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BackgroundPatients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient’s self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it. ObjectiveThis study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed. MethodsA multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures. ResultsIn total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P

In vitro and in vivo animal studies have reported strong insulin-like or insulin-potentiating effects after cinnamon administration. Recently, a human intervention study showed that cinnamon supplementation (1 g/d) strongly reduced fasting blood glucose concentration (30%) and improved the blood lipid profile in patients with type 2 diabetes. The objective of this study was to investigate the effects of cinnamon supplementation on insulin sensitivity and/or glucose tolerance and blood lipid profile in patients with type 2 diabetes. Therefore, a total of 25 postmenopausal patients with type 2 diabetes (aged 62.9 [+ or -] 1.5 y, BMI 30.4 [+ or -] 0.9 kg/[m.sup.2]) participated in a 6-wk intervention during which they were supplemented with either cinnamon (Cinnamomum cassia, 1.5 g/d) or a placebo. Before and after 2 and 6 wk of supplementation, arterialized blood samples were obtained and oral glucose tolerance tests were performed. Blood lipid profiles and multiple indices of whole-body insulin sensitivity were determined. There were no time x treatment interactions for whole-body insulin sensitivity or oral glucose tolerance. The blood lipid profile of fasting subjects did not change after cinnamon supplementation. We conclude that cinnamon supplementation (1.5 g/d) does not improve whole-body insulin sensitivity or oral glucose tolerance and does not modulate blood lipid profile in postmenopausal patients with type 2 diabetes. More research on the proposed health benefits of cinnamon supplementation is warranted before health claims should be made. KEY WORDS: * oral glucose tolerance * lipid profile * diabetes * nutrition * insulin sensitizer

Background: There are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results. Methodology/Principal Findings: Two hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI 20.05-0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31-346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life. Conclusions/Significance: General low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is underpowered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears., Purpose: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m 2 , locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method., Results: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale., Conclusion: Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point., Registration: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Funding for the ESCAPE trial was provided by the Netherlands Organization for Health Research and Development (ZonMw; grant 837002009), Zilveren Kruis (grant Z436), and the foundation of medical research of OLVG (grant 15u.025). The funders had no role in designing and conducting this study; the collection, management, analysis, and interpretation of the data; the preparation, review, and approval of the manuscript; or the decision to submit the manuscript for publication. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Culture of the causative infectious agent is the only definitive method of diagnosing septic arthritis and can be identified by culture of synovial fluid (SF) or by tissue cultures (TC) obtained at surgery. The aim of this study is to compare the cultures of joint needle aspiration (JNA) with tissue cultures obtained at surgery. 52 patients treated for a suspicion of a septic arthritis of the native knee were retrospectively reviewed. In 84% tissue cultures were equal to joint needle aspiration. Median Gächter classification was 1.0 (range 1-3). 60% of the patients underwent multiple procedures. All patients were successfully treated with an average of 2.0 (range 1-6) arthroscopies. Our results showed that if a patient with a clinical suspicion of septic arthritis is treated, starting antibiotic therapy prior to surgery can be considered, but only after joint needle aspiration to obtain samples for bacteriologic culture. Arthroscopic surgery must be the treatment of choice in Gächter stage 1 to 3, although it might be necessary to perform multiple procedures.

Arthroscopic meniscal repair is the gold standard for longitudinal peripheral meniscal tears. The time interval between trauma and meniscal repair remains controversial. The aim of this study was to evaluate failure rates and clinical outcome of arthroscopic meniscal repair in relation to chronicity of injury. A total of 238 meniscal repairs were performed in 234 patients. Anterior cruciate ligament (ACL) was reconstructed in almost all ACL-deficient knees (130 out of 133). Time interval between injury and repair was divided into acute (< 2 weeks), subacute (> 2 to < 12 weeks), and chronic (> 12 weeks). Patients completed postal questionnaires to evaluate clinical outcome and failure rates. Study instruments included Lysholm, Knee injury and Osteoarthritis Outcome Score (KOOS), and Tegner scoring systems. At a median follow-up of 41 months (interquartile range [IQR], 34-53 months) 55 medial and 10 lateral meniscal repairs failed (overall failure rate, 27%). There was a significant higher failure rate for medial meniscal repair (p < 0.05) and ACL-deficient knees without ACL reconstruction. Functional outcome scores showed only significant differences on the KOOS subscale "function in daily living" (95% confidence interval, 1.05-15.27, p < 0.05). No significant difference was found for any interval between trauma and repair. The interval between trauma and arthroscopic meniscal repair has no influence on the failure rate. Differences in survival rate of meniscal repair are more dependent on location of the lesion and ACL status, rather than chronicity of injury., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The purpose of this study was to compare clinical outcomes in the first postoperative year of patients with full-thickness small to medium-sized tears undergoing all-arthroscopic (AA) versus mini-open (MO) rotator cuff repair., Methods: One hundred patients were randomized to either AA or MO rotator cuff repair at the time of surgery on an intention-to-treat basis. Patients were evaluated before and 6, 12, 26, and 52 weeks after surgery using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a primary outcome score and the Constant-Murley score, visual analog scale (VAS)-pain/impairment score, and measurement of active forward flexion/external rotation as secondary outcome measures. Ultrasound evaluation was used to assess structural integrity of the repair 1 year postoperatively., Results: Forty-seven patients were analyzed in the AA group and 48 in the MO group. Five patients were lost to follow-up. Mean age was 57.2 (SD 8.0) years in the AA group and 57.8 (SD 7.9) years in the MO group. Primary and secondary outcome measures significantly improved in both groups postoperatively. Overall mean primary and secondary postoperative outcome scores did not statistically significantly differ between the treatment groups (DASH between-group mean difference: -3.4; 95% confidence interval [CI], -10.2 to 3.4; P = .317). However, at the 6-week follow-up, DASH score, VAS-pain and -impairment, and active forward flexion were significantly more improved in the AA group than in the MO group. A retear was seen in 8 patients (17%) in the AA group and 6 patients (13%) in the MO group. Five patients in the AA group (11%) and 6 patients (13%) in the MO group developed adhesive capsulitis., Conclusions: Functional outcome, pain, range of motion, and complications do not significantly differ between patients treated with all-arthroscopic repair and those treated with mini-open repair in the first year after surgery. Patients do attain the benefits of treatment somewhat sooner (6 weeks) with the arthroscopic procedure., Level of Evidence: Level II, randomized controlled trial without postoperative blinding., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the intraobserver and interobserver agreement on the geometric classification and 2-dimensional measurements of rotator cuff tears based on magnetic resonance arthrography., Methods: We retrospectively reviewed preoperative magnetic resonance arthrograms of 73 consecutive patients who were surgically treated for their full-thickness rotator cuff tears. The images were blinded and evaluated by 2 orthopaedic shoulder surgeons and 2 musculoskeletal radiologists using the geometric classification of rotator cuff tears (type 1, crescent-shaped tear; type 2, longitudinal U- or L-shaped tear; type 3a, massive tear measuring between 20 and 30 mm; and type 3b, massive contracted tear measuring >30 mm) and measuring the sagittal/coronal dimensions of the tear. Review was performed twice with an interval of at least 8 weeks. Agreement was calculated using the linear weighted κ coefficient and the intraclass correlation coefficient (ICC)., Results: The intraobserver agreement was excellent for both the geometric classification and the sagittal/coronal dimension measurement (κ, 0.81 to 0.92; ICC, 0.84 to 0.98). The ICC for the interobserver agreement was excellent for all sagittal and coronal dimension measurements (ICC, 0.95 to 0.97). The interobserver agreement for the geometric classification was good for the orthopaedic surgeons (κ, 0.75 for round 1 and 0.73 for round 2). The interobserver agreement for the radiologists was excellent in observation round 1 (κ, 0.82) and good in observation round 2 (κ, 0.71). The interobserver agreement between orthopaedic surgeons and radiologists was found to be moderate to good (κ, 0.52 to 0.66). The Fleiss κ was 0.66 for round 1 and 0.62 for round 2., Conclusions: The geometric classification and the 2-dimensional measurement of rotator cuff tears using magnetic resonance arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers., Level of Evidence: Level III, diagnostic study of nonconsecutive patients without consistently applied gold standard., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

We investigated the safety of LIA (local infiltration analgesia) combined with retransfusion of drained blood. Total knee arthroplasty patients received two peri-articular injections during surgery followed by continuous infusion, both with ropivacaine (567 mg). Ropivacaine plasma concentrations were determined in blood samples taken at 0, 3, 6 and 24 hours postoperatively. The collected shed blood was not retransfused, instead retransfusion was modelled by estimating the cumulative plasma concentrations at 6 hours postoperative. Total and unbound ropivacaine plasma concentrations ranged respectively from 0.08 to 1.9 mg/L and 0.003 to 0.11 mg/L. An average of 13.1 +/- 3.7 mg unbound ropivacaine would have been returned to the patient. The estimated cumulative ropivacaine plasma levels showed that instant retransfusion would have led to plasma levels below 0.26 mg/L. It appears to be safe to transfuse autologous blood in combination with LIA. However, before drawing definite conclusions formal measurement of actual concentrations is required.

Background: Ossification of the ankle syndesmosis can occur following trauma to the ankle. Little is known about the treatment of syndesmosis ossification., Case Description: A 49-year-old man was referred to the orthopaedic outpatients' clinic by his GP with swelling on the lateral side of his right ankle. A few months earlier the patient had sustained an injury to his ankle while playing football, for which he had not been treated. X-ray examination revealed ossification of the ankle syndesmosis with an old posterior tibial fracture., Conclusion: The patient had ossification of the right ankle syndesmosis. This type of ossification has a benign natural course and a policy of wait and see, plus pain relief, is usually sufficient. Surgical removal of the ossification should only be considered in active sportsmen and sportswomen with persistent symptoms that do not respond to conservative treatment.

A rotator cuff tear is a highly prevalent disorder, occurring in 25% of people over 60 years of age. In two thirds of patients the tear is small and asymptomatic. Acute, symptomatic cuff tears may occur in active sportsmen and women aged 30-50. There is often a considerable delay in diagnosis in this group, due to a lack of recognition by either the patient or the doctor. Recently identified risk factors for the development of cuff tear are nicotine abuse, hypercholesterolaemia, contralateral cuff tear and genetic predisposition. Conservative treatment can be very successful and consists of physical therapy and effective analgesics. Repeated steroid injections are harmful to the tendinous tissue and should be avoided. The aim of surgery is anatomical reinsertion of the ruptured tendon using an open or arthroscopic procedure. The arthroscopic procedure enables the surgeon to perform a more extensive evaluation and treatment of the joint. The arthroscopic procedure is technically more demanding than the open procedure, but seems to have a shorter rehabilitation period.

There is increasingly more evidence to suggest that spontaneous femur fractures may be an adverse effect of long-term bisphosphonate use. Patients typically present with prodromal thigh pain, cortical thickening on conventional radiographs or present at A&E with a spontaneous transverse subtrochanteric femur fracture with a medial spike. Discontinuation of bisphosphonate therapy is advisable in patients presenting with a spontaneous femur fracture with specific features while using bisphosphonates. The way in which bisphosphonates alter the mechanical properties of bone is as yet unknown.