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.

Soft Tissue Radiological Knee (SToRK) Index: An observational cohort study to produce an index that quantifies the magnitude of soft tissue around the knee using standard radiographs.

INTRODUCTION: The soft tissue envelope around the knee can have an impact on the ease of performing surgery such as total knee replacement (TKR). BMI is often used in planning theatre time but may be a poor indicator of the soft tissue around the knee due to varying distribution of adipose tissue. Radiological images directly show the soft tissue. We therefore aim to develop a method of quantifying the soft tissue envelope around the knee using radiographs. METHOD: Plain weight-bearing radiographs were used to measure the total knee (soft tissue and bony) width at the level of the epicondyles of the knee and the bony epicondylar width of the femur. The ratio of the two widths was defined as the Soft Tissue Radiological Knee (SToRK) Index. The validity of the index as a true measure of soft tissue envelope was assessed using cross sectional areas on axial MRI cuts at the level of the epicondyles. The inter-observer reliability was assessed using the intra-class correlation coefficient. SToRK Index values were correlated with patients' BMI, gender and operative time. RESULTS: The results show there is a close correlation between the ratio of cross sectional area of MRI axial cuts at the level of epicondyles and the ratio of linear widths measured on plain radiographs, validating the SToRK Index as a measure of soft tissue envelope. There was also good to excellent inter-rater reliability of measurements of these widths. There was a close correlation between BMI and SToRK Index with differences between men and women. DISCUSSION: We believe the SToRK Index is a validated method of quantifying soft tissue distribution around the knee and gives surgeons a better descriptor of the knee envelope than BMI. It is easy to use, needs simple investigations and is reproducible.

The Exeter Universal hip in patients 50 years or younger at 10-17 years' followup.

UNLABELLED: The Exeter Universal hip (Stryker Inc., Newbury, UK) has reported survival rates of 91.74% at 12 years in all patients with reoperation as an endpoint. However, its performance in younger patients has not been fully established. We reviewed survivorship and the clinical and radiographic outcomes of this hip system implanted in 107 patients (130 hips) 50 years old or younger at the time of surgery. The mean age at surgery was 42 years. The minimum followup was 10 years (mean, 12.5 years; range, 10-17 years) with no patients lost to followup. Twelve hips had been revised. Of these, nine had aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation and one joint underwent revision for infection. Radiographs demonstrated 14 (12.8%) of the remaining acetabular prostheses were loose but no femoral components were loose. Survivorship of both stem and cup from all causes was 92.6% at an average of 12.5 years. Survivorship of the stem from all causes was 99% and no stem was revised for aseptic loosening. The Exeter Universal stem performed well, even in the young, high-demand patient. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ponseti treatment in the management of clubfoot deformity - a continuing role for paediatric orthopaedic services in secondary care centres.

INTRODUCTION: The Ponseti technique is a well-proven way of managing paediatric clubfoot deformity. We describe a management set-up which spreads the care between secondary and tertiary care with no loss of quality. PATIENTS AND METHODS: In our audit of the first 2 years of Ponseti casting in the treatment of idiopathic congenital talipes equinovarus (CTEV, clubfoot) deformity, we identified 77 feet having been treated in 50 patients. Forty-nine feet were treated primarily in Oswestry, a tertiary referral centre for paediatric orthopaedic conditions, and 13 feet were treated in conjunction with the physiotherapy department at one of the region's district general hospitals (Leighton Hospital, Crewe, Cheshire). RESULTS: Similar good results and low requirement for surgical interventions other than Achilles tenotomy, which forms part of the Ponseti regimen, were found in both cohorts. CONCLUSIONS: This 'hub-and-spoke' approach would appear to be efficient in terms of resource utilisation. Additional benefits for patients and their carers include ease of access to services and reduced financial and transport burdens.