Aims. To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period. Methods. This observational cohort study used electronic health record data from all patients undergoing preoperative screening for primary TKA at a Northern Netherlands hospital between 2009 and 2020. In this timeframe, three perioperative care transitions were divided into four periods: Baseline care (Joint Care, n = 171; May 2009 to August 2010), Function-tailored (n = 404; September 2010 to October 2013), Fast-track (n = 721; November 2013 to May 2018), and Prehabilitation (n = 601; June 2018 to December 2020). In-hospital recovery was measured using inpatient recovery of activities (IROA), length of stay (LOS), and discharge to preoperative living situation (PLS). Multivariable regression models were used to analyze the impact of each perioperative care transition on in-hospital recovery. Results. The four periods analyzed involved 1,853 patients (65.9% female (1,221/1,853); mean age 70.1 years (SD 9.0)). IROA improved significantly with each transition: Function-tailored (0.9 days; p < 0.001 (95% confidence interval (CI) -0.32 to -0.15)), Fast-track (0.6 days; p < 0.001 (95% CI -0.25 to -0.16)), and Prehabilitation (0.4 days; p < 0.001 (95% CI -0.18 to -0.10)). LOS decreased significantly in Function-tailored (1.1 days; p = 0.001 (95% CI -0.30 to -0.06)), Fast-track (0.6 days; p < 0.001 (95% CI -0.21 to -0.05)), and Prehabilitation (0.6 days; p < 0.001 (95%CI -0.27 to -0.11)). Discharge to PLS increased in Function-tailored (77%), Fast-track (91.6%), and Prehabilitation (92.6%). Post-hoc analysis indicated a significant increase after the transition to the Fast-track period (p < 0.001 (95% CI 3.19 to 8.00)). Conclusion. This study highlights the positive impact of different perioperative care procedures on in-hospital recovery of patients undergoing primary TKA. Assessing functional recovery, LOS, and discharge towards PLS consistently, provides hospitals with valuable insights into postoperative recovery. This can potentially aid planning and identifying areas for targeted improvements to optimize patient outcomes. Cite this article: Bone Joint J 2024;106-B(6):573–581

Introduction. The purpose of this study was to characterize the recovery of physical activity following knee arthroplasty by means of step counts and flight counts (flights of stairs) measured using a smartphone-based care platform. Methods. This is a secondary data analysis on the treatment cohort of a multicenter prospective trial evaluating the use of a smartphone-based care platform for primary total and unicondylar joint arthroplasty. Participants in the treatment arm that underwent primary total or unicondylar knee arthroplasty and had at least 3 months of follow-up were included (n=367). Participants were provided the app with an associated smart watch for measuring several different health measures including daily step and flight counts. These measures were monitored preoperatively, and the following postoperative intervals were selected for review: 2–4 days, 1 month, 1.5 month, 3 months and 6 months. The data are presented as mean, standard deviation, median, and interquartile range (IQR). Signed rank tests were used to assess the difference in average of daily step counts over time. As not all patients reported having multiple stairs at home, a separate analysis was also performed on average flights of stairs (n=214). A sub-study was performed to evaluate patients who returned to preoperative levels at 1.5 months (step count) and 3 months (flight count) using an independent samples T test or Fisher's Exact test was to compare demographics between patients that returned to preoperative levels and those that did not. Results. The mean age of the step count population was 63.1 ± 8.3 years and 64.31% were female, 35.69% were male. The mean body mass index was 31.1 ± 5.9 kg/m. 2. For those who reported multiple stairs at home, the mean age was 62.6 ± 8.3 years and 62.3% were female. The mean body mass index was 30.7 ± 5.4 kg/m. 2. . As expected, the immediate post-op (2–4 days) step count (median 1257.5 steps, IQR 523 – 2267) was significantly lower than preop (median 4160 steps, IQR 2669 – 6034, p < 0.001). Approximately 50% of patients returned to preoperative step counts by 1.5 months postoperatively with a median 4,504 steps (IQR, 2711, 6121, p=0.8230, Figure 1). Improvements in step count continued throughout the remainder of follow-up with the 6-month follow-up visit (median 5517 steps, IQR 3888 – 7279) showing the greatest magnitude (p<0.001). In patients who reported stairs in their homes, approximately 64% of subjects returned to pre-op flight counts by 3 months (p=0.085), followed similar trends with significant improvements at 6 months (p=0.003). Finally, there was no difference in age, sex, BMI, or operative knee between those that returned to mean preoperative step or flight counts by 1.5 months and 3 months, respectively. Discussion and Conclusion. These data demonstrated a recovery curve similar to previously reported curves for patient reported outcome measures in the arthroplasty arena. Patients and surgeons may use this information to help set goals for recovery following total and unicondylar knee arthroplasty using objective activity measures. For any figures or tables, please contact the authors directly

Purpose. This research project explored the experiences, attitudes, beliefs, and perceptions of healthcare professionals (physiotherapists and orthopaedic surgeons) and people with chronic low back pain (CLBP) regarding the barriers and facilitators to activity normalisation following physiotherapy. Methods. A qualitative study of the perspectives of patients, physiotherapists and orthopaedic surgeons on CLBP was undertaken in Saudi Arabia. One focus group discussion was conducted with seven patients who had received physiotherapy for CLBP, along with one focus group discussion with eight physiotherapists and seven individual interviews with orthopaedic surgeons. The focus group discussions and interviews were transcribed and analysed using framework analysis. Results. We identified seven factors facilitating or hindering activity normalisation following physiotherapy: symptom control, patient education and awareness, adherence to treatment plan, psychosocial factors, role of the clinician, social support, and issues relating to the healthcare system. Conclusion. Clinicians stressed the importance of exercise and regular activity in spite of pain as an important factor hindering activity normalisation. Patients appreciated reassurance and advice from clinicians but also noted that conflicting and ambiguous advice and diagnosis was common. This may contribute to poor adherence with advice and exercise. Fear of pain and recurrence of injury were highlighted as important factors hindering activity normalisation, particularly since some patients did not take active steps to control pain. Finally, whilst multidisciplinary teams may support patient recovery and activity normalisation, this is often expensive and intensive and may be beyond the reach of a healthcare system without a properly functioning referral system and insufficient specialised clinics and physicians. Conflicts of interest: None. Sources of funding: This research was supported through a PhD scholarship from Prince Sattam bin Abdulaziz University, Saudi Arabia, at the University of Nottingham, United Kingdom

Aims

The aim of this study was to explore parents’ experience of their child’s recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture.

Eliminating pain and restoring physical activity are the main goals of total hip arthroplasty (THA). Despite the high relevance of activity as a rehabilitation goal of and criterion for discharge, in-hospital activity between operation and discharge has hardly been investigated in orthopaedic patients. Therefore, the aim of this study was to a) measure for reference the level of in-hospital physical activity in patient undergoing a current rapid discharge protocol, b) compare these values to a conventional discharge protocol and c) test correlations with pre-operative activities and self-reported outcomes for possible predictors for rapid recovery and discharge. Patients (n=19, M:F: 5:14, age 65 ±5.7 years) with osteoarthritis treated with an elective primary THA underwent a rapid recovery protocol with discharge on day 3 after surgery (day 0). Physical activity was measured using a 3D accelerometer (64×25×13mm, 18g) worn on laterally on the unaffected upper leg. The signal was analysed using self-developed, validated algorithms (Matlab) calculating: Time on Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min), walking bouts, longest walk (steps). For the in-hospital period (am: ca. 8–13h; pm: ca. 13–20h) activity was calculated for day 1 (D1) and 2 (D2). Pre-operative activity at home was reported as the daily averages of a 4-day period. Patient self-report included the HOOS, SQUASH (activity) and Forgotten Joint Score (FJS) questionnaires. In-hospital activity of this protocol was compared to previously collected data of an older (2011), standard conventional discharge protocol (day 4/5, n=40, age 71 ±7 years, M:F 16:24). All activity parameters increased continuously between in-hospital days and subsequent am and pm periods. E.g. Time-on-feet increased most steeply and tripled from 21.6 ±14.4min at D1am to 62.6 ±33.4min at D2pm. Mean Steps increased almost as steep from 252 to 655 respectively. SST doubled from 4.9 to 10.5. All these values were sign. higher (+63 to 649%) than the conventional protocol data. Cadence as a qualitative measure only increased slowly (+22%) (34.8 to 42.3steps/min) equalling conventional protocol values. The longest walking bout did not increase during the in-hospital period. Gender, age and BMI had no influence on in-hospital activity. High pre-op activity (ToF, steps) was a predictor for high in-hospital activity for steps and SST's at D2pm (R=0.508 to R=0.723). Pre-op self-report was no predictor for any activity parameter. In-hospital recovery of activity is steep following a cascade of easy (ToF) to demanding (SST) tasks to quality (cadence). High standard deviations show that recovering activity is highly individual possibly demanding personalised support or goals (feedback). Quantitative parameters were all higher in the rapid versus the conventional discharge protocol indicating that fast activation is possible and safe. Equal cadence for both protocols shows that functional capacity cannot be easily accelerated. Pre-op activity is only a weak predictor of in-hospital recovery, indicating that surgical trauma affects patients similarly, but subjects may be identified for personalized physiotherapy or faster discharge. Reference values and correlations from this study can be used to optimize or shorten in-hospital rehabilitation via personalization, pre-hab, fast-track surgery or biofeedback

Introduction. Total knee arthroplasty (TKA) is highly successful due to pain reduction, patient satisfaction, and increased range of motion (ROM) during activities of daily living (ADL). ROM recovery is critical for successful outcomes, however ROM values are typically captured during routine physical therapy (PT) appointments via simplified measures (e.g. goniometric maximum passive ROM). These measures are imprecise, potentially neglecting patients’ home experiences. Accordingly, improved measurement methods are necessary to realistically represent ROM recovery. A validated inertial measurement unit (IMU) method continuously capturing knee ROM was deployed assessing knee ROM recovery during PT appointments and during patients’ routine daily experiences. Our objectives were to 1) continuously capture knee ROM pre-/post-TKA via IMUs and 2) divide each day's data to PT/non-PT segments comparing ‘gold standard’ ROM measurements (PT periods) with non-invasive home measurements (non-PT periods). Given patients are verbally/physically encouraged during PT, we hypothesized PT and non-PT metrics would be significantly different including 1) greater kinematics, 2) shorter times, and 3) greater activity level during PT compared to non-PT. Methods. Following IRB approval, IMUs captured long duration, continuous (8–12 hours/day, ∼50 days) knee ROM pre-/post-TKA. Post-TKA metrics were subdivided to PT/non-PT time periods including maximum ROM, gait phase ROMs (stance/swing), gait times (stride/stance/swing), and activity level. Clinical ROM and patient reported outcome measures (PROMs) were also captured before/after TKA. Statistical comparisons were completed between pre-TKA, post-TKA PT, and post-TKA non-PT metrics. Correlation analyses were completed between IMU, clinical ROM, and PROMs. Results. 10 TKA patients (3M, 69±13 years) enrolled. Patient compliance with sensor use was high (pre-TKA: 9.7±1.8 hours/day, 6±1 days; post-TKA: 8.5±2.3 hours/day, 37±4 days). Patients received 1.5±0.5 standard PT sessions per postop week (1.1±0.2 hours/session). All patients were well-healed at 6-weeks post-TKA with no additional surgical interventions required. Dividing ROM data showed distinct qualitative differences between PT and non-PT periods. Specifically, maximum knee ROM was significantly less during PT than outside PT during late rehabilitation weeks. Additionally, PT stance and swing phase ROM were significantly greater during PT throughout recovery. No differences in stride/stance/swing time were noted between PT/non-PT periods during recovery. However, significant activity level differences were noted throughout recovery. Discussion. This study highlights limitations utilizing clinic captured ROM establishing recovery. Notably, IMU ROM measurements allow capturing richer information than discrete simplified clinical measures. Maximum flexion during PT was likely less than non-PT due to exercises completed (i.e. high passive ROM vs. low ROM gait performance). PT gait flexion was likely greater than non-PT because of ‘white coat effects’ wherein patients are closely monitored clinically, whereas gait is completed as desired at home. Interestingly, temporal metrics were equal between PT/non-PT implying clinician's presence encourages improved kinematics but has no impact on ambulation timing. Activity level was significantly greater during PT than non-PT likely resultant from clinicians enforcing high activity levels throughout PT sessions. In total, these results imply data captured clinically represents optimum patient performance whereas data captured non-clinically represents realistic patient performance. For any figures or tables, please contact authors directly

Osteocytes are terminally differentiated long-lived cells and account for greater than 95% of the bone cell population. It has been established that osteocytes are connected through their highly developed dendritic network, which is necessary for the maintenance of optimal bone homeostasis. However, little is known on how osteocytes use the network to coordinate their cellular function and communication that requires energy and protein turnover. Here using super-resolution confocal imaging on both live and fixed osteocytes, we demonstrated conclusively that mitochondria are widely distributed and dynamically shared between osteocytes. Using confocal live cell imaging analysis we showed that inhibiting the contact between mitochondria and endoplasmic reticulum (ER) by the knockdown of MFN2 in osteocytes impedes the transfer of mitochondria suggesting the involvement of ER contact with mitochondria in the transfer process. Moreover, we showed that transport of mitochondria between osteocytes within the network enables rescue of osteocytes with dysfunction of mitochondria. Using the 3D tetraculture system with confocal imaging, we identify the transfer of mitochondria from healthy osteocytes enables recovery of mitochondria activities in osteocytes that devoid of mitochondrial DNA by ethidium bromide. The results indicated that when osteocytes are depleted of functional mitochondria, normal parental osteocytes can transfer mitochondria to these stressed osteocytes to provide them with energy. Collectively we show for the first time that the utilisation of mitochondrial transfer enables osteocytes to function with a network and coordinate their cellular activities in response to different energy demands

Numerous sequelae are reported after treatment, conservative or surgical, for proximal humerus fractures, which may result in shoulder pain and disability. The treatment of these conditions is still controversial. The aim of the present study was to evaluate the results achieved with the use of non-constrained shoulder prostheses. Twelve patients (seven men, five women) were included in the study. The indications for prosthetic shoulder replacement were pain and loss of function that did not respond to medical and physical therapy. All the patients were clinically evaluated preoperatively and postoperatively with the Constant scoring system and by X-ray. Fracture sequelae were grouped in type A, humeral head collapse (n=5); type B, locked fracture/dislocation (n=3); type C non-union of the surgical neck (n=2); and type D malunion of the tuberosity (n=2). In all the patients the same prosthetic implant (Aequalis, Tornier, France), and the same post-operative rehabilitation programme were employed. The mean follow-up was 4 years. The best results were observed in the sequelae grouped as type A and B with an impressive reduction in pain and good recovery of activity. At the last follow-up no radiological signs of implant mobilisation were registered. In our small series shoulder replacement seems to be the treatment of choice, in particular for sequelae of intracapsular impacted fractures of the proximal humerus. A larger series and a longer follow-up are still required to clarify these results

INTRODUCTION: The authors present the results of a surgical technique for lateral ankle chronic instability, derived from Castaing and Duquennoy procedures. It uses a half peroneus brevis with a tightening of the antero- lateral capsule. A Plasty with the extensorum digitorum brevis was used in the event of associated subtalar instability. MATERIAL AND METHODS: Between 2001 and 2005, 38 cases of ligamentoplasties have been performed for chronic instability of the ankle. 32 (25 men and 7 women) of them have been reviewed with a mean delay of 26 months (extremes of 10 months to 5 years). They were middle-aged of 28,5 years. All the patients have been reviewed with stress X-Ray in varus of the both ankles (measure of tibio talar angle, arthritis) and had a strength measure in eversion by the same examiner. The functional evaluation was performed with Molander and Olerud ankle score. RESULTS: There were 20% of complications, especially cutaneous cicatrisation problems and algodystrophy. After surgery, no patient had instability; only one, had apprehension of the ankle. 90 % retrieved the same sport with the same level. No body changed of job. 3 patients were disappointed because of pain in sports and stiffness. At revision, the functional score was 90 against 59 at the pre operative time. The difference of strength in eversion between the two ankles was about 7%. Laxity had a good correction seeing the average tibio talar angle between the both ankle is 0,5°. DISCUSSION: The results of this procedure show a distinct improvement of stability, radiological laxity and functional activity. The arthrotomy performed in Duquennoy procedure, is useful for diagnosis and treatment. It shows the cartilage and allows the removal of impingement and foreign bodies. A plasty that uses the single evertor deprives the ankle of a part of active and proprioceptive control. However, the patients didn’t feel a difference or a discomfort. The patients who had the surgery on the jump foot side had no significative difference of strength in eversion between the both ankles. CONCLUSION: This anatomical procedure gives 91% of satisfaction, for these active young people. The postoperative physiotherapy allows the complete recovery of activities from the sixth month after surgery

Whiplash remains a challenging condition because the pathology is undefined. The purpose of this study was to evaluate the response of chronic neck, shoulder and arm pain to decompression of the median nerve at the wrist and pronator teres level. In a prospective study of 150 cases following whiplash injury (108 carpal tunnel and 42 pronator teres syndrome) clinical symptoms were assessed by clinical, neurological, radiological and visual analogue scale. The pathophysiology of pain and effects of surgery have also been assessed by neuropeptide studies. Clinical and neurological examination revealed signs and symptoms of carpal tunnel and pronator teres syndrome along with severe neck, shoulder and arm pain. Local anesthetic infiltration around the median nerve at the wrist and forearm abolished the chronic neck and shoulder pain within 10mins of injection. This demonstrated the site of pathology and temporarily relieved upper limb symptoms and trapezius muscle spasm as well. Neurophysiological studies were always normal. Surgical intervention in successful cases cured chronic neck shoulder and arm pain with sensory and motor recovery. Also activities of daily life normalised permanently. The main neurotransmitter peptides Substance P and Calcitonin gene related peptide levels returned to control levels six weeks after surgery in successful cases (p< 0. 005 and p< 0. 05 respectively). This is the biochemical evidence of effect of surgery in relieving pain and neuroinflammatory process. Our study suggests that neck shoulder and arm pain following whiplash injury is caused by entrapment of the median nerve due to stretching. Surgical decompression of the carpal tunnel and pronator teres muscle yielded 93% and 80% good results respectively with the disappearance of chronic neck shoulder and arm pain. Consequently normalisation of daily activities were observed. Although mild hand symptoms caused by carpal tunnel syndrome have also been cured the primary aim of surgical intervention is to cure chronic neck shoulder and arm pain

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.

Aims: This is a retrospective study, comparing prosthesis survivorship, complications and functional results in geriatric patients treated with different types of prosthetic replacement for subcapital fractures of the hip. Methods: In the years 1985–1999, 292 elderly (aged 65–80 years) patients with displaced, nonpathologic sub-capital hip fractures were operated on. Of those, 143 were lost to follow-up; therefore, prospectively collected data of 149 patients were retrospectively reviewed. 54 patients received a unipolar, 48 a bipolar prosthesis and 47 underwent a primary total hip arthroplasty (THA). Mean follow-up was 5.3 years. The patients did not differ in pre-injury characteristics. Analysis of variance was used to compare the three patient groups in terms of early and late complications, need for revision surgery, and functional outcome. Results: A statistically signiþ-cant difference was noted, regarding need for revision surgery, since 5 (9.25%) of the unipolar and 5 (10.4%) of the bipolar prostheses had to be re-operated, compared to 2 (4.25%) from the THA group. Of note, 4 of the revised bipolar prostheses had loose stems. The THA group also proved superior, when recovery of instrumental activities was investigated. Conclusions: Elderly patients, whose biologic age poses high functional demands on them, with a displaced subcapital hip fracture, should receive a total hip arthroplasty. Stem loosening seems more likely, as a mode of failure, in bipolar prostheses, than acetabular erosion

Following acute ACL rupture patients are routinely referred for rehabilitation but the timing and level of functional recovery related to rehabilitation outcome are poorly defined. The primary aim of this study was to measure functional recovery following acute ACL rupture in the clinical setting using a two dimensional movement analysis system. A longitudinal research design was used; we aimed for three clinical movement analysis sessions over the course of rehabilitation. One hundred and fifteen patients were recruited. Sixty three uninjured matched controls were recorded once performing all the functional activities; walking, jogging, distance hop and run and stop. Participants were filmed in the sagittal plane using a digital camcorder to extract kinematic data. Average recovery over time was modelled using a least squares third order polynomial. The secondary aim was to define the outcome measures and treatment goals used in ACL rehabilitation by specialist knee physiotherapists. A questionnaire was distributed to 300 hospitals across the UK. From the 44 responses insight was obtained about parameters physiotherapists use to plan treatment and evaluate recovery. Repeated movement analysis showed that gait velocity took on average 85 days to recover to within the normal limits of uninjured controls. Jogging velocity took 30 days; Hop distance took 55 days for the non-injured leg and 100 days for the injured leg; Knee range during the landing phase of run and stop took 80 days to recover but demonstrated some deterioration. The questionnaire identified that specialist knee physiotherapists use 60 different outcome measures and 34 rehabilitation treatment goals, which can be sub-divided into patient reported (PR), functional activities (A) and impairments (I). The percentage usage by physiotherapists for each category of outcome measure were 55.8% (A), 62.8% (I) to 67.4% (PR) and for treatment goals 55.8% (PR), 69.8% (A) to 81.4% (I). Hopping is the most frequently evaluated functional activity but there are large differences in its utilisation. The application of functional goals and outcome measures in rehabilitation is not universal with specialist physiotherapists generally adopting an impairment approach. Repeated movement analysis in the clinical setting provided objective data on the recovery of functional activities that progressively challenge knee stability. Gait and hop distance appear to be the most useful variables for tracking performance over time but their predictive value needs to be explored further. Adaptations in the non-injured leg indicate that its use as a control needs to be done with caution. For jogging and run and stop there appears to be a threshold after which patients can perform these activities rather than a gradual recovery. Clinical movement analysis could be used to provide objective feedback on recovery levels and help guide the rehabilitation process. However, currently functional goals and milestones are not always included in the planning and evaluation of rehabilitation. Developing better rehabilitation should involve greater integration of functional activity measures into practice. This would require a shift from an impairment rehabilitation approach to focus on functional goals

Purpose: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity. Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%). Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome. Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity