Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools

As the numbers of revision total knee arthroplasty (RTKA) rise, we continually need current information regarding the etiology/modes of failure and functional disability of patients presenting for RTKA. We used a prospective cohort study to assess these fundamental aspects of RTKA. 290 consecutive subjects presenting for RTKA had relevant clinical information, including modes of failure, collected from surgeon-completed documents. Patients themselves also completed quality of life and functional questionnaires, including the SF-36 and WOMAC Osteoarthritis Index. Mean patient age was 68.6 years (55 to 79 years). Mean SF-36 and WOMAC score at baseline indicated significant functional disability. The mean time from primary procedure to RTKA was 7.9 years (6 months to 27 years). Our series included 31 percent ‘early’ (under 2 years) revisions and 69 percent ‘late’ revisions. Sepsis was the cause of 10.4 percent revisions. The tibia needed revision in 78 percent, femur in 71 percent and patella in 31 percent of cases. The predominant modes of failure (non-exclusive frequency values as patients could have more than one cause) were (in percentages): instability (28.9), malalignment (27.5), tibial osteolysis (27.5), polyethylene wear (24.5), femoral osteolysis (22.5) and tibial loosening (22.2). These patients are relatively young, and considerably disabled by their failed primary procedure. Many modes of failure are within surgical control and direct us toward improved techniques and approaches. Other modes confirm the need for continued development of implants and materials. Information gained here will allow better formulation of measures and resource allocation that may prevent RTKAs

Purpose of Study:. To describe the degree and type of disability experience by patients with combined postero-lateral corner and posterior cruciate ligament knee injuries. To document any dynamic abnormalities of the lower limbs through the gait cycle using kinematic and kinetic gait analysis. To identify abnormal electromyographic signals of the quadriceps, hamstring and gastrocnemius muscles through normal gait. Methods and Results: After rigorous exclusion criteria were instituted twelve patients were identified as having the required combined knee ligament injuries. These patients underwent functional assessment, clinic examination and gait analysis at the Oxford Gait Laboratory. Significant functional disability was noted in all patients. Characteristic gait abnormalities identified included hyperextension and dynamic varus deformity with a corresponding increase in the internal valgus knee moment. Electromyographic data revealed early and prolonged contraction of the medial hamstrings and gastrocnemius muscles. Conclusion: These results suggest the presence of compensatory mechanisms of the musculature around the knee and suggest direction in rehabilitation programs in patients with combined injuries to the posterior cruciate ligament and posterolateral corner of the knee. The results also provide baseline data that will be useful when evaluating the post-operative outcomes in patients undergoing knee ligament reconstruction in the future

Purposes of the study and background

Characteristics of muscle activity, represented by surface electromyography (EMG), have shown differences between patients with low back pain and healthy adults; how they relate to functional/clinical scales remains unclear. The purpose of the current study was to examine the correlation between frequency characteristics of EMG and patients' self-rated score of disability using continuous wavelet transform (CWT) analysis.

Background: Activity advice and prescription are commonly used in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome, recovery and course of LBP.

Methods: One hundred and one patients with acute LBP were recruited into a longitudinal cohort study. Each participant completed the Roland Morris Disability Questionnaire (RMDQ), Visual Analogue Scale and a “simple” activity question, detailing whether they had resumed full “normal” activities (Y/N), at baseline (T0) and 3 months (T1); Baecke Physical Activity Questionnaire, Fear-Avoidance Beliefs Questionnaire and the 12-item General Health Questionnaire at T0. Physical activity was measured for 7 days at T0 and T1 with an RT3 accelerometer and the seven day physical activity recall questionnaire (7d-PAR).

Results: The only significant predictor of RMDQ change was RMDQ score at T0 (p < .0001). Physical activity change did not predict RMDQ change in both univariate (p = 0.82) and multivariate analysis (p = 0.84). Paired t-tests found a significant change in RMDQ (p < .0001) and return to full “normal” activities (p < .0001) from T0 to T1, but no significant change in activity levels measured with the RT3 (p = 0.56) or the 7d-PAR (p = 0.43). RMDQ change (OR 1.72, p = 0.01) and RMDQ at T1 (OR 0.65, p = 0.04) predicted return to full “normal” activities at T1.

Conclusions: These results question the role of physical activity in LBP recovery and the assumption that activity levels change as LBP symptoms resolve.

Conflicts of Interest: None

Sources of Funding: This research was supported by a University of Otago Establishment Grant

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Aims. To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs. Methods. The medical records of 75 patients who underwent surgery between 2000 and 2020 were retrospectively reviewed, and 44 patients who were alive and available for follow-up (at a mean of 9.7 years postoperatively) were included in the study. Leg length discrepancy was measured on whole-leg radiographs, and functional assessment was performed with PROMs (Toronto Extremity Salvage Score (TESS) and Comprehensive Outcome Measure for Musculoskeletal Oncology Lower Extremity (COMMON-LE)) with two different aspects. The thresholds for unfavourable PROMs were determined using anchor questions regarding satisfaction, and the risk factors for unfavourable PROMs were investigated. Results. The thresholds for favourable TESS and COMMON were 64.8 and 70.4 points, respectively. Multivariate analysis showed that age at surgery (p = 0.004) and postoperative leg length discrepancy (p = 0.043) were significant risk factors for unfavourable TESS results, while age at surgery (p < 0.001) was a significant risk factor for unfavourable COMMON-LE results. Following receiver operating characteristic analysis, the threshold for both TESS and COMMON-LE was 29 years of age at surgery. Additionally, a leg length discrepancy of 8.2 mm was the threshold for unfavourable TESS. Conclusion. Patients aged > 29 years at the time of surgery require appropriate preoperative counselling and adequate postoperative physical and socioemotional support. Reconstruction equivalent to the length of the resected bone can reduce the risk of functional disabilities in daily living. Cite this article: Bone Jt Open 2023;4(12):906–913

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

Abstract. Introduction. Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives. To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods. Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P<0.05. Results. There was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P<0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P<0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P<0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P<0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P<0.001). Conclusion. Skeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes. Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm. Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported. Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption

In a previous study, we found that pre-TKA patients were severely disabled in high-flexion activities but perceived these disabilities as being no more important than pain relief and the restoration of daily routine activities. This study was conducted to investigate functional disabilities and patient satisfaction in Korean patients after TKA. Of 387 patients who had undergone TKA with a follow-up longer than 12 months, 270 (69.7%) completed a questionnaire designed to evaluate functional disabilities, perceived importance and patient satisfaction. The top 5 severe functional disabilities were difficulties in kneeling, squatting, sitting with legs crossed, sexual activity, and recreational activities. The top 5 in order of perceived importance were difficulties in walking, using a bathtub, working, climbing stairs, and recreation activities. Severities of functional disabilities were not found to be correlated with perceived importance. The patients (8.5%) dissatisfied with their replaced knees had more severe functional disabilities than the satisfied for most activities. The dissatisfied patients tended to perceive functional disabilities in high-flexion activities to be more important than the satisfied. This study indicates that despite severe disabilities in high-flexion activities, most Korean patients after TKA would not consider high-flexion disability to be more important than other daily routine activities. Moreover, postoperative high-flexion disabilities would not adversely influence satisfaction for most patients. Nevertheless, such disabilities are likely to cause dissatisfaction among those that are not prepared to modify their traditional life-styles

Background. Although the aetiology of chronic low back pain (CLBP) is unknown, it is suggested that several subgroups among CLBP-patients might be identified who are likely to benefit from different interventions. The results of these interventions might be improved by matching interventions to patient characteristics. Purpose. The purpose of this longitudinal study is to determine which subgroup of CLBP-patients benefits most from the short, intensive pain management program of RealHealth_NL. Methods. A prospective cohort of 524 selected consecutive CLBP-patients was followed. Potential predictive indicators included demographic characteristics, functional disability, experienced pain and cognitive behavioural factors as measured at pre-treatment assessment. The outcome is defined as one year improvement in functional disability. A successful outcome is a value as seen in healthy populations. The two-week residential program is in line with recommendations in international guidelines, based on cognitive behavioural principles and delivered in collaboration with orthopedic spine surgeons. Results. Multivariate logistic regression revealed pre-treatment being employed (OR 3.609 [95%CI 1.795–7.256]), and functional disability (OR 0.943 [95%CI 0.921–0.965]) as significant predictive factors of a successful outcome in functional disability at one year follow-up. Conclusion. The results imply that CLBP-patients, who are employed, and less disabled at pre-treatment assessment, who participated in the RealHealth_NL program, are consistently associated with one year follow-up improvement of functional disability toward normal values. A small set of indicators is more easily identified and addressed and CLBP-patients who are more likely to benefit from the program could be given a higher entry priority. Conflict of Interest: J O'Dowd owns shares in RealHealth_NL; Research Development & Education independent research organisation; Sint Maartenskliniek health care provider and referral organisation. Source of funding: None. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

To determine the number of patients with low back pain who have low serum Vitamin-D levels in our local population and the clinical efficacy of Vitamin-D supplementation on VAS and MODQ scores. This Prospective cohort study was conducted from 20th March 2016 to 19th March 2017. 600 patients were included in the study who met the inclusion criteria, i.e. patients presenting to the Out Patient Department (OPD) with low back pain for a duration of less than six months aged between 15 to 55 years. Venous blood withdrawn and serum levels of Vitamin-D measured. According to serum Vitamin-D levels, categorized as deficient, sufficient or excess. Those having deficient Vitamin-D levels (< 2 0 ng/dL) were given Vitamin-D supplementation as Oral 50,000 IU Vitamin-D3 daily for 05 days, then once weekly for 08 weeks while those having insufficient levels (20–30 ng/dL) given Oral 50,000 IU Vitamin-D3 once weekly for 08 weeks. Vitamin-D levels, Visual Analog Pain Scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) scoring done at baseline, 02, 03 and 06 months. Data analyzed using SPSS version 23. Mean age of patients included in the study 44.21 ± 11.92 years. Out of the total, 337 (56.17%) were males and 263 (43.83%) females. Out of the total, 20.67%, 26.17% and 28.83% had mild, moderate and severe Vitamin-D deficiency, respectively. Predominantly patients with severe Vitamin-D deficiency presented in winters (October – February) (17.16%) as compared to other seasons. The most pre-dominant risk factor in patients with low Vitamin-D levels was smoking (21.33%). Mean baseline Vitamin-D levels were 13.32 ± 6.10 ng/dL and after supplementation these levels improved to 37.18 ± 11.72 ng/dL. VAS score improved from a mean baseline value to 81 to 36 at 6 months (p < 0 .01). Likewise, MODQ score decreased from a baseline mean of 46 to 25 at 6 months (p < 0 .01). Vitamin D plays a crucial role in the musculoskeletal framework of the body. The deficiency is more prevalent in the youth due to sedentary lifestyle and indoor preference. Improvement in pain & functional disability with Vitamin-D supplementation. For any reader queries, please contact . virgo_r24@hotmail.com

Background and purpose. The Fear Avoidance Model is used to explain why some patients with acute low back pain develop chronic low back pain (CLBP). Cognitive behavioural therapy (CBT) targeting dysfunctional behavioural cognitions (pain catastrophizing and fear of movement) is recommended. Purpose: to investigate whether a two-week CBT-based pain management program results in improvement in dysfunctional behavioural cognitions and whether these improved cognitions improve functional outcomes. Methods and Results. Cohort study including 524 consecutive CLBP-patients. Main outcome: functioning (ODI). Secondary outcomes: pain severity (NRS), pain catastrophizing (PCS), fear of movement (TSK). Assessments: pre- and post-treatment, 1 and 12-months follow-up (FU). Improvement over time was analysed with repeated measures ANOVA. Path analyses were used to examine the influence of pain catastrophizing and fear of movement on functional disability and pain severity. Multiple imputation was used to complete missing data. Participants with incomplete data (12.8%) did not differ from those with complete data (n= 457). 59% were females, mean age 46 (± 9.5) years, mean CLBP-duration 12 (± 10.8) years. All outcomes significantly improved at post-treatment and a slight significant improvement between post-treatment and 12 months FU was observed. Path analyses showed a direct effect for catastrophizing on post-treatment functioning and an indirect effect for catastrophizing through fear of movement on post-treatment functioning. Comparable results with pain severity as outcome. Conclusion. A two-week pain management program improved dysfunctional behavioral cognitions and functional outcomes in patients with longstanding CLBP up to one year. Targeting both pain catastrophizing and fear of movement during the program resulted in improved outcomes. Conflicts of Interest: JK O'Dowd is director of and shareholder in RealHealth. The authors declare that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national or international meeting. Sources of Funding:. No funding obtained

Background and purpose. Sleep disturbance is a prevalent symptom in people with chronic low back pain (CLBP >12 weeks), but there is currently no knowledge of the effectiveness of physiotherapy for this problem. This study evaluated the feasibility of a randomised controlled trial (RCT) exploring the effects of physiotherapy on sleep disturbance in CLBP [Current controlled trial ISRCTN 54009836]. Methods. A sample of 60 consenting patients with CLBP [23 M, 37 F; mean (SD) age = 44.93 (13.41) years] were recruited in Beaumont Hospital, Dublin and randomly allocated to one of three groups [supervised exercise class (SEC), walking programme (WP) and usual physiotherapy (UP)] in a concealed manner. The main outcomes were sleep quality, functional disability, pain, and quality of life at baseline, 3 and 6 months. Results. The majority of participants reported sleep disturbance (95%, n=57) and related it to their LBP (81%, n=46). At 3 months compared with the WP and SEC, participants in the UP group displayed greater reductions in average low back pain VAS (WP d=.97, SEC d=.86) and greater improvements in sleep disturbance (Pittsburgh Sleep Quality Index WP d=.59, SEC d=.29; Insomnia Severity Index WP d= .56, SEC d= .24). However, compared to UP there were greater improvements in functional disability (SF-36 PCS) in the WP (d= .32) and the SEC (d= .21). Conclusions. The results provide preliminary evidence of the effects of physiotherapy on sleep disturbance in CLBP, demonstrate the feasibility of undertaking a RCT in this field and inform refinement of the study protocol for a fully powered trial

Background: Although most proximal humerus fractures occur in postmenopausal women and are attributed to osteoporosis, they are usually not considered individually in osteoporotic studies due to their theoretical lower incidence. We hypothesized that proximal humeral fractures patients are among the commonest fractures associated to osteoporosis, and may represent a major cause of functional disability. Objective: To evaluate the incidence of non-displaced proximal humeral fractures in comparison with other outpatient treated osteoporotic fractures, and to assess their functional impact and on the quality of life perceived by the patients. Methods: In this multicenter, cross-sectional, prospective study, all osteoporotic fractures in postmenopausal women aged 50 years or older treated non-operatively in 358 trauma centres were recorded during a three month period. The fractures were considered osteoporotic if they were caused by a low-energy trauma. Pathologic fractures were ruled out. The incidence of proximal humeral fractures in relation to other osteoporotic fractures was calculated. Patients were interviewed by telephone six months after the fracture using the Spanish versions of the DASH and EuroQoL 5D questionnaires. Results: 5762 women (mean age: 73± 7.5 years) were studied. 912 (17.5%) had suffered proximal humeral fractures. Overall, proximal humerus fracture was the most frequent site, after distal radius and vertebral fractures, and was the most common in patients older than 75 years (393 cases, 43.1%). The mean DASH score was 26,62±17,9. The EuroQoL 5D questionnaire showed that 67,3% had pain or discomfort, and disclosed significant reductions in the functional capacity, especially concerning problems with self care (44,5%), performing usual activities (56,5%), and anxiety or depression (32,7%). Discussion: Non-displaced proximal humeral fractures are among the most common fractures associated to osteoporosis, and constitute the most frequent non-operatively treated fracture in patients older than 75 years. Even if they are non-displaced, they can be a major cause of functional disability, and result in a reduction in the patient’s subjective perception of health

Non-unions of the supracondylar area of the humerus are uncommon but they produce profound functional disability. We have successfully treated a series of these non-unions surgically using the Coventry hip screw. This is a large metaphyseal screw which is applied through both humeral condyles and then compressed on to a single 4. 5mm narrow tibial plate applied to the lateral aspect of the humeral shaft. Between 1993 and 2000 we operated on thirteen consecutive patients aged 20 to 81 years (mean age 51 years). All the patients had a severe functional disability. The mean time to surgery was 23 months following their accidents. The average follow up was 16 months (range 8–18 months). All but two of the thirteen patients went on to bony union. The mean time to radiological union was six months (2 to 12 months). The mean arc of flexion doubled to 90 degrees. Until now, the recommended operative technique for stabilisation of non-unions of the distal humerus is identical to that described for primary fracture repair, and involves fixation with two 3. 5 mm plates at 90 degrees. In our experience, this was the technique usually used at the initial operation/s, and is therefore likely to fail again. This correlates with the reported 6–12% non-union rate in the literature. In this series, stable fixation was achieved by using the Coventry hip screw

The most commonly used surgical techniques used to treat recurrent or habitual patellar dislocation in the child do not specifically address the patella alta, one of the major causes of patellar dislocation. Twelve knees in eight patients had a lowering of the patella by total tendon transfer, lateral release and vastus medialis obliquus advancement. At two years of follow-up, only one knee had redislocated. Radiographically, the patellar height was anatomically restored in all other knees. All patients were pain free. This surgical technique is a good treatment option in the immature patient with recurrent or habitual patellar dislocation. Patella alta is one of the major causes known to predispose children to recurrent or habitual patellar dislocation. However, the surgical treatment of such a condition, before squeletal maturity, is rarely if ever mentioned in the literature. Twelve knees in eight patients were treated with a surgical procedure designated to correct patella alta, the major predisposing factor causing recurrent patellar dislocation. The technique involves lowering of the patella by total tendon transfer, lateral release and vastus medialis obliquus advancement. All patients were complaining of recurrent or habitual dislocations leading to functional disability. Patellar height was assessed radiographically by the Koshimoto index (PT/FT) and Caton-Deschamps index (AT/AP). The average at surgery was 10.9 years and mean follow-up was 45.1 months. Follow-up revealed redislocation in one knee. This patient required a second operation to achieve patellar stability. At the latest follow-up, all operated knees were functionally stable and pain free. The average preoperative ratios were 1.28 (PT/FT) and 1.53 (AT/AP) which improved to 0.97 (PT/FT) and 0.96 (AT/AP) at the time of follow-up. Few complications were noted. This technique is a valid surgical alternative to treat the immature patient presenting with functional disability related to recurrent or habitual patellar dislocation associated with patella alta

Introduction. Although total knee arthroplasty (TKA) in end-stage hemophilic arthropathy can reduce the severe joint pain and improve the functional disability, it is technically demanding. In addition, it has generally reported a high rate of complication including periprosthetic joint infection (PJI) and component loosening up to 20%. Although the Knee Society classification system of TKA complication was introduced, the complications of TKA in hemophilic arthropathy has not stratified using this classification system in previous articles to the best of our knowledge. The purpose of this study was to evaluate the mid-term outcomes and complications of TKA in hemophilic arthropathy. Methods. The study retrospectively reviewed 131 consecutive primary TKAs (102 patients) in single institute. The mean patient age was 41.0 years and mean follow-up time was 6.4 years. The clinical and radiographic results were evaluated. The complications were categorized according to the classification system of the Knee Society for TKA complications. Results. The average WOMAC score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre and postoperative maximum flexion did not differ (80.9 ° vs. 85.6°). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal position of femoral and tibial components and sagittal position of those components were within ±3° in 83.2%, 89.3%, 63.4%, and 73.3%. The complications occurred in 17 knees (13.0%). There were 7 bleeding and hemarthrosis. Five knees were treated with increased amounts of coagulation factor concentrate and two knees were treated with incision and drainage of hematoma. One medial collateral ligament injury of grade 2 required change of postoperative rehabilitation protocol and bracing. Two stiffness of grade 3 required unplanned admission and manipulation under anesthesia. Three deep PJI were treated with 2 stage revision TKA. There were 4 periprosthetic fractures. Three distal femur fractures were treated with open reduction and internal fixation for 3 knees. One patellar fracture was healed with conservative treatment. Conclusions. The mid-term results of TKA in end-stage hemophilic arthropathy were satisfactory with obtaining pain relief, improving function, and decreasing flexion contracture. Bleeding and PJI continues to be a major concern for TKA in patients with hemophilic arthropathy, and risk of periprosthetic fracture has to be taken into account for patient education and appropriate prevention. Level of evidence. Level IV