Moving towards evidence-based healthcare for musculoskeletal injuries: featuring the work of the Cochrane Bone, Joint and Muscle Trauma Group

Efficacy and safety of Wuhu oral liquid in treating acute soft tissue injuries: a multicenter, randomized, double-blind, double-dummy, parallel-controlled trial

Background: Wuhu Oral Liquid (WHOL) is a modified preparation derived from the famous Wuhu Powder, which has a long history of use in treating traumatic injuries. This preparation has anti-inflammatory and analgesic properties and accelerates recovery following acute soft tissue injuries. Aims: To evaluate the efficacy and safety of WHOL in treating acute soft tissue injury associated with qi stagnation and blood stasis syndrome and to provide a basis for applying for the protection of varieties of Chinese medicine for WHOL. Methods: This study was a randomized, controlled, double-blind, multicenter clinical trial in which Fufang Shang Tong Capsule (FFSTC) was selected as the control drug. A total of 480 subjects with acute soft tissue injury associated with qi stagnation and blood stasis syndrome were randomly divided into a test and control group in a 3:1 ratio. The duration of drug treatment was 10 days. The primary outcome was Visual Analogue Scale (VAS) score for pain (including pain at rest and pain on activity). Secondary outcomes included the disappearance time of the pain at rest and on activity; the curative effect of TCM syndrome and improvement in the individual symptoms of TCM (swelling, ecchymosis, and dysfunction); and changes in C-reactive protein (CRP) and interleukin-6 (IL-6) levels. Safety was assessed using vital signs, laboratory examinations, electrocardiograms, and physical examinations. Results: Patient compliance was satisfactory in both groups (all between 80% and 120%). After 4 days of treatment, the WHOL group was superior to the FFSTC group in decreasing the VAS scores for pain at rest (-1.88 ± 1.13 vs. -1.60 ± 0.93, p < 0.05) and on activity (-2.16 ± 1.18 vs. -1.80 ± 1.07, p < 0.05). After 7 days of treatment, the WHOL group was superior to the FFSTC group in decreasing the VAS scores for pain on activity (-3.87 ± 1.60 vs. -3.35 ± 1.30, p < 0.01) and improving swelling (cure rate: 60.4% vs. 46.2%, p < 0.05; obvious effective rate: 60.7% vs. 47.0%, p < 0.05). After 10 days of treatment, the WHOL group was superior to the FFSTC group in decreasing the levels of CRP (-0.13 ± 2.85 vs. 0.25 ± 2.09, p < 0.05) and improving the TCM syndrome (cure rate: 44.1% vs. 30.8%, p < 0.05) and swelling (cure rate: 75.6% vs. 67.5%, p < 0.01; obvious effective rate: 75.6% vs. 68.4%, p < 0.05; effective rate: 77.0% vs. 71.8%, p < 0.05). The disappearance time of pain at rest was 8 days in both groups and 9 days on activity in both groups. In addition, there was no statistical difference between the incidence of adverse events (4.5% vs. 2.6%, p > 0.05) and adverse reactions (0.3% vs. 0%, p > 0.05) between the WHOL group and the FFSTC group. No serious adverse events occurred in either group, and no subjects were withdrawn because of adverse events. Conclusion: WHOL relieves the symptoms caused by acute soft tissue injury associated with qi stagnation and blood stasis syndrome more rapidly than FFSTC, and it is effective and safe in the treatment of acute soft tissue injury. Future studies still need a larger sample size to verify its efficacy and safety. Clinical Trial Registration: https:// www.chictr.org.cn/showproj.html?proj=149531, Identifier ChiCTR2200056411.

Electroacupuncture of Weizhong (BL-40) Acupoint Inspires Muscular Satellite Cell Regeneration and Promotes Muscle Repair Capacity after Back Muscle Injury in Sprague-Dawley Rat Model

Background

Back muscle injury is the most common illness involved in aged people. Muscular satellite cells, playing a key role in the muscle repairing process, are gradually losing their regenerative ability with aging, which attenuates the injured muscle repairing process. Electroacupuncture at Weizhong acupoint has been widely used in the treatment of young and aged patients with back muscle damage. Its efficacy has been proven by a randomized double-blind placebo clinical trial. However, the rehabilitation mechanisms are largely unknown. This study will explore the possible mechanisms associated with electroacupuncture at the Weizhong acupoint (BL 40) promoting muscle repairing ability.

Method

A total of 58 male and female Sprague-Dawley rats were divided into a younger group (4-month-old) and an aged group (16-month-old), younger and aged rats were further divided as a sham, injured, injured rats treated with electroacupuncture at Weizhong point or treated with Non-Weizhong point groups. The back muscle injury model was produced in rats as a previously described method with modification. Furthermore, Weizhong acupoints underwent electroacupuncture treatment with 15 V magnitude, 2 Hz/10 Hz frequency density, 1.0 mA current intensity, and 10 min each day for 10 consecutive days using HANS's electroacupuncture apparatus. After the last treatment, the paravertebral muscles and serum of all animals were undergone histological, immunohistochemistry, and flow cytometry analysis. Serum levels of Creatine Kinase (CK) and proinflammatory cytokine, interleukin 6 (IL-6), were measured separately by using ELISA kit.

Results

Electroacupuncture of Weizhong (BL 40) acupoints significantly attenuated back muscle damage in both young and aged rats, increasing PAX7 (a marker of muscle satellite cells) and MYOD (major marker of myoblasts) cells, simultaneously, reducing serum proinflammatory cytokines, IL-6, and downregulation of p38 MAPK signaling in aged muscular satellite cells.

Conclusion

Our studies suggest that electroacupuncture of Weizhong (BL 40) acupoints can restore aged back muscular satellite cells and their regeneration capacity. These suggested electroacupuncture may be a potential means of promoting rehabilitation for muscular injury in aged patients.

Comparison of functional outcome of simultaneous and staged bilateral total knee arthroplasty : systematic review of literature

Safety of simultaneous bilateral TKA (simBTKA) and staged BTKA (staBTKA) have been compared in previous systematic reviews but functional outcome remains neglected aspect of the debate. We performed a systematic review of contemporary literature to compare the functional outcome of simBTKA and staBTKA. We searched PubMed/MEDLINE, EMBASE and Cochrane Central Database to identify all articles published between 2000 and July 2020 that evaluated the outcome of patients undergoing BTKA either in simultaneous or staged manner. Ten articles were identified which met the inclusion criteria. Functional outcome was reported in terms of Knee Society score (KSS), range of motion (ROM), Oxford Knee Score (OKS) and Western Ontario and McMaster University score (WOMAC) in seven, five, four and two studies respectively. KSS gained on average 66.6 points (47.5-95.3) for simBTKA and 65.1 points (44.4-97.2) for staBTKA without significant difference between two groups. There was no difference in post-operative ROM (maximum post-operative flexion being 124.4 and 125.1 for simBTKA and staBTKA groups respectively). Mean improvement in OKS ranged from 20 to 32.6 for simBTKA and 21.6 to 33.1 for staBTKA. There was moderate evidence to suggest that both simultaneous BTKA and staged BTKA produce equivalent improvement in functional scores.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

BACKGROUND

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015.

OBJECTIVES

To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

SEARCH METHODS

We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology.

MAIN RESULTS

We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to result in gastrointestinal or neurological adverse events compared with opioids. Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. Very low-certainty evidence means we are uncertain of the findings of no differences between the two interventions in the numbers with little or no pain at day one (51 participants, 1 study), day three (149 participants, 2 studies), or day seven (138 participants, 2 studies); swelling (230 participants, 3 studies); return to function at day seven (89 participants, 1 study); and the risk of gastrointestinal or neurological adverse events (141 participants, 3 studies). No studies reported re-injury rates. No studies compared NSAIDs with oral complementary and alternative medicines, AUTHORS' CONCLUSIONS: Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.

Efficacy and safety of loxoprofen sodium topical patch for the treatment of pain in patients with minor acute traumatic limb injuries in Brazil: a randomized, double-blind, noninferiority trial

Posttraumatic injury pain is commonly treated with oral nonsteroidal anti-inflammatory drugs. However, oral nonsteroidal anti-inflammatory drugs cause several adverse events, with topical formulations arising as an important alternative. Therefore, we aimed at evaluating the efficacy and safety of loxoprofen patch (LX-P) in the treatment of patients with posttraumatic pain. This phase III, randomized, double-blind, noninferiority study enrolled Brazilian patients aged 18 to 65 years diagnosed with lower and upper limb posttraumatic injury who were experiencing moderate or severe pain. Patients were assigned to active LX-P or to loxoprofen tablet (LX-T), and pain intensity was measured based on a visual analog scale score variation after 7 days of treatment. Data on clinical symptoms, rescue medication use, and adverse events were also collected. Visual analog scale score variation was compared using a 10% noninferiority margin. Two hundred forty-two patients were randomly assigned to LX-P (n = 123) or to LX-T (n = 119). The results showed a reduction in pain after 7 days of treatment: -49.96 (n = 118; SE 1.7) in the LX-P and -47.71 (n = 117; SE 1.6) in the LX-T groups (difference of -2.25; 95% CI: -5.97 to 1.47; P = 0.23). On the safety analysis, the LX-T group presented twice as many patients with treatment-emergent adverse events as the LX-P group (30.8% and 14.2%, respectively). A sensitivity analysis demonstrated that rescue medication use has not affected the primary end point. This study showed that LX-P has a comparable efficacy to LX-T, but with a better safety profile, being a therapeutic option for the treatment of posttraumatic injury pain.

Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs

Several meta-analyses have been published on the effectiveness of anterior cruciate ligament (ACL) injury prevention training programs to reduce ACL injury risk, with various degrees of risk reduction reported. The purpose of this research was to perform a systematic review and meta-analysis of overlapping meta-analyses evaluating the effectiveness of ACL injury prevention training programs so as to summarize the amount of reduction in risk for all ACL and non-contact ACL injuries into a single source, and determine if there were sex differences in the relative efficacy of ACL injury prevention training programs. Five databases (Medline, PubMed, Embase, CINAHL, and Cochrane) were searched to identify meta-analyses that evaluated the effectiveness of ACL injury prevention training programs on ACL injury risk. ACL injury data were extracted and the results from each meta-analysis were combined using a summary meta-analysis based on odds ratios (OR). Eight meta-analyses met eligibility criteria. Six of the eight only included data for female athletes. Summary meta-analysis showed an overall 50% reduction (OR = 0.5 [0.41-0.59]; I²  = 15%) in the risk of all ACL injuries in all athletes and a 67% reduction (OR = 0.33 [0.27-0.41]; I²  = 15%) for non-contact ACL injuries in females. This paper combines all previous meta-analyses into a single source and shows conclusive evidence that ACL injury prevention programs reduce the risk of all ACL injuries by half in all athletes and non-contact ACL injuries by two-thirds in female athletes. There is insufficient data to make conclusions as to the effectiveness of ACL injury prevention programs in male athletes. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2696-2708, 2018.

[Clinical results following conservative and surgical treatment of osteoporotic distal radius fractures in the elderly : Overview of best available evidence]

Fractures of the distal radius in elderly patients increasingly contribute to the workload in emergency departments worldwide. There is still no consensus about the best treatment option, e. g. closed reduction and cast stabilization, percutaneous pinning, external fixation or open reduction and internal fixation with volar locking plates (ORIF). In addition, the influence of pharmacological antiosteoporotic treatment (e. g. bisphosphonates) is unclear. In this overview five comparative studies were analyzed, which had been identified in a previous systematic review. The evaluation included 3 cohort studies and 2 randomized trials enrolling a total of 515 patients. A clinical or statistical advantage of ORIF over conservative treatment with respect to DASH scores 12 months after the index fracture event could not be demonstrated with a mean difference of 0.25 (95 % confidence interval CI -0.57-1.07). According to current best scientific evidence from preclinical and clinical investigations, antiosteoporotic medication does not have an unfavorable influence on fracture healing and should be continued due to its proven effectiveness in reducing subsequent osteoporotic fractures. Following distal radius fractures in elderly patients with clinical risk factors, an osteoporosis screening should be routine practice and a specific therapy should be initiated if the fracture risk is increased.

Deducing a mechanism of all musculoskeletal injuries

BACKGROUND

The mechanism of musculoskeletal (MSK) injuries is not well understood. This research applies principles of elastic motion to the anatomy and movement patterns of MSK structures. From this an insight into the application and timing of forces on MSK structures can be established and the mechanism/s of injury derived.

METHODS CURRENT KNOWLEDGE

All MSK structures demonstrate varying degrees of elasticity. Movement occurs primarily as a consequence of Muscle Tendon Unit (MTU) shortening. The application of an applied external force results in MSK structure lengthening.

RESULTS

The MTU acts as a non-idealised Hookean Spring. The resting length of MSK structures is the minimum distance between attachment points. The anatomical constraints results in MSK structures having adequate compressive strength during shortening. Thus MSK injuries only occur during lengthening of the MSK structure. From this with knowledge of MSK movement cycles, we can derive the mechanism of injury.

CONCLUSIONS

MSK injuries result from an inability to counter applied forces whilst lengthening. Muscles, tendons and ligaments can only injure during their lengthening contraction phase. Insertional tendons and bone near attachment points injure during the MTU shortening phase. Injuries to other MSK structures can occur independent of the lengthening and shortening phases such as direct contact injuries.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

BACKGROUND

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended.

OBJECTIVES

To assess the effects (benefits and harms) of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1937 to November 2012), AMED (1985 to November 2012), International Pharmaceutical Abstracts (1970 to November 2012), PEDro (1929 to November 2012), and SPORTDiscus (1985 to November 2012), plus internet search engines, trial registries and other databases. We also searched reference lists of relevant articles and contacted authors of retrieved studies and pharmaceutical companies to obtain relevant unpublished data.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain or contusion of a joint, ligament, tendon or muscle occurring up to 48 hours prior to inclusion in the study) and comparing oral NSAID versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects and early re-injury.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies for eligibility, extracted data and assessed risk of bias. We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

MAIN RESULTS

We included 16 trials, with a total of 2144 participants. Two studies included children only. The other 14 studies included predominantly young adults, of whom over 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, one was at high risk of bias due to incomplete outcome data, and four were at high risk of selective outcome reporting bias. The evidence was usually either low quality or very low quality, reflecting study limitations, indirectness such from as suboptimal dosing of single comparators, imprecision, or one or more of these. Thus we are either uncertain or very uncertain of the estimates.Nine studies, involving 991 participants, compared NSAIDs with paracetamol. While tending to favour paracetamol, there was a lack of clinically important differences between the two groups in pain at less than 24 hours (377 participants, 4 studies; moderate-quality evidence), at days 1 to 3 (431 participants, 4 studies; low quality), and at day 7 or over (467 participants, 4 studies; low quality). A similar lack of difference between the two groups applied to swelling at day 3 (86 participants, 1 study; very low quality) and at day 7 or over (77 participants, 1 study; low quality). There was little difference between the two groups in return to function at day 7 or over (316 participants, 3 studies; very low quality): based on an assumed recovery of function of 804 per 1000 participants in the paracetamol group, 8 fewer per 1000 recovered in the NSAID group (95% confidence interval (CI) 80 fewer to 73 more). There was low-quality evidence of a lower risk of gastrointestinal adverse events in the paracetamol group: based on an assumed risk of gastrointestinal adverse events of 16 per 1000 participants in the paracetamol group, 13 more participants per 1000 had a gastrointestinal adverse event in the NSAID group (95% CI 0 to 35 more).Four studies, involving 958 participants, compared NSAIDs with opioids. Since a study of a selective COX-2 inhibitor NSAID (valdecoxib) that was subsequently withdrawn from the market dominates the evidence for this comparison (706 participants included in the analyses for pain, function and gastrointestinal adverse events), the applicability of these results is in doubt and we give only a brief summary. There was low quality evidence for a lack of clinically important differences between the two groups regarding pain at less than 24 hours, at days 4 to 6, and at day 7. Evidence from single studies showed a similar lack of difference between the two groups for swelling at day 3 (68 participants) and day 10 (84 participants). Return to function at day 7 or over favoured the NSAID group (low-quality), and there were fewer gastrointestinal adverse events in the selective COX-2 inhibitor NSAID group (very low quality).Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is partly in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. While the point estimates favoured NSAID, the very low-quality evidence did not show a difference between the two interventions in the numbers with little or no pain at day 1 (51 participants, 1 study), day 3 (149 participants, 2 studies), or day 7 (138 participants, 2 studies). Very low-quality evidence showed a similar lack of difference between the two groups applied to swelling at day 3 (reported in two studies) and at day 7 (reported in two studies), in return to function at day 7 (89 participants, 1 study), and in gastrointestinal adverse events (141 participants, 3 studies).No studies compared NSAIDs with complementary and alternative medicines, and no study reported re-injury rates.

AUTHORS' CONCLUSIONS

There is generally low- or very low-quality but consistent evidence of no clinically important difference in analgesic efficacy between NSAIDs and other oral analgesics. There is low-quality evidence of more gastrointestinal adverse effects with non-selective NSAID compared with paracetamol. There is low- or very low-quality evidence of better function and fewer adverse events with NSAIDs compared with opioid-containing analgesics; however, one study dominated this evidence using a now unavailable COX-2 selective NSAID and is of uncertain applicability. Further research is required to determine whether there is any difference in return to function or adverse effects between both non-selective and COX-2 selective NSAIDs versus paracetamol.

Developing Community-Based Rehabilitation Programs for Musculoskeletal Diseases in Low-Income Areas of Mexico: The Community-Based Rehabilitation for Low-Income Communities Living With Rheumatic Diseases (CONCORD) Protocol

BACKGROUND

The negative impact of musculoskeletal diseases on the physical function and quality of life of people living in developing countries is considerable. This disabling effect is even more marked in low-socioeconomic communities within developing countries. In Mexico, there is a need to create community-based rehabilitation programs for people living with musculoskeletal diseases in low-socioeconomic areas. These programs should be directed to prevent and decrease disability, accommodating the specific local culture of communities.

OBJECTIVE

The objective of this paper is to describe a research protocol designed to develop, implement, and evaluate culturally sensitive community-based rehabilitation programs aiming to decrease disability of people living with musculoskeletal diseases in two low-income Mexican communities.

METHODS

A community-based participatory research approach is proposed, including multi and transdisciplinary efforts among the community, medical anthropology, and the health sciences. The project is structured in 4 main stages: (1) situation analysis, (2) program development, (3) program implementation, and (4) program evaluation. Each stage includes the use of quantitative and qualitative methods (mixed method program).

RESULTS

So far, we obtained resources from a Mexican federal agency and completed stage one of the project at Chankom, Yucatán. We are currently receiving funding from an international agency to complete stage two at this same location. We expect that the project at Chankom will be concluded by December of 2017. On the other hand, we just started the execution of stage one at Nuevo León with funding from a Mexican federal agency. We expect to conclude the project at this site by September of 2018.

CONCLUSIONS

Using a community-based participatory research approach and a mixed method program could result in the creation of culturally sensitive community-based rehabilitation programs that promote community development and decrease the disabling effects of musculoskeletal diseases within two low-income Mexican communities.

All-arthroscopic versus mini-open repair of small to large sized rotator cuff tears: a meta-analysis of clinical outcomes

Purpose

The purpose of this study was to compare clinical outcomes of patients with full-thickness small to large sized tears undergoing all-arthroscopic versus mini-open rotator cuff repair.

Method

A literature search for electronic databases and references for eligible studies was conducted through Medline, Embase and Cochrane library between 1969 and 2013.

Results

A total of 12 comparative studies (n = 770 patients) were included. Pooled results showed: there were no differences in function outcome, pain scores, retear rate or the incidence of adhesive capsulitis between all arthroscopic and mini-open repair groups.

Conclusions

There were no differences in outcomes between the arthroscopic and mini-open rotator cuff repair techniques, they should be considered alternative treatment options.

Level of Evidence

Level IV, Meta analysis.

Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies

The purpose of this study is to conduct a systematic review assessing the clinical outcome associated with Simultaneous bilateral and staged bilateral total knee arthroplasty (TKA). A literature search for eligible studies was conducted. Eighteen retrospective comparative studies were included. Pooled results showed that the prevalence of mortality at 30 days postoperatively, pulmonary embolism, blood transfusion rate were significantly higher in simultaneous TKA group. A significantly lower rate of deep infection and revision were found in simultaneous TKA. No significant difference was seen in regard to neurological complications, deep-vein thrombosis, cardiac complications, superficial infection. Compared with staged bilateral TKA, simultaneous bilateral TKA is associated with higher rates of mortality, pulmonary embolism and blood transfusion, while decreasing the risk of deep infection and revision rate.

Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials

BACKGROUND

Studies have shown that tranexamic acid reduces blood loss and transfusion need in patients undergoing total hip arthroplasty. However, no to date, no study has been large enough to determine definitively whether the drug is safe and effective. We examined whether intravenous tranexamic acid, when compared with placebo, was safe and effective in total hip arthroplasty.

METHODS

The literature search was conducted using the PubMed, Cochrane Library, MEDLINE, EMBASE, and China National Knowledge Infrastructure (CNKI) databases. Data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. Ultimately, 19 randomized controlled trials involving 1,030 patients were included.

RESULTS

The use of tranexamic acid significantly reduced total blood loss by a mean of 305.27 mL [95 % confidence interval (CI) -397.66 to -212.89, p < 0.001], intraoperative blood loss by a mean of 86.33 mL(95 % CI -152.29 to -20.37, p = 0.01), postoperative blood loss by a mean of 176.79 mL (95 % CI -236.78 to -116.39, p < 0.001), and "hidden" blood loss by a mean of 152.70 mL (95 % CI -187.98 to -117.42, p < 0.001), resulting in a meaningful reduction in the proportion of patients requiring blood transfusion (odds ratio 0.28, 95 % CI 0.19 to 0.42, p < 0.001). There was no significant difference in occurrence of deep vein thrombosis, pulmonary embolism, or other complications among the study groups, or cost or hospitalization duration.

CONCLUSIONS

The data from this meta-analysis indicate that intravenous tranexamic acid may reduce blood loss and transfusion need in patients undergoing total hip arthroplasty without increasing the risk of complications. However, high-quality randomized controlled trials are required to validate the results.

Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis

We conducted a systematic review of comparative clinical trials assessing the results of high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) in patients with strictly unilateral osteoarthritis of the knee. A literature search was conducted through Medline, Embase and Cochrane library. A total of 11 comparative studies were included. Pooled results showed: UKA showed significantly better results compared to HTO in terms of function results, however, no difference in specific knee score was observed; HTO got slightly better results of the range of motion; a trend towards an increased velocity was found in UKA without significant difference. Postoperative rate of revision and complications did not differ significantly between two groups. With the correct patient selection, both HTO and UKA show effective and reliable results.

Suggestion of GLYAT gene underlying variation of bone size and body lean mass as revealed by a bivariate genome-wide association study

Bone and muscle, two major tissue types of musculoskeletal system, have strong genetic determination. Abnormality in bone and/or muscle may cause musculoskeletal diseases such as osteoporosis and sarcopenia. Bone size phenotypes (BSPs), such as hip bone size (HBS), appendicular bone size (ABS), are genetically correlated with body lean mass (mainly muscle mass). However, the specific genes shared by these phenotypes are largely unknown. In this study, we aimed to identify the specific genes with pleiotropic effects on BSPs and appendicular lean mass (ALM). We performed a bivariate genome-wide association study (GWAS) by analyzing ~690,000 SNPs in 1,627 unrelated Han Chinese adults (802 males and 825 females) followed by a replication study in 2,286 unrelated US Caucasians (558 males and 1,728 females). We identified 14 interesting single nucleotide polymorphisms (SNPs) that may contribute to variation of both BSPs and ALM, with p values <10(-6) in discovery stage. Among them, the association of three SNPs (rs2507838, rs7116722, and rs11826261) in/near GLYAT (glycine-N-acyltransferase) gene was replicated in US Caucasians, with p values ranging from 1.89 × 10(-3) to 3.71 × 10(-4) for ALM-ABS, from 5.14 × 10(-3) to 1.11 × 10(-2) for ALM-HBS, respectively. Meta-analyses yielded stronger association signals for rs2507838, rs7116722, and rs11826261, with pooled p values of 1.68 × 10(-8), 7.94 × 10(-8), 6.80 × 10(-8) for ALB-ABS and 1.22 × 10(-4), 9.85 × 10(-5), 3.96 × 10(-4) for ALM-HBS, respectively. Haplotype allele ATA based on these three SNPs was also associated with ALM-HBS and ALM-ABS in both discovery and replication samples. Interestingly, GLYAT was previously found to be essential to glucose metabolism and energy metabolism, suggesting the gene's dual role in both bone development and muscle growth. Our findings, together with the prior biological evidence, suggest the importance of GLYAT gene in co-regulation of bone phenotypes and body lean mass.

Bivariate genome-wide association analyses of femoral neck bone geometry and appendicular lean mass

OBJECTIVE

Femoral neck geometric parameters (FNGPs), such as periosteal diameter (W), cross-sectional area (CSA), cortical thickness (CT), buckling ratio (BR), and section modulus (Z), are highly genetically correlated with body lean mass. However, the specific SNPs/genes shared by these phenotypes are largely unknown.

METHODS

To identify the specific SNPs/genes shared between FNGPs and appendicular lean mass (ALM), we performed an initial bivariate genome-wide association study (GWAS) by scanning ∼690,000 SNPs in 1,627 unrelated Han Chinese adults (802 males and 825 females) and a follow-up replicate study in 2,286 unrelated US Caucasians.

RESULTS

We identified 13 interesting SNPs that may be important for both FNGPs and ALM. Two SNPs, rs681900 located in the HK2 (hexokinase 2) gene and rs11859916 in the UMOD (uromodulin) gene, were bivariately associated with FNGPs and ALM (p = 7.58×10(-6) for ALM-BR and p = 2.93×10(-6) for ALM-W, respectively). The associations were then replicated in Caucasians, with corresponding p values of 0.024 for rs681900 and 0.047 for rs11859916. Meta-analyses yielded combined p values of 3.05×10(-6) and 2.31×10(-6) for rs681900 and rs11859916, respectively. Our findings are consistent with previous biological studies that implicated HK2 and UMOD in both FNGPs and ALM. Our study also identified a group of 11 contiguous SNPs, which spanned a region of ∼130 kb, were bivariately associated with FNGPs and ALM, with p values ranging from 3.06×10(-7) to 4.60×10(-6) for ALM-BR. The region contained two neighboring miRNA coding genes, MIR873 (MicroRNA873) and MIR876 (MicroRNA876).

CONCLUSION

Our study implicated HK2, UMOD, MIR873 and MIR876, as pleiotropic genes underlying variation of both FNGPs and ALM, thus suggesting their important functional roles in co-regulating both FNGPs and ALM.

Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis

OBJECTIVE

To evaluate the mortality and postoperative morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty (TKA).

METHODS

We identified eligible studies in PubMed (1980-2010), OVID MEDLINE (1980-2010) and the Cochrane library. Data were extracted and evaluated by two reviewers independently. Data analyses were conducted with Stata 10.0.

RESULTS

Fourteen studies met our inclusion criteria. Combined results showed that the prevalence of mortality [OR = 3.202, 95% CI (1.852-5.537)], mortality at 30 days postoperatively [OR = 5.564, 95% CI (2.392-12.939)] and neurological complications [OR = 2.906, 95% CI (1.200-7.037)] were significantly higher in the population who had undergone simultaneous TKA compared with those who had undergone staged TKA. The prevalence of infection, pulmonary embolism, deep-vein thrombosis, and cardiac complications between the two populations was not significantly different.

CONCLUSION

Compared with staged bilateral TKA, simultaneous bilateral TKA might carry a higher potential risk of postoperative complications. Patients should be aware of this information when deciding whether to proceed with simultaneous bilateral TKA. The poor quality of the studies calls into question the robustness of the analyses.

Oral cyclo-oxygenase 2 inhibitors versus other oral analgesics for acute soft tissue injury: systematic review and meta-analysis

BACKGROUND

Acute soft tissue injuries are common and carry significant societal costs. Cyclo-oxygenase 2 (COX-2) inhibitors (coxibs), non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics are used to treat acute soft tissue injuries, with ongoing debate about their analgesic efficacy, effects on tissue healing and adverse effects (AEs).

OBJECTIVES

To systematically review the evidence comparing oral coxibs with other oral analgesics for acute soft tissue injuries, using the outcomes: pain, swelling, function and AEs.

METHODS

The following databases were searched: MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, AMED, PEDro and SPORTDiscus. Further studies were sought through clinical trials registries, dissertations, correspondence with pharmaceutical companies and manual searches of relevant journals. There was no language restriction.

DEFINITIONS

'Coxibs' were defined as drugs that inhibit COX-2 >5-fold more than COX-1; 'acute' was defined as injury occurring within 48 hours of enrollment; 'soft tissue injury' was defined as closed injuries to upper or lower limb soft tissues (ligaments, muscles or tendons).

STUDY SELECTION

Randomized controlled trials in humans comparing a coxib to a different class of oral analgesic agent for the treatment of acute soft tissue injuries for <30 days, and in which >or=80% of participants met the definition of acute soft tissue injury, were included. Studies were excluded if >20% of participants enrolled had back pain, cervical spine injury, repetitive strain injuries, delayed-onset muscle soreness, fractures, cartilage injury, penetrating wounds or primary inflammatory conditions (tendonitis, bursitis and arthritis). Nine out of 23 (39.1%) potentially relevant studies met the selection criteria.

DATA EXTRACTION

A standard form was used to extract data. Included studies were screened by the authors for risk of bias using the Cochrane risk of bias tool and evidence was graded for quality using the GRADE tool.

DATA SYNTHESIS

Clinical heterogeneity was minimized by application of strict selection criteria. Statistical heterogeneity was assessed using the I2 statistic and meta-analysis was undertaken if appropriate. Weighted mean difference (WMD) was used to assess pain, relative risk (RR) to assess AEs, and Peto odds ratio (OR) to assess return to function.

RESULTS

The nine RCTs evaluated in the meta-analysis included 3060 patients. Coxibs were found to be equal to NSAIDs (day 7+, n = 1884, 100 mm visual analogue scale [VAS]), WMD = 0.18 mm (95% CI -1.76, 2.13), p = 0.85 and tramadol (day 7+, n = 706, 100 mm VAS), WMD = -6.6 mm (95% CI -9.63, -3.47) [single study, difference clinically insignificant] for treating pain after soft tissue injuries. Coxibs had fewer gastrointestinal AEs than NSAIDs, even with short-term use (RR 0.59 [95% CI 0.41, 0.85], p = 0.004) [low quality evidence]. Swelling was measured in two studies with no difference being found between groups, but the presentation of the data was not sufficient to allow further analysis. Coxibs were found to be unlikely to be different to NSAIDs in helping patients return to function (OR 1.0 [95% CI 0.77, 1.3], p = 0.99); however, a single study suggested they may improve time to return to function (moderate quality evidence) and may have fewer AEs than tramadol (very low quality evidence). The risk of serious AEs with both coxibs and NSAIDs in this setting was low (but incompletely defined).

CONCLUSIONS

More studies comparing coxibs with NSAIDs and other analgesics in the setting of acute soft tissue injuries are necessary. A different review methodology would be required to answer the question of cardiovascular risk associated with short-term use of coxibs and NSAIDs.