The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Hypothesis: In severely the injured, there has been a move away from early total care to staged physiological and anatomic reconstruction, damage control orthopaedics (DCO). This seeks to limit the magnitude of the second hit insult resulting from operative treatment after trauma, deferring complex reconstructive work until a later stage. For femoral shaft fracture, this entails initial external fixation, to provide early skeletal stabilisation, and subsequent conversion to an intramedullary nail (IMN). Materials and Methods: Patients with femoral shaft fracture, who underwent primary IMN or DCO between 1996 and 2002 were identified from our database. Those with New Injury Severity Score (NISS) < 20 were excluded. The systemic inflammatory response (SIRS) and Marshall multi-organ failure scores (MMOFS) were calculated every 12h for 4 days. These systems have been previously correlated with outcome and complications in critical care. Results: 174 patients were included. The mean SIRS score was higher at each time period post operatively in the IMN group (p < 0.01). The MMOFS was slightly higher at each point in the DCO group, (only sig. at 48h). There was a higher incidence of pneumonia and mortality (significant p < 0.02), ARDS and MOF (both n.s.) in the DCO group, this being attributable to the higher incidence of head and thoracic injury (AIS severity 2 or more). The mean peak post-operative SIRS score was significantly higher in the IMN group than in the DCO group, both at primary procedure and conversion, as was the time with SIRS score above 1. The pre-op and peak post-op SIRS score correlated with the peak post op MMOFS score (p 0.0002). The conversion pre-op SIRS score correlated with post-operative peak SIRS score and MMOFS score (p 0.0001). On average, a significant rise in the MMOFS score did not occur following the conversion procedure. Conclusion: It would appear that despite having significantly more severe injuries, patients in the DCO group had a smaller, shorter postoperative systemic inflammatory response and suffered only slightly more pronounced organ failure than the IMN group. They did suffer more complications, but this was only significant for pneumonia. DCO patients undergoing conversion whilst their SIRS score was raised suffered the most pronounced subsequent inflammatory response and rise in organ failure score

Aims. The aim of this study was to determine the fracture haematoma (fxH) proteome after multiple trauma using label-free proteomics, comparing two different fracture treatment strategies. Methods. A porcine multiple trauma model was used in which two fracture treatment strategies were compared: early total care (ETC) and damage control orthopaedics (DCO). fxH was harvested and analyzed using liquid chromatography-tandem mass spectrometry. Per group, discriminating proteins were identified and protein interaction analyses were performed to further elucidate key biomolecular pathways in the early fracture healing phase. Results. The early fxH proteome was characterized by immunomodulatory and osteogenic proteins, and proteins involved in the coagulation cascade. Treatment-specific proteome alterations were observed. The fxH proteome of the ETC group showed increased expression of pro-inflammatory proteins related to, among others, activation of the complement system, neutrophil functioning, and macrophage activation, while showing decreased expression of proteins related to osteogenesis and tissue remodelling. Conversely, the fxH proteome of the DCO group contained various upregulated or exclusively detected proteins related to tissue regeneration and remodelling, and proteins related to anti-inflammatory and osteogenic processes. Conclusion. The early fxH proteome of the ETC group was characterized by the expression of immunomodulatory, mainly pro-inflammatory, proteins, whereas the early fxH proteome of the DCO group was more regenerative and osteogenic in nature. These findings match clinical observations, in which enhanced surgical trauma after multiple trauma causes dysbalanced inflammation, potentially leading to reduced tissue regeneration, and gained insights into regulatory mechanisms of fracture healing after severe trauma. Cite this article: Bone Joint Res 2024;13(5):214–225

Objectives. Our objectives were to describe the therapeutic aspects and assess the prognosis of chronic osteomyelitis in children. Materials and methods. We made a retrospective study from January 2007 to December 2016. The study concerned children from 0 to15 years, treated for chronic osteomyelitis and monitored in the pediatric surgery department of the teaching hospital Gabriel Toure, Bamako (Mali). The other types of bone infections, osteitis and bone tumors were not included in the study. In 10 years we received and treated 215 children with chronic osteomyelitis. This represented 3.56% of all the hospitalizations. The mean age was 8.8 (± 6.67) years with extremes of 28 days and 15 years. The patients were first seen by the traditional healer in 165 (76.7%) cases. The sex ratio was 1.26. The major clinical feature was local swelling associated with pain in 110 cases (51.2%). In 135 cases (62.8%) the staphylococcus aureus was found in direct examination or culture. After a year we performed a functional and morphological assessment according to the method of DIMEGLIO. Results. Surgical treatment was performed in all patients. The average delay of stay in hospital was 4.95 ± 4.57 weeks, with extremes of 2 and 12 weeks. The means follow-up was 13 months with extremes of 3 and 20 months. Good results were found in 115 patients, fair in 60 (40 in keloid knee valgus to 11 ° in 10, muscular atrophy 10), bad in 40 (shortening member in 25 non-union in 10 valgus to 18 ° in 5) According Dimeglio score. There was no significant association between the time of consultation, prior treatment received, the surgical technique and the occurrence of complications (p> 0.05). Conclusion. The management of the chronic osteomyelitis is well codified. The functional prognosis is dependent on an early care and sequels can be dramatic in children of school age. Keywords. Chronic osteomyelitis, Treatment, Prognosis, Children

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Aims. The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation. Methods. All patients transferred to a national tertiary spinal referral centre for primary surgical fixation of unstable spinal injuries without preoperative neurological deficit between 1 July 2016 and 20 October 2017 were eligible for inclusion. Data were collected retrospectively. Patients were divided into early and late cohorts based on timing from initial trauma to first spinal operation. Early fixation was defined as within 72 hours, and late fixation beyond 72 hours. Results. In total, 86 patients underwent spinal surgery in this period. Age ranged from 16 to 88 years. Mean Injury Severity Score (ISS) was higher in the early stabilization cohort (p = 0.020). Age was the sole significant independent variable in predicting morbidity on multiple regression analysis (p < 0.003). There was no significant difference in complication rates based on timing of surgical stabilization (p = 0.398) or ISS (p = 0.482). Conclusion. Our results suggest that these patients are suitable for early appropriate care with spinal precautions and delayed definitive surgical stabilization. Earlier surgery conferred no morbidity benefit and had no impact on length of stay. Cite this article: Bone Joint J 2020;102-B(5):627–631

Aims

Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications.

The Winston Churchill Memorial Trust was established in 1965 on Sir Winston's death as a national memorial and living tribute to him, and funded by many thousands of people who contributed to a public subscription. This now funds Travelling Fellowships to allow Churchill Fellows to travel abroad and learn lessons that can be brought back to benefit the local community and ultimately the UK as a whole. Both authors were recipients of this prestigious 2009 Fellowship in the category of “Treatment & Rehabilitation of Traumatic Injuries”. Over fifteen weeks we visited hospitals in Germany, Canada, and the USA with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies. We aimed to learn lessons from their experience, exchange ideas and to make contacts. We visited the US military hospital in Landstuhl Regional Medical Center, Germany, the University of Alberta Hospital and Glenrose Rehabilitation Hospital and the two major centres of US military care at the Walter Reed Army Medical Center/National Naval Medical Center in Washington DC, and the Brooke Army Medical Center in San Antonio Texas. We present our experience from this Fellowship, some of the lessons we have learnt and the problems that we face in common with our NATO allies

Traumatic hemipelvectomy is rare, and is usually accompanied by injury to the genito-urinary tract and bowel. Recently, there have been an increasing number of reports of patients who have survived this injury, probably as a result of improved early care. We report three such cases and review the literature. The amputation wound should not be closed initially; early re-exploration to remove any dead tissue is indicated, and this should be repeated as necessary

Algorithms for the treatment of multiply-injured patients with concomitant orthopaedic injuries have continued to evolve over the past several decades. Advances in surgical techniques and implants have revolutionised the treatment of specific musculoskeletal injuries. Improved understanding of the implications of applying these techniques to patients with compromised physiology has led to critical reevaluation of the issues surrounding definitive orthopaedic care. A discussion of these issues as they apply to the multiply-injured patient with associated femoral shaft fracture provides insight into how Damage Control Orthopaedics has evolved. As well as what questions remain unanswered in our ongoing efforts to decrease mortality and improve long-term functional recovery in this difficult and challenging patient population. While femur fracture patients in the 1950s and 1960s were often deemed ‘too sick’ for surgical treatment, the high morbidity and mortality associated with long-term traction as a primary treatment modality led to recognition of the benefits of early fracture care in the 1980s. Multiple studies demonstrating the benefit of early fixation of femur fractures in multiply-injured patients led to a dramatic shift in treatment protocols towards urgent, if not emergent, definitive stabilisation of the femur. However, weaknesses of these early studies exist and their results were often over-interpreted. In the late 1980s and early 1990s, evidence began to accumulate that early definitive treatment consisting of reamed intramedullary nailing of the femur might actually be detrimental in an at risk subgroup of patients. Early interpretation of these results led to a move toward ‘unreamed’ nails in multiply-injured patients in an effort to minimise the pulmonary impact of reaming. Our current level of understanding appears to indicate that there exists a much more complex interaction between multiple factors including patient characteristics, associated injuries, timing and mode of orthopaedic stabilisation employed. As the relative importance and influence of these multiple factors becomes clearer, our ability to appropriately select patients for early total care versus damage control orthopaedics should improve the potential for damaging physiological effects of treatment. In the meantime, application of the principles of damage control to those patients for whom it is clearly indicated, as well as to those for whom it may not be clear cut, appears to have minimal, if any, deleterious effect

The modern generation of hip resurfacing arthroplasties was developed in the early 1990's with one of the original designs being the McMinn Resurfacing Total Hip System. This was a hybrid metal on metal prosthesis, with a smooth hydroxyapetite coated press fit mono block cobalt chrome shell with a cemented femoral component. Although no longer produced in this form, lessons may be learned from this original series of components. With metal on metal resurfacing arthroplasty now facing criticisms and concerns with regard function, bone preservation capability and soft tissue issues such as ‘pseudotumors’, it is the aim of this long-term study to assess the outcome and survival of an original series of resurfacing arthroplasties. 27 resurfacing arthroplasties were performed in 25 consecutive patients between June 1994 and November 1996. 16 right hips and 11 left were performed in 14 female patients and 11 male patients. The average age at the time of surgery was 50.5 years (SD 7.9, range 30-63). All surgeries were performed by a single surgeon using a posterior lateral approach. Following the initial early care, each patient received bi-annual follow up along with open access to the clinic with any concerns or complications. A retrospective review of the case notes was conducted and outcome scores retrieved from a prospectively updated database. Radiographs were analyzed and a Kaplan Meier survival chart was constructed for the group. At latest review 3 patients have died (5yrs, 8yrs and 13.8yrs) and 1 patient has been lost to follow up (5yrs). 7 resurfacings have required revision, all due to acetabular loosening, at a mean follow up of 7 years 11months (SD 2.03years, range 4-10). Metallosis was documented in 4 of the revision cases, however no extensive soft tissue inflammation or ‘pseudotumor’ identified. The mean follow up of the remaining 16 hips is 12years and 10months (SD 12.8months, Range 10.4yrs-14.0 years). The Kaplan Meier survival at a minimum follow up of 10 years is 75.8% (95% CI 0.67-0.95). Mean Oxford hip scores at latest follow up was 20.6 (SD 8.8, range 12-38). There was no significant difference between cup inclination angles for the surviving cohort and those who required a revision procedure with mean cup inclinations of 52.5 (SD 5.5, range 45-60) and 58 degrees respectively (SD 9.1, range 50-70)(p=0.255). This original series of hip resurfacings, with up to 14 years follow up, shows a survival of 76% at the minimum follow up of 10 years. All failures were due to loosening of the smooth backed acetabulum, which with a modern porous coating, failure may have been avoided or delayed. Despite high inclinations angles no soft tissue reactions were identified within this series. No femoral failures were identified suggesting unlike much literature focus, long-term failure may not be related to the femoral head or neck

Background. Polytrauma patients are at high risk of systematic inflammatory response syndrome (SIRS) due to an exaggerated unbalanced immune response that can lead to multiple organ failure and increased mortality. This response is often heightened following acute surgical management as a result, damage-control orthopaedics (DCO) was born. This allows the patient to be stabilised using external fixation allowing physiology to improve. This systematic review aims to compare DCO against early total care (ETC) (<24hrs intramedullary nailing) in polytraumatised patients with femoral shaft fractures using a diagnosis of acute lung injury (ALI) as the primary outcome measure. Method. A systematic review of MEDLINE, EMBASE, CENTRAL and AMED was carried out to identify all English language studies comparing ETC versus DCO using ALI as the primary outcome measure. Two authors independently screened the studies and performed data extraction. Risk of bias was assessed using the Cochrane risk of bias tool and the Risk-of-Bias Assessment Tool for Non-randomised Studies. Results. Three studies were selected for final inclusion. One multicentre RCT demonstrated a significantly higher odds ratio (6.69) of ALI in the subgroup receiving ETC compared to DCO. The two other studies were retrospective case series with one reporting no significant difference and the second study reporting a significant reduction in ARDS when a DCO approach was used (7.8% vs 15.1%). Meta-analysis was not possible due to heterogeneity. Conclusions. This review supports evidence that in the more unstable patients (Injury Severity Score≥30) treated surgically for femoral shaft fractures in the first 24 hours, DCO may have a protective effect over ETC for ALI. However further studies with large sample sizes are needed to provide clarity on the subject area. Level of Evidence. 1. Ethics. No approval required given the nature of this study (systematic review)

Purpose: The modern generation of hip resurfacing arthroplasties was developed in the early 1990’s with one of the original designs being the McMinn Resurfacing Total Hip System. This was a hybrid metal on metal prosthesis, with a smooth hydroxyapetite coated press fit mono block cobalt chrome shell with a cemented femoral component. Although no longer produced in this form, lessons may be learned from this original series of components. With metal on metal resurfacing arthroplasty now facing criticisms and concerns with regard function, bone preservation capability and soft tissue issues such as ‘pseudotumors’, it is the aim of this long-term study to assess the outcome and survival of an original series of resurfacing arthroplasties. Method: 27 resurfacing arthroplasties were performed in 25 consecutive patients between June 1994 and November 1996. 16 right hips and 11 left were performed in 14 female patients and 11 male patients. The average age at the time of surgery was 50.5 years (SD 7.9, range 30–63). All surgeries were performed by a single surgeon using a posterior lateral approach. Following the initial early care, each patient received bi-annual follow up along with open access to the clinic with any concerns or complications. A retrospective review of the case notes was conducted and outcome scores retrieved from a prospectively updated database. Radiographs were analyzed and a Kaplan Meier survival chart was constructed for the group. Results: At latest review 3 patients have died (5yrs, 8yrs and 13.8yrs) and 1 patient has been lost to follow up (5yrs). 7 resurfacings have required revision, all due to acetabular loosening, at a mean follow up of 7 years 11months (SD 2.03years, range 4–10). Metallosis was documented in 4 of the revision cases, however no extensive soft tissue inflammation or ‘pseudotumor’ identified. The mean follow up of the remaining 16 hips is 12years and 10months (SD 12.8months, Range 10.4yrs-14.0 years). The Kaplan Meier survival at a minimum follow up of 10 years is 75.8% (95% CI 0.67–0.95). Mean Oxford hip scores at latest follow up was 20.6 (SD 8.8, range 12–38). There was no significant difference between cup inclination angles for the surviving cohort and those who required a revision procedure with mean cup inclinations of 52.5 (SD 5.5, range 45–60) and 58 degrees respectively (SD 9.1, range 50–70)(p=0.255). Conclusion: This original series of hip resurfacings, with up to 14 years follow up, shows a survival of 76% at the minimum follow up of 10 years. All failures were due to loosening of the smooth backed acetabulum, which with a modern porous coating, failure may have been avoided or delayed. Despite high inclinations angles no soft tissue reactions were identified within this series. No femoral failures were identified suggesting unlike much literature focus, long-term failure may not be related to the femoral head or neck

The modern generation of hip resurfacing arthroplasties was developed in the early 1990’s with one of the original designs being the McMinn Resurfacing Total Hip System. This was a hybrid metal on metal prosthesis, with a smooth hydroxyapetite coated press fit mono block cobalt chrome shell with a cemented femoral component. Although no longer produced in this form, lessons may be learned from this original series of components. With metal on metal resurfacing arthroplasty now facing criticisms and concerns with regard function, bone preservation capability and soft tissue issues such as ‘pseudotumors’, it is the aim of this long-term study to assess the outcome and survival of an original series of resurfacing arthroplasties. 27 resurfacing arthroplasties were performed in 25 consecutive patients between June 1994 and November 1996. 16 right hips and 11 left were performed in 14 female patients and 11 male patients. The average age at the time of surgery was 50.5 years (SD 7.9, range 30–63). All surgeries were performed by a single surgeon using a posterior lateral approach. Following the initial early care, each patient received bi-annual follow up along with open access to the clinic with any concerns or complications. A retrospective review of the case notes was conducted and outcome scores retrieved from a prospectively updated database. Radiographs were analyzed and a Kaplan Meier survival chart was constructed for the group. At latest review 3 patients have died (5yrs, 8yrs and 13.8yrs) and 1 patient has been lost to follow up (5yrs). 7 resurfacings have required revision, all due to acetabular loosening, at a mean follow up of 7 years 11months (SD 2.03years, range 4–10). Metallosis was documented in 4 of the revision cases, however no extensive soft tissue inflammation or ‘pseudotumor’ identified. The mean follow up of the remaining 16 hips is 12years and 10months (SD 12.8months, Range 10.4yrs–14.0 years). The Kaplan Meier survival at a minimum follow up of 10 years is 75.8% (95% CI 0.67–0.95). Mean Oxford hip scores at latest follow up was 20.6 (SD 8.8, range 12–38). There was no significant difference between cup inclination angles for the surviving cohort and those who required a revision procedure with mean cup inclinations of 52.5 (SD 5.5, range 45–60) and 58 degrees respectively (SD 9.1, range 50–70)(p=0.255). This original series of hip resurfacings, with up to 14 years follow up, shows a survival of 76% at the minimum follow up of 10 years. All failures were due to loosening of the smooth backed acetabulum, which with a modern porous coating, failure may have been avoided or delayed. Despite high inclinations angles no soft tissue reactions were identified within this series. No femoral failures were identified suggesting unlike much literature focus, long-term failure may not be related to the femoral head or neck

Purpose. There are concerns with regard to the physiological effects of reamed intramedullary femoral fracture stabilisation in patients who have received a pulmonary injury. This large animal study used invasive monitoring techniques to obtain sensitive cardiopulmonary measurements and compared the responses to Early Total Care (reamed intramedullary femoral fracture fixation) to Damage Control Orthopaedics (external fixation), after the induction of acute lung injury. We hypothesised a greater cardiopulmonary response to intramedullary fracture fixation. Method. Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised male sheep via the infusion of oleic acid into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Simultaneous haemodynamic and arterial blood-gas measurements were recorded at baseline and at 5, 30 and 60 minutes after fracture stabilisation. Results. The mean (S.E.) PaO2/FiO2 fell significantly (p<0.05) from 359(37) to 107 (23) and 382 (33) to 128 (18) in the externally fixated and intramedullary nailed groups respectively as a result of the acute lung injury. The further combined effect of surgical osteotomy and subsequent fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 114 (21) and 113 (12), in the externally fixated and intramedullary nailed groups respectively, immediately after surgery. This was not significantly different either within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 4.7 (0.9) and 4.2 (0.5) in the externally fixated and intramedullary nailed groups respectively after lung injury changed to 4.9 (0.7) and 4.3 (0.6) after surgical osteotomy and subsequent fracture fixation which, again was not significantly different either within or between groups. No significant difference in either PaO2/FiO2 or PVR was detected at the monitored 5, 30 and 60 minute intervals that followed fracture stabilisation. Conclusion. Against a background of standardised acute lung injury, there appeared to be no further deterioration produced by the method of isolated femoral fracture fixation in two sensitive physiological parameters commonly used by intensive care physicians

A series of sixteen patients, 14 males and 2 females with an average age of 50 years (28–93) underwent total hip replacement surgery after acetabular fracture. Thirteen patients had previously undergone internal fixation of their acute fractures. Hip replacement surgery was performed by a single surgeon over an eight year period at an average of 30.36 (range 3–84) months after injury. Cases include high energy injuries as well as low energy fractures of the elderly (2 patients). These were complex procedures due in some cases to the dramatic femoral head and acetabular bone stock loss when avascular necrosis had occurred following internal fixation. The use of acetabular mesh, allograft and reinforcement rings is discussed. At the time of reporting the total hip replacements in this group of relatively young patients continue to be highly successful. One hip has been revised for recurrent dislocation. This paper describes important surgical tips for the management of these complex cases. Removal of exposed metal work can be difficult. A role for MRI scanning in the early postoperative care following fracture fixation is postulated. The importance of early liaison of fracture fixation surgeons with arthroplasty colleagues leads to earlier surgery with reduction of bone stock loss

Aims

Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery.

Introduction. Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association proposed the clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the elderly population with high risk of fall and ambulatory disability caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS has not been well evaluated. In the present study, we analyzed the early post-operative functional recovery after TKA using 2 simple performance tests to diagnose MADS. Material & Method. Fifty patients with varus type osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 44 female and 6 male patients. The mean age of the patients was 71.6 years (range, 59 to 84 years). Patients were subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation. Secondary one leg standing time with open eyes was measured to assess balancing ability. 2 tests were performed pre-operatively, 2 weeks after surgery and at discharge (23.8 days po). MADS was defined to be diagnosed if TUG and one leg standing time was not less than 11 seconds and/or less than 15 seconds respectively. Each parameter was compared among at above mentioned three time points -using a repeated measured analysis of variance (p<0.05). Results. The number of the patients with MADS were 37, 44 and 38 in 50 patient pre-operatively, 2 weeks after surgery and at hospital discharge respectively. Mean TUG was 12.9, 16.9 and 14.0 sec. respectively [fig 1]. TUG significantly increased during 2 weeks after TKA, followed by significant decrease at discharge. There were no significant improvements in ambulation during hospital stay. Mean one leg standing time with operated and non-operated side leg at three time points were 11.0, 12.4, 17.9 sec, and 18.4, 17.9, 24.2 sec. each respectively [fig 2]. There were no significant improvements during initial 2 weeks after surgery. Significant increase of one leg standing time was found after 2 weeks, and balancing ability was found to be improved during hospital stay. Discussion & Conclusion. Although both parameters assessing ambulatory and balancing function were found to be improved post-operative 2 weeks, still as much as 76% of patients were suffered from MADS at hospital discharge in our patient population. These results indicate that the patient after TKA has still exposed to high risk of fall and ambulatory dysfunction at discharge. We should reconsider the appropriate rehabilitation protocol especially for the elderly patient with MADS to meet with patient expectation and enhance early post-operative care