Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness.

OBJECTIVE: To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee. DESIGN: In this 2 × 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation. RESULTS: Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group. CONCLUSIONS: Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

Identifying the source of bullet wipe: a randomised blind trial.

OBJECTIVE: To assess the usefulness of scanning electron microscopy and energy dispersive x-ray spectroscopy in matching bullet wipe to the bullet. HYPOTHESIS: Bullet wipe can be used to match a bullet type to a crime scene.

Gunshot induced indirect femoral fracture: mechanism of injury and fracture morphology.

INTRODUCTION: Indirect ballistic fractures occur when a projectile passes close to, but not contacting, the bone. The mechanism of how these fractures occur is not yet proven, but recently the acoustic shockwave has been excluded as a cause. The objective of this study is to determine whether the expanding temporary cavity, the collapse of this cavity or its oscillation causes these fractures. In addition, we describe the fracture morphology and biomechanical causes of this injury. METHOD: 40 fresh deer femora were strain gauged and embedded in ballistic gelatin before being shot with four different projectiles with varying distances off the bone. Pressure recordings, chronographs and radar allowed assessment of local pressures and energy transfer. High-speed video allowed the temporal relationship between the temporary cavity and fracture formation to be analysed, while sample dissection allowed the fracture morphology to be described. RESULTS: The fractures produced were consistently wedge-shaped and caused by the expansion of the temporary cavity, flexing the bone beyond its yield point, causing tension failure on the cortex opposite the expanding temporary cavity and a compression wedge on the side of the cavity. Local pressure was not predictive of fracture formation but the energy transfer to the gelatin block was predictive. CONCLUSIONS: Indirect fractures are caused by the expansion of the temporary cavity and relate to the proximity of this cavity to the bone. Fractures occur from flexion of the bone and classically display wedge-shaped fracture patterns with the apex of the wedge pointing away from the expanding cavity.

Variability of blood lactate during and between given constant prolonged cycling power.

AIM: Blood lactate concentration (BLC) has been the basis of rational performance diagnostics for almost five decades. Aim of this study was to identify the variability of the BLC during repeated constant power tests (VC-BLC) and to quantify the corresponding variability of changes in the BLC over time (VC-BLC-Difference). METHODS: Twelve healthy male subjects (24.8±3-8 years, 182.9±7.5 cm, 75.7±7.1 kg, ·VO2peak: 4.1±0.6 l min-1) performed four series of three constant power tests at exercise intensities of 45% (A), 60% (B), 75% (C) and 90% (D) of VO2peak. Blood sampling was conducted before, at the end of every 5th min and at the end of each test terminated ahead of schedule. RESULTS: BLC was different at all exercise intensities from minute five onwards. Power output was equivalent to 142.1±18.9 W (A), 196.3±25.2 W (B), 247.9±30.3 W (C) and 302.5±38.4 W (D). VC-BLC varied between 9±2.2% and 21±10.1%. VC-BLC and VC-BLC-Difference between 10th and 30th min correlated inversely with mean BLC level and BLC-Difference respectively. CONCLUSION: By providing first data on constant power test VC-BLC and VC-BLC-Difference this study might help to improve performance diagnostics and training control in sports medicine and medical exercise therapy by assisting in selecting and monitoring exercise intensity. Performance monitoring with BLC-Differences is feasible at moderate and high exercise intensities; single BLC measurements at termination of tests might not be sufficient.

Predicting the transition from acute to persistent low back pain.

BACKGROUND: Most people experience low back pain (LBP) at least once in their lifetime. Only a minority of them go on to develop persistent LBP. However, the socioeconomic costs of persistent LBP significantly exceed the costs of the initial acute LBP episode. AIMS: To identify factors that influence the progression of acute LBP to the persistent state at an early stage. METHODS: Prospective inception cohort study of patients attending a health practitioner for their first episode of acute LBP or recurrent LBP after a pain free period of at least 6 months. Patients were assessed at baseline addressing occupational and psychological factors as well as pain, disability, quality of life and physical activity and followed up at 3, 6, 12 weeks and 6 months. Variables were combined to the three indices 'working condition', 'depression and maladaptive cognitions' and 'pain and quality of life'. RESULTS: The index 'depression and maladaptive cognitions' was found to be a significant baseline predictor for persistent LBP up to 6 months (OR 5.1; 95% CI: 1.04-25.1). Overall predictive accuracy of the model was 81%. CONCLUSIONS: In this study of patients with acute LBP in a primary care setting psychological factors at baseline correlated with a progression to persistent LBP up to 6 months. The benefit of including factors such as 'depression and maladaptive cognition' in screening tools is that these factors can be addressed in primary and secondary prevention.

Identification of prognostic factors for chronicity in patients with low back pain: a review of screening instruments.

Low back pain (LBP) is currently the most prevalent and costly musculoskeletal problem in modern societies. Screening instruments for the identification of prognostic factors in LBP may help to identify patients with an unfavourable outcome. In this systematic review screening instruments published between 1970 and 2007 were identified by a literature search. Nine different instruments were analysed and their different items grouped into ten structures. Finally, the predictive effectiveness of these structures was examined for the dependent variables including "work status", "functional limitation", and "pain". The strongest predictors for "work status" were psychosocial and occupational structures, whereas for "functional limitation" and "pain" psychological structures were dominating. Psychological and occupational factors show a high reliability for the prognosis of patients with LBP. Screening instruments for the identification of prognostic factors in patients with LBP should include these factors as a minimum core set.

Implant retention in infected joint replacements: a surgeon's perspective.

There is no standard treatment for infected joint replacements. The surgical options are varied and treatment choices may pose problems in relation to both efficacy and cost effectiveness. Surgical debridement combined with antibiotic therapy is an appealing option for surgeons and patients as it can lead to eradication of the infection with implant retention and good functional outcome. It avoids major revision surgery which can result in significant morbidity and mortality in an elderly group of patients.The author reviewed 73 patients with hip and knee periprosthetic infections and the data was analyzed in terms of outcome of primary treatment and final outcome, including bacteriology and prosthesis retention. Out of the 73 patients (53 hips and 20 knees), the majority (69%) were managed by primary surgical debridement followed by antibiotics and about one third (34%) lost their implants as a result of the infection. Retention of implants was higher in acute infections (85-100%) as opposed to late infections (20-50%). The microbiological analysis showed that Staphylococcus and Streptococcus caused the majority (76%) of infections. In this series, patients with an infected joint replacement had roughly the same probability (30%) of retaining the original prosthesis, undergoing a successful revision, or having no implants in situ at the end of treatment.

Perioperative mortality in New Zealand related to hip and knee replacement surgery: comparing administrative and registry data.

INTRODUCTION: Perioperative mortality is of considerable importance, but few national assessments are available. New Zealand has a clinical registry and an administrative dataset that both capture national information about hip and knee arthroplasties. National perioperative mortality rates were compared between the two data sources. METHOD: Data related to all patients undergoing an elective hip or knee replacement procedure (primary or revision) between 1 January 2007 and 31 December 2011 were separately extracted from the New Zealand Joint Registry and the National Minimum Dataset. The procedure date was used to define the occurrence of an event and dates were compared between datasets plus or minus 3 days. Date of death information was obtained from the National Mortality Collection and used to estimate 30 day mortality rates. RESULTS: No statistically significant differences in perioperative mortality were evident between comparisons from the two data sources although more deaths were recorded among Registry-only procedures. CONCLUSIONS: Estimates of 30 day perioperative mortality related to hip and knee arthroplasty procedures in New Zealand 2007-2011 are very similar regardless of data source. These data, coupled with perioperative mortality review using structured reports obtained from clinicians, could be used to develop a surveillance system to promote surgical safety.

Long-term follow-up of a recurrent multifocal desmoid tumour treated with tamoxifen: a case report.

We report a long-term follow-up of a female patient with a multifocal extremity desmoid tumour. She had 3 local recurrences after excision and developed a second unresectable pelvic tumour that has remained unchanged in size for 14 years since starting tamoxifen treatment.

Femoral nerve infusion after primary total knee arthroplasty: a prospective, double-blind, randomised and placebo-controlled trial.

OBJECTIVES: Effective analgesia after total knee arthroplasty (TKA) improves patient satisfaction, mobility and expedites discharge. This study assessed whether continuous femoral nerve infusion (CFNI) was superior to a single-shot femoral nerve block in primary TKA surgery completed under subarachnoid blockade including morphine. METHODS: We performed an adequately powered, prospective, randomised, placebo-controlled trial comparing CFNI of 0.125% bupivacaine versus normal saline following a single-shot femoral nerve block and subarachnoid anaesthesia with intrathecal morphine for primary TKA. Patients were randomised to either treatment (CFNI 0 ml to 10 ml/h 0.125% bupivacaine) or placebo (CFNI 0 ml to 10 ml/h normal saline). Both groups received a single-shot femoral nerve block (0.25% 20 ml bupivacaine) prior to placement of femoral nerve catheter and subarachnoid anaesthesia with intrathecal morphine. All patients had a standardised analgesic protocol. The primary end point was post-operative visual analogue scale (VAS) pain score over 72 hours post-surgery. Secondary outcomes were morphine equivalent dose, range of movement, side effects, and length of stay. RESULTS: A total of 86 patients were recruited. Treatment and placebo groups were comparable. No significant difference was found in VAS pain scores, total morphine equivalent requirements, side effects, range of movement, motor block, or length of hospital stay. CONCLUSION: No significant advantage was found for CFNI over a single-shot femoral block and subarachnoid anaesthesia after TKA. Cite this article: Bone Joint Res 2015;4:11-16.