The December 2022 Sports Roundup. 360. looks at: Anterior cruciate ligament (ACL) repair with dynamic intraligamentary stabilization or anterior ACL at five years?; Femoroacetabular impingement in mild osteoarthritis: is hip arthroscopy the answer?; Steroids in Achilles tendinopathy: A randomized trial

Objective:

To study whether intra-articular triamcinolone hexacetonide (iaTH) for the treatment of coxitis in patients with juvenile rheumatoid arthritis (JRA) causes femoral head necroses (FHN).

Methods:

Fifty consecutive patients with JRA and coxitis were studied prospectively. Forty-eight children received iaTH in sixty-seven arthritic hips. The remaining two children exhibited three cases of femoral head necrosis at the initial assessment and were only followed; both were receiving long-term systemic steroids (LTSS). After a minimum of two years, the study was concluded with a final evaluation including MRI.

Results:

In thirty-nine of sixty-seven hip joints (58%), remission of the coxitis for a period of two years was obtained through a single administration of iaTH, another twelve hip joints went into remission after repeated TH injections (total remission rate = 76%). We observed two cases of femoral head necrosis (FHN) following iaTH. Both children were receiving LTSS. During the period between onset of JRA and screening assessment for this study, the children exhibited 2. 4 cases of FHN per 100 patient years vs. 1. 5 cases of FHN per 100 patient years between iaTH treatment and final follow-up. All five observed cases of FHN occurred among the twenty children who received LTSS, whereas no necrosis occurred in the thirty children who did not receive systemic corticosteroids (PÊ=Ê0. 009 Fisher’s Exact Test).

Conclusions:

IaTH for juvenile rheumatoid coxitis was an effective treatment which did not increase the rate of FHN. Systemic steroids, however, (or their co-variable, severity of JRA) do increase the risk of FHN in JRA.

Introduction and Aims: Intra-articular steroid hip injection (IASHI) for osteoarthritis of the hip has not been well studied. The immunosuppressive nature of steroids may be hypothesised to interfere with asepsis in subsequent total hip arthroplasty (THA). We evaluate the infectious complications and functional outcomes of THA performed in patients who previously received IASHI.

Method: This is a retrospective cohort study of functional outcomes (Harris and Oxford hip scores), and infectious complications in the first year following THA, in patients without (n=40 controls) or with (n=40) a history of ipsilateral IASHI. Functional scores had been compiled in our database, at one tertiary care centre, and infectious complications (wound infection, deep infection, work-up with bone scans, revision surgery) were retrospectively reviewed from hospital records.

Results: The IASHI group had worse post-THA function (p=0.0008 ANOVA for Oxford functional hip scores across time, with mean one-year scores being worse by seven points out of 60). In the IASHI group there were five revision surgeries, four of which were for deep infection of the hip replacement (10%, versus 0% in controls, versus 1.02% in our database of 979 THA primaries, p < 0.001 by Log-Rank testing of Kaplan-Meier survivor-ship analysis). Additionally, each group had two superficial wound infections. Six additional IASHI patients underwent infectious work-ups for ongoing hip problems (compared to one patient worked-up in the control group). The total rate of culture-proven infection (either superficial or deep), or problems leading to negative infectious work-up, was 12/40 (steroid, 30%) versus 3/40 (control, 7.5%, p = 0.010 by Fisher’s Exact test).

Conclusion: IASHI should now be considered as relatively contra-indicated in patients who are (or will become) candidates for THA. IASHI appears to compromise the functional results of subsequent THA, with much higher infection and revision rates. We suggest a multi-centre review of infected THA post-IASHI.

Introduction: The aim of this study was to investigate if steroids enhance the vasoconstrictive effect of nor-adrenaline on femoral arteries, which may result in femoral head blood flow reduction.

Materials and Methods: Ten male Wistar rats 62 to 88 days of age, 254 to 318 g of body weight, were used. Twenty femoral artery segments were harvested. These arterial segments were mounted as ring preparations on a small vessel myograph for isometric force measurements. The arteries were stimulated cumulatively with noradrenaline before and after incubation with methylprednisolone (5 μg/ml). Isometric wall tension was plotted and quantified by the EC50, the vasoconstrictor concentration resulting in halfmaximal contraction.

Results: The noradrenaline dose-response curve displayed a shift to the left for the steroid group in relation to the controls. This was reflected by a significantly lower EC50 of 9.5*10⁻⁷ M ± 5.1*10⁻⁷ M for the steroid vessels compared to 2.5*10⁻⁶ M ± 1.1*10⁻⁶ M for the control vessels (mean ± SD; p< 0.005).

Discussion: This study showed that incubation with methylprednisolone enhanced noradrenaline-mediated contraction of femoral arteries. Enhanced contraction of femoral arteries can diminish blood flow within the vascular bed supplying the femoral head. This may be a relevant cofactor in the early pathogenesis of steroid-associated femoral head necrosis.

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.

Abstract: Plantar fasciitis is the most common cause of heel pain for which medical care is sought. It is associated with significant morbidity placing activity limitations on the patients. The response of plantar fasciitis to any treatment is unpredictable. Many different modalities of treatment are used in its management. Injection of plantar fascia with local anaesthetic and steroids under general anaesthesia was carried out in 50 patients who had a clinical diagnosis of plantar fasciitis of greater than 3 month duration. Following induction of general anesthesia, a 20-gauge needle was guided toward and into the plantar fascia. 5mls of local anaesthetic and steroid was injected into the proximal plantar fascia. The patients were followed up over a mean of 6 months. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires with the VAS were filled out after treatment to determine the effectiveness of the procedure. The mean pain score decreased by 5.4 points. There were no complications during or after the procedure. Patients were questioned in relation to their occupational, athletic and recreational activities pre and post the injection.

Injection of the plantar fascia under general anaesthesia is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. A larger patient population and a greater than 1 year follow up would be helpful to determine the long term benefits & outcomes of this treatment.

Objective: To assess the clinical effectiveness of dexamethasone wound infiltration post lumbar discectomy.

Design: A prospective, double blind, randomised study comparing morphine consumption in two groups of patients in elective lumbar spine surgery via the posterior approach.

Subjects: There were forty patients divided into two randomly selected groups, one received postoperative wound infiltration with dexamethasone, the other with saline. Their morphine usage was measured.

Outcome measures: These included levels of morphine use postoperatively, pain scores and length of hospital stay.

Results: There was no statistically significant difference between postoperative morphine consumption in the two groups or in the length of hospital stay. There appeared to be improvement in pain scores with dexamethasone. There were no complications.

Conclusion: Postoperative wound infiltration with dexamethasone may result in some subjective improvement in pain, but none in analgesic consumption. Despite the lack of complications the subjective benefits do not outweigh the risks in the absence of objective improvement in pain.

Background

The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroids injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of neuroma.

Study Design: A retrospective study of the clinical outcome of patients with lumbar discogenic pain with Modic changes on MRI prior to intradiscal steroid injection.

Objectives: To determine whether the clinical outcome of patients with discogenic back pain who underwent intradiscal steroid injection could be predicted from MRI Modic changes.

Methods: The pre-operative scans were studied by two senior spinal surgeons. The lumbar vertebral end-plate changes were then classified according to the method described by Modic. The intra- and inter-observer ratings were satisfactory.

Subjects: 40 patients with discogenic back pain were recruited in this study. The mean age was 43.6 years (23 to 72 years). The male to female ratio was 1 to 1.

Outcome Measures: The clinical outcomes at six months post-intradiscal steroid injection were correlated with the Modic changes. The clinical outcomes were assessed using visual analogue scores for back pain as well as Oswestry disability index (ODI). At least a 2-point improvement in visual analogue score and a 20-point improvement in ODI were required to indicate significant symptomatic relief.

Results: We found that in those patients without Modic changes there was improvement of the low back pain in 9% (1/11). In those with Modic I changes there were significant relief in 64% (9/14), moderate relief in 29% (4/14) and no relief in 7% (1/14). In those with Modic II changes there were significant relief in 27% (4/15), moderate relief in 27% (4/15) and no relief in 47% (7/15). There were no cases with Modic III changes.

Conclusions: Previous studies on intradiscal steroid injections have shown variable results. Two prospective double-blind clinical trials, using intradiscal steroids, identified no significant benefit or improvement in the clinical outcome. Our results however suggest that patients with Modic I changes on MRI are most likely to benefit from intradiscal steroid injection in the short term.

Introduction: The results of treating chondral lesions with microfracture have been well documented. The lesion heals by fibrocartilage and the functional results tend to deteriorate through time.

Hypothesis: The use of steroids an platelet rich plasma (PRP) as coadjuvants to microfracture for the treatment of full thickness chondral lesions improve the results of this marrow stimulating technique.

Purpose: To macroscopically, histologically and molecularly evaluate the repair tissue generated after treating full thickness chondral lesions with microfracture and local steroids or PRP in an animal model.

Materials: Experimental in-vivo study in 40 femoral condyles (FC) from New Zealand rabbits. Chondral lesions were induced in all the samples and divided into 4 groups:

Group 1: control, lesion left untreated.

Animals were sacrificed after 3 months and the samples were evaluated macroscopically, histologically (H and E, Toluidine Blue) and molecularly (RT-PCR for Col1 and Col2). The results were analyzed with ANOVA and Bonferroni tests (p< 0.05).

Results: Macroscopy: the control group had no healing tissue. In all the other groups there was a variable presence of a fibrocartilaginous tissue without significant differences among groups.

Histology: all the groups had the presence of fibrocartilage.

Molecular analysis: all the groups had a significantly poorer Col2/Col1 relation when compared to normal hyaline cartilage, without significant difference among groups.

Conclusions: The local use of betamethasone and PRP as coadjuvants to microfracture does not improve the macroscopical, histological and molecular results of the treatment of full thickness chondral lesions.

Introduction

Following tear of its tendon, the muscle undergoes retraction, atrophy and fatty infiltration. These changes are inevitable and considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can prevent these muscular changes following experimental supraspinatus tendon release in the rabbit.

Objectives: To assess whether peri-radicular infiltration of corticosteroids has any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Study Design: A double blinded randomised controlled trial

Methods: 81 patients with unilateral radicular pain and failed conservative management were randomised to two groups (B and S). Group B received a single peri-radicular injection with bupivacaine and group S received bupivacaine and methylprednisolone. Both patient and surgeon were blinded to the method of treatment. Statistical analysis involved the use of a Chi Square test.

Outcome measures: 1. Number of additional root blocks required and 2. Requirement for surgery.

Results: At a median follow-up of 20 months (range 12–31 months) follow-up data was available for 70 patients (86%) with 35 patients in each group. There were an equal number of males and females in the groups. In group B, 10 patients required a further root block (29%) compared with 6 patients in group S (17%) [p=0.39]. Similarly 8 patients in group B required subsequent surgery (23%) compared with 3 in group S (9%) [p=0.19]. These differences did not achieve statistical significance probably due to the modest size of this study.

Conclusion: Our findings suggest that adding corticosteroid to bupivacaine nerve root blocks may reduce the need for further root blocks and surgery.

Avascular necrosis (AVN) is a serious complication of high-dose chemotherapy for haematological malignancy in childhood. In order to describe its incidence and main risk factors and to evaluate the current treatment options, we reviewed 105 children with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall, eight children (7.6%) developed AVN after a mean of 16.8 months (8 to 49). There were four boys and four girls with a mean age of 14.4 years (9.8 to 16.8) and a total of 18 involved sites, 12 of which were in the femoral head. All these children were aged > nine years (p < 0.001). All had received steroid treatment with a mean cumulative dose of prednisone of 5967 mg (4425 to 9599) compared with a mean of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No difference existed between genders and no thrombophilic disorders were identified. Their initial treatment included 11 core decompressions and two bipolar hip replacements. Later, two salvage osteotomies were done and three patients (four hips) eventually needed a total joint replacement. We conclude that AVN mostly affects the weight-bearing epiphyses. Its risk increases with age and higher steroid doses. These high-risk patients may benefit from early screening for AVN.

Cite this article: Bone Joint J 2013;95-B:1708–13.

The August 2024 Wrist & Hand Roundup. 360. looks at: Methotrexate shows potential in reducing pain for hand osteoarthritis with synovitis; Circumferential casting versus plaster splinting in adult distal radius fractures: the CAST study findings; Surgery shows superior long-term success for Dupuytren contracture compared to needle fasciotomy and collagenase injection; Evolving trends in surgical management of wrist arthritis: a decade-long national analysis; Mid-term outcomes of three commonly used surgical reconstructions for scapholunate instability; SLAC and SNAC: what is the evidence for treatment?; Steroids for trapeziometacarpal osteoarthritis?; When is it safe to return to driving after distal radius fracture fixation? A prospective study

The August 2015 Spine Roundup360 looks at: Steroids may be useful in avoiding dysphagia in anterior cervical discectomy and fusion (ACDF); Perhaps X-Stop ought to stop?; Is cervical plexus block in ACDF the gateway to day case spinal surgery?; Epidural past its heyday?; Steroids in lumbar back pain; Lumbar disc replacement improving; Post-discectomy arthritis

Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England. Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs. In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1. Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology. For any figures or tables, please contact the authors directly

The April 2015 Foot & Ankle Roundup. 360 . looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

The February 2015 Shoulder & Elbow Roundup. 360 . looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow

The April 2015 Knee Roundup360 looks at: Genetic determinants of ACL strength; TKA outcomes influenced by prosthesis; Single- or two-stage revision for infected TKA?; Arthroscopic meniscectomy: a problem that just won’t go away!; Failure in arthroscopic ACL reconstruction; ACL reconstruction in the over 50s?; Knee arthroplasty for early osteoarthritis; All inside meniscal repair; Steroids, thrombogenic markers and TKA