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

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.

Musculoskeletal ultrasound (MSK-US) can have many uses for orthopaedic surgeons, such as assisting in clinical diagnosis for muscle, tendon and ligament injuries, providing direct guidance for joint injections, or assessing the adequacy of a reduction in the emergency department. However, proficiency in sonography is not a requirement for Royal College certification, and orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK-US course in an orthopaedic surgery program. A MSK-US course for orthopaedic surgery residents was developed by an interdisciplinary team involving a paediatric orthopaedic surgeon, an emergency physician with a fellowship in point-of-care ultrasonography, and an orthopaedic surgery resident. Online videos were created to be viewed by residents prior to a half-day long practical course. The online portion covered the basics of ultrasonography, as well as the normal and abnormal appearance of musculoskeletal structures, while the practical portion applied those principles to the examination, injection, and aspiration of joints, and ultrasound-guided fracture reduction. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was filled by the participants prior to the course. Resident's knowledge acquisition was measured with a written pre-course, same-day post-course and six-month follow-up tests. Residents were also scored on a practical shoulder examination immediately after the course and at six-month follow-up. An online survey was also sent to evaluate residents' satisfaction with different aspects of the course (NAS). Change in test scores were calculated using an ANOVA and a Wilcoxon signed-rank test. Ten orthopaedic surgery residents underwent the MSK-US curriculum. Pre-course interest to MSK-US was moderate (65%) and prior exposure was low (1.5 hours mean total experience). MSK-US has been previously mostly observed in the emergency department and sports orthopaedic clinic. Satisfaction with the online curriculum, hands-on practice session and general quality of the course were high (8.78, 8.70 and 8.60/10 respectively). Written test scores improved significantly from 50.7 ± 17% to 84 ± 10.7% immediately after the course (p < 0 .001) and suffered no significant drop at six months (score 75 ± 8.7%, p=0.303). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at six months (p=0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at six months (p=0.007–0.018) but did not significantly increase clinical usage frequency. A MSK-US curriculum was successfully developed and implemented using an interdisciplinary approach. The course was rated high quality and succeeded in improving the residents' knowledge, skills, and comfort with MSK-US. This improvement was maintained at six months on the written test, but did not result in higher frequency of use by the residents

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Aim. To see if minor upper limb surgery procedures like CTR, Trigger release, Joint injections are safe for a remote telephonic review by specialist nurse. This arrangement was to help maintain our current agreed departmental New to Follow up ratio of 1:1.56 and also to improve access to specialist clinics. Methods. This was a prospective study. Patients undergoing minor procedures were informed about the remote follow up arrangements when placed on waiting list and on the day of surgery. Patients were assured access to clinic up to 3 months after procedure. A specialist nurse undertook a telephone consultation at 2 and 6 weeks using a proforma provided by the Consultant. Results. From Dec 2012 to June 2014, we have undertaken a total of 155 minor procedures in 134 patients. We were unable to contact 15 (11%) patients for remote review. Twelve of 39 (30%) in injection subgroup requested repeat injections, they were added to the waiting list saving OPD visit 3(8%) based on response to treatment. In Procedure subgroup 20 needed review of which 15 were reassured and discharged. Only 5 needed further investigations and follow ups. Twenty-three (15%) out of 155 procedures needed review in clinic. We used available resources prudently avoiding follow up without clinical benefit for 85% of our patients. Five adverse reactions were reported but none of them had complications related to procedure nor did we receive any complaints. Conclusion. Based on our pilot study “Remote Review” of patients is safe in carefully selected procedures. This innovative arrangement helped us improve the specialist access for more new patients without compromising the patient safety

The causes of pain after TKA can be local (intra or extra-articular) or referred from a remote source. Local intra-articular causes include prosthetic loosening, infection, aseptic synovitis (wear debris, hemarthrosis, instability, allergy), impingement (bone soft tissue or prosthetic), an un-resurfaced patella and stress fracture of bone or the prosthesis. Some surgeons think that isolated component mal-rotation can be a source of pain, but component mal-rotation is rarely present in the absence of other technical abnormalities. Local extra-articular causes include pes anserine bursitis, saphenous neuroma/dysasthesias, post-tourniquet dysasthesias, complex regional pain syndrome and vascular claudication. Referred pain is most often from an arthritic hip or radicular pain from a spinal source. Patients with fibromyalgia can have persistent pain following their knee arthroplasty and should be warned of this possibility. Evaluation of the patient includes a history, physical exam, joint aspiration and plain radiographs. In selected patients, an anesthetic joint injection, bone scan, CT scan or MRI with metal subtraction may be helpful in the diagnosis. The joint aspiration should include a CBC and differential as well as an aerobic and anaerobic culture. Fungal and TB cultures are sometimes indicated. Re-operation for pain of unknown etiology following TKA is unlikely to yield an excellent result and both surgeons and patients should be aware of this probability

Aims

To describe the incidence of adverse clinical outcomes related to COVID-19 infection following corticosteroid injections (CSI) during the COVID-19 pandemic. To describe the incidence of positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing, positive SARS-COV2 IgG antibody testing or positive imaging findings following CSI at our institution during the COVID-19 pandemic.

Aims

This study aimed to identify patients receiving total hip arthroplasty (THA) for trauma during the peak of the COVID-19 pandemic in the UK and quantify the risks of contracting SARS-CoV-2 virus, the proportion of patients requiring treatment in an intensive care unit (ICU), and rate of complications including mortality.

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.