Local Steroid Injection Research Articles

EFFECTIVENESS OF EPIDURAL INJECTION UNDER FLOUROSCOPIC GUIDANCE IN CHRONIC LOW BACK PAIN WITH BILATERAL LOWER LIMB RADICULOPATHY

Introduction: Chronic Low back pain with lumbosacral radiculopathy is one of the most common complain amongst patient in any orthopaedic out patient department . Therapeutic management of this problem is still a big task. Lumbar intervertebral disc herniation stands out to be most common cause , others include spinal stenosis , disc degeneration, post lumbar surgery syndrome. Epidural injections are used in patients with chronic low back pain with radiculopathy not relieved by conservative management. The aim of the study was to check the efcacy of uoroscopy guided epidural Injection of local anaesthetic and steroid in chronic low back pain with bilateral lower limb radiculopathy and compare the results with existing data of blind epidural injection without uoroscopic control. Materials And Method: The study was conducted among 52 patients visiting our out patient department at SMIMER hospital with complain of chronic low back pain bilateral lower limb radiculopathy not responding to conservative treatment. Outcomes were evaluated on the basis of pain relief (VAS score was used pre and post procedure), improvement in Oswestry low back disability score ,short term relief -6 months and long term relief > 6 months. Secondary outcome measure was functional status , psychological status and return to work. Results: In our study of 52 patients with chronic low back pain with bilateral lower limb radiculopathy not responding to medications, epidural injection was given under uoroscopic guidance after which 90.3%(47 patients) reported signicant improvement with mean VAS score improvement to 1.89 post procedure from mean score of 8.89 post procedure. Oswestry low back disability score decreased post procedure to 9% from pre-procedure score of 56.8%. No complications were reported in our study group. Conclusion: Epidural steroid injection is an effective treatment for the patients with chronic low back pain with bilateral lower limb radiculopathy not responding to therapeutic treatment. It is cost effective, safe and minimizes use of analgesics, allows early return to work and prevents or postpones surgical intervention needed for the same. Fluoroscopy adds on the benet of precision and accuracy of the epidural space for injection leading to increased efcacy and no requirement of sequential dosage as in epidural injection without uoroscopy due to lack of accuracy in that.

Läsionen der Trizepssehne

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents arare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is adirect fall onto the extended forearm or ablow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Outcome of Corticosteroid Injection in De Quervain's Tenosynovitis

Background: De Quervain's tenosynovitis is a painful and swollen stenosing tenosynovitis of the first dorsal compartment of the wrist. After analysing the patient's medical history and doing a physical examination, a diagnosis is made. Finkelstein's test is almost always positive. Objective: The goal of this study was to investigate the effectiveness of local corticosteroid injections in the treatment of de Quervain's tenosynovitis. Material & Methods: The study enrolled fifty patients with De Querven's Tenosynovitis. NSAIDs were provided orally and topically to all patients for an average of six weeks with no obvious improvement. Using a visual analogue scale, it was determined how much soreness would be felt in the first dorsal compartment and how much pain would be felt during the Finkelstein test. The edoema was removed by injecting a mixture of 1 mL (10 mg) triamcinolone-acetonide and 1 mL of 1% lidocain hydrochloride into the affected wrist's first dorsal compartment. They were subsequently examined every two weeks for twenty-four weeks. After a local triamcinolone acetonide injection, pain and discomfort on the radial side of the wrist were alleviated, and a negative Finkelstein test was done. Results: The mean age among the patients was 36.6 years with 12.4 SD. The maximum age was 60 years and the minimum age was 25 years old. The duration of symptoms in 4-8 weeks was observed, the mean value was 6 weeks with 1.4 as SD the minimum duration recorded was 4 weeks with 8 weeks as maximum duration. At the start of the week of appearance of symptoms the pain score was 6.44 with 1.6 as SD. The minimum pain score was 4 and maximum pain score was 8. Pain score at 4 weeks was 0.66 with 1.6 as SD. As per the independent t-test the p value was less than 0.05 so the test was significant statistically. Conclusion: One or two local steroid injections in the first dorsal compartment can give considerable pain and inflammation alleviation in people with de Quervain's tenosynovitis.

Cross-Sectional Area of the Median Nerve as a Prognostic Indicator in Carpal Tunnel Syndrome Treated With Local Steroid Injection

Local steroid injection is an effective treatment modality for carpal tunnel syndrome. This study aimed to investigate the success rate of ultrasonography-guided local steroid injection and determine the prognostic value of the cross-sectional area (CSA) of the median nerve for steroid injection. We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm2 (large-CSA group; n= 16) or ≤15 mm2 (small-CSA group; n= 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period. The treatment success rate was 45% (n= 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively. Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection. Therapeutic IV.

Local steroid injection versus surgical release for treatment of persistent De Quervain’s stenosing tenosynovitis (DQST): a prospective comparative study

Background: De Quervain’s stenosing tenosynovitis (DQST) can prevent patients from performing minor tasks as opening jars and texting. It is common in pregnant women and nursing mothers. The etiology is thought to be from repetitive manual work with thumb abduction and wrist ulnar deviation. The aim of this study was to compare steroid injection versus surgical release results for treatment of persistent DQST. Methods: Thirty-one hands of 30 patients with DQST who fulfilled the study selection criteria and treated during 2020 were included in this prospective study after institutional ethics committee approval. Patients were grouped into the mini-injection (group A) or surgical category (group B). Retrograde injection parallel to the tendons was used for injection. Transverse skin incision followed by longitudinal dissection and incision of the extensor retinaculum was used for surgical release. Clinical assessment of patients was done using a functional De Quervain’s score modified after the Disabilities of the Arm, Shoulder and Hand Score and Michigan Hand Outcome Questionnaire. Results: At the final follow-up, 13 out of 16 hands in group A improved. The mean score was 14±12.38, with nine, four, one, and two hands having excellent, good, fair, and absolute disability results, respectively. All 15 hands of group B improved. The mean score was 9.87±5.17, with nine, five, and one hands having excellent, good, and fair results, respectively. Conclusions: Both corticosteroid injection and surgical release were effective in persistent DQST treatment with insignificant differences, therefore the less invasive injection would be preferred. Level of Evidence: Level II.

Healthcare costs among patients with macular oedema associated with non-infectious uveitis: a US commercial payer’s perspective

ObjectiveTo describe patient characteristics and healthcare costs associated with uveitic macular oedema (UME) in US clinical practices from a commercial payer’s perspective.Methods and analysisThe IBM MarketScan Commercial Subset (1 October...

Extended Follow-up of Local Steroid Injection for Carpal Tunnel Syndrome

Local steroid injection is commonly used in treating patients with idiopathic carpal tunnel syndrome, but evidence regarding long-term efficacy is lacking. To assess the long-term treatment effects of local steroid injection for carpal tunnel syndrome. This exploratory 5-year extended follow-up of a double-blind, placebo-controlled randomized clinical trial was conducted from November 2008 to March 2012 at a university hospital orthopedic department. Participants included patients aged 22 to 69 years with primary idiopathic carpal tunnel syndrome and no prior treatment with local steroid injections. Data were analyzed from May 2018 to August 2018. Patients were randomized to injection of 80 mg methylprednisolone, 40 mg methylprednisolone, or saline. The coprimary outcomes were the symptom severity score and rate of subsequent carpal tunnel release surgery on the study hand at 5 years. Secondary outcomes were time from injection to surgical treatment, SF-36 bodily pain score, and score on the 11-item disabilities of the arm, shoulder, and hand scale. A total of 111 participants (mean [SD] age at follow-up, 52.9 [11.6] years; 81 [73.0%] women and 30 [27.0%] men) were randomized, with 37 in the 80 mg methylprednisolone group, 37 in the 40 mg methylprednisolone group, and 37 in the saline placebo group. Complete 5-year follow-up data were obtained from all 111 participants with no dropouts (100% follow-up). At baseline, mean (SD) symptom severity scores were 2.93 (0.85) in the 80 mg methylprednisolone group, 3.13 (0.70) in the 40 mg methylprednisolone group, and 3.18 (0.75) in the placebo group, and at the 5-year follow up, mean (SD) symptom severity scores were 1.51 (0.66) in the 80 mg methylprednisolone group, 1.59 (0.63) in the 40 mg methylprednisolone group, and 1.67 (0.74) in the placebo group. Compared with placebo, there was no significant difference in mean change in symptom severity score from baseline to 5 years for the 80 mg methylprednisolone group (0.14 [95%CI, -0.17 to 0.45]) or the 40 mg methylprednisolone group (0.12 [95%CI, -0.19 to 0.43]). After injection, subsequent surgical treatment on the study hand was performed in 31 participants (83.8%) in the 80 mg methylprednisolone group, 34 participants (91.9%) in the 40 mg methylprednisolone group, and 36 participants (97.3%) in the placebo group; the number of participants who underwent surgical treatment between the 1-year and 5-year follow-ups was 4 participants (10.8%) in the 80 mg methylprednisolone group, 4 participants (10.8%) in the 40 mg methylprednisolone group, and 2 participants (5.4%) in the placebo group. All surgical procedures were conducted while participants and investigators were blinded to type of injection received. The mean (SD) time from injection to surgery was 180 (121) days in the 80 mg methylprednisolone group, 185 (125) days in the 40 mg methylprednisolone group, and 121 (88) days in the placebo group. Kaplan-Meier survival curves showed statistically significant difference in time to surgical treatment (log-rank test: 80 mg methylprednisolone vs placebo, P = .002 ; 40 mg methylprednisolone vs placebo, P = .02; methylprednisolone 80 mg vs 40 mg, P = .37). These findings suggest that in idiopathic carpal tunnel syndrome, local methylprednisolone injection resulted in statistically significant reduction in surgery rates and delay in need for surgery. ClinicalTrials.gov Identifiers: NCT00806871 and NCT02652390.

Pharmacological and non-pharmacological strategies for preventing postherpetic neuralgia: a systematic review and network meta-analysis.

BackgroundPostherpetic neuralgia (PHN) is a refractory complication of herpes zoster (HZ). To prevent PHN, various strategies have been aggressively adopted. However, the efficacy of these strategies remains controversial. Therefore, we aimed to estimate the relative efficacy of various strategies used in clinical practice for preventing PHN using a network meta-analysis (NMA).MethodsWe performed a systematic and comprehensive search to identify all randomized controlled trials. The primary outcome was the incidence of PHN at 3 months after acute HZ. We performed both frequentist and Bayesian NMA and used the surface under the cumulative ranking curve (SUCRA) values to rank the interventions evaluated.ResultsIn total, 39 studies were included in the systematic review and NMA. According to the SUCRA value, the incidence of PHN was lower in the order of continuous epidural block with local anesthetics and steroids (EPI-LSE), antiviral agents with subcutaneous injection of local anesthetics and steroids (AV + sLS), antiviral agents with intracutaenous injection of local anesthetics and steroids (AV + iLS) at 3 months after acute HZ. EPI-LSE, AV + sLS and AV + iLS were also effective in preventing PHN at 1 month after acute HZ. And paravertebral block combined with antiviral and antiepileptic agents was effective in preventing PHN at 1, 3, and 6 months.ConclusionsThe continuous epidural block with local anesthetics and steroid, antiviral agents with intracutaneous or subcutaneous injection of local anesthetics and a steroid, and paravertebral block combined with antiviral and antiepileptic agents are effective in preventing PHN.

IRON PILL ASPIRATION MIMICKING ASTHMA

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Foreign body aspiration can be a life-threatening event. Aspiration of iron pill can cause significant bronchial destruction via necrosis. Iron pill quickly disintegrates in the airway, inducing deep mucosal necrosis responsible for severe complications if not diagnosed promptly. We report a case of iron pill aspiration with asthma like presentation leading to severe bronchial stenosis. CASE PRESENTATION: A 50-year-old nonsmoking female, with past medical history of hypertension and arthropathy was referred to pulmonology for wheezing and shortness of breath that started after she had accidentally aspirated an iron pill. Examination was significant for expiratory wheezing. X-ray of the chest was normal. Bronchoscopy performed for the removal of the iron pill revealed complete obstruction of the right lower lobe (RLL) bronchus with thick mucoid secretions coated in iron and granulation tissue. Follow up bronchoscopy showed similar findings which included severe persistent airway inflammation. Cultures obtained grew cryptococcus neoformans. For which patient was she was treated with oral Diflucan for 1 year. Pulmonary function test showed no evidence of restriction or obstruction Once the infection was fully treated patient underwent endobronchial ultrasound (EBUS) which was performed as a therapeutic intervention for the RLL lesion as patient still had persistent symptoms of wheezing. EBUS showed severe stenosis of the RLL which was relieved following CRE balloon-tipped catheter insertion into the stenotic segment of the lower trachea followed by local intralesional steroid injection. On follow up three months later patient reported significant improvement in her symptoms. DISCUSSION: Iron pill aspiration syndrome is a relatively rare cause of severe bronchial inflammation leading to endobronchial stenosis [1,2]. The diagnosis is made by the presence of history of aspiration, airway inflammation and iron deposition as noted on histopathology. Oxidation of iron pill can cause bronchial mucosal inflammation, ulceration and necrosis which progresses to bronchial narrowing and possibly irreversible stenosis [3]. Early diagnosis with bronchoscopy and treatment plays a crucial role in overall prognosis. Our case represents a remarkable recovery with balloon dilation and intralesional steroid injection resulting in relief of stenosis. CONCLUSIONS: •Physicians should be very prudent with prescribing iron pills in individuals who are at high risk of aspiration in order to avoid serious bronchial complications. •Prompt bronchoscopic intervention and management is required to prevent progression to serious complications. •Physicians should consider balloon dilation with intralesional steroid injection for patients with refractory symptoms after removal of the foreign object. REFERENCE #1: Caterino U., Battistoni P., Batzella S., Iacono R. Dello, Lucantoni G., Galluccio G. Syndrome of iron pill inhalation in four patients with accidental tablet aspiration: severe airway complications are described. Respir. Med. Case Rep. 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501451/ REFERENCE #2: Management of Iron Pill Aspiration Syndrome: Advanced Bronchoscopic InterventionMonali Patil MD* Arjun Mohan MD; and Kassem Harris MD University at Buffalo, Buffalo, NY, https://journal.chestnet.org/article/S0012-3692(16)57346-2/pdf REFERENCE #3: The Iron Lung: When Iron Pill Aspiration Results in an Immediate Bronchoscopy. A Successful Medical Therapy to a Serious ConditionSarah Abuseif, Mohamed Elsawaf, Gustavo De La Luz, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5565 DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Adel El Abbassi, source=Web Response No relevant relationships by Saman Saeed, source=Web Response No relevant relationships by Haniya Saeed, source=Web Response No relevant relationships by Dima Youssef, source=Web Response

Steroid injection in Orthopaedics: Does addition of lidocaine actually reduce pain?

Background: Local corticosteroid preparations are conventionally mixed with local anaesthetic agents to reduce pain during injection for various soft tissue affections in Orthopaedics. Although it can anaesthetise the area after injection, the infiltration process itself can be more painful because of low pH of the lidocaine. Objectives: To assess whether addition of lidocaine actually reduces pain during local steroid injection. Methods: This was a prospective comparative study conducted at Kathmandu Medical College over a period of nine months from June 2020 to February 2021 after obtaining ethical clearance. Patients requiring local corticosteroid injection for various indications in Orthopaedics were included by convenience sampling and divided into two groups. Out of 147 patients, 75 received steroid with lidocaine and 72 with normal saline. The Visual Analogue Score was recorded immediately along with injection in a scale of 0 to 10 where 0 meant no pain at all and 10 meant maximum pain imaginable. The difference in median Visual Analogue Score and the mean cost of injection between two groups was compared. Findings were analysed using SPSS v.20. Results: Median Visual Analogue Score in lidocaine group was 5 whereas in normal saline group was 4 (p-value = 0.33, Mann-Whitney U test). The mean cost of injection in lidocaine and normal saline groups were Nepali Rupees 339.3 ± 37.7 and 282.3 ± 36.7 respectively (p <0.001, Student’s t-test) Conclusion: Removal of lidocaine from steroid preparations in orthopaedics does not make it more painful if not less. It also reduces the cost of injection.

Le plasma riche en plaquettes donne de meilleurs résultats cliniques à moyen terme que l’injection traditionnelle de stéroïdes pour la fasciite plantaire: revue systématique et méta-analyse

IntroductionRecently, local platelet-rich plasma (PRP) injection has been gradually used in the treatment of plantar fasciitis (PF). However, compared with traditional steroid injection, the clinical results of local PRP injection for PF patients remain controversial. Therefore, we performed a systematic review to focus on two questions as follows: (1) is PRP more effective than steroid to relieve pain in PF patients? (2) is PRP more effective than steroid to improve the foot and ankle function of PF patients? HypothesisThe PRP could be more effective to relieve pain and improve the foot and ankle function in PF patients. Material and methodsWe systematically searched electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Web of Science, and Embase) from inception to October 20, 2019. The data of clinical results, including visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) scores, were extracted and analyzed. ResultsFinally, twelve randomized controlled trials (RCT), involving 653 PF patients, were enrolled. All enrolled trials were considered to be of high quality. The results showed that the VAS of the PRP group was significantly lower than that of the steroid group at 6-month (p=0.02), 1-year (p=0.02), and 1.5-year (p<0.00001) follow-up. The AOFAS scores of the PRP group were significantly higher than that of the steroid group at 1-year (p=0.005) follow-up. DiscussionCompared to local steroid injection, local autologous PRP injection is more effective in relieving pain and improving the foot and ankle function at mid-term follow-up. Level of evidenceII; Systematic review and Meta-analysis.

A better functional outcome with platelet rich plasma compared with local steroid injection in tennis elbow

Lateral epicondylitis commonly referred to as 'tennis elbow,' is mainly observed in the 3rd and 4th decade of life in around 2% -3% of the population. Treatment modalities for lateral epicondylitis include analgesics, immobilization, tennis elbow brace, local steroid infiltration, and ultrasound therapy. Recent studies have explored the effectiveness of platelet-rich plasma (PRP) injections in lateral epicondylitis. We used the block randomization technique. Two groups were prepared with 30 patients in each group. One group of patients received PRP and the other received local steroid injection. Patients were evaluated at the time of procedure and immediately after the procedure, at six weeks, three months, and six months, using the visual analog score and Liverpool's elbow score. At the end of 6 months, follow-up patients in the PRP injection group show good clinical and functional compare to the steroid group of patients. PRP and local corticosteroid injection provide symptomatic relief in the treatment of lateral epicondylitis. PRP infiltration gives better results in pain relief and functional activities with statically significant values when compared with corticosteroid injections.

Analgesic effect of perineural local anesthetics, steroids, and conventional medical management for trauma and compression-related peripheral neuropathic pain: a retrospective cohort study.

Trauma and compression are common causes of peripheral neuropathic pain (NP) refractory to conventional medical management (CMM). The role of perineural interventions in relieving this type of pain is unclear. The objectives of this retrospective study were to determine the analgesic benefits of adding a combination of perineural local anesthetic and steroids (LA-S) to CMM compared with CMM alone in patients who had moderate-to-severe refractory NP after trauma to the ankle and the foot. Health care records of 60 patients in exposed (3 injections of perineural LA-S at weekly intervals with CMM) and 60 in unexposed (CMM) cohorts were reviewed. Data on patient characteristics, pain, and mental and physical function were extracted at baseline and at the postintervention follow-up. Data were analyzed to evaluate analgesic benefit from the study interventions and the impact of baseline characteristics. Perineural LA-S with CMM cohort had lower pain numerical rating scale scores at 1 to 3 months after the intervention as compared to the CMM alone cohort (5.50 [interquartile range 4.00-7.00] and 7.00 [interquartile range 5.00-8.00], respectively; P < 0.01). However, multivariable analysis did not show an independent beneficial analgesic effect with the addition of perineural LA-S to CMM compared with CMM alone. A greater severity of preintervention catastrophizing (each unit increase in pain catastrophizing score increased pain score at follow-up by 0.04, 95% confidence interval: 0.01-0.07) was associated with reduction in the analgesic benefit. Perineural local anesthetic and steroid injections do not confer an analgesic benefit for trauma- or compression-related peripheral NP.

Platelet-rich plasma has better mid-term clinical results than traditional steroid injection for plantar fasciitis: A systematic review and meta-analysis

IntroductionRecently, local platelet-rich plasma (PRP) injection has been gradually used in the treatment of plantar fasciitis (PF). However, compared with traditional steroid injection, the clinical results of local PRP injection for PF patients remain controversial. Therefore, we performed a systematic review to focus on two questions as follows: (1) is PRP more effective than steroid to relieve pain in PF patients? (2) is PRP more effective than steroid to improve the foot and ankle function of PF patients? HypothesisThe PRP could be more effective to relieve pain and improve the foot and ankle function in PF patients. Material and methodsWe systematically searched electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Web of Science, and Embase) from inception to October 20, 2019. The data of clinical results, including visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) scores, were extracted and analyzed. ResultsFinally, twelve randomized controlled trials (RCT), involving 653 PF patients, were enrolled. All enrolled trials were considered to be of high quality. The results showed that the VAS of the PRP group was significantly lower than that of the steroid group at 6-month (p=0.02), 1-year (p=0.02), and 1.5-year (p<0.00001) follow-up. The AOFAS scores of the PRP group were significantly higher than that of the steroid group at 1-year (p=0.005) follow-up. DiscussionCompared to local steroid injection, local autologous PRP injection is more effective in relieving pain and improving the foot and ankle function at mid-term follow-up. Level of evidenceII; Systematic review and Meta-analysis.

Isolated Deep MCL tear: an easily missed injury and cause of persistent medial side knee pain

Introduction:The usual treatment of medial collateral ligament (MCL) grades I / II injuries is conservative, with good healing rates reported in the literature. Isolated deep MCL tears are reported rarely in literature, possibly due to under diagnosis. The usual reported mechanism is rapid external rotation of tibia at knee during sports.Methods:We report here 14 cases (all males, age range 21 - 35 years) of deep MCL tears with intact superficial MCL. All Patients were level 6 (recreational sports) on the Tegner- Lysholm activity scale. Diagnosis was done by grade 1 valgus stress test at 30-degree flexion, normal on 0 degrees. Confirmation was done by MRI imaging showing deep MCL fibers rupture on coronal T2 images. All of these patients had medial sided knee pain. Ten had associated knee injuries (10 had ACL tears, 5 had medial meniscus tears, 3 had lateral meniscus tears). Nine patients were diagnosed retrospectively on MRI due to symptom persistence; five were diagnosed preoperatively. Deep MCL repair was done in five patients. The dMCL was found to be avulsed from the femoral origin underneath an intact sMCL in all the cases. The repair was done over a suture anchor and was checked with intraoperative correction of the valgus stress test to normal. The Average follow-up duration was 10 months.Results:Five patients, diagnosed preoperatively, had medial sided knee pain resolution and no laxity complaints. The other nine patients reported slight pain on medial knee side at follow-up, for which local depomedrol and lignocaine injections were given under ultrasound guidance. The pain was resolved immediately and remains reduced at the time of last follow-up. The patient with repaired dMCL had better symptom resolution as compared to the patients managed with local steroid injections. Although there were no symptoms of laxity in any of the patients, even though the conservatively managed patients had valgus stress test grade 1 positive in 30 degree flexion, at the time of last follow-up.Conclusion:Isolated deep MCL tears are reported sparsely in literature. They can be a cause of persistent medial sided knee pain at follow-up, compromising the result of associated ligament reconstructions. The long-term outcomes of such injuries in terms of media laxity are not known, but a timely diagnosis can allow repair of the dMCL and better patient satisfaction.

POS1269 THE UTILITY OF ULTRASOUND TO PREDICT PATIENT OUTCOMES IN SHOULDER PAIN: A PROSPECTIVE OBSERVATIONAL STUDY OF 500 PATIENTS

Background:Shoulder pain is common and persistent, with a large socioeconomic burden. Ultrasound (US) scans are used for diagnosing and managing shoulder pain, but the extent to which it informs management and improves outcomes is unknown. A recent retrospective study identified groups with different patterns of US pathologies.Objectives:To confirm the existence of US-based groups of shoulder pain and determine if US-detected pathology (grouped or individual) predicts outcomes in the context of usual care. Response to local steroid injection was also evaluated.Methods:This was a 6 month, prospective, single centred, community based, observational cohort study. Inclusion: shoulder pain, ≥18 years, first shoulder US. Exclusion: shoulder surgery, inflammatory arthritis, steroid/physiotherapy in prior 6 weeks. Standardised reporting for 10 US pathologies was employed. Latent class analysis (LCA) identified pathology-based groups. Multiple linear regression analysis explored associations between baseline pathologies, subsequent treatment and 6-month Shoulder Pain and Disability Index (SPADI). Growth mixture modelling (GMM) identified groups with common trajectories of change.Results:Of 500 patients (mean age 53.6; 52% female), 330 completed follow-up. LCA identified 4 groups: bursitis without acromioclavicular joint degeneration (ACJD) (group 1), bursitis with ACJD (group 2), rotator cuff tear (group 3), no bursitis/tear (group 4). SPADI was higher at baseline for tears (55.1 vs. 49.7-51.3) (overall p=0.005), but groups did not differ at 6 months (p=0.379) (Table 1). No individual pathologies predicted 6-month outcomes. Response to baseline injection at week 2 did not differ between groups (p=0.423). GMM found 4 trajectories; the majority of patients followed trajectory 1 (little change), irrespective of US pathology group (79%, 77%, 87%, 70% of US groups 1-4 respectively) (Figure 1).Conclusion:This is the largest prospective study involving US of symptomatic shoulders, and the first to investigate groups with distinct patterns of US pathologies in predicting outcome. US-based classification of pathology (as groups or individually) did not predict 6-month outcomes with current treatments and there were no differences in short-term response to steroids between groups. The role of routine diagnostic US for shoulder pain needs consideration; it may be useful if evidence-based therapies for specific pathologies are established.Table 1.Predictors of SPADI score at 6 monthsBaseline characteristicCoefficient* (95% CI), p-valuePathology group:Bursitis w/o ACJ degeneration (group 1)ReferenceBursitis with ACJ degeneration (group 2)0.08 (-5.15, 5.32), p=0.975RC tear (group 3)5.01 (-1.48, 11.50), p=0.130No bursitis, no RC tear (group 4)1.98 (-4.00, 7.96), p=0.516Injection at scan4.87 (0.40, 9.34), p=0.033Age, years-0.01 (-0.17, 0.15), p=0.898Female-1.51 (-5.42, 2.40), p=0.448Symptom duration, months0.00 (-0.04, 0.05), p=0.879Uses arms to rise from chair2.65 (-1.50, 6.81), p=0.210Physiotherapy before baseline-0.23 (-4.78, 4.31), p=0.9201 injection before baseline2.35 (-2.87, 7.56), p=0.377≥2 injections before baseline6.53 (-2.50, 15.57), p=0.156Total SPADI0.62 (0.35, 0.89), p&lt;0.001Shoulder activity score-0.59 (-1.15, -0.04), p=0.037P-SEQ score-0.20 (-0.46, 0.07), p=0.141Brief IPQ score0.19 (-0.16, 0.54), p=0.298HADS score0.01 (-0.38, 0.41), p=0.947Constant**35.44 (29.50, 41.38), p&lt;0.001*Interpreted as unit difference in Rasch-transformed SPADI score per 1 additional unit of the independent variable **Estimated SPADI at 26 weeks in patients in the reference category for all categorical variables and with mean values for continuous covariates. ACJ=acromioclavicular joint; HADS=hospital anxiety and depression scale; IPQ=illness perception questionnaire; P-SEQ=pain self-efficacy questionnaire; RC=rotator cuff; SPADI=shoulder pain and disability indexFigure 1.Trajectories of total SPADI over time by the pathology groups found and response to injectionsAcknowledgements:This research was funded by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC) and by a NIHR Doctoral Research Fellowship (GT; DRF-2016-09-159). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This study was also part-funded through the Arthritis Research UK Leeds Experimental Osteoarthritis Treatment Centre (20083).Disclosure of Interests:None declared

Comparison between different methods of trigger finger treatment – USG assisted steroid injection, USG guided percutaneous pulley release and open surgery: A randomized controlled trial

Introduction: Trigger finger is frequently encountered in outpatient department, mostly idiopathic but seen especially in diabetic, hypothyroid or gout patients, the cause being, stenosing tenosynovitis at the A1 pulley, which is usually progressive. There are various treatment options available for this problem.Objective: The aim of this study was to compare the efficacy of USG guided corticosteroid injection, USG guided percutaneous pulley release and open surgery for the treatment of trigger finger in view of cure, relapse and complication rates.Methods: Sixty patients, >20 years of age with a trigger on any finger of the hand (Quinnell Type II - IV) were randomly categorized into one of the 3 treatment groups, each consisting of 20 patients, with one of the 3 treatment modalities allocated equally, from 60 sealed nontransparent envelopes, were studied and followed up for at least 6 months for cure, relapse and failure rates. Group A (N = 20) – Patients to be treated with conservative steroid injection under USG guidanceGroup B (N = 20) – Patients to be treated with percutaneous pulley release under USG guidance andGroup C (N = 20) – Patients to be treated with open surgery as minor OT procedure.Results: Cure rate for first (steroid inj.) group of patients was 60%, and in some patients second injection was repeated, which escalated the cure rate to 85%.For USG guided percutaneous release and open surgery groups, there was complete remission in all cases.Conclusions: The percutaneous release and open surgery methods were equally effective and proved superior to local steroid injections method in terms of trigger cure and relapse rates.

XANTHO-GRANULOMATOUS OSTEOMYELITIS OF STERNUM, RESEMBLING A TUMOR: FIRST REPORTED CASE

Xantho-granulomatous inflammation is a rare type of chronic inflammation, when seen in the bones it is known as xanthogranulomatous osteomyelitis (XO). Here we present a rare case XO of the manubrium sterni, to best of our knowledge this is the first diagnosed. XO of the manubrium sterni mimics radiologically as tuberculosis and as eosinophillic granuloma. We have a 23 year old lady who presented with pain and swelling in the anterior chest, radiology was done and finally the lesion was biopsied. We accepted the patient as Xanthomatous Osteomyelitis and planned for into excision of manubrium sterni, with a flap comprising of ribs and muscle advancements to cover the midline gap in the chest wall, that would have been created. Meanwhile she was put on a short course of antibiotics. It had been observed that the first open biopsy scar had exhibited a tendency for keloid formation. Hence, the risk of final surgery incision producing a disfiguring keloid was informed to the patient, which unfortunately led the patient deter surgery indefinitely, since she was to be married soon. We proposed a local injection of steroid into the lesion to minimize the inflammation. Under image intensifier we injected 40 mg of methyl prednisolone into the tumor. There was some tolerable discomfort the next day of injection that eventually subsided in 3 days. However, the biopsy came inconclusive second core needle biopsy came as XO. Since 1984 with the first case by Cozzutto et al, only 17 cases have been reported in the worldwide literature including us.

Short term effect of local steroid injection in lateral epicondylitis

Introduction: Lateral epicondylitis is a common cause of pain in the lateral side of elbow. It affects 1% to 3% of adults in general population per year.' it is common in dominant arm, tennis players and in workers who are involved in repetitive gripping and heavy lifting tasks because of repeated micro trauma to extensor tendons origin from lateral epicondyle. Objective: To compare the outcome of local steroid injection and local anesthetic injection after 2 weeks in management of lateral epicondylitis. Setting: Department of orthopedics, Hayatabad Medical Complex, Peshawar. Study design: Randomized clinical trial. Study Duration: 21st September 2020 to 21st March 2021. Methodology: A total of 60 patients were included in study (30 in each group). All patients were observed to compare the outcome of local steroid injection and local anesthetic injection after 2 weeks in management of lateral epicondylitis. Results: Distribution of Age among groups of 60 (30 in each group) were analyzed. Most of the patients between the age category (31-40 years) group A (steroid injection) was 9(42.9%) and group B 12(57.1%). Mean age was 41.56 ±3.357. There were 16(50.0%) male &amp; 14(50%) female in group A. In group B, there were 16 (50.0%) male &amp;14(50% female.

The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review.

Background: Peripheral nerve entrapment syndromes commonly result in pain, discomfort, and ensuing sensory and motor impairment. Many conservative measures have been proposed as treatment, local injection being one of those measures. Now with high-resolution ultrasound, anatomical details can be visualized allowing diagnosis and more accurate injection treatment. Ultrasound-guided injection technique using a range of injectates to mechanically release and decompress the entrapped nerves has therefore developed called hydrodissection or perineural injection therapy. Several different injectates from normal saline, local anesthetics, corticosteroids, 5% dextrose in water (D5W), and platelet-rich plasma (PRP) are available and present clinical challenges when selecting agents regarding effectiveness and safety. Aims: To systematically search and summarize the clinical evidence and mechanism of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment. Methods: Four databases, including PubMed, EMBASE, Scopus, and Cochrane were systematically searched from the inception of the database up to August 22, 2020. Studies evaluating the effectiveness and safety of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment were included. Injectate efficacy presents clinical effects on pain intensity, clinical symptoms/function, and physical performance, electrodiagnostic findings, and nerve cross-sectional areas. Safety outcomes and mechanism of action of each injectate were also described. Results: From ten ultrasound-guided hydrodissection studies, nine studies were conducted in carpal tunnel syndrome and one study was performed in ulnar neuropathy at the elbow. All studies compared different interventions with different comparisons. Injectates included normal saline, D5W, corticosteroids, local anesthetics, hyaluronidase, and PRP. Five studies investigated PRP or PRP plus splinting comparisons. Both D5W and PRP showed a consistently favorable outcome than those in the control group or corticosteroids. The improved outcomes were also observed in comparison groups using injections with normal saline, local anesthetics, or corticosteroids, or splinting. No serious adverse events were reported. Local steroid injection side effects were reported in only one study. Conclusion: Ultrasound-guided hydrodissection is a safe and effective treatment for peripheral nerve entrapment. Injectate selection should be considered based on the injectate mechanism, effectiveness, and safety profile.