Randomized controlled trial of supervised physiotherapy versus a home exercise program after hydrodilatation for the management of primary frozen shoulder.

HYPOTHESIS AND BACKGROUND: Hydrodilatation and physiotherapy are commonly used treatments for primary frozen shoulder. Little is known about the optimal form of physiotherapy. This study reports a randomized controlled trial comparing 2 forms of physiotherapy after hydrodilatation. The null hypothesis was that there would be no difference between the 2 groups at 1 year as measured by the Oxford Shoulder Score (OSS). METHODS: We randomized 41 patients undergoing hydrodilatation for primary frozen shoulder into 2 treatment groups: group 1 (n = 20) underwent supervised physiotherapy in addition to a home exercise program, and group 2 (n = 21) followed a self-directed home exercise program in isolation. Assessment was carried out by a blinded research nurse at baseline, 4 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was the OSS. Other measures were range of movement, visual analog scale pain score, and EQ-5D index. RESULTS: There was no significant difference between the treatment groups at any time point as measured by the OSS or EQ-5D index. In group 1, the OSS improved significantly from 25.00 (95% confidence interval [CI], 21.92-28.08) at baseline to 38.29 (95% CI, 34.01-42.58; P < .0001) at 4 weeks and 43.71 (95% CI, 41.61-45.80; P < .0001) at 1 year. In group 2, the OSS improved significantly from 26.60 at baseline (95% CI, 22.50-30.70) to 40.07 (95% CI, 36.77-43.36; P < .0001) at 4 weeks and 43.00 (95% CI, 39.69-46.31; P < .0001) at 1 year. All outcome measures improved significantly from baseline to 4 weeks. CONCLUSION: In this group of patients, after a hydrodilatation procedure for the treatment of primary frozen shoulder, there was no significant difference in clinical outcomes between supervised physiotherapy in addition to a home exercise program and a self-directed home exercise program in isolation.

Polymerase chain reaction can detect bacterial DNA in aseptically loose total hip arthroplasties.

Identifying low-grade infection in failed total hip arthroplasties is an important but difficult task. This study investigated the ability of the polymerase chain reaction to identify low-grade infection during revision of total hip arthroplasties that failed from aseptic causes. One hundred thirteen specimens from 31 total hip arthroplasties revised for aseptic loosening were compared with 105 control specimens from 28 primary total hip arthroplasties. All surgeries were done in laminar flow operating rooms. No primary or revision specimen had positive microbiologic cultures. No revision specimen had histologic evidence suggestive of infection. Using the polymerase chain reaction with a detection threshold of 10 organisms per cubic centimeter of specimen, bacterial DNA was identified in 39 of 85 revision tissue specimens (46%) compared with 18 of 84 primary tissue specimens (21.4%). Bacterial DNA was identified in the synovial fluid of three specimens taken from 28 revision total hip arthroplasties (10.7%) and in two specimens taken from 21 primary total hip arthroplasties (9.5%). As multiple specimens were sent for each hip, a maximum of 16 of 31 revision total hip arthroplasties (52%) and eight of 28 primary total hip arthroplasties (29%) were considered to be infected. Bacterial DNA can be found in many specimens obtained from revised total hip arthroplasties considered to be aseptically loose. Because bacterial DNA identified at primary total hip arthroplasty was assumed to be attributable to contamination rather than present in healthy tissues, the overall specimen contamination rate of 19% and case contamination rate of 29% indicate that the polymerase chain reaction has poor specificity at this sensitivity level for diagnosing infection in revision total hip arthroplasty.

Contamination of primary total hip replacements in standard and ultra-clean operating theaters detected by the polymerase chain reaction.

BACKGROUND: Many organisms that are responsible for low-grade infection after total hip replacement (THR) are not recognized by routine culture. PATIENTS AND METHODS: We examined wound contamination during primary total hip replacement performed in standard and ultra-clean operating theaters. 20 THRs were performed in each type of theater. Paired tissue specimens taken at the beginning and end of surgery were analyzed by bacterial culture and for the presence of bacterial DNA by the polymerase chain reaction (PCR). In total, 160 specimens (80 for culture, 80 for PCR) from 40 THRs were tested. RESULTS: In standard theaters, none of the 20 specimens taken at the start of surgery were positive by culture, but 3 were positive by PCR (15%). Of the 20 specimens taken at the end of surgery, 2 were positive by enriched culture and 9 were positive by PCR. All specimens positive by culture were also positive by PCR. In ultra-clean theaters, none of the 20 specimens taken at the start of surgery were positive by culture, but 2 were positive by PCR. Of the 20 specimens taken at the end of surgery, none were positive by culture, but 6 were positive by PCR. All specimens that were positive by culture were positive by PCR. INTERPRETATION: Wound contamination of primary THR occurs frequently in both standard and ultra-clean operating theaters and contamination is greater at the end of surgery than at the beginning (p=0.04). In this small series, we found no differences in wound contamination between standard and ultra-clean theaters (p=0.1).