulates osteogenesis. Injection mould nanopatterning therefore has the potential to improve osseointegration of PEEK implants in vivo

Aims: To assess the effectiveness of intra-articular facet joint injections in controlling disability in patients with low back pain. Methods: 100 consecutive patients admitted in our day case unit for facet joint injections were included in the study. Fluoroscopically controlled intra-articular facet joint block with injection of a local anaesthetic and corticosteroid suspension was performed after clinical and radiological assessment. Disability due to back pain was assessed by determining a revised Oswestry Low Back Pain Disability Index (Oswestry Score). The patients completed a questionnaire immediately prior to treatment, two weeks following injection and three months following injection. Results: Facet joint injections were performed for intervertebral disc prolapse (66%), spondylolysthesis (13%), spinal stenosis (10%), spondylosis (7%), and sacro-iliac joint pain (4%). The mean Oswestry Score prior to injection was 40.6% (95% conþdence interval 4.4), at two weeks following injection was 26.6% (95% conþdence interval 4.9) and at three months following injection was 21.5% (95% conþdence interval 4.8). 78% of the patients found the facet joint injections useful at 2 weeks following treatment and this þgure was maintained (79%) at 3 months after injection. No complications were reported following treatment. Conclusions: We have found intra-articular facet joint block for the treatment of low back pain a valid therapeutic option, acceptable by the patients and with negligible risks

To investigate the significance of a cluster of cases of glenohumeral chondrolysis occuring following the intra-articular injection of methylene blue to assess rotator cuff integrity during open anterior acromioplasty. All cases of acromioplasty during the period 1999 to 2004 were reviewed to determine the incidence of chondrolysis with and without methylene blue injection. There was a significantly higher incidence of chondrolysis following intra-articular injection of methylene blue. The association of intra-articular methylene blue with chondrolysis has not been previously described in the literature. We conclude that methylene blue should not be used for intra-articular injection

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects

To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles. In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months. Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001). The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection