Long-term effectiveness of transforaminal anterolateral approach CT-guided cervical epidural steroid injections for cervical radiculopathy treatment

AIM

To evaluate the long-term clinical effectiveness of computed tomography (CT)-guided transforaminal cervical epidural steroid injection using an anterolateral approach for the treatment of cervical radiculopathy (CR) using well-established robust clinical scoring systems for neck pain and neck disability. Despite its widespread use, evidence to support the long-term benefit of routine cervical epidural steroid injection is currently very limited.

MATERIALS AND METHODS

This study included 113 patients with magnetic resonance imaging (MRI)-confirmed CR who underwent a steroid injection at a single cervical level via a unilateral transforaminal anterolateral approach. Pain was assessed quantitatively at pre-injection, 15 minutes post-injection, 1 month, 3 months, and at 1 year. Neck disability was assessed using the Oswestry Neck Disability Index (NDI) at pre-injection, 1 month, 3 months, and 1 year time points.

RESULTS

Eighty patients completed the study. Sixty per cent reported reduced neck pain (mean pain reduction, 55%), which was clinically significant in 45% cases. Furthermore, 66% reported an improvement in neck disability (mean improvement, 51%), which was clinically significant for 56% patients. Clinically significant good outcomes in both neck pain and neck disability were evident from as early as 1-month, and importantly, were independent both of pre-treatment CR characteristics (including severity of pre-injection neck pain or disability) and of findings on pre-injection MRI imaging.

CONCLUSION

Transforaminal anterolateral approach CT-guided epidural steroid injection resulted in a clinically significant long-term improvement in both neck pain and disability for half of the present cohort of patients with unilateral single-level CR. This improvement was independent of the severity of the initial symptoms and pre-injection MRI findings.

Higher preoperative sensitivity to pain and pain at rest are associated with worse functional outcome after stemless total shoulder arthroplasty

Aims

The aims of this study were to investigate any possible relationship between a preoperative sensitivity to pain and the degree of pain at rest and on exertion with postoperative function in patients who underwent stemless total shoulder arthroplasty (TSA).

Patients and Methods

In this prospective study, we included 63 patients who underwent stemless TSA and were available for evaluation one year postoperatively. There were 31 women and 32 men; their mean age was 71 years (53 to 89). The pain threshold, which was measured using a Pain Matcher (PM) unit, the degree of pain (visual analogue scale at rest and on exertion, and function using the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), were recorded preoperatively, as well as three and 12 months postoperatively.

Results

We found an inverse relationship between both the preoperative PM threshold and pain (VAS) at rest and the 12-month postoperative QuickDASH score (Pearson correlation coefficient (r) ≥ 0.4, p < 0.05). A linear regression analysis showed that the preoperative PM threshold on the affected side and preoperative pain (VAS) at rest were the only factors associated with the QuickDASH score at 12 months.

Conclusion

These findings indicate the importance of central sensitization in the restoration of function after TSA. Further studies are required to investigate whether extra analgesia and rehabilitation could influence the outcome in at risk patients. Cite this article: Bone Joint J 2018;100-B:480–4.

The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life

Late displacement of distal radius fractures, still in acceptable radiological position after 1-2 weeks, occurs in approximately one-third of cases. The aim of this study was to investigate the influence of late displacement on the functional outcome and quality of life at 1 year in non-operatively treated distal radius fractures. One hundred and seventy five unilateral conservatively treated distal radius fractures with minimal displacement after 10-14 days were finally evaluated in the study. Follow-up included radiographs at 3 months and clinical examination 1 year after the fracture. Final radiographic parameters, grip strength, range of motion, QuickDASH, EQ-5D and pain visual analogue scale were evaluated with multivariate analysis. Late displacement occurred in 28% of the cases and was associated with loss of grip strength and range of motion. No significant differences were seen in the outcome questionnaires.

LEVEL OF EVIDENCE

II.

Geometrical restoration and component positioning after hip arthroplasty for femoral neck fracture

In this study, the restoration of leg length and global femoral offset and positioning of the femoral stem and acetabular cup of hemiartroplasty (HA) and total hip arthroplasty (THA) after femoral neck fracture (FNF) were compared at the postoperative radiographs between 181 hips operated using the direct lateral (DL) approach and 127 hips operated using the posterolateral (PL) approach. Regarding HA, the DL approach was associated with lengthening of the operated leg (5.7 mm vs. 2.1 mm), p = 0.001. The PL approach had more varus stem position (23% vs. 12%, p = 0.03) and the DL approach had more stems with C-position (58% vs. 32%, p = 0.001). Regarding THA, the DL approach showed increased cup anteversion (28° vs. 21°), p = 0.016, and a decrease in FO (-5.9 mm vs. -2.0 mm, p = 0.04). Surgeons caring for FNF patients are to be aware of the differences in geometrical restroration and component positioning -between the two approaches.

Cortical comminution in distal radial fractures can predict the radiological outcome

This paper investigates whether cortical comminution and intra-articular involvement can predict displacement in distal radius fractures by using a classification that includes volar comminution as a separate parameter.

A prospective multicentre study involving non-operative treatment of distal radius fractures in 387 patients aged between 15 and 74 years (398 fractures) was conducted. The presence of cortical comminution and intra-articular involvement according to the Buttazzoni classification is described. Minimally displaced fractures were treated with immobilisation in a cast while displaced fractures underwent closed reduction with subsequent immobilisation. Radiographs were obtained after reduction, at 10 to 14 days and after union. The outcome measure was re-displacement or union.

In fractures with volar comminution (Buttazzoni type 4), 96% (53 of 55) displaced. In intra-articular fractures without volar comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106 of 145) displaced while in non-comminuted fractures (Buttazzoni 1), 16 % (13 of 81 ) displaced.

A total of 32% (53 of 165) of initially minimally displaced fractures later displaced. All of the initially displaced volarly comminuted fractures re-displaced. Displacement occurred in 31% (63 of 205) of fractures that were still in good alignment after 10 to 14 days.

Regression analysis showed that volar and dorsal comminution predicted later displacement, while intra-articular involvement did not predict displacement. Volar comminution was the strongest predictor of displacement.

Cite this article: Bone Joint J 2014;96-B:978–83.

Greater trochanteric pain after total hip arthroplasty: the incidence, clinical outcome and associated factors

We evaluated any residual pain around the hip joint 11 to 23 months post-surgery in 172 consecutive patients who underwent total hip arthroplasty (THA) for primary or secondary osteoarthritis during 2002 at Sundsvall Hospital, Sweden. Patients with suspected greater trochanteric pain (GTP) were matched with controls from the same cohort. The two groups were assessed with the Western Ontario and McMaster Universities Arthrosis Index (WOMAC) and were examined for localised tenderness over the trochanteric area by algometer. The pre- and postoperative radiographs including femoral offset were evaluated. We found that 21 patients (12%) had GTP with a male to female ratio of 1:6. The WOMAC index revealed a reduction in the clinical outcome in this group. An associated factor of significance was postoperative uncorrected lengthening of the operated limb equal to or more than one centimetre. We found no correlation between the prevalence of GTP and body weight or length, femoral offset or size of the prosthetic components used.