Trigger thumb: results of a prospective randomised study of percutaneous release with steroid injection versus steroid injection alone

One hundred and twenty-seven trigger thumbs in 115 adult patients were randomised to either percutaneous release with steroid injection (n=66) or steroid injection alone (n=61). Two patients, one from each group, were lost to follow-up. Percutaneous release with steroid injection produced satisfactory results in 91% of cases whereas steroid injection alone produced satisfactory results in 47% of cases. One case in the percutaneous group developed stiffness and one in the injection group developed cellulitis. No digital nerve injury occurred in either group. We conclude that percutaneous trigger thumb release combined with steroid injection has a higher success rate than that of steroid injection alone.     

Defining predictors of response to intralesional verapamil injection therapy for Peyronie's disease

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Intralesional verapamil (ILV) injection therapy is useful to prevent progression of Peyronie’s Disease in some patients. These data are analyzed to identify predictors to better indentify patients likely to benefit from ILV therapy.

OBJECTIVE

? To assess factors that predict penile curvature responses to intralesional verapamil (ILV) injection therapy for men with Peyronie’s disease (PD).

PATIENTS AND METHODS

? Men with PD for <1 year were assessed at baseline and after 3 months of bi‐monthly ILV‐injection therapy. Curvature was assessed at the time of maximum penile rigidity. ? Univariate relationships were tested with correlation or chi‐square analyses. ? Multivariate analyses included logistic and linear regression. ? We analysed curvature improvement, defined as a decrease of ≥10 ° from baseline. Additionally, the relationship between curvature outcomes and patient age and degree of baseline penile curvature were assessed.

RESULTS

? Data from 131 men were included and the rates of penile curvature change were:26% improved, 12% worsened, and 62% stable. ? Age (r=?0.24, P < 0.01) and larger baseline penile curvature (r= 0.33, P < 0.01) were associated with improved curvature on univariate analysis. ? On multivariate analysis (logistic regression), both age [odds ratio (OR) 0.93, P < 0.01, 95%CI 0.89–0.97] and larger baseline penile curvature (OR 1.07, P < 0.01, 95%CI 1.04–1.11) were associated with improvements in curvature after ILV‐injection therapy. ? Improvements in curvature were associated with age (≤40 years vs >40 years; OR 0.27, P < 0.05, 95%CI 0.10–0.75) and degree of penile curvature at baseline (≤30 ° vs >30 °; OR 9.12, P < 0.01, 95%CI 1.94–42.84) when dichotomized as indicated.

CONCLUSION

? Younger age and larger baseline penile curvature were predictive of favourable curvature outcomes. ? Analysis of dichotomized variables suggests that age and baseline curvature thresholds may be important to consider when deciding on ILV as a therapeutic strategy for PD.     

The effect of corticosteroid injection for trigger finger on blood glucose level in diabetic patients

PURPOSE: To determine how corticosteroid injections for trigger finger affect the blood glucose level in diabetic patients and the clinical results of those injections. METHODS: Eighteen diabetic patients receiving a methylprednisolone injection for a single trigger finger were studied. Six patients had type I (juvenile-onset) diabetes and 12 patients had type II (adult-onset) diabetes. Patients recorded their usual blood glucose measurements and then they recorded their blood glucose measurements for 5 days after injection. Clinical efficacy of the injections was measured by avoidance of surgery. RESULTS: There were 3 men and 15 women with an average age of 58 years. The blood glucose level increased after corticosteroid injection for all patients. The first morning after injection showed the biggest increase in blood glucose level: 73% more than the average preinjection levels. By the fifth morning after injection the blood glucose levels still were increased by 26% more than the preinjection levels. This trend was marked particularly in type I diabetic patients, who had an average blood glucose level increase the first morning after injection of 145%, which decreased over 5 days to 22% greater than baseline levels. Sixteen patients had follow-up evaluation over a period of 1 year and of these 16 patients 7 required surgery for this condition. CONCLUSIONS: A digital injection of the corticosteroid methylprednisolone acetate in diabetic patients with trigger finger causes a hyperglycemic effect that lasts for at least 5 days but can help prevent the need for surgery more than half the time. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits

Background

Stenosing flexor tenosynovitis of the digital flexor tendon (trigger digit) is a common condition encountered by hand surgeons. Our purpose was to determine the efficacy of corticosteroid injections and review the demographic profile of patients with trigger digits.

Methods

We reviewed the records of 362 patients (577 trigger digits) treated with steroid injections (8 mg of triamcinolone acetonide in 1 % lidocaine) from 1998 through 2011. Follow-up (intervention to last visit) averaged 66.4 months. We assessed patient demographics (e.g., gender, age, diabetes mellitus, hand dominance, trigger digit distribution) and determined recurrence rate and injection duration of efficacy. If one injection failed, additional injections or surgical A1 pulley release were offered. Results were analyzed with Student''s t test or Fisher''s exact test (significance, p < 0.05).

Results

Women (258, 71.3 %) were affected significantly (p < 0.001) more frequently than men (104, 28.7 %) and at a significantly (p < 0.001) younger age (average, 58.3 versus 62.1 years, respectively). Eighty patients (22.1 %) were diabetic. We observed no correlation between trigger digit and hand dominance. The two most commonly affected digits were the right long finger (17.8 %) and right thumb (17.7 %). For 721 injections, the recurrence rate was 20.3 %; there were no major complications. For recurrences, the injection efficacy averaged 315 days. Surgery was required for 117 patients.

Conclusions

Injection therapy is safe and highly effective (79.7 %). Women were affected by trigger digits more often than men and at a younger age. Surgical release provides a definitive therapeutic option if corticosteroid injection fails.     

Birth of healthy twins after intracytoplasmic sperm injection using ejaculated immotile spermatozoa from a patient with Kartagener's syndrome

This case report demonstrates a successful pregnancy after ICSI combined with hypo-osmotic swelling test in a couple with Kartagener's syndrome with complete immotile ejaculated spermatozoa. Our result suggests that even for complete immotile spermatozoa, the use of hypo-osmotic swelling test is a good alternative to identify viable spermatozoa. When associated with ICSI, it can be a valuable tool to get fertilisation and pregnancy.     

Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis

Background  The aim of the study was to compare the efficacies of steroid injections guided by scintigraphy, ultrasonography, and palpation in plantar fasciitis. Methods  A total of 35 heels of 27 patients were randomly assigned to three steroid injection groups: palpation-guided (pg), ultrasound-guided (ug), and scintigraphy-guided (sg). Patients were evaluated for pain intensity before the injections and at the last follow-up of 25.3 months with a 100-mm visual analog scale (VAS). Results  There were significant improvements in plantar fascia thickness, fat pad thickness, and VAS. Among the three groups of ug–pg, ug–sg, and pg–sg there were no statistically significant differences after treatment (P = 0.017, MWU = 36.5; P = 0.023, MWU = 29.5; and P = 0.006, MWU = 13, respectively). Conclusions  The ug, pg, and sg injections were effective in the conservative treatment of plantar fasciitis. We are of the opinion that steroid injections should be performed, preferably with palpation or ultrasonographic guidance.     

Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial

Background  To determine the effectiveness of three different local injection modalities in the treatment of lateral epicondilitis. Methods  In a prospective randomized study on lateral epicondilitis, 75 patients were divided into three equal groups A, B and C (n = 25) and were treated using three different method of local injection. The patients in group A were treated with local injection of a steroid (1 mL triamcinolone) combined with local anaesthetic (1 mL lidocaine), those in group B were treated with injection of local anaesthetic (1 mL lidocaine) combined with peppering technique and those in group C with local injection of a steroid (1 mL triamcinolone) combined with local anaesthetic (1 mL lidocaine) and peppering technique. The outcome was defined by measuring the elbow pain during the activity using a 10-cm visual analogue scale (VAS) and satisfaction with the treatment using a scoring system based on the criteria of the Verhaar et al. at 3 weeks and 6 months after the injection and compared with the pre-treatment condition. Results  There were significant (P = 0.006) differences in the successful outcomes between the three groups at 6 months. In group C in which local steroid + peppering injection technique were used; excellent results were obtained in 84% of patients comparing to 36% and 48% for patients in groups A and B, respectively. The successful outcomes were statistically higher in group C comparing to group A (P = 0.002) and group B (P = 0.011). In all groups, there was a significantly lower pain (VAS) at the 3-week and 6-month follow-ups comparing to the pre-treatment condition. VAS measured at 6-month follow-up were significantly lower in group C comparing to other groups (P = 0.002). Conclusion  In the treatment of lateral epicondilitis, combination of corticosteroid injections with peppering is more effective than corticosteroid injections or peppering injections alone and produces better clinical results.     

Prospective comparison of the six-item carpal tunnel symptoms scale and portable nerve conduction testing in measuring the outcomes of treatment of carpal tunnel syndrome with steroid injection

Background

We prospectively studied patients clinically diagnosed with carpal tunnel syndrome (CTS) and treated with the injection of corticosteroid into their carpal tunnel in order to compare changes in the six-item CTS symptoms scale and portable nerve conduction study (NCS) parameters as outcome tools. Our pilot study was the first to assess the utility of the six-item CTS symptom scale (CTS-6) with steroid injections as a patient-directed outcome measure for the treatment of CTS.

Methods

We enrolled patients who presented to our county hospital orthopedic surgery clinic from August 2012 through August 2013. The patients were clinically diagnosed with CTS. After completing the six-item CTS symptoms scale questionnaire, portable NCS was obtained. Each patient then received an injection of 1 ml of triamcinolone acetonide 40 mg/ml mixed with 1 ml of 1 % lidocaine into the carpal tunnel. Six weeks postinjection, each patient repeated a CTS-6 questionnaire and underwent a repeat portable NCS. The CTS-6 and NCS results were analyzed using the paired samples t test. A Pearson correlation was used to assess the correlation between the changes in the CTS-6 and the NCS measurements. Statistical significance was set at P < 0.05.

Results

Thirty-two wrists in 20 patients were evaluated. There was a statistically significant difference between the CTS-6 scores before and after injection. There were also statistically significant changes in the five of the NCS parameters. None of the correlations between the CTS-6 and the NCS parameters were statistically significant.

Conclusions

The six-item CTS symptoms scale and portable NCS are both useful measures for evaluating the results of steroid injections. The CTS-6 is an effective tool because of its ease of use, low cost, correspondence with changes in NCS, and ability to monitor the outcome of steroid treatment for carpal tunnel syndrome.     

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

Introduction  

Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of low-back pain with radiculopathy. Most interventional pain physicians strongly believe in their efficacy and safety. Recent Cochrane systematic reviews have disclosed controversial results and have questioned the effectiveness of ESIs. Moreover, a few neurological adverse events have been reported recently.     

A double‐blind placebo‐controlled study of the efficacy and safety of pentoxifylline in early chronic Peyronie’s disease

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVE

To analyse the safety and efficacy of pentoxifylline sustained‐release (PTX‐SR) treatment in patients with early chronic Peyronie’s disease (PD).

PATIENTS AND METHODS

In all, 228 patients with a mean (sd ) age of 51 (9) years who had early chronic PD were randomized to receive 400 mg PTX‐SR (Apo‐Pentoxifylline, Apotex Inc., Toronto, Canada) twice daily (group 1, 114) or similar regimen of placebo (group 2, 114) for 6 months. A medical history was taken and the men had a complete physical examination. The following variables were assessed before and after therapy: penile curvature and penile artery spectral traces (end‐diastolic velocity, EDV, peak systolic velocity, PSV, and resistivity index, RI, of the right and left cavernous arteries assessed with dynamic penile duplex ultrasonography), plaque characteristics (assessed by penile X‐ray and penile ultrasonography), pain (assessed by visual analogue scale), erectile function (assessed by the International Index of Erectile Function, IIEF questionnaire), treatment satisfaction (assessed by Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire), and side‐effects. Patient perception of penile curvature and plaque size, and mean weekly intercourse attempts were also assessed.

RESULTS

Overall, 36.9% of patients who received PTX‐SR reported a positive response, vs only 4.5% in the placebo group. Of patients in PTX‐SR group, 12 (11%) had disease progression, vs 46 (42%) in placebo group (P = 0.01). Improvement in penile curvature (P = 0.01), and plaque volume (P = 0.001) was significantly greater in patients treated with PTX‐SR than placebo. The increase in IIEF total score was significantly higher in the PTX‐SR group (P = 0.02). Mean PSV changes after therapy compared to baseline were statistically significant between PTX‐SR (right, +11.4%, left, +11.7%) and placebo‐treated (+0.2% and ?4.2%, respectively) patients (both P = 0.04).

CONCLUSIONS

PTX‐R was moderately effective in reducing penile curvature and plaque volume in patients with early chronic PD. Further studies with different treatment regimens are needed to better elucidate the beneficial effects of PTX‐SR in PD.     

Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery

Background Context

Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.

Tissue engineering scaffolds in the treatment of brain disorders in geriatric patients

The world population is ageing at an alarming rate, currently increasing at around 3% per year for people over 60 years. This fast growing demography is largely unproductive and prone to many brain disorders such as Alzheimer's disease, Parkinson's disease, and brain tumors. Currently available treatment modalities are inadequate to stop neural degeneration or to completely eradicate cancer cells. Exogenously engineered scaffolds hold great potential for in vivo brain regeneration and functional restoration. Ideally, scaffolds for brain tissue engineering should be biocompatible, non‐toxic, and electroactive with the ability to encourage neural elongation. These scaffolds have been successfully fabricated from a wide range of materials and techniques. Different types of stem cells have also been investigated for their ability to differentiate to nerve or glial tissue. The success of tissue engineering can thus be envisioned as a panacea for “retooling” of both individual’s ability and for immense long‐term benefit of society.     

A variant of Kaplan's accessory branch of the dorsal cutaneous branch of the ulnar nerve: a case report and review of the literature

Kaplan's accessory branch is an aberrant branch of the dorsal cutaneous branch of the ulnar nerve that arises proximal to the styloid process of the ulna and courses ulnar to the pisiform. Variations of this anomaly have been described as having an end point of connection to the sensory branch of the ulnar nerve, to the motor branch of the ulnar nerve (rare), to the digital nerve at the level of the midhypothenar eminence, or to the proximal interphalangeal joint of the small finger or as running as an independent branch to the volar aspect of the small finger. We report a variant of Kaplan's accessory branch that coursed through the insertion of the flexor carpi ulnaris, a groove on the ulnar aspect of the pisiform, and connected to the ulnar nerve trunk proximal to its bifurcation into its motor and sensory branch. Based on the findings of the case presented and a review of the literature we offer a classification system for this anomaly.