Blood loss and contributing factors in femoral fracture surgery

Background

Substantial blood losses frequently accompany orthopedic procedures.

Methods

We prospectively noted peri-operative hemoglobin changes in 93 patients undergoing surgery for femoral fracture with an aim of establishing blood loss and related factors.

Results

The mean total blood loss assessed 72 hours after the surgical procedure was 3.31 (SD 1.56) units of whole blood. A multiple regression analysis revealed diathermy use and a simple fracture pattern as significant factors in reducing blood loss (p<0.01).

Conclusions

Open intramedullary fixation of femur fractures leads to considerable peri-operative blood loss. This is can be reduced by use of diathermy during surgery.     

Effect of Anteromedial Portal Entrance Drilling Angle during Anterior Cruciate Ligament Reconstruction: A Three-Dimensional Computer Simulation

Purpose

The object of this study was to evaluate entrance angle effects on femoral tunnel length and cartilage damage during anteromedial portal drilling using three-dimensional computer simulation.

Materials and Methods

Data was obtained from an anatomic study performed using 16 cadaveric knees. The anterior cruciate ligament femoral insertion was dissected and the knees were scanned by computer tomography. Tunnels with different of three-dimensional entrance angles were identified using a computer simulation. The effects of different entrance angles on the femoral tunnel length and medial femoral cartilage damage were evaluated. Specifically, tunnel length and distance from the medial femoral condyle to a virtual cylinder of the femoral tunnel were measured.

Results

In tunnels drilled at a coronal angle of 45°, an axial angle of 45°, and a sagittal angle of 45°, the mean femoral tunnel length was 39.5±3.7 mm and the distance between the virtual cylinder of the femoral tunnel and the medial femoral condyle was 9.4±2.6 mm. The tunnel length at a coronal angle of 30°, an axial angle of 60°, and a sagittal angle of 45°, was 34.0±2.9 mm and the distance between the virtual cylinder of the tunnel and the medial femoral condyle was 0.7±1.3 mm, which was significantly shorter than the standard angle (p<0.001).

Conclusion

Extremely low and high entrance angles in both of axial plane and coronal plane produced inappropriate tunnel angles, lengths and higher incidence of cartilage damage. We recommend that angles in proximity to standard angles be chosen during femoral tunnel drilling through the anteromedial portal.     

Osteochondral avulsion fracture of the anterior cruciate ligament femoral origin in a 10-year-old child: a case report

Objective:

To describe the case of a 10-year-old football player who sustained a comminuted osteochondral avulsion fracture of the femoral origin of the anterior cruciate ligament (ACL) via a low-energy mechanism.

Background:

In children, both purely cartilaginous and osteochondral avulsion fractures have been described; most such ACL avulsions are from the tibial eminence. In the few previous case reports describing femoral osteochondral avulsion fractures, high-energy injury mechanisms were typically responsible and resulted in a single fracture fragment.

Differential Diagnosis:

Femoral osteochondral avulsion fracture at the ACL origin, femoral cartilaginous avulsion fracture at the ACL origin, midsubstance ACL tear, meniscal tear.

Treatment:

Sutures and a button were used to repair the comminuted fragments. Postoperatively, a modified ACL reconstruction rehabilitation program was instituted.

Uniqueness:

Most injuries of this nature in youngsters are caused by a high-energy mechanism of injury, result in an osteochondral avulsion fracture of the tibial eminence, and involve a single fracture fragment.

Conclusions:

Although they occur infrequently, ACL femoral avulsion fractures in children can result from a low-energy injury mechanism. Identifying the mechanism of injury, performing a thorough physical examination, and obtaining appropriate diagnostic studies will enable the correct treatment to be implemented, with the goal of safely returning the athlete to play.     

Correlation between Femoral Guidewire Position and Tunnel Communication in Double Bundle Anterior Cruciate Ligament Reconstruction

Purpose

The object of this study was to determine the shortest possible distances of antero-medial (AM) and postero-lateral (PL) guide wire tunnel positions required to prevent femoral bone tunnel communication in double-bundle anterior cruciate ligament (ACL) reconstruction using human cadaver knees.

Materials and Methods

The centers of femoral AM and PL bundles of 16 cadaveric knees were drilled with guide wires and the distances of guide wires, were measured upon entrance into the bone. Femoral tunnel drilling was performed using transportal technique. The diameters of AM and PL graft were 8 mm and 6 mm, respectively. CT scans were taken on each knee, and 3-dimensional models were constructed to identify the femoral tunnel position and to create AM and PL tunnel virtual cylinders. Thickness of the bone bridge between the two tunnels was measured.

Results

In four out of six specimens, in which the guide wires were placed at less than or equal to 9 mm, communication was noted. In specimens with guide wires placed at distances greater than or equal to 10 mm, communication was not noted. The two groups showed a statistically significant difference (p=0.008). In cases where the distance between the AM and PL femoral tunnel guide wires was 12 mm, the bone bridge thickness was greater than 2 mm along the tunnel.

Conclusion

The technique for double bundle-anterior cruciate ligament (DB-ACL) reconstruction that we show here can avoid bone tunnel communication when AM and PL femoral guide wires are placed at least 10 mm apart, and 12 mm should be kept to preserve 2 mm bone bridge thickness.     

Papillary thyroid carcinoma presenting as a lateral neck cyst

Background

Solitary lateral cervical cystic mass is an uncommon presentation of papillary thyroid carcinoma.

Objectives

To report our recent experience in the diagnosis and management of papillary thyroid carcinoma presenting as a lateral neck cyst.

Methods

Patients who had papillary thyroid carcinoma and presented as a painless lateral neck cyst at the Department of Surgery, Al-Ain Hospital, from April 2005 to June 2009 were retrospectively studied. Their clinical presentation, diagnosis and management were reviewed.

Results

Five patients were studied. No thyroid nodules were clinically palpable in all patients. Fine needle aspiration cytology from the cyst was positive for papillary thyroid carcinoma in three patients (60 percent). Two patients were diagnosed after excisional biopsy. Three patients had total thyroidectomy with modified radical neck dissection and postoperative radioactive iodine ablation. Two patients preferred to travel overseas for treatment. Thyroid histopathological examination has shown papillary thyroid carcinoma in all operated patients with multiple microscopic foci in two of them. This was associated with multiple bilateral cervical lymph node involvement.

Conclusions

Metastatic papillary thyroid carcinoma presenting as a neck cyst is a diagnostic challenge. Excisional biopsy is indicated if fine needle aspiration cytology was inconclusive so as to rule out malignancy.     

Treatment of femoral shaft fracture with an interlocking humeral nail in older children and adolescents

Purpose

Rigid interlocking nailing for femoral shaft fracture is ideal for use in adolescents in terms of stability of the fracture and convenience for the patient. However, numerous authors have reported that rigid interlocking nailing has some limitations in this age group due to the risk of complications. We evaluated the results of intramedullary nailing for femoral shaft fractures with an interlocking humeral nail in older children and adolescents.

Materials and Methods

We retrospectively reviewed records of patients treated with an interlocking humeral nail. Radiographs were examined for proximal femoral change and evidence of osteonecrosis. Outcomes were assessed by major or minor complications that occurred after operative treatment.

Results

Twenty-four femoral shaft fractures in 23 patients were enrolled. The mean age at the time of operation was 12 years and 8 months and the mean follow-up period was 21 months. Bony union was achieved in all patients without any complications related to the procedure such as infection, nonunion, malalignment and limb length discrepancy. All fractures were clinically and radiographically united within an average eight weeks. No patients developed avascular necrosis of the femoral head and coxa valga.

Conclusion

Intramedullary nailing through the greater trochanter using a rigid interlocking humeral nail is effective and safe for the treatment of femoral shaft fractures in older children and adolescents.     

Total hip arthroplasty using S-ROM prosthesis for dysplastic hip

Purpose

The purpose of this study was to evaluate the clinical and radiological results of total hip arthroplasty using a proximal modular femoral stem in patients who had secondary coxarthrosis associated with a dysplastic hip.

Materials and Methods

Forty-two patients (45 hips) with secondary coxarthrosis were evaluated after undergoing primary total hip arthroplasty using an S-ROM proximal modular femoral stem. The average follow-up was 80 months (range: 60 to 96 months). Clinical and radiological assessments were performed based on the Harris hip score and the radiological changes around the prosthesis.

Results

The average Harris hip score improved from 52.2 points to 88.5 points. All femoral stems showed stable fixation; there were 37 cases by bony ingrowth and 8 cases by stable fibrous ingrowth. Neither osteolysis nor progressive radiolucent lines around the femoral stem were found at the last follow-up. Forty-one hips (91.9%) revealed excellent or good clinical results at the most recent follow-up.

Conclusion

For advanced secondary coxarthrosis, total hip arthroplasty with the use of the proximal modular femoral stem yielded good mid-term results with respect to the clinical and radiological criteria.     

Anterograde Removal of Broken Femoral Nails without Opening the Nonunion Site: A New Technique

OBJECTIVE:

We describe a new technique for removing the distal fragments of broken intramedullary femoral nails without disturbing the nonunion site.

METHODS:

This technique involves the application of an AO distractor prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material.

RESULTS:

Nails were removed from five patients using the technique described above without any complications. After a mean follow-up period of 61.8 months, none of these patients showed worsened knee osteoarthritis.

CONCLUSION:

The original technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments.     

Comparative Study on Anterior Cruciate Ligament Reconstruction: Determination of Isometric Points with and Without Navigation

OBJECTIVES:

To compare the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot) and using traditional instruments.

METHODS:

The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). An inelastic suture was then passed through the central points of the tibial and femoral tunnels. Neither of the tunnels was drilled. All knees were then dissected, and six parameters were obtained: distances from the tibial tunnel center to the 1) posterior cruciate ligament, 2) anterior horn of the lateral meniscus and 3) medial tibial spine; 4) distance from the femoral tunnel center to the posterior femoral cortex; 5) femoral tunnel coronal angle; and 6) variation of the distance from the femoral to the tibial tunnel with the knee extended and at 90 degrees of flexion.

RESULTS:

The variation of the distance from the femoral to the tibial tunnel during flexion and extension was smaller in the Orthopilot group (better isometry) compared to the conventional group. There were no statistical differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions.

DISCUSSION:

The results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, and a navigation system is a precision tool that can assist surgeons in tunnel positioning.

CONCLUSION:

No differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments.     

Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement

Purpose

Total knee replacement is one of the most painful orthopedic procedures, and effective pain relief is essential for early mobility and discharge from hospital. The aim of this study was to evaluate whether addition of single-injection femoral nerve block to epidural analgesia would provide better postoperative pain control, compared to epidural analgesia alone, after total knee replacement.

Materials and Methods

Thirty-eight patients received a single-injection femoral nerve block with 0.25% levobupivacaine (30 mL) combined with epidural analgesia (femoral nerve block group) and 40 patients received epidural analgesia alone (control group). Pain intensity and volume of patient-controlled epidural analgesia medication and rescue analgesic requirements were measured in the first 48 hours after surgery at three time periods; 0-6 hours, 6-24 hours, and 24-48 hours. Also, side effects such as nausea, vomiting, and pruritus were evaluated.

Results

Median visual analog scale at rest and movement was significantly lower until 48 hours in the femoral nerve block group. Patient-controlled epidural analgesia volume was significantly lower throughout the study period, however, rescue analgesia requirements were significantly lower only up to 6 hours in the femoral nerve block group. The incidences of nausea and vomiting and rescue antiemetic requirement were significantly lower in the femoral nerve block group up to 6 hours.

Conclusion

The combination of femoral nerve block with epidural analgesia is an effective pain management regimen in patients undergoing unilateral total knee replacement.     

Risk factors for indoor air pollution in rural households in Mauche division, Molo district, Kenya

Background

Exposure to indoor air pollution may be responsible for nearly 2 million per year deaths in developing countries. In Kenya, it is among the factors linked to high morbidity, especially in children aged below five years.

Objectives

The survey was conducted in 2005 in 350 rural households to identify household factors that are likely to enhance indoor air pollution.

Methods

Questionnaire, continuous and spot observations were used to collect data on household characteristics, type of primary building in homestead, number of rooms, type of ventilation present and type of fuel used by the household.

Results

State of housing and type of fuel used were found to be likely risk factors for indoor air pollution. Fifty two point six percent of those interviewed live in mud walled houses with iron sheet roofs. Ninety one percent live in either single or two roomed houses. Ventilation is provided both by small windows and a space left in between the wall and roof. Thirty seven percent of observed houses have no windows. In all households, fuel wood is used for cooking.

Conclusion

State of housing and fuel used in sampled households encourage indoor air pollution, which has been associated with various diseases.     

Polysomnographic Abnormalities in Succinic Semialdehyde Dehydrogenase (SSADH) Deficiency

Objectives:

Patients with SSADH deficiency, a disorder of chronically elevated endogenous GABA and GHB, were studied for sleep symptoms and polysomnography. We hypothesized that patients would have excessive daytime somnolence and decreased REM sleep.

Design:

Polysomnography and MSLT were performed on patients enrolled for comprehensive clinical studies of SSADH deficiency.

Setting:

Sleep studies were obtained in the sleep laboratories at CNMC and NIH.

Patients:

Sleep recordings were obtained in 10 patients with confirmed SSADH deficiency.

Interventions:

Thirteen overnight polysomnograms were obtained in 10 patients (7 male, 3 female, ages 11-27 y). Eleven MSLT studies were completed in 8 patients.

Measurements and Results:

Polysomnograms showed prolongation of REM stage latency (mean 272 ± 89 min) and decreased percent stage REM (mean 8.9%, range 0.3% to 13.8%). Decreased mean sleep latency was present in 6 of 11 MSLTs.

Conclusions:

SSADH deficiency is associated with prolonged latency to stage REM and decreased percent stage REM. This disorder represents a model of chronic GABA and GHB accumulation associated with suppression of REM sleep.

Citation:

Pearl PL; Shamim S; Theodore WH; Gibson M; Forester K; Combs SE; Lewin D; Dustin I; Reeves P; Jakobs C; Sato S. Polysomnographic abnormalities in succinic semialdehyde dehydrogenase (SSADH) deficiency. SLEEP 2009;32(12):1645-1648.     

Assessment of the Anti-Diarrhea Function of Compound Chinese Herbal Medicine Cangpo Oral Liquid

Background

Diarrhea is a big problem in piglets. Cangpo Oral Liquid (COL) is a compound of Chinese herbal medicine. The preparation was fed to piglets had diarrheal disease in order to determine its anti-diarrhea activity and potential applications in vivo

Materials and Methods

The contents of Berberine hydrochloride, Magnolol and Honokiol in COL were performed on HPLC analysis. Organ bath was used to investigate the effect of COL on peristaltic reflexes and peristaltic waves in vitro. And anti-diarrhea activity of COL was evaluated in clinical.

Results

Thin layer chromatography (TLC) and HPLC analyses showed that the contents of Berberine hydrochloride, Magnolol and Honokiol in COL were 970µg/mL, 130µg/mL and 300µg/mL, respectively. Administration of the COL to the organ bath caused a concentration-dependent inhibition of intestinal peristalsis. When the COL concentration in the bath was cumulatively increased, the amplitude and frequency of the peristaltic waves was lowered. The result of clinical efficacy of COL was very effective to diarrheic piglets. COL can possibly inhibit the curve of peristaltic waves in vitro; and clinical trial showed a statistically significant therapeutic effect in vivo.

Conclusion

In conclusion, COL can be used as an effective therapeutic agent. However, the ingredients, pharmacokinetics and specific signaling pathways of COL need to be further studied.     

Gradual Lengthening of the Ulna in Patients with Multiple Hereditary Exostoses with a Dislocated Radial Head

Purpose

Multiple hereditary exostoses of the forearm typically form in the distal ulna, causing disturbances in the growth of the ulna and functional disability. Multiple hereditary exostoses inhibit the growth of the ulna, leading to an acquisition of a varus deformity in the radius, which sometimes leads to dislocation of the radial head, the development of limitations in the pronation-supination of the forearm, and cosmetic problems.

Materials and Methods

We retrospectively reviewed the cases of four patients who had deformities of the forearm with radial head dislocation associated with multiple hereditary exostoses, and evaluated the radiologic and clinical results of excision of the osteochondromas from the distal ulna and gradual ulnar lengthening with an Ilizarov external fixator.

Results

Good clinical and radiological results were obtained after a mean follow-up of 25 months. At the most recent follow-up, radial bowing, ulnar shortening, carpal slip, and the pronation/supination arch of the forearm had improved. There was little change in terms of preoperative radial articular angle and the flexion/extension arch of the elbow by the most recent follow-up.

Conclusion

Treatment of four forearms from four patients by excision of osteochondromas and gradual lengthening of the ulna with an Ilizarov external fixator spontaneously reduced dislocations of the radial heads without the need for any additional operative intervention. All patients were satisfied with the final results.     

Anthropometric measurements of children attending a vaccination clinic in Yaounde, Cameroon

Background

Growth faltering is a frequent public health problem in children and anthropometric measurements are useful tools for follow-up and early diagnosis. This problem has not been studied in the Cameroonian setting, that''s why we undertook this study.

Objectives

To have a synopsis of the nutritional status in apparently healthy children attending a vaccination clinic and show the importance of anthropometric measurements in routine child health care.

Design

A retrospective study.

Patients and Participants

1351 children aged (6–24months), who attended the vaccination clinic of the Yaounde Gynaeco-Obstetric and Pediatric Hospital over a 6 month period, were enrolled in the study.

Method

The registers of the vaccination clinic of the above hospital were retrospectively reviewed from 1^st March to 31^st August 2005. The following parameters were noted: age, height, weight, mid-upper arm circumference (MUAC), and Z scores calculated for the following indicators: weight for age (WAZ), weight for height (WHZ), and height for age (HAZ).

Results

Our results show that 12 children (1.1percent) in the 0–6 months age group and 4 (1.6 percent) in the 6–12 months age group had WAZ less than -2 indicating underweight. Also 10 children (0.9 percent) and 2 (0.8 percent) in the 0–6 and 6–12 months age groups respectively had WHZ less than −2, indicating wasting. HAZ was less than −2 in 70 children (6.4 percent) and in 8 (3.2 percent) in the 0–6 and 6–12 months age groups respectively indicating stunting. The MUAC was less than 12.5 cm in 6 children (2.4 percent).

Conclusions

From our results, we conclude that growth faltering is common in supposedly healthy children attending our vaccination clinic. Anthropometric measurements are thus recommended and should be encouraged in routine child care settings for early diagnosis of growth retardation and to provide useful interventions.     

Knee separation distance and lower extremity kinematics during a drop land: implications for clinical screening

Context:

Excessive knee valgus during dynamic tasks is thought to contribute to lower extremity overuse and traumatic injuries. Clinically, assessments of frontal-plane knee motion typically include measures of the distance between the knees during landing. However, it is not clear how this clinical assessment relates to knee-abduction angle or how it is influenced by the position of the lower extremities in the transverse and frontal planes.

Objective:

To determine whether normalized knee separation distance (NKSD) is a predictor of knee-abduction angles and to assess the influence of lower extremity transverse-plane and frontal-plane angles on NKSD during a drop land.

Design:

Cross-sectional study.

Setting:

Motion analysis laboratory.

Patients or Other Participants:

Twenty-five healthy female athletes.

Intervention(s):

The frontal-plane distance between the 2- dimensional coordinates of markers over the greater trochanters (intertrochanteric distance), lateral femoral epicondyles (knee separation distance), and lateral malleoli (stance width) bilaterally was calculated during a drop land. The knee separation distance was normalized by intertrochanteric distance (NKSD). Concurrently, 3-dimensional lower extremity transverse-plane and frontal-plane kinematics were obtained.

Main Outcome Measure(s):

We assessed NKSD, stance width, and bilateral average knee and hip transverse plane and frontal-plane angles and ankle frontal-plane angles. Linear regression was used to determine the association between NKSD and bilateral average knee frontal-plane angles. Stepwise multiple regression was used to identify the best predictors of NKSD during the drop land.

Results:

After we controlled for stance width, NKSD explained 52% of the variance in the knee frontal-plane angle. When we took lower extremity kinematics into account, after controlling for stance width, the average hip frontal-plane angle was the best predictor of NKSD, explaining 97% of the variance.

Conclusions:

Although NKSD is a predictor of knee- abduction angle, frontal-plane hip angle and stance width are strongly related to NKSD. Caution must be taken when interpreting NKSD as knee abduction.     

Application of Generalizability Theory in Estimating the Reliability of Ankle-Complex Laxity Measurement

Context:

Generalizability theory is an appropriate method for determining the reliability of measurements obtained across more than a single facet. In the clinical and research settings, ankle-complex laxity assessment may be performed using different examiners and multiple trials.

Objective:

To determine the reliability of ankle-complex laxity measurements across different examiners and multiple trials using generalizability theory.

Design:

Correlational study.

Setting:

Laboratory.

Patients or Other Participants:

Forty male university students without a history of ankle injury.

Main Outcome Measure(s):

Measures of right ankle-complex anteroposterior and inversion-eversion laxity were obtained by 2 examiners. Each examiner performed 2 anteroposterior trials, followed by 2 inversion-eversion trials for each ankle at 0° of ankle flexion. Using generalizability theory, we performed G study and D study analyses.

Results:

More measurement error was found for facets associated with examiner than with trial for both anteroposterior and inversion-eversion laxity. Inversion-eversion measurement was more reliable than anteroposterior laxity measurement. Although 1 examiner and 1 trial had acceptable reliability (G coefficient ≥ .848), increasing the number of examiners increased reliability to a greater extent than did increasing the number of trials.

Conclusions:

Within the range of examiner and trial facets studied, any combination of examiners or trials (or both) above 1 can change ankle laxity measurement reliability from acceptable (1 examiner, 1 trial) to highly reliable (3 examiners, 3 trials). Individuals may respond to examiners and their procedural nuances differently; thus, standardized procedures are important.     

White Matter Differences Predict Cognitive Vulnerability to Sleep Deprivation

Objectives:

In other disciplines, white matter (WM) differences have been linked to cognitive impairments. This study sets out to clarify whether similar microstructural differences in WM tracts predict a person''s cognitive vulnerability to the effects of total sleep deprivation (TSD).

Design:

Participants completed a simple visual-motor task both before and after 24 h of TSD. Using a median split on the percent change in accuracy from pre-TSD to post-TSD, participants were separated into susceptibility groups. A diffusion tensor MR imaging (DTI) scan was acquired from each participant, and fractional anisotropy (FA) was calculated, examined across the brain, and compared between susceptibility groups.

Setting:

University of Texas at Austin.

Participants:

Thirty-two West Point cadets (9 females, 23 males) between 19 and 25 years of age.

Results:

Participant susceptibility to TSD was correlated with lower FA values in multiple regions of white matter, including the genu of corpus callosum and ascending and longitudinal white matter pathways. Significantly higher FA values in those less vulnerable to TSD, indicating increased neural connectivity and WM organization, may moderate the cognitive effects of sleep deprivation.

Conclusions:

Differences in distributed WM pathways reflect, and may contribute to, a person''s ability to function effectively when sleep deprived. The widespread nature of this effect supports previous views that TSD has a global effect on brain functioning.

Citation:

Rocklage M; Williams V; Pacheco J; Schnyer DM. TitleTitleTitle. SLEEP 2009;32(8):1100-1103.     

Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections

Background

Adhesive capsulitis is a common, painful, and disabling condition that has been managed with corticosteroid injections for over 50 years. There is debate over the use of single or multiple injections, but no systematic review has investigated the effects of administering multiple injections.

Aim

To assess the efficacy of treating adhesive capsulitis of the shoulder with multiple corticosteroid injections.

Design of study

Systematic review.

Method

An English language search for randomised controlled trials was conducted from: MEDLINE®, EMBASE, CINAHL, PEDro, SIGLE, National Technical Information Service, British National Bibliography, Index of Scientific and Technical Proceedings® databases, and the Cochrane Library. Randomised controlled trials were identified from reference lists of review and eligible articles. The studies were assessed using a recognised rating system of methodological trial quality. The conclusions and results of the identified studies, based on their main outcome measures, were then summarised.

Results

Nine randomised controlled trials were identified and four studies were rated as high quality. Three high quality studies showed a beneficial effect for the use of multiple corticosteroid injections with outcome measures of pain reduction, improved function, and increased range of shoulder movement.

Conclusion

The evidence suggested that multiple injections were beneficial until 16 weeks from the date of the first injection. Up to three injections were beneficial, with limited evidence that four to six injections were beneficial. No evidence was found to support giving more than six injections.