Does MRI add value in general practice for patients with traumatic knee complaints? A 1-year randomised controlled trial.

OBJECTIVE: To determine whether referral to MRI by the general practitioner (GP) is non-inferior to usual care (no access to MRI by GPs) in patients with traumatic knee complaints regarding knee-related daily function. METHODS: This was a multicentre, non-inferiority randomised controlled trial with 1-year follow-up. GPs invited eligible patients during or after their consultation. Eligible patients (18-45 years) consulted a GP with knee complaints due to a trauma during the previous 6 months. Patients allocated to the MRI group received an MRI at (median) 7 (IQR 1-33) days after the baseline questionnaire. Patients in the usual care group received information on the course of knee complaints, and a referral to a physiotherapist or orthopaedic surgeon when indicated. The primary outcome measure was knee-related daily function measured with the Lysholm scale (0 to 100; 100=excellent function) over 1 year, with a non-inferiority margin of 6 points. RESULTS: A total of 356 patients were included and randomised to MRI (n=179) or usual care (n=177) from November 2012 to December 2015. MRI was non-inferior to usual care concerning knee-related daily function during 1-year follow-up, for the intention-to-treat (overall adjusted estimate: 0.33; 95% CI -1.73 to 2.39) and per-protocol (overall adjusted estimate: 0.06; 95% CI -2.08 to 2.19) analysis. There were no differences between both groups in the amount of patients visiting other healthcare providers. CONCLUSION: MRI in general practice in patients with traumatic knee complaints was non-inferior to usual care regarding knee-related daily function during 1-year follow-up. TRIAL REGISTRATION NUMBER: NTR3689.

Computer assisted surgery for knee ligament reconstruction.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer assisted surgery aims to aid graft placement. OBJECTIVES: To assess the effects of computer assisted reconstruction surgery versus conventional operating techniques for ACL or posterior cruciate ligament (PCL) deficient knees in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1937 to March 2010), article references and prospective trial registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-randomised controlled trials that compared computer assisted surgery (CAS) of the ACL and PCL with conventional operating techniques not involving CAS, were included. DATA COLLECTION AND ANALYSIS: Two authors independently screened search results, assessed risk of bias and extracted data. Where appropriate, data were pooled using risk ratios or mean differences, both with 95% confidence intervals. MAIN RESULTS: Four randomised controlled trials were included (266 participants). All involved ACL reconstructions performed by experienced surgeons. Risk of bias assessment was hampered by poor reporting of trial methods. Pooled data from two trials showed no statistically or clinically significant differences at two years or more follow-up in self-reported quality of life outcomes: International Knee Documentation Committee (IKDC) subjective scores (mean difference 2.05, 95% CI -2.16 to 6.25) and Lysholm scores (mean difference 2.05, 95% CI -2.16 to 6.25). A third trial also found a minimal difference in IKDC subjective scores (mean difference = 0.2). Pooled data from three trials for normal or nearly normal IKDC knee examination grades at final follow-up showed no significant differences between the two groups (risk ratio 1.01, 95% CI 0.96 to 1.06). No significant differences were found for other objective measures of knee function. The only adverse effects reported were some loss in range of motion in two versus three participants in one trial. CAS use was associated with longer operating times (range 9.3 to 26 minutes). AUTHORS' CONCLUSIONS: A favourable effect of computer assisted surgery for cruciate ligament reconstructions of the knee compared with conventional reconstructions could neither be demonstrated nor refuted. There is insufficient evidence to advise for or against the use of CAS. There is a need for improved reporting of future studies of this technology.

Functional capacity and actual daily activity do not contribute to patient satisfaction after total knee arthroplasty.

BACKGROUND: After total knee arthroplasty (TKA) only 75-89% of patients are satisfied. Because patient satisfaction is a prime goal of all orthopaedic procedures, optimization of patient satisfaction is of major importance. Factors related to patient satisfaction after TKA have been explored, but no studies have included two potentially relevant factors, i.e. the functional capacity of daily activities and actual daily activity. This present prospective study examines whether functional capacity and actual daily activity (in addition to an extensive set of potential factors) contribute to patient satisfaction six months after TKA. METHODS: A total of 44 patients were extensively examined preoperatively and six months post surgery. Functional capacity was measured with three capacity tests, focusing on walking, stair climbing, and chair rising. Actual daily activity was measured in the patient's home situation by means of a 48-hour measurement with an Activity Monitor. To establish which factors were related to patient satisfaction six months post surgery, logistic regression analyses were used to calculate odds ratios. RESULTS: Preoperative and postoperative functional capacity and actual daily activity had no relation with patient satisfaction. Preoperatively, only self-reported mental functioning was positively related to patient satisfaction. Postoperatively, based on multivariate analysis, only fulfilled expectations regarding pain and experienced pain six months post surgery were related to patient satisfaction. CONCLUSIONS: Functional capacity and actual daily activity do not contribute to patient satisfaction after TKA. Patients with a better preoperative self-reported mental functioning, and patients who experienced less pain and had fulfilled expectations regarding pain postoperatively, were more often satisfied.

Supervised exercises for adults with acute lateral ankle sprain: a randomised controlled trial.

BACKGROUND: During the recovery period after acute ankle sprain, it is unclear whether conventional treatment should be supported by supervised exercise. AIM: To evaluate the short- and long-term effectiveness of conventional treatment combined with supervised exercises compared with conventional treatment alone in patients with an acute ankle sprain. DESIGN: Randomised controlled clinical trial. SETTING: A total of 32 Dutch general practices and the hospital emergency department. METHOD: Adults with an acute lateral ankle sprain consulting general practices or the hospital emergency department were allocated to either conventional treatment combined with supervised exercises or conventional treatment alone. Primary outcomes were subjective recovery (0-10 point scale) and the occurrence of a resprain. Measurements were carried out at intake, 4 weeks, 8 weeks, 3 months, and 1 year after injury. Data were analysed using intention-to-treat analyses. RESULTS: A total of 102 patients were enrolled and randomised to either conventional treatment alone or conventional treatment combined with supervised exercise. There was no significant difference between treatment groups concerning subjective recovery or occurrence of resprains after 3 months and 1-year of follow-up. CONCLUSION: Conventional treatment combined with supervised exercises compared to conventional treatment alone during the first year after an acute lateral ankle sprain does not lead to differences in the occurrence of resprains or in subjective recovery.

Preventing running-related injuries using evidence-based online advice: the design of a randomised-controlled trial.

INTRODUCTION: Running-related injuries (RRIs) are frequent and can lead to cessation of health promoting activities. Several risk factors for RRIs have been identified. However, no successful injury prevention programme has been developed so far. Therefore, the aim of the present study is to investigate the effect of an evidence-based online injury prevention programme on the number of RRIs. METHODS AND ANALYSIS: The INSPIRE trial is a randomised-controlled trial with a 3-month follow-up. Both novice and more experienced runners, aged 18 years and older, who register for a running event (distances 5 km up to 42.195 km) will be asked to participate in this study. After completing the baseline questionnaire, participants will be randomised into either the intervention group or control group. Participants in the intervention group will get access to the online injury prevention programme. This prevention programme consists of information on evidence-based risk factors and advices to reduce the injury risk. The primary outcome measure is the number of self-reported RRIs in the time frame between registration for a running event and 1 month after the running event. Secondary outcome measures include the running days missed due to injuries, absence of work or school due to injuries, and the injury location. ETHICS AND DISSEMINATION: An exemption for a comprehensive application is obtained by the Medical Ethical Committee of the Erasmus University Medical Centre Rotterdam, Netherlands. The results of the study will be published in peer-reviewed journals and presented on international congresses. TRIAL REGISTRATION NUMBER: NTR5998. Pre-results.

Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice.

OBJECTIVE: To assess the diagnostic value of history-taking and physical examination of meniscal tears in general practice. DESIGN: An observational study determining diagnostic values (sensitivity, specificity, predictive value, and likelihood ratios). SETTING: General practice. PATIENTS: Consecutive patients aged 18 to 65 years with a traumatic knee injury who consulted their general practitioner within 5 weeks after trauma. ASSESSMENT: Participating patients filled out a questionnaire (history-taking) followed by a standardized physical examination. MAIN OUTCOME: Assessment of meniscal tears was determined by means of magnetic resonance imaging (MRI) and was performed blinded for the results of physical examination and history-taking. RESULTS: Of the 134 patients included in this study, 47 had a meniscal tear. From history-taking, the determinants "age over 40 years," "continuation of activity impossible," and "weight-bearing during trauma" indicated an association with a meniscal tear after multivariate logistic regression analysis, whereas from physical examination only "pain at passive flexion" indicated an association. These associated determinants from history-taking showed some diagnostic value; the positive likelihood ratio (LR+) reached up to 2.0 for age over 40 years, whereas the isolated test pain at passive flexion from physical examination has less diagnostic value, with an LR+ of 1.3. Combining determinants from history-taking and physical examination improved the diagnostic value with a maximum LR+ of 5.8; however, this combination only applied to a limited number of patients. CONCLUSION: History-taking has some diagnostic value, whereas physical examination did not add any diagnostic value for detecting meniscal tears in general practice.