Accelerated Rehabilitation Protocol Research Articles

Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis

Background: Early surgery for acute ligamentous injuries has recently shown good clinical and functional outcomes. Purpose: To assess the advantages of early vs delayed surgery in patients undergoing isolated anterior cruciate ligament (ACL) or multiligament-injured knee (MLIK) surgery. Study Design: Meta-analyses of Level 1, 2, and 3 studies; Level of evidence, 4. Methods: A systematic search was performed via PubMed, EMBASE, and Cochrane for studies reporting outcomes of timing of surgery after isolated ACL injury or in the MLIK setting using accelerated rehabilitation protocols. Two analyses were conducted to differentiate early and delayed treatment (3- and 6-week cutoffs). Collected outcomes included meniscal or chondral lesions, failure and reoperation rates, range of motion (ROM) deficits, other complications, muscle strength, instrumented laxity, and functional outcomes. Outcomes were reported in risk ratios (RR) or mean differences with 95% CIs. Results: For timing of isolated ACL surgery, 16 studies were included with 2093 patients. High-grade evidence indicated that there were no differences in meniscal or chondral lesions, failure and reoperation rates, stiffness, ROM deficits, complications, muscle strength, instrumented laxity, and functional outcomes between patients treated early and late (all P > .05). When including only studies that set no preoperative criteria for early surgery, the findings were similar. Regarding MLIK surgery, 14 studies were included with 1172 patients. Low evidence was noted for the following: patients treated early had significantly fewer meniscal injuries (RR, 0.7; P = .04) and chondral injuries (RR, 0.5; P < .001), while no differences were found in reoperation rates, complications, stiffness, ROM deficits, muscle strength, instrumented laxity, and functional outcomes between the groups. Other than higher Lysholm scores in the early group for the 3-week analysis (mean difference, 6.8; P = .01), there were no differences between cutoff analyses. Conclusion: This systematic review with meta-analysis found no differences in clinical and functional outcomes between early and delayed surgery for isolated ACL injuries. For MLIK injuries, there were also no differences in surgical outcomes between early and delayed surgery.

Влияние пандемии Сovid-19 на госпитализацию пациентов после артропластики коленного и тазобедренного суставов

Abstract. Introduction The Covid-19 pandemic has led to quite significant changes in the length of hospital stay of orthopedic patients. Meanwhile, there has been a tendency for early discharge after arthroplasty for quite some time due to the increasing burden on health care systems that became possible due to the implementation of accelerated rehabilitation protocols. This study is dedicated to the effect of discharge terms on the incidence of postoperative complications. Material and methods A retrospective study of 1,837 patients who underwent primary/revision THA and TKA at our center in 2020 was carried out. The impact of the pandemic was assessed by comparing the duration of hospitalization, the incidence of complications and functional status in patients operated on before and after the introduction of epidemiological restrictions. Purpose of the study To assess the impact of the Covid-19 pandemic on the length of patients’ hospital stay after knee and hip arthroplasty. Results The total duration of hospitalization after primary THA was reduced by 35 % (from 11.8 ± 3.3 to 7.7 ± 2.6 bed-days), and by 38 % (from 19.9 ± 7.5 to 12.8 ± 6.3 bed-days) after revision THA. The overall readmission rate (for surgical and nonsurgical complications) after primary THA was 4.1 % before the pandemic and 4.3 % during the pandemic; for primary TKA it was 2.1 % and 5.1 %, respectively; for revision THA – 13.9 % and 4.5 %, revision TKA – 4.4 % and 9.8 %, respectively. Comparative assessment for each diagnosis separately did not show significant difference. Evaluation of the questionnaire survey using the Oxford hip/knee score also showed the absence of a statistically significant relationship between the time of discharge and the functional state of the operated joint. The interviewing of patients regarding the infection with coronavirus yielded positive answers in 22 % (n = 419). The onset of symptoms during hospitalization or within 14 days after discharge was noted by 4 % of respondents (n = 75). Conclusion The incidence of complications and unfavorable outcomes did not depend on the length of hospital stay after THA and TKA.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

BackgroundThe purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.MethodsAccording to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.ResultsThe search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.ConclusionsNo statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

Avulsion Injuries and Ruptures of the Proximal Rectus Femoris in Skeletally Mature, High-Level Athletes: A Critical Analysis Review.

Injuries to the proximal rectus femoris remain rare, occurring primarily in soccer and American football athletes during kicking and sprinting because of its unique biarthrodial nature. The appropriate diagnosis is dependent on careful physical examination and imaging interpretation. While no universal treatment algorithm has been adopted for high-level athletes, recent investigations support operative repair using suture anchors to restore strength and function in order to allow an effective return to competition while minimizing the risk of injury recurrence. Complications following surgical management include injury to the lateral femoral cutaneous nerve and hematoma formation, and there are reports of residual pain and weakness with chronic injuries that fail the initial nonoperative treatment. Current investigations examining outcomes following treatment remain limited, warranting additional studies that examine patient-reported results, return-to-play rates, and the role of orthobiologics and accelerated rehabilitation protocols following injury to further improve athlete health and safety.

Motor Control Changes after Innovative Aquatic Proprioceptive Training in Athletes with Anterior Cruciate Ligament Reconstruction: Voluntary Response Index Analysis

Objectives: The main aim of this study was to determine and compare the effects of innovative aquatic proprioceptive training plus conventional rehabilitation with conventional rehabilitation alone on voluntary response index (VRI) components in athletes with anterior cruciate ligament reconstruction (ACLR). Methods: Forty male athletes with ACLR (18 - 35 years of age) voluntarily participated in this study. They were randomly allocated into two groups. The conventional therapy group (n = 20) underwent conventional rehabilitation for ten weeks, three sessions a week. The aquatic proprioceptive training plus conventional rehabilitation (n = 20) group received the same conventional rehabilitation plus 30 sessions of innovative hydrotherapy exercises. Voluntary response index analysis was carried out to determine changes in motor control and muscle activation patterns based on electromyographic (EMG) outcome measures. Results: There was a significant difference in the magnitude (MAG) and similarity index (SI) between the two groups at all phases of the functional task (sit-stand-sit) (P &lt; 0.05). Also, both groups showed a significant change in MAG and SI at all phases of the functional task (sit-stand-sit) after the intervention (P &lt; 0.05). Effect size in both groups for MAG and SI at all phases of the functional task (sit-stand-sit) ranged from 2.5 to 4.61 and from 0.29 to 1.7, respectively. Conclusions: The incorporation of innovative aquatic proprioceptive training into conventional accelerated rehabilitation protocol leads to changes in motor control due to changes in the muscle activation pattern after the intervention.

Conventional vs Accelerated Rehabilitation Protocol Following Reattachment of Achilles Tendon for Insertional Achilles Tendinopathy.

No studies have compared early vs conventional postoperative weightbearing following suture bridge Achilles tendon reattachment. We, therefore, evaluated postoperative functional outcomes in these patients. We collected data on 49 patients who underwent surgical treatment of insertional Achilles tendinopathy using a central Achilles tendon-splitting approach and reattachment with suture bridge technique by a single surgeon. Functional outcomes were measured by a visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36) at 3, 6, and 12 months postoperatively. The differences in outcomes were analyzed using multiple linear regression. Eighteen and 31 patients underwent the conventional and accelerated protocols, respectively; their corresponding mean ages were similar, 53 and 57 years, as were all other baseline characteristics. The mean scores (conventional vs accelerated group) for VAS for pain, FAAM, and SF-36 in the conventional group at 3 months postoperatively were 4 ± 1 vs 3 ± 1 points, 53 ± 8 vs 68 ± 3 points, and 57 ± 15 vs 67 ± 10 points (P < .05 for each comparison). There were no statistically significant differences between the groups at 6 and 12 months postoperatively. All patients could perform the single heel raise test at 6 months, and none experienced complications. In this small study, short-term functional outcomes were better in the accelerated group. More data are needed before the accelerated program can be recommended. Level II, prospective comparative study.

Effects of Innovative Land-based Proprioceptive Training on Knee Joint Position Sense and Function in Athletes with Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background: Proprioceptive deficits are one of the most important challenges after anterior cruciate ligament reconstruction (ACLR). Objectives: The current study aimed to investigate the effects of incorporating innovative land-based proprioceptive training into the conventional accelerated land-based rehabilitation protocol, as compared to the conventional accelerated land-based rehabilitation protocol alone, on knee function and joint position sense in male athletes after ACLR. Methods: Thirty male athletes with ACLR were randomly assigned to two rehabilitation groups. The conventional therapy (CT) group (n = 15) received conventional rehabilitation for six weeks, and the proprioception training (PT) group (n = 15) received the same conventional rehabilitation in addition to 12 sessions of innovative land-based proprioceptive training. Outcomes included joint position sense (JPS) errors, International Knee Documentation Committee (IKDC) form, and Visual Analog Scale (VAS). Results: There were significant differences in absolute errors (AE) (FAE = 56.81, P &lt; 0.001) and variable errors (VE) (FVE = 60.95, P &lt; 0.001) between the two groups. No significant differences were found in constant error (CE), VAS, and IKDC score between the two groups (P &gt; 0.05). Both groups showed significant changes in terms of AE, VE, VAS, and IKDC after the intervention (P &lt; 0.05). Percent changes after the intervention for AE, VE, CE, VAS, and IKDC were greater in the PT group than in the CT group, which were 70.19%, 69.22%, 66.20%, 38.50%, and 39.61%, respectively. Conclusions: Innovative land-based proprioceptive training incorporated into the conventional accelerated rehabilitation protocol offers the improvement of proprioception efficiency for individuals with ACL reconstruction, and therefore, it could be useful for clinicians when designing rehabilitation protocols to ensure the optimal engagement of proprioception.

Traditional Modified Broström vs Suture Tape Ligament Augmentation.

The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB. Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm. Average RTPAL was 17.5 weeks after MB and 13.3 weeks after ST (P < .001). At 26 weeks, 12.5% of patients in the MB group and 3.6% of patients in the ST group had not managed RTPAL (P = .14). The complication rate was 8.5% in the MB group vs 1.7% in the ST group (P = .12). Four patients in the MB group failed to complete the ARP vs 1 in the ST group (P = .144). Results from this multicenter, prospective, randomized trial suggest that ST augmentation allows for earlier RTPAL than MB alone. ST augmentation may support successful accelerated rehabilitation and did not result in increased complications or morbidity. Level II, prospective comparative study.

National Trends in Post-Acute Care Costs Following Total Knee Arthroplasty From 2007 to 2016

BackgroundPost-acute care continues to represent a target for cost savings with increasing popularity of value-based payment models in total knee arthroplasty (TKA). Rapid recovery and accelerated rehabilitation protocols have been successful in reducing costs at the institutional level, but national trends are less clear. This study aimed to determine if advancements in perioperative care led to a reduction in post-acute care costs and resource utilization following TKA. MethodsWe reviewed a consecutive series of 79,843 primary TKA patients from the Humana claims dataset from 2007 to 2016. Post-acute care costs included any claims within 90 days of surgery for subacute or inpatient rehabilitation, home health, outpatient or emergency visits, prescription medications, physical therapy, and readmissions. Demographics, episode-of-care and post-acute care costs, readmissions, and discharge disposition were compared. Controlling for demographics and comorbidities, multivariate regression analyses were performed to compare trends in discharge disposition and post-acute care costs. ResultsFrom 2007 to 2016, the average episode-of-care costs ($46,754 vs $31,856) and post-acute care costs per patient decreased ($20,224 vs $13,498). Rates of discharge to skilled nursing facilities (25.0% vs 22.5%) and inpatient rehabilitation also declined (12.4% vs 2.1%). Readmissions also decreased (8.1% vs 7.1%) saving an average of $324 per patient. When compared to 2007-2012, total costs declined most rapidly after 2013 primarily due to a $3516 (21%) decrease in post-acute spending. ConclusionThere has been a substantial decline in post-acute care costs and resource utilization following TKA, with the largest decrease occurring following the introduction of Medicare bundled payment models in 2013.

Modified Broström-Gould With Gracilis Autograft Augmentation Surgery and Accelerated Noncasted Rehabilitation in High Demand Patients With Lateral Ankle Instability

Lateral ankle instability that has failed conservative management can be physically debilitating. Good outcomes are obtained from Broström-Gould augmented repair techniques, however there are few studies evaluating the use of a gracilis autograft augmentation coupled with an accelerated rehabilitation program in high functional demand patients. We believe that the modified Broström-Gould technique utilizing a Gracilis autograft will provide significant improvements in stability while maintaining normal ankle biomechanics in young, high demand patients. The prospective cohort study involved 19 patients (20 ankles) who underwent surgery for chronic lateral ankle instability by a single surgeon, at a single institution between October 2014 and April 2016. Patients were followed for 33.8 ± 11.7 (range 12-48) months. Patients were assessed both pre- and postoperatively for talar tilt angle radiographically and with both American Orthopaedic Foot and Ankle Society Ankle and Hindfoot scores and Karlsson-Peterson scores. A Tegner activity score was taken at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score increased from 68.85 ± 10.57 to 91.56 ± 5.31 points (p < .01) and mean Karlsson-Peterson score increased from 50.9 ± 15.53 to 88.11 ± 8.64 points (p value <.01) when compared preoperatively to mean postoperative follow-up of 33.8 months. Tegner activity score was 7.05 ± 0.89 at last follow-up. The technique was found to be effective in treating chronic lateral ankle instability and in combination with an accelerated rehabilitation protocol, patients returned to their premorbid level of activity with improved stability and no significant effect on donor graft site morbidity.

Features of using accelerated rehabilitation protocols in obstetrics: literature review

Accelerated postoperative rehabilitation and reduction of hospitalization periods and faster recovery are modern principles of surgical treatment that are widely implemented in practical healthcare. This approach is especially relevant in obstetrics and gynecology, where the share of abdominal delivery reaches up to 80% in some countries of the world. The advantages of accelerated rehabilitation protocols to reduce the number of days of hospital stay, reduce postoperative pain, and need for analgesia, rapid recovery of bowel function, fewer complications, increased patient satisfaction. This approach has direct economic benefits for health care institutions and is carried out in the interests of the child. The article is a review of the available literature on accelerated rehabilitation and recovery of patients in the world practice, as well as the experience of implementation in some healthcare institutions of the Russian Federation.

Accelerated rehabilitation following reverse total shoulder arthroplasty.

Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks. Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically. Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n=114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n=125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n=118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization). Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Mesenchymal Stem Cells in BTB allograft ACL reconstruction:A Prospective Randomized Controlled Trial

Biologic adjuncts have shown promise in improving clinical outcomes following ACL reconstruction (ACLR). Post-operative ligament construct healing is a slow process that involves graft incorporation into bone tunnel sites and intra-articular graft ligamentization, during which failure load and stiffness of grafts decreases. Radiologic imaging has been shown to correspond with histological changes related to the ligamentization process (Hakozaki et al.). The purpose of this study is to evaluate the effects of bone marrow-aspirate concentrate (BMAC), containing mesenchymal stem cells (MSCs), on graft healing, maturation, and integration in patients, as well as patient reported outcome measures (PROMs), undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) allografts. : IRB approval was obtained for a single-blinded randomized controlled trial on patients undergoing ACLR utilizing BTB allografts. Patients were randomized to receive either MSC injection into the ACL allograft or a sham incision with no BMAC harvest or graft injection. Bone marrow aspirate was harvested from the anterior superior iliac crest and concentrated via centrifuge. A minimum of 1.25mL of BMAC was injected into the tendinous/ligamentous portion of the BTB allograft at proximal, middle, and distal sites, with 0.5 mL reserved for post-operative ELISA assay and receptor testing for validation of MSCs within the BMAC harvest. Post-operatively, patients underwent identical standard, accelerated rehabilitation protocols. Outcomes were collected at 6 weeks, 3 months, 6 months, 9 months, 12 months, and 24 months. Knee range of motion, pivot-shift test, anterior-posterior translation, and patient reported outcomes using the KOOS Jr, IKDC, Lysholm surveys, and PROMIS scores including physical function, pain interference, and depression were assessed at the above time points. MRI was performed at 3 months and 9 months. The T2-weighted MRI Signal Intensity Ratio (SIR) of the reconstructed ACL was calculated and standardized to the intensity of the PCL by a musculoskeletal radiologist. A total of 60 patients have been enrolled (54% female, 57% BMAC). The mean age for BMAC and control groups was 34.9 and 35.8, respectively (p=0.7). Mean graft soaking time was 15.9 minutes. Mean time from injury to surgery was 3.7±3.7 months for control and 6.8±14.6 months for BMAC patients (p=0.305). Signal intensity ratios at 3 months revealed significant improvement in the BMAC cohort as compared to control (3.47 and 1.78, respectively, p<0.05). Analysis of secondary clinical outcomes demonstrated that the BMAC cohort significantly outperformed control in degrees of flexion (133º vs. 128º, p=0.02), International Knee Documentation Committee (IKDC) score (64.2 vs. 61.7, p=0.04), and VR12 Mental Health (57.0 vs. 54.7, p=0.002) at 9 months postoperatively. MSC injection into BTB ACL allograft reconstructions demonstrated significantly superior signal intensity ratio on radioimaging during the early ligamentization process. We also observed improved PROMs during the early post-operative period in patients receiving BMAC. This study provides a basis and rationale for continued investigation and application of biologic augmentation of ACLR allograft constructs. Future studies may further elucidate the impact of BMAC on the ligamentization process, clinical outcomes, and PROMs.

Enhanced recovery in thoracic surgery

To present an experience of adapting the accelerated rehabilitation protocol at the thoracic surgery department of the Moscow City Clinical Oncology Hospital No. 1. An effectiveness of the accelerated rehabilitation program in the city oncology hospital was retrospectively analyzed for the period from February to December 2019. Lung resections were performed in 252 patients with median age 66 (59; 71) years and an equal ratio of men and women (124/128). Primary non-small cell lung cancer was noted in 194 (77%) patients, secondary malignant neoplasms of lungs - in 58 (23%) cases. ASA grading system of anesthetic risk was applied (American Society of Anesthesiologists): grade II - 56 (22.2%) patients, grade III - 203 (75.2%) patients, grade IV - 7 (2.8%) patients. Lobectomy was performed in 147 patients, segmentectomy - in 32, bilobectomy, pneumonectomy and marginal resection - in 1, 3 and 69 cases, respectively. Endoscopic operations made up 13.6% (n=20), 12.5% (n=4) and 78% (n=54). Postoperative 30-day complications occurred in 19 (7.5%) out of 252 patients (95% CI 4.9-11.5). Postoperative 30-day mortality was 1.98% (5 out of 252 patients, 95% CI 0.9-4.6). Median postoperative hospital-stay was 7 (6; 8) days. Implementation of fast track protocol requires time and the first results can be assessed after 6-12 months. Continuous monitoring of implementation of the protocol elements by all members of multidisciplinary team, analysis of complications and long-term results are required to realize all potential benefits of this program.

Experience of application of accelerated rehabilitation programs in patients with distal pancreas resection

Introduction. The implementation of ERAS (Enhanced recovery after surgery) protocols has been shown to be effective in orthopedics, bariatric and colorectal surgery. However, the safety and feasibility of implementing accelerated rehabilitation protocols in patients underwent distal pancreatic resection is not well studied. The objective was to analyze the results of the application of accelerated rehabilitation protocols in patients underwent distal pancreatic resection. Methods and materials . A retrospective - prospective, single-center study was conducted. The study included 60 patients. Patients were divided into two groups (control group - 30 patients, perioperative management was carried out according to standard methods and the main group - 30 patients, perioperative management was carried out according to the accelerated rehabilitation protocol). All patients included in the study underwent distal pancreas resection. Results. Patients in the analyzed groups were comparable by gender, age, body mass index, and ASA score. The frequency and severity of postoperative complications in the compared groups was comparable. The frequency of early activation of patients was significantly higher in the main group (86.7 vs 56.7; p&lt;0.001). Postoperative recovery of gastrointestinal tract function was faster in the main group ((2.4±0.9) vs (3.6±1.2); p&lt;0.001). The total duration of the postoperative hospital bed in the compared groups was comparable ((12.9±6.8) vs (14.1±6.1); p=0.2), however, when analyzing a subgroup of patients without complications and with minor complications, the differences in the duration of the postoperative hospital bed in the main and control groups was statistically significant ((8.9±3.6) and (11.7±3.4), respectively, p=0.01). Conclusion. The study showed the safety and effectiveness of implementing accelerated rehabilitation protocols in patients underwent distal pancreatic resection.

Preliminary Results of a Multicenter Prospective Randomized Trial: Traditional Modified Brostrom versus InternalBrace™ Augmentation

Category:Sports; Ankle; ArthroscopyIntroduction/Purpose:The modified Brostrom (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI) despite concerns about the strength of the repair. Recently, the InternalBraceTM (IB) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be established. The purpose of this study is to determine whether or not IB augmentation provides an advantage over the traditional MB. The preliminary results of this study are presented.Methods:Patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI, age over 18, and able to provide informed consent. Exclusion criteria included pregnancy, cognitive disability, concomitant bony correction, inadequate soft tissue for MB, or prior ankle surgery affecting the lateral ligament complex. Preliminary outcome measures included complication rates, ability to participate in an accelerated rehabilitation protocol, and time to return to pre- injury level of activity. Complications were identified during post-operative clinical evaluations. Conversion from accelerated to traditional rehabilitation protocol was determined by patient’s self-reported ability to participate or VAS >= 5 per the physical therapist. Patients were contacted every 2 weeks from 6 to 26 weeks post-operatively to determine return to pre-injury level of activity.Results:119 patients with CLAI who met criteria were enrolled in the study and randomized to the MB (59 patients) or IB (60 patients) treatment arm. At six months 11 patients (18.6%) of the MB arm and 4 patients (6.7%) of the IB arm were lost to follow up. 6/48 patients in the MB group and 2/56 patients in the IB group had not returned to preinjury activity level (p =.115). The complication rate was 8.5% in the MB group versus 1.7% in the IB Group. 4 patients in the MB group failed to complete the accelerated rehabilitation protocol versus 1 in the IB group. Average time to return to pre-injury level of activity was 17.6 weeks after MB and 13.2 weeks after IB (p<0.001).Conclusion:Preliminary results from this multicenter, prospective, randomized trial suggest that IB augmentation allows for faster return to pre-injury level of activity than MB alone. IB augmentation may support successful accelerated rehabilitation. IB augmentation did not add any additional risk of post-operative complication. Further areas of investigation include longer-term follow up and patient reported outcome scores.

Functional Outcomes and MRI Results Following Knotless Repair of Acute Achilles Tendon Ruptures

Category:Ankle; SportsIntroduction/Purpose:The surgical techniques for primary repair of acute Achilles tendon ruptures have evolved from large open incisions to mini-open and percutaneous techniques. Studies have demonstrated that lesser invasive surgical techniques may reduce the risk of post-operative wound complications. Knotless surgical repair of acute Achilles tendon ruptures can be performed through a mini-incision, but still permits a robust re-approximation of the tendon stumps and decreases suture burden through distal anchor fixation in the calcaneus. However, stress shielding and subsequent tendinosis of the distal tendon stump is a theoretical concern with this surgical technique. We hypothesize that our surgical technique allows for a durable repair through a minimally invasive approach, permitting a safe and accelerated rehabilitation protocol, excellent functional outcomes, and absence of distal stump tendinosis.Methods:A multicenter retrospective chart review was performed to identify all patients that underwent primary Achilles tendon repair using a knotless surgical technique with a minimum of one-year follow-up from three orthopedic foot and ankle surgeons’ practices. Exclusion criteria included: age <18, chronic Achilles tendon ruptures (>4 weeks), insertional Achilles tendon ruptures, revision Achilles surgery, peripheral neuropathy, and systemic inflammatory disease. All patients were contacted by phone and asked to return to the office for an MRI, clinical examination, and completion of functional outcome questionnaires. The primary outcome measure was the validated Achilles Tendon Total Rupture Score (ATRS). Secondary outcomes included the Visual Analog Score (VAS), postoperative complications, ankle range of motion, calf circumference, and single-heel rise. MRI was used to assess tendon continuity and healing, tendinosis, muscle atrophy, and bone marrow edema/stress fracture associated with anchor fixation in the calcaneus. MRI interpretation was performed by a single, blinded musculoskeletal radiologist.Results:Forty-three patients were identified with acute Achilles tendon ruptures. There were 36 patients (36/43, 84%) who underwent knotless Achilles tendon repair and agreed to participate in the study. The average time to clinical follow-up was 23.5 months (SD±16.3). The mean postoperative ATRS was 84.6 (SD±19.7). There was no significant difference in calf circumference (p=0.22), dorsiflexion (p=0.07), and plantarflexion (p=0.11) between the unaffected and surgical extremity at latest follow-up. One patient (1/36, 2.8%) experienced a re-rupture. There were no wound complications or neuritis. MRI was obtained in 26 patients (26/36, 72.2%) at an average of 17.5 months (SD±10.1). There were no MRI findings of distal stump tendinosis or calcaneal stress fractures. Thirty-two patients (32/36, 88.8%) returned to the same athletic activities one-year after surgery.Conclusion:There is paucity in the literature on functional outcomes following knotless Achilles tendon repair. In this multicenter study, we found that validated functional outcome scores and return to activity were similar to historical controls, with a low rate of surgical complications. MRI obtained in twenty-six patients (72.2%) at 17.5 months demonstrated an intact tendon without distal tendon stump stress shielding or calcaneal stress fracture. The knotless Achilles tendon repair is a unique surgical technique, minimizing suture burden and postoperative complications, while offering excellent functional outcomes and return to activity at two-year follow-up. The excellent clinical outcomes are corroborated by MRI.

Results of the Use of Accelerated Rehabilitation Protocols after Surgery in Patients with Cystic Pancreatic Formations Undergoing Resection and Resection-Draining Interventions

Introduction. The number of patients with cystic formations of the pancreas has increased significantly recently. Some of the patients need open or minimally invasive surgery. The implementation of ERAS (Enhanced recovery after surgery) protocols has been proved to be effective in orthopedics, bariatric and colorectal surgery. However, safety and feasibility of implementation of accelerated rehabilitation protocols in patients with cystic formations of the pancreas who underwent resection and resection-drainage interventions have not been sufficiently studied.The aim of the study was to assess the effectiveness and safety of implementation of the developed accelerated rehabilitation protocol in patients with cystic pancreatic formations who have undergone resection and resection-draining interventions.Material and methods. This research is a retrospective-prospective, single-center study. The study included 110 patients with cystic formations of the pancreas of various etiologies. All patients were divided into two groups: the control group consisted of 55 patients, their perioperative management was carried out according to standard protocols, and the experimental group consisted of 55 patients, their perioperative management was carried out according to the accelerated rehabilitation protocol developed in the clinic. All patients included in the study were exposed to surgery: resection and resection-draining interventions in various modifications were performed.Results. Patients in the studied groups were comparable by gender, age, body mass index, ASA score, preoperative albumin level. No statistically significant differences were found in the duration of the operation, intraoperative blood loss, or the frequency of blood transfusions. The overall complication rate was significantly lower in the experimental group compared with the control group (38,2% versus 58,2%, p = 0,03). Postoperative recovery of the gastrointestinal function was also faster in the experimental group. Thus, in the experimental group, the average time to the gas discharge was 2,1 0,8 days; in the control group - 3,1 1,1 days (p = 0,01); the average time to the first stool was 3,2 1,9 and 4,2 1,2 days, respectively (p 0,001). The total duration of the postoperative hospital bed per day was significantly lower in the experimental group compared with the control group (11,8 7,7 vs 16,2 13,2 days, respectively, p = 0,02).Conclusions. The study demonstrated safety and effectiveness of implementation of accelerated rehabilitation protocols in patients with cystic pancreatic formations who have undergone resection and resection-draining interventions. Implementation of the protocols allows reducing the duration of the postoperative hospital bed per day, incidence rate of complications, and also accelerating the gastrointestinal function recovery.

When Can I Drive? Predictors of Returning to Driving After Total Joint Arthroplasty.

A common question by patients considering total joint arthroplasty (TJA) is when can I return to driving. The ability to return to driving has enormous effect on the independence of the patient, ability to return to work, and other activities of daily living. With advances in accelerated rehabilitation protocols, newer studies have questioned the classic teaching of waiting 6 weeks after TJA. The goal of this prospective study was to determine specific patient predictors for return to driving and create individualized models able to estimate return to driving based on patient risk factors for both total knee arthroplasty (TKA) and total hip arthroplasty (THA). From July 2017 to January 2018, 554 primary TKA and 490 primary THA patients were prospectively enrolled to obtain information regarding return to driving. Patients were sent a survey every 2 weeks regarding their return to driving. Additional information regarding vehicle type, transmission, and involvement in motor vehicle accidents was collected. Bivariate analysis was done followed by the creation of a multiple linear regression models to analyze return to driving after TKA and THA. The majority (98.2%, 1,025/1,044) of patients returned to driving within 12 weeks of surgery. On average, patients returned to driving at 4.4 and 3.7 weeks for TKA and THA (P < 0.001), respectively. The rate of motor vehicle accidents was 0.7% (7/1,044) within 12 weeks after surgery with no injuries reported. After multivariate analysis, baseline return to driving began at 10.9 days for TKA and 17.1 days for THA. The following predictors added additional time to return to driving for TJA: not feeling safe to drive, limited range of motion, female sex, limitations due to pain, other limitations, discharge to a rehabilitation facility, right-sided procedures, limited ability to break, preoperative anemia, and preoperative use of a cane. Important predictors identified for return to driving were sex, joint laterality, limited ability to walk or ability to break, and feeling safe. Surgeons should consider these factors when counseling patients on their postoperative expectations regarding driving after TJA.

Enhanced recovery programs for patients after pancreatic surgery

The aim of the work is to highlight the main components of the enhanced rehabilitation programs, to compare the results of traditional pancreas operations performed under these programs, and also to present possible prospects for this area. The number of operations performed in patients with various pathologies of the pancreas has increased significantly. Despite a significant reduction in postoperative mortality, the frequency of postoperative complications remains significant, even in specialized centers. The full restoration of the quality of life after surgery takes considerable time. The concept of accelerated rehabilitation after surgery, based on the principles of evidence-based medicine, has been shown to be effective in specific areas of abdominal surgery. However, the role of this concept in surgical pancreatology is not specified. Non-randomized studies and individual randomized studies have shown that the use of accelerated rehabilitation protocols for pancreatic surgery is safe, allowing you to reduce the duration of postoperative hospital stay without increasing the number of complications and mortality.