Wide resection, with or without adjuvant therapy, is the mainstay of treatment for soft tissue sarcoma of the extremities. The surgical treatment of soft tissue sarcoma can portend a prolonged course of recovery from a functional perspective. However, data to inform the expected course of recovery following sarcoma surgery is lacking. The purpose of this study was to identify time to maximal functional improvement following sarcoma resection and to identify factors that delay the expected course of recovery. A retrospective chart review was performed of all patients undergoing surgical treatment of a soft tissue sarcoma of the extremities between January 1st, 1985 and November 15, 2020 with a minimum of 1 follow up. The primary outcome measure was time to maximal functional improvement, defined as failure to demonstrate improvement on two consecutive follow up appointments, as defined by the functional outcome measures of Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) Score or by achieving 90% of maximum outcome score. We identified 1188 patients who underwent surgical resection of a soft tissue sarcoma of the extremities. Patients typically achieved a return to their baseline level of function by 1 year and achieved “maximal” functional recovery by 2 year's time postoperatively. Patient and tumor factors that were associated with worse functional outcome scores and a delayed return to maximal functional improvement included older age (p=0.007), female sex (p-0.004), larger tumor size (p < 0 .001), deep tumor location (p < 0 .001), pelvic location (p < 0 .001), higher tumor grade (p < 0 .001). Treatment factors that were associated with worse functional outcome scores and a delayed return to maximal functional improvement included use of radiation therapy (p < 0 .001), perioperative complications (p < 0 .001), positive margin status (p < 0 .001) and return of disease, locally or systemically (p < 0 .001). Most patients will recover their baseline function by 1 year and achieve “maximal” recovery by 2 years’ time following surgical resection for soft tissue sarcoma of the extremities. Several patient, tumor and treatment factors should be used to counsel patients as to a delayed course of recovery

Smartphone-based apps that measure step-count and patient reported outcomes (PROMs) are being increasingly used to quantify recovery in total hip arthroplasty (THA). However, optimum patient-specific activity level before and during THA early-recovery is not well characterised. This study investigated 1) correlations between step-count and PROMs and 2) how patient demographics impact step-count preoperatively and during early postoperative recovery. Smartphone step-count and PROM data from 554 THA patients was retrospectively reviewed. Mean age was 64±10yr, BMI was 29±13kg/m2, 56% were female. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5–6 weeks postop (6wk), and 11–12 weeks postop (12wk). Linear correlations between step-count and HOOS12 Function and UCLA activity scores were performed. Patients were separated into three step-count levels: low (<2500steps/day), medium (2500-5500steps/day), and high (>5500steps/day). Age >65years, BMI >30, and sex were used for demographic comparisons. Student's t-tests determined significant differences in mean step-counts between demographic groups and in mean PROMs between step-count groups. UCLA correlated with step-count at all time-windows (p<0.01). HOOS12 Function correlated with step-count preoperatively and at 6wk (p<0.01). High vs low step count individuals had improved UCLA scores preoperatively (∆1.8,p<0.001), at 6wk (∆1.1,p<0.05), and 12wk (∆1.6,p<0.01), and improved HOOS12 Function scores preoperatively (∆8.4,p<0.05) and at 6wk (∆8.8,p<0.001). Younger patients had greater step-count preoperatively (4.1±3.0k vs 3.0±2.5k, p<0.01) and at 12wk (5.1±3.3k vs 3.6±2.9k, p<0.01). Males had greater step-count preoperatively (4.1±3.0k vs. 3.0±2.7k, p<0.001), at 6wk (4.5±3.2k vs 2.6±2.5k, p<0.001), and at 12wk (5.2±3.6k vs. 3.4±2.5k, p<0.001). Low BMI patients had greater step-count at 6wk (4.3±3.3k vs. 2.6±2.7k, p<0.01) and 12wk (5.0±3.6k vs. 3.6±2.6k, p<0.05). Daily step-count is significantly impacted by patient demographics and correlates with PROMs, where patients with high step count exhibit improved PROMs. Generic recovery profiles may therefore not be appropriate for benchmarking across diverse populations

Passive smartphone-based apps are becoming more common for measuring patient progress after total knee arthroplasty (TKA). Optimum activity levels during early TKA recovery haven't been well documented. This study investigated correlations between step-count and patient reported outcome measures (PROMs) and how demographics impact step-count preoperatively and during early post-operative recovery. Smartphone capture step-count data from 357 TKA patients was retrospectively reviewed. Mean age was 68±8years. 61% were female. Mean BMI was 31±6kg/m2. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5-6 weeks postop (6wk), and 11-12 weeks postop (12wk). Linear correlations between step-count and KOOS12-function and UCLA activity scores were performed. Patients were separated into three step-count levels: low (<1500steps/day), medium (1500-4000steps/day), and high (>4000steps/day). Age >65years, BMI >30kg/m2, and sex were used for demographic comparisons. Student's t-tests determined significant differences in mean step-counts between demographic groups, and in mean PROMs between step-count groups. UCLA correlated with step-count at all time-windows (p<0.01). KOOS12-Function correlated with step-count at 6wk and 12wk (p<0.05). High step-count individuals had improved PROMs compared to low step-count individuals preoperatively (UCLA: ∆1.4 [p<0.001], KOOS12-Function: ∆7.3 [p<0.05]), at 6wk (UCLA: ∆1 [p<0.01], KOOS12-Function: ∆7 [p<0.05]), and at 12wk (UCLA: ∆0.8 [p<0.05], KOOS12-Function: ∆6.5 [p<0.05]). Younger patients had greater step-count preoperatively (3.8±3.0k vs. 2.5±2.3k, p<0.01), at 6wk (3.1±2.9k vs. 2.2±2.3k, p<0.05) and at 12wk (3.9±2.6k vs. 2.8±2.6k, p<0.01). Males had greater step-count preoperatively (3.7±2.6k vs. 2.5±2.6k, p<0.001), at 6wk (3.6±2.6k vs. 1.9±2.4k, p<0.001), and at 12wk (3.9±2.3 vs. 2.8±2.8k, p<0.01). No differences in step-count were observed between low and high BMI patients at any timepoint. High step count led to improved PROMs scores compared to low step-count. Early post-operative step-count was significantly impacted by age and sex. Generic recovery profiles may not be appropriate across a diverse population

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures

INTRODUCTION. The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients' satisfaction. METHODS. We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS. Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs 4.4, p<0.001), CCI was significantly lower (12.3 vs 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced with ERAS-outpatient care (9.3 vs 26.5 MME, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner after ERAS-outpatient surgery (p<0.001), but PROMs were similar between groups at the last follow-up (p> 0.188). Patients were more satisfied with hospital stay, pain management, functional recovery, wound management, and overall experience of the ERAS-outpatient pathway and recommended it significantly more (p <0.002). DISCUSSION. Most studies comparing outpatient to inpatient programs conclude that outpatient surgeries did not increase complication or readmission rates, and, overall, were not inferior. We found that compared to std-inpatient practice, ERAS-outpatient program reduced complications by half while not resulting in more unplanned episodes of care. Moreover, it resulted in similar pain relief with fewer opioids, faster early functional recovery and higher satisfaction. Patients were significantly more inclined to recommend the ERAS-outpatient pathway after having personally experienced both outpatient and inpatient protocols. These finding are likely multifactorial and linked to the specific ERAS interventions. CONCLUSION. Results of this study highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program

Introduction. Ambulation in the postoperative period following TKR is a marker of speed of recovery and, potentally, longer term outcomes. However, patient lifestyle factors are a major confounder. This study sought to develop a model of expected patient step count taking into account preoperative condition and demographics in order to benchmark recovery at a patient specific level. Method. 94 patients were recruited to the study. BMI, demographics, the Short Form 12 (SF-12) and the Knee injury and Osteoarthritis Outcome Score (KOOS) were all captured preoperatively. Step count was measured using commercially available Fitbit devices preoperatively, immediately postoperatively and at 6 weeks postoperatively. Stepwise multiple linear regression models were developed using the preoperative information to define a predictive model of the postoperative step count levels. Spearman's Rho correlations for all relevant data series were also calculated. Results. Of the personal and clinical characteristics, BMI and the SF-12 physical component score had the strongest correlations with outcome. Prior step count periods all had significant correlations with later step count periods. The most significant correlations occurred between the 6 week postoperative step count period and the preoperative period (0.709), while correlations with the period immediately following surgery were weaker (0.389 and 0.536 for preoperative and 6 week postoperative step counts respectively.) All are significantly different from 0 (to p < 0.01.) Likewise, BMI had a significantly negative relationship with step count (−0.526, −0.346 and −0.553 for the preoperative, immediate postoperative and 6 week postoperative periods, see Figure 2), as did the KOOS activities of daily living score and the SF-12 physical health component score. Males were significantly less mobile than females during recovery. A multiple linear regression model of 6 week step count using prior data had an adjusted R. 2. of 0.754, explaining much of the variation, but the immediate postoperative period performed poorly. Predictors in the 6 week model were gender, preoperative SF-12 score, preoperative and immediate postoperative step count. Conclusions. Patient specific factors, including but not limited to that from prior step count periods need to be considered if using step count as a means of benchmarking patient recovery after surgery. The variation in recovery at 6 weeks is more readily explained with the data collected than in the immediate postoperative period, where variations in specific care received, anaesthetic response or surgical outcomes might be more expected to have an impact. Reporting patient performance against customised goals on an individual patient basis could provide a means to drive greater patient mobility and appropriate activity levels during postoperative recovery

Aims. To establish if the principles of Enhanced Recovery, an evidence-based, integrated, multi-modal approach to improving recovery following colonic resection are transferable to elective orthopaedic primary arthroplasty surgery. The principles are to reduce the stress response provoked by surgery and eliminate the peri-operative catabolic state by optimally managing patients' metabolism, expectations, postoperative pain and mobility. This combination of interventions has not been tested in Orthopaedics before. Methods. We conducted a single surgeon, consecutive patient, interventional, cohort study of primary total hip and knee arthroplasties. Our intervention was Enhanced Orthopaedic Recovery (EOR). Results. We retrospectively reviewed 138 primary joint replacements. We performed a power calculation before prospectively assessing the next 50 hip and 32 knee arthroplasties. A two-tailed t-test showed a highly statistically significant fall in mean time to discharge (Hips 8.1-5.4 total nights stay, p=0.003, knees 8.5-5.3 total nights stay, p<0.001) and a fall in expected date of discharge from 5 to 3 postoperative days. We studied the complication and readmission rate and found no apparent difference. Conclusions. We have shown that by implementing EOR, reduced time to functional recovery and subsequent hospital discharge can be safely achieved with consequent quality of life and health economic benefits

Introduction. The purpose of this study was to characterize the recovery of physical activity following knee arthroplasty by means of step counts and flight counts (flights of stairs) measured using a smartphone-based care platform. Methods. This is a secondary data analysis on the treatment cohort of a multicenter prospective trial evaluating the use of a smartphone-based care platform for primary total and unicondylar joint arthroplasty. Participants in the treatment arm that underwent primary total or unicondylar knee arthroplasty and had at least 3 months of follow-up were included (n=367). Participants were provided the app with an associated smart watch for measuring several different health measures including daily step and flight counts. These measures were monitored preoperatively, and the following postoperative intervals were selected for review: 2–4 days, 1 month, 1.5 month, 3 months and 6 months. The data are presented as mean, standard deviation, median, and interquartile range (IQR). Signed rank tests were used to assess the difference in average of daily step counts over time. As not all patients reported having multiple stairs at home, a separate analysis was also performed on average flights of stairs (n=214). A sub-study was performed to evaluate patients who returned to preoperative levels at 1.5 months (step count) and 3 months (flight count) using an independent samples T test or Fisher's Exact test was to compare demographics between patients that returned to preoperative levels and those that did not. Results. The mean age of the step count population was 63.1 ± 8.3 years and 64.31% were female, 35.69% were male. The mean body mass index was 31.1 ± 5.9 kg/m. 2. For those who reported multiple stairs at home, the mean age was 62.6 ± 8.3 years and 62.3% were female. The mean body mass index was 30.7 ± 5.4 kg/m. 2. . As expected, the immediate post-op (2–4 days) step count (median 1257.5 steps, IQR 523 – 2267) was significantly lower than preop (median 4160 steps, IQR 2669 – 6034, p < 0.001). Approximately 50% of patients returned to preoperative step counts by 1.5 months postoperatively with a median 4,504 steps (IQR, 2711, 6121, p=0.8230, Figure 1). Improvements in step count continued throughout the remainder of follow-up with the 6-month follow-up visit (median 5517 steps, IQR 3888 – 7279) showing the greatest magnitude (p<0.001). In patients who reported stairs in their homes, approximately 64% of subjects returned to pre-op flight counts by 3 months (p=0.085), followed similar trends with significant improvements at 6 months (p=0.003). Finally, there was no difference in age, sex, BMI, or operative knee between those that returned to mean preoperative step or flight counts by 1.5 months and 3 months, respectively. Discussion and Conclusion. These data demonstrated a recovery curve similar to previously reported curves for patient reported outcome measures in the arthroplasty arena. Patients and surgeons may use this information to help set goals for recovery following total and unicondylar knee arthroplasty using objective activity measures. For any figures or tables, please contact the authors directly

Introduction & Aims. Patient recovery after total knee arthroplasty remains highly variable. Despite the growing interest in and implementation of patient reported outcome measures (e.g. Knee Society Score, Oxford Knee Score), the recovery process of the individual patient is poorly monitored. Unfortunately, patient reported outcomes represent a complex interaction of multiple physiological and psychological aspects, they are also limited by the discrete time intervals at which they are administered. The use of wearable sensors presents a potential alternative by continuously monitoring a patient's physical activity. These sensors however present their own challenges. This paper deals with the interpretation of the high frequency time signals acquired when using accelerometer-based wearable sensors. Method. During a preliminary validation, five healthy subjects were equipped with two wireless inertial measurement units (IMUs). Using adhesive tape, these IMU sensors were attached to the thigh and shank respectively. All subjects performed a series of supervised activities of daily living (ADL) in their everyday environment (1: walking, 2: stair ascent, 3: stair descent, 4: sitting, 5: laying, 6: standing). The supervisor timestamped the performed activities, such that the raw IMU signals could be uniquely linked to the performed activities. Subsequently, the acquired signals were reduced in Python. Each five second time window was characterized by the minimum, maximum and mean acceleration per sensor node. In addition, the frequency response was analyzed per sensor node as well as the correlation between both sensor nodes. Various machine learning approaches were subsequently implemented to predict the performed activities. Thereby, 60% of the acquired signals were used to train the mathematical models. These models were than used to predict the activity associated with the remaining 40% of the experimentally obtained data. Results. An overview of the obtained prediction accuracy per model stratified by ADL is provided in Table 1. The Nearest Neighbor and Random Forest algorithms performed worse compared to the Support Vector Machine and Decision Tree approaches. Even for the latter, differentiating between walking and stair ascent/descent remains challenging as well as differentiating between sitting, standing and laying. The prediction accuracies are however exceeding 90% for all activities when using the Support Vector Machine approach. This is further illustrated in Figure 1, indicating the actual versus predicted activity for the validation set. Conclusions. In conclusion, this paper presents an evaluation of different machine learning algorithms for the classification of activities of daily living from accelerometer-based wearable sensors. This facilitates evaluating a patient's ability to walk, climb or descend stairs, stand, lay or sit on a daily basis, understanding how active the patient is overall and which activities are routinely performed following arthroplasty surgery. Currently, effort is undertaken to understand how participation in these activities progresses with recovery following total knee arthroplasty

An outpatient TKA program was developed by integrating advances in analgesia, rehabilitation, and minimally invasive surgical techniques with the objective of improving value in elective total knee arthroplasty (TKA) while maintaining quality standards. Previous studies have established the safety of outpatient TKA in selected populations, but the literature is devoid of outcome measures in these patients. Our goal was to investigate the quality of recovery, patient satisfaction, and safety profile in the first 90 days undergoing outpatient TKA. One hundred TKAs in 93 consecutive patients with end-stage arthritis of the knee candidate for primary TKA were enrolled in this prospective matched cohort study. Patients that underwent inpatient TKA (47 TKAs) were compared with patients that underwent planned outpatient TKA (53 TKAs). The following 28 day post-operative scores were recorded: quality of recovery (QoR-18) and pain scores by Numerical Rating Scale (NRS-11). Satisfaction with pain control (0 to 10) and quantity of opioid use was collected. Secondary outcome measures of 90-day complications, readmissions, and emergency department (ED) visits were recorded. Ninety-six percent of patients planned for outpatient TKA met our defined multidisciplinary criteria for same-day discharge. QoR-18 at post-operative day one was statistically higher in the outpatient TKA group. Otherwise, outcome measures were not statistically different between the 2 groups. Two patients required overnight admission: 1 for extended motor-block and 1 for vasovagal syncope. There were 7 ED visits in the in the outpatient group and 4 in the inpatient group. One outpatient was admitted for irrigation and debridement with liner exchange for an acute infection 2 weeks post-operatively. One inpatient required manipulation under anesthesia at six weeks post-operatively. Outpatient TKA in selected patients produced a post-operative quality of recovery and patient satisfaction similar to that of inpatient TKA. Our results support that outpatient TKA is a safe alternative that should be considered due to its potential cost-savings and comparable recovery

Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association. We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year. Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr

Aim. Bone and joint infections (BJI) need frequently prolonged antibiotic treatment at high dosage for a total of 6 or 12 weeks depending the type of infection. Impact of such prolonged antibiotic exposure on the gut microbiota has never been assessed. Method. We performed a national multicentric prospective study of patients with BJI to monitor the gut microbiota dynamic all along antimicrobial treatment. Clinical data and stool collection were performed at the baseline visit (B) within 24h before starting antibiotics, at the end of the treatment (EOT) and 2 weeks after antibiotic withdrawal during a follow-up visit (FU). Microbiota composition was determined by shotgun metagenomic sequencing. Biological markers of gut permeability and inflammation were monitored at each time point. Results. Sixty-two patients were enrolled: 27 native BJI, 14 osteosynthesis-related BJI and 21 prosthetic joint infections (PJI). At EOT there was a significant loss of alpha-diversity that recovered at FU in patients with native BJI and PJI but not in patients with osteosynthesis-related BJI (p<0.05, Wilcoxon test). At EOT, we observed an increase of Proteobacteria and Bacteroidetes that partially recovered at FU. Principal Component Analysis (PCoA) of the Bray Curtis distance, showed a significant change of the gut microbiota at the end of treatment compared to baseline (p<0.01, PERMANOVA) that only partially recover at FU. The taxonomic analysis showed that microbiota composition at FU does not differ significantly at the genus level when comparing patients treated for 6 weeks to patients treated for 12 weeks. No particular antibiotic (especially fluoroquinolones) was associated with a lower Shannon index or distinct dynamic of recovery at the end of treatment. PCoA analysis of the Bray Curtis distance shows that patients with elevated plasma level of CRP (≥5mg/L) at EOT had a distinct gut microbial composition compared to others. Conclusions. In patients with BJI, antibiotics altered the gut microbiota diversity and composition with only partial recovery 2 weeks after antibiotic withdrawal, independently on the duration of the therapy and on the type of the antibiotic used. Elevated CRP at EOT might reflect persistent alteration of the gut microbiota. Assessment of long-term impact after the end of treatment is on-going

The number of hip arthroplasty procedures has steadily increased in the United States over the last decade [Wolford, et. al, 2015]. This trend will continue as this treatment is the most effective approach in relieving pain, improving mobility, reducing fall risk and improving the quality of life in patients with end-stage osteoarthritis. The effectiveness of recovery can be impacted by factors such as access to postoperative physical therapy regimens. During the recovery period, it is important for therapists to be guided in their therapeutic decision making by accurate data concerning the patient's performance on a variety of measures. This project is designed to map the gait recovery curves of individuals who have undergone unilateral hip arthroplasty. To date, eight individuals (4 females, mean age 64.9, SD 11.1) have participated in the study. Five of the patients were treated by traditional press-fit Accolade II implants (Stryker, Mahwah, NJ USA) through a direct anterior approach THA and the other three has been treated by using DAA THA and using neck preserving Minihip. TM. short stem implant (Corin Ltd., Cirencester, UK). Each participant walked on an instrumented treadmill as a self-selected speed for three minutes pre-surgery. Post-surgery data collections occurred at three and six weeks, and three and six months and employed the same treadmill speed as used prior to surgery. Bilateral lower limb kinematic data was collected with a 12 camera motion capture system Vicon® (Oxford Metrics, Oxford, UK) using reflective markers attached to the hip, knee, ankle, heel and toe. Force plates embedded in the treadmill provided kinetic data that aided in the detection of heel strike and toe off. The temporal features associated with gait, including stride, stance time and double support time were obtained for both the surgical and non-surgical limbs and were used to assess changes in performance during the recovery period. The stance and double support data were also converted to a percentage of stance values which provide additional insights into gait control strategies. Repeated measure MANOVAs were used to evaluate any potential differences in the variables either between limbs or over time. Results from the statistical testing revealed that there were no significant differences between the two limbs for either stride or stance time. This was expected since global asymmetrical gait would have led to the participants veer off of the treadmill. There was a main effect of ‘Time’ for both stride and stance times. Post hoc testing indicated that the 6-month post-surgery measures were significantly reduced when compared to the Pre-surgery and 3-week post-surgery measures. Similarly, there were no significant differences in double support times between the two legs but there was a main effect for time. Post hoc testing revealed that the 6-month post-surgery double support time was significantly less than the Pre-surgery and 3-week post-surgery measures. These significant changes clearly indicate that surgery is effective in improving gait parameters. Moreover, clinicians may want to consider assessing double support time as this measure is a particularly robust indicator of the effectiveness of unilateral hip arthroplasty

Objective. As the aging society progresses rapidly in Japan, the number of elderly patients underwent TKA is increasing. These elderly patients do not expect to do sports, but regain independency in the activity of daily living. Therefore, we measured basic ambulatory function quantitatively using 3m timed up and go (TUG) test. We clinically experienced patient with medially unstable knee after TKA was more likely to result in the unsatisfactory outcome. We hypothesized that post-operative knee stability influenced ambulatory function recovery after TKA. In this study, we evaluated ambulatory function and knee stability quantitatively, and analyzed the effect of knee stability on the ambulatory function recovery after TKA. Materials & Methods. Seventy nine patients with varus type osteoarthritic knees underwent TKA were subjected to this study. The mean age of surgery was 72.4 years old. Preoperative standing coronal deformity was 9.6 degrees in varus. TUG test results in less duration with faster ambulatory function. TUG (seconds) was measured at 3 time periods; pre-operatively, at hospital discharge and 1year after surgery. To standardize TUG recovery time during 1 year after TKA, we defined TUG recovery rate as the percentage of recovery time to the pre-operative TUG as shown in the following equation. TUG recovery rate (%) = (TUG pre-op –TUG 1y po) / TUG pre-op ×100. We also evaluated the knee stability at hospital discharge and 1year after surgery. The knee stability at extension and flexion were assessed by varus and valgus stress radiography using Telos (10kg) and stress epicondylar view with 1.5kg weight at the ankle respectively. Image analyzing software was used to measure joint separation distance (mm) at medial as medial joint opening (MJO) and at lateral as lateral joint opening (LJO) at both knee extension and flexion. (Fig.1). The sequential change of TUG was analyzed using repeated measures ANOVA (p<0.05). The influence of joint opening distances (MJO and LJO at extension and flexion) on TUG 1y po and TUG recovery rate were analyzed using simple linear regression analysis (p<0.05). Results. The mean TUGs were 13.4, 13.7 and 10.8 seconds pre-operatively, at hospital discharge and 1 year after TKA respectively. Significant decrease was found at 1 year after surgery. TUG pre-op did not show significant correlation to any joint openings. TUG 1y po was positively correlated with both flexion and extension MJO at hospital discharge. (Fig.2) TUG recovery rate negatively correlated to flexion-MJO at hospital discharge. (Fig.3). Discussions. The most interesting findings in the present study were that both flexion and extension MJO at hospital discharge were positively correlated with TUG 1y po and negatively correlated with TUG recovery rate. This indicated that early post-operative medial stability played an important role in the recovery of ambulatory function. The early post-operative medial instability would cause pain and deteriorate functional recovery after surgery. There is some disagreement regarding the importance of pursuing the perfect ligament balance, which would be more likely to result in medial instability. Consequently, surgeons should prioritize medial stability for better ambulatory functional recovery after TKA

INTRODUCTION. Physical therapy(PT) is an integral component in the management of musculoskeletal conditions. On the other hand, there have been few reports exclusively dedicated to studying PT interventions on the same day of total hip arthroplasty(THA). In this study, we investigate the role of rehabilitation in the early postoperative period on length of stay (LOS), total medical cost, and physical recovery following total hip arthroplasty. METHODS. A prospective cohort study was carried out 104 consecutive patients who underwent 107 primary THA performed by two surgeons. Data were gathered on all patients who underwent operative management from June2016 to June 2017. Institutional review board approval was obtained before performing this study. Patient demographic, physical, and clinical dates were collected for all patients, including age, gender, body mass index (BMI), diagnosis, Japan Orthopedic Association (JOA) hip score, Japanese Orthopedic Association Hip-Disease Evaluation Questionnaire (JHEQ) score, 3min walk test, and Timed up and go (TUG) test. The patient population consisted of 5men and 99women, with an average age of 66.0 years (range, 50–84 years). There were no statistically significant differences between patients who did and did not receive PT with regard to demographic, medical, and surgical data, including gender, age, BMI, JOA hip score, JHEQ score, preoperative 3min walk test, preoperative TUG test(Table 1). All patients underwent direct anterior approach THA through navigation system. Postoperative day (POD) 0 was defined as the same day of surgery. There were no standardized criteria by which patients were selected for participation in rehabilitation with physical therapists. Patient selection for POD 0 rehabilitation was based on the end of surgery time. For instance, when the end of surgery time was in the forenoon, the patients were received POD 0 PT. In contrast, patients who ended operation in the afternoon were classified POD 1 PT. Rehabilitation protocol was adjusted based on surgical approach, and all patients were weight bearing as tolerated. TUG test and 3min walk test was done by a physiotherapist on the seventh day postoperatively. RESULTS. Patients who received PT on POD 0 were compared with patients who received PT on POD 1. (Table2) Using the operative start time to determine LOS, patients who received therapy on POD 0 stayed an average of 14.1±4.8 days, and those who received therapy on POD 1 stayed an average of 19.2±9.1 days. The LOS was statistically significantly different between groups (P = .01). In terms of physical recovery, the TUG test received therapy on POD 0 was taken an average of 14.0±6.0 seconds, and the TUG test received therapy on POD 1 was an average of 17.6±9.4 seconds. (P=.04) Furthermore, Total cost on POD0. Day 0 patients had a mean cost of ¥1,970,000±21,000 and Day 1 had a mean cost of 2,190,000±49,600, which remained significance difference(P=.01). CONCLUSION. This study suggests that early rehabilitation and patient mobilization on the date of surgery is important to shorten length of hospital stay, decrease total medical cost and to achieve faster physical recovery

Background. There is increasing impetus to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA). The direct anterior (DA) approach is a muscle sparing technique that is believed to support these new pathways. Implants designed for these approaches are available in both collared and collarless variations and understanding the impact each has is important for providing the best treatment to patients. Purpose/Aim of Study. This study aims to examine the role of implant design on implant fixation and patient recovery. Materials and Methods. Patients (n=50) with unilateral hip OA who were undergoing primary DA THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=25) or collarless (n=25) cementless, fully hydroxyapatite coated femoral stem. Patients were seen at nine appointments (pre-operative, <24 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients underwent supine radiostereometric analysis (RSA) imaging <24 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Patients also completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Findings/Results. Twenty-two patients that received a collared stem and 27 patients that received a collarless stem have been assessed. There were no demographic differences between groups. From <24 hours to two weeks the collared implants subsided 0.90 ± 1.20 mm and the collarless implants subsided 3.80 ± 3.37 mm (p=0.001). From two weeks to three months the collared implants subsided 0.67 ± 1.61 mm and the collarless implants subsided 0.45 ± 0.46 mm (p=0.377). Step count was reduced at two weeks to 3108 ± 1388 steps for collared patients and 2340 ± 1685 steps for collarless patients (p=0.072). Step count was increased at three months to 8939 ± 3494 steps for collared patients and 6114 ± 2529 steps for collarless patients (p=0.034). TUG test time was increased at two weeks compared to pre-operatively by 3.45 ± 6.01 s for collared patients and 2.29 ± 4.92 s for collarless patients (p=0.754). TUG test time decreased from two weeks to three months by 6.30 ± 6.05 s for collared patients and 5.68 ± 4.68 s for collarless patients (p=0.922). Conclusions. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. Presence of a collar on the stem impacted patient activity but not function. This suggests that both the implant design as well as the surgical technique may play a role in the patient's early post-operative experience

An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery. We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated. 99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population. We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively

Introduction. Enhanced Recovery After Surgery (ERAS) is a multi-disciplinary approach for establishing procedure–specific, evidence-based perioperative protocols to optimize patient outcomes. ERAS evidence is predominantly for non-orthopaedic procedures. We review the impact of ERAS protocol implementation on total joint arthroplasty (TJA) outcomes at our institution. Methods. All primary total hip and knee arthroplasties performed one year before and after ERAS implementation were identified by current procedural terminology code. Length of stay (LOS), disposition, readmission and opioid usage were analyzed before and after ERAS implementation and statistically analyzed with student t-test and chi-square test. Results. 2105 total patients were identified (967 THA, 494 pre-ERAS and 473 post-ERAS;1138 TKA, 575 pre-ERAS and 563 post-ERAS). TKA. After ERAS implementation, opioid consumption decreased for hospital day one (45.5MME to 36.2MME; p=0.000) and overall hospitalization (101.9MME to 83.9MME; p =0.000). Average LOS decreased (73.28hrs to 66.44hrs; p=0.000), blood transfusion rate trended down (3.3% to 1.95%; p=0.155), and disposition to home over skilled nursing facility increased (57.8% to 71.6%; p=0.000). Unplanned return-to-hospital encounters were unchanged (13.22% to 12.79%; p=0.8504). 30-day and 90-day readmission rates decreased (7.30% to 3.02%; p=0.0020 and 8.5% to 4.8%; p=0.0185, respectively). THA. After ERAS implementation, opioid consumption decreased for hospital day one (49.5MME to 35.4MME; p=0.000) and overall hospitalization (79.5MME to 59.5MME; p=0.000). Average LOS decreased (57.84hrs to 51.87hrs; p=0.011), blood transfusion rate was unchanged (4.25% to 3.81%; p=0.725), and disposition to home over skilled nursing facility increased (80.4% to 82.5%; p= 0.022). Unplanned return-to-hospital encounters were unchanged (8.51% to 8.88%; p=0.8486). Readmission trended up during postoperative days 0–30 and trended down during postoperative days 31–90. (1.42% to 2.96%; p=0.1074) and (1.21% to 0.85%; p=0.5748), respectively. Conclusion. ERAS protocols reduce postoperative opioid consumption, decrease hospital LOS, and increase patient disposition to home without adversely affecting short-term readmission rates

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI). The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme. Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group. There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated

Patients who have undergone Total Knee Replacement (TKR) improve their knee functions with time dependent recovery. However, the speed and degree of recovery widely varies from person to person. Practitioners generally find that postoperative satisfaction after TKR is closely related to the degree of preoperative severity in deformity. We focused on preoperative FTA to determine how the degree of deformity affects postoperative improvements after TKR. Methods:. 44 consecutive knees of 44 patients with medial osteoarthritis underwent TKR for nomination in this study. All operations were conducted by a single surgeon using a mid vastus approach with cemented posterior stabilized (PS) implant and patellar resurfacing. Patients were targeted for full weight bearing the next day. Patients were divided into 3 groups of preoperative FTA: 174–180 degrees (11 knees), 181–189 degrees (17 knees), and more than 190 degrees (16 knees). Walking ability was assessed by gait speed and width of step. Balance was measured by a “Functional Reach Test (FR),” which is the difference between arm's length and maximal forward reach (Duncan PW et al. 1990), a “Timed Up and Go Test (TUG),” the time interval for a patient rise from an arm chair, walk 3 meters, and return (Podsiadlo and Richardson 1991), and the capacity to stand on one leg (one leg standing time trial). Every measurement was performed prior to the operation (pre-op), and 4 weeks after operation (post-op 4w). The recovery rate (%) was defined as post-op 4w/pre-op ×100. Data were analyzed by one-way ANOVA, and then differences among means were analyzed using Bonferroni procedures. P-values lower than 5% are regarded as significant. Result:. The recovery rate of walking speed and TUG showed significant improvement in the FTA more than >190 degree group than that of 174–180 degree group. Every other result showed a higher recovery rate for the >190 degree group, although results were not statistically significant. Discussion:. Both walking speed and TUG represent the patients' ability for walking and dynamic balancing, while FR and one leg standing depend more on the ability for static balancing. This study demonstrates that patients with severely deformed knees could show better postoperative recovery in walking and dynamic balancing than those with less severely deformed knees. Moreover, this study could suggest it is always not too late for patients with severely deformed knees to undergo TKR