Purpose & Background: Posteroanterior mobilisation (PA) is a manual physiotherapy technique that is commonly used as an examination tool and a form of conservative treatment for spinal complaints. The efficacy of this technique is controversial and this may be in part due to a limited knowledge of the mechanical and physiological mechanisms underlying this technique. This study aims to evaluate the ability of interventional MRI to image the mechanics of mobilisation in terms of spinal movement and soft tissue deformation during a PA mobilisation. Methods: 5 normal subjects (4 female, 1 male, mean age 29.6 ± 3.9 years) with no current or history of neck pain requiring intervention were recruited into this study, and written informed consent obtained. Subjects were scanned using a General Electric Signa SP10 Interventional MRI scanner (iMR). This is an open MRI scanner consisting of 2 connected but opposing ring “doughnut” magnets. The gap between these magnets is 56 cm generating a uniform field of 0.5Tesla. Subjects were scanned in the prone position with their necks in either a neutral or flexed position. In each position, subjects underwent a PA mobilisation to the 2nd and 6th cervical vertebrae. Sagittal and axial images of the spine were obtained prior to, during and following the mobilisation. Measurements of intervertebral rotation and translation were obtained from the sagittal images, and measures of soft tissue compression with respect to the spinous process were obtained from the axial images. Paired analysis of variance was used to investigate the impact of the mobilisations in each position. Results: Clear images of vertebral position could be obtained if the mobilisation was sustained once the appropriate force had been delivered. From these images, it is possible to measure vertebral angulation, translation and soft tissue compression. From these measures, it became clear that intersegmental vertebral angulation and translation did not alter as a result of the force applied regardless of cervical position. However, marked and significant changes were seen in terms of soft tissue compression and in some instances overall angulation of the cervical spine. Conclusion: This pilot work suggests that it is feasible to use iMR technology to study the mechanics of spinal mobilisation. Preliminary findings suggest that there is little or no displacement of the vertebral bodies as a result of an AP mobilisation, although there is considerable soft tissue compression

Background. Rapid mobilisation programs, or “fast track” protocols, are aimed at shorter hospital stays. We found a limited local experience with these programs in total hip arthroplasty in South Africa, and decided to introduce a pilot study at our institution. Purpose. This pilot study is aimed at the feasibility and safety of a RM program in the private sector setting, as well as a review of the pertinent literature. Methods. 40 patients who met inclusion criteria underwent THR and TKR according to a specific protocol. Key aspects of the protocol included: minimum use of opiates, high volume pericapsular local block at time of surgery, no urinary catheter, mobilisation within 6 hrs of surgery and no high care admission. Target Discharge was 3 days. Patients were followed up retrospectively and outcomes included; length of stay, intra- and post-operative complications, subjective patient experience, re-admissions and re-operations. Results. 36 patients, (90 %), were discharged by day 3, 4 patients were discharged at day 4. Mean stay 2,8 days, shortest 2 days, and longest 4 days. 3 elderly female patients required catheterization for urinary incontinence, on the first night post surgery. No complications were experienced. The problems that prevented discharge within 3 days were post operative pain and orthostatic hypotension. There were no re-admissions or re-operations. One TKR required manipulation at 6 weeks. 5 patients required changes of dressings at home within one week post surgery. All the patients in this study were extremely satisfied. Conclusion. A rapid mobilisation program is relatively easy to implement although extra paramedical staff input is required. The results of this pilot study show that the protocol was effective and safe, as well as showing a significant hospital cost reduction. The obvious saving of costs are encouraging us to implement the protocol on a wider scale. Appendix. Lorem ipsum dolor sit amet, ligula suspendisse nulla pretium, rhoncus tempor placerat fermentum, enim integer ad vestibulum volutpat. Nisl rhoncus turpis est, vel elit, congue wisi enim nunc ultricies sit, magna tincidunt. Maecenas aliquam maecenas ligula nostra, accumsan taciti. Sociis mauris in integer, a dolor netus non dui aliquet, sagittis felis sodales, dolor sociis mauris, vel eu libero cras. Interdum at. Eget habitasse elementum est, ipsum purus pede porttitor class, ut adipiscing, aliquet sed auctor, imperdiet arcu per diam dapibus libero duis. Enim eros in vel, volutpat nec pellentesque le. NO DISCLOSURES

Background: Both chemical and mechanical methods of prophylaxis have reduced the the incidence of thromboembolic complications following Total Knee Replacement (TKR). Only a few studies have shown that mobilisation on the first post operative day further reduces the incidence of thromboembolic phenomena. Aims: We conducted a prospective study to verify not only if early mobilisation but also whether the distance mobilised on the first post-operative day after TKR reduced the incidence of thromboembolic complications. Methodology: The incidence of deep venous thrombosis and pulmonary embolism were compared in 50 consecutive patients who underwent TKR from July 2006 following a change in the mobilisation protocol with 50 consecutive patients who underwent TKR before the protocol was instigated. The mobilisation protocol changed from strict bed rest the first post operative day to mobilisation on the first post operative day. Mobilisation was defined as sitting out of bed or walking for at least 15–30 minutes twice a day. The distance mobilised was accurately recorded by the physiotherapists. All patients underwent duplex scans of both lower limbs on the fourth post operative day. Results: There was a Significant reduction in the incidence of thromboembolic complications in the mobilisation group (7 in total) compared to the control group (16 in total) (p=0.03). Furthermore in the mobilisation group the odds of developing a thromboemobloic complication was Significantly reduced the greater the distance the patient mobilised, (Chi squared linear trend=8.009, p =0.0047). Early mobilisation in the first 24 hours post TKR is a cheap and effective way to reduce the incidence of post-operative DVT

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Purpose. We report our initial results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. Methods and Results. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal analogue pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PE rates were 0.6% and 0.5% respectively. Conclusion. This new comprehensive care plan provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Despite surgeons' concerns early discharge was not detrimental to flexion achieved at six weeks and infection rates did not increase with the use of intra-articular catheters

Aims: To compare two protocols of early mobilisation for minimally displaced radial head fractures through a single-blinded, prospective randomised trial. Methods: Sixty patients were randomly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after injuries. A blinded observer assessed each patient. Results: All fractures united by the third month. At the end of 7days, the mobilisation group had less pain (VAS 6 vs 7.6, p=0.002); greater ßexion (mean 112û vs 98û, p=0.0004); greater strength in supination (p< 0.001) and better elbow function (Morrey Score 54 vs 43, p=0.005). By the fourth week, both groups were comparable in all parameters and improvement continued into the third month. Mean limit of extension at the third month were 2.3û in the immediate mobilisation group and 1.8û in the delayed group (NS). All had excellent function on the basis of the Morrey Score. Conclusions: Immediate mobilisation did not adversely affect the outcome; the patients had less pain and better elbow function at one week post-injury. Pain, ranges of movement and function were similar by the fourth week post-injury

Introduction. Venous thromboembolism (VTE) is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. This incidence should in theory reduce if the patients are ambulatory early in the treatment phase. The aim of this study was, therefore, to identify a difference in the incidence of symptomatic VTE by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were retrospectively reviewed and prospectively followed. The patients' demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and the type of plaster immobilisation was compared to assess whether they affect the incidence of clinical VTE. The predisposing risk factors were also analysed between the treatment groups. Out of 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a conventional non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. On the other hand, 41 patients were treated with functional weight bearing mobilisation (Vacupad). Patients who did have a symptomatic thromboembolic event also had an ultrasound scan to confirm a deep vein thrombosis of the lower limb or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients had a thromboembolic event (19.1%). On the other hand, out of the 41 patients who were treated with functional weight bearing mobilisation, only 2 patients had a symptomatic thromboembolic event (4.2%). This was statistically significant (p=0.012). This shows that patients who are treated in a non-weight bearing plaster have about five times increased risk of developing a sypmptomatic VTE compared to those treated by functional weight bearing mobilisation. There was however no difference in the predisposing factors in patients who developed VTE compared to those who did not. Conclusion. The incidence of symptomatic VTE after acute Achilles tendon rupture is high and under-recognised. Asymptomatic VTE after this injury is probably even higher. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast. There is a need for further research to define the possible benefit of thromboprophylaxis in patients treated by non-weight bearing plasters

Introduction. Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols. Materials and Methods. Patients undergoing primary TAA with a diagnosis of Osteoarthritis (OA) or Post-traumatic Osteoarthritis (PTOA) were recruited into a randomized controlled trial. These patients did not require any additional procedures. Patients were consented for the trial and randomized to one of two treatment groups (Early mobilisation after surgery vs. immobilisation in a plaster cast for 6 weeks post operatively). Plaster group patients underwent a graduated physiotherapy program from 6-12 weeks and early mobilisation group patients from 1-12 weeks. Complications any were recorded at 2, 4, 6 and 12 weeks post-operatively. Results. A total of 16 ankle replacements were done for a diagnosis of OA (10) and PTOA (6). Mean age was 58 years (±11.75) for the plaster group and 64 years (± 9.32) for the early mobilisation group. 7 patients were randomized to the plaster group and 9 patients were randomized to the early mobilisation group. Of the plaster group 1 patient sustained an intra-operative fracture tibia and 2 patients reported with a fractured medial malleolus. Of the early mobilisation group, 1 patient reported with a peri prosthetic fracture tibia at 6 weeks and 3 patients reported a fractured medial malleolus at 3 months follow up. The percentage of fracture incidence between plaster versus early immobilisation group was 42.8% and 44.4 % respectively. Conclusions. These early results demonstrate no significant differences in the incidence of fracture rates between groups. Further studies of post-operative management are needed to study the correlation with peri-prosthetic fracture rates after TAA

Aims: Circulating endothelial precursor cells (CEPs) are thought to play a role in angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, deþned by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bonemarrow precursors deþned byLy-6A/E and c-Kit expression were harvested following the traumatic insult from the murine model and quantiþed on ßow cytometry. Human and murine progenitor populations were cultured on þbronectin and examined for markers of endothelial cell lineage (Ulexeuropaeus- agglutinin-1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300% (p=0.008) and returning to normal levels by day 10. Murine bone marrow precursors were mobilisd within 24 hrs peaking at 48hrs (900% p=0.035). On culture, morphologically characteristic endotheliallike cells binding UEA-1 and incorporating LDL were identiþed. Serum VEGF levels increased signiþcantly within 24 hrs of the insult, (p=0.018) preceeding the peak in CEP mobilisation. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEPs from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients' demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non- weight bearing cast

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast

The aim of this study was to compare immediate weight-bearing mobilisation with traditional plaster casting in the rehabilitation of non-operatively treated Achilles tendon ruptures. Forty-eight patients with Achilles tendon rupture were randomised into two groups. The treatment group was fitted with an off-the-shelf carbon-fibre orthotic and the patients were mobilised with immediate full weight-bearing. The control group was immobilised in traditional serial equinus plaster casts. The heel raise within the orthotic and the equinus position of the cast was reduced over a period of eight weeks and then the orthotic or cast was removed. Each patient followed the same rehabilitation protocol. The primary outcome measure was return to the patient's normal activity level as defined by the patient. There was no statistical difference between the groups in terms of return to normal work [p=0.37] and sporting activity [p=0.63]. Nor was there any difference in terms of return to normal walking and stair climbing. There was weak evidence for improved early function in the treatment group. There was 1 re-rupture of the tendon in each group and a further failure of healing in the control group. One patient in the control group died from a fatal pulmonary embolism secondary to a DVT in the ipsilateral leg. Immediate weight-bearing mobilisation provides practical and functional advantages to patients treated non-operatively after Achilles tendon rupture. However, this study provides only weak evidence of faster rehabilitation

Dysfunction of the pelvic girdle causes alteration of the lumbopelvic muscle supporting function and thus disruption of the load transference through the pelvis. Walking loads symmetrically the muscles that provide stability to the pelvis for load transference and is an easy way to evaluate bilateral muscle function. The aim of this study was to find out if mobilisation of the symptomatic sacroiliac joint (SIJ) in chronic low back pain patients could alter the lumbopelvic muscle activity measured by surface EMG (sEMG) on the symptomatic side during walking. The resulting change in the muscle activity seemed to be relaxation of the muscles evaluated. The muscles whose activity changed for the most during walking after mobilization of the symptomatic SIJ were biceps femoris, on the right side 17,8% (p= 0.007) and on the left side 12.8% (p= 0.012). The right gluteus medius relaxed 14.4% (p=0.016) and left side 6.1% (p=0.033). Lumbar multifidi reacted more on the right side 14.5% (p=0.003) and on the left the decrease was 8.3% (p=0.021). Oblique abdominal externus muscles showed very little change after intervention. This study gives us the point of view that the main influence the mobilisation has on SIJ is neurophysiological, reflectoric on muscle tone

Background: There is a huge controversy regarding the period of immobilization after Bankart stabilisation. This ranges from 2 days to 5 weeks for open repair and from 3 to 6 weeks for arthroscopic Bankart repair. We believe it is inappropriate to immobilise the operated shoulder after Bankart repair. In our study all the patients were allowed to use their arm, the same day, pain permitting. No restrictions were imposed for the type and range of movement for those who had open repair. With arthroscopic repair they were asked to limit their shoulder abduction upto 45-degreee and external rotation to neutral. Method: In this retrospective study (1998–2003) we have analyzed the outcome of mobilisation of operated shoulder on the same day.43 primary stabilisations were performed by the senior author.one patient was uncontactble. We reviewed the records of 42 patients. Subsequently the General Practitioners were contacted to collect information about these patients and the patients were contacted, if needed. Out of 42 patients 34 were males and 8 females. 35 patients had an average of 7 episodes of anterior shoulder dislocations (range 2–25), 7 had unstable shoulder pre-operatively.30 had open repair, 12 had arthroscopic stabilisation. The average follow-up is 3.5years(1–6 years). Result: 41 patients did hot have any further episode of frank anterior shoulder dislocation and they had returned to their previous level of activities. Only one patient injured his operated shoulder year later while playing football. He underwent arthroscopic capsular shrinkage for traumatic deformation of the capsular and inferior glenohumeral ligament. Conclusion: In primary straightforward Bankart stabilisation, same day mobilisation does not increase the risk of anterior shoulder dislocation

Aim: To study the results of a percutaneous suture technique for the management of acute ruptures of the Achilles’ tendon. Method: Ten patients with acute Achilles’ tendon rupture were entered into the study. We utilised a percutaneous surgical technique and functional post-operative regime described in the current literature. Results: All were recreational sports people with an average age of 42.9 years. At an average follow-up of six months there were no re-ruptures, no wound complications, no sural nerve injuries, and no episodes of deep vein thrombosis. No patient had any discomfort during normal walking. In comparison to the uninjured side, there was still a mild reduction in calf circumference but minimal deficits in endurance, strength or range of motion. Conclusions: The technique was easily performed and overall the treatment appeared to have very high patient acceptance and low morbidity. The well described benefits of early mobilisation were evident

Purpose of the study: Recent data in the literature regarding intra-articular deliver of analgesics during the postoperative period have been encouraging. Patients benefit from optimal analgesia and earlier mobilisation, shortening rehabilitation time and hospital stay and limiting complications. In light of these encouraging results, our institution developed a programme designed to address all postoperative situations associated with implantation of a total knee arthroplasty (TKA). Material and methods: The programme combines pre-operative counselling and a postoperative programme for multimodal anaesthesia in addition to intra-articular analgesia for 24 hours and early mobilisation. We present here the results of this technique in patients undergoing first-intention TKA. We analysed information collected prospectively in all patients who had TKA from January to June 2008: 319 patients in six months. The operation was performed under peridural anaesthesia supplemented by intra-articular ropivacaine delivered by a catheter for 24 hours. Patients were mobilised, or verticalised, the day of surgery according to individual capacities. Data collected included: pain scores, date of the end of physical therapy, and data reviewed at six weeks. Results: A cohort of 305 patients was analysed; 36% of patients were mobilised the day of the operation and 93% on day 2. The rate of urinary catheters was 12% and administration of intravenous fluids 10%. Physical therapists determined that 58% of patients could be discharged on 3 after surgery and 85% on day 5. Eighty-percent of patients were free of nausea or vomiting and had well controlled pain. Regarding function, mean range of motion was 85° at discharge with 31% of patients requiring physical therapy. At six weeks, mean range of motion was 95° and only 5% of patients had lost amplitude (reduction > 10° of range of motion) compared to discharge values. Mean scores on the Oxford questionnaire improved from 43 preoperatively to 26 six weeks postoperatively. Discussion: This multidisciplinary approach guarantees excellent postoperative analgesia with early mobilisation and provides satisfactory results at six weeks. To this can be added the benefit of a lower rate of urinary catheters, administration of intravenous fluids, and physical therapy

Introduction: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Hip Arthroplasty (THA). Methods: Our organisation has instituted a regime covering all aspects of the peri-operative care for THA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary THA in the six months from January to June 2008 (total of 138 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks. Results: A total of 122 THAs with complete data sets were included in the analysis. Of these 27% were mobilised on the day of surgery and 97% by post-operative day 1. Catheterisation rates were 16% and the need for post-operative intra-venous fluids was 15%. In-house physiotherapy discharged 58% of patients by day 3 and 87% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (medians were 2.5 and 2 respectively) and 84% of patients experienced no nausea or vomiting. Functionally 14% of patients required out-patient physiotherapy assessment. At three months the median Oxford scores had improved from 43 pre-operatively to 20. Discussion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia

Purpose: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Knee Arthroplasty (TKA). Methods and Results: Our organisation has instituted a regime covering all aspects of the peri-operative care for TKA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary TKA in the six months from January to June 2008 (total of 319 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks. A total of 305 TKAs with complete data sets were included in the analysis. Of these 36% were mobilised on the day of surgery and 93% by post-operative day 1. Catheterisation rates were 12% and the need for postoperative intra-venous fluids was 10%. In-house physiotherapy discharged 58% of patients by day 3 and 85% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (median = 3) and 80% of patients experienced no nausea or vomiting. Functionally, the median range of movement at discharge was 85° with 31% of patients requiring out-patient physiotherapy assessment. At six weeks the median range of motion was 95° with only 5% of patients having a reduced range of motion (reduction of > 10°) when compared to discharge. The median Oxford scores improved from 43 pre-operatively to 26 at six weeks. Conclusion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia

Background: Circulating endothelial precursor cells (CEPS) are thought to play a role in postnatal angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, defined by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bone marrow precursors defined by Ly-6A/E and c-Kit expression were harvested following traumatic insult from the murine model and quantified on flow cytometry. Human and murine progenitor populations were cultured on fibronectin and examined for markers of endothelial cell linage (Ulexeuropaeus- agglutinin- 1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300%. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEP from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing