Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial.

Importance: Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period. Objective: To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery. Design, Setting, and Participants: This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019. Interventions: Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR. Main Outcomes and Measures: The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale. Results: A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes. Conclusions and Relevance: This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery. Trial registration: ClinicalTrials.gov Identifier: NCT01671917.

Lumbar spinal stenosis and disc alterations affect the upper lumbar spine in adults with achondroplasia.

In achondroplasia, lumbar spinal stenosis arises from congenital dysplasia and acquired degenerative changes. We here aimed to describe the changes of the lumbar spinal canal and intervertebral disc in adults. We included 18 adults (age ≥ 18 years) with achondroplasia and lumbar spinal stenosis. Radiographs were used to analyze spinal-pelvic angles. Antero-posterior diameter of the spinal canal and the grade of disc degeneration were measured by MRI. Antero-posterior diameters of the spinal canal differed by spinal level (P < 0.05), with lower values observed at T12-L1, L1-2 and L2-3. Degrees of disc degeneration differed by intervertebral level, with higher degrees observed at L1-2, L2-3 and L3-4. A significant correlation was found between disc degeneration and thoraco-lumbar kyphosis at L2-3, between antero-posterior diameter of the spinal canal and lumbar lordosis at T12-L1 and L2-3, and between antero-posterior diameter of the spinal canal and thoraco-lumbar kyphosis at L1-2. Unlike the general population, spinal stenosis and disc degeneration involve the upper part of the lumbar spine in adults with achondroplasia, associated with thoraco-lumbar kyphosis and loss of lumbar lordosis.

Impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy in Dupuytren's disease: A model analysis.

OBJECTIVE: To assess the cost of switching surgical aponeurectomy to percutaneous needle aponeurotomy in one-ray Dupuytren's disease. METHODS: A model analysis was performed with a cross-sectional national survey of public and private French hospitals in 2012. All stays for one-ray aponeurectomy were "virtually" replaced with 1, 2 or 3 outpatient sessions of percutaneous needle aponeurotomy. The costs were based on the hospital cost (tariff per disease-related group) and on common classification of medical procedures performed in outpatient care for 2013. RESULTS: Dupuytren's disease represented 18,707 hospitalizations (€26 million [2013 euros]) in France in 2012, 8534 hospitalizations for one-ray aponeurectomy (€11.9 million). By replacing surgical aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren's disease, 91% to 97% and 56% to 59% of the treatment costs could be saved using hospitalizations for one-ray aponeurectomy or total hospital costs, respectively, as reference. CONCLUSIONS: Replacing aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren's disease could greatly reduce the treatment costs for all Dupuytren's disease. Effective alternatives to surgery for Dupuytren's disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective.

URAM scale for functional assessment in Dupuytren's disease: a comparative study of its properties.

OBJECTIVE: To test the convergent validity and ease of use of the Unité Rhumatologique des Affections de la Main (URAM) scale for patients with Dupuytren's disease. METHODS: Patients were prospectively included. We compared the convergent validity of the URAM scale, the Cochin Hand Function Scale (CHFS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, in terms of their correlation with the Tubiana score and self-assessed disability on a visual analog scale (VAS). Pearson's correlation was used for the convergent validity study. The response time for questionnaire completion was the outcome for ease of implementation. RESULTS: We included 53 patients with Dupuytren's disease in the convergent validity study and 30 other patients with the disease in the time-response assessment. The URAM scale showed strong convergence with the Tubiana scale (r=0.64) and self-assessed disability on a VAS (r=0.69). Convergence with the Tubiana and self-assessed disability was higher for the URAM scale than the CHFS or DASH questionnaire. The mean [SD] response time was shorter for the URAM scale than the CHFS or DASH questionnaire (42 [20] vs 71 [35] and 103 [59] s, respectively, P<0.0001). CONCLUSIONS: The results reinforce the psychometric merits of the URAM scale. Furthermore, the response time for assessing disability was shorter with the URAM scale than the CHFS or DASH questionnaire. This evidence supports the high recommendation for the use of the URAM scale in clinical practice and clinical studies to assess disability in Dupuytren's disease.

Genetics of Dupuytren's disease.

Dupuytren's disease (DD) is a progressive fibrosis of the palmar fascia characterized by the formation of a nodule, which evolves into a cord. DD is the most common hereditary disease of the connective tissue preferentially affecting Caucasoids originating from Northern Europe. Some environmental factors are associated with DD, namely alcohol consumption, tobacco exposure and, possibly, manual activities. Diabetes and epilepsy are the most frequently reported DD-associated diseases. The genetic mode of inheritance is not well understood, but seems to be heterogeneous: most frequently, autosomal dominant with variable penetrance, and rarely recessive autosomal or maternal (matrilinear), suggesting a mitochondrial heredity. Initially, a suggestion of linkage with the DUPC1 locus at 16q was proposed. Then, among the genomic variations observed in DD, alterations in the copy number of genes in chromosomal regions 10q22, 16p12.1 and 17p12, associations with the HLA-DRB1*15 allele and a mutation in the rRNA 16s identified in forms with a matrilinear heredity, were reported. Finally, a genome-wide study has shown a genetic association of DD with 6, 11 and 16 chromosomes. Pathophysiology of DD involves mainly myofibroblasts and the extracellular matrix of collagen. Gene and protein expression studies have confirmed the central role of the ß catenin of the TGFß pathways in the pathogenesis of DD.

Needle aponeurotomy in Dupuytren's disease.

Needle aponeurotomy (NA) is recommended as a nonsurgical treatment for Dupuytren's disease. The aim of the procedure is to cut the Dupuytren's cord by use of the bevel of a needle and to restore full extension of the metacarpophalageal or proximal interphalangeal joints. According to Lermusiaux's standard, NA is performed in an outpatient setting, with the patient under local anesthesia. It entails the use of a 25-gauge, 16 mm-long needle and an anesthetic mixture of lidocaine and acetate of prednisolone. Various modifications have been proposed since the description of Lermusiaux's standard. Lermusiaux's and modified standards demonstrated structural efficacy in Dupuytren's disease. Clinical studies indicate that the mean rate of good structural results of NA is 80% at short-term assessment and 69% at 5-year assessment. Most of the studies are case series and only one is a randomized trial. Better results are demonstrated in early stages of the disease. NA also reduces disability and patients are highly satisfied. The short-term results with Lermusiaux's standard do not appear to be impaired in digital involvement. This is not the case for modified standards providing better results with palmar involvement. Lermusiaux's standard appears to provide less recurrences and less adverse events. In the largest study, skin fissure was observed in 8% of hands, transient dysesthesia in 3%, local infection in 0.7%, and flexor tendon rupture in 0.2%. Values were lower if related to NA sessions or NAs during each session. We therefore recommend Lermusiaux's standard for safe and effective NA in patients with Dupuytren's disease.

Unité Rhumatologique des Affections de la Main (URAM) scale: development and validation of a tool to assess Dupuytren's disease-specific disability.

OBJECTIVE: To our knowledge, no functional outcome measure has been developed and validated for Dupuytren's disease. We aimed to develop and validate a patient-reported functional outcome measure for Dupuytren's disease. METHODS: Patients with Dupuytren's disease (n = 9) and medical experts (n = 7) provided input and opinions about limiting activities that were difficult to perform because of Dupuytren's disease for item generation. The provisional scale was studied in an independent sample of patients (n = 85) for item reduction according to response distribution, reliability, redundancy, and loading in a 1-factor solution. The final scale was evaluated as follows: reliability using Cronbach's alpha coefficient and test-retest intraclass correlation coefficient from the previous 85-patient population, and construct validity and responsiveness after needle aponeurotomy in another independent 53-patient sample. For construct validity, convergent validity and divergent validity were tested. The clinically important change was estimated relative to a 1-point categorical change on the Tubiana scale. RESULTS: A 52-item provisional scale was generated and reduced to the final 9-item scale called the Unité Rhumatologique des Affections de la Main (URAM) scale (total score 0-45). The scale showed good to excellent reliability and suitable construct validity. The URAM score improved after needle aponeurotomy: the standardized effect size was 0.56. The estimated clinically important change of the URAM scale was 2.9 points. CONCLUSION: We provide the first patient-reported functional measure for Dupuytren's disease. The URAM scale demonstrated suitable psychometric properties, and is short and convenient enough for easy use in daily practice and in clinical studies.

Multi-needle aponeurotomy for advanced Dupuytren's disease: preliminary results of safety and efficacy (MNA 1 study).

AIM: To assess the safety and efficacy of multi-needle aponeurotomy (MNA) for advanced Duputren's disease. METHODS: This prospective study included patients with age more than 17 years, Dupuytren's contracture with palmo-digital or poly-digital involvement, presumed NA number needed to treat>4, and availability for at least 1-month follow-up after MNA. Outcome measures were Tubiana score and passive extension deficit, after MNA and at 1 and 6 months; self-assessed disability and satisfaction at 1 and 6 months; and adverse events (AEs). RESULTS: Thirty patients were included. MNA was performed on 37 hands and 99 rays. Among 25 assessed MNA sessions for treatment-related discomfort, patients considered 22 (88%) not at all to moderately painful. Six minor AEs, representing 2 for every 100 NAs, were reported. Tubiana scores at baseline (5.3±2.3, n=35) were improved after treatment (1.7±1.8, n=32, P<0.0001), at 1 month (2.2±1.4, n=26, P<0.0001) and at 6 months (2.8±2.7, n=19, P<0.01). Passive extension deficit was greatly reduced after treatment and persisted at follow-up. Disability scores at baseline (27.6±26.9, n=37) were reduced at 1 month (13.2±19.5, n=26, P=0.02) and at 6 months (5.2±11.6, n=20, P<0.001). Patients were highly satisfied at 1 month (100%, n=25) and 6 months (95%, n=19). CONCLUSION: MNA appears safe and effective for advanced Dupuytren's disease. It could become a treatment of reference and contribute to reducing the need for surgery in this indication.

[Non-traumatic pathology of the shoulder: medical treatment]. / Pathologie non traumatique de l'épaule: les traitements médicaux.

Recently published meta-analyses emphasized weak methodology of clinical research evaluating medical treatment of non-traumatic shoulder pathology. Experts recommend medical treatment as the first step in the management of rotator cuff tendinopathies, the focus of this review. This step precedes surgical treatment of rotator cuff tear with the objective of recovering passive motion of the shoulder. It can be the unique therapeutic phase of rotator cuff tear or simple tendinopathy when clinical results match functional needs of the patient. Therefore, the physician prior treatment has to establish a lesion diagnostic, which is necessary to propose an appropriate strategy. Medical treatment includes NSAID, local injections of corticosteroids and physiotherapy with the double objective of a painless shoulder and normal range of motion. In case rotator cuff calcifying tendinitis, medical treatment is specific with first NSAID and local injections of cortico-steroïds, second needle aspiration and third arthroscopic removal, which remains the gold-standard procedure when other treatments failed.

A pilot study on the recovery from paresis after lumbar disc herniation.

BACKGROUND: Although the existence of a motor defect in discogenic sciatica is a sign of severity, the literature does not provide evidence for an immediate requirement for surgery. OBJECTIVE: To assess the course of sciatica with discogenic paresis and to determine possible prognostic factors for recovery or improvement. STUDY DESIGN: This open prospective multicenter study included patients with discogenic sciatica with paresis that had been developing for less than 1 month and was rated < or =3 on a 5-grade scale. Pain, the strength of 11 muscles, return to work, and analgesic intake were assessed at 1, 3, and 6 months. Recovery and improvement were defined by pain not exceeding 20 mm or < or =50% of the initial pain score and a score of either 5 (recovery) or 4 (improvement) for the weakest muscle at inclusion. RESULTS: Sixty-seven patients were enrolled; 39 (58%) patients were treated surgically and 28 (42%) medically. Surgically treated patients differed from medically treated patients by a higher rate of extruded herniation, a higher number of paretic muscles (6.3 vs. 5; P = 0.051), and a longer course of sciatica (31.4 vs. 17.3 days; P = 0.034). At 6 months, 7 (10.4%) patients were lost to follow-up; 32 (53.3%) had improved, including 18 (30%) recovered, 33 (85%) back to work and having a professional activity, and 22 (39%) still taking analgesics. The only significant difference between recovered and not recovered patients was mean age at inclusion (43 vs. 51 years, P = 0.034). There were no significant differences between improved and not improved patients. Moreover, the outcome was not different in the two treatment groups: there were 17 (53%) improvements in surgically treated patients, including 8 (25%) recoveries, and 14 (56%) improvements in medically treated patients, including 8 (40%) recoveries. CONCLUSION: This pilot study showed no difference between surgical or medical management for recovery or improvement in patients with discogenic paresis. These results need confirmation by a randomized study.

Bisphosphonates in bone diseases other than osteoporosis.

The range of bone diseases in which bisphosphonates are used has extended far beyond osteoporosis during the last few years. Bisphosphonate therapy is now so well validated as to be the reference standard in Paget's disease and in the prevention of bone complications related to malignant osteolysis. Promising preliminary findings warrant the use of bisphosphonates in conditions that are either rare (fibrous dysplasia) or severe (pediatric osteogenesis imperfecta). The third category of indications encompasses many conditions in which the limited available data do not warrant widespread use: examples include reflex sympathetic dystrophy syndrome, acute back pain after a vertebral crush fracture, and chronic inflammatory joint disease not treated by glucocorticoids.