Objective To assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy. Design A systematic review and meta-analysis were conducted as per the PRISMA guidelines. Data sources PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018. Eligibility criteria Randomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles. Results Seven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of −5.65 (-10.51 to −0.79, three studies). However, this difference is unlikely to be clinically significant. Conclusion Current evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different. Systematic review registry PROSPERO registration number: CRD4201804493 Protocol reference This protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Systematic Reviews 2018; 7: 58

https://bjsm.bmj.com/content/bjsports/early/2019/08/03/bjsports-2018-099934.full.pdf

Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis

Physiotherapy management of Achilles tendinopathy.

This randomized clinical trial assesses the efficacy and cost-effectiveness of liposomal bupivacaine plus bupivacaine hydrochloride compared with bupivacaine hydrochloride alone for postoperative recovery and pain management among patients undergoing knee replacement.

/pdf/efficacy-of-liposomal-bupivacaine-and-bupivacaine-4nzu4tnq.pdf

Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement

Local infiltration anaesthesia (LIA) consisting of ropivacaine, epinephrine and ketorolac administered at the end of surgery has become the gold standard for postoperative analgesia as it provides improved postoperative pain relief compared to other methods. The use of LIA has retrospectively been shown to be associated with decreased perioperative blood loss. However, no randomised controlled trials have examined the effect of of preoperative LIA on blood loss. This study aimed to compare pre- vs perioperative LIA during TKA surgery, with a primary outcome of perioperative blood loss.The present study was performed as a prospective single-center randomised controlled trial. A total of 100 patients undergoing primary TKA between October 2016 and March 2018 were randomised to receive either pre- or perioperative LIA. Perioperative blood loss was measured, as well as pre- and postoperative haemoglobin levels. Postoperative pain was estimated at intervals approximately 24, 48 and 72 hours after surgery; analgesic drug consumption was recorded for each patient, as well as the total length of stay as an in-patient.Ninety six patients received either pre- or perioperative LIA as part of the intervention and control group respectively. Average blood loss was 39% lower in the intervention group at 130 ml vs 212 ml in the control group (p=0.002). No significant difference in haemoglobin drop, postoperative pain or length of hospital stay was found.Preoperative LIA resulted in a 39% decrease in perioperative blood loss during TKA surgery compared to perioperative administration while providing non-inferior postoperative pain relief. 

/pdf/preoperative-administration-of-local-infiltration-30gwq15i.pdf

Preoperative administration of local infiltration anaesthesia decreases perioperative blood loss during total knee arthroplasty – a randomised controlled trial

Local infiltration analgesia (LIA) has been proven to be efficient in total knee arthroplasty (TKA). However, the effect of single-shot LIA is temporarily limited. The objective of this prospective trial was to investigate if the potential benefits resulting from LIA can be prolonged by a continuous intra-articular perfusion of LIA. The hypothesis of the present study was that the use of an additional continuous intra-articular perfusion delivering LIA would result in less pain and better function compared to single-shot LIA in the immediate post-operative period. 50 consecutively selected patients undergoing TKA received either a single-shot LIA (S-LIA group, 25 knees) or single-shot LIA combined with a continuous post-operative intra-articular perfusion for three post-operative days (CP-LIA group, 25 knees). VAS (visual analogue scale) for pain, pain medication consumption and flexion ability were recorded postoperatively for 6 days. All patients had the same implant, surgeon and intra- as well as post-operative setting. The VAS score was significantly better for CP-LIA 6 h after surgery and on post-operative day 1, 2 and 6. There was no significant difference with regard to additional opioid consumption or flexion ability of the knee. However, there was a trend of the CP-LIA group requiring less additional opioids over the complete post-operative period compared to the S-LIA group. There were no complications or revisions. LIA combined with an additional intra-articular catheter provides better short-term pain control compared to single-shot LIA. However, no significant differences in terms of knee flexion were observed. This limited benefit should be balanced against the additional costs and the possible higher risk of infection. Level II.

Local infiltration analgesia with additional intraarticular catheter provide better pain relief compared to single-shot local infiltration analgesia in TKA

Treatment of mid-portion Achilles tendinopathy with eccentric training and its effect on neovascularization

Local infiltration analgesia (LIA) has attracted growing interest in recent years. To prolong the positive effects of LIA, a continuous intraarticular perfusion has been introduced in total knee arthroplasty with good clinical results. The purpose of the present study was to evaluate if similar results can be obtained with the use of a continuous periarticular perfusion in unicondylar knee arthroplasty (UKA). 50 consecutively selected patients undergoing UKA received either a single-shot LIA (control group; n = 25) or single-shot LIA combined with a continuous postoperative periarticular perfusion for 2 postoperative days (intervention group, n = 25). VAS (visual analogue scale) for pain, pain medication consumption and range of flexion were recorded postoperatively for 6 days. The catheter was removed after 2 days. Only minor advantages of using a continuous periarticular catheter could be shown. Patients in the intervention group showed significant lower VAS scores on day 1 and required significant less pain medication on day 6. Further, there was a significant difference in the range of flexion on day 3, on which patients of the intervention group were able to bend the knee joint on average by 12° more than patients of the control group. On the other days, any significant differences between the two groups were not observed. In summary, the present study could not identify any superiority of a periarticular catheter over single-shot LIA in UKA. Because of additional costs and the potential risk of infection, the conclusion of this study is to not recommend adding a periarticular catheter to the single-shot LIA in UKA. II

Additional periarticular catheter shows no superiority over single-shot local infiltration analgesia alone in unicondylar knee replacement

Die Behandlung der Midportion-Achillessehnen-Tendinopathie mit exzentrischem Krafttraining und dessen Auswirkung auf die Neovaskularisation

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Treatment of mid-portion Achilles tendinopathy with eccentric training and its effect on neovascularization

Additional periarticular catheter shows no superiority over single-shot local infiltration analgesia alone in unicondylar knee replacement

Die Behandlung der Midportion-Achillessehnen-Tendinopathie mit exzentrischem Krafttraining und dessen Auswirkung auf die Neovaskularisation