Previous Steroid Injection Research Articles

Percutaneous Release of Trigger Finger Under Local Anesthesia

Objective: The trigger finger involves the hindrance of the flexor tendon in the hand, commonly leading to pain, discomfort, and dysfunction in the hand. This work aimed to assess the results of percutaneous release using local anesthesia for the treatment of the trigger finger. Patients and Methods: This single-arm trial was carried out on 30 patients, aged 18 years old, both sexes, and diagnosed by clinical assessment by the percutaneous release of A1 pulley of the diseased finger with a history of triggering for at least 3 months and failure of previous steroid injection into the flexor sheath at least once. Results: The complications were pain in 10%, swelling in 13.33%, numbness in 3.33% of the patients, triggering, stiffness, digital nerve injury, scar, and recurrence were not present in any patients. Patient satisfaction was poor in 26.67%, good in 16.67%, and excellent in 56.67% of the patients. Age, sex, duration of symptoms, occupation, hand side, grade, and finger affection were insignificantly different among the 3 groups. Conclusion: The percutaneous release of the trigger finger under local anesthesia can be a safe and effective treatment for the trigger finger, applicable to a broad range of patients indicating a generally favorable outcome with minimal complications and higher satisfaction rates.

The safety of corticosteroid injection prior to shoulder arthroplasty: A systematic review.

Intra-articular corticosteroid injections are frequently utilised in patients with glenohumeral arthritis for diagnostic and therapeutic purposes. A systematic review was performed to assess the relationship between prior corticosteroid injection and infection following shoulder arthroplasty. A search was performed, using databases Medline, EMBASE and CINAHL. Studies with comparative data of post-arthroplasty infection following previous corticosteroid injection versus controls were included. Seven studies fulfilled the inclusion criteria, comprising 87,820 patients. On pooled analysis, previous steroid injection did not increase the overall risk of infection (risk ratio 1.17; confidence interval 1.00-1.37, p = 0.06). On subgroup analysis for timing of injection, one given within 3 months before arthroplasty conferred a greater risk of infection than no injection (risk ratio 2.30; confidence interval 1.13-4.69, p = 0.02) or one given between 3 and 12 months before arthroplasty (risk ratio 3.32; confidence interval 1.43-7.72, p = 0.005). An injection at 3 to 12 months before arthroplasty did not increase the risk of infection over controls (risk ratio 0.89; confidence interval 0.63-1.25, p = 0.50). This review has found there to be a time-dependent relationship between prior corticosteroid injection and infection post-arthroplasty, with an increased risk when performed within three months before arthroplasty. Thus, an interval of at least three months is recommended between injection and arthroplasty.

Prevalence of Adrenal Insufficiency in Korean Patients undergoing Total Knee Arthroplasty.

This study investigated the prevalence of adrenal insufficiency among patients admitted for total knee arthroplasty (TKA) due to osteoarthritis and identified factors contributing to adrenal insufficiency. We divided the patients into two groups based on the results of preoperative standard-dose short synchronous stimulation tests: group 1 (adrenal insufficiency) and group 2 (normal adrenal function). We also assessed the prevalence of adrenal insufficiency and compared the numbers of patients who received oral steroids, the frequency of previous steroid injection use, and the frequency of systemic symptoms of steroid depletion such as fatigue and loss of appetite between the two groups. Multiple regression analysis was performed to identify factors related to adrenal insufficiency. The prevalence of adrenal insufficiency was 60.0% (120/200). Group 1 had higher numbers of previous steroid injections (12.8±10.2 vs. 6.8±7.9) and patients taking oral steroids (18/120 vs. 3/80) (p<0.001 and p=0.011, respectively). The frequency of systemic symptoms of steroid depletion, such as fatigue and loss of appetite, was also higher in group 1 (94/120 vs. 42/80, p<0.001). Recent steroid injections and loss of appetite were associated with adrenal insufficiency (p=0.002 and p=0.009, respectively). The results of this study revealed a high prevalence of adrenal insufficiency in Korean patients hospitalized for TKA due to end-stage osteoarthritis. Recent steroid injections were causally related to the development of adrenal insufficiency. Therefore, adrenal function should be assessed preoperatively to prevent postoperative complications related to adrenal insufficiency.

66 Central Palmar Necrosis Following Steroid Injections for the Treatment of Carpal Tunnel Syndrome - a Case Report

Abstract Aim Steroid injections are commonly used as a diagnostic tool or an alternative to surgical management of carpal tunnel syndrome (CTS) and are generally safe. Ischaemia is a rare complication with very few cases reported in the literature. Method We report a case of a 50-year-old female that presented with a necrotic wound to her left palm one month after a steroid injection into the carpal tunnel. She had a 2-year history of CTS in her left hand that was treated with six previous steroid injections in primary care during this period. The wound evolved from a blister to a necrotic ulcer which led to a painful, hollow defect in the centre of her palm. She did not report any history of trauma, nor did she have any co-morbidities. Clinical photographs were taken. Results On examination she had a 0.5cmx1cm defect in the palm of her left hand down to aponeurosis. There was purulent discharge in the wound with surrounding erythema but no spreading cellulitis. She had full function of her fingers but was very tender on movements and at rest. She was admitted for intravenous antibiotics and underwent a debridement, washout and carpal tunnel release the next day. The defect was packed to heal by secondary intention and has now fully healed one-month following her operation. Conclusions This is an extremely rare complication of steroid injections to the carpal tunnel and may have been avoided by earlier referral for surgery rather than treatment using multiple steroid injections.

474 Effectiveness of Platelet Rich Plasma in the Treatment of Recalcitrant Shoulder Pathology

Abstract Aim To assess the outcome of platelet rich plasma injections (PRP) in patients with recalcitrant shoulder pathology using steroid injections as a control. Method This was a pragmatic retrospective analysis of patients treated for recalcitrant shoulder pathology between October 2018 to March 2019 with either PRP or steroid injection. Results In the PRP group 10 patients (n = 15) had previous steroid injections and 7 had previous surgery. 2 progressed to shoulder replacement. 5 have progressed to arthropathy. 4 patients were discharged due to improving symptoms. In the steroid group 2 patients (n = 15) were lost to follow up, 0 had previous surgery and 1 had a previous steroid injection. 6 were discharged due to improving symptoms. The average time to discharge post procedure was 241 days for PRP and 173 days for the steroid group. No complications were noted in either group. Conclusions Our findings show that PRP injections are a safe and effective treatment for cases of recalcitrant shoulder pathology leading to a 27% success rate for patients who have required steroid injections or arthroscopy in the past. In patients with arthropathy, PRP only has a short effect and should only be offered to patients that are unable to have surgery either due to high risk or patient choice. PRP requires a centrifuge machine and an operating theatre, thus incurring higher costs compared to steroid injections which may be given in clinic. Steroid injections should therefore remain the first line of treatment for recalcitrant shoulder pathology.

Arthroscopic Management of Resistant Lateral Epicondylitis

Lateral epicondylitis treatment is still controversial, most of patients managed with conservative measures including rest, NSAIDs and physiotherapy. However, some of them do not respond well and have to be managed surgically. That can be done either open or arthroscopic technique. The aim is to study the technique and functional outcome of arthroscopic management of lateral epicondylitis. Prospective study. Between December 2016 and July 2019, 26 (16 female and 10 male) patients aged (28-57) presented with resistant lateral epicondylitis treated with elbow arthroscopy. Functional assessment preoperative and postoperative using VAS and Mayo score was done to all patients. The study included patients with elbow pain and weak grip symptoms with failure of conservative treatment for at least 6 months excluding revision, infected, rheumatoid arthritis patients, and previous steroid injection in past 3 weeks. The mean operative time was 65 minutes; the mean follow-up time was 20.3 months. The patients were reintegrated into their activities at 21 days postoperatively. Pain as a sign and capital symptom improved significantly within 12 days of surgery. Mayo score improved postoperatively. The Mean ± SD preoperative Mayo score was 59.5 ± 7.23 and to 96.5 ± 3.03 after follow up for six months. The Mean ± SD preoperative VAS score was 8.9 ± 0.76 and raised to 0.84 ± 0.74 and to 0.5 ± 0.5 after follow up for six months (Table 2). All patients were satisfied because of small wound size with cosmetic suture, rapid return of movement of elbow after operation and rapid improvement of pain level. One patient developed transient forearm neuropraxia that resolved within three weeks with neurotonics. Short-term evaluation of arthroscopic release of resistant lateral epicondylitis gives good functional outcome in the form of pain relief, patient satisfaction, and low complication rate. Die Behandlung von Epicondylitis humeri radialis wird nach wie vor kontrovers diskutiert. Beim Großteil der Patienten führten konservative Maßnahmen wie Ruhe, NSAIDs und Physiotherapie zu Verbesserungen. Für einige Patienten führen diese Maßnahmen allerdings nicht zum gewünschten Ergebnis, sodass ein chirurgischer Eingriff notwendig wird, der entweder offen oder arthroskopisch durchgeführt werden kann. Ziel dieser Arbeit ist die Untersuchung von Technik und funktionellen Ergebnissen der arthroskopischen Behandlung von Epicondylitis humeri radialis. Prospektive Studie. Zwischen Dezember 2016 und Juli 2019 stellten sich 26 Patienten (16 weiblich, 10 männlich im Alter zwischen 28 und 57 Jahren) mit chronischer Epicondylitis humeri radialis, die mittels Ellenbogenarthroskopie behandelt worden waren, vor. Allen Patienten wurde eine visuelle Analogskala (VAS) zur Bewertung der prä- und postoperativen Funktion sowie zur Bestimmung des Mayo-Scores vorgelegt. Patienten mit den Symptomen Ellenbogenschmerzen und Griffschwäche sowie einer seit mindestens 6 Monaten andauernden, erfolglosen konservativen Therapie wurden in die Studie eingeschlossen. Ausgeschlossen wurden Patienten mit sich bessernden Symptomen, Infektionen, rheumatischer Arthritis oder einer weniger als 3 Wochen zurückliegenden Steroid-Injektion. Die durchschnittliche Operationszeit lag bei 65 Minuten. Die Nachbeobachtungszeit lag im Mittel bei 20,3 Monaten. 21 Tage nach dem Eingriff nahmen die Patienten ihre gewohnten Aktivitäten wieder auf. Das Hauptsymptom Schmerz verbesserte sich innerhalb von 12 Tagen nach der Operation signifikant. Der Mayo-Score verbesserte sich postoperativ. Der Mayo-Score (Mittelwert ± Standardabweichung) lag präoperativ bei 59.5 ± 7.23 und lag nach 6 Monaten Nachbeobachtung bei 96.5 ± 3.03. Der mittels VAS gemessene Wert (Mittelwert ± Standardabweichung) lag bei 8.9 ± 0.76 und reduzierte sich auf 0.84 ± 0.74 bzw. auf 0.5 ± 0.5 nach sechsmonatiger Nachbeobachtungszeit (Tabelle 2). Alle Patienten zeigten sich zufrieden mit der geringen Wundgröße mit kosmetischer Naht, der schnellen Rückkehr zur Ellenbogen-Beweglichkeit nach der Operation sowie mit dem schnellen Absinken des Schmerzniveaus. Ein Patient entwickelte eine vorübergehende Neurapraxie des Unterarms, die unter Einsatz von Neurotonika innerhalb von 3 Wochen wieder abklang. Kurzzeitbewertung der arthroskopischen Freisetzung resistenter lateraler Epicondylitis führt zu einem guten funktionellen Ergebnis in Form einer Schmerzlinderung, Patient Zufriedenheit und niedrige Komplikationsrate.

Reconstruction of neglected tendo-Achilles tears using the technique of gastrocnemius-soleus turndown graft: A case series

Chronic, neglected Achilles tendon ruptures cause a significant impairment of ankle function due to weakness of active plantar flexion which is required in performing day-to-day activities such as walking and climbing stairs. The causes range from trivial trauma like a slip and fall to high impact injuries. Predisposing factors include a history of previous steroid injections, advanced age, and vigorous sporting activities. Tears involving the zone 2, where vascularity is compromised, pose a challenge to surgeons, as the repair is often jeopardized by wound complications and re-ruptures. Of the several techniques described, we have used the Bosworth's technique of gastrocnemius-soleus turndown to reconstruct defects in this zone in 16 patients and have achieved a satisfactory functional outcome at 1 year with a relatively low incidence of complications. However, this technique requires the presence of an intact distal stump of the tendon of adequate length, the absence of which precludes the use of this method.

P09 Juvenile osteochondritis dissecans in juvenile idiopathic arthritis: a case series review

Abstract Background Juvenile osteochondritis dissecans (JOCD) is a condition of bone and cartilage lesions. Contributory factors may include ischaemia, trauma, genetic or biomechanical factors such as abnormal joint loading. Children and young people (CYP) with juvenile idiopathic arthritis (JIA) have low physical activity levels, present with joint abnormalities and are exposed to immunosuppression including steroids which may cause reduced bone density. Here we describe JOCD in CYP with JIA in our service. Methods Retrospective reviews of case notes were conducted for current CYP with JIA in our service with known JOCD, detailing: JIA diagnosis Age & BMI at diagnosisSymptom duration pre-diagnosisManagement (including steroids)JOCD diagnosis Age & BMI at diagnosisImagingManagement Results Table 1 summarises the results. Twelve (n = 10 female) CYP in our cohort of 270 had JOCD with 20 lesions diagnosed on magnetic resonance imaging (MRI). Polyarticular (n = 4) and extended oligoarticular (n = 5) were the commonest JIA sub-types with all CYP receiving systemic therapy and 75% (n = 9) requiring more than one biologic. Mean symptom duration before JIA diagnosis was 6 months (range: 1-24 months) with a mean age of 6.5 years (range: 1.5-13 years). Mean time to JOCD diagnosis was 5.5 years (range: 1.5-10.25 years) with a mean age of 12 years (range: 8-17 years) and 7 CYP having a high BMI (>85th percentile for age). The mean number of previous steroid injections per JOCD joint was 4 (range: 0-17) compared with 3 (range: 0-8) in the non-JOCD joint. Talar dome lesions (n = 9) were commonest, followed by femoral condyle (n = 4 medial, n = 3 lateral). Initial management was conservative, with half (n = 10) requiring surgery. P09 Table 1 Conclusion This review identifies that 4% (n = 12/270) of our CYP with JIA have known JOCD, compared with 0.03% (n = 29/100,000) of the general population. Risk factors appear to be polyarticular disease, exposure to ≥ 4 steroid injections per joint, biologic-resistant disease and high BMI with low physical activity. Where CYP with JIA report symptoms which do not fit an inflammatory pattern there should be a low threshold to consider JOCD, with prospective research needed to better understand the relationship between JOCD and JIA. Conflicts of Interest The authors declare no conflicts of interest.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial.

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow. Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months. Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection. L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Increasing age and tear size reduce rotator cuff repair healing rate at 1 year

Background and purpose — There is a need to understand the reasons why a high proportion of rotator cuff repairs fail to heal. Using data from a large randomized clinical trial, we evaluated age and tear size as risk factors for failure of rotator cuff repair.Patients and methods — Between 2007 and 2014, 65 surgeons from 47 hospitals in the National Health Service (NHS) recruited 447 patients with atraumatic rotator cuff tendon tears to the United Kingdom Rotator Cuff Trial (UKUFF) and 256 underwent rotator cuff repair. Cuff integrity was assessed by imaging in 217 patients, at 12 months post-operation. Logistic regression analysis was used to determine the influence of age and intra-operative tear size on healing. Hand dominance, sex, and previous steroid injections were controlled for.Results — The overall healing rate was 122/217 (56%) at 12 months. Healing rate decreased with increasing tear size (small tears 66%, medium tears 68%, large tears 47%, and massive tears 27% healed). The mean age of patients with a healed repair was 61 years compared with 64 years for those with a non-healed repair. Mean age increased with larger tear sizes (small tears 59 years, medium tears 62 years, large tears 64 years, and massive tears 66 years). Increasing age was an independent factor that negatively influenced healing, even after controlling for tear size. Only massive tears were an independent predictor of non-healing, after controlling for age.Interpretation — Although increasing age and larger tear size are both risks for failure of rotator cuff repair healing, age is the dominant risk factor.

Prognostic Factors Affecting the Clinical Outcome of Septic Arthritis of the Shoulder.

The objective of this study was to determine prognostic factors affecting the clinical outcome of septic arthritis of the shoulder. We retrospectively reviewed 34 shoulders from 32 patients, two of which had bilateral involvement. Arthroscopic (22 shoulders) or open surgery (12 shoulders) was performed by a single surgeon. The mean follow-up period was 32.4 ± 17.0 months. Clinical outcomes according to the University of California at Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, and Subjective Shoulder Value (SSV) were assessed at the final follow-up period. Various factors were included for statistical analysis. The mean UCLA, ASES scores, and SSV were 28.9 ± 7.2, 81.3 ± 21.0, 79.7 ± 2.5%, respectively. Positive culture was observed in only 13 shoulders (38.2%) and the most common organism was Staphylococcus aureus (seven shoulders). Five shoulders (14.7%) required two or three operations. Age and comorbidity were negatively correlated with the UCLA, ASES score, and/or SSV (p < 0.05). There was no correlation between clinical outcome and various parameters, including gender, location of lesion, history of previous steroid injection, interval between onset of symptoms and surgical intervention, bacterial organisms, operative method, and presence of rotator cuff tear and reoperation (p > 0.05). Both arthroscopic and open surgery for septic shoulders showed satisfactory clinical outcomes. Old age and comorbidity were poor prognostic factors of clinical outcomes after treatment.

A retrospective comparison of the management of recalcitrant lateral elbow tendinosis: platelet-rich plasma injections versus surgery.

The aim of this study is to compare the outcomes of platelet-rich plasma (PRP) injections to surgical release and decortication for lateral elbow tendinosis within a similar patient population. A retrospective chart review was performed on two groups of patients, receiving either PRP injections (n = 28) or surgery (n = 50). Patient demographics, clinical presentation, pain score, worker's compensation status, and previous steroid injections were recorded. Primary outcomes included pain and symptom improvement, range of motion, return to work, and postoperative complications. Demographics, duration of symptoms, and exam findings were similar between the PRP and surgical patients. There was no significant difference in pain and symptom improvement. Pain improvement was reported in 89.3% of PRP patients and 84% of surgical patients, with a reported percent reduction in pain of 61.1 and 55%, respectively. Symptoms other than pain improved in 85.7 and 88% of the PRP and surgical patients, respectively. Tenderness to palpation at the lateral epicondyle (64.3% PRP, 44% surgical), pain with resisted wrist extension (35.7% PRP, 30% surgical), or residual symptoms other than pain (14.3% PRP, 10% surgical) were not significantly different between groups at last follow-up. Eighty-two percent of patients in both the PRP and surgical groups returned to work. No complications were reported. Mean follow-up was 315 vs. 352days for the PRP and surgical groups, respectively. Similar outcomes in pain improvement and return to work may be achievable with either PRP injections or surgery in recalcitrant lateral elbow tendinosis. PRP injections may be a reasonable alternative for patients apprehensive to proceed with surgery or poor surgical candidates.

Methylprednisolone Injections for the Carpal Tunnel Syndrome

Steroid injections are used in idiopathic carpal tunnel syndrome (CTS), but evidence of efficacy beyond 1 month is lacking. To assess the efficacy of local methylprednisolone injections in CTS. Randomized, placebo-controlled trial. (ClinicalTrials.gov: NCT00806871). Regional referral orthopedic department in Sweden. Patients aged 18 to 70 years with CTS but no previous steroid injections. Three groups (37 patients each) received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo. The patients and treating surgeons were blinded. Primary end points were the change in CTS symptom severity scores at 10 weeks (range, 1 to 5) and rate of surgery at 1 year. Three patients had missing 10-week data. All patients had 1-year data. Improvement in CTS symptom severity scores at 10 weeks was greater in patients who received 80 mg of methylprednisolone and 40 mg of methylprednisolone than in those who received placebo (difference in change from baseline, -0.64 [95% CI, -1.06 to -0.21; P = 0.003] and -0.88 [CI, -1.30 to -0.46; P < 0.001], respectively), but there were no significant differences at 1 year. The 1-year rates of surgery were 73%, 81%, and 92% in the 80-mg methylprednisolone, 40-mg methylprednisolone, and placebo groups, respectively. Compared with patients who received placebo, those who received 80 mg of methylprednisolone were less likely to have surgery (odds ratio, 0.24 [CI, 0.06 to 0.95]; P = 0.042). With time to surgery incorporated, both the 80- and 40-mg methylprednisolone groups had lower likelihood of surgery (hazard ratio, 0.46 [CI, 0.27 to 0.77; P = 0.003] and 0.57 [CI, 0.35 to 0.94; P = 0.026], respectively). The study was conducted at 1 center, and wrist splinting had previously failed for all patients. Methylprednisolone injections for CTS have significant benefits in relieving symptoms at 10 weeks and reducing the rate of surgery 1 year after treatment, but 3 out of 4 patients had surgery within 1 year. Region of Scania Research and Development Foundation and Hässleholm Hospital Organization.

Myofascial Pain Syndrome: Trigger Points

SUMMARY The aim of this observational study from Spain was to determine the prevalence of mechanical hypersensitivity and active and latent trigger points [TrPs] in elite swimmers with and without unilateral shoulder pain. Seventeen elite swimmers with and 18 without shoulder pain were included, while 15 elite athletes acted as matched controls. The subjects were assessed for pressure pain thresholds [PPT] and the presence of active and latent TrPs in the levator scapulae, sternocleidomastoid, upper trapezius, infraspinatus, subscapularis and scalene muscles. The PPT was also assessed over the tibialis muscle. Subjects were included when aged between 18 and 30 years of age and swimming more than 6 h per week. The subjects with shoulder pain had these complaints for more than 3 months. Pain was described as pain felt in the shoulder or arm with an intensity of at least 4 on an 11-point numerical pain rating scale. They had to report a positive Neer test and Hawkins-Kennedy test at physical examination. Subjects were excluded with a history of shoulder or neck surgery, fracture of the shoulder region, bilateral shoulder symptoms, cervical radiculopathy, previous steroid injections or any type of physical intervention within the last year. The age-matched controls were right-handed elite athletes without shoulder complaints and with a negative Neer test and Hawkins-Kennedy test and the abovementioned exclusion criteria were used. A mechanical pressure algometer was used to establish PPT, which was defined as the minimal amount of pressure needed to elicit pain. The PPT was measured at predefined points within the muscles. The TrPs were explored by a blinded assessor with more than 8 years of experience in TrPs diagnosis following the guidelines described by Simons et al. (1) and by Gerwin et al. (2). The TrPs were considered active, when local and referred pain PPTs were significant reduced in the swimmers with shoulder pain group compared with the healthy controls in all muscles, but not when compared to the swimmers without shoulder pain group. Furthermore, much higher numbers of active and latent TrPs were found in swimmers with and without shoulder pain compared to healthy athletes.

Obesity-related Adipokines and Shoulder Osteoarthritis

To the Editor: It is increasingly understood that the association between obesity and osteoarthritis (OA) is partially mediated by a systemic, inflammatory effect of adipokines such as leptin (LEP), adiponectin (ADIPO), and resistin. The association of obesity and OA of non-weight-bearing joints, such as the hand, lends further support to this hypothesis1,2. LEP and resistin have been suggested to have a strong proinflammatory influence3,4, while the role of ADIPO in a knee joint is unclear, as some have shown an antiinflammatory effect5 and others suggest a proinflammatory effect6. Similarly, the ADIPO receptors have been identified in the knee joint only6. No study has examined the epidemiologic relationship between obesity and shoulder OA or identified these obesity hormones in the shoulder joint. The objective of our study was to determine if the adipokines LEP, ADIPO, and resistin are present in the shoulder synovial fluid (SF) of patients with OA and to examine the relationships of these hormones to measures of body habitus. We recruited patients awaiting elective arthroscopic rotator cuff repair or shoulder replacement surgery to participate, between 2009 and 2011. We excluded patients with a history of previous shoulder surgery, previous steroid injection, posttraumatic arthritis, or a history of inflammatory arthropathy. Patients undergoing shoulder replacement surgery for a diagnosis of … Address correspondence to Dr. R. Gandhi, Toronto Western Hospital, East Wing 1-439, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. E-mail: rajiv.gandhi{at}uhn.on.ca

Local steroid injection for moderately severe idiopathic carpal tunnel syndrome: Protocol of a randomized double-blind placebo-controlled trial (NCT 00806871)

BackgroundPatients with idiopathic carpal tunnel syndrome (CTS) are commonly treated with steroid injection into or proximal to the carpal tunnel. However, evidence for its efficacy beyond one month has not been established in randomized placebo-controlled trials. The primary aim of this randomized trial is to assess the efficacy of steroid injection into the carpal tunnel in relieving symptoms of CTS in patients with symptoms of such severity to warrant surgical treatment but have not been treated with steroid injection.Methods/DesignThe study is a randomized double-blind placebo-controlled trial. Patients referred to one orthopedic department because of CTS are screened. Eligibility criteria are age 18 to 70 years, clinical diagnosis of primary idiopathic CTS and abnormal nerve conduction tests or clinical diagnosis made independently by two orthopedic surgeons, failed treatment with wrist splinting, symptom severity of such magnitude that the patient is willing to undergo surgery, no severe sensory loss or thenar muscle atrophy, and no previous steroid injection for CTS. A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after injection includes validated questionnaires (CTS symptom severity scale, QuickDASH and SF-6D), adverse events, physical examination by a blinded assessor, and nerve conduction tests. The primary outcome measures are change in the CTS symptom severity score at 10 weeks and the rate of surgery at 52 weeks. The secondary outcome measures are the score change in the CTS symptom severity scale at 52 weeks, time to surgery, and change in QuickDASH and SF-6D scores and patient satisfaction at 10 and 52 weeks. The primary analysis will be carried out using mixed model analysis of repeated measures.DiscussionThis paper describes the rationale and design of a double-blind, randomized placebo-controlled trial that aims to determine the efficacy of two different doses of steroid injected into the carpal tunnel in patients with moderately severe idiopathic CTS.Trial registrationClinicaltrials.gov identifier NCT00806871

Sudden loss of visual acuity following intra-articular steroid injection in to the knee joint: a case report

BackgroundExogenous and endogenous steroids have been implicated in the pathogenesis of central serous choroioretinopathy in the literature. Central serous choroioretinopathy presents as sudden reduction in visual acuity.Case presentationDespite the fact that steroid injections are so commonly used in the Orthopaedics there is no information regarding central serous chorioretinopathy in Orthopaedic literature. We report a case of acute onset central serous chorioretinopathy following an intra-articular injection.ConclusionOrthopaedic surgeons and doctors dealing with Musculoskeletal problems need to be aware of this unusual complication of systemic steroid therapy and refrain from administering further steroids to patients with history of blurring of vision or sudden loss of visual acuity following previous steroid injections.

Incidental finding of skin deposits of corticosteroids without associated granulomatous inflammation: Report of three cases

Three cases are described in whom deposits of depot steroids were seen in skin biopsies done for diagnostic purposes. In the first case the skin lesion was clinically suspected to be due to the steroid injected more than a year ago and a diagnosis of pseudo-morphea due to steroid injection was made by the clinician. The other cases had clinical diagnoses of dermatofibroma and morphea with no clinical suspicion of previous steroid injection. The steroid deposits were present in the subcutaneous fat in all three cases. Histologically the findings were distinctive with collections of acellular, amorphous, fuzzy basophilic material surrounded by lipophages and disrupted adipocytes (in Case 2) and without any significant inflammatory infiltrate or granulomatous reaction (in Cases 1 and 3). The absence of inflammatory and granulomatous responses were the findings at variance with the cases described earlier in the literature.

Poster 242: Histologic and Histomorphometric Analysis of Posterior Region of the Human Temporomandibular Disc

Objective. The aim of this study was to analyze histologic and histomorphometric features of the articular disc in groups with and without disc displacement. Study design. A sample of 39 temporomandibular joints TMJs (31 case specimens, 8 control specimens) from 28 patients (mean age 31.2 years) were recruited for this study. The patients were considered to be affected and treated surgically with disc repositioning when presenting painful clinical signs of disc displacement after unsuccessful nonsurgical treatment for at least 6 months. Of the control patients, 4 presented condyle fracture which required opening to be reduced for treatment, and 4 displayed active condyle hyperplasia. The posterior region of the disc was removed and sent for histologic and histomorphometric analysis. Histologic (hematoxylin-eosin) and histomorphometric (picro-Sirius red) analyses were performed. Statistically significant differences between the analyzed groups were accessed through the chi-squared test (P .05). The Mann-Whitney U test was used to observe the differences between mean values when variables did not present normal distribution [Kolmogorov-Smirnov(a) test]. Results. There were no significant differences between the groups in relation to the parameters studied by histologic and histomorphometric analysis (using or not using polarization). Conclusions. To the limits of this study, there were no significant histologic and histomorphometric differences in the articular disc between groups with and without TMJ dysfunction. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e6-e11)

The effects of intra-articular botulinum toxin on sacroiliac, cervical/lumbar facet and sterno-clavicular joint pain and C-2 root and lumbar disc pain: a case series of 11 patients

Abstract Aims and Objective: In this small case series, we evaluated the effects and safety of injecting botulinum toxin type A (BoTN/A; Botox) and botulinum toxin type B (BoTN/B; Myobloc) into the sacroiliac joints, cervical/lumbar facet joints, C-2 roots, sternoclavicular joint and lumbar disc in patients with refractory pain. Methods: Eleven adult patients with refractory pain were injected with BoTN/A or BoTN/B. Results: All 11 patients had either a decrease (8 out of 11) or no change (3 out of 11) in their pain score after BoTN injection. All patients who responded to the injections noted improved function in activities of daily living and range of motion because of pain reduction. No side effects were noted. The mean duration of pain relief for the first BoTN treatments was 2.0 months. The median difference of duration of pain relief between BoTN and previous steroid injection was 1.6 months with BoTN being superior. The median change in pain score (0 to 10) after BoTN injection was −3. Conclusions:...