Access to health care, including physiotherapy, is increasingly occurring through virtual formats. At-home adherence to physical therapy programs is often poor and few tools exist to objectively measure low back physiotherapy exercise participation without the direct supervision of a medical professional. The aim of this study was to develop and evaluate the potential for performing automatic, unsupervised video-based monitoring of at-home low back physiotherapy exercises using a single mobile phone camera. 24 healthy adult subjects performed seven exercises based on the McKenzie low back physiotherapy program while being filmed with two smartphone cameras. Joint locations were automatically extracted using an open-source pose estimation framework. Engineered features were extracted from the joint location time series and used to train a support vector machine classifier (SVC). A convolutional neural network (CNN) was trained directly on the joint location time series data to classify exercises based on a recording from a single camera. The models were evaluated using a 5-fold cross validation approach, stratified by subject, with the class-balanced accuracy used as the performance metric. Optimal performance was achieved when using a total of 12 pose estimation landmarks from the upper and lower body, with the SVC model achieving a classification accuracy of 96±4% and the CNN model an accuracy of 97±2%. This study demonstrates the feasibility of using a smartphone camera and a supervised machine learning model to effectively assess at-home low back physiotherapy adherence. This approach could provide a low-cost, scalable method for tracking adherence to physical therapy exercise programs in a variety of settings

Physiotherapy is generally accepted as an important component in the care pathway surrounding total knee replacement. Therapy interventions can be delivered prior to surgery, as part of the inpatient stay, and post-operation through outpatient appointments. Though ‘physiotherapy’ is generally promoted there is considerable national and international variation in actual therapy provision. Specific rehabilitation protocols are strongly entrenched at individual physiotherapy departments however the wider efficacy of varying physiotherapeutic interventions is poorly established. This uncertainty as to effectiveness of physiotherapy makes it difficult for commissioning organisations, healthcare providers, and patients to make decisions as to what therapy is ‘needed’ and therefore the correct level and mechanism of funding for such services. This talk will explore the variation in physiotherapy service provision and evidence for different interventions surrounding total knee replacement

Physiotherapy is a critical element in successful conservative management of low back pain (LBP). The aim of this study was to develop and evaluate a system with wearable inertial sensors to objectively detect sitting postures and performance of unsupervised exercises containing movement in multiple planes (flexion, extension, rotation). A set of 8 inertial sensors were placed on 19 healthy adult subjects. Data was acquired as they performed 7 McKenzie low-back exercises and 3 sitting posture positions. This data was used to train two models (Random Forest (RF) and XGBoost (XGB)) using engineered time series features. In addition, a convolutional neural network (CNN) was trained directly on the time series data. A feature importance analysis was performed to identify sensor locations and channels that contributed most to the models. Finally, a subset of sensor locations and channels was included in a hyperparameter grid search to identify the optimal sensor configuration and the best performing algorithm(s) for exercise classification. Models were evaluated using F1-score in a 10-fold cross validation approach. The optimal hardware configuration was identified as a 3-sensor setup using lower back, left thigh, and right ankle sensors with acceleration, gyroscope, and magnetometer channels. The XBG model achieved the highest exercise (F1=0.94±0.03) and posture (F1=0.90±0.11) classification scores. The CNN achieved similar results with the same sensor locations, using only the accelerometer and gyroscope channels for exercise classification (F1=0.94±0.02) and the accelerometer channel alone for posture classification (F1=0.91±0.03). This study demonstrates the potential of a 3-sensor lower body wearable solution (e.g. smart pants) that can identify proper sitting postures and exercises in multiple planes, suitable for low back pain. This technology has the potential to improve the effectiveness of LBP rehabilitation by facilitating quantitative feedback, early problem diagnosis, and possible remote monitoring

Background. The physiotherapy profession has experienced a paradigm shift in recent years where mounting research evidence, indicating better patient outcomes, has led to an increase in popularity of a biopsychosocial model of care. In turn physiotherapists have begun to address psychosocial ‘obstacles’ to recovery, as means of improving outcomes for patients. To date, research has not examined how this change has affected the perceptions of physiotherapists about delivering care. The aim of this study was to explore these perceptions through exploratory interviews with physiotherapists in the UK. Methods. A qualitative interview study using a purposive sample of physiotherapists (n=12), nested within a larger study, exploring the attitudes and behaviours of UK general practitioners and physiotherapists about managing patients with low back pain. Interview transcripts were coded by the lead researcher and independently validated by a further team member. Transcripts were coded thematically using the constant comparative method to identify similarities and differences between the data and to determine fit and relevance. Results. The findings demonstrate that a combination of traditional physical therapy with a biopsychosocial approach presented significant challenges for professionals during the consultation. Physiotherapists perceived a number of ‘obstacles to recovery’ and responded to these through adoption of ‘health corrective’ strategies and by imposing limits around the management of these concerns with patients. Conclusion. A model of care combining a biopsychosocial approach with traditional physiotherapy can increase pressure on physiotherapists to use consultation strategies which appear to be patient-centred but may fail to shift from a professional-led agenda. Conflicts of interest. None. Sources of funding. Arthritis Research UK and the North Staffordshire Primary Care Research Consortium. We confirm that this abstract has not been previously published in whole or part nor has it been presented at a national meeting

Virtual physiotherapy has been provided to hundreds of patients at the Holland Centre during the COVID pandemic. As we plan for virtual care to be one part of our care delivery we want to evaluate it and ensure the care delivery is safe and effective. The objectives of this project was two-fold: 1) to examine the outcome of virtual physiotherapy and/ or a hybrid of virtual and in-person care in patients who received post-operative treatment following total knee replacement at the Holland Centre, 2) to explore the challenges of virtual care participation in the joint replacement population. Patients who received either virtual care or a combination of in-person and virtual care (hybrid model) based on the patients’ needs were included. Patient-related outcomes were the Patient Specific Functional Scale (PSFS) and pain scale. Flexion and extension range of motion were measured before and after treatment. A modified Primary Care Patient Experience Virtual Care Survey was used to examine barriers for virtual care. Sixty patients, mean age 68(8), ranging between 45-83 years, 34(57%) females, who received either virtual care or a combination of in-person and virtual care based on the patients’ needs were included. Patients showed improvement in the PSFS and pain scores (p<0.0001). Flexion (p<0.0001) and extension (p=0.02) improved at a statistically significant level. A separate sample (N=54) (age range 50-85 years) completed the patient experience survey. A well-designed post-operative virtual physiotherapy program, initially implemented to maintain continuity of care during the pandemic, continues to be an important part of our model of care as we normalize our activities. Clear understanding of barriers to virtual care and mitigation strategies will help us create virtual care standards, meet our patient needs, optimize our care delivery and potentially increase the use of virtual rehab in the future

Abstract. Objectives. Stiffness is reported in 4%–16% of patients after having undergone total knee replacement (TKR). Limitation to range of motion (ROM) can limit a patient's ability to undertake activities of daily living with a knee flexion of 83. o. , 93. o. , and 106. o. required to walk up stairs, sit on a chair, and tie one's shoelaces respectively. The treatment of stiffness after TKR remains a challenge. Many treatment options are described for treating the stiff TKR. In addition to physiotherapy the most employed of these is manipulation under anaesthesia (MUA). MUA accounts for up to 36% of readmissions following TKR. Though frequently undertaken the outcomes of MUA remain variable and unpredictable. CPM as an adjuvant therapy to MUA remains the subject of debate. Combining the use of CPM after MUA in theory adds the potential benefits of CPM to those of MUA potentially offering greater improvements in ROM. This paper reports a retrospective study comparing patients who underwent MUA with and without post-operative CPM. Methods. Standard practice in our institution is for patients undergoing MUA for stiff TKR to receive CPM for between 12–24hours post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period several MUA procedures were undertaken without subsequent inpatient CPM. We retrospectively identified two cohorts of patients treated for stiff TKR: group 1) MUA + post-operative CPM 2) Daycase MUA. All patients had undergone initial physiotherapy to try and improve their ROM prior to proceeding to MUA. In addition to patients’ demographics pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded for each patient. Results. In total 168 patients who had undergone MUA between 2017–2022 were identified with a median Age of 66.5 years and 64% female. 57% had extension deficit (>5. o. ), 70% had flexion deficit (< 90. o. ), and 37% had both. 42 had daycase MUA without CPM and the remaining 126 were admitted for post-operative CPM. The mean Pre-operative ROM was 72.3. o. (SD:18.3. o. ) and 68.5. o. (19.0. o. ) for the daycase and CPM groups respectively. The mean ROM recorded at MUA was 95.5. o. (SD:20.7. o. ) and 108.3. o. (SD:14.1. o. ) [p<0.01] and at final follow-up was 87.4o (SD:21.9o) and 92.1o (SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92% (SD:17%) and 85% (SD:14%) [p=0.03] for daycase and CPM groups respectively. Conclusion. Overall, there was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. Analysis of the percentage ROM gained at MUA maintained at follow up showed that most patients regressed from ROM achieved at MUA in both groups with those in the CPM only maintaining 85% as opposed to 92% in the daycase patients. It is our observation that post-operative CPM does not improve ROM achieved after MUA as compared to MUA alone. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Tendon injuries present a major clinical challenge, as they necessitate surgical intervention and are prone to fibrotic progression. Despite advances in physical therapy and surgical technique, tendons fail to return to full native functioning, underlining the need for a biological therapeutic to improve tendon healing. Myofibroblasts are activated fibroblasts that participate in the proliferative and remodeling phases of wound healing, and while these matrix-producing cells are essential for proper healing, they are also linked to fibrotic initiation. A subset of tenocytes has been shown to give rise to the myofibroblast fate, and potentially contribute to fibrotic tendon healing. A viable anti-fibrotic therapy in other tissues has been reprogramming the fibroblast-myofibroblast differentiation route, avoiding a more pro-fibrotic myofibroblast phenotype. Thus, defining the molecular programs that underlie both physiological and pathological tendon healing is critical for the development of potential pharmacologic treatments. Towards that end, we have taken advantage of spatial transcriptomics, using the tenocyte marker Scleraxis as a tool, and have outlined three major spatiotemporally distinct tenocyte differentiation trajectories (synthetic, proliferative, and reactive) following acute tendon injury in mouse FDL. We have further outlined key transcriptional controls that may be manipulated to alter the differentiation process and influence the resulting myofibroblast phenotype, thereby promoting regenerative tendon healing

Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes. We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations. 13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery. With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations

Our knowledge of primary bone marrow edema (BME) of the knee is still limited. A major contributing factor is that it shares several radiological findings with a number of vascular, traumatic, and inflammatory conditions having different histopathological features and etiologies. BME can be primary or secondary. The most commonly associated conditions are osteonecrosis, osteochondritis dissecans, complex regional pain syndrome, mechanical strain such as bone contusion/bruising, micro-fracture, stress fracture, osteoarthritis, and tumor. The etiology and pathogenesis of primary BME are unclear. Conservative treatment includes analgesics, non-steroidal anti-inflammatory drugs, weight-bearing limitations, physiotherapy, pulsed electromagnetic fields, prostacyclin, and bisphosphonates. Surgical treatment, with simple perforation, fragment stabilization, combined scraping and perforation, and eventually osteochondral or chondrocyte transplant, is reserved for the late stages. This retrospective study of a cohort of patients with primary BME of the knee was undertaken to describe their clinical and demographic characteristics, identify possible risk factors, and assess treatment outcomes. We reviewed the records of 48 patients with primary BME of the knee diagnosed on MRI by two radiologists and two orthopedists. History, medications, pain type, leisure activities, smoking habits, allergies, and environmental factors were examined. Analysis of patients’ characteristics highlighted that slightly overweight middle-aged female smokers with a sedentary lifestyle are the typical patients with primary BME of the knee. In all patients, the chief symptom was intractable day and night pain (mean value, 8.5/10 on the numerical rating scale) with active as well as passive movement, regardless of BME extent. Half of the patients suffered from thyroid disorders; indeed, the probability of having a thyroid disorder was higher in our patients than in two unselected groups of patients, one referred to our orthopedic center (odds ratio, 18.5) and another suffering from no knee conditions (odds ratio, 9.8). Before pain onset, 56.3% of our cohort had experienced a stressful event (mourning, dismissal from work, concern related to the COVID-19 pandemic). After conservative treatment, despite the clinical improvement and edema resolution on MRI, 93.8% of patients described two new symptoms: a burning sensation in the region of the former edema and a reduced ipsilateral patellar reflex. These data suggest that even though the primary BME did resolve on MRI, the knee did not achieve full healing

Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for paediatric foot and ankle disorders, such as CTEV. Our objective was to assess the efficacy of distal tibial modulation in correcting various paediatric foot and ankle disorders. Methods. This retrospective study analysed 205 cases of paediatric foot and ankle disorders treated between 2003 and 2022, including only cases where the eight plate or screw was fixed on the anterior surface of the distal tibia. Our aim was to measure post-operative changes in dorsiflexion, the distal tibial angle, and the tibiocalcaneal angle by examining clinical records and radiology reports. Results. We identified nine cases (nine feet) meeting the full inclusion criteria, comprising seven cases of CTEV, one case of arthrogryposis, and one case of cavovarus foot. The cohort consisted of five male and four female patients, with a mean age of 10 years and 9 months at the time of surgery. Seven cases involved the left tibia, and two cases involved the right tibia. The mean time between pre-operative X-ray to surgery was 168 days, and the mean turnaround time between surgery and post-operative X-ray was 588 days. A mean change in the distal tibial angle of 4.33 degrees was noted. However, changes in dorsiflexion were documented in only one case, which showed a change of 13 degrees. Notably, our average distal tibial angle was significantly lower than reported in the literature, at 4.33 degrees. Additionally, some studies in the literature used the Oxford Ankle Foot Questionnaire for Children to assess pre- and post-operative outcomes, but it is important to note that it is validated only for children aged 5 to 16. Furthermore, most cases reported an improved tibiocalcaneal angle except for an anomaly of 105 degrees. We assessed satisfactory patient outcomes using patient notes. Out of the 6 procured notes, one has been discharged. The rest are still under yearly or 6-monthly review and are at various stages, such as physiotherapy, removing the eight plate, or requiring further surgery. The most common presentations at review are plantaris deformity and pain. Conclusions. Our study suggests that distal tibial growth modulation can be an effective treatment option for selected paediatric foot and ankle disorders. However, due to the limited number of cases in our study, the lack of documentation of changes in dorsiflexion, and a lack of pre- and post-operative outcomes using a standardised method, further research is needed to investigate this procedure's long-term outcomes and potential complications. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here. The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center. To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first. The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part

Background. To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging the MRC framework for complex interventions we assessed the evidence-base for components of comprehensive rehabilitation in total hip (THR) and total knee replacement (TKR) pathways. Methods. We conducted systematic reviews and meta-analyses of randomised controlled trials (RCT) of pre-surgical exercise and education, occupational therapy and post-operative physiotherapy. In feasibility RCTs we explored acceptability of pain self-management and occupational therapy before THR, and physiotherapy after TKR. We searched trial registers for ongoing RCTs. Results. Pre-surgical interventions. Systematic review identified 38 interventions targeting physical function before THR and TKR. Interventions showed functional benefit compared with controls, standardised mean difference (SMD) 0.32 (95% CI 0.20, 0.44; p<0.00001). In 27 studies targeting in-hospital recovery, intervention patients had lower anxiety, SMD 0.38 (95% CI 0.13, 0.63; p=0.003), and earlier mobilisation by 4 hours (95% CI 0.04, 0.30; p=0.009). In 20 studies, interventions targeting long-term recovery showed no benefit for function or pain. We randomised 88 patients into a feasibility RCT of group-based pain self-management. Attendees were highly satisfied but participation was low. Pre-operatively, many patients may perceive that only surgery can treat their symptoms. Occupational therapy. Systematic review identified 7 small RCTs in THR. Function improved in patients receiving occupational therapy, SMD 0.40 (95%CI 0.09, 0.70; p=0.01) but this was not sustained post-surgery. In our feasibility study with 44 patients randomised to pre-operative provision of aids and appliances or usual care, the intervention was delivered successfully and acceptable to participants. We identified no ongoing studies. Post-discharge physiotherapy. Systematic review identified 7 small studies suggesting that physiotherapy after TKR gives functional benefit at 3–4 months, SMD 0.37 (95%CI 0.12, 0.62; p=0.004) but not at later follow up. As noted in a recent review in THR, quality of evidence was limited. Our feasibility study evaluated six weeks of group-based activity-orientated rehabilitation in 46 TKR patients. The programme was well-received and attendance good. A fully-powered RCT is underway. We identified two ongoing studies targeting patients at risk of, or with, poor recovery. Conclusion. The evidence-base for comprehensive rehabilitation in THR and TKR is growing. Pre-surgical interventions may be effective but, in isolation, not acceptable to many patients. Ongoing definitive trials in TKR physiotherapy will guide future care. Well-designed trials of physiotherapy after THR and occupational therapy are needed. Ultimately, rehabilitation interventions throughout THR and TKR pathways may provide optimal care but this will need appropriate evaluation

There has been significant interest in day-case and rapid discharge pathways for unicompartmental knee replacements (UKR). Pathways to date have shown this to be a safe and feasible option; however, no studies to date have published results of rapid-discharge pathways using the NAVIO robotic system. To date there is no published experience with rapid discharge UKR patients using the NAVIO robotic system. We report an initial experience of 11 patients who have safely been discharged within 24 hours. With the primary goal of investigating factors that led to rapid discharge and a secondary goal of evaluating the safety of doing so. All patients were discharged within 24 hours; there were no post-operative complications and no readmissions to hospital. The mean length of stay was 16.9 hours (SD=7.3), with most patients seen once on average by physiotherapy. Active range of motion at 6 weeks was 0.7o to 130.5 o, with all patients mobilising independently. The average 6-month post-operative Oxford Knee Score was 43.5 out of 48. There were no readmission or complications in any of our patients. This initial feasibility study identified that patients could be safely discharged within 24 hours after UKR using the NAVIO robotic system. With growing uptake of robotic procedures, with longer operative durations than traditional procedures, it is essential to ensure a rapid discharge to reduce healthcare cost whilst ensuring that patients are discharged home in a safe manner

Background. Inpatient physiotherapy is routinely provided after total knee replacement (TKR) surgery to enhance recovery prior to discharge. However, the provision of outpatient physiotherapy is variable in the UK, and the longer-term benefits of outpatient physiotherapy are unclear. This study aimed to evaluate the feasibility of conducting a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of group-based outpatient physiotherapy after TKR. Methods. Patients listed for primary TKR were recruited prior to surgery. Patients who decided not to participate were asked about their reasons for non-participation. Patients were randomised to attend a newly developed post-operative physiotherapy class plus usual care or usual care alone. Patients allocated to the intervention group were invited to attend a weekly one-hour physiotherapy class, starting at 6 weeks after surgery and running over 6 consecutive weeks. The group classes were run by two physiotherapists within an outpatient gym, and involved task-orientated and individualised exercises. Classes ran on a rolling system, allowing new patients to join each week. Participants completed an evaluation questionnaire after the final class. Outcomes assessment was by questionnaire prior to surgery and 2 weeks, 3 months and 6 months after surgery. Outcomes related to function, pain, balance, self-efficacy, participation, quality of life and resource use. Results. 46/124 patients consented to participate (37% recruitment rate). Frequent reasons for non-participation were related to travelling distance, transportation, and time commitments. 17/23 patients randomised to the intervention group attended the exercise classes. Most (15) patients were very satisfied with the range of exercises on offer. The task-orientated and individual exercises were given average usefulness ratings of 9.6/10 and 9.5/10, respectively. Retention of participants was acceptable; 2 patients were withdrawn from the intervention group and 2 patients from the usual care group. Questionnaire return rates were high in the intervention group (91% at 6 months post-operative) but lower in the usual care group (65% at 6 months post-operative). Conclusion. This study highlights the importance of conducting feasibility work for a RCT. Collecting data on reasons for non-participation provided valuable information on barriers to participation in a trial with this population. The intervention was well attended, and feedback was positive. Questionnaire completion was lower in the usual care group, highlighting the need for additional strategies to improve data collection. Findings from this feasibility study have informed the design of a multi-centre RCT to evaluate the clinical and cost-effectiveness of a group-based outpatient physiotherapy intervention following TKR

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement. Over 1,000 operations are performed annually in the United Kingdom for PJI following hip replacement, using either one- or two-stage revision arthroplasty. It is unclear which is preferred by patients and which has the best long-term outcome. This qualitative study aims to describe patient experiences of treatment and recovery following one- and two-stage revision arthroplasty for PJI within the context of a pragmatic randomised controlled trial comparing these two approaches. Semi-structured interviews were conducted with 32 patients undergoing one- or two-stage revision treatment for PJI as part of a UK multi-centre randomised controlled trial. Patients were recruited from 12 participating National Health Service (NHS) Orthopaedic Departments and were interviewed 2–4 months after their first revision surgery and again approximately 18 months later. Final sample size was justified on the basis of thematic saturation. All patients consented to the interview being audio-recorded, transcribed, anonymised and analysed using an inductive thematic approach. Ethical approval was provided by NRES Committee South-West Frenchay, 14/SW/116. Patients in both the one- and two-stage treatment groups described prolonged hospital stays, with burdensome antibiotics and brief physiotherapy treatment. However, following discharge home and during recovery, participants undergoing two-stage revision with an ‘empty hip' or with a spacer reported being physically restricted in almost every aspect of their daily life, resulting in inactivity and confinement to home. Mobility aids were not sufficiently available through the health service for these patients. A key difference is that those with a spacer reported more pain than those without. Approximately one year following their second-stage revision, participants described being more independent and active, but two directly attributed muscle weakness to the lengthy period without a hip and described resulting falls or dislocations that had complicated their recovery. In contrast, those undergoing one-stage revision and CUMARS appeared to be more alike, reporting better mobility, functionality and independence, although still limited. Participants in these groups also reported minimal or no pain following their revision. A key difference between CUMARS and one-stage revision was the uncertainty of whether a second operation was necessary, which participants described as “hanging over them”, while those in the two-stage empty hip or spacer group described a more positive anticipation of a second definitive operation as it marked an end to what was described as a detachment from life. Our findings highlight the differences between patient experiences of recovery following revision arthroplasty, and how this is influenced by the surgical approach and presence or lack of spacers. An understanding of lived experiences following one- and two-stage surgical interventions will complement knowledge about the clinical effectiveness of these different types of revision surgery

Around 1% of the 185,000 primary hip and knee arthroplasties performed in the UK are followed by prosthetic joint infection (PJI). Although PJI affects a small percentage of patients, it is one of the most devastating complications associated with this procedure. Treatment usually involves further major surgery which can adversely affect patients' quality of life. Understanding current service provision provides valuable information needed to design and evaluate support interventions for patients. The aim of this survey was to identify usual care pathways and support in UK NHS orthopaedic centres for this population. The 20 highestvolume UK NHS orthopaedic centresfor hip and knee arthroplasty account for 33–50% of all cases treated for prosthetic joint infection. Infection leads at each centre were invited to participate in a survey about usual care provision and support for PJI. Questions exploredfollow up time-points; use of standard outcome measures; multidisciplinary care plans; supportive in-patient care and care after treatment; and onward referrals. Survey responses were recorded on a standardised proforma. Data were entered into Excel for analysis, then reviewed and coded into categories and frequency statistics to describe categorical data. A descriptive summary was developed based on these categories. Eleven of the highestvolume orthopaedic centres completed the survey. Follow-up of patients varied greatly across centres; some centres reviewed patients at weekly or 2 week intervals, while all centres saw patients at 6 weeks. Long-term follow-up varied across centres from 3–4 monthsto 12 monthly. Length of follow-up period varied from until the infection had cleared toindefinitely. Follow-up timepoints were only standardised in 4 out of 11 centres. Only 1 centre had a dedicated infection clinic. Advice on who patients should contact if they had concerns included the consultant, community nurse, extended scope practitioner or the ward, while 3 centres told patients to avoid calling their GP. Only half of the centres routinely used standardised outcome measures with patients with PJI. The majority of centres provided standard physiotherapy and occupational therapy (OT) to in-patients while approximately half also offered social support. Only one centre provided dedicated physiotherapy and OT on a separate infection ward. Three centres provided hospital at home or community services to patients in-between operative stages. Only 3 out of 11 centres stated they had specific multidisciplinary care plans in place for patients. Once discharged most patients were provided with physiotherapy, OT and social services if needed. Common barriersto referral included complexities of referring patients outside the hospital catchment area;lack of availability of community services, and shortage of staff including physiotherapists. Delays in rehab and social services could also be problematic. Findings show wide variation intreatment pathways and support for patients treated for PJI, both as inpatients and in the community. Only one of the 11 centreswho participated had a dedicated infection clinic. Only one centre suggested they individualised their physiotherapy support. A number of barriers exist to referring patients on to other support services after revision surgery

Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

Summary Statement. This work proved by prospective clinical and radiological controlled study that the best regimen for treatment of early KOA is combination of NSAIDS, physiotherapy, vasoprotective and vasodilator drugs, and alendronate. Introduction. There is controversy in the literatures regarding the best treatment for early knee osteoarthritis because there is a more controversy regarding the initiating factor of KOA The Objectives of this work were to evaluate the efficacy of various treatment regimens for the prevention of progression of early knee osteoarthritis (KOA). Also, to elucidate the factors for initiation and progression of KOA. Patients and Methods. Four groups of 50 patients with early KOA were treated with four treatment regimens. The first group (control) received analgesics as needed for one year. The second group received non steroidal anti-inflammatory drugs (NSAIDS) plus physiotherapy for one month; with analgesics as needed for the rest of the year. The third group received NSAIDS plus physiotherapy, plus vasoprotective and vasodilator drugs for one month; vasoprotective and vasodilator drugs for the next six months, and analgesics as needed for the rest of the year. The fourth group received NSAIDS plus physiotherapy, plus vasoprotective and vasodilator drugs plus alendronate for one month; vasoprotective and vasodilator drugs plus alendronate for the next six months; and analgesics as needed for the rest of the year. The age of the patients was from 40 to45years. There were 25 males and 25 females in each group. Patients with causes of secondary KOA (e.g. rheumatoid, gouty, traumatic, etc.) were excluded. All patients were subjected to Pre- and post treatment regimens clinical and radiological evaluation Clinical evaluation included history of progressive knee pain for 3–6weeks, limping, Visual analog pain score, tenderness, and knee range of motion. Radiological evaluation included 1.0 T MRI which was performed using proton density-weighted, fat-suppressed sequences. BML size and cartilage status were scored in the same sub regions according to the WORMS system. Results. Progression of KOA in the first, second, third, and fourth group were 66%, 55%, 25%, and 19% of patients respectively No sex difference was detected. Conclusion. The best treatment regimen for early KOA is combination of NSAIDS, physiotherapy, vasoprotective and vasodilator drugs, and alendronate. Vascular and local osteoporotic factors may play a major role in progression of KOA

Adductor strain is a common injury among football players. The adductor muscle group contains the three adductor muscles. (adductor longus, magnus and brevis) Adductor longus muscle is a triangular-shaped long muscle. This muscle originates from the superior ramus of the pubic bone and inserted into the middle part of the linea aspera. Adductor longus muscle is the most commonly injured muscle of adductors. Sudden acceleration, jumping, stretching, and kicking the ball are common causes of an adductor injury. Adductor muscle strains can result in missed playing time for football players. We present a 26-year-old man soccer player with pain in the left groin and proximal thigh. The symptoms had started during training and after kicking the ball with left foot (dominant side), he felt an acute pain in the groin region and proximal thigh. Despite the injury, he managed to finish the training. The team physician examined the patient immediately after training. The range of motion of both hip joints was in normal ranges and mild pain with adduction. There was a palpable mass at the inner proximal thigh during contraction of adductor muscles. There was no history of groin pain or adductor problems before this injury. Conventional radiographs showed no osseous abnormalities. 36 hours after the injury, MRI revealed acute grade IIB strain in the left adductor longus muscle, including both superior and inferior parts of the muscle. A hematoma was observed in the superior part of the left adductor muscle, with a craniocaudal length of 42 millimeters. There was an adductor muscle strain with hyperintensity extending for a craniocaudal length of approximately 12 centimeters involving more than 50% crosses sectional diameter of the muscle belly. Conservative treatment started immediately, consisting of cold therapy and soft tissue massage. Compression of the injured tissue using a 15-cm elastic bandage roll is done to limit bleeding and provide support. Iced water machine (Game Ready) was used. The team physician examined the player every day and prescribed physiotherapy protocol daily. Additionally, short interval follow-up MRI is used to evaluate the injury. (After 7 and 14 days of the injury) No injection was performed. The player is able to return to play immediately, despite MRI's strain images. The player started straight running 5 days later and joined to team training 8 days later and played 90 minutes-league-match 12 days after injury without any pain. No injection was performed. The player is able to return to play immediately, despite MRI's strain images. The player started straight running 5 days later and joined to team training 8 days later and played 90 minutes-league-match 12 days after injury without any pain. MRI is a useful technique in diagnosing trauma in football players presenting with groin pain. In this case, to estimate time-to-return-to-play, MRI alone is not strong evidence. MRI is a good option for follow up, but anamnesis and clinical examination is not inferior to diagnostic imaging

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty.