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Background: Haglund's syndrome involves a prominent posterior superior prominence of the calcaneus. If nonoperative management fails, operative management with calcaneoplasty is often needed. No study has assessed Achilles tendon pullout strength after an open calcaneoplasty for Haglund's syndrome. The purpose of this study was to investigate those changes in a cadaveric model and provide objective data upon which to base postoperative recovery., Methods: Seven matched pairs of cadaveric specimens (mid-tibia to toes) were divided into 2 cohorts: (1) intact/untreated and (2) open resection. The open resection group was treated with an open calcaneoplasty through a posterior approach using a microsagittal saw. We compared Achilles pullout strength between the 2 groups through the use of a mechanical testing system. Specimens were then loaded to failure. Lateral radiographs were obtained before and after surgery to quantify bone removal. Outcome measures included height of bony resection, angle of bone resection, and load to failure., Results: The mean maximum pullout strength was significantly higher in the intact specimens (1300 ± 500 N) compared to the open resection group (740 ± 180 N) ( P < .01), representing a 45% reduction in pullout force in the open resection group. Pullout force was significantly correlated to bone mineral density (BMD) ( P < .05). Pullout force was negatively correlated to both radiographic measures of resection level, angle, and height, but neither of these were significant., Conclusion: Open calcaneoplasty demonstrated a significant weakness of the Achilles tendon insertion. Pullout strength of the Achilles was also positively correlated with BMD., Clinical Relevance: Biomechanical evidence presented above supports the practice of protected weightbearing and cautious return to activity after open calcaneoplasty for Haglund's syndrome.

Background: Animal-assisted therapy (AAT) is a growing form of intervention in the field of rehabilitation often with the goals of decreasing pain, anxiety, and depression. There is a lack of literature on the use of AAT in inpatient rehabilitation facilities (IRF)., Purpose: This intrinsic case report describes the use of AAT in combination with physical therapy (PT) in the treatment of a middle-aged female status-post spinal surgery., Materials and Methods: This patient was treated with standard of care physical and occupational therapy in an IRF with the addition of AAT within 32% of the therapy sessions. AAT sessions focused on sitting and standing tolerance, standing balance, endurance, ambulation, stair negotiation and kitchen mobility. Clinical measures included the 6 Minute Walk Test (6MWT), the Functional Independence Measure (FIM) total score and the FIM motor subscale score., Clinical Findings: From admission to discharge from the IRF, change was noted in the areas of sitting tolerance, total FIM score, the motor subscale score of the FIM, and on 6MWT distance. Due to other therapies simultaneously occurring, no conclusions on AAT as a treatment can be made. AAT did provide more opportunities for this patient to engage in therapeutic activities., Conclusion: AAT was used during PT, in attempt to facilitate participation and distract from pain in order to work on therapeutic activities and achieve the patient's functional goals. This case report can be used as a model for other IRF therapy programs interested in AAT, can provide information about a therapeutic modality and hopefully will inspire future rigorously designed research studies., (Copyright © 2018. Published by Elsevier Ltd.)

Personalized (based on a percentage of a patient's limb occlusion pressure) blood flow restriction is emerging as a potential advancement in orthopaedic surgery. Safe application of the technology requires the use of medical devices capable of customizing the pressures applied to individual patients. In those circumstances, it is a low risk and noninvasive technique. By limiting muscle atrophy and aiding in the recovery of strength and function, it has the potential to significantly reduce the morbidity from limb trauma and surgery, and aid in achieving a substantially earlier return to full activity., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the hypothesis that an increased duration of immobilization following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) leads to improved patient-reported outcomes compared with an early mobilization protocol., Methods: At 2 institutions, we prospectively randomized 223 patients (238 thumbs) undergoing LRTI to receive 1 of 2 postoperative rehabilitation protocols. The immobilization protocol consisted of use of a postoperative forearm-based thumb-spica splint for 7 days followed by a forearm-based thumb-spica cast for 5 weeks and then by a custom forearm-based thermoplastic thumb-spica splint for an additional 6 weeks. An active range of motion (ROM) was started 6 weeks postoperatively. The early mobilization protocol consisted of the same postoperative splint for 7 days followed by use of a forearm-based thermoplastic thumb-spica splint for 3 weeks and then by a hand-based thumb-spica splint for 4 weeks. An active ROM was started 4 weeks postoperatively. The outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; pinch and grip strength; 9-hole peg test (NHP); visual analog scale (VAS) for pain; VAS for patient satisfaction; and wrist and thumb ROM. These were measured preoperatively and at 6, 12, 26, 52, and 104 weeks postoperatively. Differences in continuous and categorical variables were assessed with use of Tukey multiple comparisons following 1-way analysis of variance and Fisher exact tests, respectively., Results: A minimum follow-up of 1 year (mean, 1.7 years) was achieved for 71% (169) of the 238 randomized thumbs (157 of the 223 patients): 74 patients (80 thumbs) treated with the immobilization protocol and 83 patients (89 thumbs) treated with the early mobilization protocol. DASH scores, VAS pain scores, VAS patient satisfaction scores, and strength all improved similarly with no significant differences between groups at any time point. Wrist and thumb ROM and NHP outcomes were significantly worse for the immobilization group at 6 weeks postoperatively, with no differences observed between groups at 12 weeks and beyond., Conclusions: A conservative immobilization protocol does not improve functional outcomes, satisfaction, strength, or ROM following LRTI compared with an early mobilization protocol., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: A major goal of care for orthopaedic surgical patients is the achievement of their pre-morbid functional level or at least an improvement of their functional ability. However, patients with altered mental status can significantly impact this and other outcomes and influence the delivery of care. Patient mobilisation is a role shared by both nurses and physiotherapists., Aims: To enhance the understanding of nurses and physiotherapists' experience in mobilising postoperative orthopaedic patients with altered mental status., Method: Three nurses and three physiotherapists were recruited using purposive sampling. Data was collected through interviews and analysed using Burnard's 14 stages of thematic content analysis., Results: Four main categories emerged from the study: altruism, interprofessional specialist practice, patient dynamics and challenges. Nurses and physiotherapists' experience have more similarities than differences under the four categories., Conclusion: Nurses and physiotherapists experience numerous challenges from both patient and resources related factors such as environment, staffing and time limitations; safety risks to patient and staff; and communication barriers due to patient's altered mental state. While tensions and variations in priorities of care delivery exist between the two groups, interdisciplinary collaboration of both professional groups was clearly evident and enabled optimisation of mobilisation goals for this patient population and revealed more similarities than differences in their experience. Patient and staff safety takes precedence over mobilisation and safety risks in this patient group can be mitigated by adequate resources, competence, and teamwork., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Whether reconstruction is more beneficial after iliosacral bone tumor resection remains controversial. Because of high rates of complications and recurrence, few patients benefit from reconstruction. The aim of this study is to assess functional outcomes and to reveal changes in the ipsilateral hip joint after partial iliosacral resection., Methods: From 1998 to 2016, 21 patients aged 20-66 years underwent iliosacral resection, 18 without reconstruction (group 1) and 3 with reconstruction (group 2). Function was evaluated using the Musculoskeletal Tumor Society 1993 rating scale (MSTS 1993), and disability was measured using the Toronto Extremity Salvage Score (TESS). I-A distance was defined as the distance from the iliosacral joint to the upper line of the acetabulum along the curved line. Group 1 were subdivided into two groups: group 1A included the patients with a defect less than one-third of the I-A distance and group 1B the remainder. Acetabulum-head index (AHI) and center-edge angle (CE angle) were measured. The relationship between defect length and femoral head coverage was analyzed., Results: The mean follow-up was 67.3 months. Eighteen patients were included in group 1 and three in group 2. Preoperative data of the 3 groups were statistically equivalent. In addition, no difference of postoperative functional outcome has been highlighted. The final average MSTS 1993 score was 93.6% in group 1 and 93.3% in group 2. The mean TESS was 98 in group 1 and 98.5 in group 2. AHI and CE angle between groups 1 and 2 were not different. The AHI was 80 ± 5.4% in group 1A and 67 ± 9.0% in group 1B (t = - 3.740, P = 0.002), while the CE angle was 29 ± 5.9° in group 1A and 20 ± 6.3° in group 1B (t = - 3.172, P = 0.006) at the last follow-up. Regarding the limb-length discrepancy, group 1 and 2 were similar whereas group 1A and 1B were statistically different (group 1A: 0.7 ± 0.7 cm; group 2: 2.6 ± 1.0 cm; t = - 4.324, P = 0.001)., Conclusions: Ilio-sacral resection without reconstruction removing more than one- third of the I-A distance leads to an impairement of the limb-length discrepancy and an increase of the defect of the acetabular coverage without altering the functional outcome. Nevertheless, iliosacral resection without reconstruction could serve as a viable treatment option for pelvic type I-IV tumors.

The hip is the second most common involved joint in cerebral palsy. Hip displacement occurs in more than 33% of children with cerebral palsy, with a higher prevalence in nonambulatory children. Hip displacement in this population is typically progressive. Hip dislocation can result in pain and difficulty with sitting and perineal care. Since early stage of hip displacement can be silent, and hip surveillance programs are recommended. Most programs use the degree of hip dysplasia and Growth Motor Function Classification System level for screening recommendations. Treatment depends on the degree of dysplasia, functional status of the patient, and patient's age., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design Case report. Background An os trigonum can be a source of pain for dancers due to impingement during repetitive ankle plantar flexion movements. Following excision of an os trigonum, it is important to have a gradual, progressive return-to-dance program for optimal recovery. The purpose of this case report is to describe the postoperative management and return-to-dance progression of an adolescent dancer post os trigonum excision. Case Description An adolescent preprofessional female dancer had an extensive history of left posterior heel pain, beginning at age 8, that led to surgical removal of an os trigonum at age 15. Post surgery, the patient was seen for a total of 22 visits over the course of 20 weeks. Treatment included therapeutic exercises, neuromuscular re-education, and manual therapy. Return-to-dance tests and guidelines were used to safely progress to full, unrestricted dance participation. Outcomes The dancer had a full return of ankle range of motion, strength, and balance, improved patient-reported outcome scores, and was able to fully return to dance participation. Discussion Treating a dancer following os trigonum excision should involve a screen for hypermobility, clear communication with the dance instructor, awareness of dance-specific biomechanics, and proper reintegration into dance participation. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):194-203. Epub 7 Nov 2017. doi:10.2519/jospt.2018.7508.

Background: The Broström procedure is the most commonly used lateral ligament repair for chronic instability, but there is concern about the strength of the repair and the risk of reinjury. Currently, the InternalBrace TM ligament augmentation repair is an accepted augmentation method for management of a Broström procedure. Our hypothesis was that augmentation of the Broström repair with an InternalBrace TM would allow accelerated rehabilitation and return to activity and would aid in stability of the repair without a tendency to stretch., Methods: Eighty-one patients with lateral ankle instability procedures repaired with a Broström and InternalBrace TM augmentation were evaluated at a one-time postoperative visit between 6 and 24 months. Outcomes included demographics, surgical time, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Veterans Rand 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), satisfaction, and objective clinical measurements. Eighty-one patients were analyzed including 30 males and 51 females. Median age was 34 years (range, 18-62 years) with a median return for follow-up of 11.5 months (range, 6-27 months)., Results: Average postoperative VAS and satisfaction were 0.8 ± 1.4 and 9.1 ± 1.6, respectively. Mean return to sport (n = 68) was 84.1 days. Average AOFAS Ankle-Hindfoot score was 94.3. A score of 90 or higher on the FAAM Sports subscale was seen in 79.0% of the subjects. The single-leg hop test (Limb Symmetry Index %) showed that 86.4% of patients returned to normal or near normal function. The tape measure method and ankle dorsiflexion comparisons showed a significant difference: 9.2 ± 3.3 cm (operative side) and 10.4 ± 3.7 cm (contralateral side) ( P = .034). Ankle plantar flexion comparison (goniometer) was 48.5 ± 11.5 degrees (operative side) and 49.7 ± 11.9 degrees (contralateral side), showing no difference ( P = .506)., Conclusion: These results suggest that InternalBrace TM augmentation of a Broström procedure is a safe and efficacious procedure that produces favorable outcomes in patients in terms of preventing recurrent instability in the ankle in the short term., Level of Evidence: Level IV, case series.

Background: Spinal surgeries have strongly increased in number over the past decade. The question of when it is safe to resume driving is thereby one the most frequently asked questions that patients ask of their treating physician., Objective: The aim of this study was to assess braking performance before and after spine surgery., Methods: Reaction time, foot transfer time (together brake response time [BRT]), and brake force (BF) were evaluated in a drive simulator. A longitudinal patient cohort (n= 27) was tested preoperatively and at the first follow-up. A cross-sectional cohort (n= 27) was tested at > 1 year postoperatively. The values from these groups were compared with a healthy age-matched control group of 24 volunteers., Results: No significant improvement in BRT was seen in lumbar fusion three months postoperatively (p= 0.597); BF was even weaker than it was preoperatively (p= 0.044). In comparison to the control group (median BRT 479 ms), preoperative BRT was already impaired in lumbar fusion patients (median 560 ms), representing an increased braking distance of 2.25 m at 100 km/h., Conclusion: Although most patients performed adequately, about one third presented critical braking performance. Risk factors for impaired braking may include scheduled multisegmental fusion surgery, female sex, and pain.

The aim of this article is to share the experience of how a multi-disciplinary team worked together to develop the nursing role to incorporate the practitioners supporting mobilisation of a patient. The role developed nurses' competence, ensuring that the information and instruction patients received were consistent between therapists and nursing staff, but also supported the Enhanced Recovery Programme (2010). There were issues with the level of therapy support, especially out of hours. The team agreed a vision together, with a solution to the problem on how the mobilisation of patients post-surgery could be achieved. This would ensure postoperative complications were reduced and that there was continuity in education for the patients. This experience is an example of how staff can be empowered to provide patients with a positive experience through challenging practices and behaviours and resulting in innovative practice and role development., (Copyright © 2017. Published by Elsevier Ltd.)

Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

Background: Falls are a common adverse event in both elderly inpatients and patients admitted to rehabilitation units. The Hendrich Fall Risk Model II (HIIFRM) has been already tested in all hospital wards with high fall rates, with the exception of the rehabilitation setting. This study's aim is to address the feasibility and predictive performances of HIIFRM in a hospital rehabilitation department., Methods: A 6 months prospective study in a Italian rehabilitation department with patients from orthopaedic, pulmonary, and neurological rehabilitation wards. All admitted patients were enrolled and assessed within 24 h of admission by means of the HIIFRM. The occurrence of falls was checked and recorded daily. HIIFRM feasibility was assessed as the percentage of successful administrations at admission. HIIFRM predictive performance was determined in terms of area under the Receiver Operating Characteristic (ROC) curve (AUC), best cutoff, sensitivity, specificity, positive and negative predictive values, along with their asymptotic 95% confidence intervals (95% CI)., Results: One hundred ninety-one patents were admitted. HIIFRM was feasible in 147 cases (77%), 11 of which suffered a fall (7.5%). Failures in administration were mainly due to bedridden patients (e.g. minimally conscious state, vegetative state). AUC was 0.779(0.685-0.873). The original HIIFRM cutoff of 5 led to a sensitivity of 100% with a mere specificity of 49%(40-57%), thus suggesting using higher cutoffs. Moreover, the median score for non-fallers at rehabilitation units was higher than that reported in literature for geriatric non fallers. The best trade-off between sensitivity and specificity was obtained by using a cutoff of 8. This lead to sensitivity = 73%(46-99%), specificity = 72%(65-80%), positive predictive value = 17% and negative predictive value = 97%. These results support the use of the HIIFRM as a predictive tool., Conclusions: The HIIFRM showed satisfactory feasibility and predictive performances in rehabilitation wards. Based on both available literature and these results, the prediction of falls among all hospital wards, with high risk of falling, could be achieved by means of a unique tool and two different cutoffs: a standard cutoff of 5 in geriatric wards and an adjusted higher cutoff in rehabilitation units, with predictive performances similar to those of the best-preforming pathology specific tools for fall-risk assessment.

OBJECTIVE Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery. METHODS Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach. CONCLUSIONS The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group. Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

Background: Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical results in the treatment of knee chondral defects. However, earlier studies suggested that chondrocyte implantation in the patellofemoral (PF) joint was less effective than in the tibiofemoral (TF) joint., Purpose: To compare the radiological and clinical outcomes of those undergoing MACI to either the femoral condyles or PF joint., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 194 patients were included in this analysis, including 127 undergoing MACI to the medial (n = 94) and lateral (n = 33) femoral condyle, as well as 67 to the patella (n = 35) or trochlea (n = 32). All patients were evaluated clinically (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale, Short Form-36) before surgery and at 3, 12, and 24 months after surgery, while magnetic resonance imaging (MRI) was undertaken at 3, 12, and 24 months, with the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system employed to evaluate the quality and quantity of repair tissue, as well as an MRI composite score. Patient satisfaction was evaluated., Results: No significant group differences ( P > .05) were seen in demographics, defect size, prior injury, or surgical history, while the majority of clinical scores were similar preoperatively. All clinical scores significantly improved over time ( P < .05), with a significant group effect observed for KOOS activities of daily living ( P = .008), quality of life ( P = .008), and sport ( P = .017), reflecting better postoperative scores in the TF group. While the PF group had significantly lower values at baseline for the KOOS activities of daily living and quality of life subscales, it actually displayed a similar net improvement over time compared with the TF group. At 24 months, 93.7% (n = 119) and 91.0% (n = 61) of patients were satisfied with the ability of MACI to relieve their knee pain, 74.0% (n = 94) and 65.7% (n = 44) with their ability to participate in sport, and 90.5% (n = 115) and 83.6% (n = 56) satisfied overall, in the TF and PF groups, respectively. MRI evaluation via the MOCART score revealed a significant time effect ( P < .05) for the MRI composite score and graft infill over the 24-month period. While subchondral lamina scored significantly better ( P = .002) in the TF group, subchondral bone scored significantly worse ( P < .001). At 24 months, the overall MRI composite score was classified as good/excellent in 98 TF patients (77%) and 54 PF patients (81%)., Conclusion: MACI in the PF joint with concurrent correction of PF maltracking if required leads to similar clinical and radiological outcomes compared with MACI on the femoral condyles.

Background: Pain following orthopedic surgery can be intense due to the nature of the surgical procedure. Pain is a multilevel phenomenon that includes physiological and psychosocial components. Interventions that address body, mind, and spirit are needed to provide holistic management of pain. Guided imagery is a mind-body intervention that can address all aspects of the patient's pain experience., Purpose: This integrative review, informed by Watson's theory of human caring, identifies evidence that either supports or refutes the use of guided imagery as a supplement to pharmaceutical pain management for postoperative orthopedic patients., Method: An integrative literature search was conducted. Twenty-two studies were identified as potentially relevant to this study. Nine of the articles met all inclusion criteria and were included in this study., Results and Conclusions: Based on the evidence reviewed, it is recommended that guided imagery be used as an adjunct for pain management in patients undergoing orthopedic surgery. However, additional research in this area is needed. Future research: Two topics for further research were identified. The first is a need to identify an optimal frequency of use of guided imagery. The second is to identify how to ensure patients are using the intervention as recommended.

Although patellofemoral (PF) chondral lesions are common, the presence of a cartilage lesion does not implicate a chondral lesion as the sole source of pain. As attributing PF pain to a chondral lesion is "diagnosis by exclusion," thorough assessment of all potential structural and nonstructural sources of pain is the key to proper management. Commonly, multiple factors contribute to a patient's symptoms. Each comorbidity must be identified and addressed, and the cartilage lesion treatment determined. Comprehensive preoperative assessment is essential and should include a thorough "core-to-floor" physical examination. Treatment of symptomatic chondral lesions in the PF joint requires specific technical and postoperative management, which differs significantly from management involving the tibiofemoral joint. Attending to all these details makes the outcomes of PF cartilage treatment reproducible. These outcomes may rival those of chondral repair in the tibiofemoral joint., Competing Interests: Author's Disclosure Statement: Dr. Gomoll reports that he is a paid consultant/advisory board member for Vericel, Joint Restoration Foundation, LifeNet, Smith & Nephew, and NuTech Medical. Dr. Farr reports that he is a paid consultant/advisory board member for Arthrex, Osiris Therapeutics, Vericel, and Zimmer Biomet; receives research/institutional support from Arthrex, RTI Biologics, Vericel, and Zimmer Biomet; and holds a design patent for a DePuy Synthes patellofemoral arthroplasty device. Dr. Hinckel reports no actual or potential conflict of interest in relation to this article.

Smoking increases the risk of complications associated with orthopaedic trauma surgery, however delivery of care is low. Online interventions may provide needed smoking cessation care and promote abstinence. This study aims to examine the engagement, acceptability, and retention of an online smoking cessation program (Smoke-Free Recovery; SFR) among a sample of orthopaedic trauma patients, as well as themes around the smoking cessation process. A pilot study of SFR with 31 orthopaedic trauma patients admitted to a public hospital in New South Wales, Australia took place. Semi-structured telephone interviews were conducted following hospital discharge. Thematic analysis and descriptive statistics were used. Engagement was high with 28 participants accessing SFR during admission. Twenty individuals completed follow-up phone calls. Program acceptability was rated favourably. After discharge, changes in smoking habits were noted, with program retention low. Themes on program use included: lack of time or need for additional support; computer illiteracy or technology issues; feeling unready or too stressed to quit; or feeling they had reached the boundary of what could be learnt from the program. This study highlights the difficulties faced by patients following hospital admission, the lack of follow-up support received, and the need for consumer testing prior to roll out. Continuing to develop interventions to promote hospital-initiated cessation attempts that continue post-discharge should be a priority., Competing Interests: The authors declare no conflict of interest.

Question: Is referral for early rehabilitation after lumbar disc surgery effective and cost-effective compared to no referral?, Design: Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis., Participants: Adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level., Intervention: Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge., Outcome Measures: In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery., Results: There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year., Conclusion: Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral., Trial Registration: Netherlands Trial Register NTR3156. [Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW (2017) Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. Journal of Physiotherapy 63: 144-153]., (Copyright © 2017. Published by Elsevier B.V.)

Objective: We aimed to evaluate the clinical outcomes after surgical repair of patellar tendon rupture (PTR) and compare the evolution of 2 types of rupture (acute and chronic) after the same rehabilitation protocol., Methods: This was a prospective cohort study of patients with PTR treated between January 2006 and January 2014 in the department of trauma surgery, Ibn Rochd university hospital, Casablanca., Results: We evaluated 25 patients (21 men) after a median follow-up of 75 months (range 29-120). The mean age was 34.7±8.59 years. Overall, 17 patients had acute rupture and 8 chronic rupture. Fifteen healthy volunteers (13 men) were recruited as a control group. Mean Knee Society Score (KSS) knee score was significantly higher after than before surgery (82.28±12.297 vs 20.64±7.6; P<0.0001) as was KSS function score (88.40±17.483 vs 23.40±8.98; P<0.0001). Pain measured on a visual analog scale was significantly lower after than before surgery (1.96±1.24 vs 6.60±1.26; P<0.0001). ROM and KSS knee and function scores were significantly lower on the operated than non-operated side after surgery. For both types of PTR, only knee extensor muscle strength was significantly lower on the operated than non-operated side and as compared with healthy volunteer knees., Conclusions: Surgical repair of PTR with reinforcement and an early rehabilitation program demonstrate good results after a long follow-up. However, chronic PTR may need longer or a different rehabilitation protocol of the knee-extensor apparatus., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Injuries to the central slip of the extensor mechanism can lead to a Boutonniere deformity with important functional consequences. We report a series of 11 patients treated by lengthening-dorsalizing the lateral bands and tightening the central slip with early mobilization. The average age of the patients was 42 years (14;52). The extension defect of the proximal interphalangeal (PIP) joint was 64 degrees (80;55) and the hyperextension of the distal interphalangeal joint was 10 degrees (15;5). The surgery was performed with peripheral nerve block (sensitive), allowing dynamic adjustment of the tendinous sutures. With a dorsal incision, a tenolysis of the extensor was performed. The central slip was tightened and the lateral bands dorsalized by cross-stitches over the PIP joint. The active flexion/extension was tested, and then lengthening of the lateral bands by "mesh graft" tenotomy was performed over the second phalange. There was no immobilization. The deformity was improved in 10 patients with a total flexion of the finger. The mean lack of extension in the PIP was 8 degrees (0;20) and the active flexion of the distal interphalangeal joint was 80 degrees (70;85). There was 1 failure. The majority of techniques necessitate an immobilization of 3 to 6 weeks. Our procedure uses the elastic properties of the elongation and allows immediate mobilization. The result can be compromised in case of insufficient tendinous surface or if postoperative instructions are not followed.

Background: We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery., Methods: We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW., Results: Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval., Conclusions: WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Hallux valgus-the most common forefoot deformity-can cause both pain and decreased mobility. The development and progress of the hallux valgus is a multifactorial process. Different intrinsic and extrinsic causes are responsible. Various conservative and operative treatment options exist and have to been chosen regarding the stage of the disease. Conservative orthopedic measures may prevent a deterioration of hallux valgus only at an early stage of the disease. Concerning operative techniques, more than 150 different surgical procedures are described in the literature, which can be reduced to some common procedures. These are dependent on the manifestation of the bunion as well as on associated foot and ankle pathologies. Patients should be informed that postoperative follow-up treatment until complete recovery is time-consuming.

Chronic patellar tendinopathy affects athletes, with a higher incidence in high-impact sporting activities. It can seriously impair sports activities. Many patients respond well to conservative treatment, but about 10% of them are refractory to conservative treatment. In these cases, surgery is indicated. Multiple surgical techniques have been reported, including both open and arthroscopic procedures with good results. However, in a small percentage of patients surgery is unsuccessful. This group of patients presents a major challenge, as options are limited. We describe our surgical approach in the management of recalcitrant patellar tendinopathy.

Aim: The objective of the present work was to rehabilitate more efficiently the patients who had undergone the surgical treatment for herniated discs in the lumbosacral spine by applying general magnetic therapy during the combined treatment., Material and Methods: A total of 73 patients underwent the medical examination and treatment. The patients matched for age and sex presenting with similar clinical symptoms were divided into two groups. All of them received initial therapy that included medication, therapeutic physical exercises, and aquatic therapy. The patients in the main study group were given, in addition, general magnetic therapy. All the patients had their lower back examined before and after the treatment; moreover, they were asked to report their pain intensity based on the visual-analogue scale. The patients had their spinal and lower extremity temperature measured by means of thermal scanning with the use of remote infrared thermography and the non-invasive thermal imaging to check temperature fluctuations. To evaluate the psycho-emotional condition of the patients and to obtain their quality of life characteristics, they were asked to fill up the WAM (wellbeing, activity, mood) questionnaire; moreover, the disability Index was determined using the Oswestry questionnaire (version 2.1.), and the State-Trait Anxiety Inventory (STAI) was employed., Results: 75.7% of the patients in the main group had the positive treatment results in the form of improvement of the affected movement skills, sensory processing abilities, and reflex functions as compared with the 58,3% success rate among the patients in the control groupd. Based on the data of non-invasive infrared thermal imaging, the patients of the main group had significantly lower post-treatment topical hyperthermia in the region of the surgical intervention in comparison with the controls which suggested the reduction of the severity of the inflammatory process and the manifestations of the muscular-tonic syndrome. Their temperature dropped by 1,46±0,07 °С in contrast to the patients of the control group whose temperature decreased only by 0,91±0,04 °С (р<0.05). These observations gave evidence that the inflammation had been alleviated and the muscle tension relieved. The adopted recovery program promoted, in addition, a temperature drop at the area of the skin innervated by the affected root. It has been found that not only the pain subsided and the compromised motor skills and sensory processing abilities improved but also the quality of life tended to ameliorate resulting in the occupational rehabilitation of the patients following the surgical treatment of herniated intervertebral discs., Conclusion: It has been found that the addition of general magnetic therapy to the combined treatment of the patients who had undergone the surgical treatment of herniated intervertebral discs favourably affects the clinical symptoms of the disease, intensifies regeneration, as well as improves blood circulation in the area affected by surgery, improves the psychoemotional state and the quality of life of the patients in such conditions thus making therapy considerably more efficient by preventing the complications and significantly shortening the duration of the treatment. .

Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that practitioners understand the most effective and efficient means for remediating impairments and supporting clients in progressing to independence in purposeful occupations. This systematic review provides an update to a previous review by summarizing articles published between 2006 and July 2014 related to the focused question, What is the evidence for the effect of occupational therapy interventions on functional outcomes for adults with musculoskeletal disorders of the forearm, wrist, and hand? A total of 59 articles were reviewed. Evidence for interventions was synthesized by condition within bone, joint, and general hand disorders; peripheral nerve disorders; and tendon disorders. The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions. Very few studies have examined occupation-based interventions. Implications for occupational therapy practice and research are provided., (Copyright © 2017 by the American Occupational Therapy Association, Inc.)

Learning Objectives: After reading this article, the participant should be able to: 1. Appreciate the variation and evolution of flexor tendon management 2. Know how to assess the patient who presents with a flexor tendon laceration. 3. Understand the biology of repairing flexor tendon lacerations. 4. Appreciate the technical challenges in flexor tendon repair relating to different zones. 5. Understand the rationale of postoperative hand therapy. 6. Have an overview of the types of secondary tendon surgery., Background: Flexor tendon injury constitutes a considerable trauma workload for hand surgeons, and a vast amount of research is dedicated toward improving outcomes in tendon repair. This Continuing Medical Education article aims to provide an up-to-date evidence-based outline of flexor tendon surgery in the hand., Methods: The authors reviewed the literature on flexor tendon repairs to include a balanced overview of the experimental and clinical research. For each section, the best levels of evidence were assessed in the context of past research to provide a comprehensive opinion on best management., Results: The review highlights current trends in flexor tendon surgery, clinical assessment, anesthetic technique, surgical approach, repair technique, and rehabilitation. Carefully selected illustrations, figures, tables, and video have been used to supplement the findings of the review., Conclusions: Early active mobilization remains the only long-term proven strategy to improve outcomes. Incorporating intraoperative mobilization using "wide-awake" surgery could emerge to further improve tendon outcomes. Good surgical approach, meticulous surgery, up-to-date physiotherapy regimens, and patient education remain the cornerstone of obtaining best outcomes.

Clinical Scenario: There are 2 approaches available for surgical repair of the Achilles tendon: open or percutaneous. However, there is controversy over which repair is superior. Focused Clinical Question: Which type of surgery is better in providing the best overall patient outcome, open or percutaneous repair, in physically active men and women with acute Achilles tendon ruptures? Summary of Search, "Best Evidence" Appraised, and Key Findings: The literature was searched for studies of level 3 evidence or higher that investigated the effectiveness of open repair versus percutaneous repair on acute Achilles tendon ruptures in physically active men and women. The literature search resulted in 3 studies for possible inclusion. All 3 good-quality studies were included. Clinical Bottom Line: There is supporting evidence to indicate that percutaneous repair is the best option for Achilles tendon surgery when it comes to the physically active population. Percutaneous repair has faster surgery times, less risk of complications, and faster recovery times over having an open repair, although it is acknowledged that every patient has a different situation and best individual option may vary patient to patient.

Background: Physiotherapists are commonly involved in the management of patients immediately following lumbar spinal surgery. There is however, very little research to guide physiotherapy intervention in the acute post-operative period, and the advice provided to patients regarding post-operative walking and physical activity has been shown to be highly variable. The primary aim of this research is to establish whether the amount of walking patients perform in the week following lumbar spinal surgery predicts improvement in function at 6 months., Methods: This study will be a prospective cohort study design, with a projected sample size of 250 participants. Patients undergoing surgery for the management of a disc prolapse, degenerative disc disease, lumbar spinal stenosis and/or degenerative spondylolysthesis will be invited to participate in this study. Outcome measurement will take place pre-operatively and at six months post-operatively. The primary outcome variable will be self-reported function, measured using the Modified Oswestry Disability Questionnaire and the physical component summary of the SF-36. Each participant will be fitted with an activPAL3 accelerometer to be worn for the first seven post-operative days. This accelerometer will record time spent in active versus sedentary postures, step count and time spent walking. Multivariable logistic regression analysis will be used to investigate the relationship between the total time spent walking over the first seven post-operative days, and outcome at six months., Discussion: The results from this research will help to guide patient management during the inpatient phase, by identifying patients who are at risk of poorer outcome due to limited walking time. These patients may benefit from ongoing rehabilitation and outpatient physiotherapy services. This information will also provide a foundation for further research into interventions designed to optimise post-operative activity., Trial Registration: ACTRN12616000747426 , retrospectively registered 7th June 2016.

Objective: The objective of this review was to identify current practices and relevant patient-reported and objective outcome measures with regard to rehabilitation protocols directed at the lumbar spine in perioperative procedure settings in order to inform clinical practice and future research., Methods: A literature search was performed in MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Central Register of Controlled Trials, PEDro (Physiotherapy Evidence Database), and PubMed using terms relevant to surgical interventions, rehabilitation, and the lumbar spine., Results: Twenty-nine studies met the inclusion criteria, and 28 investigated postoperative forms of rehabilitation. Patient-reported outcomes typically used were pain and disability, although a wide range of objective measures based on physical capacities were often reported. Rehabilitation programs, for the most part, included some form of strengthening exercises alone or in combination with stabilization exercises, aerobic conditioning, stretching, or education. Despite most studies reporting statistically significant results between intervention groups, considering clinically significant improvement within intervention groups yielded a different portrait., Conclusions: A wide range of objective and subjective outcomes is used to document changes after active rehabilitation. Program components include both active and assisted interventions combined with various means of education and discussion. Multimodal rehabilitation protocols after lumbar surgery may be used to improve patient-reported and objective outcome measures such as pain, disability, and physical function. Further research should be conducted on the effects of preoperative rehabilitation programs., (Copyright © 2016. Published by Elsevier Inc.)

Purpose: The aim of this study was to evaluate the outcome of a minimally invasive surgical technique for the treatment of patients with acromioclavicular joint dislocation., Methods: Sixteen patients with complete acromioclavicular joint dislocation were enrolled in this study. All patients were asked to follow the less active rehabilitation protocol post-operatively. Computed tomography with 3-D reconstruction of the injured shoulder was performed on each patient post operatively for the assessment of the accuracy of the suture anchor placement in the coracoid process and the reduction of the acromioclavicular joint. Radiographs of Zanca view and axillary view of both shoulders were taken for evaluating the maintenance of the acromioclavicular joint reduction at each follow-up visit. The Constant shoulder score was used for function assessment at the final follow-up., Results: Twenty seven of the 32 anchors implanted in the coracoid process met the criteria of good position. One patient developed complete loss of reduction and another had partial loss of reduction in the anteroposterior plane. For the other 14 patients, the mean Constant score was 90 (range, 82-95). For the patients with partial and complete loss of reduction, the Constant score were 92 and 76 respectively. All of them got nearly normal range of motion of the shoulders and restored to pre-operative life and works., Conclusion: With this minimally invasive approach and limited exposure of the coracoid, a surgeon can place the suture anchors at the anatomical insertions of the coracoclavicular ligament and allow the dislocated joint reduced and maintained well., Level of Evidence: Level IV, Case series; therapeutic study.

Objective: Effects of a combined orthopedic and psychosomatic rehabilitation (VOP) concept are evaluated in contrast to psychosomatic and orthopedic rehabilitation. Therefore both mental and physical health of rehabilitants are compared. Methods: A prospective case-control study was performed in order to gather psychic strain and bodily constitution. Covariance analysis was conducted to expose significant differences between groups. Results: An equal clinically relevant reduction of psychological distress could be achieved with psychosomatic rehabilitation (N=322) and VOP (N=511). Moreover, bodily constitution could be increased by the same amount through VOP and orthopedic rehabilitation (N=135). In conclusion the therapy concept is successful in patients with both somatic and psychic problems., (© Georg Thieme Verlag KG Stuttgart · New York.)

Myeloma bone disease (MBD), the skeletal lesions caused by multiple myeloma, is also known as skeletal related events and includes bone pain, osteoporosis, pathological fractures, osteolytic bone lesions, spinal instability, spinal cord and nerve root compression and extramedullary plasmacytoma. It is now generally accepted that patients with these complications usually require surgical management and that such treatment is safe and effective. The aims of surgical interventions are to alleviate pain, improve quality of life, treat potential or existing pathological fractures, decompress the spinal cord and nerve roots, and reestablish bone continuity. Thus far, there have not been uniform standards for surgical treatment of MBD. The Surgeon's Committee of the Chinese Myeloma Working Group has therefore achieved a consensus with the aim of providing guidance for clinicians and benefitting patients with MBD. This consensus focuses on the treatment of MBD, including its clinical definition and characteristics, diagnosis and surgical management. This expert consensus document was compiled after discussion and revision by experts from several relevant institutions in China. However, it is only an interim guide that cannot be enforced legally. It will be updated with development of new techniques of treatment., (© 2016 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Objectives: The aim of this study is to analyse the outcomes of the surgical treatment of metacarpophalangeal stiffness by dorsal teno-arthrolysis in our centre, and present a review the literature., Material and Methods: This is a retrospective study of 21 cases of metacarpophalangeal stiffness treated surgically. Dorsal teno-arthrolysis was carried out on all patients. A rehabilitation programme was started ten days after surgery. An evaluation was performed on the aetiology, variation in pre- and post-operative active mobility, complications, DASH questionnaire, and a subjective satisfaction questionnaire., Results: The mean age of the patients was 36.5 years and the mean follow-up was 6.5 years. Of the 21 cases, the most common cause was a metacarpal fracture (52.4%), followed by complex trauma of the forearm (19%). Improvement in active mobility was 30.5°, despite obtaining an intra-operative mobility 0-90° in 80% of cases. Mean DASH questionnaire score was 36.9 points. The outcome was described as excellent in 10% of our patients, good in 30%, poor in 40%, and bad in the remaining 20%. There was a complex regional pain syndrome in 9.5% of cases, and intrinsic muscle injury in 14.3%., Conclusion: Because of its difficult management and poor outcomes, surgical treatment of metacarpophalangeal stiffness in extension is highly complex, with dorsal teno-arthrolysis being a reproducible technique according to our results, and the results reported in the literature., (Copyright © 2016 SECOT. Published by Elsevier Espana. All rights reserved.)

Purpose: Postoperative exercises may increase load on repaired tendons. Differences in the activity of the rotator cuff muscles were assessed during several different types of passive shoulder and active elbow exercises., Methods: In 15 healthy subjects, passive forward flexion of the shoulder was performed using a table, pulley and rope, and a cane, and external rotation was performed using a cane and a wall. The active elbow flexion-extension exercise was also performed while holding the upper arm with the contralateral hand. Activation amplitudes of the supraspinatus, infraspinatus and subscapularis muscles were evaluated using electromyography with fine wires., Results: During passive forward flexion, the supraspinatus and infraspinatus muscles exhibited lower activity when using a table compared with a cane (both P < 0.01) and a pulley and rope (both P < 0.05). Flexion of <90° decreased supraspinatus activation compared with 170° (P = 0.047). During external rotation of the shoulder while using the cane and wall, there was no difference in the activity of any muscles. Electromyographic activity during the active elbow exercise was lower in the supraspinatus while holding the upper arm (P = 0.018)., Conclusion: The table sliding exercise may reduce stress on the rotator cuff during passive forward flexion more than the other exercises do. Decreasing the range of motion to less than 90° in forward flexion activated the supraspinatus less. Moreover, movement of the elbow can be performed holding the upper arm to activate the rotator cuff to a lesser extent., Level of Evidence: Prognostic study, Level II.

Purpose: Treatment of neglected Achilles tendon rupture is very challenging. This randomized study aimed to compare the clinical outcome of early post-operative rehabilitation (EPR) with post-operative cast immobilization (PCI)., Methods: Fifty-seven patients with neglected Achilles tendon rupture were randomized to receive EPR (n = 26) or PCI (n = 31) management following surgery. Clinical outcome was monitored by follow-up at weeks 8, 12, 18 and 26 and year 2. The significance of intergroup differences from the Leppilahti scoring system (LSS), ultrasonography, multislice spiral computerized tomography (MSCT) and electromyography was assessed., Results: Ultrasonography and MSCT revealed no occurrence of tendon elongation or adhesion. Four patients could perform sustained single-leg heel-raise exercise for 60 s at post-operative day 40. The PCI group also showed increased post-operative LSS score, but recovery was slower. Post-operative complications, such as ankle joint ankylosis and osteoporosis, only occurred in the PCI group., Conclusions: Compared with cast immobilization, early post-operative rehabilitation results in better clinical outcome and faster overall tendon regeneration of neglected Achilles tendon rupture., Level of Evidence: II.

Introduction: Despite scientific progress with regard to pain neuroscience, perioperative education tends to stick to the biomedical model. This may involve, for example, explaining the surgical procedure or 'back school' (education that focuses on biomechanics of the lumbar spine and ergonomics). Current perioperative education strategies that are based on the biomedical model are not only ineffective, they can even increase anxiety and fear in patients undergoing spinal surgery. Therefore, perioperative pain neuroscience education is proposed as a dramatic shift in educating patients prior to and following surgery for lumbar radiculopathy. Rather than focusing on the surgical procedure, ergonomics or lumbar biomechanics, perioperative pain neuroscience education teaches people about the underlying mechanisms of pain, including the pain they will feel following surgery., Research Objectives: The primary objective of the study is to examine whether perioperative pain neuroscience education ('brain school') is more effective than classic back school in reducing pain and improving pain inhibition in patients undergoing surgery for spinal radiculopathy. A secondary objective is to examine whether perioperative pain neuroscience education is more effective than classic back school in: reducing postoperative healthcare expenditure, improving functioning in daily life, increasing return to work, and improving surgical experience (ie, being better prepared for surgery, reducing incongruence between the expected and actual experience) in patients undergoing surgery for spinal radiculopathy., Design: A multi-centre, two-arm (1:1) randomised, controlled trial with 2-year follow-up., Participants and Setting: People undergoing surgery for lumbar radiculopathy (n=86) in two Flemish hospitals (one tertiary care, university-based hospital and one regional, secondary care hospital) will be recruited for the study., Intervention: All participants will receive usual preoperative and postoperative care related to the surgery for lumbar radiculopathy. The experimental group will also receive perioperative pain neuroscience education comprising one preoperative and one postoperative individual educational session plus an educational booklet., Control: Participants in the control group will receive perioperative back school on top of usual preoperative and postoperative care, comprising one preoperative and one postoperative individual educational session plus an educational booklet., Measurements: Self-reported pain and endogenous pain modulation (including measurements of simultaneous cortical activation via electroencephalography) will be the primary outcome measures. Secondary outcome measures will include daily functioning, return to work, postoperative healthcare utilisation and surgical experience/satisfaction. Psychological factors will be measured as possible treatment mediators., Procedure: All assessments will take place in the week preceding surgery (baseline), and at 3 days and 6 weeks after surgery. Intermediate and long-term follow-up assessments will take place at 6, 12 and 24 months after surgery., Analysis: All data analyses will be based on the intention-to-treat principle. Repeated measures AN(C)OVA analyses will be used to evaluate and compare treatment effects. Baseline data, treatment centre, age and gender will be included as covariates. Statistical, as well as clinically, significant differences will be evaluated and effect sizes will be determined. In addition, the numbers needed to treat will be calculated., Discussion: This study will determine whether pain neuroscience education is worthwhile for patients undergoing surgery for lumbar radiculopathy. It is expected that participants who receive perioperative pain neuroscience education will report less pain and have improved endogenous pain modulation, lower postoperative healthcare costs and improved surgical experience. Lower pain and improved endogenous pain modulation after surgery may reduce the risk of developing postoperative chronic pain., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Recent years have witnessed a growing number of people practising sports both at professional and amateur level. This trend led to a progressive rise in the incidence and prevalence of acute and chronic hip damage. The treatment of hip disease in subjects practising sports is a major challenge for the orthopaedic surgeon. The evaluation of patients, in particular those of young age with high functional demands, is inevitably complex and should be performed with a multidisciplinary approach; from a surgical point of view, it is essential to carefully assess whether the indication is towards conservative surgery or hip replacement surgery. The advent of arthroscopic surgery in recent years has allowed us to improve our knowledge of hip joint diseases, such as femoroacetabular impingement that is typical of sports and overuse activity. A correct and early diagnosis of the disease can direct the patient promptly to a conservative surgical treatment that could reduce the progression of degenerative pathology. However, when the joint is permanently damaged, the only reliable solution remains prosthetic surgery, leading to a series of issues that the orthopaedic surgeon should be able to master, leading to a thoughtful decision on, for example, which implant to use, which biomaterials, which surgical approach or which sport to practise after surgery. This supplement contains selected contributions stemming from the work performed by internationally recognised experts in the field and presented during the 1st European Hip Sport Meeting held in Bologna on May 19th, 20th, 2016 that we had the honour to co-chair. We hope that these contributions will help the orthopaedic surgeon, the sports physician and physiotherapist in their day-to-day practice, and will help in fulfilling our ultimate aim to improve the knowledge of the hip pathology related to sports and overuse activities.

Unlabelled: The flexors/extensors imbalance can be a cause knee instability and therefore lead to progression of osteoarthritis. The isokinetic evaluation of the strength of flexors after the autoplastic reconstruction the anterior cross-shaped (cruciate) ligament (ACL) is of primary importance bearing in mind that certain authors have reported a persistent deficiency in flexor strength after surgery., Aim: The purpose of the present study was to objectively evaluate the isokinetic function of the knee during each treatment stage and estimate the influence of harvesting semitendinosus/gracilis tendon (SGT) on the knee flexion., Material and Methods: During the period from 2012 to 2014, a total of 44 patients (20 women and 24 men) presenting with ACL rupture were available for the examination. All the patients underwent the isokinetic evaluation of the knee function before operation, 6-8 weeks and 3-4 months after the arthroscopic ACL reconstruction with the use of the SGT graft. The patients were divided into two groups. The first group was comprised of 22 subjects who were treated in accordance with the standard protocol of therapeutic physical exercises starting from week 6 after the initiation of the physiotherapeutic rehabilitative measures. The second group consisted of 22 patients who had to perform the isokinetic training within 6-8 weeks after surgery., Results: The results of the study indicate that all the patients suffering injuries to the anterior cross-shaped ligaments had well apparent flexor/extensor imbalance. In those of the first group, the flexor imbalance amounted to 25-35% while the extensor imbalance was 10-15% within 3-4 months after the surgery. The second group showed a 10-15% flexor imbalance and 2-5% extensor imbalance after 3-4 months., Conclusion: The isokinetic testing provides a tool for the objective evaluation of the knee function. It helps to reveal the high effectiveness of isokinetic rehabilitation protocol leading to the recovery of the patients within 3-4 months after the surgery. It can be assumed based on the results of the present study that harvesting of the semitendinosus/gracilis tendon does not exert any negative influence on the knee flexion strength given the rehabilitation program includes the isotonic training protocol.

Background: Surgery to repair rotator cuff (RC) tears is a commonly performed orthopaedic procedure with the aim of reducing pain and improving function. Surgery is followed by rehabilitation and recommendations for postoperative rehabilitation include; exercise therapy, continuous passive motion machines and aquatic therapy. Currently, there is uncertainty in the literature as to what constitutes best postsurgical rehabilitation., Objective: To systematically review postsurgical research investigations to provide clinical guidance regarding postsurgical management., Data Sources: A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from September 1993 to September 2013., Study Selection: Reviewer assessment using inclusion and exclusion criteria of randomised controlled trials., Data Extraction: Data pertaining to research design, intervention and subjects was extracted from included papers by one author. The data was grouped by reference to the objectives of the study and collated in themes., Data Synthesis: Narrative synthesis of the data was used to describe the effects of the intervention. The methodological quality and risk of bias of the included studies was assessed using the standardised Physiotherapy Evidence Database scale. Eleven studies met the inclusion criteria. All the studies were of fair to good methodological quality. No one rehabilitation protocol was found to be superior to another. The findings of this review suggested that following RC repair, patients should expect improvement in pain, ROM and function., Conclusion: This review concludes that no single rehabilitation protocol is superior to another following RC repair. Studies with larger study populations and longer term follow up are required to investigate this further., (Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Recurrent tears after rotator cuff repair are common. Postoperative rehabilitation after rotator cuff repair is a modifiable factor controlled by the surgeon that can affect re-tear rates. Some surgeons prefer early mobilization after rotator cuff repair, whereas others prefer a period of immobilization to protect the repair site. The tendon-healing process incorporates biochemical and biomechanical responses to mechanical loading. Healing can be optimized with controlled loading. Complete load removal and chronic overload can be deleterious to the process. Several randomized clinical studies have also characterized the role of postoperative mobilization after rotator cuff repair., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This article explored the perspectives of 25 patients regarding virtual reality (VR)-based rehabilitation following knee surgery and identified the important factors that allowed patients to immerse themselves in rehabilitation. Qualitative analysis of data collected via open-ended questionnaire and quantitative analysis of data from physical assessments and surveys were conducted. In the open-ended questionnaire, the majority of participants mentioned level of difficulty as the most common reason for selecting both the most and the least immersive exercise programs. Quantitative analysis showed that participants experienced a high level of flow (3.9 +/- 0.3 out of 5.0) and a high rate of expectation of therapeutic effect (96%) and intention of exercise adherence (96%). Further, participants with more severe pain or physical dysfunction tended to have more positive experiences (e.g., Difficulty-Skill Balance, Clear Goals, and Transformation of Time), leading to high levels of flow during VR-based rehabilitation. In conclusion, VR-based games are potentially acceptable as a motivational rehabilitation tool for patients following knee surgery. However, to best meet patients' needs, it might be useful to equip a VR program with varied levels of difficulty, taking into account the severity of the individual's knee injury. Additionally, severe pain or physical dysfunction might act as an indication rather than a contraindication for VR-based rehabilitation.

Purpose: To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques., Methods: The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total., Results: A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic)., Conclusions: Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality., Level of Evidence: Level IV, economic., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Orthopaedic surgery often requires many months of rehabilitation to achieve a successful outcome, regardless of subspecialty. Several important psychological factors strongly influence pain perceptions, rehabilitation compliance, and patient outcomes after common orthopaedic surgeries that require extensive rehabilitation, including total joint arthroplasty, anterior cruciate ligament reconstruction, and spine surgery for degenerative disease. Early recognition of patients exhibiting psychological distress, fear-avoidance behavior, or poor perceived self-efficacy or pessimistic personality traits can be used to improve preoperative risk stratification for poor rehabilitation or surgical outcomes. Several intervention strategies exist to address these psychological factors when they appear to contribute suboptimal postoperative rehabilitation or recovery., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)