Background: Many factors contribute to suboptimal results after total knee arthroplasty (TKA) but little is known regarding the value of postsurgical rehabilitation after TKA. We examined the effects of an enhanced closed kinematic chain exercises program (AposTherapy) on gait patterns and clinical outcomes among patients with a lack of progress in their postsurgical rehabilitation.Methods: Twenty-two patients were prospectively followed during the study. Gait spatiotemporal parameters were measured at the initial evaluation, after 15 minutes of therapy, and after 3 months of therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the short form (SF) 36 health survey were completed by patients before treatment and after 3 months of treatment.Results: The WOMAC and SF-36 scores improved significantly after 3 months of treatment. Gait velocity, single limb support, and step length of the operated leg improved significantly even after a single 15 minutes treatment. Normal gait velocity was observed in 36% of patients after 3 months of treatment.Conclusions: A physiotherapy program that included enhanced closed kinematic chain biomechanical therapy was beneficial for patients who experienced a suboptimal rehabilitation course after TKA.

Purpose: The predicted increase in primary and revision total knee arthroplasty (TKA) for knee osteoarthritis is a major concern. The demand for primary TKA in the United States alone is expected to grow by 673% (3.48 million annual procedures) by 2030 and the demand for TKA revisions is expected to grow by 601%. Yet, up to 50% of patients continue to suffer from pain and disability following the surgery. In most of the cases those finding cannot be explained by implant factors or surgical technique. Additionally, physiotherapy functional exercises after discharge result in small to moderate effect sizes with no long-term benefits. Evidence shows that gait patterns after TKA do not return to healthy ranges. These pathological gait patterns may partially explain the difficulty in postoperative recovery in pain and function, as well the wear and tear of the TKA implant in the long-term. In this study we applied a biomechanical therapy program after surgery aimed at reducing pain, improving function and correcting gait patterns. Methods: We conducted a randomized, controlled, double-blind trial involving fifty patients after unilateral TKA for end-stage knee OA. The active group underwent a therapy program using a biomechanical foot-worn device, while the control group received a similar training program with a sham walking shoe. Treatment was initiated 6 weeks postoperatively. Patients were examined at baseline, 3 months, 6 months, 9 months and 12 months postoperatively. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and three-dimensional gait analysis measurements in the frontal and sagittal planes. Comparisons of categorical variables between the intervention groups (active vs. control) were carried out with the chi-square tests. Comparisons of continuous variables such as demographic data and baseline gait data between the groups were done by the Wilcoxon-Mann-Whitney rank-sum test. A linear mixed effect model was used to determine the effect of the treatment over time in each parameter. Results: There were no differences between groups at baseline. Both groups improved with time after surgery, but the active group consistently showed significantly better outcomes in WOMAC pain (Figure 1; 91% reduction compared to 33%), function (Figure 2; 93% reduction compared to 21%) and stiffness (85% reduction compared to 32%) sub-scales (all p = 0.001), in SF-36 physical score (107.3% increase compared to 59%) and mental scores (51% increase compared to 45%) (all p<0.001). Patients from the active group also showed lower second peak knee adduction moment (Figure 3; p = 0.007) and greater peak knee extension moment (p = 0.009). Linear mixed effect models over time showed faster improvements in the active group in all clinical parameters, stride, cadence, double-limb-support, step-length, knee range of motion and impulses of the knee flexion and extension moments, as well as slower regression of the knee adduction impulse (all p<0.01). The knee varus angle did not differ between groups over time. Conclusions: A patient-specific biomechanical therapy program applied to patients after unilateral TKA may lead to a greater improvement and more rapid recovery time in pain and function, as compared to regular rehabilitation protocols after TKA. Furthermore, this biomechanical training program may lead to healthier loading patterns on the knee joint.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Background: Total knee arthroplasrty (TKA) is the most common treatment for end-stage knee OA, with approximately 500,000 procedures performed each year in the United States. Several studies have examined the long-term effects of TKA on the biomechanics of the operated knee and have found that most patient still demonstrate poor gait patterns that are similar to their gait patterns preoperatively. In the frontal plane, researchers have found that KAM is improved at 6 months after surgery, but slowly regresses back to higher, preoperative levels after 1 year. In the long-term, KAM is not significantly different from preoperative levels. This finding is noteworthy since high KAM may result in prosthetic degradation and failure in the long term. There is a lack of information on the biomechanical postoperative results of surgery in the period earlier than six months. The purpose of the present study was to determine if gait patterns of the knee in the frontal plane are improved in the early postoperative period. This would help determine what, if any, changes can be made to therapy protocols to prevent regression to preoperative gait levels with time. Furthermore, outcomes were examined across different knee prosthetics to determine if differences exist between prosthetic types. Methods: Fifty patients were examined before and two months after TKA. Patients underwent a 3D gait analysis using the Vicon Motion Analysis system (Oxford Metrics Ltd., Oxford, UK). Patients completed a VAS scale for pain and functional tests. Knee prosthetics included either PCL-retaining or PCL sacrificing, and custom fit design or not. Results: Peak knee varus angle during gait showed a significant reduction and improvement of 3.1° postoperatively (p=0.001) (Figure 1). After surgery, first and second peak KAM decreased to 71% and 77% of preoperative values (Figure 2), respectively (both p=0.001), and knee adduction impulse decreased by 30% postoperatively (p<0.001) (Table 1) and VAS pain scores decreased by 21% (p<0.001). Spatiotemporal parameters and functional tests did not yet show significant improvements by two months. No significant differences were found between outcomes in patients undergoing PCL retaining TKA or PCL sacrificing TKA, or between patients undergoing custom fit TKA and those not. Changes were consistent across BMI, age, gender and pain scores. Conclusions: TKA results in high improvement in kinematic and kinetic parameters in the frontal plane early in postoperative recovery. The results also suggest that there is an absence of differences between types of knee prostheses. When compared to the findings of previous studies, the results suggest that early after surgery, TKA patients will show decreased, improved KAM, but these improvements are slowly lost over the first and second year postoperatively. This highlights the importance of early intervention postoperatively aimed at maintaining the low levels of KAM and joint loading. This may help reduce the risk of prosthetic failure and surgical revision in the long-term.Tabled 1Frontal Gait Biomechanical Parameters Before and Two Months After Total Knee ArthroplastyParameterPreoperativeTwo Month Follow-UpSignificanceSpatiotemporalWalking speed (m/s)0.78±0.220.72±0.21P=0.069Step length normalized to leg length0.56±0.120.54±0.12P=0.294Single limb support (%GC)33.6±5.132.8±5.0P=0.368Kinematic and KineticPeak varus angle (deg.)4.5±8.41.4±5.3P=0.001**Varus angle range of motion (deg.)4.2±2.83.0±2.0P=0.007**Peak adduction moment 1 (%BW*Ht)3.1±1.52.2±0.81P<0.001**Peak adduction moment 2 (%BW*Ht)2.6±1.42.0±0.86P=0.001**Adduction impulse120.1±60.084.4±36.2P<0.001**Symptoms and FunctionVAS Pain Scale7.2±2.05.7±2.0P<0.001**Timed-Up-Go Test (min)12.4±3.312.1±2.5P=0.5446 Minute Walk Test (min)330.7±102.9304.9±95.8P=0.102 Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Background: Total knee arthroplasty (TKA) is most commonly used for end-stage knee osteoarthritis (OA). TKA procedures are expected to number over 3 million by 2030 in the United States alone. Although TKA is generally successful at reducing pain and improving quality of life after surgery, several studies on the long-term effects of TKA on the biomechanics of the operated knee have shown poor gait patterns postoperatively. Most of these abnormalities have been found in the sagittal plane. Specifically, there is limited knee flexion-extension range of motion postoperatively as well as poor flexion-extension moments. Studies have related these findings to "stiff knee" muscle activation patterns due to habits developed preoperatively, as well as proprioceptive deficiency, instability and quadriceps weakness leading to a "quadriceps avoidance gait". There is, however, a lack of information on the early postoperative sagittal plane biomechanics after TKA, as well as adequate comparisons to gait patterns preoperatively. The present study was designed to examine the early biomechanical TKA outcomes in the sagittal plane of the knee to determine if they reflect patterns before surgery or change significantly after surgery. Furthermore, outcomes were examined across different knee prosthetics to determine if differences exist between knee designs. Methods: Fifty patients were examined before and two months after TKA. Patients underwent a 3D gait analysis using the Vicon Motion Analysis system (Oxford Metrics Ltd., Oxford, UK) and completed the VAS scale for pain. Knee prosthetics included either PCL-retaining or PCL sacrificing, and custom fit design or not. Results: Results are presented in Table 1. Although pain showed a significant decrease of 21% postoperatively (p<0.001), knee flexion-extension range of motion decreased significantly by 22% (p<0.001). Knee flexion angle and moment did not change significantly postoperatively (p=0.231 and 0.169, respectively) (Figure 1 & 2). Knee extension angle, moment and impulse were significantly worse postoperatively than preoperatively (all p<0.01), and extension impulse showed a significant positive correlation of 0.4 with BMI (p<0.05) (Figure 1 & 2). Spatiotemporal parameters did not show significant changes after surgery. Gait differences were not found between prosthetic types, age or BMI, but female patients had greater knee extension postoperatively than males. Conclusions: Knee biomechanics in the sagittal plane worsen significantly in the early postoperative period after TKA. These changes are consistent across different TKA prosthetic designs. When considering long-term postoperative studies, these results suggest that the knee biomechanics of gait in the sagittal plane will improve with time, but they will not reach the levels of function of healthy individuals. Although postoperative training usually involves muscle strengthening and flexion-extension exercise, there may be a need to apply these exercise in a dynamic, walking form. This may help improve early and even long-term gait patterns postoperatively.Tabled 1Knee Biomechanics in the Sagittal Plane Before and After Total Knee ArthroplastyParameterPreoperativeTwo Month Follow-UpSignificancePain SymptomsVisual Analog Scale for Pain7.2±2.05.7±2.0P<0.001**Kinematic ParametersPeak Flexion Angle in Stance (deg.)10.2±7.312.2±6.4P=0.071Peak Extension Angle in Stance (deg.)4.5±6.77.9±6.3P=0.005**Peak Flexion Angle in Swing (deg.)47.3±10.641.2±9.0P=0.001**Range of motion (deg)42.9±10.333.4±8.7P<0.001**Kinetic ParametersPeak Flexion Moment (%BW*Ht)1.4±1.11.6±1.3P=0.231Flexion Impulse28.7±26.335.4±31.5P=0.169Peak Extension Moment (%BW*Ht)-1.0±1.3-0.32±0.89P<0.001**Extension Impulse-25.6±31.3-11.3±19.8P<0.001** Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Purpose: Some patients after total Hip Arthroplasty (THA) may suffer from a limp and periarticular discomfort due to muscle weakness. Physiotherapy is important in restoring muscle strength. Evidence-based guidelines on rehabilitation after THA are scarce. We examined the immediate and longer term effect of closed kinetic chain exercises (AposTherapy) causing controlled perturbations over gait parameters after THA. Methods: Thirty three patients were prospectively followed during the study. Gait parameters were measured at initial evaluation, after 15 minutes of therapy and after 3 months of treatment. SF-36 and WOMAC scores were filled by patients before treatment and after 3 months of treatment. Results: Gait velocity, single limb support (SLS) and step length of the operated leg significantly improved after a single 15 minute treatment (72.9 cm/s vs. 87.6 cm/s, 33.3% vs. 35.2 % of gait cycle and 45.8 cm vs. 50.2 cm, respectively, p<0.001) and furthermore after 3 months of treatment (72.9 cm/s vs. 108.5 cm/s, 33.3% vs. 38.2 % of gait cycle and 45.8 cm vs. 56.7 cm, respectively, p<0.001). Forty three percent of patients had a normal gait velocity after 3 months of treatment; SF-36 and WOMAC scores significantly improved after 3 months of treatment (p<0.008). Conclusions: Using a closed kinetic chain exercise implemented by a foot-worn platform is useful for patients post THA. Improvement in gait, limb functionality, stiffness and pain may be seen after a single session and may be more noticeable after 3 months of treatment.

Background After unilateral total knee arthroplasty, frontal plane loading patterns on the operated knee remain pathological in the long term, but it is unclear how they change in the early postoperative period. Additionally, researchers have suggested that the non-operated knee bears greater frontal plane loads postoperatively, but this effect is unclear. The objective of the present study was to compare the preoperative and early postoperative frontal plane loading patterns of both knees after unilateral total knee arthroplasty. Methods Fifty patients with end-stage knee osteoarthritis were examined prior to and six weeks after surgery. Patients underwent a three-dimensional gait analysis that determined the frontal plane loading patterns of knee varus angle and knee adduction moment during gait, and completed self-evaluative questionnaires and functional tests. Findings There were no significant loading differences between limbs preoperatively. The operated knee showed large reductions in varus angle and adduction moment after surgery (all p < 0.001). The non-operated knee showed no increases in varus angle or adduction moment, but did show a small reduction in the adduction moment (p < 0.001). Both knees showed reduction in pain after surgery (p < 0.001) and the operated Knee Society Score improved after surgery (p = 0.01). Interpretation Total knee arthroplasty reduces frontal plane loading in the operated knee and does not worsen frontal plane loading in the non-operated knee. Therapy after surgery should focus on retaining the reduction in knee adduction moment in the operated knee and preventing further worsening loading patterns in the non-operated knee.

Eytan M. Debbi, Benjamin Bernfeld, Arielle G. Fisher, Moshe Salai, Aviram Gold, Aharon Menachem, Nadav Shaha, Yadin D. Levy Alon Wolf Biorobotics and Biomechanics Lab, Faculty of Mechanical Engineering, Technion Israel Institute of Technology, Israel; Department of Orthopedic Surgery, Carmel Medical Center, Israel; Division of Orthopedics, Sourasky Medical Center,Israel; email: edebbi@technion.ac.il, web: brml.technion.ac.il

We present a 9-year-old girl who had chronic recurrent multifocal osteomyelitis. The bones involved were: right clavicle, distal fibula (bilateral), left sacroiliac and right wrist. After 10 years of follow-up; she is asymptomatic but presents radiological evidence of lesions in the right clavicle and left sacroiliac joint. The diagnosis was made by exclusion criteria. The biopsy and results of cultures from various bones were negative 4 times. Although chronic recurrent multifocal osteomyelitis is rare, it should be considered in the differential diagnosis of acute or chronic osteomyelitis and neoplasma. Its recognition avoids unnecessary laboratory tests and antibiotic therapy.

Nine closed tibial plateau fractures in nine patients were treated with arthroscopic-assisted reduction and percutaneous fixation or buttress plate. These procedures were performed between 1993 and 1994 and represent an exclusive and nonselected, consecutive series. The mean follow-up period from time of operation was 10.6 months (range, 6 months to 1.5 years). The results were satisfactory. All the reductions remained roentgenographically anatomic with good to excellent clinical function. Concomitant knee pathology included three cases of partial tear of the anterior cruciate ligament that required special postoperative treatment, and two cases of partial tear of the lateral meniscus that were treated arthroscopically. There were no intraoperative complications. There was one case of postoperative peroneal nerve neuropraxia that resolved spontaneously. Our conclusion is that this technique should be considered as a treatment alternative in the treatment of tibial plateau fractures.

Fracture of the humeral shaft as a complication of total shoulder replacement or shoulder hemiarthroplasty is infrequent, but has serious consequences. Traumatic injury is the most common reason for humeral fracture. The prosthesis causes corticolysis as a result of aseptic and septic loosening. Concomitant with increasing use of total and hemiarthroplasty of the shoulder, is an increase in aseptic loosening of the prosthesis. This increases the frequency of humeral fracture after the procedures. We reviewed the results of 3 patients, women aged 54 and 68 years, respectively, and a man of 65, who were treated for humeral fracture as a complication of hemiarthroplasty of the shoulder. We recommend surgical treatment for fracture around the tip of the prosthesis. Humeral fracture below the tip of the prosthesis should be treated individually, depending on the surgeon's experience.