The SToICAL trial: study protocol for the soft tissue injection of corticosteroid and local anaesthetic trial-a single site, non-inferiority randomised control trial evaluating pain after soft tissue corticosteroid injections with and without local anaesthetic

BACKGROUND

Corticosteroid injections are used in the treatment of hand and wrist conditions. The co-administration of a local anaesthetic and corticosteroid aims to reduce pain after the injection, although no studies have directly compared this with using corticosteroid alone. The aim is to determine whether pain experienced during the 24 h after a corticosteroid injection to the hand and wrist is no worse than (not inferior to) the pain experienced after a corticosteroid and local anaesthetic injection.

METHODS

A single-site, patient- and assessor-blinded, non-inferiority randomised control trial recording pain visual analogue scale (VAS) scores in patients with a clinical diagnosis of trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome, treated with a 1-ml triamcinolone (40 mg/1 ml) injection co-administered with or without 1 ml of 1% lidocaine. The primary aim is to investigate a difference in pain VAS scores at 1 h after the injection using a mean change score. A 95% power calculation was made using a minimally clinical important difference of 20 mm as the clinically admissible margin of non-inferiority and an assumed standard deviation of 25 mm, from previous studies. Including a 20% fall out rate, 100 patients are required.

DISCUSSION

Patients with a clinical diagnosis of trigger finger, de Quervains and carpal tunnel syndrome, are over the age 18 years old and who are able to give written informed consent will be included. Patients will be excluded if they have had previous surgery or corticosteroid injection for the condition being treated at the site considered for injection. Patients will be electronically randomised and injections delivered during their clinic appointment. Pain is assessed using a 100-mm VAS score taken, before and at the time of injection and at 5 min, 1 h, 2 h, 3 h and 24 h after the injection. The secondary outcomes are to determine a difference in pain VAS score at the time of injection and during the 24 h after.

TRIAL REGISTRATION

This study is registered on the IRAS (259336) on November 11, 2019, and EudraCT database on October 31, 2019 (2019-003742-32). REC/HRA approval was given in January 2020, and Clinical Trial Authorisation from the MHRA was given in December 2019. The study is registered on ClinicalTrials.gov ( NCT04253457 ) on February 5, 2020.

Dorsally displaced fractures of the distal radius: a critical appraisal of the DRAFFT (distal radius acute fracture fixation trial) study

The results of the DRAFFT (distal radius acute fracture fixation trial) study, which compared volar plating with Kirschner (K-) wire fixation for dorsally displaced fractures of the distal radius, were published in August 2014. The use of K-wires to treat these fractures is now increasing, with a concomitant decline in the use of volar locking plates. We provide a critical appraisal of the DRAFFT study and question whether surgeons have been unduly influenced by its headline conclusions.

Does postoperative hand elevation reduce swelling? A randomized study

The purpose of this study was to assess the effect of limb elevation on hand swelling after surgery. We prospectively randomized 113 patients undergoing fasciectomy or a trapeziectomy into one of two groups. The first group had the hand elevated postoperatively and the hands of the second group were not elevated. Hand swelling was assessed using a volumetric method. Although the swelling was less in the elevated group this did not reach statistical significance. Subgroup analysis revealed no further significant differences. There were no complications in patients who did not have limb elevation. This study does not support the routine use of elevation for 24 hours after fasciectomy for Dupuytren's disease and trapeziectomy to reduce hand swelling.

The development of a model for in vitro testing of femoral stems in impaction bone grafting

Comprehension of the biomechanical behaviour of orthopaedic implants is essential. This paper describes the development of an in vitro model to investigate the behaviour of femoral implants in the revision setting.

The development of a femoral model and a bone graft substitute is described. The properties of human, bovine, ovine morselized bone graft, and a graft substitute were compared. On measuring hoop strain after impaction bone grafting there was no significant difference between the ovine bone graft and graft substitute with the size 1 Exeter stem. The results suggest that this bone graft substitute is a viable alternative for in vitro testing. The authors recommend the use of the graft substitute and the femoral model to predict femoral stem biomechanics.

An in-vitro investigation into the cement pressurization achieved during insertion of four different femoral stems

Adequate cement pressurization during stem insertion improves the interdigitation of cement into bone. This increases the strength of the cement-bone interface, thus contributing to the reduction of the incidence of aseptic loosening, the commonest cause of revision surgery. This in-vitro study compared the cement pressurization achieved during insertion of four different stems of equivalent sizes: the Elite Plus (DePuy, UK), C-Stem (DePuy, UK), Exeter (Stryker, USA), and CPS-Plus (Plus Orthopedics, Switzerland). The maximum pressures attained at the time of stem insertion were recorded at proximal, mid and distal stem levels. The Elite Plus generated significantly higher distal pressures than the other stems. The CPS-Plus generated significantly greater proximal cement pressures than the Elite Plus, C-Stem, and Exeter prostheses. The triple taper of the C-Stem increased the cement pressurization medial to the stem. The stem shape and the presence or absence of a proximal stem centralizer affect cement pressurization. The presence of a proximal stem centralizer, a large stem volume, and a lateral-medial taper are all factors associated with increased cement pressurization during stem insertion.

Hand elevation test for assessment of carpal tunnel syndrome

The Hand Elevation test is a new provocative test for the diagnosis of carpal tunnel syndrome. We have investigated the sensitivity and specificity of this test in 48 patients with a clinical diagnosis of carpal tunnel syndrome and compared it to Tinel's and Phalen's tests. The Hand Elevation test was found to be 88% sensitive and 98% specific. This test is a simple, reproducible provocative test which is easily employed in conjunction with other known tests to assist in the diagnosis of carpal tunnel syndrome.

Bacterial strike-through of re-usable surgical drapes: the effect of different wetting agents

Wound contamination and the resultant postoperative infection is a major problem in all forms of surgery. Air contamination, gloves, surgical instruments and drapes have all been investigated as sources of wound contamination. We investigated the effect of different wetting agents on strike-through rate of bacteria through re-usable polyester/cotton surgical drapes using a newly described method. Within 30 min bacterial strike-through of dry surgical drapes occurs. Wetting drapes with blood or normal saline enhances the strike-through rate of bacteria. Wetting drapes with iodine or chlorhexidine diminishes, but does not stop, bacterial strike-through. The use of re-usable polyester/cotton drapes is a potential source of wound contamination especially when wetted with blood or normal saline.

The effect of preparatory technique on the compressive properties of morsellised bone graft

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Factors affecting employment after whiplash injury

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.

Factors affecting employment after whiplash injury

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.