With the drawdown from Afghanistan focus turns towards future operations, and their demands on the DMS. Training for surgeons deploying to military operations will have to take into account the decreased opportunities and experience gained by current conflicts. The aim is to focus on current UK surgical training for military operations specifically. A comparison is made with US surgical training.

A questionnaire was distributed to UK military surgical consultants in General Surgery, Trauma and Orthopaedics and Plastic Surgery. A similar questionnaire was sent to deployed US surgeons in SE Afghanistan. Response rates of 55% were achieved. Respondents were questioned on their confidence to perform several key procedures. Most UK consultants were satisfied with their overall training for deployment. Satisfaction rates were high for the MOST course and Danish Surgery. US satisfaction with pre-deployment training was poor. The majority of respondents felt confident to perform all haemorrhage and contamination control procedures in an emergency. However, most felt training for military personnel should be lengthened by a year or more to include greater exposure to other specialties.

Whilst satisfaction with surgical training is high, many UK surgeons appear to suggest an increase in specialty exposure in preparation for future deployments.

Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections.

A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents.

The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free.

This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The infective bone and joint destruction did not respond to the management described in the current literature. There remains a further management issues as to whether arthroplasty surgery can be offered to post-TB infected shoulder joints.

Taking a TB exposure history is indicated prior to local immunosuppressant injection, particularly in the older age group of western populations and ethnicities with known risk factors.