Objectives . A rigorous approach to developing, delivering and documenting rehabilitation within randomised controlled trials of surgical interventions is required to underpin the generation of reliable and usable evidence. This article describes the key processes used to ensure provision of good quality and comparable rehabilitation to all participants of a multi-centre randomised controlled trial comparing surgery with conservative treatment of proximal humeral fractures in adults. Methods . These processes included the development of a patient information leaflet on self-care during sling immobilisation, the development of a basic treatment physiotherapy protocol that received input and endorsement by specialist physiotherapists providing patient care, and establishing an expectation for the provision of home exercises. Specially designed forms were also developed to facilitate reliable reporting of the physiotherapy care that patients received. Results. All three initiatives were successfully implemented, alongside the measures to optimise the documentation of physiotherapy. Thus, all participating sites that recruited patients provided the sling immobilisation leaflet, all adhered to the physiotherapy protocol and all provided home exercises. There was exemplary completion of the physiotherapy forms that often reflected a complex patient care pathway. These data demonstrated equal and high access to and implementation of physiotherapy between groups, including the performance of home exercises. Conclusion . In order to increase the validity and relevance of the evidence from trials of surgical interventions and meet international reporting standards, careful attention to study design, conduct and reporting of the intrinsic rehabilitation components is required. The involvement of rehabilitation specialists is crucial to achieving this. Cite this article: Bone Joint Res 2014;3:335–40

The outcome of one-stage bilateral open reduction through a medial approach for the treatment of developmental dysplasia of the hip in children under 18 months was studied in 23 children, 18 girls and five boys. Their mean age at operation was 10.1 months (6 to 17) and the mean follow-up was 5.4 years (3 to 8). Acceptable clinical and radiological results were achieved in 44 (95.7%) and 43 (93.5%) of 46 hips, respectively. Excellent results were significantly evident in patients younger than 12 months, those who did not require acetabuloplasty, those whose ossific nucleus had appeared, and in those who did not develop avascular necrosis. One-stage bilateral medial open reduction avoids the need for separate procedures on the hips and has the advantages of accelerated management and shorter immobilisation and rehabilitation than staged operations

In a prospective study, 204 consecutive patients with displaced Colles' fractures had closed reduction then plaster immobilisation. Three different positions of the wrist in plaster were randomly allocated: palmar flexion, neutral and dorsiflexion. The results in the three groups were compared. Fractures immobilised with the wrist in dorsiflexion showed the lowest incidence of redisplacement, especially of dorsal tilt, and had the best early functional results. Immobilisation of the wrist in palmar flexion has a detrimental effect on hand function; it is suggested that it is also one of the main causes for redisplacement of the fracture. This is discussed in relation to the functional anatomy of the wrist and the mechanics of plaster fixation

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described

We describe two patients with a diffuse haemangioma of the lower limb complicated by pathological fracture of the femoral shaft, one of whom was treated by a bone graft and immobilisation in a cast, and the other by external fixation and injection of bone marrow. A review of the literature identified difficulty in control of bleeding and obtaining bony union

The presence of the connective tissue components fibronectin and the different types of collagen was demonstrated by histological and immunohistological methods in the granulation and scar tissue of a healing injury in rat muscle. The effects of physical activity on granulation tissue production, scar formation and muscle regeneration at various stages of healing were studied. It was shown that immobilisation after injury accelerates granulation tissue production, but if continued too long, leads to contraction of the scar and to poor structural organisation of the components of regenerating muscle and scar tissue. However, a certain period of immobilisation, about five days for rat muscle, is required to allow newly-formed granulation tissue to cover the injured area and to have sufficient tensile strength to withstand subsequent mobilisation. This mobilisation, at the correct interval, seems essential for the quicker resorption of scar tissue and the better structural organisation of the muscle

One hundred and sixteen patients with 129 ununited fractures were treated either by rigid internal fixation and bone grafting or, in 14 tibial non-unions, by posterolateral bone grafting. In 37 actively infected cases this was combined with sequestrectomy and appropriate antibiotics. The final success rate was 98.4%. Technical errors or inadequate immobilisation after operation in patients with severe osteoporosis led to some early failures. No patient had a discharge or evidence of osteomyelitis after removal of metal. Rigid internal fixation with or without bone grafting is the treatment of choice for established non-union with bone loss when true synovial pseudarthrosis is present, when malalignment or shortening needs correction, and when prolonged immobilisation is either difficult or would lead to unacceptable stiffness in adjacent joints. Active osteomyelitis is not a contra-indication to internal fixation

A high rate of complications is associated with open reduction and internal fixation of Sanders type 4 fractures of the calcaneum. We assessed the long-term outcome of 83 Sanders type 4 comminuted intra-articular fractures of the calcaneum in 64 patients who underwent non-operative treatment between 1999 and 2005. Each fracture was treated by closed reduction and immobilisation in a long leg cast. Patients were reviewed every three months in the first year, and every six months thereafter. At each visit, the involved ankles were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) criteria. The degree of fracture healing and the presence of osteoarthritis were assessed. At a mean follow-up of 51 months (24 to 70) the mean AOFAS score was 72 (52 to 92). Osteoarthritis was scored radiologically using Graves’ classification and was evident in the subtalar joints of 75 ankles (90%) on x-ray and in all ankles on CT scans, of which 20 were grade 0 or 1, 39 grade 2, and 24 grade 3. A non-operative approach to treating these fractures may be simpler, less expensive, easier to administer with fewer complications, and may be better tolerated than surgery, by many patients

We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery. On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved. Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment

We have investigated those factors which influence the range of movement after total knee arthroplasty, including sex, age, preoperative diagnosis and preoperative flexion deformity and flexion range. We also compared cemented and cementless tibial fixation, the influence of collateral ligament and lateral parapatellar releases and of replacement of the patella, and of the period of postoperative immobilisation. We reviewed 516 Johnson-Elloy (Accord) knee arthroplasties performed between 1982 and 1989, with a minimum follow-up of 12 months. The most important factors in the range of flexion achieved after arthroplasty are the diagnosis and the preoperative range of flexion. In patients with osteoarthritis there was a mean loss of flexion; in rheumatoid arthritis there was a mean gain. In both groups, the stiffer knees gained motion and the more mobile knees lost it. Post-operative range of motion was not influenced significantly by cement fixation, collateral ligament or patellar retinacular releases, prolonged immobilisation or patellar replacement

Our purpose was to determine whether continuous passive motion enhanced the quality of knee ligament reconstruction using carbon fibre. In 46 rabbits the medial collateral ligaments were excised and replaced with carbon fibre prostheses. The animals were treated postoperatively by either continuous passive motion, cast immobilisation or cage activity, termed intermittent active motion. At six weeks, the ligaments were compared histologically and biomechanically with normal (control) medial collateral ligaments and with sham-operated controls. The ligaments treated with continuous passive motion were superior to those in the other two treatment groups. There were no ligament failures in any of the groups. This study suggests that continuous passive motion, initiated immediately postoperatively, enhances the biomechanical properties of carbon fibre ligament replacement of the medial collateral ligament while preventing the harmful effects of joint immobilisation

Forty patients with acute complete rupture of the calcaneal tendon were managed conservatively and randomly allocated to treatment groups using either cast immobilisation for eight weeks, or cast immobilisation for three weeks, followed by controlled early mobilisation in a Sheffield splint. The splint is an ankle-foot orthosis which holds the ankle in 15 degrees of plantar flexion, but allows some movement at the metatarsophalangeal joints. It is removed to allow controlled movement during physiotherapy. Patients treated with the splint regained mobility significantly more quickly (p less than 0.001) and preferred the splint to the plaster cast. The range of dorsiflexion at the ankle improved more rapidly after treatment in the splint (p less than 0.001), and patients were able to return to normal activities sooner. Recovery of the power of plantar flexion was similar in the two treatment groups, and no patient had excessive lengthening of the tendon. One re-rupture occurred in each group

We treated 36 patients with unilateral facet dislocations or fracture-dislocations of the cervical spine at the Mayo Clinic between 1975 and 1986. Adequate records were available for 34: ten patients were treated by open reduction and posterior fusion, and 24 by nonoperative management. Of these, 19 had halo traction followed by halo-thoracic immobilisation, four had a simple cervicothoracic orthosis, and one received no active treatment. Anatomical reduction was achieved more frequently in the operative group (60% compared with 25%). Nonoperative treatment was more likely to result in cervical translation on flexion/extension lateral radiographs, and in significant symptoms. Only 36% of the patients treated by halo traction achieved anatomical alignment; in 25% halo traction failed to achieve or maintain any degree of reduction. During halo-thoracic immobilisation, half of the patients lost some degree of reduction and patient satisfaction with the appliance was low. Open reduction and internal fixation of unilateral facet injuries gave better results. 6

A modification of a previously reported one-stage technique for reduction and stabilisation of severe spondylolisthesis using a posterior route is described. Reduction is obtained by inserting Harrington rods to lift L5 vertically out of the pelvis and two double-threaded screws to pull it backwards. After reduction the rods are taken away and stabilisation achieved by means of screws and a sacral bar. With this modified technique lumbar vertebrae above L5 are never immobilised, compared with the previous method where the retention of the Harrington rods resulted in more lumbar vertebrae being immobilised than was necessary for fusion. Bone is resected from the sacrum and the fifth lumbar vertebra to avoid too much tension on the nerve roots. Bone grafts are not needed and lumbosacral fusion is achieved within six months due to close contact between the raw bone of the vertebral bodies. Three patients have been treated with this modified technique; there was no reslip, neither during the period when the metallic fixation was in situ nor after its removal

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation. The strength of the construct removes the need for post-operative immobilisation

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures

We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B). At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function. Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock

1. A regime of treatment for acute suppurative arthritis in childhood has been proposed. This consists of: urgent arthrotomy of the affected joint, if possible within five days; skin closure without drainage; antibiotics; and immobilisation of the joint for six weeks. 2. Fifty hips have been treated by this regime: all are clinically and radiologically normal The failure to achieve these results with other forms of treatment is due to delay in diagnosis, inadequate drainage together with lack of immobilisation of tile affected joint, and inadequate treatmellt with antibiotics. 3. Early diagnosis determines the ultimate prognosis. It is suggested that in doubtful cases exploratory arthrotomy is indicated. Eleven hips were found to Ilave some other cause for the signs and symptoms, but the children have suffered no ill effects from the arthrotomy. 4. Diagnostic aspiration is an unsatisfactory method, especially ill the case of tile hip, and should be avoided. Incision is preferable. 5. Acute suppurative arthritis of infancy is a serious condition. Diagnosis is difficult and is often delayed, so that the affected joint may be destroyed. In this small series of nine, seven affected joints were destroyed