Prior to the introduction of steroid management in Duchenne Muscular Dystrophy (DMD), the prevalence of scoliosis approached 100%, concomitant with progressive decreases in pulmonary function. As such, early scoliosis correction (at 20-25°) was advocated, prior to substantial pulmonary function decline. With improved pulmonary function and delayed curve progression with steroid treatment, the role of early surgery has been questioned. The purpose of this study was to compare the post-operative outcomes of early versus late scoliosis correction in DMD. We hypothesize that performing later surgery with larger curves would not lead to worse post-operative complications. Retrospective cohort study. Patients with DMD who underwent posterior scoliosis correction, had pre-operative pulmonary function testing, and at least 1-year post-operative follow-up, were included; divided into 2 Groups by pre-operative curve angle – 1: ≤45°, 2: >45°. Primary outcome was post-operative complications by Clavien-Dindo (CD) grading. Secondary outcomes included: age at surgery, forced vital capacity (FVC), steroid utilization, fractional shortening (FS) by echocardiogram, surgery duration, blood transfusion requirements, ICU length of stay (LOS), days intubated post-operatively, hospital LOS, infection, curve correction. Two-tailed t-test and chi-square testing were used for analysis of patient factors and CD complication grade, respectively. 31 patients met the inclusion criteria, with a mean total follow-up of 8.3±3.2 years. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients, for a mean duration of 8.2±4.0 years. Groups were comparable for steroid use, FVC, echo FS, and age at surgery (p>0.05). Primary curve angle was 31.7±10.4° and 58.3±11.1° for Groups 1 and 2, respectively (p 0.05). Surgery duration, ICU LOS, days intubated, hospital LOS, were also not different between Groups. For the entire cohort, however, the overall complication rate was higher for patients with steroid treatment [61.9% vs 10%, respectively (p=0.008)], the majority being CDII. Neither FVC nor echo FS were different between Groups at final follow-up (p=0.6; p=0.4, respectively). Post-operative complication rates were not different for early and late scoliosis correction in DMD. In general, however, patients undergoing steroid treatment were at higher risk of blood transfusion and deep infection. Delaying scoliosis correction in DMD while PF is favourable is reasonable, but patients with prior steroid treatment should be counseled regarding the higher risk of complications

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

Following arthroscopic arthrolysis for frozen shoulder, steroid injections may become necessary to improve ongoing pain and facilitate stretching exercises. The aim of this study was to evaluate the rate of steroid injections needed post-arthroscopic arthrolysis of frozen shoulder. Case series review carried out in a District General Hospital in UK. 30 consecutive patients who had arthroscopic arthrolysis under the care of the senior author were included. Patients’ records were analysed to identify the number of steroid injections administered post-operatively. 11 males and 19 females were examined, aged 46–83 years old (mean 56.1). 7 patients were diabetic. 10 patients (33.3%) received steroid injections post-operatively, with 8 of them receiving the injection within the first 6 post-operative months. The average post-operative time of steroid injection was 9.8 months. There was no association between diabetes and administration of a post-operative steroid injection P>0.01. Following arthroscopic arthrolysis a substantial proportion of patients may require one or more steroid injections to help pain and facilitate stretching exercises and physiotherapy. This study showed that 1 in 3 frozen shoulders treated with arthroscopic arthrolysis may need a subsequent steroid injection in the first year post surgery. Patients should be counselled preoperatively with regards to that, and be warned that arthroscopic arthrolysis is only the first step in the treatment pathway leading to recovery. Blackpool Victoria Hospital Orthopaedic Department

Purpose. Osteoarthritis of the trapezio-metacarpal joint (TMJ or basal thumb joint) is a common condition causing significant disability. A range of non-operative and operative management options can be used for its treatment. One of the most common conservative treatments is a steroid injection into the joint. To confirm correct placement of the steroid it is preferable to use X-ray image intensification. Few previous studies have audited effectiveness, particularly with the use of radiological guidance. Methods. This clinical observational study prospectively reviewed the longevity of benefit of steroid injections into the TMJ. They were followed up until the analgesic effects ceased with a questionnaire including visual analogue scores. The clinical improvement was compared with the degree of radiological osteoarthritis (Eaton grade). Seventy-seven patients were recruited with a median age of 62 years and injected with steroid and local anaesthetic under radioscopic guidance. Results. Nearly half of the patients had a 3-month improvement. Two-thirds benefited for at least 2 months. One in six patients had a 6-month benefit, with some patients still improved 2 years after injection. Previously injected patients had a reduced duration of benefit compared to their previous injection. Effectiveness was not affected by Eaton grade. We had no complications except pain during injection. Conclusion. This study demonstrates that there are potentially significant benefits to be gained from steroid injections into the TMJ. We believe the outcome is improved by using radiological guidance and by adding local anaesthetic. Based on this study we recommend steroid injections in all degrees of TMJ osteoarthritis

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

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

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

Introduction. 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?. Methods. A prospective, randomized, double-blinded study was undertaken to assess the efficacy of adding peri-articular corticosteroids to intra-operative, peri-articular high volume local anaesthetic in post-operative pain management following TKA. 127 patients were randomised into three groups receiving local anaesthetic alone (control) or either low dose (40 mg) or high dose (80 mg) peri-articular corticosteroid plus local anaesthetic. Primary outcomes included ROM and visual analog pain scores (VAS). Pain was defined as the worst pain lasting for more than 20 minutes, measured at both rest (RVAS) and during activity (AVAS). Results. There were no significant between-group differences for age, body mass index (BMI), pre-operative ROM or pre-operative pain scores. There were no statistically significant differences in primary or secondary outcomes between the groups. This was the case at all time points. Analysis of non-significant trends demonstrated a 17.7% reduction in RVAS between the control group and high dose steroid group at 12-weeks. This trend was also apparent at 2 and 6 weeks. There was no trend towards decreased total morphine equivalents (or any other secondary outcome) between the control and high dose groups. Discussion. Corticosteroids have been postulated to facilitate post-operative ROM and reduce pain after TKA. However we were unable to show any significant clinical effect of peri-articular triamcinolone acetate at two different dosages. While it appears that corticosteroids are safe to administer in a select patient population, the results of this paper do not suggest a benefit in TKA

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

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. This study was performed to investigate the efficacy of steroid and local anaesthesia (LA) in reducing post-operative pain in lumbar discectomy. Materials and methods. The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups, which were (Group 1) 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine, (Group 2) 10mg of adcortyl and 1ml of normal saline, (Group 3) 1ml of 0.5% marcaine and 1ml of normal saline and (Group 4) 2mls of normal saline as control. Combinations of the above were applied topically over the nerve root prior to closure. Pre-operative, day 1 and eight weeks post-operative pain scores were recorded. 24 hours post-operative opiate analgesia requirements and duration of inpatient stay were recorded. Data were analysed using student t-test for statistical significance. Results. 100 patients were recruited into the study. There were no significant differences seen in the mean age, gender and the mean pre-operative pain score between all groups. Mean day one pain score in groups 1,2,3 and 4 was 0.9,2.5, 2.1 and 3.3 respectively. Mean 24 hours post-operative opiate requirement was 32.4mg, 54mg, 48.8mg and 56.4mg respectively. Mean inpatient stay was 2.2 days, 3.9 days, 4.62 days and 3.63 days respectively. A significant different (p<0.05) was noted in day one post-operative mean pain score, mean 24 opiate requirement and mean inpatient stay in the corticosteroid and LA group. At 8 weeks post-operatively, no significant differences were seen in the pain score in all groups. Conclusions. Significant early post-operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p<0.05). A significant reduction in the 24-post operative analgesia requirement (p<0.05) and in inpatient stay (p<0.05) was also observed

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. Methods. We undertook a retrospective analysis of 204 patients who underwent a hip anesthetic-steroid arthrogram for diagnostic purposes matching our inclusion criteria. Patient charts were scrutinized carefully for outcomes of arthrogram and treatment. Harris Hip Score was used to quantify outcome. Results. The results show that out of 204, 162 patients had positive and 42 had negative response to arthrogram. Of the positive responders (N=162), 76 underwent uncemented Total Hip Arthroplasty (THA), all with good results, and the rest are being treated conservatively. From the negative responder group (N=42), 33 were successfully treated for spinal and other disorders, 8 underwent successful THA and 1 had an unsuccessful THA. Conclusion. Our findings suggest that the relief of symptoms following instillation of local anaesthetic and steroid into the hip joint has a positive predictive value and specificity of 100%, sensitivity of 95% and negative predictive value of 89.5%. We thereby believe that this is useful and reliable test with low morbidity for distinguishing between pain arising from the hip and other sources and can predict the potential benefit of THA in this diagnostic challenging group of patients

Psoas tendinopathy is a potential cause of groin pain after primary total hip arthroplasty (THA). The direct anterior approach (DAA) is becoming increasingly popular as the standard approach for primary THA due to being a muscle preserving technique. It is unclear what the prevalence is for the development of psoas-related pain after DAA THA, how this can influence patient reported outcome, and which risk factors can be identified. This retrospective case control study of prospectively recorded data evaluated 1784 patients who underwent 2087 primary DAA THA procedures between January 2017 and September 2019. Psoas tendinopathy was defined as (1) persistence of groin pain after DAA THA and was triggered by active hip flexion, (2) exclusion of other causes such as dislocation, infection, implant loosening or (occult) fractures, and (3) a positive response to an image-guided injection with xylocaine and steroid into the psoas tendon sheath. Complication-, re-operation rates, and patient-reported outcome measures (PROMs) were measured. Forty-three patients (45 hips; 2.2%) were diagnosed with psoas tendinopathy according to the above-described criteria. The mean age of patients who developed psoas tendinopathy was 50.8±11.7 years, which was significantly lower than the mean age of patients without psoas pain (62.4±12.7y; p<0.001). Patients with primary hip osteoarthritis were significantly less likely to develop psoas tendinopathy (14/1207; 1.2%) in comparison to patients with secondary hip osteoarthritis to dysplasia (18/501; 3.6%) (p<0.001) or FAI (12/305; 3.9%) (p<0.001). Patients with psoas tendinopathy had significantly lower PROM scores at 6 weeks and 1 year follow-up. Psoas tendinopathy was present in 2.2% after DAA THA. Younger age and secondary osteoarthritis due to dysplasia or FAI were risk factors for the development of psoas tendinopathy. Post-operatively, patients with psoas tendinopathy often also presented with low back pain and lateral trochanteric pain. Psoas tendinopathy had an important influence on the evolution of PROM scores

Necrotizing Fasciitis (NF) is a life-threatening infectious condition which requires expedient diagnosis to proceed with urgent surgical debridement. However, it can be difficult to establish an early diagnosis and expedite operative management as signs and symptoms are often non-specific and may mimic other pathology. Scoring systems such as The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) have been proposed to incorporate laboratory findings to predict whether a soft tissue infection is likely to be NF. Recent studies have found the sensitivity and specificity of the LRINEC tool to be lower than originally cited by the LRINEC authors in a validation cohort. Furthermore, there seems to be a predilection for certain geographic locations of patients with NF transferred to our tertiary care center for management, however, to our knowledge, geographic risk factors for NF have not been reported. This study also aims to determine the morbidity and mortality rate of NF at our Canadian tertiary hospital in recent years. Comorbidities such as smoking, diabetes, and steroid use will be analyzed for any correlation with developing NF. Identification of patient factors in correlation with laboratory values may help identify patients at higher risk for having NF upon their presentation to the emergency department. A resultant earlier diagnosis of necrotizing soft tissue infections would allow for earlier surgical debridement and positively influence patient outcomes. A retrospective chart review of 125 cases of NF at Kingston Health Sciences Centre from 2005 to 2017 was carried out to assess the validity of the LRINEC in our population and to examine the effect of comorbid factors such as smoking, diabetes, and corticosteroid use on the development of NF. The study cohort included patients treated by all surgical disciplines at our institution over twelve years. A separate cohort of 125 cellulitis or abscess cases was analyzed to assess the validity of the LRINEC tool in differentiating necrotizing fasciitis from non-necrotizing infections such as cellulitis and soft tissue abscess. The 30-day mortality rate of NF treated at our institution during the study period was 21%. Advanced age was found to be a significant risk factor for death within 30 days of diagnosis (p=0.001). Smoking and steroid use were both found to increase risk for developing NF (p=0.01 and p=0.03, respectively). Diabetes did not appear to increase risk NF. There was no statistical difference in mortality rates between males and females with NF. The sensitivity of LRINEC in detecting NF was only 47% with a specificity of 74%. The mortality rate of NF at our center is similar to that of other countries in recent years. Males and females have nearly equal mortality rates from NF. Smoking and steroid use appear to increase risk for developing NF, while diabetes may not. The LRINEC assessment tool alone may underestimate risk for developing NF, however, use of other clinical factors such as comorbidity analysis will further aide in the diagnosis of NF allowing for earlier surgical debridement

It has been reported that the total steroid dose and acute rejection episodes after organ transplantation is one of the risk factors for the development of osteonecrosis of the femoral head (ONFH), and ONFH in steroid-iduced subgroup may progress more aggressively to femoral head collapse requiring total hip arthroplasty. Despite inherent medical co-morbidities of solid organ transplantation patients, most authors recently have reported successful outcomes of THAs in those patients. But there are few comparative studies on the outcome of THAs for ONFH after different organ transplantations. The purpose of this study was to evaluate and compare a single tertiary referral institution's experience of performing primary THAs in kidney transplantation (KT) and liver transplantation (LT) patients with specific focus on the total steroid dose, clinical outcomes, and relationship between ONFH and absence or presence of acute rejection (AR). Between 1999 and 2010, 4,713 patients underwent organ transplantations (1,957 KT and 2,756 LT) and AR was occurred in 969 patients (20.6%) after transplantation. Among these patients, 131 patients (191 hips) underwent THA for ONFH, and they were retrospectively reviewed. In KT groups, there were 57 men and 36 women with a mean age of 43.7 years. In LT groups, there were 26 men and 13 women with a mean age of 50.4 years. We investigated the dose of steroid administration on both groups, the time period from transplantation to THA, Harris hips score (HHS), visual analogue scale (VAS) and complications. The mean follow up period was 8.1 years (range, 5 to 14 years). One-hundred and thirty-one (2.8%) patients [93 KT and 38 LT] underwent THA after transplantation. The total steroid dose after transplantations was significantly higher in KT group (10,420 mg) than that in LT group (4,567 mg), but the total steroid dose in the first 2 weeks after transplantation was significantly higher in LT group (3,478 mg) than that in KT group (2,564 mg). Twenty-three (2.4%) patients (19 KT and 4 LT) who underwent THA had an episode of AR. In LT group, the total steroid dose in AR groups was significantly higher than that in non-AR groups, whereas in KT group, there was no significant difference of the total steroid dose between AR group and non-AR group. The rate of THAs for ONFH was similar in both groups (2.4% in AR group, 2.9% in non-AR group). The mean time period from transplantation to THA was 986 days for KT and 1,649 days for LT patients. Both groups showed satisfactory HHS and VAS at final follow up, revealed no differences between the groups. The rate of THAs for ONFH was three times higher in KT patients than that in LT patients, but it was similar in both AR group and non-AR group. The total steroid dose was also higher in KT patients compared to LT patients. The clinical outcomes of THA were satisfactory with few complications in both KT and LT patients. Therefore, THAs seems to be a good option for the patients with symptomatic steroid-induced ONFH after KT and LT

Estimated to affect 2–5% of the population, adhesive capsulitis is a common cause of shoulder pain and dysfunction. The objective of this study is to determine if arthrographic injection of the shoulder joint with steroid, local anesthetic and contrast is an effective treatment modality for adhesive capsulitis and whether it is superior to arthrographic injection with local anesthetic and contrast alone. This is a double-blinded RCT of patients with a diagnosis of adhesive capsulitis who were randomly assigned to receive an image guided arthrographic glenohumeral injection with either triamcinalone (steroid), lidocaine (local anesthetic) and contrast or lidocaine and contrast alone. Outcome measures included active and passive shoulder range of motion (ROM) and functional outcomes assessed using the Shoulder Pain and Disability Index (SPADI), the Constant Score and a Visual Analog Scale for pain. Post-operative evaluation occurred at 3 weeks, 6 weeks and 12 weeks. Descriptive statistics were utilised to summarise patient demographics and other study parameters. One-way ANOVAs compared the VAS, Constant and SPADI scores across the different time points for both study groups. The post hoc Bonferroni correction was used to adjust for multiple comparisons. There were 37 shoulders injected with follow-up visits at 12 weeks. Twenty shoulders were randomised to receive local plus steroid and 17 shoulders received local anesthetic only. There were 21 females and 14 males with an average age of 54 years (range, 42–70). VAS scores for both patient groups were significantly improved (p<0.05) at all follow-up times. Goniometric testing demonstrated significant improvements in forward flexion and internal rotation at 90 degrees in the local group and only abduction in the local plus steroid group. There were no significant changes in the Constant scores for the local group (p=0.08), however, the Constant scores showed significant improvement for the local plus steroid group (p=0.003) at all follow-up time points. The local group showed significant improvement in their SPADI pain scores at the 12 week follow-up only (p=0.01). There were no significant differences in their SPADI disability scores (p=0.09). The local plus steroid group had significant improvement in SPADI pain and disability scores at all follow-up time points (p=0.001). The optimal treatment for adhesive capsulitis remains unclear. Our study demonstrated that patients receiving an arthrographic injection of either steroid and local anesthetic or local anesthetic alone had significantly improved post-injection pain scores. However, only the steroid and local anesthetic group demonstrated improved SPADI disability and Constant scores. Thus, we believe that either treatment may be a good option for patients with adhesive capsulitis and can reliably relieve pain, but we would recommend the steroid with local anesthetic over the local anesthetic alone as it may provide improved function

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003. We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone

Total knee arthroplasty (TKA) is the most commonly performed elective orthopaedic procedure. With an increasingly aging population, the number of TKAs performed is expected to be ∼2,900 per 100,000 by 2050. Surgical Site Infections (SSI) after TKA can have significant morbidity and mortality. The purpose of this study was to construct a risk prediction model for acute SSI (classified as either superficial, deep and overall) within 30 days of a TKA based on commonly ordered pre-operative blood markers and using audited administrative data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All adult patients undergoing an elective unilateral TKA for osteoarthritis from 2011–2016 were identified from the NSQIP database using Current Procedural Terminology (CPT) codes. Patients with active or chronic, local or systemic infection/sepsis or disseminated cancer were excluded. Multivariate logistic regression was conducted to estimate coefficients, with manual stepwise reduction to construct models. Bootstrap estimation was administered to measure internal validity. The SSI prediction model included the following co-variates: body mass index (BMI) and sex, comorbidities such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), smoking, current/previous steroid use, as well as pre-operative blood markers, albumin, alkaline phosphatase, blood urea nitrogen (BUN), creatinine, hematocrit, international normalized ratio (INR), platelets, prothrombin time (PT), sodium and white blood cell (WBC) levels. To compare clinical models, areas under the receiver operating characteristic (ROC) curves and McFadden's R-squared values were reported. The total number of patients undergoing TKA were 210,524 with a median age of 67 years (mean age of 66.6 + 9.6 years) and the majority being females (61.9%, N=130,314). A total of 1,674 patients (0.8%) had a SSI within 30 days of the index TKA, of which N=546 patients (33.2%) had a deep SSI and N=1,128 patients (67.4%) had a superficial SSI. The annual incidence rate of overall SSI decreased from 1.60% in 2011 to 0.68% in 2016. The final risk prediction model for SSI contained, smoking (OR=1.69, 95% CI: 1.31 – 2.18), previous/current steroid use (OR=1.66, 95% CI: 1.23 – 2.23), as well as the pre-operative lab markers, albumin (OR=0.46, 95% CI: 0.37 – 0.56), blood urea nitrogen (BUN, OR=1.01, 95% CI: 1 – 1.02), international normalized ratio (INR, OR=1.22, 95% CI:1.05 – 1.41), and sodium levels (OR=0.94, 95% CI: 0.91 – 0.98;). Area under the ROC curve for the final model of overall SSI was 0.64. Models for deep and superficial SSI had ROC areas of 0.68 and 0.63, respectively. Albumin (OR=0.46, 95% CI: 0.37 – 0.56, OR=0.33, 95% CI: 0.27 – 0.40, OR=0.75, 95% CI: 0.59 – 0.95) and sodium levels (OR=0.94, 95% CI: 0.91 – 0.98, OR=0.96, 95% CI: 0.93 – 0.99, OR=0.97, 95% CI: 0.96 – 0.99) levels were consistently significant in all prediction models for superficial, deep and overall SSI, respectively. Overall, hypoalbuminemia and hyponatremia are both significant risk factors for superficial, deep and overall SSI. To our knowledge, this is the first prediction model for acute SSI post TKA whereby hyponatremia (and hypoalbuminemia) are predictive of SSI. This prediction model can help fill an important gap for predicting risk factors for SSI after TKA and can help physicians better optimize patients prior to TKA

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

Objective. We have been using continuous epidural block and local infiltration cocktail for the pain management after TKA since 2005, and good pain control has been acquired with this method. During the past few years we have changed our protocol of postoperative pain management. We have stopped the administration of Loxoprofen starting next morning of the operation, instead Celecoxib was given starting before the operation. We have started mixing steroid to the intraoperative local infiltration cocktail to reduce acute pain as well as swelling. We also have stopped using suction drain, and delayed the timing of CPM start from day 2 to day 3. Methods. This is case control study, and 78 cases of unilateral TKA were investigated for the study. All cases were anesthetized with continuous epidural block with intravenous dosage of phentanyl and propofol. Compositions of local infiltration cocktail are 40ml 0.75% Ropivacaine, 60ml saline, 0.5ml epinephrin. Group1 (n=40) used this cocktail independently, and Group2 (n=38) used this cocktail with addition of 40mg of triamcinolone(Fig.1). Local infiltration cocktail was used during operation, which was injected to the whole joint capsule. In group1 Loxoprofen was given starting next morning, in group 2 Celecoxib was given starting at 7am on the day of operation. In group1 suction tube was left for 2 days, where as in group2 no suction tube was used postoperatively, and continuous epidural block catheter was removed on postoperative day 2 in both groups. CPM was started at postoperative day 2 in group 1 and postoperative day 3 in group 2. Numerical Rating Scale (NRS) was used to analyze the pain. Circumferences of knee and thigh, as well as ROM of knee joint were measured periodically. Results. Preoperative demographics showed no statistical difference between two groups(Fig. 2). Group 2 showed significantly less pain at 6am next morning postoperatively (Fig.3&4). Group 2 showed significantly lower NRS on motion at postoperative day1, 3, 5 and 7 (Fig.5). Group 2 also showed significantly less swellings of knees and thighs at postoperative day 7 (Fig.6). The ROM of the knee joints at postoperative day 7, 14 and 21 were better in group2(Fig.7). Discussions. Our new method of multimodal pain control is effective. It significantly decreased the pain at 6am next morning postoperatively, which is due to preoperative administration of Celecoxib. The pain on motion during 1 st week was significantly decreased which is probably due to the addition of steroid to the cocktail. Suction drain was not needed, if you use steroid in the cocktail and delay the timing to start CPM. The swelling was significantly reduced by steroid injection and delay in ROM exercise. As a result better ROM at postoperative day 7,14 and 21 were obtained. To view tables/figures, please contact authors directly