Early Rehabilitation Protocol Research Articles

Fast-track in Abdominal Aortic Surgery: Experience in Over 1,000 Patients

Fast-track recovery programs have led to reduced patient morbidity and mortality after surgery. Minimally invasive surgery and anesthesia, with programs of early postoperative recovery are the main aspects of fast-track recovery programs. The optimization of pain control, early mobilization, and oral feeding allows for a rapid functional rehabilitation, which leads to minor morbidity and early discharge from the hospital to home. We enrolled all nonemergent patients treated for elective abdominal aortic surgery for an aneurysm or obstructive disease from April 2000 to June 2014. The fast-track protocol was applied to all these patients. A transperitoneal aortic approach was used through a left subcostal incision and was complemented with epidural anesthesia-analgesia and a protocol of early rehabilitation. A total of 1,014 patients were treated for elective aortic surgery. For 980 patients (96.6%), clear liquids followed by a semisolid diet were tolerated starting on the afternoon of the day of intervention (day 0). Nine hundred eighty-seven patients (97.3%) began early ambulation on day 0, and for 81.2% of the population, regular colonic function returned within the second postoperative day. Seventeen deaths (1.7%) occurred. Nine hundred ten patients (89.7%) had no complications. The median hospital length of stay was 3 days for the entire series, and 80.4% of patients (n = 815) were discharged to their homes between the second and fifth days after surgery. The fast-track program can be efficiently and safely applied to aortic surgery and that this program improves surgical outcomes, allows for earlier discharge, and reduces costs.

Evaluation of the implementation of the protocol of an early vocational rehabilitation intervention for people with acquired brain injury

Purpose: The purpose of this study was to evaluate (1) the feasibility of an early vocational rehabilitation (EVR) protocol in the standard rehabilitation process, (2) promoting factors and barriers encountered with the EVR protocol, and (3) perceived effectiveness of the protocol in facilitating return to work (RTW) following acquired brain injury (ABI). Method: A pre- and post-process evaluation was performed in a Dutch rehabilitation center. Dependent variables were feasibility (defined by the usability on process level and fulfillment of usability expectations), promoting factors and barriers, and perceived effectiveness of the protocol. Usability (defined by 13 performance and timing goals) was evaluated with existing forms and registrations. Fulfillment of usability expectations, perceived promoting factors and barriers, and perceived effectiveness were investigated with questionnaires. Data of 23 patients were available for process evaluation. Nine rehabilitation professionals, 10 patients with ABI, nine employers, and six occupational physicians completed the questionnaires. Results: Two-thirds of the performance goals and one-fourth of the timing goals were reached. All respondents cited the structured protocol as a promoting factor. Thirty-two of the thirty-four participants perceived the protocol as being suitable facilitating RTW after ABI. Conclusions: The EVR protocol provides a structured strategy to focus on RTW during standard rehabilitation. It is now possible to implement and test the protocol in other rehabilitation settings.Implications for RehabilitationThe early vocational rehabilitation (EVR) facilitates an interdisciplinary and systematic focus on return to work during rehabilitation of people with acquired brain injury.The feasibility of the EVR protocol has been tested.The EVR protocol is ready for implementation and wider testing in other rehabilitation settings.

Early rehabilitation after total knee replacement surgery: a multicenter, noninferiority, randomized clinical trial comparing a home exercise program with usual outpatient care.

To determine, at 6 weeks postsurgery, if a monitored home exercise program (HEP) is not inferior to usual care rehabilitation for patients undergoing primary unilateral total knee replacement (TKR) surgery for osteoarthritis. We conducted a multicenter, randomized clinical trial. Patients ages 45-75 years were allocated at the time of hospital discharge to usual care rehabilitation (n = 196) or the HEP (n = 194). Outcomes assessed 6 weeks after surgery included the Western Ontario and McMaster Universities Osteoarthritis Index pain and physical function subscales, knee range of motion, and the 50-foot walk time. The upper bound of the 95% confidence interval (95% CI) mean difference favoring usual care was used to determine noninferiority. At 6 weeks after surgery there were no significant differences between usual care and HEP, respectively, for pain (7.4 and 7.2; 95% CI mean difference [MD] -0.7, 0.9), physical function (22.5 and 22.4; 95% CI MD -2.5, 2.6), knee flexion (96° and 97°; 95% CI MD -4°, 2°), knee extension (-7° and -6°; 95% CI MD -2°, 1°), or the 50-foot walk time (12.9 and 12.9 seconds; 95% CI MD -0.8, 0.7 seconds). At 6 weeks, 18 patients (9%) allocated to usual care and 11 (6%) to the HEP did not achieve 80° knee flexion. There was no difference between the treatment allocations in the number of hospital readmissions. The HEP was not inferior to usual care as an early rehabilitation protocol after primary TKR.

Early vocational rehabilitation after acquired brain injury: A structured and interdisciplinary approach

BACKGROUND: There are indications that specialist vocational rehabilitation is beneficial when trying to return to work after acquired brain injury (ABI). OBJECTIVE: To give a description of the Early Vocational Rehabilitation (EVR) protocol and its development in order to make it available for implementation in rehabilitation institutes to strengthen the appearance of these institutes as relevant partners and supporters during the process of (sustaining) return to work of people with ABI. METHODS: The Early Vocational Rehabilitation (EVR) protocol is a process guideline to facilitate the interdisciplinary rehabilitation team to systematically focus on return to work during an early stage of (inpatient or outpatient) rehabilitation of people with ABI. The development was expert based. RESULTS: The EVR protocol consists of four stages: 1) orientation of the rehabilitation team towards the patient’s work; 2) investigating the gap between the patient’s abilities and work; 3) work training; and 4) finalizing EVR. Cooperation among all relevant partners from inside or outside the rehabilitation institute is important for maximally adapting the EVR treatment to the individual (work) situation of the person with ABI. CONCLUSION: The EVR protocol is available for implementation in other rehabilitation institutes. Performing a context analysis for each new context in which it is implemented is recommended.

Functional evolution of critically ill patients undergoing an early rehabilitation protocol.

ObjectiveEvaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit.MethodsA retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial).ResultsIn total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays.ConclusionThe maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol.

A Biomechanical Comparison of Femoral Cortical Suspension Devices for Soft Tissue Anterior Cruciate Ligament Reconstruction Under High Loads

Background: Graft healing after soft tissue anterior cruciate ligament (ACL) reconstruction requires rigid fixation to allow for soft tissue healing. Cortical suspension devices for femoral fixation should be biomechanically tested under high loads representative of early rehabilitation to evaluate whether they provide sufficient fixation. Purpose/Hypothesis: To biomechanically compare current fixed-loop and adjustable-loop cortical suspension devices for soft tissue femoral fixation under high loads. The hypotheses were that there would be significant differences in cyclic displacement between devices, independent of loop type, and that retensioning of the adjustable-loop devices would not significantly alter the biomechanical properties of these devices. Study Design: Controlled laboratory study. Methods: Five different femoral ACL graft cortical suspension devices (3 fixed and 2 adjustable) were compared under high cyclic forces (100-400 N for 1000 cycles) and then pulled to failure at 50 mm/min. In addition, the effect of retensioning after simulated preconditioning was evaluated for the 2 adjustable-loop devices. Results: On average, the least amount of cumulative peak cyclic displacement (mean ± SD) was observed for the ENDOBUTTON (1.05 ± 0.05 mm), followed by the RIGIDLOOP (1.09 ± 0.16 mm), XO Button (1.65 ± 0.43 mm), TightRope with retensioning (1.81 ± 0.51 mm), TightRope without retensioning (2.20 ± 0.62 mm), ToggleLoc with retensioning (3.22 ± 1.41 mm), and ToggleLoc without retensioning (3.69 ± 2.39 mm). The ENDOBUTTON displaced significantly less after cyclic loading than all adjustable-loop devices (TightRope and ToggleLoc, both with and without retensioning) and the XO Button. The RIGIDLOOP displaced significantly less than the TightRope without retensioning and ToggleLoc with and without retensioning. There was no significant difference in biomechanical properties after retensioning for both adjustable-loop devices. Conclusion: Significant differences were observed between current fixed-loop and adjustable-loop cortical suspension devices for soft tissue femoral fixation when subjected to high loads experienced during rehabilitation. Retensioning did not significantly alter the biomechanical properties of adjustable-loop devices. Clinical Relevance: Early rehabilitation protocols subject the graft construct to higher forces than what has been previously tested biomechanically. Biomechanical testing of cortical suspension devices under simulated high rehabilitation loads demonstrated significant differences between devices. Future studies should investigate the clinical implications of these time zero results.

Long term results of acute Achilles repair with triple-bundle technique and early rehabilitation protocol

BackgroundThe best treatment for acute rupture of the Achilles tendon is still under debate. Our purpose was to evaluate surgical triple-bundle technique in selected patients with full subcutaneous rupture of Achilles tendon. MethodsSixty-six consecutive patients (56 men, 10 women; age range 20–61 years) with full unilateral rupture of the Achilles tendon were surgically treated by the triple-bundle technique. Seventy-four percent of the lesions occurred during sport activity. Each patient was assessed by: (1) The American Orthopaedic Foot and Ankle Society (AOFAS) score; (2) the Leppilahti score; (3) the range of movement measurement of ankle joint; (4) ipsilateral thigh, calf, and ankle circumferences compared to the contralateral limb; (5) functional evaluation with isokinetic dynamometry of both limbs. Results80.3% of the patients were fully satisfied (AOFAS ≥90) with treatment and resumed their previous level of sport. Concerning the outcomes, (1) the mean AOFAS score at 36 months was 93.9; (2) the mean Leppilahti score at 36 months was 91.8; (3) the mean difference in dorsiflexion and plantarflexion between the healthy side and the operated side was 4.3° and 6.9°, respectively. We observed calf muscle hypotrophy in two cases and scar complication in one. No re-ruptures occurred. Isokinetic tests performed 36 months after surgery showed a good restoration of plantarflexion. At univariate analysis AOFAS was influenced by age and difference between the healthy side and the operated side in dorsiflexion, plantarflexion, and circumference at all three levels and strenght at 60°/s. At univariate analysis, Leppilahti score confirmed the significant parameters of the AOFAS with the exception of age and difference of thigh circumference. The only predictive parameters in multivariate analysis were dorsiflexion difference (O.R.=0.831; 95% C.I. 0.694–0.995; p=0.044) and plantarflexion difference (O.R.=0.777; 95% C.I. 0.631–0.958; p=0.018). ConclusionIn this case series the triple-bundle technique showed a low rate of complications and good functional restore tested with isokinetic tests. For these reasons afforded by biomechanical strength test reported in literature, this technique has to be considered a valid choice for the treatment of Achilles tendon rupture in young patients with a high level of sport activity.

A systematic review of rehabilitation protocols following surgical repair of the extensor pollicis longus

Introduction The goal of this systematic review was to determine which rehabilitation protocol (static, dynamic or early active) yields the best outcomes following repair of the extensor pollicis longus (EPL) tendon in the following domains: total active motion (TAM), grip strength and range of motion. Methods A comprehensive and systematic literature search was run. The retrieved abstracts and titles were screened by two independent reviewers. Rehabilitation protocols were classified as static, dynamic or early active. Methodological quality of included randomized controlled trials and cohort studies were assessed using the SIGN50 scale. Results Fifteen articles were included in the final analysis ( κ = 0.8). From this total, five studies employed static splinting, 12 dynamic splinting and two early active splinting. Static splinting yielded ‘excellent’/‘good’ results ranging from 50% (minimum) to 60% (maximum) on the TAM classification system and a weighted mean TAM of 73.0 ± 24.0° (range 58.75–85°). Dynamic splinting studies demonstrated ‘excellent’/‘good’ results ranging from 64.4% (minimum) to 98% (maximum) and a weighted mean TAM of 111.2 ± 11.7° (range 89–134°) ( P &lt; 0.001 and mean difference of 38.2 (95% confidence interval: 32.2–44.2). In one study, early active motion resulted in 83% of patients having ‘excellent’/‘good’ ratings. Discussion The available level II–IV evidence suggests better outcomes when using dynamic splinting over static splinting for rehabilitation of the EPL tendon repair. Further evidence is required to clinically confirm the differences between early active and dynamic rehabilitation protocols.

Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage Revision for Prosthetic Knee Infection? A Randomized Prospective Study

Although 7% to 38% of revision total knee arthroplasties (RTKAs) are attributable to prosthetic knee infections, controversy exists regarding the best surgical approach while reducing the risk of extensor mechanism complications and the reinfection rate. We compared The Knee Society Score(©) (KSS), incidences of complications, maximum knee flexion, residual extension lag, and reinfection rate in patients with prosthetic knee infections treated with two-stage RTKAs using either the tibial tubercle osteotomy (TTO) or the quadriceps snip (QS) for exposure at the time of reimplantation. We prospectively followed 81 patients with chronic prosthetic knee infections treated between 1997 and 2004. Patients were randomized to receive a TTO or QS for exposure at the time of reimplantation. All patients had the same rehabilitation protocol. The minimum followup was 8years (mean, 12years; range, 8-15years). Patients in the TTO group had a higher mean KSS than the QS group (88 versus 70, respectively). Mean maximum knee flexion was greater in the TTO group (113° versus 94°); with a lower incidence of extension lag (45% versus 13%). We observed no differences in reinfection rate between groups. We found the TTO combined with an early rehabilitation protocol associated with superior KSS did not impair extensor mechanism function or increase the reinfection rate. We believe a two-stage RTKA with TTO is a reasonable approach for treating prosthetic knee infections. Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Stiffness after Arthroscopic Shoulder Surgery: Incidence, Management and Classification

Background Stiffness after arthroscopic shoulder surgery is of significant concern to the patient, surgeon and therapist. The present study aimed to investigate the natural history of stiffness after shoulder arthroscopic procedures. Methods Postoperative recovery of range of motion (ROM) in patients who underwent 234 consecutive arthroscopic procedures over a 1-year period was reviewed. The time needed to regain full ROM was recorded for every patient. Stiffness was graded from 0 to 3 depending on the loss of movements as compared to the opposite side. Results Postoperative ROM returned to normal in 63% of patients within 3 months, 94% of patients within 6 months, 96% of patients within 9 months and 97% of patients within 1 year after surgery. Stiffness was graded as a loss of ROM compared to the contralateral shoulder, with less than a third loss as grade 1, one third to two-thirds loss as grade 2 and more than two thirds loss as grade 3. Some 85% patients with Grade 1 stiffness recovered complete ROM at 6 months, whereas only 43% of grade 2/3 stiffness returned to normal at 6 months. Only four patients required further active intervention for recovery from stiffness. Risk of developing stiffness was related to the pre-operative diagnosis. Conclusions Although, minor (grade 1) stiffness after shoulder surgery occurs commonly despite early mobilization rehabilitation protocols; it resolves rapidly without further surgical intervention in a majority of the patients.

Early rehabilitation for unilateral peripheral vestibular disorders: a prospective, randomized investigation using computerized posturography

Patients with unilateral vestibular lesions have a set of deficits requiring compensation based on the inherent plasticity of the central nervous system. In the 1940s, it was reported that patients with unilateral vestibular dysfunctions who exercised recovered faster than those who did not. The present prospective, randomized investigation aimed to assess the role of a computerized posturography-assisted early vestibular rehabilitation protocol combined with a home-based exercise program in the treatment of patients with unilateral peripheral vestibular disorders occurring 2 weeks previously. Fifteen patients were randomly assigned to a 5-week posturography-assisted vestibular rehabilitation protocol and a home-based exercise program (Group A), while 15 simply awaited spontaneous compensation (Group B). All patients underwent computerized posturography approximately 2 weeks after their vestibular disorder was diagnosed and again after 6 weeks. Ten healthy volunteers were also studied (Group C). After rehabilitation, Group A patients improved significantly in most sensory measures [modified clinical test of sensory organization and balance (mCTSIB)] and motor parameters [limits of stability (LOS)] by comparison with preliminary outcomes, and there were no significant differences in sensory (mCTSIB) and motor (LOS) findings between Group A and the healthy volunteers. At the same time point, several motor (LOS) parameters were still altered in Group B by comparison with the healthy volunteers. These preliminary outcomes support the hypothesis that the compensation achievable after 6 weeks with a customized program of posturography-assisted vestibular rehabilitation and home-based exercises is superior to the results of physiological spontaneous compensation.

Current concepts in the rehabilitation of an acute rupture of the tendo Achillis

Rupture of the tendo Achillis is a common injury with a rising incidence. Traditionally the key question following this injury has been whether or not to operate. However a contemporary Cochrane review highlighted that the method of rehabilitation may also have an important contribution to the outcome. Since this review, various early weight-bearing rehabilitation protocols have been described. Currently evidence points to the use of early functional rehabilitation, regardless of operative or non-operative management. However, there is no consensus on which exact functional rehabilitation protocol should be used. Future research should be directed towards improving our understanding of how the different rehabilitative components interact in the tendo Achillis as it heals.

Effect of Two Rehabilitation Protocols on Range of Motion and Healing Rates After Arthroscopic Rotator Cuff Repair: Aggressive Versus Limited Early Passive Exercises

To compare range of motion and healing rates between 2 different rehabilitation protocols after arthroscopic single-row repair for full-thickness rotator cuff tear. Sixty-four shoulders available for postoperative magnetic resonance imaging (MRI) evaluation after arthroscopic rotator cuff repair were enrolled in this study. Aggressive early passive rehabilitation (manual therapy [2 times per day] and unlimited self-passive stretching exercise) was performed in 30 shoulders (group A) and limited early passive rehabilitation (limited continuous passive motion exercise and limited self-passive exercise) in 34 shoulders (group B). A postoperative MRI scan was performed at a mean of 7.6 months (range, 6 to 12 months) after surgery. Regarding range of motion, group A improved more rapidly in forward flexion, external rotation at the side, internal and external rotation at 90° of abduction, and abduction than group B until 3 months postoperatively with significant differences. However, there were no statistically significant differences between the 2 groups at 1-year follow-up (P = .827 for forward flexion, P = .132 for external rotation at the side, P = .661 for external rotation at 90° of abduction, and P = .252 for abduction), except in internal rotation at 90° of abduction (P = .021). In assessing the repair integrity with postoperative MRI scans, 7 of 30 cases (23.3%) in group A and 3 of 34 cases (8.8%) in group B had retears, but the difference was not statistically significant (P = .106). Pain, range of motion, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of early postoperative rehabilitation protocols. However, aggressive early motion may increase the possibility of anatomic failure at the repaired cuff. A gentle rehabilitation protocol with limits in range of motion and exercise times after arthroscopic rotator cuff repair would be better for tendon healing without taking any substantial risks. Level II, randomized controlled trial.

Zone II Flexor Tendon Repair: A Randomized Prospective Trial of Active Place and Hold Therapy Compared with Passive Motion Therapy

The results of this randomized, prospective study indicate that early postoperative active exercise results in significantly better active range of motion (AROM) and patient satisfaction than an early passive rehabilitation protocol in patients with zone II flexor tendon repairs. The study also found that an active program does not increase the risk of tendon rupture.

Biomechanical analysis suggests early rehabilitation is possible after single-incision EndoButton distal biceps repair with FiberWire

Previous studies that have encouraged early postoperative motion after distal biceps repair shows little agreement on exactly when activity should be resumed after surgery or on the level of weight restriction that should be used. The aim of the current study was to define a service load that would permit, without failure, 2,000 cycles of immediate motion after single-incision EndoButton distal biceps repair with FiberWire. In each of 15 cadaveric elbows, the distal biceps tendon was divided at its insertion and then repaired using a single-incision EndoButton technique with FiberWire. The repairs were then challenged according to the "staircase method" by cyclically loading the biceps tendon, so that the forearm flexed between 0° and 90°. The mean failure load of the repair was 166.7N (95% confidence interval, 132.6-200.8). The data suggested that a 0.9 kg (9-N) weight at the hand was the limit for a 2,000-cycle early rehabilitation protocol after repair of a ruptured distal biceps tendon via a single-incision EndoButton repair technique. Early active motion with a 0.9-kg weight restriction may therefore be possible in those patients undergoing distal biceps tendon repair using this technique.

Axial and torsional stability of supracondylar femur osteotomies: biomechanical comparison of the stability of five different plate and osteotomy configurations

Little is known regarding the biomechanical stability and stiffness of implants and techniques used in supracondylar femur osteotomies (SCO). Therefore, fixation stability and stiffness of implants to bone was investigated under simulated physiological loading conditions using a composite femur model and a 3D motion-analysis system. Five osteotomy configurations were investigated: (1) oblique medial closing-wedge fixated with an angle-stable implant; (2) oblique and (3) perpendicular medial closing-wedge, both fixated with an angled blade plate; and lateral opening-wedge fixated with (4) a spacer plate and (5) an angle-stable lateral implant. The motion measured at the osteotomy was used to calculate the stiffness and stability of the constructs. The least amount of motion and highest stiffness was measured in the medial oblique closing-wedge osteotomy fixated with the angled blade plate. The lateral opening-wedge techniques were less stable and had a lower stiffness compared with the medial; the oblique saw cuts were more stable and had a higher stiffness than the perpendicular. This experimental study presents baseline data on the differences in the primary stability of bone-implant constructs used in SCO. The data in this study can be used as reference for future testing of SCO techniques. Furthermore, it is recommended that based on the differences found, the early postoperative rehabilitation protocol is tailored to the stability and stiffness of the fixation method used.

Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?

To determine the feasibility and interest of an early rehabilitation protocol with no initial immobilisation after proximal row carpectomy. Thirteen patients were included in this retrospective study. Range of motion (ROM) and wrist strength (grip strength and grasp strength) were evaluated 3 and 6 weeks after surgery on the both wrists (operated and non-operated). Postoperatively, patients had no immobilisation of the wrist, and began a rehabilitation program immediately after surgery in the department of Physical Therapy and Rehabilitation under multidisciplinary team supervision. The same surgical technique was used for all patients by the same surgeon. Six weeks after PRC, there was a 25-51% deficit in passive ROM and 54-64% deficit in active ROM compared to the corresponding non-operated wrist. Six weeks after PRC, mean overall grip strength was nearly 55% and Jamar dynamometer grip strength was 51% of the contralateral side. This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. Early rehabilitation could reduce the delay necessary to recover range of motion and strength, and probably the time to return to work. Level 4, prospective cohort study.

Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study

Currently, many rehabilitation protocols for total hip replacements (THRs) include activity restrictions to prevent postoperative dislocation. There is increasing demand for more efficient and safe rehabilitation protocols. This randomized prospective study evaluates the need for hip restrictions following a modified anterolateral procedure. From 2004 to 2008, 81 patients seeking elective THRs were randomly assigned into a standard rehabilitation group or an early rehabilitation group. The standard group included restrictions to avoid hip flexion >90 degrees and avoidance of riding in a car for the first postoperative month. The early group had no flexion or car riding restrictions. Forty-three patients were in the standard group and 38 patients were in the early group. There were no significant demographic differences between the 2 groups. All patients completed the Short Form 12-question Health Survey and Harris Hip Score preoperatively and at 4 weeks, 1 month, 3 months, and 1 year postoperatively. The time-points at which the patient first drove and ambulated with a cane, without a cane, and without a limp were also collected. No incidents of dislocation occurred. Patients in the early group were faster to ambulate with only a cane (P=.03), without a cane (P<.001), and without a limp (P=.003). They also drove earlier (P=.02). Pace of recovery was the only significant difference between the 2 groups. The early rehabilitation protocol increases the pace of recovery compared to a pathway with hip precautions without increasing complications.

Biomechanical Comparison of the Banana Peel to a Tibial Tubercle Osteotomy for Knee Exposure

The ‘banana peel’ is a novel extensile exposure for complex primary and revision knee replacement. The tensile strength of the patellar tendon after the peel procedure is unknown. We chose to compare the banana peel exposure to a tibial tubercle osteotomy, because the osteotomy has been shown to withstand early rehabilitation protocols. Our null hypothesis was that the strength post banana peel was no different than that of the tibial tubercle osteotomy when tested for load to failure in a cadaveric knee.

Graft healing in anterior cruciate ligament reconstruction

Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. However, remarkable advances in knowledge of this process have been made based primarly on animal models. According to the findings of this review, some surgical and postoperative variables are known to directly affect time-course and quality of graft-tunnel healing. The type of graft, graft motion, and fixation methods have shown to directly affect time-course and quality of graft-tunnel healing. Therefore, the application of early and aggressive rehabilitation protocols should be cautious when using soft-tissue graft, allografts, and direct or aperture type of fixation for ACL reconstruction. With regard to graft placement, several cadaveric models showed biomechanical advantages of a more anatomical graft location; however, there are no studies that explore the relationship between graft placement and healing process. The precise effect of graft tensioning, graft/tunnel diameter disparity, and graft length within the bone tunnel in the graft healing process remains unclear and requires more research. To enhance graft-tunnel healing, tissue-engineering approaches, including the use of growth factors, mesenchymal stem cells, and periosteum graft augmentation, have been tested on animal models. These have shown promising results in terms of enhancement of bone-graft healing rate.