An add-on training program involving breathing exercises, cold exposure, and meditation attenuates inflammation and disease activity in axial spondyloarthritis - A proof of concept trial.

OBJECTIVES: The primary objective of this trial was to assess safety and anti-inflammatory effects of an add-on training program involving breathing exercises, cold exposure, and meditation in patients with axial spondyloarthritis. METHODS: This study was an open-label, randomised, one-way crossover clinical proof-of-concept trial. Twenty-four patients with moderately active axial spondyloarthritis(ASDAS >2.1) and hs-CRP ≥5mg/L were included and randomised to an intervention (n = 13) and control group (n = 11) group that additionally received the intervention after the control period. The intervention period lasted for 8 weeks. The primary endpoint was safety, secondary endpoints were change in hs-CRP, serum calprotectin levels and ESR over the 8-week period. Exploratory endpoints included disease activity measured by ASDAS-CRP and BASDAI, quality of life (SF-36, EQ-5D, EQ-5D VAS), and hospital anxiety and depression (HADS). RESULTS: We found no significant differences in adverse events between groups, with one serious adverse event occurring 8 weeks after end of the intervention and judged 'unrelated'. During the 8-week intervention period, there was a significant decline of ESR from (median [interquartile range] to 16 [9-26.5] to 9 [5-23] mm/hr, p = 0.040, whereas no effect was found in the control group (from 14 [8.3-27.3] to 16 [5-37] m/hr, p = 0.406). ASDAS-CRP declined from 3.1 [2.5-3.6] to 2.3 [1.9-3.2] in the intervention group (p = 0.044). A similar trend was observed for serum calprotectin (p = 0.064 in the intervention group versus p = 0.182 in the control group), but not for hs-CRP. CONCLUSIONS: This proof-of-concept study in axial spondyloarthritis met its primary endpoint with no safety signals during the intervention. There was a significant decrease in ESR levels and ASDAS-CRP upon the add-on training program in the intervention group. These findings warrant full-scale randomised controlled trials of this novel therapeutic approach in patients with inflammatory conditions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT02744014.

Pain experience and functional outcome of inpatient versus outpatient anterior cruciate ligament reconstruction, an equivalence randomized controlled trial with 12 months follow-up.

BACKGROUND: Arthroscopic reconstruction of the anterior cruciate ligament (ACL) has traditionally been performed in an inpatient setting. Outpatient treatment may offer the advantages of cost reduction and higher patient satisfaction. HYPOTHESIS/PURPOSE: We investigated whether ACL reconstruction in an outpatient setting is equally safe as in an inpatient setting and whether comparable functional outcomes can be achieved. We hypothesized that the outcomes of outpatient ACL reconstruction result in similar outcomes as inpatient ACL reconstruction. STUDY DESIGN: A prospective randomized controlled trial was conducted at one centre. METHODS: Forty-six patients were randomized to outpatient treatment or a 2-day admission after ACL reconstruction. The functional outcome was evaluated with the Lysholm, Tegner and International Knee Documentation Committee scores. Safety of the procedures was judged according to pain experience and readmission rate. The duration of follow-up was 1 year after ACL reconstruction. The patients were provided with a simple postoperative analgesic protocol. The linear mixed effect model for repeated measures was used for testing the differences between the study groups. RESULTS: No significant differences were found between the study groups in all the outcome measures. No readmissions were recorded related to pain. One complication was recorded in the outpatient group versus three in the inpatient group. CONCLUSION: This study indicates that outpatient care after ACL reconstruction yields comparable functional results and postoperative pain experience as inpatient care and is a safe option. A simple analgesic protocol provides adequate pain relief during the postoperative phase. LEVEL OF EVIDENCE: I.

Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical trials.

PURPOSE: There is no consensus on the relation between ulnar styloid process nonunion and outcome in patients with distal radius fractures. The aim of this study was to analyze whether patient-reported outcome is influenced by the nonunion of the accompanying ulnar styloid fracture in distal radius fracture patients. METHODS: A meta-analysis of published studies comparing outcomes after distal radius fractures with a united versus a non-united ulnar styloid process was performed. In addition, if provided by the authors, the raw data of these studies were pooled and analysed as one study. The outcome measures of the analyses included patient-reported outcome, functional outcome, grip-strength, pain, and distal radioulnar joint (DRUJ) instability. RESULTS: Data from six comparative studies were included, concerning 365 patients with a distal radius fracture. One hundred and thirty-five patients with an ulnar styloid union were compared with 230 patients with a nonunion of the ulnar styloid. No significant differences were found between groups regarding any outcome measure. CONCLUSION: Based on this meta-analysis, there is no relation between the nonunion of the ulnar styloid process and function in patients with a distal radius fracture.

Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial.

PURPOSE: The aim of this prospective randomized trial was to test the null hypothesis that there was no difference in the percentage of the fracture line of scaphoid waist fractures that demonstrated bridging bone on computed tomography (CT) 10 weeks after injury between patients treated in a below-elbow cast including or excluding the thumb. METHODS: A total of 62 patients with a CT or magnetic resonance image-confirmed nondisplaced or minimally displaced fracture of the scaphoid were enrolled in a prospective, multicenter, randomized trial comparing treatment in a below-elbow cast including or excluding the thumb. There were 55 waist and 7 distal fractures (owing to a miscommunication at 3 of the centers). We adhered to intention-to-treat principles. The primary outcome was the extent of union on CT performed after 10 weeks of cast treatment, expressed as a percentage of the fracture line that had bridging bone, determined by musculoskeletal radiologists blinded to treatment. Secondary study outcomes included wrist motion; grip strength; the Mayo Modified Wrist Score; the Disabilities of the Arm, Shoulder and Hand score; a visual analog scale for pain; and radiographic union at 6 months after injury. RESULTS: There was a significant difference in the average extent of union on CT at 10 weeks (85% vs 70%) favoring treatment with a cast excluding the thumb. The overall union rate was 98%. The 1 exception was a patient in the thumb immobilization group who elected operative treatment 1 week after enrollment, used crutches, and failed to heal. There were no significant differences between groups for wrist motion; grip strength; Mayo Modified Wrist Score; Disabilities of the Arm, Shoulder, and Hand score; or pain intensity. CONCLUSIONS: Immobilization of the thumb appears unnecessary for CT or magnetic resonance image-confirmed nondisplaced or minimally displaced fractures of the waist of the scaphoid. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Predictors of fracture following suspected injury to the scaphoid.

A prospective study was performed to develop a clinical prediction rule that incorporated demographic and clinical factors predictive of a fracture of the scaphoid. Of 260 consecutive patients with a clinically suspected or radiologically confirmed scaphoid fracture, 223 returned for evaluation two weeks after injury and formed the basis of our analysis. Patients were evaluated within 72 hours of injury and at approximately two and six weeks after injury using clinical assessment and standard radiographs. Demographic data and the results of seven specific tests in the clinical examination were recorded. There were 116 (52%) men and their mean age was 33 years (13 to 95; SD 17.9). In 62 patients (28%) a scaphoid fracture was confirmed. A logistic regression model identified male gender (p = 0.002), sports injury (p = 0.004), anatomical snuff box pain on ulnar deviation of the wrist within 72 hours of injury (p < 0.001), and scaphoid tubercle tenderness at two weeks (p < 0.001) as independent predictors of fracture. All patients with no pain at the anatomical snuff box on ulnar deviation of the wrist within 72 hours of injury did not have a fracture (n = 72, 32%). With four independently significant factors positive, the risk of fracture was 91%. Our study has demonstrated that clinical prediction rules have a considerable influence on the probability of a suspected scaphoid fracture. This will help improve the use of supplementary investigations where the diagnosis remains in doubt.

Predictors of the accuracy of quotation of references in peer-reviewed orthopaedic literature in relation to publications on the scaphoid.

Using inaccurate quotations can propagate misleading information, which might affect the management of patients. The aim of this study was to determine the predictors of quotation inaccuracy in the peer-reviewed orthopaedic literature related to the scaphoid. We randomly selected 100 papers from ten orthopaedic journals. All references were retrieved in full text when available or otherwise excluded. Two observers independently rated all quotations from the selected papers by comparing the claims made by the authors with the data and expressed opinions of the reference source. A statistical analysis determined which article-related factors were predictors of quotation inaccuracy. The mean total inaccuracy rate of the 3840 verified quotes was 7.6%. There was no correlation between the rate of inaccuracy and the impact factor of the journal. Multivariable analysis identified the journal and the type of study (clinical, biomechanical, methodological, case report or review) as important predictors of the total quotation inaccuracy rate. We concluded that inaccurate quotations in the peer-reviewed orthopaedic literature related to the scaphoid were common and slightly more so for certain journals and certain study types. Authors, reviewers and editorial staff play an important role in reducing this inaccuracy.

Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?

Irreparable posterior cuff tears can cause pain and lack of shoulder function. Surgical treatment includes musculotendinous transfers of either latissimus dorsi (LD) or teres major (TM). This study aimed to give a detailed description of the morphology of these two muscles with particular regard to their suitability for use in transfers. Sixty-two shoulders in 31 cadaveric specimens (mean age 50 years) were dissected. The mean length of the TM was 13.7 cm at its superior edge while the distance from the muscle origin to the greater tuberosity (GT) was 19.2 cm. The tendon of the TM had a length of 1.5 cm, a width of 3.4 cm, and a thickness of 1.3 mm. The mean length of the LD was 26.0 cm and the distance from its origin to the GT was 32.9 cm. The mean length of the LD tendon was 5.2 cm, its width 2.9 cm, and its thickness 1.0 mm. The increased length required to achieve transfer was 47% (of the original length) for TM and 33% for LD. Both TM and LD could reach the GT with ease, according to the potential muscle excursions. Tension of the neurovascular bundle is more probable with LD because it enters the muscle relatively closer to the tendon. Problems with regard to reattachment may be more likely to occur in a transfer of the TM because of its short tendon.