Foam roller-based self-induced myofascial therapy in patients with hemophilic knee arthropathy: a multicenter, single-blind, randomized clinical study

BACKGROUND

Hemophilia is a congenital coagulopathy characterized by degenerative joint damage. Self-induced myofascial therapy aims to decrease pain and improve tissue mobility, functionality and proprioception.

AIM

The aim of this study was to evaluate the safety and efficacy of self-induced myofascial release in patients with hemophilic knee arthropathy.

DESIGN

This is a randomized clinical study.

SETTING

This study was carried out in different patient associations.

POPULATION

Fifty-two patients with hemophilia were included in the study.

METHODS

Patients were randomized to the experimental group (daily home protocol of foam roller-based self-induced myofascial therapy for 8 weeks) or the control group (no intervention). The variables were the frequency of hemarthrosis (self-reporting), pain intensity (visual analog scale), range of motion (goniometry) and muscle strength (dynamometry). All variables were evaluated at baseline, post-treatment and after a 10-week follow-up.

RESULTS

The patients included in the experimental group showed significant improvements in terms of a decrease in frequency of hemarthrosis (mean difference [MD]=-0.61; 95% confidence interval [CI]: -0.81; -0.41) and pain intensity (MD=-0.33; 95% CI: -0.48, -0.18), increased range of motion (MD=0.88; 95% CI: 0.39; 1.37), strength in quadriceps (MD=0.88; 95% CI: 0.39; 1.37). (MD=12.39; 95% CI: 3.44; 21.34) and hamstrings (MD=7.85; 95% CI: 0.60; 15.11). There were intergroup differences in the frequency of hemarthrosis (F=14.51; P<0.001), pain intensity (F=9.14; P<0.001) and range of motion (F=13.58; P<0.001).

CONCLUSIONS

Self-induced myofascial therapy can be an effective complementary technique in the treatment of patients with hemophilic arthropathy. Self-induced myofascial therapy can reduce the frequency of knee hemarthrosis in patients with hemophilia. This technique can improve pain intensity and range of motion in patients with hemophilic knee arthropathy.

CLINICAL REHABILITATION IMPACT

Hemophilic knee arthropathy is characterized by chronic pain, decreased range of motion, and periarticular muscle atrophy. Foam roller-based self-induced myofascial therapy can reduce the frequency of hemarthrosis and pain intensity and improve range of motion in patients with hemophilic arthropathy. Foam roller-based self-induced myofascial therapy is safe and effective in the treatment of patients with hemophilia. The inclusion of self-induced myofascial therapy exercises in the approach to degenerative joint pathologies may be an effective and safe treatment option.

Risk Factors for Symptomatic Cyclops Lesion Formation after Anterior Cruciate Ligament Reconstruction

Objective  To evaluate the incidence of symptomatic cyclops lesions requiring surgical treatment after anterior cruciate ligament (ACL) reconstruction and to establish possible intraoperative risk factors related to it. Methods  Three hundred and eighty-nine patients aged between 18 and 50 years who underwent primary ACL reconstruction were retrospectively evaluated. Patients were divided into groups according to the presence or absence of symptomatic cyclops lesions, and their characteristics were compared. Patients with associated lesions that required additional surgical procedures (except anterolateral extra-articular procedures) were not included. The rate of symptomatic cyclops lesions was recorded and the following parameters were evaluated: age, gender, time from injury to surgery, graft type and diameter, femoral tunnel perforation technique, fixation type, presence of knee hyperextension, preservation of the ACL remnant, associated anterolateral extra-articular procedure, associated meniscal injury and participation in sports. Results  389 patients were evaluated and 26 (6.7%) patients developed cyclops. The patients with and without cyclops lesions did not differ in age, time from injury to surgery, graft type or diameter, surgical technique, femoral fixation method, presence of knee hyperextension, remnant preservation and associated meniscal injury. The group with cyclops lesion had a higher proportion of females (10 (38.4%) vs 68 (18.7%); OR = 2.7; p  = 0.015), higher proportion of extra-articular reconstruction (18 (11.8%) vs 8 (3.4%); OR = 3.8; p  = 0.001) and higher proportion of sports practice (23 (8.6%) vs 3 (2.5%); OR = 3.6; p  = 0.026). Conclusion  In our series, 6.7% of the patients required arthroscopic removal of cyclops lesions. Female gender, associated extra-articular reconstruction and sports practice were factors related to this lesion. Remnant preservation had no relationship with cyclops lesion formation.

Comparative Analysis of Mandibular and Cervical Mobility in Young Adults with Temporomandibular Joint Disorders: A Case-Control Study

BACKGROUND Temporomandibular joint disorders (TMJD) affect the muscles of the mandible or the temporomandibular joint (TMJ). The objective of this case-control study was to compare mandibular and cervical joint mobility in young adults diagnosed with TMJD to a healthy control group. MATERIAL AND METHODS We enrolled 60 participants aged 18-30 years, split evenly between 30 TMJD patients and 30 healthy controls. We employed a millimeter gauge to measure TMJ mobility and a tape-based tool for assessing the range of cervical mobility. RESULTS Our data revealed that TMJD patients exhibited a significantly reduced range of mobility in both the TMJ and cervical spine compared to controls. Controls demonstrated a greater mean cervical mobility through left and right lateral flexion movements (P<0.01 and P<0.05 respectively), as well as right and left rotations (P<0.05). Additionally, they showed significantly higher mandibular mobility across all tested parameters (P<0.001). Within the TMJD group, we observed a significant correlation between cervical and mandibular mobility (P<0.05). CONCLUSIONS Our findings underline that TMJD patients possess significantly diminished mandibular and cervical mobility, particularly in lateral movements and rotations, compared to those without the disorder. The observed correlation between cervical and mandibular mobility in the TMJD group implies the necessity to consider these interconnected aspects when designing rehabilitation programs, thereby enhancing patient quality of life and impeding further mobility deterioration.

Immediate Effects of Ankle Mobilization on Range of Motion, Balance, and Muscle Activity in Elderly Individuals with Chronic Ankle Instability: A Pre-Post Intervention Study

BACKGROUND This study aimed to identify the immediate effect of applying ankle mobilization to the elderly with chronic ankle instability on the range of joint motion, balance, and lower extremity muscle activity. MATERIAL AND METHODS This study, the Cumberland Ankle Instability Tool (CAIT) was used to evaluate chronic ankle instability, and as a result, 65-year-olds with a score of 24 or less were conducted. In this study, the grade III of Maitland mobilization was used to increase the range of joint motion in older people with chronic ankle instability. And four joint mobilizations were administered for a total of 40 minutes, 10 minutes per run. In the pre-examination, the range of motion of ankle joints, balance, and lower extremity muscle activity in the Limit of Stability (LOS) position prior to ankle mobilization. The reexamination was taken a right after the intervention to see the immediate effect of applying joint mobilization. This study was conducted after receiving the approval of the Institutional Review Board of the Korea National University of Transportation. RESULTS The study results show that, as a result of applying the ankle mobilization intervention, the range of dorsi flexor and plantar flexor motion increased, resulting in the improvement of balance and an immediate effect on the lower extremity muscle activity when measuring the Limit of Stability. CONCLUSIONS The conclusion of this study is ankle mobilization may be a useful intervention method in preventing falls and improving balance in older adults with chronic ankle instability.

Effectiveness of bee venom acupuncture for patients suffering from periarthritis humeroscapularis

OBJECTIVE

To evaluate the efficacy of bee venom acupuncture in humeroscapularis (PHS) patients.

METHODS

One hundred and twenty patients diagnosed with PHS were assigned into four groups: BV1 (0.01 mg/kg), BV2 (0.005 mg/kg), BV3 (0.0025 mg/kg), and control group (vitamin B1 plus novocain 3% injection) with 15 d of treatment. The outcomes of the study including visual analogue scale (VAS) score and β-endorphin, inflammatory cytokines including interleukin-10 (IL-10), IL-1β and tumor necrosis factor α (TNF-α) and shoulder function score were assessed at baseline, after 10 and 15 d of treatment.

RESULTS

All four groups reported statistically significant improvement in VAS score, motion range, and shoulder function score ( < 0.01), only the BV3 group showed significant increase of anti-inflammatory (IL-10) and decrease of pro-inflammatory (IL-1β, TNF-α) cytokines after treatment ( < 0.05). The BV3 group presented a significant difference between all outcomes compared to the control and other groups.

CONCLUSION

BV3 groups showed better recovery including reduced pain, improved motor function and normalized inflammatory cytokines than current therapy used in Vietnam and other groups.

Correlations Between Hip Extension Range of Motion, Hip Extension Asymmetry, and Compensatory Lumbar Movement in Patients with Nonspecific Chronic Low Back Pain

BACKGROUND This study aimed to confirm the correlations among hip extension range of motion, hip extension asymmetry, pain intensity, disability index, and compensatory lumbar movement in patients with nonspecific chronic low back pain. MATERIAL AND METHODS Of 66 patients with nonspecific chronic low back pain and limited hip extension, 59 met the inclusion criteria and were enrolled in the study. Pain intensity, Oswestry Disability Index (ODI), hip range of motion, compensatory lumbar extension, and compensatory lumbar rotation of the subjects were assessed. Pain was measured using a numeric pain rating scale (NPRS), and hip extension range of motion and compensatory lumbar movement were evaluated using a digital dual inclinometer (Dualar IQ, JTech Medical, United States). Correlation analysis was used to analyze the data. RESULTS A strong correlation was observed among hip extension asymmetry, pain intensity, and disability index (P<0.05). However, no correlation was observed among compensatory lumbar rotation and extension, pain intensity, and ODI. A strong correlation also was observed between limited hip extension range of motion and compensatory lumbar rotation (P<0.05) but not between limited hip extension range of motion and compensatory lumbar extension (P>0.05). CONCLUSIONS The results of this study showed that hip extension asymmetry might be a more critical factor than hip extension range of motion. The strong correlation between limited hip extension and compensatory lumbar rotation suggests a risk of micro-trauma due to compensatory lumbar rotation.

Reliability and concurrent validity of a new iPhone® goniometric application for measuring active wrist range of motion: a cross-sectional study in asymptomatic subjects

Measurement of wrist range of motion (ROM) is often considered to be an essential component of wrist physical examination. The measurement can be carried out through various instruments such as goniometers and inclinometers. Recent smartphones have been equipped with accelerometers and magnetometers, which, through specific software applications (apps) can be used for goniometric functions. This study, for the first time, aimed to evaluate the reliability and concurrent validity of a new smartphone goniometric app (Goniometer Pro©) for measuring active wrist ROM. In all, 120 wrists of 70 asymptomatic adults (38 men and 32 women; aged 18-40 years) were assessed in a physiotherapy clinic located at the School of Rehabilitation Sciences, Iran University of Medical Science and Health Services, Tehran, Iran. Following the recruitment process, active wrist ROM was measured using a universal goniometer and iPhone® 5 app. Two blinded examiners each utilized the universal goniometer and iPhone® to measure active wrist ROM using a volar/dorsal alignment technique in the following sequences: flexion, extension, radial deviation, and ulnar deviation. The second (2 h later) and third (48 h later) sessions were carried out in the same manner as the first session. All the measurements were conducted three times and the mean value of three repetitions for each measurement was used for analysis. Intraclass correlation coefficient (ICC) models (3, k) and (2, k) were used to determine the intra-rater and inter-rater reliability, respectively. The Pearson correlation coefficients were used to establish concurrent validity of the iPhone® app. Good to excellent intra-rater and inter-rater reliability was demonstrated for the goniometer with ICC values of ≥ 0.82 and ≥ 0.73 and the iPhone® app with ICC values of ≥ 0.83 and ≥ 0.79, respectively. Minimum detectable change at the 95% confidence level (MDC95 ) was computed as 1.96 × standard error of measurement × √2. The MDC95 ranged from 1.66° to 5.35° for the intra-rater analysis and from 1.97° to 6.15° for the inter-rater analysis. The concurrent validity between the two instruments was high, with r values of ≥ 0.80. From the results of this cross-sectional study, it can be concluded that the iPhone® app possesses good to excellent intra-rater and inter-rater reliability and concurrent validity. It seems that this app can be used for the measurement of wrist ROM. However, further research is needed to evaluate symptomatic subjects using this app.

Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) tears are frequently treated with surgical reconstruction with grafts, frequently patella tendon or hamstrings. Interference screws are often used to secure the graft in bone tunnels in the femur and tibia. This review examines whether bioabsorbable interference screws give better results than metal interference screws when used for graft fixation in ACL reconstruction.

OBJECTIVES

To assess the effects (benefits and harms) of bioabsorbable versus metallic interference screws for graft fixation in ACL reconstruction.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, LILACS, trial registers and reference lists of articles. Date of search: January 2016.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised trials comparing bioabsorbable with metallic interferences screws in ACL reconstruction. The main outcomes sought were subjective-rated knee function, failure of treatment, and activity level.

DATA COLLECTION AND ANALYSIS

At least two review authors selected eligible trials, independently assessed risk of bias, and cross-checked data. Data were pooled whenever relevant and possible. Requests for further information were sent to the original study authors.

MAIN RESULTS

We included 12 trials (11 randomised and one quasi-randomised) involving a total of 944 participants, and reporting follow-up results for 774. Participants in the 12 trials underwent ACL reconstruction with either hamstring tendon grafts (five trials) or patellar tendon grafts (seven trials). Trials participants were randomly allocated to bioabsorbable or metallic interference screws for graft fixation in both femur and tibia (seven trials); femur only (three trials); tibia only (one trial); location was not reported in the remaining trial. A variety of materials was used for the bioabsorbable screws, Poly-L-lactic acid (PLLA) being the most common. The metallic screws, where reported, were titanium.All trials were at high risk of bias, which invariably included performance bias. Seven trials were at high risk of attrition bias and eight at high risk of reporting bias. The quasi-randomised trial was assessed as being at high risk for selection bias. Based on these study limitations and insufficiency of the available data, we judged the quality of evidence for all outcomes was very low.The majority of the available data for patient-reported knee function was presented as Lysholm scores (0 to 100; higher scores = better function). There was very low quality but consistent evidence of no clinically important differences between the two groups in Lysholm scores at 12 months follow-up (mean difference (MD) -0.08, 95% confidence interval (CI) -1.48 to 1.32; three trials, 168 participants); 24 months (MD 0.35, 95% CI -1.27 to 1.98; three trials, 113 participants) or five or more years follow-up (MD 1.23, 95% CI -2.00 to 4.47; two trials, 71 participants). This lack of between-group differences was also reported for Lysholm scores in several trials that did not provide sufficient data for pooling as well as for other self-reported knee function scores reported in several trials.Treatment failure was represented by the summed data for implant breakage during surgery and major postoperative complications (implant failure, graft rupture, symptomatic foreign body reactions, effusion and treated arthrofibrosis and related conditions) that were usually described in the trial reports as requiring further substantive treatment. There is very low-quality evidence of greater treatment failure in the bioabsorbable screw group (60/451 versus 29/434; risk ratio (RR) 1.94 favouring metallic screw fixation, 95% CI 1.29 to 2.93; 885 participants, 11 studies). In a population with an assumed risk (based on the median control group risk) of 56 participants per 1000 having treatment failure after metallic screw fixation, this equates to 53 more (95% CI 17 to 108 more) per 1000 participants having treatment failure after bioabsorbable screw fixation. All 16 intraoperative complications in the bioabsorbable screw group were implant breakages upon screw insertion. Treatment failure defined as postoperative complications only still favoured the metallic screw group but the 95% CI also included the potential for a greater risk of treatment failure after metallic screw fixation: 44/451 versus 29/434; RR 1.44, 95% CI 0.93 to 2.23. Based on the assumed risk of 56 participants per 1000 having postoperative treatment failure after metallic screw fixation, this equates to 25 more (95% CI 4 fewer and 69 more) per 1000 participants having this outcome after bioabsorbable screw fixation.There was very low-quality evidence of very similar activity levels in the two groups at 12 and 24 months follow-up measured via the Tegner score (0 to 10; higher scores = greater activity): 12 months (MD 0.08, 95% CI -0.39 to 0.55; 122 participants, two studies); 24 months (MD 0.01, 95% CI -0.54 to 0.57; 72 participants, two studies).

AUTHORS' CONCLUSIONS

There is very low-quality evidence of no difference in self-reported knee function and levels of activity between bioabsorbable and metallic interference screws for graft fixation in ACL reconstruction. There is very low-quality evidence that bioabsorbable screws may be associated with more overall treatment failures, including implant breakage during surgery. Further research does not appear to be a priority, but if undertaken, should also examine costs.

Short duration and low suction pressure drain versus no drain following total knee replacement

PURPOSE

To compare the short-term outcome in patients with or without a drain (short duration and low suction pressure) following total knee replacement (TKR).

METHODS

A consecutive series of 106 women and 48 men (mean age, 69 years) underwent unilateral TKR. The first 77 patients used a low suction pressure (200 mm Hg) drain following TKR for 24 hours, and the next 77 patients used no drain.

RESULTS

The 2 groups were comparable in terms of preoperative characteristics, the proportion of patients with pharmacological prophylaxis for deep vein thrombosis, the tourniquet time, and mode of anaesthesia. The mean drain output in the drain group was 221 ml. The time to achieve straight-leg-raising was earlier in the drain group (3.1 vs. 4.2 days, p<0.001).

CONCLUSION

The use of a short duration, low suction pressure drain following TKR enabled an earlier return of quadriceps power, without increasing haemoglobin drop and transfusion rate.

Chronic Periodontitis Is Associated With Spinal Dysmobility in Patients With Ankylosing Spondylitis

BACKGROUND

Although microbes have been suggested to play a role in the pathogenesis of ankylosing spondylitis (AS), several studies present contradictory results regarding the association between AS and chronic periodontitis (CP).

METHODS

Clinical, laboratory, and medication data were collected from 84 patients with AS and 84 age- and sex-matched controls. Periodontal measurements, including probing depths (PDs), clinical attachment loss (AL), serum anti-Porphyromonas gingivalis titers, and the detection of P. gingivalis DNA in gingival crevicular fluid, were recorded. All participants with periodontitis with PD ≥4 to <7 mm received scaling and root planing and were re-evaluated at 12 weeks; those still exhibiting periodontitis with PD of ≥4 to <7 mm at 12 weeks were followed at 24 weeks.

RESULTS

The prevalence of moderate-to-severe CP was not different between patients with AS and controls (70.2% versus 66.6%). The P. gingivalis detection rate was not different between patients with AS and controls or between patients with AS receiving and not receiving anti-tumor necrosis factor (TNF)-α agents. However, CP was positively associated with impaired spinal mobility of patients with AS in multivariate analyses. After periodontal treatment, PD and AL levels were improved in both groups, but the change was significantly greater in patients with AS than in controls. Patients with AS receiving anti-TNF-α agents exhibited a greater improvement in PD and AL than those who did not.

CONCLUSIONS

Although AS was not associated with the presence of CP, CP was associated positively with the severity of spinal dysmobility in Korean patients with AS. These results suggest that periodontitis can have a negative effect on axial movement in AS.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Mobile bearing vs fixed bearing prostheses for posterior cruciate retaining total knee arthroplasty for postoperative functional status in patients with osteoarthritis and rheumatoid arthritis

BACKGROUND

It is unclear whether there are differences in benefits and harms between mobile and fixed prostheses for total knee arthroplasty (TKA). The previous Cochrane review published in 2004 included two articles. Many more trials have been performed since then; therefore an update is needed.

OBJECTIVES

To assess the benefits and harms of mobile bearing compared with fixed bearing cruciate retaining total knee arthroplasty for functional and clinical outcomes in patients with osteoarthritis (OA) or rheumatoid arthritis (RA).

SEARCH METHODS

We searched The Cochrane Library, PubMed, EMBASE, CINAHL and Web of Science up to 27 February 2014, and the trial registers ClinicalTrials.gov, Multiregister, Current Controlled Trials and the World Health Organization (WHO) International Clinical Trials Registry Platform for data from unpublished trials, up to 11 February 2014. We also screened the reference lists of selected articles.

SELECTION CRITERIA

We selected randomised controlled trials comparing mobile bearing with fixed bearing prostheses in cruciate retaining TKA among patients with osteoarthritis or rheumatoid arthritis, using functional or clinical outcome measures and follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

We found 19 studies with 1641 participants (1616 with OA (98.5%) and 25 with RA (1.5%)) and 2247 knees. Seventeen new studies were included in this update.Quality of the evidence ranged from moderate (knee pain) to low (other outcomes). Most studies had unclear risk of bias for allocation concealment, blinding of participants and personnel, blinding of outcome assessment and selective reporting, and high risk of bias for incomplete outcome data and other bias. Knee painWe calculated the standardised mean difference (SMD) for pain, using the Knee Society Score (KSS) and visual analogue scale (VAS) in 11 studies (58%) and 1531 knees (68%). No statistically significant differences between groups were reported (SMD 0.09, 95% confidence interval (CI) -0.03 to 0.22, P value 0.15). This represents an absolute risk difference of 2.4% points higher (95% CI 0.8% lower to 5.9% higher) on the KSS pain scale and a relative percent change of 0.22% (95% CI 0.07% lower to 0.53% higher). The results were homogeneous. Clinical and functional scores The KSS clinical score did not differ statistically significantly between groups (14 studies (74%) and 1845 knees (82%)) with a mean difference (MD) of -1.06 points (95% CI -2.87 to 0.74, P value 0.25) and heterogeneous results. KSS function was reported in 14 studies (74%) with 1845 knees (82%) as an MD of -0.10 point (95% CI -1.93 to 1.73, P value 0.91) and homogeneous results. In two studies (11%), the KSS total score was favourable for mobile bearing (159 vs 132 for fixed bearing), with MD of -26.52 points (95% CI -45.03 to -8.01, P value 0.005), but with a wide 95% confidence interval indicating uncertainty about the estimate.Other reported scoring systems did not show statistically significant differences: Hospital for Special Surgery (HSS) score (seven studies (37%) in 1021 knees (45%)) with an MD of -1.36 (95% CI -4.18 to 1.46, P value 0.35); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (two studies (11%), 167 knees (7%)) with an MD of -4.46 (95% CI -16.26 to 7.34, P value 0.46); and Oxford total (five studies (26%), 647 knees (29%) with an MD of -0.25 (95% CI -1.41 to 0.91, P value 0.67). Health-related quality of lifeThree studies (16%) with 498 knees (22%) reported on health-related quality of life, and no statistically significant differences were noted between the mobile bearing and fixed bearing groups. The Short Form (SF)-12 Physical Component Summary had an MD of -1.96 (95% CI -4.55 to 0.63, P value 0.14) and heterogeneous results. Revision surgeryTwenty seven revisions (1.3%) were performed in 17 studies (89%) with 2065 knees (92%). In all, 13 knees were revised in the fixed bearing group and 14 knees in the mobile bearing group. No statistically significant differences were found (risk difference 0.00, 95% CI -0.01 to 0.01, P value 0.58), and homogeneous results were reported. MortalityIn seven out of 19 studies, 13 participants (37%) died. Two of these participants had undergone bilateral surgery, and for seven participants, it was unclear which prosthesis they had received; therefore they were excluded from the analyses. Thus our analysis included four out of 191 participants (2.1%) who had died: one in the fixed bearing group and three in the mobile bearing group. No statistically significant differences were found. The risk difference was -0.02 (95% CI -0.06 to 0.03, P value 0.49) and results were homogeneous. Reoperation ratesThirty reoperations were performed in 17 studies (89%) with 2065 knees (92%): 18 knees in the fixed bearing group (of the 1031 knees) and 12 knees in the mobile group (of the 1034 knees). No statistically significant differences were found. The risk difference was -0.01 (95% CI -0.01 to 0.01, P value 0.99) with homogeneous results. Other serious adverse eventsSixteen studies (84%) reported nine other serious adverse events in 1735 knees (77%): four in the fixed bearing group (of the 862 knees) and five in the mobile bearing group (of the 873 knees). No statistically significant differences were found (risk difference 0.00, 95% CI -0.01 to 0.01, P value 0.88), and results were homogeneous.

AUTHORS' CONCLUSIONS

Moderate- to low-quality evidence suggests that mobile bearing prostheses may have similar effects on knee pain, clinical and functional scores, health-related quality of life, revision surgery, mortality, reoperation rate and other serious adverse events compared with fixed bearing prostheses in posterior cruciate retaining TKA. Therefore we cannot draw firm conclusions. Most (98.5%) participants had OA, so the findings primarily reflect results reported in participants with OA. Future studies should report in greater detail outcomes such as those presented in this systematic review, with sufficient follow-up time to allow gathering of high-quality evidence and to inform clinical practice. Large registry-based studies may have added value, but they are subject to treatment-by-indication bias. Therefore, this systematic review of RCTs can be viewed as the best available evidence.

Outcome of fixation for nonunion of extremities

PURPOSE

To review the outcomes of 102 consecutive patients who underwent fixation for nonunion of extremities.

METHODS

Medical records of 71 men and 31 women aged 16 to 82 (mean, 45; standard deviation [SD], 19) years who underwent fixation for nonunion of the upper (n=31) and lower (n=71) extremities were reviewed. The nonunion types included oligotrophic (n=47), hypertrophic (n=22), atrophic (n=17), defect (n=12), and comminuted (n=4). 13 of the nonunions were infected. 10 patients had concomitant injuries of the brain (n=2), abdomen (n=5), chest (n=1), and spine (n=2). 43 patients were smokers, and 19 had diabetes mellitus. 80 patients had had previous surgery, and 3 had undergone previous radiotherapy. The mean time from injury to nonunion surgery was 19 (SD, 25.6; range, 6-180) months. Outcome measures included bone union, ability to return to original work, pain, gait, and loss of range of motion.

RESULTS

The mean follow-up period was 26.6 (SD, 19.9; range, 8-121) months. 100 patients achieved bone union. 83 of them achieved bone union after a single surgery in a mean of 5.6 (SD, 2.9) months. The remaining 17 patients underwent multiple surgeries, 13 of whom had infected nonunions. Two patients did not achieve bone union. Of 64 patients who had work, 47 returned to their original work and 17 did not. Outcome was unsatisfactory in 5 patients who had persistent pain and/or no improvement in gait.

CONCLUSION

Bone union is not necessarily associated with adequate recovery of function.

Femoral and tibial tunnel positioning on graft isometry in anterior cruciate ligament reconstruction: a cadaveric study

PURPOSE

To assess distance changes between the femoral and tibial attachment points of 3 different anterior cruciate ligament (ACL) tunnel entry positions throughout the range of knee motion in cadaveric knees.

METHODS

The ACLs of 11 fresh-frozen cadaveric knees (from 6 men and 5 women) were removed using radiofrequency. Three tibial tunnel placements were made using a cannulated awl, and three 2.4-mm pilot tunnels were drilled on the lateral femoral condyle. One end of an inelastic suture was inserted from each of the 3 femoral holes and fixed on the femoral cortex using a suture button in turn, whereas the other end of the suture was passed through the cannulated awl and fixed on each of the 3 tibial placements in turn, with constant tension. Distance changes of the suture throughout the range of knee movement (0º, 90º, and 135º of knee flexion) were measured for each combination of tibial and femoral positions.

RESULTS

The distance was minimum when the knee was in full extension (p < 0.0001). Most of the distance changes occurred during initial flexion (0º-90º). The most isometric position (mean ± standard deviation [SD] distance change, 2.78 ± 0.93 mm; p < 0.0001) was noted when the suture was at the anteromedial bundle placement in the femur and anterior in the tibia. The least isometric position (mean ± SD distance change, 10.37 ± 2.08 mm; p < 0.0001) was noted when the suture was at the mid-bundle position in the femur and at the posterolateral bundle insertion in the tibia. The anatomic position resulted in a mean ± SD distance change of 7.63 ± 2.01 mm (p < 0.0001). The femoral position had a greater influence on distance change than the tibial position.

CONCLUSION

None of the ACL graft positions was isometric. Anatomic ACL positioning resulted in comparable anisometry to the native ACL. The minimum distance for all graft positions was noted in full extension, in which position the graft should be fixed during anatomic ACL reconstruction.

Passive movements for the treatment and prevention of contractures

BACKGROUND

Contractures, a common complication following immobility, lead to restricted joint range of motion. Passive movements (PMs) are widely used for the treatment and prevention of contractures; however, it is not clear whether they are effective.

OBJECTIVES

The aim of this review was to determine the effects of PMs on persons with contractures or at risk of developing contractures. Specifically, the aim was to determine whether PMs increase joint mobility.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), EMBASE (Ovid SP), ISI Web of Science (SCI-EXPANDED; SSCI; CPCI-S; CPCI-SSH), PEDro and PsycINFO (Ovid SP). The search was run on 21 November 2013.

SELECTION CRITERIA

Randomised controlled trials of PMs administered for the treatment or prevention of contractures were included. Studies were included if they compared the effectiveness of PMs versus no intervention, sham intervention or placebo in people with or at risk of contracture. Studies that involved other co-interventions were included, provided the co-interventions were administered in the same way to all groups. Interventions administered through mechanical devices and interventions that involved sustained stretch were excluded.

DATA COLLECTION AND ANALYSIS

Three independent review authors screened studies for inclusion. Two review authors then extracted data and assessed risk of bias. Primary outcomes were joint mobility and occurrence of adverse events such as joint subluxations or dislocations, heterotopic ossification, autonomic dysreflexia and fractures or muscle tears. Secondary outcomes were quality of life, pain, spasticity, activity limitations and participation restrictions. We used standard methodological procedures as advocated by the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Two identified studies randomly assigned a total of 122 participants with neurological conditions comparing PMs versus no PMs. Data from 121 participants were available for analysis. Both studies had a low risk of bias. One within-participant study involving 20 participants (40 limbs) measured ankle joint mobility and reported a mean between-group difference of four degrees (95% confidence interval (CI), two to six degrees) favouring the experimental group. Both studies measured spasticity with the Modified Ashworth Scale, but the results were not pooled because of clinical heterogeneity. Neither study reported a clinically or statistically relevant reduction in spasticity with PMs. In one study, the mean difference on a tallied 48-point Modified Ashworth Scale for the upper limbs was one of 48 points (95% CI minus two to four points), and in the other study, the median difference on a six-point Modified Ashworth Scale for the ankle plantar flexor muscles was zero points (95% CI minus one to zero points). In both studies, a negative between-group difference indicated a reduction in spasticity in the experimental group compared with the control group. One study with a total of 102 participants investigated the short-term effects on pain. The mean difference on a zero to 24-point pain scale was -0.4 points in favour of the control group (95% CI -1.4 to 0.6 points). The GRADE level of evidence about the effects of PMs on joint mobility, spasticity and pain is very low. Neither study examined quality of life, activity limitations or participation restrictions or reported any adverse events.

AUTHORS' CONCLUSIONS

It is not clear whether PMs are effective for the treatment and prevention of contractures.

Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis

BACKGROUND

The functional and clinical basis on which to choose whether or not to retain the posterior cruciate ligament during total knee arthroplasty surgery remained unclear after a Cochrane systematic review and meta-analysis in 2005, which contained eight clinical trials. Several new trials have been conducted since then. Hence, an update of the review was performed.

OBJECTIVES

Our aim was to assess the benefits and harms of retention compared to sacrifice of the posterior cruciate ligament in total knee arthroplasty in patients with osteoarthritis of the knee.

SEARCH METHODS

An extensive search was conducted in CENTRAL, MEDLINE (PubMed), EMBASE, Web of Science, CINAHL, Academic Search Premier, Current Contents Connect and Science Direct. All databases were searched, without any limitations, up to 6 December 2012. References of the articles were checked and citation tracking was performed.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing retention with sacrifice of the posterior cruciate ligament in primary total knee arthroplasty in patients with osteoarthritis of the knee.

DATA COLLECTION AND ANALYSIS

Data were collected with a pre-developed form. Risk of bias was assessed independently by two authors (WV, LB). The level of evidence was graded using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies, when possible. Subgroup analyses were performed for posterior cruciate ligament retention versus sacrifice using the same total knee arthroplasty design, and for studies using a posterior cruciate ligament retaining or posterior stabilised design, and when sufficient studies were available subgroup analyses were performed for the same brand.

MAIN RESULTS

Seventeen randomised controlled trials (with 1810 patients and 2206 knees) were found, described in 18 articles. Ten of these were new studies compared to the previous Cochrane Review. One study from the original Cochrane review was excluded. Most new studies compared a posterior cruciate ligament retaining design with a posterior stabilised design, in which the posterior cruciate ligament is sacrificed (a posterior stabilised design has an insert with a central post which can engage on a femoral cam during flexion).The quality of evidence (graded with the GRADE approach) and the risk of bias were highly variable, ranging from moderate to low quality evidence and with unclear or low risk of bias for most domains, respectively.The performance outcome 'range of motion' was 2.4 ° higher in favour of posterior cruciate ligament sacrifice (118.3 ° versus 115.9 °; 95% confidence interval (CI) of the difference 0.13 to 4.67; P = 0.04), however the results were heterogeneous. On the item 'knee pain' as experienced by patients, meta-analysis could be performed on the Knee Society knee pain score; this score was 48.3 in both groups, yielding no difference between the groups. Implant survival rate could not be meta-analysed adequately since randomised controlled trials lack the longer term follow-up in order to evaluate implant survival. A total of four revisions in the cruciate-retention and four revisions in the cruciate-sacrifice group were found. The well-validated Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score was not statistically significantly different between the groups (16.6 points for cruciate-retention versus 15.0 points for cruciate-sacrifice). One study reported a patient satisfaction grade (7.7 points for cruciate-retention versus 7.9 points for cruciate-sacrifice on a scale from 0 to 10, 10 being completely satisfied) which did not differ statistically significantly. Complications were distributed equally between both groups. Only one study reported several re-operations other than revision surgery; that is patella luxations, surgical manipulation because of impaired flexion.The mean functional Knee Society Score was 2.3 points higher (81.2 versus 79.0 points; 95% CI of the difference 0.37 to 4.26; P = 0.02) in the posterior cruciate ligament sacrificing group. Results from the outcome Knee Society functional score were homogeneous. All other outcome measures (extension angle, knee pain, adverse effects, clinical questionnaire scores, Knee Society clinical scores, radiological rollback, radiolucencies, femorotibial angle and tibial slope) showed no statistically significant differences between the groups. In the subgroup analyses that allowed pooling of the results of the different studies, no homogeneous statistically significant differences were identified.

AUTHORS' CONCLUSIONS

The methodological quality and the quality of reporting of the studies were highly variable. With respect to range of motion, pain, clinical, and radiological outcomes, no clinically relevant differences were found between total knee arthroplasty with retention or sacrifice of the posterior cruciate ligament. Two statistically significant differences were found; range of motion was 2.4 ° higher in the posterior cruciate ligament sacrificing group, however results were heterogeneous; and the mean functional Knee Society Score was 2.3 points higher in the posterior cruciate ligament sacrificing group. These differences are clinically not relevant.

Reliability and validity of a weight-bearing measure of ankle dorsiflexion range of motion

PURPOSE

To examine reliability and validity of the Lunge Test (LT) of dorsiflexion range of motion and determine the impact of different approaches to obtain a score on these parameters.

METHODS

Fifty-three patients with ankle injury/dysfunction provided initial assessment data for cross-sectional convergent and known-groups validity analysis with the Pearson coefficient (r) and paired t-test, respectively; data after 4-8 weeks of treatment for longitudinal validity analysis with coefficient r; and data 3 days later for test-retest reliability using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC). LT scores were determined for the affected leg only (LTAff) and for the difference between the two limbs (LTDiff). Two strategies were used to calculate LT scores: a single series and the mean of three series of lunges. LTs were correlated with the Lower Extremity Functional Scale and Global Foot and Ankle Scale.

RESULTS

Reliability coefficients were high (ICC=0.93-0.99). The MDC=1.0/1.5 cm, LTAff/LTDiff, respectively. Cross-sectional validity was confirmed for LTDiff (r=-0.40 to -0.50). Between-limb differences (p<0.05) supported known-groups validity. Longitudinal validity was supported for both LT change scores (r=0.39-0.63). The number of series of lunges used did not impact results.

CONCLUSIONS

A single series of lunges produces a reliable LT score. From a validity perspective, clinicians should use LTDiff on initial assessment and either LT to assess change.

The effect of previous loading cycles on the reliability of a clinical measure of hamstring flexibility

PURPOSE

The aim of the study was to determine the effect of successive repetitions of a measure of hamstring flexibility-the passive unilateral straight leg raise (SLR)-on the reliability of this measure.

METHOD

Ten repetitions of the SLR were performed on nine healthy adults. Measures were quantified using an electromagnetic tracking system and standardized using a handheld dynamometer by stopping the SLR at a set end-point force. The 10 repetitions were analyzed as two blocks of five, and intra-class correlation coefficients-models (2,1) and (3,k)-were calculated for each block of data.

RESULTS

ICC values for both models were comparable between the two blocks of data.

CONCLUSION

Previous loading cycles, to a set end-point force, are unlikely to improve the reliability of muscle flexibility assessment in a clinical setting.

Interventions for treating acute elbow dislocations in adults

BACKGROUND

Dislocation of the elbow joint is a relatively uncommon injury.

OBJECTIVES

To assess the effects of various forms of treatment for acute simple elbow dislocations in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March Week 5 2011), EMBASE (1980 to 2011 Week 14), PEDro (April 2011), CINAHL (April 2011), various trial registers, various conference proceedings and bibliographies of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of conservative and surgical treatment of dislocations of the elbow in adults. Excluded were trials involving dislocations with associated fractures, except for avulsion fractures.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias were independently performed by two review authors. There was no pooling of data.

MAIN RESULTS

Two small randomised controlled trials, involving a total of 80 participants with simple elbow dislocations, were included. Both trials were methodologically flawed and potentially biased.One trial, involving 50 participants, compared early mobilisation at three days post reduction versus cast immobilisation. At one year follow-up, the recovery of range of motion appeared better in the early mobilisation group (e.g. participants with incomplete recovery of extension: 1/24 versus 5/26; risk ratio 0.22, 95% confidence interval 0.03 to 1.72). However, the results were not statistically significant. There were no reports of instability or recurrence. One person in each group had residual pain at one year.The other trial, involving 30 participants, compared surgical repair of the torn ligaments versus conservative treatment (cast immobilisation for two weeks). At final follow-up (mean 27.5 months), there were no statistically significant differences between the two groups in the numbers of patients who considered their injured elbow to be inferior to their non-injured elbow (10/14 versus 7/14; RR 1.43, 95% CI 0.77 to 2.66) or in other patient complaints about their elbow such as weakness, pain or weather-related discomfort. There were no reports of instability or recurrence. There were no statistically significant differences between the two groups in range of motion of the elbow (extension, flexion, pronation, and supination) or grip strength at follow-up. No participants had neurological disturbances of the hand but two surgical group participants had recurrent dislocation of the ulnar nerve (no other details provided). One person in each group had radiologically detected myositis ossificans (bone formation within muscles following injury).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for simple dislocations of the elbow in adults. Although weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment does not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improves long-term function. Future research should focus on questions relating to non-surgical treatment, such as the duration of immobilisation.

Insufficient flexion of the metacarpophalangeal joint of the little finger following Swanson silicone arthroplasty for rheumatoid arthritis

Twenty-one patients with rheumatoid arthritis who underwent Swanson metacarpophalangeal (MP) arthroplasty from 1994 to 1999 were assessed for active flexion of individual MP joints an average of 59 months (range 27-114 months) postoperative. Published articles of Swanson MP arthroplasty were reviewed. Experienced hand surgeons were surveyed regarding outcomes of metacarpophalangeal arthroplasty. The MP joint of the little finger displayed significantly less flexion than that of the middle and index finger. Seven of eight published studies which present active MP flexion by individual digit demonstrated less flexion in the little finger compared to the index, middle, and ring finger. Half of surgeons surveyed reported that MP range of motion is shifted toward a more extended position, that MP flexion is limited in the ulnar digits, and that an implant that encourages MP flexion would be helpful. Our experience with this cohort, a review of published literature, and a survey of international experts suggest that Swanson arthroplasty frequently results in a range of flexion of the MP joint of the little finger that may be insufficient for its principal functions.