Background

Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen.

Cite this article: Bone Joint Res 2023;12(8):494–496.

Purpose of the study and background. An integrated rehabilitation programme was developed and found feasible taking into account the existing evidence base, appropriate theories, and patient and public involvement. The integrated programme encompasses inpatient activities supported by a multidisciplinary team, and integration of knowledge, skills and behaviours in the patient's everyday life. The aim of this trial was to compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain (CLBP). Methods and Results. Comparison of two parallel rehabilitation programmes in a randomised controlled trial including 165 patients with CLBP. The integrated rehabilitation programme comprised an alternation of in total three weeks of inpatient stay and in total 11 weeks of home-based activities. The existing rehabilitation programme comprised a four-week inpatient stay. Primary outcome was changes in disability (Oswestry Disability Index). Secondary outcomes were changes in pain, pain self-efficacy, health related quality of life and depression. Outcomes were collected at baseline and 26-week follow-up. Disability decreased −5.76 (95%CI; −8.31, −3.20) for the integrated programme and −5.64 (95%CI; −8.45, −2.83) for the existing programme. The adjusted difference between the two programmes was −0.28 (95%CI; −4.02, 3.45). No statistically significant difference was found in any of the secondary outcomes. Conclusion. The results of the trial were consistent, showing no significant differences in patients' outcomes when comparing an integrated rehabilitation programme with an existing programme. Conflicts of interest: None. Sources of funding: Aarhus University, The Danish Rheumatism Association and Familien Hede Nielsens Fond

Introduction. Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. Methods. A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. This was performed arthroscopically using a hamstring autograft (2 portal technique). Patients completed a home-based rehabilitation programme of appropriate simplicity for the home setting. The programme consisted of stretching, range of motion and strengthening exercises based on criterion rehabilitation progressions. A full description of the programme is provided at: . https://ngmvcharity.co.uk/. . Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. Results. The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. A peak score of 90 was observed at nine months. Post-operative TAS results showed an improvement in level of function but did not reach pre-injury levels by the final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. Conclusion. Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world

Quadriceps tendon ruptures are a rare but debilitating injury resulting in loss of knee extension necessitating surgical intervention. Currently, multiple different surgical techniques and rehabilitation programs are utilized by surgeons. Researchers have been unable to determine the best surgical technique with respect to function and complication rate; certain techniques are more cost-effective than others. Early vs. late motion rehabilitation programs are utilized; recent evidence suggests that less aggressive initial rehabilitation may lead to decreased extensor lag and fewer additional surgeries. The goal of our study is to determine the treatment practices of orthopaedic surgeons across Canada. Our study was completed anonymously via . SurveyMonkey.com. (Palo Alto, California). Based on current literature, a 26-question survey was distributed. E-mail invitations were be sent to all members of the Canadian Orthopaedic Association. Participation is voluntary. Currently, 104 surveys have been completed. 78% of respondents utilize transosseous drill holes, 13% utilize suture anchors and 9% utilize a combined surgical technique. The majority of surgeons begin range of motion (ROM) at 2 weeks (42%) or 6 weeks (24%); ROM is then commonly progressed in a step-wise fashion at 2-week intervals (58%). Approximately half of respondents have performed revision surgery for quadriceps re-rupture. Surgical management of quadriceps tendon ruptures is fairly consistent amongst Canadian orthopaedic surgeons. However, wide variation exists regarding rehabilitation, favoring early initiation and progression of ROM despite some evidence recommending a longer period of immobilization

The original RCT demonstrated that a limitedly-supervised post-ACL reconstruction rehabilitation program was both clinically more effective and less costly than the traditional physiotherapy-supervised program. This study contacted patients from the original RCT a minimum of two years post-surgery to evaluate whether or not the clinical findings of the RCT were upheld over the long term. This study of eighty-eight patients has upheld the original findings in that the patients who performed the limitedly-supervised (home-based) program had a significantly higher mean disease-specific quality of life score compared to the patients who performed the physiotherapy-supervised rehabilitation program. To determine whether or not there were any differences in long-term outcome between those patients who performed a physiotherapy-supervised rehabilitation program (PT) and those who performed a primarily home-based rehabilitation program (H) in the first three months following ACL reconstruction. Patients were originally randomized, before ACL reconstruction surgery, to either the physiotherapy-supervised (seventeen physiotherapy sessions) or home-based program (four physiotherapy sessions). Eighty-eight of the original patients were able to return two to four years following surgery to assess their long-term clinical outcomes. Primary outcome: the Mohtadi ACL disease-specific quality of life questionnaire (ACL QOL). Secondary outcomes: bilateral difference in knee extension and flexion range of motion, sagittal plane knee laxity, relative quadriceps and hamstrings strength, and IKDC score. Unpaired t-tests were used to compare the two groups across the continuous variables. A Chi square test was used for the categorical data. The home-based group had a significantly higher (p = 0.02, 95% CI [18.4, 1.7]) mean ACL QOL score (80.0 ± 16.2) compared to the physiotherapy-supervised group (69.9 ± 22.0) a mean of forty months post-surgery. There were no significant differences between the two groups with respect to any of the secondary outcome measures. This long-term study upholds the short-term findings of the original RCT in that the home-based rehabilitation program is more effective than a more physiotherapy-intensive program for patients in the first three months following ACL reconstruction. Given the resource savings demonstrated in the original RCT, the home-based program is clearly economically-dominant (i.e., clinically more effective and less expensive). FUNDING: Calgary Health Region

In Far East, including Japan and the Middle East, daily activities are frequently carried out on the floor. Deep flexion of the knee joint is therefore very important in these societies. Some patients who underwent total knee arthroplasty (TKA) in these countries often perform deep flexion activity, such as squatting, cross-leg sitting and kneeling. However it is still unknown that deep flexion activity affects long term durability after TKA. The purpose of this study was to examine the correlation between deep flexion and long term durability. Between December 1989 and May 1997, 507 total knee arthroplasties were carried out in 371 patients using the Bi-Surface Knee System (Japan Medical Material, Osaka, Japan) at two institutions and routine rehabilitation program continued for one to two months after TKA. One patient who underwent simultaneous bilateral TKA was excluded because of pulmonary embolism within one month. The other 505 knees (370 patients) were divided into two groups according to the range of flexion after our routine rehabilitation program; one group (Group A: 207 knees) consisted of more than 135 degrees flexion knees and the other group (Group B: 298 knees) consists of less than 135 degrees flexion knees. Patients whose follow-up period was less than 10 years were excluded from this clinical evaluation. Range of flexion was measured preoperatively, at the time after routine rehabilitation program, and at the latest follow-up. Knee function was evaluated on the basis of Knee Society knee score and functional score preoperatively and at the latest follow-up. Kaplan-Meier survivorship analysis was performed with revision for any operation as the end point. In Group A, the mean preoperative range of flexion was 133.0±16.3 degrees, and at the time after routine rehabilitation program, this improved to 139.7±5.1 degrees. This angle maintained to 136.2±14.3 at the latest follow-up. In Group B, the mean preoperative range of flexion was 111.6±20.4 degrees, and at the time after routine rehabilitation program, this improved to 114.5±13.6 degrees. This angle maintained to 118.2±17.8 at the latest follow-up. The Knee Society knee score and functional score was improved from 43.0±16.9 points and 39.0±20.2 points preoperatively to 95.1±5.8 points and 51.8±21.2 points at the latest follow-up, respectively in Group A. The Knee Society knee score and functional score was improved from 37.1±16.7 points and 31.9±18.4 points preoperatively to 92.5±8.7 points and 53.1±26.1 points at the latest follow-up, respectively in Group B. Kaplan-Meier survivorship at 10-year was 95.5% in Group A and 96.2% in Group B with any operation as the end point. The survivorship between Group A and Group B was not statistically significant. Good range of flexion was maintained and Knee society score was excellent after a long time follow-up for the patients who achieved deep flexion after TKA. Deep flexion was proved not to affect long term durability in this Bi-Surface Knee System

Purposes and Background. Musculoskeletal disorders including as back and neck pain are leading causes of work disability. Effective interventions exist (i.e. functional restoration, multidisciplinary biopsychosocial rehabilitation, workplace-based interventions, etc.), but it is difficult to select the optimal intervention for specific patients. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions. The WATT algorithm categorizes patients based on individual, occupational, and clinical characteristics according to likelihood of successful return-to-work following rehabilitation. Internal validation showed acceptable classification accuracy, but WATT has not been tested beyond the original development sample. Our purpose was to externally validate the WATT. Methods and Results. A population-based cohort design was used, with administrative and clinical data extracted from a Canadian provincial compensation database. Data were available on workers being considered for rehabilitation between January 2013 and December 2016. Data was obtained on patient characteristics (ie. age, sex, education level), clinical factors (ie. diagnosis, part of body affected, pain and disability ratings), occupational factors (ie. occupation, employment status, modified work availability), type of rehabilitation program undertaken, and return-to-work outcomes (receipt of wage replacement benefits 30 days after assessment). Analysis included classification accuracy statistics of WATT recommendations for selecting interventions that lead to successful RTW outcomes. The sample included 5296 workers of which 33% had spinal conditions. Sensitivity of the WATT was 0.35 while specificity was 0.83. Overall accuracy was 73%. Conclusion. Accuracy of the WATT for selecting successful rehabilitation programs was modest. Algorithm revision and further validation is needed. No conflicts of interest. Sources of funding: Funding was provided by the Workers' Compensation Board of Alberta

Abstract. Source of Study: London, United Kingdom. This intervention study was conducted to assess two developing protocols for quadriceps and hamstring rehabilitation: Blood Flow Restriction (BFR) and Neuromuscular Electrical Stimulation Training (NMES). BFR involves the application of an external compression cuff to the proximal thigh. In NMES training a portable electrical stimulation unit is connected to the limb via 4 electrodes. In both training modalities, following device application, a standardised set of exercises were performed by all participants. BFR and NMES have been developed to assist with rehabilitation following lower limb trauma and surgery. They offer an alternative for individuals who are unable to tolerate the high mechanical stresses associated with traditional rehabilitation programmes. The use of BFR and NMES in this study was compared across a total of 20 participants. Following allocation into one of the training programmes, the individuals completed training programmes across a 4-week period. Post-intervention outcomes were assessed using Surface Electromyography (EMG) which recorded EMG amplitude values for the following muscles: Vastus Medialis, Vastus Lateralis, Rectus Femoris and Semitendinosus. Increased Semitendinosus muscle activation was observed post intervention in both BFR and NMES training groups. Statistically significant differences between the two groups was not identified. Larger scale randomised-controlled trials are recommended to further assess for possible treatment effects in these promising training modalities

Background:. The aim of this study was to investigate the outcome after ACL reconstruction between a group of patients receiving a standardized supervised physiotherapy guided rehabilitation program and a group of patients who followed an un-supervised, home-based rehabilitation program. Methods:. 40 patients with isolated anterior cruciate ligament injuries were allocated to either a supervised physiotherapy intervention group or home-based exercise group. Patients were investigated by an independent examiner pre-operative, 3, 6, 9 and 12 months post-surgery using the following outcome measures: Lysholm Score and Tegner Activity Scale, functional hopping tests, isometric and isokinetic strength assessments. Results:. Both groups improved significantly (p=0.01–0.04) following 12 months after surgery. The median Lysholm score increased from 57 (34–90) to 94 (90–100) in the supervised group and 60 (41–87) to 97 (95–100) in the unsupervised group. The median Tegner Activity Scale increased from 3 (2–8) to 6 (3–8) in the supervised group and 4 (2–8) to 5 (3–10) in the unsupervised group. The combined mean symmetry indices for the hopping tests improved from 77.3+ 18.7 to 86.8+11.1 (supervised) and from 78.1+30.5 to 88.3+10.9 (unsupervised). Isometric and isokinetic strength symmetry indices for knee extension improved from 68.9+23.5 to 82.8+11.9 resp. 63.7+22.8 to 82.7+15.1 in the supervised group and from 73.6+20.5 to 76.5+17.9 resp. 69.5+24.3 to 76.9+16.9 in the unsupervised group. Eccentric strength symmetry indices for knee extension improved from 67.9+27.7 to 87.8+6.8 in the supervised group and from 71.3+17.8 to 82.6+15.6 in the unsupervised group. Conclusion:. This study could not demonstrate a benefit in a rehabilitation program supervised by a physiotherapist in our population compared to an unsupervised cohort

Purpose. Lumbar paraspinal muscle dysfunction and low back pain are strongly correlated. Muscle atrophy is common in LBP and is recognised by MRI scan. Corticosteroid injections and physical rehabilitation programs are advocated for treatment of LBP. The purpose is to evaluate efficacy of specific lumbar multifidus muscle retraining exercises and perifacet multifidus injections in treatment of Low Back Pain (LBP) and referred leg pain. Method. 63 patients with non-specific LBP, with or without leg pain, were randomised to three treatment groups. MR images of paraspinal muscle and the atrophy classified. A-Control group, standard physiotherapy for 10 weeks. B-Multifidus rehabilitation program for 10 weeks. C-Perifacet injection (multifidus injection) with methylprednisolone. ODI was primary outcome measure and the SF-36, modified Zung Depression Index and others were secondary outcome measures. Results. 56 patients completed trial. ODI improved from a mean of 29.9 to 25.9, but there were no statistically significant differences between groups. 62% of patients were at risk/had major psychological overlay. LBP improved most in group C (Perifacet injection) (P< 0.02), mean improvement in SF-36 bodily pain score was 21.2 (with a 95% CI of 2.1-44.0) while PF and SF were improved most in group B (multifidus rehabilitation) (P< 0.03). Conclusion. Perifacet injection and a multifidus retraining program are more effective than standard physiotherapy in relieving pain and improving physical capacity respectively. Multifidus rehabilitation program is the recommended treatment for non-specific LBP, as the ultimate goal should be to restore function. Perhaps the combination of perifacet injection to relieve pain followed by multifidus retraining program is the best treatment option. No change in the multifidus muscle was seen over time

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Background. Free From Pain (aka Fear Reduction, Exercise Early with Food from plants, Rest and relaxation, Organisation and Motivation to decrease Pain from Arthritis and Increase Natural Strength) is a functional rehabilitation programme to combat sarcopenia and musculoskeletal pain in seniors. It is also published as a book (ISBN-0995676941). The aim of this audit was to evaluate the safety and suitability of the exercises and the usefulness of the exercise book. Methods and Results. Participants were volunteers who paid to attend the Free From Pain Exercise programme. Participants evaluated the exercises using a 5-point Likert scale and the Exercise Book using the Usefulness Scale for Patient Information Material (USE). 30 participants attended the Free From Pain programme. 26 participants completed the questionnaire. This included 20 females and 6 males, with a mean age of 76 years. The mean scores on the 0 to 5 Likert scales were A) Exercises were suitable? 4.69; B) Exercises were safe? 4.58; C) Absence of any injury or medical event whilst exercising? 4.58; D) Covered all body parts? 4.38; E) Easy to do at home? 4.42; F) Encouraged to do more exercise? 4.42; G) Recommend to family and friends? 4.50. The mean scores of the cognitive, emotional, and behavioural sub domains of the USE scale, scored 0 to 30, were 25.23, 23.73 and 23.69, respectively. Conclusion. The pre-pilot study suggests that the suggested exercises are safe and suitable for seniors, and that the exercise book is holistically useful. Conflict of Interest: G Ampat sells the Free From Pain Exercise book online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Free From Pain is a trading name. Jacqueline Howard is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

Abstract. Introduction. Autologous chondrocyte implantation (ACI) is a common procedure, primarily performed in active, young patients to treat knee pain and functional limitations resulting from cartilage injury. Nevertheless, the functional outcomes of ACI remain poorly understood. Thus, the aim of this systematic review was to evaluate the biomechanical outcomes of ACI. Methodology. Ovid MEDLINE, Embase, and Web of Science were systematically searched using the terms ‘Knee OR Knee joint AND Autologous chondrocyte implantation OR ACI’. Strict inclusion and exclusion criteria were used to screen publications by title, abstract, and full text. Study quality and bias were assessed by two reviewers. PROSPERO ID: CRD42021238768. Results. 28 articles including 35 ACI cohorts were included in this review. The average range of motion (ROM) was found to improve with clinical significance (>5˚) and statistical significance (p < 0.05) postoperatively: 133.9 ± 5.5˚ to 139.2 ± 4.9˚ (n=12). Knee strength significantly improved within the first two postoperative years, but remained poorer than control groups at final follow-up (n=17). No statistical differences were found between ACI and control groups in their ability to perform functional activities like the 6-minute walk test. However, peak external knee extension and adduction moments during gait were significantly poorer in ACI patients when compared to controls. Conclusion. Generally, functional outcomes improved with clinical and statistical significance following ACI. However, knee strengths and external knee moments during gait remain significantly poorer than healthy controls, particularly >2-years postoperatively. Thus, ACI patients likely require targeted strength training as part of their rehabilitation programme

Lumbar discectomy is now the operation of choice for lumbosacral radicular syndrome. Few studies of high quality have been performed on the post surgical management of these cases. The studies that have been reported compare one exercise regime to another. The aim of this study was to compare long term outcomes of usual surgical advice, involving no formal post-surgical rehabilitation, with a non-aggravating six month gym rehabilitation programme post lumbar discectomy. This study is a prospective randomised controlled trial using a cohort followed for three years. The patients were computer randomised into two groups. Group A, the control group followed usual surgical advice which was to resume normal activity as soon as pain allowed. Group B, undertook the gym rehabilitation programme. Inclusion criteria were: age 17 to 65 years, good health and no major medical problems. The surgical level had to be L3, L4, or L5. Patients were excluded if they had central neurological disorders, communication difficulties, any condition making gym-based exercises unsafe, or if the surgery was indicated for spinal infection, tumour or inflammatory disease. Patients were followed for a three year period using validated outcome measures (Roland-Morris Questionnaire and Oswestry Low Back Pain Index) and an annual Quality of Life (QoL) questionnaire. The annual questionnaire reported information on number of GP visits, other therapist visits, medication levels and time off work. Ninety three participants were randomised; Control n=46 and trial n=47. Eighty nine participants completed the study. Randomisation achieved a balance of confounding factors, with the exception of work heaviness, where there were a greater number of participants in the very heavy and heavy categories in the trial group (P< 0.01). Functional outcome measures did not achieve statistical difference over the three year period. Other studies have shown these measures to be reliable for short term follow up but their reliability diminishes with time (. 1. ,. 2. ). Key findings of cumulative three year data for the QoL questionnaire were in the intent-to-treat analysis: fewer GP visits in the trial group p< 0.008; and per protocol: fewer episodes off work p< 0.01 (49% versus 15%), fewer days off p< 0.053 and fewer GP visits p< 0.009. The results reveal an advantage in terms of episodes off work and GP visits for participants in Group B who completed the programme. Time off work is a significant consideration for funding providers. These results suggest that surgeons should consider referral of discectomy patients to appropriate post-surgical rehabilitation programmes

The jackaling position within rugby has not been previously described as a mechanism for proximal hamstring injuries. This prospective single surgeon study included 54 professional rugby players (mean age 26 ± 4.8 years) undergoing acute primary surgical repair of complete, proximal hamstring avulsion injuries confirmed on preoperative magnetic resonance imaging. All study patients underwent a standardised postoperative rehabilitation programme. Predefined outcomes were recorded at regular intervals. Mean follow-up time was 17 months (range, 12 months to 24 months) from date of surgery. 51 patients (94.4%) returned to their pre-injury level of sporting activity. Mean time from surgical repair to full sporting activity was 7 months (range, 4 months to 12 months). Zero patients had recurrence of the primary injury. At 1 year after surgery compared to 3 months after surgery, patients had increased mean isometric hamstring muscle strength at 0° (98.4 ± 2.8% vs 88.1% ± 5.4%, p<0.001), 15° (95.9 ± 2.9 vs 88.2 ± 8.1%, p<0.001) and 45° (92.9% ± 4.1% vs 76.8% ± 9.7%, p<0.001), higher mean lower extremity functional scores (77.0 ± 2.3 vs 64.5 ± 4.5, p<0.001), and improved Marx activity rating scores (14.3 ± 1.5 vs 10.7 ± 2.6, p<0.001). Acute surgical repair of proximal hamstring avulsion injuries caused by the contact jackaling position produces high patient satisfaction, high return to preinjury level of sporting activity, with low risk of recurrence at short-term follow-up

Abstract. Objectives. This study aims to evaluate the functional outcomes of early weight-bearing in a functional orthosis for conservatively managed, complete AT ruptures. Also we tried to evaluate the patient reported outcome with this form of treatment. Design. In this prospective study, we have analysed data from 41 patients with ultrasound diagnosed compete AT ruptures, with a gap of less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. Methods. Patients were followed up with foot and ankle trained physiotherapist for at least 1 year post-injury. At final follow up, the followings were measured: calf girth, single-leg heel raise height and repetitions. Furthermore, ATRS score and a patient feedback were taken on this final visit. Result. The mean ATRS score was 82.1, with a re-rupture rate of only 2% as compared to 5% in normal orthosis. The average calf bulk difference was 1.6 cm, the average heel raise height difference was 1.8cm and a heel raise repetition difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p=0.02). However, there was no significant correlation between ATRS and heel raise height or heel raise repetitions. Conclusion. Early weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. A multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome

Introduction: Lumbar discectomy is now the operation of choice for lumbosacral radicular syndrome. Few studies of high quality have been performed on the post surgical management of these cases. The studies that have been reported compare one exercise regime to another. The aim of this study was to compare long term outcomes of usual surgical advice, involving no formal post-surgical rehabilitation, with a non-aggravating six month gym rehabilitation programme post lumbar discectomy. This study is a prospective randomized controlled trial using a cohort followed for three years. Methods: The patients were computer randomised into two groups. Group A, the control group followed usual surgical advice which was to resume normal activity as soon as pain allowed. Group B, undertook the gym rehabilitation programme. Inclusion criteria were: Age 17 to 65 years, good health and no major medical problems. The surgical level had to be L3, L4, or L5. Patients were excluded if they had central neurological disorders, communication difficulties, any condition making gym-based exercises unsafe, or if the surgery was indicated for spinal infection, tumour or inflammatory disease. Patients were followed for a three year period using validated outcome measures (Roland-Morris Questionnaire and Oswestry Low Back Pain Index) and an annual Quality of Life (QoL) questionnaire. A sample of 40 per group provided the study with 80% power (P< 0.05) to detect a 3.5 point change in the RMQ and a 10% change in the ODI. The annual questionnaire reported information on number of GP visits, other therapist visits, medication levels and time off work. Results: Ninety three participants were randomised; Control n=46 and trial n=47. Eighty nine participants completed the study. Randomisation achieved a balance of confounding factors, with the exception of work heaviness, where there were a greater number of participants in the very heavy and heavy categories in the trial group (P< 0.01). Thirty nine of 47 participants completed the gym programme (83%). Functional outcome measures did not show statistically significant differences between groups over the three year period. Key findings of cumulative 3 year data for the QoL questionnaire are: on intent-to-treat analysis; fewer patients having GP visits in the trial group P=0.048 (18% vs 5%). In the per protocol subset; fewer episodes off work P=0.074 (range control 0–3 vs trial 0–2), GP visits P= 0.089 (range control 0–12 vs trial 0–3) and in the per-protocol minus re-operation group; GP visits P< 0.008 (range control 0–3 vs trial 0–2), patients requiring medication use P=0.05 (37% control vs 17% trial) days off work P=0.099 (range control 0–30 vs trial 0–3). Discussion: The results reveal an advantage in terms of episodes off work, GP visits and medication use for participants in the trial group who completed the programme. Time off work is a significant consideration for funding providers. These results suggest that surgeons should consider referral of discectomy patients to appropriate post-surgical rehabilitation programmes

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes

Introduction: Thermal shrinkage represents a major innovation in the evolving field of surgery for shoulder instability. The basic science of collagen fiber change has been studied in detailed and set the physical basis for mechanical properties change of the capsule. Animal models and clinical studies has been published for the last decade with short and mid-term results. A clinical application has proceeded basic knowledge in many respects and there is concern about the safety and efficacy of the procedure. Materials and Methods: Between February 1999 and January 2001, 25 patients, mean age 21.5 (range 16–28) were operated (single shoulder) for radiofrequency capsular shrinkage with VAPR device. In this group 2 high performance sportsmen (basketball and judo), 4 leisure sports activities (mainly basketball), 6 combat soldiers and 13 non related to sporting activities. In 5 of these patients arthroscopic Bankart repair was performed. In one case the procedure was performed after failure of capsular shift in an extreme hyperlax multidirectional instability and this patients was excluded from the study. Indication for surgery were: 1. Multidirectional instability with less than 3 frank dislocation. 2. Symptomatic subluxators with positive apprehension test after failed non-operative rehabilitation program. 3. High demands first dislocators sportsman with failure of non operative rehabilitation program. The arthroscopy was performed in sitting position with posterior and anterior portals as a day surgery or overnight hospitalization. Anterior portal was used for VAPR probe first and portals were switched if needed. All patients were immobilized in shoulder immobilizer for 6 weeks. Rehabilitation program was planed on individual basis and patients were instructed not to return to full contact sport or activities at least 6 months post operatively. Patients were checked at 2 and 6 weeks before commence rehabilitation and than at 3, 6, 24 months. Mean follow up was 17.6 months (range 6–27 m.). Results: Operation and postoperative course was uneventful and no complications were detected. All patients had normal axillary nerve sensation and normal deltoid function. 21 of 24 (87.5%) regain pre dislocation activity between 6 to 12 months and had no dislocation or instability symptoms. Range of motion after 6 months was fully functional and comparable with the opposite side in 22 of these 23 patients. One patient had postoperative stiffness up to 12 months from operation and recover completely then. All but two followed rehabilitation instructions One of these two regains basketball activities 4 weeks postoperatively and dislocated his shoulder immediately. These patients underwent inferior capsular shift operation later on. The second patient, a 16 years female elite judoka, commenced judo matches after 3 months and was asymptomatic with 24 months follow-up time. Conclusion: In selective indications with multidirectional instability, individual rehabilitation program and good cooperation success rate of 91% could be achieved among mixed activities group. We think that this procedure is a good alternative in selected cases. Longer follow-up for selected groups is still needed