Greater trochanteric pain syndrome: focused shockwave therapy versus an ultrasound guided injection: a randomised control trial.

BACKGROUND: Greater trochanteric pain syndrome (GTPS) is a common problem with an incidence of 1.8-5.6 per 1000 population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential non-invasive management option for this difficult presentation. METHOD: We ran a prospective, 2-arm, single-blinded, randomised control trial comparing focused shockwave therapy (f-ESWT) to an ultrasound guided corticosteroid injection. Primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris Hip Score (HHS) and Trendelenburg test for function; SF-36 for quality of life (QoL); and a Likert scale question for subjective assessment of symptom improvement. RESULTS: 104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image-guided injection. 11 patients were lost to follow-up. There were no significant differences in baseline scores between groups.At 3 months, pain, function and QoL scores had improved in both groups but were not statistically significant. The Trendelenburg test was significantly improved in the f-ESWT group with 80% patients being negative compared to 20% at baseline (p < 0.001).At 12 months, across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 37.1 versus 55.0 (p = 0.007, 95% confidence interval [CI], 6.3-30.8), HHS 69.7 versus 57.5 (p = 0.002, 95% CI, -20.0 to -4.6) and SF-36 52.4 versus 47.7 (p = 0.048, 95% CI, -9.31 to -0.04). The improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline (p < 0.001). CONCLUSIONS: We have shown f-ESWT is an effective treatment for patients with GTPS. We would advocate f-ESWT as an effective non-invasive treatment modality for this challenging patient population.Trial Registration No. ISRCTN8338223.

The influence of the COVID pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom.

OBJECTIVES: Management strategies of the COVID pandemic included isolation to prevent transmission. This study aimed to determine if the pandemic of 2020 influenced the epidemiology of Achilles tendon rupture (ATR). METHODS: The demographics of presentations from the local population to Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust hospital, Shropshire, United Kingdom, with an ATR were analysed and compared together with the season, month, and year of the injury. RESULTS: From 2009 to 2019, there was no significant change in the incidence of ATR over time with a mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase in 2021 to 22.4 per 100,000. In 2021, there was an increase in injuries from March with numbers maintained until October. The most common activity of ATR was team sport (36.2%), followed by the activities of daily living (28.9%), other physical activities (21.0%), and racket sports (13.9%). In 2020, there was the lowest number of injuries sustained in team and racket sports; however, in 2021, they accounted for over half of injuries. CONCLUSIONS: There were significantly more patients sustaining ATR in 2021, the year after the COVID pandemic and mandatory isolation. This was considered to be related to altered activity and team and racket sports during 2020. LEVELS OF EVIDENCE: IV case series.

Anterior meniscopexy: a meniscal sparing technique for the treatment of locking but intact discoid lateral meniscus.

PURPOSE: Symptomatic discoid lateral meniscus without tears has traditionally been treated with excision of part or the entire meniscus. Resection of 15-34% of the meniscus increases tibiofemoral contact pressures by more than 350%. Treatment of discoid lateral meniscus with partial or total meniscectomy in childhood increases the risk of early-onset osteoarthritis in the knee. The incidence of osteoarthritis is directly proportional to the amount of meniscal tissue resected. This paper describes the meniscus-preserving technique of meniscopexy and presents the outcomes of all patients who have undergone this procedure in the management of lateral discoid meniscus in a single unit over a 14-year period. METHODS: A retrospective study was carried out reviewing all patients who underwent meniscopexy for the treatment of MRI-confirmed discoid lateral meniscus without meniscal tear between 2001 and 2015 with a minimum of 1-year follow-up. Eleven patients (12 knees) were identified using a patient database of all patients that had undergone this procedure in our institution. Two patients were excluded from the final results, so nine patients (10 knees) were scored post-operatively at last follow-up using the Lysholm knee score. We reviewed all available post-operative MRI scans and recorded any complications. RESULTS: Four patients were male and seven were female. The median age of the patients at the time of surgery was 9 (6-14), and the median follow-up was 4.5 years (2-14). The median Lysholm knee score was 91 (86-100). The outcome for all patients scored was either good or excellent. CONCLUSION: The established treatment options for symptomatic discoid lateral meniscus without associated tear involve resection of meniscal tissue. Using this technique, all the meniscal tissue is preserved, thus reducing the risk of arthritic change in the future. MRI studies performed post-operatively suggested normalisation of meniscal morphology with time. Meniscopexy offers an effective alternative to the established treatment options in the management of symptomatic discoid lateral meniscus without meniscal tears. LEVEL OF EVIDENCE: IV.

Patient factors affecting the Toronto extremity salvage score following limb salvage surgery for bone and soft tissue tumors.

BACKGROUND AND OBJECTIVES: The Toronto extremity salvage score (TESS) assesses physical function following limb salvage for bone and soft tissue sarcoma. In 2012, Clayer et al. showed increasing age affects the TESS score in normal individuals. The purpose of this study was to investigate what other patient factors affect outcome? METHODS: We reviewed the TESS scores, age, sex, BMI, diagnosis, smoking status, and social deprivation score of patients who have undergone limb salvage in our unit. Data were extracted from our tumor database and reviewed. Statistical analysis was performed using Wilcoxon pairwise test and linear regression analysis. RESULTS: Four hundred and ninety-eight TESS scores were found for 198 patients. Data were analyzed separating upper limb (UL) and lower limb (LL) tumors. In the UL group, being female (P = 0.01) and having a bone lesion (P < 0.001) were associated with a lower TESS score. In the LL group, being female (P = 0.04), increasing age (P = 0.002), having a bone lesion (P < 0.001), increasing BMI (P < 0.001), and smoking (P = 0.005) were associated with a lower TESS score. CONCLUSIONS: Analysis has shown that female sex, increasing age and BMI, smoking and having a bone lesion have an adverse effect on physical function following limb salvage, as indicated by the mean TESS score. J. Surg. Oncol. 2016;113:804-810. © 2016 Wiley Periodicals, Inc.

Measuring limb length discrepancy using pelvic radiographs: the most reproducible method.

Leg length inequality following total hip replacement remains common. In an effort to reduce this occurrence, surgeons undertake pre-operative measurements, templating and use various forms of intraoperative measurements, including computer navigation. This study aims to delineate which measurement technique is most appropriate for measuring leg length inequality from a pelvic radiograph. Three observers took a total of 9600 measurements from 100 pelvic radiographs. Four lines were constructed on each of the radiographs, bisecting the acetabular teardrops, ischial spines, inferior sacroiliac joint and inferior obturator foramen. Measurements were taken from these lines to the most prominent medial point on the lesser trochanter and to the tip of the greater trochanter. The effect of pelvic positioning was also assessed using radiographs of a synthetic pelvis and femur. Intra-observer and inter-observer variability were calculated. Measuring from the inferior aspect of the ischial tuberosities to the most prominent medial point on the lesser trochanter appears to be the best method for measuring LLD however large error margin still exist, even when corrected for magnification errors.

A comparison of subsidence of Exeter standard and long stems.

The survivorship of the polished, double taper Exeter stem is related to subsidence within the cement mantle. Long Exeter stems have altered geometry which may influence subsidence characteristics. Using digitised x-rays and appropriate computer software we measured the subsidence of 35 standard and 40 long stem Exeter implants. Measurements were taken from initial postoperative radiographs and repeated at intervals up to 5 years. Long stem implants were used in cemented revisions without the use of impaction bone grafting. Subsidence rates of the standard length stems in our study were comparable to that in published literature. Long stems did not replicate this subsidence pattern and had subsided less at 6, 12 and 24 months. However, the 205mm long stem, which has a fully tapered design, did follow the subsidence characteristics of the standard stem. Subsidence of long stem Exeter implants does not mirror that of the standard length stem. Loss of the fully tapered geometry of the longer stem implants may account for this finding. We suggest that whenever possible, the 205mm long stem should be used if the biomechanical principles of the standard Exeter stem are to be utilised.

Retrograde amnesia following carbon monoxide poisoning: a case report.

Retrograde amnesia is a recognised neurological complication of carbon monoxide poisoning. This article describes the case of a female found dead in her bath where initial post-mortem findings and the surrounding circumstances raised strong suspicions of homicide, especially when there was contradictory evidence from her husband who was the only other person present. He was later diagnosed as having retrograde amnesia between his two visits to the bathroom to attend to his wife which caused him to merge them into one event, thus arousing suspicions of foul play. The discussion explores the current clinical views on non-fatal carbon monoxide poisoning as well as problems of interpretation of information derived from case work.