Experimental restoration of the function of the knee joint using an intercondylar endoprosthesis of a new design

The method and results of intercondylar endoprosthesis of the knee joint in combination with the removal from the joining surfaces of the epicondyle of the articular cartilage with the subchondral plate are described. The method was used in experiment in 25 dogs on 27 joints. Early and persistent recovery of the joint function and the supporting abilities of the extremity was achieved. The proposed method of endoprosthesis of the knee joint is thought to be expedient in the clinical practice.     

Criteria of assessment of restriction of vital activity of patients after total endoprosthesis of the hip joint

Total endoprosthesis of the hip joint is an effective method of rehabilitation of patients with a severe pathology of the hip joint. But the lack of exact criteria of assessment of restriction of vital activity of patients after total endoprosthesis results in leveling the effects of medical rehabilitation due to the existing stereotype solution of the MSE bureau and so the majority of patients (90%) after operation get invalidization of the I and II groups for a long time without sufficient causes. Results of complex clinico-rentgenological, biomechanical, electrophysiological examinations and expert assessment of 450 patients after implantation of various domestic and foreign endoprostheses allowed the elaboration of differentiated criteria for the examination of restricted viral activity depending on the nosological form of the disease, degree of the disturbance of the statico-dynamic function, prognosis, complications, character and conditions of work.     

Rehabilitation of orthopedic patients after hip replacement

A comparative analysis of the treatment of 120 patients after endoprosthesis for degenerative-destructive diseases of the hip joint was carried on. All the patients were divided into two groups: the main group included 74 patients who underwent a full course of rehabilitation, the control group consisted of 46 patients without rehabilitation. The results of a comparative assessment of the static-dynamic function in the two groups of patients after operation of endoprosthesis have shown the inclusion of an obligatory program of rehabilitation to be expedient for the restorative treatment in addition to the operation of endoprosthesis.     

Unicompartmental meniscal knee replacement in treatment of patients with knee osteoarthrosis

One condyle meniscal endoprosthesis is thought to be an adequate method of surgical treatment of patients with isolated symptoms of degenerative diseases of the knee joint when the indications and contraindications are carefully observed. The method includes the substitution of the articulation surfaces of only internal condyles of the femur and tibia for artificial ones leaving intact the external and anterior parts of the joint as well as the crucial and lateral ligaments. It results in elimination of the pain syndrome, rapid restoration of the knee joint function and the supporting ability of the lower extremity.     

Muscle transposition and skin grafting for salvage of below-knee amputation level after bilateral lower extremity thermal injury

Thermal injury to the lower extremity sometimes necessitates amputation around the knee joint. Knee function is so critical to prosthetic rehabilitation that every attempt should be made to salvage the knee joint. This report presents an unusual case of bilateral lower extremity flame burn requiring amputations. While the distal two-thirds of the legs and both feet were totally necrotic, the thermal damage was limited to skin and subcutaneous tissue sparing muscle and bone in the proximal one-third of the legs and posterior thighs. The below-knee amputation level was salvaged by muscle transposition over the anterior tibia and resurfacing of muscle cuffs with thick split-thickness skin grafts. The post-operative period was uneventful. Amputation stumps tolerated the below-knee prosthesis well and the patient attained independent functional prosthetic ambulation at the post-operative fourth month. It is known from the reconstruction of the plantar foot that skin-grafted muscle tissue tolerates weight bearing and shearing forces well. This principle can also be used for salvage aspects of the below-knee amputation level.     

Treatment of osteosarcomata of the distal femur by rotation-plasty

Rotation-plasty was carried out on fifteen patients--10 male and 5 female patients aged between 6 and 32--with an osteosarcoma of the distal femur following resection of the tumor. In the operation the lower leg was rotated through 180 degrees after resection of the distal femur and knee joint so that the ankle joint was effectively turned into a "knee joint". The indication for this operation was initially limited to children for whom the only possible therapeutic alternative was a high above-knee amputation. The surprisingly good functional rehabilitation justifies the indication of this method as an alternative to an endoprosthesis or arthrodesis even for young adults. In spite of the cosmetically very unusual position of the foot, none of the patients has so far experienced psychological problems thanks to suitable guidance. Both from an oncological and psychological point of view, this method represents an extremely responsible operation and should therefore only be carried out by hospital departments specializing in the therapy of bone tumors.     

Rowing with an endoprosthesis of the hip (author's transl)

After inserting an endoprosthesis of the hip sports activities are mandatory to restore and maintain joint function. Rowing is compared with other disciplines as a most suitable sport. It entails all the advantages which are beneficial to patients with a hip endoprosthesis and should be generally adopted as an appropriate rehabilitation measure.     

Functional outcome after prosthetic rehabilitation of children with acquired and congenital lower limb loss

The purpose of this study was to compare the functional status of children with acquired and congenital lower limb loss after 3 weeks and 6 months of prosthetic rehabilitation. Forty-one children aged between 8 and 17 years participated in the study. The children underwent prosthetic fitting, prosthetic training and rehabilitation after physiotherapy evaluations. Gait patterns and weight bearing values were assessed, and the Amputee Mobility Predictor (AMP) Questionnaire was applied. The congenital group had better gait patterns, weight bearing values and AMP scores in the initial assessment and after 3 weeks. The statistical analyses of the same parameters after 6 months showed that there were no significant differences between the two groups (P>0.05). It was determined that all congenital patients and only 16 of 20 acquired patients were wearing their prostheses for more than 8 h a day. When the outcomes of the first assessments were compared, the congenital group showed a better functional level, gait pattern and weight bearing value. At the end of 6 months, an improvement was observed in the functional level, gait pattern and weight bearing value in both the groups. The functional state, gait pattern and weight bearing value of children with limb loss can be improved if they actively use their prosthesis.     

髁钢板治疗股骨转子部骨折的并发症及防治

探讨髁钢板内固定治疗股骨转子部骨折的并发症及其防治措施。方法：对１９９０～１９９７年采用髁钢板治疗股骨转子部骨折８９例中发生的３５例４９处术后并发症进行总结，分析其发生的主要原因。结果：发生下肢旋转畸形１３处，髋内翻和髋外展１１处，小转子未复位７处，内固定失效４处，晚期髋内翻５处，迟缓愈合５处和膝关节僵硬４处。结论：主要原因是手术时机掌握欠妥，未正确掌握髁钢板的设计特点和应用要领，术后过早下地负重。并提出相应防治措施。强调尽量早期手术，规范手术操作，正确指导术后功能锻炼是预防术后并发症的重要措施。     

Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression

The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology. LEVEL OF EVIDENCE: Therapy, level 5.     

Immediate weight bearing after plate fixation of fractures of the tibial plateau

BackgroundProximal articular fractures of the tibia are commonly stabilised with internal fixation using plates and screws. There is a lack of evidence and conflicting guidelines as to the most suitable post-operative rehabilitation regime including weight bearing status. There are numerous physiological and socioeconomic benefits of early weight bearing after orthopaedic surgery, but concerns remain around loss of fracture reduction. Therefore, the aim of this study is to investigate whether the weight bearing status after tibial plateau plate fixation is associated with any loss of reduction or articular collapse.MethodsWe retrospectively analysed data from our prospectively collected major trauma centre database. All tibial plateau fractures that required open reduction and internal fixation with plate and screws were included. The immediate post-operative weight bearing status of these patients was recorded. Group I consisted of those patients that were either non-weight bearing or touch weight bearing for the first six post-operative weeks. Group II consisted of patients who were instructed to weight bear fully (as tolerated) immediately after the operation. Radiographs were taken on day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation.ResultsA total of 90 patients were included in the study. Group I (non-weight bearing or touch weight bearing) consisted of 60 patients (67%). Group II (full weight bearing as tolerated) consisted of 30 patients (33%). The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1 mm joint depression (4 mm) identified at the first follow up, which did not progress.ConclusionsThis study shows immediate post-operative full weight bearing does not affect the fixation or cause articular collapse up to three months after surgery and thus we propose that patients should be allowed to weight bear immediately after surgical stabilisation of tibial plateau fractures. This will enable patients to benefit from the positive effects on fracture healing of early weight bearing post-surgery and avoid the complications of non-weight bearing without loss of fixation or articular collapse.     

Posttraumatische Arthrose: Arthrodese/Endoprothese

Posttraumatic arthrosis of the ankle joint can be tolerated for a long time before the patient asks for operative treatment, whether an endoprosthesis or arthrodesis appears more desirable. Patients’ expectations are relief of pain, plus stability and restored function. Provided a safe technique is used, patients can regain good joint function, as outlined in various studies. This depends on ligamentous stability, solid bone structure and a physiological position of the hindfoot. After arthrodesis even a largely destroyed ankle joint can be pain free, stable and normally functional in terms of weightbearing. Walking ability is particularly good when a good shape of the hindfoot is achieved and the other joints in the lower extremity on the same side are intact.     

How to Interpret Postoperative X‐rays after Total Knee Arthroplasty

Today, total knee arthroplasty (TKA) is one the most commonly performed surgeries worldwide. The purpose of this article is to review the appearance of normal post‐TKA roentgenographs and describe the correct sequence for their interpretation. It is unwise to depend solely on patients’ symptoms when diagnosing TKA complications because serial radiographs can foresee failures well before they manifest clinically. Ideal post‐TKA radiographs comprise whole lower extremity anteroposterior and lateral views taken under weight bearing conditions along with a skyline view of the patellofemoral joint. Among other things, weight bearing exposes the true alignment, ligamentous laxity and polyethylene wear. On the basis of follow‐up of our TKA cases, we have drawn up a protocol for assessing postoperative X‐ray films after TKAs. Following the proposed sequence, surgeon can easily decide how to proceed with follow‐up and foresee complications. Careful interpretation of postoperative radiographs after TKA is essential to careful monitoring of patients and implant survival.     

A novel tool for continuous fracture aftercare – Clinical feasibility and first results of a new telemetric gait analysis insole

Weight bearing after lower extremity fractures still remains a highly controversial issue. Even in ankle fractures, the most common lower extremity injury no standard aftercare protocol has been established. Average non weight bearing times range from 0 to 7 weeks, with standardised, radiological healing controls at fixed time intervals. Recent literature calls for patient-adapted aftercare protocols based on individual fracture and load scenarios. We show the clinical feasibility and first results of a new, insole embedded gait analysis tool for continuous monitoring of gait, load and activity.Ten patients were monitored with a new, independent gait analysis insole for up to 3 months postoperatively. Strict 20 kg partial weight bearing was ordered for 6 weeks. Overall activity, load spectrum, ground reaction forces, clinical scoring and general health data were recorded and correlated. Statistical analysis with power analysis, t-test and Spearman correlation was performed.Only one patient completely adhered to the set weight bearing limit. Average time in minutes over the limit was 374 min. Based on the parameters load, activity, gait time over 20 kg weight bearing and maximum ground reaction force high and low performers were defined after 3 weeks. Significant difference in time to painless full weight bearing between high and low performers was shown. Correlation analysis revealed a significant correlation between weight bearing and clinical scoring as well as pain (American Orthopaedic Foot and Ankle Society (AOFAS) Score r_s = 0.74; Olerud–Molander Score r_s = 0.93; VAS pain r_s = −0.95).Early, continuous gait analysis is able to define aftercare performers with significant differences in time to full painless weight bearing where clinical or radiographic controls could not. Patient compliance to standardised weight bearing limits and protocols is low. Highly individual rehabilitation patterns were seen in all patients. Aftercare protocols should be adjusted to real-time patient conditions, rather than fixed intervals and limits. With a real-time measuring device high performers could be identified and influenced towards optimal healing conditions early, while low performers are recognised and missing healing influences could be corrected according to patient condition.     

Editorial Commentary: Rehabilitation After Hip Arthroscopy—Bear in Mind the Bearing of Weight

Hip arthroscopy is the surgical treatment of choice for the treatment of femoroacetabular impingement syndrome and hip labral tears. Current guidelines on postoperative rehabilitation protocols are based on expert opinion, and evidence-based protocols are scarce. Previously, a non–weight-bearing protocol for several weeks after surgery was thought to prevent axial-load damage to the newly repaired labrum. However, there is a trend toward using immediate weight bearing as tolerated for early joint mobilization and pressurization. Strict weight-bearing restrictions may not be as necessary as once thought. We recommend that the first phase of rehabilitation prioritize joint protection to prevent joint inflammation and tissue irritation with a gradual increase in mobility exercises to restore range of motion. However, rehabilitation protocols should be tailored to address specific surgical findings, procedures, patient characteristics, and athletic goals. It is wise to be more conservative in older patients with poor bone quality. Bearing in mind this caveat, weight-bearing restrictions after hip arthroscopy may not improve outcomes and instead may have the negative effect of preventing patients from re-establishing a normal gait pattern.     

Gait analysis in patients with gonarthrosis treated by high tibial osteotomy

The basic parameters of gait were studied in 14 patients with medial gonarthrosis before and eight to 12 months after high tibial osteotomy. In seven patients, the osteotomy was fixed with staples. The patient was placed in plaster immobilization for six weeks and weight bearing was allowed after ten weeks. In the other seven patients, the osteotomy was fixed with a T-plate, and immediate joint motion and weight bearing were allowed after six weeks. There was no difference in any parameter of gait among patients treated with the two techniques. For all patients, the mean maximal velocity preoperatively was 65% of that of normal people, with only a slight, nonsignificant increase at the follow-up examination. An additional indication of insufficient rehabilitation was the decrease in stride length at constant maximal velocity at the follow-up evaluation. Positive correlations were found between stride length and muscle torque in the thigh. Positive correlations were also found between a subjective score and maximal velocity. Simple tests of velocity, stride length, and stride frequency are recommended as an easy and decisive method of follow-up evaluation.     

Management after application of the Pavlik harness in congenital dislocation of the hip

The Pavlik harness was applied to a group of outpatients to treat CDH (group I), to a group of hospitalized patients (group II), and to a third group who received additional treatment to prevent avascular necrosis of the femoral head, based on the theory that the weight of the lower extremity plays an important role in the successful reduction by the Pavlik harness (group III). The results of the three groups were carefully compared in order to determine the ideal management of infants after application of the harness. No difference was found in the therapeutic results between group I and group III, when the reduction was attempted on the outpatient basis. However, the rates of reduction and anatomical healing were lower in the hospitalized patients of group III than in group II patients, but there was no difference in the incidence of avascular necrosis of the femoral head between the two groups. In the treatment of CDH using the Pavlik harness, application of the harness on the outpatient basis should be the first choice. It is fundamental to let the weight of the lower extremity help in effecting abduction of the hip joint, but the general and local reactions of the infant must be watched constantly, because too much pressure on the hip joint could invite avascular necrosis of the femoral head. If reduction at the outpatient clinic fails, the patient should be regarded as having the treatment-resistant type of CDH, and should be treated further with traction of the lower extremity, muscle release, and adjustment of the hip joint angle.     

Management after application of the Pavlik harness in congenital dislocation of the hip

Summary The Pavlik harness was applied to a group of outpatients to treat CDH (group I), to a group of hospitalized patients (group 11), and to a third group who received additional treatment to prevent avascular necrosis of the femoral head, based on the theory that the weight of the lower extremity plays an important role in the successful reduction by the Pavlik harness (group III). The results of the three groups were carefully compared in order to determine the ideal management of infants after application of the harness. No difference was found in the therapeutic results between group I and group III, when the reduction was attempted on the outpatient basis. However, the rates of reduction and anatomical healing were lower in the hospitalized patients of group III than in group 11 patients, but there was no difference in the incidence of avascular necrosis of the femoral head between the two groups. In the treatment of CDH using the Pavlik harness, application of the harness on the outpatient basis should be the first choice. It is fundamental to let the weight of the lower extremity help in effecting abduction of the hip joint, but the general and local reactions of the infant must be watched constantly, because too much pressure on the hip joint could invite avascular necrosis of the femoral head. If reduction at the outpatient clinic fails, the patient should be regarded as having the treatment-resistant type of CDH, and should be treated further with traction of the lower extremity, muscle release, and adjustment of the hip joint angle.     

Normal axial alignment of the lower extremity and load-bearing distribution at the knee

Based on a series of 120 normal subjects of different gender and age, the geometry of the knee joint was analyzed using a full-length weight-bearing roentgenogram of the lower extremity. A special computer program based on the theory of a rigid body spring model was applied to calculate the important anatomic and biomechanical factors of the knee joint. The tibiofemoral mechanical angle was 1.2 degrees varus. Hence, it is difficult to rationalize the 3 degree varus placement of the tibial component in total knee arthroplasty suggested by some authors. The distal femoral anatomic valgus (measured from the lower one-half of the femur) was 4.2 degrees in reference to its mechanical axis. This angle became 4.9 degrees when the full-length femoral anatomic axis was used. When simulating a one-legged weight-bearing stance by shifting the upper-body gravity closer to the knee joint, 75% of the knee joint load passed through the medial tibial plateau. The knee joint-line obliquity was more varus in male subjects. The female subjects had a higher peak joint pressure and a greater patello-tibial Q angle. Age had little effect on the factors relating to axial alignment of the lower extremity and load transmission through the knee joint.