Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint

The sternoclavicular joint (SCJ) has a complete intra-articular disk that can be damaged either as a result of trauma or as part of ongoing degenerative joint disease. Although often asymptomatic, SCJ disk tears may lead to mechanical symptoms and pain. Previously, isolated symptomatic SCJ disk tears have only occasionally been mentioned in the literature with a few associated case reports of diskectomy by open arthrotomy. With improved imaging and availability of magnetic resonance imaging scans and the advent of SCJ arthroscopy it is now possible to treat symptomatic SCJ disk tears by arthroscopic excision. In this Technical Note, we describe the diagnosis of a torn SCJ disk and the technique of arthroscopic excision of a torn SCJ disk.

Tendinopathic supraspinatus tenocytes may have a neuroendocrine-like function, secreting CGRP, SP and VEGF: a pilot immunohistochemistry study

We wanted to observe and compare the appearance of neurovascular tissue from tendon ex vivo, in patients with and without painful rotator cuff tendinopathy. Supraspinatus tendons were biopsied from 5 participants with painful tendinopathy and normal tendon from a young male. Slides were stained with haematoxylin and eosin and toluidine blue for histological assessment. Immunohistochemical markers for general nerves (protein gene-product 9.5 and synaptophysin), sensory nerves (calcitonin gene-related peptide; substance-P) and vascularisation (vascular endothelial growth factor) were used. PGP9.5 and CGRP-immunoreactive fibres were associated with vessels in cases and control. Synaptophysinlabelled fibres were observed in close relation to vessels in tendinopathy. PGP9.5, CGRP, SP and VEGF-immunoreaction also labelled tenocyte-like cells in degenerative areas and fibres in regions of fat and collagen. Sensory innervation and vascularity are increased in tendinopathy. The evidence for innervation and vascularity of symptomatic rotator cuff tendon may aid the development of novel investigations and therapies in the management of patients with this ailment.

All patients deserve holistic care

Towards the end of my first year of training, I was on placement on a hospital ward when I heard the alarm bell go off in a bathroom.

In vivo biological response to extracorporeal shockwave therapy in human tendinopathy

Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment for chronic tendinopathies, however little is known about the in-vivo biological mechanisms of ESWT. Using microdialysis, we examined the real-time biological response of healthy and pathological tendons to ESWT. A single session of ESWT was administered to the mid-portion of the Achilles tendon in thirteen healthy individuals (aged 25.7 ± 7.0 years) and patellar or Achilles tendon of six patients with tendinopathies (aged 39.0 ± 14.9 years). Dialysate samples from the surrounding peri-tendon were collected before and immediately after ESWT. Interleukins (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, vascular endothelial growth factor and interferon-γ were quantified using a cytometric bead array while gelatinase activity (MMP-2 and -9) was examined using zymography. There were no statistical differences between the biological tissue response to ESWT in healthy and pathological tendons. IL-1β, IL-2, IL-6 and IL-8 were the cytokines predominantly detected in the tendon dialysate. IL-1β and IL-2 did not change significantly with ESWT. IL-6 and IL-8 concentrations were elevated immediately after ESWT and remained significantly elevated for four hours post-ESWT (p < 0.001). Pro-forms of MMP-2 and -9 also increased after ESWT (p < 0.003), whereas there were no significant changes in active MMP forms. In addition, the biological response to ESWT treatment could be differentiated between possible responders and non-responders based on a minimum 5-fold increase in any inflammatory marker or MMP from pre- to post-ESWT. Our findings provide novel evidence of the biological mechanisms underpinning ESWT in humans in vivo. They suggest that the mechanical stimulus provided by ESWT might aid tendon remodelling in tendinopathy by promoting the inflammatory and catabolic processes that are associated with removing damaged matrix constituents. The non-response of some individuals may help to explain why ESWT does not improve symptoms in all patients and provides a potential focus for future research.

Feasibility of the hydrogen sulfide test for the assessment of drinking water quality in post-earthquake Haiti

In 2010, a magnitude 7.0 earthquake struck Haiti, severely damaging the drinking and wastewater infrastructure and leaving millions homeless. Compounding this problem, the introduction of Vibrio cholerae resulted in a massive cholera outbreak that infected over 700,000 people and threatened the safety of Haiti's drinking water. To mitigate this public health crisis, non-government organizations installed thousands of wells to provide communities with safe drinking water. However, despite increased access, Haiti currently lacks the monitoring capacity to assure the microbial safety of any of its water resources. For these reasons, this study was designed to assess the feasibility of using a simple, low-cost method to detect indicators of fecal contamination of drinking water that could be implemented at the community level. Water samples from 358 sources of drinking water in the Léogâne flood basin were screened with a commercially available hydrogen sulfide test and a standard membrane method for the enumeration of thermotolerant coliforms. When compared with the gold standard method, the hydrogen sulfide test had a sensitivity of 65 % and a specificity of 93 %. While the sensitivity of the assay increased at higher fecal coliform concentrations, it never exceeded 88 %, even with fecal coliform concentrations greater than 100 colony-forming units per 100 ml. While its simplicity makes the hydrogen sulfide test attractive for assessing water quality in low-resource settings, the low sensitivity raises concerns about its use as the sole indicator of the presence or absence of fecal coliforms in individual or community water sources.

Musculoskeletal triage: a mixed methods study, integrating systematic review with expert and patient perspectives

BACKGROUND

Triage is implemented in healthcare settings to optimise access to appropriate care and manage waiting times.

OBJECTIVES

To determine the optimum features of triage systems for patients with musculoskeletal conditions.

DATA SOURCES

AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, MEDLINE, Cochrane Library, Web of Science and Google Scholar.

STUDY SELECTION OR ELIGIBILITY CRITERIA

Studies that included non-musculoskeletal conditions, concerned patients aged <18 years or were set in emergency departments were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was graded using the Downs and Black quality index. Qualitative methods were used to further inform the findings of the literature review.

RESULTS

Thirty-four studies met the inclusion criteria, with study quality ranging from eight to 24 out of a possible 27. Musculoskeletal triage is conducted via face-to-face consultation, paper referral letter or telephone consultation. Triage performed by physiotherapists, general practitioners, multidisciplinary teams, nurses, occupational therapists and speech therapists has been shown to be effective using a range of outcomes. Qualitative data revealed the value of supportive interdisciplinary teams, and suggested that this support is more important than choice of clinician. Patients trusted, and expressed preferences for, experienced clinicians to perform triage.

CONCLUSION

Triage can be performed effectively via a number of methods and by a range of clinicians. Satisfaction, cost, diagnostic agreement, appropriateness of referral and waiting list time have been improved though triage. Multidisciplinary support mechanisms are critical elements of successful triage systems. Patients are more concerned with access issues than professional boundaries.

Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review

BACKGROUND

Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services.

OBJECTIVES

This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence.

DATA SOURCES

PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013.

STUDY SELECTION/ELIGIBILITY CRITERIA

Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded.

RESULTS

Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists' clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction.

LIMITATIONS

These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services.

FUNDING

Part funded by EPSRC and AXA-PPP.

CONCLUSION

Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients.

General practitioners' attitude to sport and exercise medicine services: a questionnaire-based survey

AIM

Sport and exercise medicine (SEM) aims to manage sporting injuries and promote physical activity. This study explores general practitioners' (GPs) awareness, understanding and utilisation of their local SEM services.

DESIGN

A questionnaire survey, including patient case scenarios, was administered between February and May 2011.

PARTICIPANTS AND SETTING

693 GPs working in Cardiff and Vale, Leicester and Tower Hamlets were invited to participate.

RESULTS

244 GPs responded to the questionnaire (35.2% response rate). Less than half (46%; 112/244) were aware of their nearest SEM service and only 38% (92/244) had a clear understanding on referral indications. The majority (82%; 199/244) felt confident advising less active patients about exercise. There were divergent management opinions about the case scenarios of patients who were SEM referral candidates. Overall, GPs were significantly more likely to refer younger patients and patients with sport-related problems rather than patients who would benefit from increasing their activity levels in order to prevent or manage chronic conditions (p<0.01). GPs with previous SEM training were significantly more likely to refer (p<0.01). The majority (62%; 151/244) had never referred patients to their local SEM clinics but of those who had 75% (70/93) rated the service as good.

CONCLUSIONS

There is a lack of awareness and understanding among GPs on the role of SEM within the National Health Service which may be resulting in suboptimal utilisation especially for patients who could benefit from increasing their activity levels.

High-volume image-guided injection for recalcitrant medial collateral ligament injuries of the knee

AIM

To evaluate the effectiveness of a novel injection technique in the management of recalcitrant medial collateral ligament (MCL) injuries of the knee.

MATERIALS AND METHODS

The injection, comprising 10 ml local anaesthetic with 25-50 mg hydrocortisone, is directed beneath the periosteal attachment of the MCL. Twenty-eight patients who received the intervention were asked to complete a questionnaire, a visual analogue scale (VAS) and the International Knee Documentation Committee (IKDC) subjective knee form to quantify symptoms pre-injection and at follow-up. Data were assessed using descriptive statistics. Further analysis was conducted using the Wilcoxon signed-rank test and Fisher's exact test.

RESULTS

Sixty-eight percent (n = 19) of patients responded. Three patients were excluded according to the exclusion criteria. Of those studied, 37.5% (n = 6) were professional athletes. At follow-up, patients reported a mean improvement on the VAS of 75.5% (SD = 23.6). There was a significant improvement in IKDC scores (mean difference 42%, SD = 14.2) pre- and post-injection (Wilcoxon signed-rank test, p < 0.001). No residual symptoms were reported by 50% (n = 8) of patients, and a further 37.5% (n = 6) of patients had improved. Of those patients who played sport, two-thirds (n = 10) had returned to their previous level of sport at follow-up, including all of the professional athletes.

CONCLUSION

Periosteal high-volume image-guided injection is a useful treatment for recalcitrant MCL injury. Results are encouraging, particularly amongst the professional athletes studied.

Whole-body scanning PCR; a highly sensitive method to study the biodistribution of mRNAs, noncoding RNAs and therapeutic oligonucleotides

Efficient tissue-specific delivery is a crucial factor in the successful development of therapeutic oligonucleotides. Screening for novel delivery methods with unique tissue-homing properties requires a rapid, sensitive, flexible and unbiased technique able to visualize the in vivo biodistribution of these oligonucleotides. Here, we present whole body scanning PCR, a platform that relies on the local extraction of tissues from a mouse whole body section followed by the conversion of target-specific qPCR signals into an image. This platform was designed to be compatible with a novel RT-qPCR assay for the detection of siRNAs and with an assay suitable for the detection of heavily chemically modified oligonucleotides, which we termed Chemical-Ligation qPCR (CL-qPCR). In addition to this, the platform can also be used to investigate the global expression of endogenous mRNAs and non-coding RNAs. Incorporation of other detection systems, such as aptamers, could even further expand the use of this technology.

Doppler ultrasound signal in Achilles tendinopathy reduces immediately after activity

BACKGROUND

A relationship has been identified between vascularization on Doppler ultrasound (Doppler signal) and Achilles tendon pain. Doppler signal may increase minutes after prolonged activity, but the immediate effect is unknown. The aim of the study was to investigate the immediate effect of short term activity on Achilles tendon Doppler signal. Achilles tendinopathy patients (7 patients, 10 tendons) and asymptomatic controls (6 controls, 12 tendons) performed 2 activity tasks; a 2 minute continuous step task and one minute continuous calf raise task. Doppler signal was measured at rest and within a minute after each activity. The presence of Doppler signal was quantified using both semi quantitative (modified Ohberg scale; 0=no signal, 5 = > 90% of pathological area contains Doppler signal) and quantitative methods (pixel number). Doppler signal was present in 90% of symptomatic individuals and in none of the asymptomatic controls. The modified Ohberg scale and pixel number reduced significantly after both activity tasks and heart rate increased significantly (p < 0.05). Doppler signal in Achilles tendinopathy may decrease immediately after activities that load the calf muscle and increase heart rate, suggesting that this activity should be avoided prior to imaging to avoid false negative results.