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. 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

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

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

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

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

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: 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

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

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

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

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

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

In this study, 40 patients who underwent total hip arthroplasty (THA) and had a history of previous steroid injections were compared retrospectively with 40 carefully matched patients who underwent THA in the same period but had never received steroid injections. The development of sepsis under standard care was one of the outcome measures. This occurred in 20% of steroid patients within the first 36 months after THA, compared to 0% in the control group. Further, in a detailed analysis of Harris and Oxford scores, patients treated with steroid had a higher incidence of night pain, more severe pain, and greater loss of function in activities of daily living at one year. There were two revisions for deep infection in the steroid and control groups. Based on the incidence of pain and infectious complications in the first postoperative year, and pending completion of the study, we provisionally suggest that steroid injection of hips may be ill advised in patients who are likely candidates for future THA

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

The effectiveness of steroid injection in the treatment of primary osteoarthritis of the acromioclavicular joint (ACJ) has been questioned. We prospectively evaluated the outcome of 20 consecutive patients (25 shoulders) with clinical and radiological evidence of primary ACJ arthritis after steroid injections. All patients were evaluated using the Constant score after a minimum of 12 months follow up. Only patients with a negative provocative test after injection of 2ml of depomedrone and lignocaine were included in the study. Eleven females (14 shoulders) and 9 males (11 shoulders) were included. The average age was 53.9 years. The mean preinjection score was 61.6 points (SD 13.12) and at 6 months this improved to 81 points, mean difference of 19.36 (CI = 14.19 – 24.53), p< 0.01, which was highly statistically significant. There was further improvement at 12 months, on the 6 month score, mean 88.4 points, mean difference of 7.4 (CI = 3.55 – 11.25), p = 0.001 which was also statistically significant. In addition, the younger the patient, the greater the improvement in the objective score which measures the range of movement and power (r = −0.47; p = 0.01). We conclude that local steroid injection is an effective method of treatment for primary isolated acromioclavicular arthritis and improvement continues for at least 12 months, but may require more than one injection

Study Design: A consecutive retrospective cohort including all patients treated by a single consultant spinal surgeon (BJCF) with targeted foraminal epidural steroid injection (FESI) for radicular pain. Objective: To assess the efficacy of targeted foraminal epidural steroid injection (FESI) for radicular pain in preventing surgical intervention. Summary of Background Data: 90% of sciatica resolves within 90 days. Beyond this period, decompresssive surgery for pain relief maybe considered. Open surgery however carries attendant risk including nerve root injury, dural laceration, cauda equina syndrome, deep infection, recurrent disc prolapse, epidural fibrosis and post-discectomy lumbar instability. Peri-radicular infiltration of local anaesthetic and steroid has been shown to reduce pain, at least in the short term. We were interested in whether FESI could obviate the need for surgery in refractory cases of nerve root pain. Methods: 83 consecutive patients (45 female, 38 male) with a mean age of 51 years (range 24 to 87) presenting between November 2000 and February 2003 with radicular pain were treated with targeted FESI. 55 patients had a principal diagnosis of disc prolapse, 20 had lateral canal stenosis and 8 had degenerative spondylolisthesis. Fourteen had previous surgery and 38 had previous caudal or lumbar epidural injections. Outcome Measures: Pain was assessed using the Visual Analogue Score and disability by the Oswestry Disability Index. The product-limit method of Kaplan Meier was used to assess the time to further procedure or the date of last review. Results: 21 of 83 patients (25.3%) underwent an open procedure (discectomy/decompression) within the designated time period (median 20 months). Median time to open procedure was 6.5 months (mean 8.2 months). Repeat FESI was required in 16 patients (19.2%). The remaining 46 (55.4%) patients avoided any further procedure at a median of 20 months (range 13 to 36). No complications resulted from these procedures. Conclusions: Targeted foraminal epidural steroid injection can resolve radicular pain caused by varying pathologies. Surgical procedures (decompression/discectomy) can be avoided in 74.7% of cases up to a median of 20 months thereby avoiding unnecessary surgical risk

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst. A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score. Overall patient satisfaction was recorded on a scale of 0-10. 38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group. Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications

Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection. Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength. Successful treatment was defined as more than a 25% reduction in visual analogue score or DASH score and more than 75 score in Mayo elbow performance score. We observed that 35 of the 70 patients (50%) in corticosteroid group and 47 of the 63 patients (75%) in PRP group were successful, which was significantly different (p<.001), according to DASH score 37 of the 70 patients (53%) and 47 of the 63 patients (75%) in the PRP group were successful which was also significantly different (P = .005), Mayo elbow performance score was successful in 36 of the 70 patients (51%) in corticosteroid group and 49 of the 63 patients (78%) in PRP group. The improvement in hand grip strength of hand from 24.7kg (mean) 26kg in corticosteroid group and 23.5kg (mean) to 32.9kg (mean) in PRP group. PRP injection for chronic lateral epicondylitis reduces pain, improve functionality and hand grip strength when compared to steroid injection

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

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

Background: Caudal extradural steroid injection is an alternative method of treating patients with chronic low back pain and sciatica. Aim: The purpose of our study is determining the effectiveness of the caudal extradural steroid injection in patients with severe chronic low back pain and sciatica. Patients – Methods: A total of 158 patients with severe and chronic low back pain and sciatica participated in the study, aged 23–78 years old. 86 patients were men and 72 women. Patients were divided into two groups according to the injected drug. Group 1 or the injected group (n=91) received a caudal extradural injection (CEI) that consists of 12 to 15 ml of 2% xylocaine together with 1 ml of Betamethasone Dipropionate and Betamethasone phosphate. Group 2 or the placebo group (n=52), received a caudal extradural injection that consists of 6–8 ml of 2% xylocaine mixed with 6–8 ml of water for injection. The mean duration of symptoms was comparable between the two groups. In order to estimate the degree of recovery from symptoms, all patients answered a specific questionnaire. The Oswestry Disability Index Questionnaire (ODI) was answered by all patients on the first day of clinical examination, and on different follow-up periods after caudal injection. The straight leg-raising test was evaluated in all patients at the same follow – up periods. Results: Recovery from symptoms and a decrease in the O.D.I score after the CEI was observed in both groups. However the mean ODI score of the injected group was statistically significant lower than this of control group for a period until one month after the injection (p < 0,001, Wilkoxon Signed Ranks test). Also the mean improvement time of positive SLR test in the injected group was statistically significant lower than this of control group (log rank test, p = 0,019). Conclusions: The caudal extradural steroid injection is a reasonable non-surgical therapeutic option among patients with severe chronic low back pain and sciatica. It offers pain relief to patients who do not respond to prolonged conservative therapy, or who refuse surgery. It can easily be performed in the outpatient clinic

To assess whether epidural steroid injection [ESI] is effective in the treatment of nerve root pathology caused by compression in the lumbar spine secondary to either spinal stenosis or disc prolapse, we carried out a prospective randomised controlled trial; patients were randomised either to ESI or Intramuscular steroid injection, with minimum two year follow-up. Ninety two patients with symptoms, signs and radiological findings consistent with lumbar nerve root compression suitable for surgical decompression. The main outcome measures were the Oxford Pain Chart over the first month, Oswestry Disability Index, and the need for surgery. There was a significant reduction in pain early on after ESI compared with controls [p=< 0.004] between 10 and 35 days. There was no difference in the long term between the two groups and the rate of surgery in the two groups was not significantly different. Indeed the rate of surgery was higher in the ESI group than the control group [41% vs.31%] but this was not significant. A second ESI did not change the likelihood that surgery would be required. Conclusion: ESI is effective for early pain relief for lumbar nerve root compression. However it does not change the natural history of the condition and does not reduce the ultimate need for surgery. It is probably effect to “buy time” in acute sciatica until improvement occurs naturally

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

Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of discogenic back pain after two years. Introduction: Discography remains the main method to assess whether a degenerate disc is the source of back pain. The treatment of such discogenic pain is difficult. There is only one previous RCT of the use intradiscal steroids, but with a short follow-up. Patients and Methods: 120 consecutive patients with positive discography were randomised intra-operatively to receive an intradiscal injection of saline or 40mgs Depomedrone. Outcome was assessed using a back pain questionnaire at six weeks, three and six months, and at two years. Pain (using a visual analogue score), disability (the Oswestry Disability Index), and psychological status (DRAM score) were measured. The results were correlated with Modic changes and high intensity zones on MRI scan. Results: An initial improvement of back pain in the steroid group is not maintained at two years, with no statistical difference between the two groups. Correlation of the results with the MRI findings will be presented. Conclusion: This study demonstrates the need for long-term follow-up of such intradiscal therapeutic methods of treating discogenic pain

We present a unique prospective study which estimates the median sustained stage related improvement in pain and hand function predicting symptomatic relief period with high accuracy with a single steroid injection. Patients were grouped into stages, I to IV according to the Eaton and Glickel radiological criteria. The steroid injection contained 40mg triamcelone and 1% lido-caine. The response was assessed by DASH and a visual analogue score before and at six-week interval. We used the Kaplan-Meier method to estimate median length of sustained improvement by grade of disease, with 95% confidence interval. All the patients were injected by an upperlimb physiotherapist (DD). Post injection review was carried out by an independent observer(MK). Forty patients were studied: 33 females and 7 males. The age ranged from 53 to 81 years, (mean 65years). No patient was lost to follow-up. Mean duration of symptoms were 36 months. Six patients has stage I disease(15%), eighteen patients had stage II disease (45%), ten patients had stage III disease (25%) and six patients has stage IV disease (15%). Pain score ranged from 4 to 9 on visual analogue score. Reduction in pain visual analogue score was noticed in all but 3 patients. With the exception of Grade III patients, DASH scores decreased significantly at 6 weeks (Grade I 14.9, Grade II 19.3, Grade III 6.2 and Grade IV 10.0.). With the exception of Grade IV patients, pain scores decreased significantly at 6 weeks. In Grade II patients, over half had sustained symptomatic relief at 6 months. So on average, we can expect grade I patients to sustain symptomatic relief for an average of 17 weeks. The true average is likely to be between 13 and 21 weeks. For grade II patients, most will still have improved at 6 months. Grade III and IV patients have an identical prognosis of 4 weeks, though the true prognosis may be between 2 and 6 weeks. In conclusion it is possible to predict the period of symptomatic improvement in each of the four disease stages. This allows the treating clinician to discuss the outcome of treatment with reasonable accuracy

The aim was to investigate whether or not the pre-operative injection of cortico-steroids into the knee influences the infection rate of a subsequent total knee replacement. This was a case controlled study, in which it was calculated that 152 controls and 38 infected cases would give sufficient power to the study. The infection group had to have had a delay in wound healing or have had a revision for infection. A total of 32.8% had had an injection at some time pre-operatively. The average number of injections was 2.23, with a range of 1–15. 37% were performed by a G.P., 35% by an orthopaedic surgeon, and 22% by a rheumatologist.79% had the injection within 12 months of surgery. The rate of injection was the same in the two groups. There was no significant difference in the infection rate between the two groups (OR 1.38; 95%CI 0.55–3.31). Despite recent literature indicating that there is a 10% increase in infection in patients having steroid injections into the hip prior to THR this study does not confirm this risk in patients undergoing TKR

Introduction: The treatment with epidural steroids and local anaesthetic for radicular pain arising from nerve root compression is a commonly utilised and recognised treatment. The aim of this study is to determine the efficacy of CT-guided injection of epidural steroids without anaesthetic for radicular pain but without clinical neurology in the presence of a degenerative of lytic spondylolisthesis and concomitant foraminal narrowing. Method: The study subjects, 21 in total, were selected over a 1-year period by the surgeon. All patients had either degenerative or lytic spondylolisthesis as determined by CT, MRI and plain film and were suffering from radicular pain – sharp, shooting and burning in the L5 or S1 dermatome. For inclusion, there had to be no associated evidence of nerve root compression. All patients completed, prior to epidural therapy, a pain diagram, visual analogue scale (VAS) of pain severity on a scale of 1 to 10 and Oswestry Disability Index (ODI). The MRI and clinical pain picture were correlated. The level of the spondylolithesis was determined. Highly selective CT-guided epidural steroid injection was then carried out at the level of spondylolithesis by an experienced interventional radiologist. The pain diagram, VAS of pain severity and ODI were all completed again by the subjects themselves or by telephone at 1 and 3 months after injection in the presence of an independent assessor (nurse) and then reviewed and discussed with the treating doctor. All subjects were also asked to complete a functional questionnaire. Results: One month after injection 86% of those treated had greater than 50% radicular pain relief and from this group 72% had radicular pain reduction of greater than 80%. All had improvement in function. All of the above, confirmed that their quality of life had certainly improved. Three months after injection 76% of those treated still had a reduction in their radicular pain of greater than 50% (92% of these still had pain reduction of over 80%). Again all reported continued functional improvement. Discussion: Despite the small sample size, this study highlights the short-term Benefit of CT-guided steroid epidural injections with symptomatic lumbosacral spondylolisthesis and spondylolysis with radicular pain. Pain can be relieved without anaesthesia. The mechanisms of pain relief are speculative

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine. The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection. Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone

Introduction. Tennis and Golfers elbows (TE, GE) are difficult conditions to treat. Ultrasound guided steroid injection (UGSI) is one of the treatment modalities in treating refractory TE and GE. We present our clinical experience and short to mid-term results of patients with TE and GE treated with UGSI. Methods. Patients with persistent TE and GE treated with UGSI (Marcaine and kenalog) at a tertiary centre between 2007 and 2010 were retrospectively reviewed. Mean follow up was 4 months (Range 2–21 months). Patients were assessed for pain relief, recurrence of symptoms and surgical release. Results. USGI was performed on 181 elbows (144 patients). There were 68 male and 76 female patients. Mean age 49.5 years (range 17–82). At the time of UGSI, chronic features of TE were established in 144 elbows and signs of GE were identified in 37 elbows. At the review clinic, 155 (86%) elbows were reported to be completely pain free, 10 (5%) elbows experienced no improvement and 16 (9%) elbows encountered residual symptoms. However, a total of 98 (54%) elbows experienced recurrence of symptoms. For TE, symptoms recurred in 74/144 (51%) elbows at a mean interval of 5.8 months (95% CI: 4.6 to 6.9 months). For GE, symptoms recurred in 24/37 (64%) elbows at a mean interval of 4.2 months (95% CI: 3.4 to 5.0 months). Repeat USGI was performed in 24 elbows, of which 20 elbows were associated with further recurrence. Fifty seven (50%) elbows underwent surgical release (45 TE and 12 GE). Discussion. USGI appears to be a beneficial short term measure in controlling the symptoms of TE and GE. However, recurrence or failure to improve occurred in 68% of elbows. Repeat USGI is associated with high failure rate (83%) and surgical option should be explored in these refractory conditions

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.

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

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.

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.

Aims. Osteoarthritis (OA) affecting the thumb carpometacarpal joint (CMCJ) is a common painful condition. In this study, we aimed to explore clinicians’ approach to management with a particular focus on the role of specific interventions that will inform the design of future clinical trials. Methods. We interviewed a purposive sample of 24 clinicians, consisting of 12 surgeons and 12 therapists (four occupational therapists and eight physiotherapists) who managed patients with CMCJ OA. This is a qualitative study using semi-structured, online interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Results. A total of 14 themes were developed, six of which were developed relating to the clinical management of CMCJ OA: 1) A flexible ‘ladder’ approach starting with conservative treatment first; 2) The malleable role of steroid injection; 3) Surgery as an invasive and risky last resort; 4) A shared and collaborative approach; 5) Treating the whole person; and 6) Severity of life impact influences treatment. The remaining eight themes were developed relating to clinical trial barriers and facilitators: 1) We need to embrace uncertainty; 2) You are not losing out by taking part; 3) It is difficult to be neutral about certain treatments; 4) Difficult to recruit to ‘no treatment’ ; 5) Difficult to recruit to a trial comparing no surgery to surgery; 6) Patients are keen to participate in research; 7) Burden on staff and participants; and 8) A enthusiasm for a variety of potential trial arms. Conclusion. Our findings contribute to a better understanding of how clinicians manage thumb CMCJ OA in their practice settings. Our study also provides useful insights informing the design of randomized clinical trials involving steroid injections and surgery in people with thumb CMCJ OA. Cite this article: Bone Jt Open 2022;3(4):321–331

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

The June 2023 Shoulder & Elbow Roundup. 360. looks at: Proximal humerus fractures: what does the literature say now?; Infection risk of steroid injections and subsequent reverse shoulder arthroplasty; Surgical versus non-surgical management of humeral shaft fractures; Core outcome set needed for elbow arthroplasty; Minimally invasive approaches to locating radial nerve in the posterior humeral approach; Predictors of bone loss in anterior glenohumeral instability; Does the addition of motor control or strengthening exercises improve rotator cuff-related shoulder pain?; Terminology and diagnostic criteria used in patients with subacromial pain syndrome

The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

The February 2023 Wrist & Hand Roundup. 360. looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion

Introduction. Epidural steroid injection is an established treatment modality for intervertebral disc prolapse. It is a low-risk alternative to surgical intervention in some patients for whom noninvasive treatment has failed. Caudal epidural steroid injection is one of the most widely used methods for pain relief. The aim of this study was to determine the significance of same dose in different volume of caudal epidural steroid injection in the treatment of lumbar degenerative disc disease. Material/Methods. Prospective study was conducted during 2007 to 2009. 100 Patients were randomized in to two groups, of which 50 % (group A) received 4 ml of steroid with isotonic saline and remaining 50 % (group B) received 12 ml. Injection was given in prone position through a 22-G needle in to the epidural space through the sacral hiatus. The average follow-up was 18 months. Outcomes scores included the SF-36, Oswestry disability index and pain VAS and were recorded in the pre and post injection periods. Results. In group A, 18 patients had significant pain relief and 32 had no relief during the early period. Whereas in group B, 22 had significant pain relief and 28 had no relief. The quality of pain relief of 50% or greater was considered as significant. Follow up after 1 year does not show much difference. Group B had significant decrease in symptoms in the initial post injection period (P<0.05). Conclusions. The volume of steroid solution in the treatment of lumbar degenerative disc disease is significant in the early post injection period only

Introduction

Total knee arthroplasty is a painful operation. Peri-articular local anesthetic injections reduce post-operative pain and assist recovery. It is inconclusive whether intra-operative injections of peri-articular corticosteroids are of benefit. Clinical Question: In patients with osteoarthritis who are undergoing TKA, does the addition of high or low dose corticosteroid to peri-articular injections of local anesthetic and adrenaline improve post-operative pain and range of motion?

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.

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good. The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome. The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded. Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient. 58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003). In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection

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

Aims

To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective.

Introduction

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinico-radiological features and concomitant hip and lumbar spine arthritis. It has been hypothesized that an anaesthetic hip arthrogram can help identify the source of pain in these cases. The purpose of this study is to analyze our experience with this technique in order to verify its accuracy.

Aims. This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. Methods. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. Results. Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. Conclusion. The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773–784

Aims. Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. Methods. A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. Results. In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). Conclusion. This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305–308