Utilization of nerve conduction studies in the investigation and management of carpal tunnel syndrome varies according to their perceived usefulness and availability. The use of steroid injections and splinting also varies according to service availability and their perceived effectiveness. We present a three year follow up of 230 patients managed in an environment where nerve conduction testing was not readily available. The majority received splinting and a steroid injection in an effort to manage their symptoms conservatively in the first instance. Our results show that a clear majority of patients who were treated with initial splinting and steroid injections saw a recurrence of their symptoms (71.9% and 79.7% respectively) requiring eventual surgical decompression. These results would seem to suggest that conservative management of carpal tunnel does not produce the desired curative results and that there may be an argument for proceeding directly to surgery. We also showed that 55% of patients referred for Nerve Conduction Studies seem to progress to surgical decompression. This would seem to suggest that Nerve Conduction Studies could form a robust part of the standard investigation of carpal tunnel in order to identify those who would benefit from surgery

Osteoarthritis of the trapezometacarpal joint is a common form of arthritis. At present, there is a significant void between conservative and operative managements. Viscosupplementation is occasionally considered as an in-between therapy. We aimed to compare the therapeutic benefit of a single intra-articular injection of Sodium Hyaluronate (SH; Ostenil®mini) to a single intra-articular injection of Methylprednisolone Acetate (MA; Depomedrone) in the management of rhizarthrosis (TMOA; Trapezometacarpal Osteoarthritis). A retrospective review was performed over a 12 month period. We reviewed 25 patients who had received a single injection of viscosupplementation (SH) performed with fluoroscopic guidance and had been followed up at 12 weeks. These patients were compared with 21 patients who had received a single steroid injection (MA) and had been followed up at 12 weeks. Of the SH group, 52% (n = 13) reported some benefit from the injection. The MA group reported an 86% (n=18) benefit from the injection. We found that a single injection of viscosupplementation (SH) is effective in relieving pain and improving function in about half of patients with rhizarthrosis (TMOA). The efficacy of a single steroid injection (MA), however, was superior with a far greater proportion of patients reporting analgesic and functional benefits

Background. Epidural steroid injections can provide temporary relief of symptoms in the treatment of lumbar spinal stenosis. Surgery is indicated when conservative measures fail. We hypothesise that patients who gain temporary relief of symptoms from the administration of epidural steroid injections are more likely to result in an improvement in symptoms following surgical intervention compared to patients who do not respond to injection therapy. Method. The records of patients who had received both an epidural injection and surgical intervention for lumbar spinal stenosis between July 2008 and July 2010 were identified and retrospectively reviewed. Relief of symptoms following epidural injection was noted at 6 weeks post procedure and the patients symptoms following surgical intervention was noted and classified according to MacNab's criteria at 3 months post-surgery. Results. 60 patients who received both an epidural injection and surgical intervention for lumbar spinal stenosis were identified. 76% of patients who gained relief of symptoms from epidural injection scored good or excellent according to MacNab's criteria following surgery (n=34). Only 30% of patients who did not respond to injection therapy scored good or excellent according to MacNab's criteria following surgical intervention (n=5). Conclusion. Patients who gained temporary relief of symptoms from epidural injection were more likely to benefit from surgical intervention in the treatment for lumbar spinal stenosis. No conflicts of interest. No funding obtained. We confirm that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. Recently, some studies have focused attention on the possibility that anaerobic pathogens of low virulence could constitute an etiological factor in disc herniation. There have been isolated such strains, predominantly Propionibacterium acne, between 7 and 53% of patients undergoing surgery for disc pathology. According to these studies, patients with anaerobic infections of the disc are more likely to develop Modic changes in the adjacent vertebrae. The aim of this work was to test this hypothesis by growing in specific media the disc material extracted in a series of lumbar discectomy and relating this factor with the presence of pre-intervention Modic changes. Methods. A total of 22 consecutive patients undergoing primary unisegmental discectomy for lumbar disc herniation (77.2% male, mean age 40.1 ± 9.1 years) were included. All patients were immunocompetent and none had previously received an epidural steroid injection prior surgery. MRI study confirmed the disc herniation. Following strict antiseptic protocols, the extracted disc material was sent for slow-growth anaerobic enriched culture (>10 days). Results. In total, anaerobic cultures were positive in 7 cases (31.8%) all men. In 5 of these cases, the symptoms developed with an acute onset. The isolated germs were always unique: Propionibacterium acne (3), Streptococcus parasanguinis (1), Actinomyces naeslundii (1), Actinomyces meyeri (1) and methicillin sensitive Staphylococcus epidermidis. Only two (28.6%) of these 7 patients had Modic changes on MRI prior surgery (one type I, one type 2). None of the patients with negative cultures had Modic changes. Conclusions. These findings support the theory that anaerobic infections of low virulence and slow growth may contribute to the pathogenesis of herniated discs. However, these cases do not necessarily develop type 1 Modic changes as previously speculated. Level of evidence. Level IV

Osteonecrosis of the femoral head is a complex pathologic process with many aetiological factors. Factors most often mentioned in the literature are mechanical disruption (hip trauma or surgery), steroid use, smoking, haemoglobinopathies and hyperlipidaemia. 1. Our case depicts a rare association of crack cocaine related to osteonecrosis of the femoral head which has never been reported in the available literature. Case Report: A 32 year old man was referred to our Orthopaedic clinic with right hip pain. He had a 9 pack-year history of cigarette smoking and had also smoked crack cocaine between ages 20 to 28; shortly after this the hip pain started. He denied antecedent injury. He had undergone a steroid injection into his right ankle abroad for swelling one year before referral, which was after onset of hip pain. MRI of his hip previously performed abroad had been normal. The patient had an indoor job and was otherwise fit and well. On examination he had reduced of movement in his right hip with 5–10 degrees of fixed flexion deformity. Plain radiography demonstrated cyst formation and sclerosis of both femoral heads. Repeat MRI confirmed bilateral osteonecrosis, worse on the right with risk of head collapse. The patient underwent bilateral core decompressions. Subsequent follow-up demonstrated a mobile patient with no need for arthroplasty and he was discharged after two years. Osteonecrosis is caused by the coagulation of the intra-osseous microcirculation leading to thrombosis formation and eventual reduction in osseous blood supply. Steroid use is associated with increased risk of osteonecrosis to the femoral head, however in these cases the patients often undergo either direct local or systemic infiltration of steroid. In this case steroid was administered after symptoms began to a far distant site and therefore cannot be the cause. Cigarette smoking is also known to cause osteonecrosis. Our patient had smoked cigarettes for fourteen years without problems, and it was after he ceased to smoke crack cocaine that his symptoms began. Cocaine blocks voltage-gated sodium-channels causing vasospasm. It is known to cause nasal and facial bone osteonecrosis due to its common intranasal method of delivery. We postulate that in this case crack cocaine was a synergistic factor towards development of femoral head osteonecrosis

Failure of conservative treatment for tennis elbow is an indication for surgical decompression. The Topaz® technique utilises radiofrequency to decompress(detension) the tendon and in addition, it is thought to stimulate angiogenesis thereby facilitating healing. Initially we reviewed the three month follow up of 25 tennis elbow decompressions performed using the Topaz® technique. The case notes were reviewed and findings recorded on a structured proforma. After a minimum of 1 year we re-reviewed the case notes to identify recurrences or patients requiring revision surgery. The majority of patients were aged between 35–50 years. 87% of patients had symptoms for more than 12 months and symptoms experienced were mainly pain (100%). All patients had a full trial of physiotherapy and had minimum of two steroid injections. At three month follow up symptoms were completely relieved or improved in 88%. All patients were given an open appointment to review if symptoms recurred. On review of the notes after a minimum of one year, 84% had no further clinic attendances. Four elbows re-attended with symptom recurrence, two underwent traditional open release and two declined revision surgery. In the two patients who declined further surgery, symptoms had resolved at one year. The results of the Topaz® technique are comparable to that of the results of the traditional release from the literature both in terms of success and problems. It would be important to compare it to the traditional release to gauge its benefits against the standard practice

We report an unusual case of knee disease where calcific tendonitis occurring in both quadriceps and patellar tendon simultaneously in the same knee. A 47 year old female presented to orthopaedics outpatient clinic with acute onset of swelling and knee pain with no history of trauma. She was found to have a moderate effusion of the knee joint with mild tenderness over the mid quadriceps tendon. Active flexion of the knee joint was painful with a range of motion between 0-90 degrees. She is otherwise healthy with no past medical history. Plain radiographs and Magnetic Resonance Imaging (MRI) Scan revealed calcification of both tendons. Calcific tendonitis is classically found in the supraspinatus tendon of the shoulder. In addition, it has been described in other areas of the body such as the wrist, thigh, hip, knee and ankle. This condition usually occurs in the quadriceps or patellar tendons separately and rarely affecting both tendons in the same knee simultaneously. The patients condition improved significantly with physiotherapy, anti-inflammatory medications and ultrasound therapy. Calcific tendinitis of both quadriceps and patellar tendon is a very rare cause of knee pain. Most of the time it is treated conservatively with non-steroidal anti-inflammatory drugs and ultrasound therapy and some times steroid injection. However; patient may require surgical intervention especially in refractory cases to resolve the condition

Summary Statement. The incidence of osteonecrosis was significantly lower in the anti-vasospasm agent group (32%) than that in the control group (75%). Vasospasm is one of the important factors involved in the pathogenesis of steroid-induced osteonecrosis. Introduction. A number of studies have suggested that ischemia is the principal pathomechanism of osteonecrosis, however, the detailed mechanism responsible for ischemia remains unclear. It has recently been reported that the Rho/Rho-kinase mediated pathway (Rho-kinase pathway) is considered to be involved in the possible pathogenesis of various cardiovascular disorders as well as cerebral vasospasm. We examined the effects of fasudil (Rho-kinase inhibitor), an anti-vasospasm agent, on the development of steroid-induced osteonecrosis in rabbits. Materials & Methods. One group of rabbits received 15 mg/kg of fasudil intravenously, which were then injected once intramuscularly with 20 mg/kg of methylprednisolone (n = 33, MF group), and one received methylprednisolone alone as a control (n = 28, M group). Eight rabbits from each group were sacrificed 24 hour after the methylprednisolone injection to analyze them by immunohistochemical staining, a Western blotting analysis. Two weeks after the steroid injection, the femora and humeri were examined histopathologically for the incidence of osteonecrosis. Results. The incidence of osteonecrosis was significantly lower in the MF group (32%) than that in the M group (75%) (P < 0.01). Immunohistochemically, endothelin. A. -receptor (ET. A. Rc) expressions levels were decreased in the smooth muscle of the bone marrow in the MF group in comparison to that in the M group. In the M group, the average relative phospho-myosin light chain (p-MLC) expression level in the bone marrow tissue was significantly higher than that observed in the MF group (P < 0.01). In the MF group, the average relative total-eNOS expression level as well as the average relative phospho-eNOS (p-eNOS) expression level was almost 1.5 times higher than that observed in the M group (P < 0.05). The eNOS expressions levels in both serum and bone marrow in the MF group were significantly higher than those in the M group (P < 0.05). Discussion/Conclusion. The potential mechanisms resulting in vasospasm include the increased release of vasoconstrictors or increased sensitivity to these vasoconstrictors. ET-1 has been demonstrated to cause vascular smooth muscle cell constriction via ET. A. Rc stimulation. The expression of ET. A. Rc in rabbits treated with methylprednisolone plus fasudil (MF group) decreased in comparison with that in rabbits treated with the methylprednisolone alone (M group). In this study, both the eNOS and p-eNOS expressions levels in the M group were decreased in comparison to those observed in the MF group. A previous study suggested that high-dose steroid administration causes the overproduction of reactive oxygen species, and thereby perturbs nitric oxide (NO) availability in the vascular endothelium, leading to vascular endothelial dysfunction in patients receiving high-dose steroid therapy. Considering the pathogenesis of the development of osteonecrosis, we speculate that endothelial dysfunction may thus be a preliminary condition leading to the vasospasm. In conclusion, this study indicates that vasospasm is one of the important factors involved in the pathogenesis of steroid-induced osteonecrosis and that the anti-vasospasm agents seem to decrease the incidence of steroid-induced osteonecrosis

Objectives

Triamcinolone acetonide (TA) is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, TA can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of TA and PRP have not yet been made clear. The objective of this study was to determine how the combination of TA and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß.

Objectives

The objectives of this study were: 1) to examine osteophyte formation, subchondral bone advance, and bone marrow lesions (BMLs) in osteoarthritis (OA)-prone Hartley guinea pigs; and 2) to assess the disease-modifying activity of an orally administered phosphocitrate ‘analogue’, Carolinas Molecule-01 (CM-01).

Objectives

To investigate the appropriate dose and interval for the administration of triamcinolone acetonide (TA) in treating tendinopathy to avoid adverse effects such as tendon degeneration and rupture.

The aim of this study was to investigate the occurrence of tissue hypoxia and apoptosis at different stages of tendinopathy and tears of the rotator cuff.

We studied tissue from 24 patients with eight graded stages of either impingement (mild, moderate and severe) or tears of the rotator cuff (partial, small, medium, large and massive) and three controls. Biopsies were analysed using three immunohistochemical techniques, namely antibodies against HIF-1α (a transcription factor produced in a hypoxic environment), BNip3 (a HIF-1α regulated pro-apoptotic protein) and TUNEL (detecting DNA fragmentation in apoptosis).

The HIF-1α expression was greatest in mild impingement and in partial, small, medium and large tears. BNip3 expression increased significantly in partial, small, medium and large tears but was reduced in massive tears. Apoptosis was increased in small, medium, large and massive tears but not in partial tears.

These findings reveal evidence of hypoxic damage throughout the spectrum of pathology of the rotator cuff which may contribute to loss of cells by apoptosis. This provides a novel insight into the causes of degeneration of the rotator cuff and highlights possible options for treatment.

Objectives

The effects of disease progression and common tendinopathy treatments on the tissue characteristics of human rotator cuff tendons have not previously been evaluated in detail owing to a lack of suitable sampling techniques. This study evaluated the structural characteristics of torn human supraspinatus tendons across the full disease spectrum, and the short-term effects of subacromial corticosteroid injections (SCIs) and subacromial decompression (SAD) surgery on these structural characteristics.