Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial.

Background: Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS. Methods: A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work. Results: In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial. Conclusion: MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

Manipulation under anesthesia for frozen shoulders : a retrospective cohort study.

ABBREVIATIONS: MUA, manipulation under anesthesia ; FS, frozen shoulder ; SPADI, Shoulder Pain and Disability Score ; OSS, Oxford Shoulder Score ; NPRS, Numeric Paind Rating Scale. Manipulation under anesthesia is a well-established, but controversial, treatment for frozen shoulders. We will evaluate our results of manipulation and physiotherapy in stage two frozen shoulders. Questionnaires were sent to 65 patients with stage 2 frozen shoulders, treated with manipulation under anaesthesia between January 2012 and January 2014. Outcome parameters consisted of SPADI, OSS, EQ-5D, pain and satisfaction. A response rate of 75% was obtained. Mean follow up was 21 months (range 11-36). The median SPADI score was 11.2 (IQR 0.8-25.2) and median OSS was 39.0 (IQR 30-43). Only 72% of patients reported that they reached their pre injury level of functioning. A satisfaction rate of 92% was reported. Manipulation is a relatively easy intervention with a high satisfaction rate. We assume that manipulation could shorten the duration of symptoms. However, this needs to be confirmed in a randomized trial with a control group.

Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder: a study protocol for a randomized controlled trial.

BACKGROUND: There is no consensus about the optimal treatment strategy for frozen shoulders (FS). Conservative treatment consisting of intra-articular corticosteroid infiltrations and physiotherapy are considered appropriate for most patients. However, with a conservative strategy, patients experience a prolonged rehabilitation period with a considerable amount of pain and disabilities in daily life. Also, at long term, a residual amount of pain and restriction of range of motion is frequently reported. Manipulation under anesthesia is a short and relative simple procedure with the potential to rapidly reduce symptoms and restore the range of motion. The objective of this trial is to evaluate the effectiveness of MUA followed by a PT program compared to a PT program alone, in the treatment of patients with a stage two FS. We hypothesize that the course of the disease can be shortened with MUA with a quicker functional recovery. METHODS: This is a prospective, single center, randomized controlled trial. Eligible patients will be allocated to either the manipulation (MUA) group or the physiotherapy alone (PT) group. In the MUA group manipulation will be performed under interscalene block, directly followed by an intensive physiotherapy treatment protocol, with the goal to maintain the obtained range of motion. Patients allocated to the PT group are given advice and education and receive a written protocol to hand out to their physical therapist based on the recent guideline of the Dutch Shoulder Network for the treatment of frozen shoulders. Descriptive statistics will be used to describe the sample size, patients demographics, presence of diabetes mellitus, range of motion, duration of symptoms till randomization and will be presented for each treatment group. The SPADI is used as primary functional outcome parameter. Secondary outcome parameters are; OSS, NPRS, EQ-5D 3-L, passive range of motion, WORQ-UP, duration of symptoms, usage of analgesics and adverse events. A sample size of 41 subjects in each group was calculated. Follow up is planned after 1,3 and 12 months. The length of physiotherapy treatment in both groups is variable, depending on individual progression. Differences between groups in outcome parameters will be analysed using the linear mixed modelling and the restricted maximum likelihood ratio technique for estimating the model parameters. DISCUSSION: Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. The results of this study can lead to a better understanding for the role of manipulation in the treatment of frozen shoulders. TRIAL REGISTRATION: This trial is registered in the Dutch Trial Register under the number NTR6182 on the 20th of February 2017.

Non-target screening with high-resolution mass spectrometry: critical review using a collaborative trial on water analysis.

In this article, a dataset from a collaborative non-target screening trial organised by the NORMAN Association is used to review the state-of-the-art and discuss future perspectives of non-target screening using high-resolution mass spectrometry in water analysis. A total of 18 institutes from 12 European countries analysed an extract of the same water sample collected from the River Danube with either one or both of liquid and gas chromatography coupled with mass spectrometry detection. This article focuses mainly on the use of high resolution screening techniques with target, suspect, and non-target workflows to identify substances in environmental samples. Specific examples are given to emphasise major challenges including isobaric and co-eluting substances, dependence on target and suspect lists, formula assignment, the use of retention information, and the confidence of identification. Approaches and methods applicable to unit resolution data are also discussed. Although most substances were identified using high resolution data with target and suspect-screening approaches, some participants proposed tentative non-target identifications. This comprehensive dataset revealed that non-target analytical techniques are already substantially harmonised between the participants, but the data processing remains time-consuming. Although the objective of a "fully-automated identification workflow" remains elusive in the short term, important steps in this direction have been taken, exemplified by the growing popularity of suspect screening approaches. Major recommendations to improve non-target screening include better integration and connection of desired features into software packages, the exchange of target and suspect lists, and the contribution of more spectra from standard substances into (openly accessible) databases. Graphical Abstract Matrix of identification approach versus identification confidence.

Total shoulder arthroplasty versus hemiarthroplasty for glenohumeral arthritis: A systematic review of the literature at long-term follow-up.

INTRODUCTION: The optimal surgical treatment of end-stage primary glenohumeral osteoarthritis remains controversial. The objective of this article is to systematically review the current available literature to formulate evidence-based guidelines for treatment of this pathology with an arthroplasty. MATERIALS AND METHODS: A systematic literature search was performed to identify all articles from 1990 onward that presented data concerning treatment of glenohumeral arthritis with total shoulder arthroplasty (TSA) or head arthroplasty (HA) with a minimal follow-up of 7 years. The most relevant electronic databases were searched. RESULTS: After applying the inclusion and exclusion criteria, we identified 18 studies (of the initial 832 hits). The search included a total of 1,958 patients (HA: 316 and TSA: 1,642) with 2,111 shoulders (HA: 328 + TSA: 1,783). The revision rate for any reason in the HA group (13%) was higher than in the TSA group (7%) (P < 0.001). There was a trend of a higher complication rate (of any kind) in the TSA group (12%) when compared with the HA group (8%) (P = 0.065). The weighted mean improvement in anteflexion, exorotation and abduction were respectively 33°, 15° and 31° in the HA group and were respectively 56°, 21° and 48° in the TSA group. Mean decrease in pain scores was 4.2 in the HA and 5.5 in the TSA group. CONCLUSION: Finally, we conclude that TSA results in less need for revision surgery, but has a trend to result in more complications. The conclusions of this review should be interpreted with caution as only Level IV studies could be included. LEVEL OF EVIDENCE: IV.

Identification strategy for unknown pollutants using high-resolution mass spectrometry: androgen-disrupting compounds identified through effect-directed analysis.

Effect-directed analysis has been applied to a river sediment sample of concern to identify the compounds responsible for the observed effects in an in vitro (anti-)androgenicity assay. For identification after non-target analysis performed on a high-resolution LTQ-Orbitrap, we developed a de novo identification strategy including physico-chemical parameters derived from the effect-directed analysis approach. With this identification strategy, we were able to handle the immense amount of data produced by non-target accurate mass analysis. The effect-directed analysis approach, together with the identification strategy, led to the successful identification of eight androgen-disrupting compounds belonging to very diverse compound classes: an oxygenated polyaromatic hydrocarbon, organophosphates, musks, and steroids. This is one of the first studies in the field of environmental analysis dealing with the difficult task of handling the large amount of data produced from non-target analysis. The combination of bioassay activity assessment, accurate mass measurement, and the identification and confirmation strategy is a promising approach for future identification of environmental key toxicants that are not included as priority pollutants in monitoring programs.

Dynamic and static external fixation for distal radius fractures--a systematic review.

INTRODUCTION: External fixation of distal radius fractures may be static (wrist-bridging) or dynamic (wrist-bridging with mobile hinge or non-bridging). The aim of this systematic review is to investigate the effectiveness of different methods of external fixation for unstable distal radius fractures. METHODS: A Medline database search was performed with strict eligibility criteria to obtain the highest quality evidence from meta-analyses, RCTs and comparative studies. Eligible studies were critically appraised using levels of evidence and RCTs were further appraised using a validated scoring tool. RESULTS: Fifty-four studies were identified of which eight were included. There were six RCTs and two retrospective comparative studies. Three RCTs compared non-bridging with static wrist-bridging fixation. Two RCTs compared dynamic wrist-bridging with static wrist-bridging fixation. One study compared dynamic wrist-bridging with non-bridging fixation. The RCTs varied in quality and scored between 12 and 23 out of a maximum of 33 points. The evidence suggests that there are no functional or radiological benefits for a dynamic wrist-bridging external fixator with a mobile hinge joint over a static wrist-bridging external fixator. The evidence also suggests that there are no benefits for non-bridging over static wrist-bridging external fixation in older patients but there do appear to be clear benefits both functionally and radiologically when considering patients of all ages. CONCLUSION: Dynamic and static external fixators both achieve good outcomes for patients with unstable distal radius fractures with comparable complication rates. Non-bridging fixation may result in better functional and radiological results than static wrist-bridging fixation when considering patients of all ages with earlier return of function. This benefit does not seem apparent when considering older patients. Although a benefit was not seen in this group, the technique may have practical advantages over wrist-bridging fixation by allowing increased mobility and use of the limb during the fixation period and enabling such patients to maintain their independence. Cost effective analyses are required to assess whether this would be an economically viable option for this group of patients.

Neglected Achilles tendon rupture with central insertional plantaris tendon hypertrophy: two cases.

A neglected Achilles tendon rupture is often characterized by muscle weakness and an overlengthened repair by scar tissue. Reconstructive surgery is usually performed taking into account the patient's required level of function. Two surgical cases of neglected Achilles tendon rupture are presented in this article. In both instances it was expected that central fibrosis, possibly after neglected tendon rupture, would be found. However, after longitudinal opening of the tendons, a thickened plantaris tendon was evident at the insertion on the calcaneus in both cases. This hypertrophic tendon occupied most of the diameter of the Achilles tendon. Due to partial or complete rupture of the Achilles tendon, there was notable weakening and tendon transfer-augmentation was performed. A thickened plantaris tendon as a reaction to a neglected rupture of the Achilles tendon is a rare presentation. It can be detected preoperatively by MRI and subsequently preoperative planning can be optimized.

Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures--a systematic review.

INTRODUCTION: Undisplaced and minimally displaced scaphoid waist fractures can be managed either operatively (percutaneous or ORIF) or non-operatively with both methods obtaining high rates of fracture union and subsequent return of function. The aim of this systematic review is to identify and evaluate the best available evidence to determine whether they should be managed operatively or non-operatively. MATERIALS AND METHODS: A Medline and journal hand search was performed with strict eligibility criteria to obtain the highest quality evidence from meta-analyses, randomised controlled trials (RCT) and comparative studies. Included studies were critically appraised using levels of evidence and RCTs were further appraised using a scoring tool. RESULTS: The search found 112 studies, of which 12 met the eligibility criteria for inclusion. Three level 1 RCTs, three level 2 RCTs, two meta-analyses, one economic analysis, and three retrospective studies were critically appraised. The evidence suggests that percutaneous fixation may result in faster union rates by approximately 5 weeks and an earlier return to sport and work by approximately 7 weeks over cast treatment. This difference is not seen when comparing ORIF with cast treatment. Although cast treatment results in a higher non-union rate than ORIF, this needs to be balanced with the 30% minor complication rate. Manual workers require significantly longer time off work than non-manual workers regardless of the method of treatment, although they did return to work sooner after ORIF than after cast treatment. CONCLUSION: The majority of these injuries can be treated in a cast with good results. Operative treatment should be reserved for patients unable to work in a cast and considered for most manual workers and high-level athletes.

Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail.

New techniques for tibiotalocalcaneal arthrodesis ideally should improve union rate and reduce the complication rate. The purpose of this study was to evaluate the union rate of tibiotalocalcaneal arthrodesis achieved using an intramedullary nail without formal debridement of the subtalar joint and open or percutaneous debridement of the ankle joint. Consolidation time, complication and satisfaction rates, American Orthopaedic Foot and Ankle Society ankle/hindfoot score, and shoe adaptation were assessed. Fifty patients who had tibiotalocalcaneal arthrodeses with a minimum followup of 12 months (mean, 51 months; range, 12-84 months) were retrospectively reviewed. All patients completed a questionnaire and underwent physical examination and radiographic investigations. Fusion was achieved in all ankles; two subtalar joints did not fuse. The average time of fusion was 20 weeks for both joints. Observed complications were few and the satisfaction rate was 92%. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 70. Tibiotalocalcaneal arthrodesis with a specifically designed retrograde intramedullary nail without formal debridement of the subtalar joint and a choice between open or percutaneous debridement of the ankle is a reliable method to achieve fusion. Opening and debriding the subtalar joint is, in our opinion, not necessary, and percutaneous debridement of the ankle is a good alternative to open debridement.