Driving is an important part of a modern life style. ACL injury is the most common ligamentous injury of the knee. However, there is a paucity of information about the pre and post-operative ability of an ACL injured knee to respond to stimuli for specific situation such as braking reaction in an emergency. Does an ACL unstable knee affect braking reaction time? If it does, is there a difference between left and right injured knee? When is it safe to resume driving after an ACL reconstructive surgery? Is there any simple clinical test to assess patient’s recovery after surgery?. Braking reaction time of 73 patients who underwent arthroscopic ACL reconstruction and 25 normal controls was prospectively studied using a computer-link automobile simulator. Majority of these patients had autologous hamstring tendon graft. Every patients and controls were tested pre-operatively, and every 2 weeks after surgery up to 8 weeks. At each time point, two clinical tests namely stepping and standing test were also performed. The pre-operative results did not differ significantly between controls, left ACL group and right ACL group for the braking reaction time and the two clinical tests. Post-operatively, it took 6 weeks for braking reaction time of the right ACL group to be equivalent to that of the controls, compared to 2 weeks for the left ACL group. There were a strong corelation between the stepping and standing test and the braking reaction time at each time point. Conclusion: an ACL unstable knee does not affect patient’s braking reaction time. After a right ACL reconstruction, patient should delay at least 6 weeks before resuming driving. However, patient may resume driving as early as 2 weeks after a left ACL reconstruction. The stepping and standing test can be used at follow-up to assess patient’s recovery after surgery and to suggest appropriate time to resume driving

Aim. The purpose of this study was to investigate the effects of plaster/splint immobilisation of the knee/ankle on driving performance in healthy individuals. Methods & Materials. Twenty-three healthy drivers performed a series of emergency brake tests in a driving simulator having applied above knee plaster casts, below knee plaster casts, or a knee brace with increasing restriction. Results. Our study showed that compared to braking normally, total brake reaction time was significantly longer when wearing an above knee plaster cast, below knee plaster cast or a knee brace with zero degrees of freedom (p<0.001). Increases in movement time from accelerator to brake accounted for some of the increase in the total brake reaction time. However, unexpectedly thinking time also increased with the level of restriction (p<0.001). Conclusion. These results suggest that all patients wearing a plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation that prevents patients driving with lower limb plaster casts or knee braces

In a society dependent upon the motor car, impaired driving ability is a significant disability which may affect patients with total knee replacement during the postoperative rehabilitation. Recently, there has been much interest in minimally invasive surgery for total knee arthroplasty (TKA). This study evaluated the hypothesis that a minimally invasive technique using a small incision (7 to 10 cm), and a minimal quadriceps muscle splitting without eversion of the patella (MIS approach) would have a beneficial effect on driving reaction time. 15 patients undergoing a primary TKA with the MIS approach were compared with 15 TKAs using a standard approach. An experimental car was used to measure the force and timing of pressure by the foot on accelerator and break pedals. The mean reaction time for normal adults was 0.442 s to go from the accelerator to the brake pedal. This time falls well within the code guideline of 0.7 s. The driving reaction times of the patients with knee arthroplasty were measured at one, two and three months after the operation. The ability to perform an emergency stop was assessed as the time taken to achieve a brake pressure of 100 N after a visual stimulus.The patients have an actual follow-up of 2 years. A clinical and radiological evaluation was performed. Radiographic analysis included evaluation of postoperative alignment variables and progressive radioluciencies. Over all 27 among the 30 knees have good and excellent objective knee Society Scores and patient satisfaction indices. The patients in the MIS group had a statistically shorter time until they could straight leg raise, used less epidural analgesia, used less overall analgesics and had a more rapid regaining of flexion. Patients with standard approach and technique for total knee replacement recovered sufficient knee function to return to driving at only three months after the operation according to the time and the force necessary to the brake pedal. Patients with mini invasive surgery approach have recovered sufficient knee function to return driving at one month after the operation. There was no significant difference in alignment of implants and in alignment of the knee between the two groups. Three knees had radioluciencies (two with a standard incision and one with a MIS approach). Using a small incision without patellar eversion does not jeopardize the alignment of the implants and improves postoperative rehabilitation

Background. Studies have investigated driver reaction time (DRT) following hip replacement, knee replacement and arthroscopy. This study tests the null hypothesis that there is no difference in DRT between patients after right ankle fracture and healthy controls. Methods. Patients with right ankle fractures were recruited and DRT was measured using a simulator (time taken to achieve a brake pressure of 100 Newtons after a visual stimulus). Inclusion criteria: drivers aged 17–70 years with right ankle fractures. Patients were tested when first out of plaster (T0), two, four and six weeks subsequently. DRT was compared to controls matched for age, sex and driving experience (paired T test). The percentage reaching a “safe” DRT (0.7 seconds) was determined. Results. There were 25 patients: 18 conservatively and seven operatively treated fractures. The age range of patients was 19 to 69yrs (mean 41.4yrs), and of controls: 19 to 68yrs (mean 41.8yrs). Conservative group DRT was significantly slower than controls at T0 (p< 0.001) but not thereafter. Operative group DRT was significantly slower than controls at T0 (p< 0.003) and two weeks (p< 0.005) but not thereafter. Conclusion. Following right ankle fracture and removal of cast, DRT is initially prolonged. This study suggests a return to normality within two weeks after conservatively treated fractures and four weeks after operatively treated fractures

Aims: To validate a set of simple clinical tests, these could then be used to establish an objective assessment of an individualñs ability to perform an emergency stop safely in orthopaedic clinics. Methods: This prospective ethically approved study involved assessment of emergency breaking reaction times of Right knee arthroscopy patients using a computer linked car simulator designed by Transport Research Laboratory (TRL). The ability to perform an emergency stop was assessed as the time taken to achieve a brake pressure of 200N after a visual stimulus. Each patient was tested preoperatively, 1 day and 1 week after arthroscopy. In addition three speciþcally designed clinical tests were performed, i.e, a) Knee ßexion during single leg stance; b) Active plantar ßexion against the weight of the whole body during single leg stance c) straight leg raise for 10 seconds. Results: In total 31 patients completed the study. The average reaction time preoperatively was 750ms; Correlation between driving reaction times and the results of clinical tests was performed. Statistical analysis revealed sensitivity up to 96%, speciþcity up to 71% and positive predictive value up to 92% for the clinical tests. Conclusions: Ç Doctor when I can drive? È is a common question faced by all orthopaedic surgeons in the clinics. As driving simulators are not available in the clinics it is appropriate for patients to be assessed with these simple clinical tests, to decide the actual timing of return to driving. A similar study involving joint replacement patients is underway

Background: Recently, the effects of radiculopathy and nerve root blocks on driving reaction time (DRT) have been presented in the literature. To our knowledge, the relation between lumbar spinal fusion and DRT has not been studied before, although important for driving safety. So, we conducted the current study to test the hypotheses that DRT in the context of lumbar fusion is 1) altered in pre-postoperative comparison, 2) influenced by pain, 3) influenced by the patient’s driving skill and 4) different to the DRT of healthy controls. Methods: 21 consecutive patients (age 53.5 years, SD 10.8) receiving primary lumbar fusion were tested for their DRT 1 day preoperatively (pre-op), 1 week postoperatively at the day before discharge (post-op) and at 3 months (follow-up; FU). DRT was assessed with a custom made driving simulator. Additionally, also the level of back pain was determined by VAS for usual pain (VAS-U) and for pain during testing (VAS-T). We also collected the participants’ subjective driving frequency. We used normative DRT data from 31 healthy controls of similar age for comparison with the patients. Results: Pre-op DRT was 685 msec (Md; IQR 246), post-op DRT increased to 728 msec (Md; IQR 264) and decreased again to 671 msec (Md; IQR 202) at FU (p=0.007). Post-hoc analyses (alpha=0.017) found significant differences between post-op and FU DRT (p=0.007). Moderate to high correlations (between 0.537 and 0.680) were found between VAS of back pain and DRT (p between 0.001 and 0.012). No correlations were found between driving frequency and DRT. Controls showed a DRT of 487 msec (Md; IQR 116) which was significantly different from DRT of the patients at all three test occasions (p< 0.001). Conclusion: We found minor increase in DRT 1 week post-op followed by a definite and significant decrease at 3 months FU. We think it is safe – with respect to DRT - to resume driving 3 months after lumbar fusion. It is difficult to draw any conclusions about the period between discharge and 3 months. We also found moderate and high correlations between DRT and the level of back pain and assume that back pain is a relevant factor influencing DRT

Aims

The aim of this study was to assess the current available evidence about when patients might resume driving after elective, primary total hip (THA) or total knee arthroplasty (TKA) undertaken for osteoarthritis (OA).

The purpose of this study was to investigate the effects of right leg restriction at the knee, ankle or both, on a driver’s braking times. Previous studies have not investigated the effects of knee restriction on braking performance. A total of 23 healthy drivers performed a series of emergency braking tests in a driving simulator in either an above-knee plaster cast, a below-knee cast, or in a knee brace with an increasing range of restriction. The study showed that total braking reaction time was significantly longer when wearing an above-knee plaster cast, a below-knee plaster cast or a knee brace fixed at 0°, compared with braking normally (p < 0.001). Increases in the time taken to move the foot from the accelerator to the brake accounted for some of the increase in the total braking reaction time. Unexpectedly, thinking time also increased with the level of restriction (p < 0.001). The increase in braking time with an above-knee plaster cast in this study would increase the stopping distance at 30 miles per hour by almost 3 m. These results suggest that all patients wearing any lower-limb plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation to prevent patients from driving with lower-limb plaster casts or knee braces

The August 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data.

Study Design: observational study over time. Objectives: 1. To investigate the effect of right and left radiculopathy on driver brake-reaction time (DBRT) 2. Determine the effect of selective nerve root block (SNRB) on DBRT. Summary of Background Data: DVLA guidelines for fitness to drive after orthopaedic procedures remain vague. DBRT has been assessed using different driving simulators in several surgical and non-surgical conditions. To date the effect of sciatica and SNRB on DBRT has not been studied. Methods: DBRT s of 20 patients with sciatica (10 right, 10 left) were measured using a custom-built car simulator. Each patient was tested pre-SNRB, immediate post-SNRB, 2 and 6 weeks post-SNRB. As controls 20 age-matched normal subjects were tested once. Full departmental, institutional and ethical committee approval were obtained. Results: The mean reaction time of the control group was 459 ms. The mean reaction times of the patients at different points of assessment were as follow:. Conclusions:. This study confirms the intuitive impression that patients with sciatica have prolonged DBRT compared to normal population. This represents an extra absolute increase in traveling distance of 2.4 meters in a 70 mph speed zone. Left and Right sided sciatica patients should not drive immediately after SNRB. Right sided sciatica patients suffer from a prolonged increase in their reaction time post SNRB

Aims

This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation.

Purpose: The objective of the study was to determine the changes in the driving pattern – especially the capacity to use the steering wheel after carpal tunnel surgery so that recommendation for suitability to return back to driving can be made. Methods Used: A computerised driving simulator normally used for driving assessment of drivers with disability at the regional mobility centre at the Wrightington Hospital was used to assess the patient’s driving. Static and dynamic steering torque was measured before and at 2 & 6 weeks after carpal tunnel release in 25 patients using the static assessment rig. Driving reaction time was also studied in these patients. Results: There was decrease from preoperative static steering torque to that at 2 weeks postoperatively but the dynamic steering torque did not differ in most cases. By 6 to 8 weeks postoperatively, the mean torque values for static and dynamic steering capacity had significantly improved. The driving reaction times at preoperative assessment did not differ significantly from the post operative ones at all times. Conclusion: Although at 2 weeks postoperatively the ability to use the operated hand for static steering had not returned in most patients, their overall steering capacity was not affected as suggested by their unaffected dynamic steering time and the reaction time

Seven subjects with normal joints were tested for active and passive position sense of ankle inversion, peroneal reflex reaction time to sudden ankle inversion, and postural stability during single-leg stance. The tests were performed before and after regional block of the ankle and foot with local anaesthetic. Passive position sense, assessed with the muscles relaxed, was greatly impaired by anaesthesia but active position sense, with the calf muscles activated, was preserved, and the peroneal reaction time to sudden ankle inversion was not altered. The magnitude of postural sway during single-leg stance was also unchanged by anaesthesia of the ankle and foot. The results suggest that the afferent input from intact lateral ankle ligaments is important in sensing correct placement of the foot at heel-strike, but that this input can be replaced by afferent information from active calf muscles. Afferent input from these muscles seems also to be responsible for dynamic ankle protection against sudden ankle inversion and is adequate to allow stable single-leg stance

Aims

Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs.

Summary. Cognitive testing scores do not correlate with physical braking performance. Psychological questioning shows patients are more dependent on driving than a control group. Introduction. Returning to driving after surgery is a multifaceted issue. There are the medical aspects to consider- whether the patient is medically fit to drive. The term ‘medically fit to drive’ can encompass a range of issues which fall to doctors to solve, including the psychological and mental wellbeing. Groups whose governance involves patients or driving do not issue sound advice for patients or doctors to follow. Investigation of aspects affecting a driver's ability to control their vehicle in a safe manner could go towards providing an evidence base for guidance to be issued in the future. Methods. A custom force assessment rig was used to gather peak force and reaction time measurements from a group of patients waiting for, or having undergone lower limb surgery. A bespoke questionnaire that investigated patient's attitudes towards returning to driving; their behaviours and concerns was issued. Other mobility questions were also issued to these patients, including the lower extremity functional scale (LEFS). The final tests (Stroop task, tower of Hanoi, and the opposite worlds test [OWT]) were aimed at assessing a patient's neurological function, in an attempt to investigate the effect of post-operative cognitive dysfunction (POCD) on driving ability. These data were compared against a control cohort. Results. No significant differences were observed in the physical results between cohorts. However, significant differences between the control cohort and patient cohort were observed in a number of tests. The tower of Hanoi was the only significantly different neurological test (p=0.027). The Stroop task and OWT were not significantly different (p=0.103, p=0.131 respectively). There were significant differences in many of the psychological and mobility questions posed (reliance on driving [p<0.001], keenness to return [p=0.014], anxiety about being unable to drive [p=0.019], depression at being unable to drive [p=0.011], worries that driving would cause them pain [p<0.001], and confidence in using public transport [p=0.002]). Activity rankings also had a significant difference, with driving becoming a higher priority in the patient group (p=0.002). There were no significant differences between cohorts in physical testing, but LEFS was significantly different (p<0.001). There was no significant correlation between physical testing and neurological function, so we cannot prove nor disprove that neurological deficits affect physical function. Psychological variables and physical function did not correlate, but LEFS was correlated to a number of psychological variables. Conclusions. Due to the insignificance of correlations between neurological function tests and physical function, further work is recommended to conclusively determine whether there is a link or not. Different and/or additional neurological test batteries should be also considered, for example the CANTAB. Future studies should stratify cohorts based on surgical indication. Extension of the psychological research could identify the most popular goals or activities for those returning from surgery, potentially creating targets for the rehabilitation process

Purpose: In this study, we evaluated AGEs(advanced glycation end products) based on the following points. In routine clinical practice, some patients with intervertebral disc hernia show or previously showed a high blood glucose level, similar to the state in cataract patients. This study is significant for hernia therapy in the near future in context of an approach from sugar(cause),not aging(result). Materials and Methods: Herniated intervertebral discs were obtained during surgery. We obtained human fetal (aborted) tissue and immunohistologically stained. Results: AGEs were already exposed during histogenesis, suggesting a relation to apoptosis. Discussion: In this study, a relationship between programmed cell death and AGEs was suggested. During the early step of glycosylation, the reaction progresses in a manner dependent on saccharide concentration and reaction time. In patients in whom the blood glucose level had been high in the past, the incidence remained high even though the blood glucose level is currently controlled, suggesting that AGEs affect a gene and the effect is memorized

Clinical follow-up of hip and knee arthroplasty is not related to objective functional parameters while this is one of the main goal of evidence based medicine. Therefore a functional test was defined in order to correlate clinical and biomechanical data. The experimental set-up has been presented [1] as well as the test protocol [2]. Three parameters have been analyzed: reaction time (Tr), flight time (Tf) and maximum force (Fmax). The data refer to 21 subjects with hip joint replacement (HRG) and 22 subjects with knee joint replacement (KRG). Tests, were performed before surgery and after one, three and six months. The results were compared with values obtained from a control group of 402 normal subjects. One months after surgery the performance is lower respect to normal data, both for HRG and KRG. Three months later, there is a partial recover expecially for HRG. At six months follow-up, also the KRG reach better performance. While the performance starting point is higher in the HRG, the percentage recovery is equal in both the groups. During the follow-up also the non operated leg, both for HRG and KRG, shows a progressive changing in its performances, which can increase or decrease, but always it brings at the same level of ability for both legs. The data suggest that there are different performance and time recover related to the replaced joint (hip or knee) while the total amount of recover is not joint related and there are no differences for laterality. Experimental data correlate with clinical observation; therefore the proposed protocoll seems to be usefull for objective evaluation of joint replacement follow-up. The re-equilibration of the kinematic abilities between the limbs, which cannot be detected by clinical observation, requires further investigation and could be related to neurological integration and less algia limitation

Purpose: Until now no experimental study has evaluated the effect of orthopedic immobilizations of the lower right limb on driving performances. Clinicians and legislators therefore cannot appropriately advise patients with this type of treatment on their driving capabilities and put forth recommendations for road safety. Method: An experimental study of the effect of orthopedic immobilizations of the lower right limb on driving performances has been conducted at the Research Center on Aging of the Sherbrooke Geriatric University Institute. The breaking capabilities of forty-eight healthy volunteers were tested in three conditions: wearing their usual running shoes and two types of immobilization, namely the walking cast (Delta-Cast Conformable, BSN Medical, Leuven, Belgium) and the foam pneumatic walker (Aircast, Vista, CA). The order in which each condition was tested was randomly determined for each volunteer. A custom driving simulator was used to measure the force applied on the break pedal and the breaking time using the software LabVIEW (National Instruments, Austin, TX). In addition, each volunteer completed a socio-demographic survey, a brief physical exam and two clinical tests (stepping and standing). Results: The average maximum breaking forces exerted by the volunteers with the walking cast, the foam walker and the shoes are 275,4 lb, 287,2 lb and 293,8 lb respectively. The two significant differences are between the walking cast and the shoes (18,4 lb, p< 0,001) and between the walking cast and the foam walker (11,8 lb, p< 0,001). The measured average breaking reaction times are (from the slowest to the fastest) 619 ms, 609 ms, and 580 ms with the foam walker, the walking cast and the shoes respectively. The two significant differences are between the shoes and the foam walker (39 ms, p< 0,001) and between the shoes and the walking cast (29 ms, p< 0,001). The results of this study also confirm the correlation between the measured breaking reaction times and the stepping and standing clinical test (p< 0,05). Conclusion: Although this study observed statistically significant changes in breaking force and reaction time in volunteers wearing two common

Aims

The purpose of this study was to report bone adaptive changes after anatomical total shoulder arthroplasty (TSA) using a standard-length hydroxyapatite (HA)-coated humeral component, and to report on a computer-based analysis of radiographs to determine changes in peri-implant bone density objectively.

The histopathology of periprosthetic tissues has been important to understanding the relationship between wear debris and arthroplasty outcome. In a landmark 1977paper, Willert and Semlitsch (1) used a semiquantitative rating to show that tissue reactions largely reflected the extent of particulate debris. Notably, small amounts of debris, including metal, could be eliminated without “overstraining the tissues” but excess debris led to deleterious changes. Currently, a plethora of terms is used to describe tissues from metal-on-metal (M-M) hips and corroded modular connections. We reviewed the evaluation and reporting of local tissue reactions over time, and asked if a dose response has been found between metal and tissue features, and how the use of more standardized terms and quantitative methodologies could reduce the current confusion in terminology. Methods. The PubMed database was searchedbetween 2000 and 2015 for papers using “metal sensitivity /allergy /hypersensitivity, Adverse Local Tissue Reaction (ALTR): osteolysis, metallosis, lymphocytic infiltration, Aseptic Lymphocytic Vasculitis-Associated Lesions (ALVAL), Adverse Reaction to Metal Debris (ARMD) or pseudotumor/ pseudotumour” as well as metal-on-metal / metal-metal AND hip arthroplasty/replacement. Reports lacking soft tissue histological analysis were excluded. Results. 131 articles describing M-M tissue histology were found. In earlier studies, the terms metal sensitivity / hypersensitivity /allergy implied or stated the potential for a Type IV delayed type hypersensitivity response as a reason for revision. More recently those terms have largely been replaced by broader terms such as ALTR, ALVAL and ARMD. ALVAL and metal hypersensitivity were often used interchangeably, both as failure modes and histological findings. Several histology scoring systems have been published but were only used in a limited number of studies. Correlations of histological features with metal levels or component wear were inconclusive, typically because of a high degree of variability. Interestingly, there were very few descriptions that concluded that the observed reactions were benign / normal or anticipated i.e. regardless of the histological features, extent of debris or failure mode, the histology was interpreted as showing an adverse reaction. Discussion. There is now an expanded set of terms to describe tissues but they lack clear definitions and typically do not use quantitative histological data to describe a wide range of periprosthetic reactions to metal. Lower limits of inflammation, necrosis or re-organization that represent a “normal” reaction to surgery and/or small amounts of wear debris are not clearly defined and are rarely discussed. The widespread adoption of the term “adverse” in the present tissue lexicon implies a cause and effect relationship between metal wear and corrosion products and histological features even though this has yet to be determined. The use of quantitative histological scores rather than subjective histological descriptions is imperative to improve the understanding and reporting of the range of periprosthetic reactions. In particular, a new lexicon that allows for a level of tissue reaction that is not misinterpreted as adverse is required