Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT.

Background: Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. Objective(s): To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). Design: A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Setting: Twenty-nine NHS orthopaedic units in the United Kingdom. Participants: Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Interventions: Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. Main outcome measures: The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Results: Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Limitations: Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Conclusions: Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Future work: Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. Trial registration: This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

The study aimed to find out whether it is better to offer surgical reconstruction or rehabilitation first to patients with a more long-standing injury of their anterior cruciate ligament in their knee. This injury causes physical giving way of the knee and/or sensations of it being wobbly (instability). The instability can affect daily activities, work, sport and can lead to arthritis. There are two main treatment options for this problem: non-surgical rehabilitation (prescribed exercises and advice from physiotherapists) or an operation by a surgeon to replace the damaged ligament (anterior cruciate ligament reconstruction). Although studies have highlighted the best option for a recently injured knee, the best management was not known for patients with a long-standing injury, perhaps occurring several months previously. Because the surgery is expensive to the NHS (around £100 million per year), it was also important to look at the costs involved. We carried out a study recruiting 316 non-acute anterior cruciate ligament-injured patients from 29 different hospitals and allocated each patient to either surgery or rehabilitation as their treatment option. We measured how well they did with special function and activity scores, patient satisfaction and costs of treatment. Patients in both groups improved substantially. It was expected that some patients in the rehabilitation group would want surgery if non-surgical management was unsuccessful. Forty-one per cent of patients who initially underwent rehabilitation subsequently elected to have reconstructive surgery. Overall, the patients allocated to the surgical reconstruction group had better results in terms of knee function and stability, activity level and satisfaction with treatment than patients allocated to the non-operative rehabilitation group. There were few problems or complications with either treatment option. Although the surgery was a more expensive treatment option, it was found to be cost-effective in the UK setting. The evidence can be discussed in shared decision-making with anterior cruciate ligament-injured patients. Both strategies of management led to improvement. Although a rehabilitation strategy can be beneficial, especially for recently injured patients, it is advised that later-presenting non-acute and more long-standing anterior cruciate ligament-injured patients undergo surgical reconstruction without necessarily delaying for a period of rehabilitation.

Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability - a Delphi consensus.

BACKGROUND: There is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice. METHOD: Expert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement. RESULTS: 11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined "safe zone." Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks. Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient's confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score. CONCLUSION: This consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. CONTRIBUTION OF THE PAPER.

Clinical Efficacy of Arthroscopic Transplantation of Palmaris Longus Tendon Combined with Early Accelerated Motion Rehabilitation After Scapholunate Ligament Reconstruction for Geissler Type IV Scapholunate Instability.

Objective: The aim of this study is to investigate the clinical efficacy of early accelerated motion rehabilitation in treating wrist joint instability with Geissler IV scapholunate instability (SLI) using arthroscopic palmaris longus tendon transplantation in conjunction with scapholunate ligament reconstruction. Methods: From June 2019 to January 2022, seven patients with Geissler Type IV SLI underwent arthroscopic ligament reconstruction and repair surgery of the wrist joint, followed by early accelerated motion rehabilitation. Postoperative follow-up indicators included visual analogue scale (VAS) for pain assessment, DASH-CHINESE upper limb function score, Mayo wrist joint score, wrist joint range of motion, and grip strength. Surgical efficacy was evaluated based on these indicators. Results: All patients were followed up postoperatively, with a follow-up duration ranging from 6 to 20 months (mean: 15.3 months). No postoperative complications occurred, and significant improvements were observed in all measured parameters. Postoperative MRI results at one year indicated restoration of the anatomical structure of the scapholunate joint with good healing. Both VAS and DASH-CHINESE scores significantly decreased, and the differences between pre- and postoperative scores were statistically significant (P < .001). The preoperative Mayo wrist joint score was (47.857±21.380) points, with 2 cases rated as fair and 5 cases as poor. At the latest follow-up, the score was (84.286±6.726) points, with 2 cases rated as excellent, 2 cases as good, and 3 cases as fair. Wrist joint flexion-extension range, rotation range, and grip strength all significantly improved compared to the preoperative values, with statistically significant differences (P < .001). Conclusion: The combined approach of arthroscopic transplantation of the palmaris longus tendon and early accelerated motion rehabilitation shows satisfactory clinical outcomes in treating Geissler Type IV scapholunate instability of the wrist joint. This combined approach is of great significance in improving the patient's quality of life and wrist function and helps reduce pain symptoms. Furthermore, in future research, it is recommended to increase the sample size and prolong the observation period to further validate the efficacy.

The use and effectiveness of exercise for managing postural orthostatic tachycardia syndrome in young adults with joint hypermobility and related conditions: A scoping review.

PURPOSE: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue. METHODS: A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included. RESULTS: Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life. CONCLUSION: The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed.

Arthroscopic Bankart Procedure: Clinical Outcomes with a Minimum Follow-Up of 10 Years / Cirurgia de Bankart artroscópica: Resultados clínicos com seguimento mínimo de 10 anos

Abstract Objective To evaluate the functional outcome of patients submitted to arthroscopic Bankart repair in the long-term. Methods Retrospective evaluation of 41 patients (45 shoulders) operated between 1996 and 2009 followed-up for a mean period of 14.89 years. Functional scores were analyzed by the University of California, Los Angeles (UCLA) and Carter-Rowe scores, physical examination, and analysis of medical records. Results The Carter-Rowe score showed an average improvement of 46.11 points, with a final average of 85.89 points, and the UCLA score showed an average improvement of 31.33 points. Ten patients (22.22%) relapsed, with the number of preoperative dislocations being the most correlated factor. Conclusion It was demonstrated that the number of preoperative dislocations negatively influenced the failure rate.

Resumo Objetivo Avaliar o desfecho funcional dos pacientes submetidos ao reparo de Bankart artroscópico no longo prazo. Métodos Avaliação retrospectiva de 41 pacientes (45 ombros) operados entre 1996 e 2009 acompanhados por um período médio de 14,89 anos. Foram feitas análises das pontuações funcionais de University of California, Los Angeles (UCLA) e Carter-Rowe, exame físico e análises de prontuários. Resultados O escore Carter-Rowe apresentou melhora média de 46,11 pontos, com média final de 85,89 pontos, e o UCLA apresentou melhora de 31,33 pontos. Um total de 10 pacientes (22,22%) apresentou recidiva, sendo o número de luxações pré- operatórias o fator mais correlacionado. Conclusão Foi demonstrado que o número de luxações pré-operatórias influenciou negativamente na taxa de falha.

Subjective assessment reported by patients shows differences between single-bundle and double-bundle anterior cruciate ligament reconstruction, systematic review and meta-analysis.

To determine the functional recovery, active reincorporation, and anteroposterior and rotational stability of patients undergoing anterior cruciate ligament (ACL) reconstruction using arthroscopy techniques with simple-bundle (SB) or double-bundle (DB). The following databases were searched: PubMed, Embase (Elsevier platform), the Cochrane Central Register of Controlled Trials (Wiley platform), Web of Science, and CINAHL. Level I and II studies involving anterior cruciate ligament arthroscopy were included in the search. Records were screened by title and abstract and assessed the risk of bias of selected studies. Meta-analyses using RevMan 5.3 software were conducted on the following outcomes: knee functionality, objective measurements of knee stability, rotational knee stability and knee anterior stability, sports reincorporation, and subjective assessments. Twenty-four studies of patients undergoing ACL reconstruction were included in the qualitative and quantitative synthesis (1707 patients) for Lysholm score, Subjective International Knee Documentation Committee (IKDC) score, Tegner score, KT-1000/2000, Lachman test, Objective IKDC score, and Pivot-Shift test. A return to pre-injury level showed a significant decrease in the Lysholm score (mean difference, - 0.99; 95% CI - 1.71 to - 0.40; P = 0.007) and Tegner score (mean difference, - 0.07; 95% CI, - 0.13 to - 0.01; P = 0.02) at DB reconstruction, similar to the knee functionality outcome of the subjective IKDC score (mean difference - 1.42; 95% CI - 2.46 to - 0.38; P = 0.007). There is no clear or significant difference in clinical stability and knee function or in sports incorporation with the true difference occurring in the subjective assessment.

Postoperative Rehabilitation of Anterior Glenohumeral Joint Instability Surgery: A Systematic Review.

Anterior glenohumeral instability is the most common form of shoulder instability. The systematic review summarizes the latest research on rehabilitation after Bankart repair. Inclusion criteria included postoperative rehabilitation and published in English between 2000 and 2019. Studies were excluded if they were addresses, comments, or editorials, or included other shoulder injuries or cadaver models. Two rounds of review using Rayyan QCRI software were performed for screening and full text search, and the articles were graded for levels of evidence. Of the 1982 articles, 14 articles were included with levels of evidence 1 through 4. Both arthroscopic and open Bankart repair have demonstrated improving functional outcomes and reducing recurrence rates of anterior shoulder instability. Accelerated postoperative rehabilitation may be comparable to a conventional protocol for arthroscopic repair, and the subscapularis musculature involvement during open repair can impact the timeframe. Strong evidence supports 4 phases of rehabilitation and future clinical trials are needed to compare different programs.

Postoperative Rehabilitation of Multidirectional Instability Surgery: A Systematic Review.

Multidirectional instability (MDI) of the shoulder is managed with surgery when conservative rehabilitation fails. The optimal postsurgical management of MDI is not well understood. The purpose of this study is to create a systematic review evaluating postsurgical rehabilitation protocols treating MDI. Articles were included if a postsurgical rehabilitation protocol was described following surgical treatment for MDI. Identified articles underwent 2 phases of screening by blinded team members. Remaining articles had their level of evidence determined by a predefined grading system, ranging from levels I to V. Articles with evidence levels I to IV were included in analysis. Of the 163 articles identified in the literature, 9 were included in this study. Surgical techniques examined in these articles include capsular plication, rotator interval closure, and capsular shift. Rehabilitation protocols were evaluated for duration of treatment and physical therapy modalities. Article results were evaluated for subjective and objective measures of protocol success. Overall, there is a lack of evidence to indicate the optimal rehabilitation protocol post-MDI surgery. Further research is needed to compare rehabilitation protocols following specific surgical procedures to determine their effect on postsurgical patient outcomes.

Postoperative Rehabilitation of Posterior Glenohumeral Joint Instability Surgery: A Systematic Review.

Posterior glenohumeral (GH) joint instability is uncommon compared with anterior and multidirectional instability. A variety of surgical techniques are used to treat posterior GH instability. As a result, there are numerous rehabilitation protocols that vary greatly. The objective of this review was to define, evaluate and compare the postsurgical rehabilitation protocols for patients treated surgically for posterior GH instability. The review contains articles that outline a rehabilitation protocol following a surgical repair of posterior GH instability. A multidatabase search was conducted. Two independent, blinded reviewers decided on inclusion and exclusion of each study, with a second round to resolve conflicts. Data was extracted from the pertinent studies after the grading of evidence was conducted by 2 reviewers. Sixteen studies of the original 859 were included. Most studies included a 3-phase to 4-phase protocol that consisted of immobilization, remobilization, strength training, and sport-specific training. A review of current literature shows a paucity of high-quality studies regarding outcomes of rehabilitation following surgery for posterior GH instability. Most studies had favorable results, with most patients returning to their presurgical level of activity.

Postoperative Rehabilitation of Chronic Lateral Ankle Instability: A Systematic Review.

Chronic lateral ankle instability often causes adults to require a surgical intervention with subsequent physical therapy to assist with returning to their prior level of function. This systematic review is hoping to provide an up to date understanding of surgical procedures performed to correct chronic lateral ankle instability and establish a protocol for others to follow when treating adults who are status-post chronic lateral ankle instability surgery. This review looked at level I to III research studies that included surgical interventions to correct chronic lateral ankle instability as well as a rehabilitation protocol. This study found implementation of a rehabilitation protocol after surgical intervention could improve balance and subjective functional outcomes. It also determined that early weight-bearing may allow for early strengthening as range of motion returns faster. Further research is required utilizing larger randomized studies to better evaluate the outcomes of specific rehabilitation protocols in this patient population.

Effectiveness of Hospital-Based Systemic Rehabilitation in Improving Ankle Function after Surgery in Chronic Ankle Instability Patients.

We investigated the therapeutic effect of a postoperative hospital-based systemic rehabilitation protocol on ankle function in chronic ankle instability (CAI) patients. Thirty-five patients who underwent a modified Broström procedure for CAI were recruited in this prospective randomized controlled trial. Fifty-minute sessions of hospital-based rehabilitation were performed three times weekly for 12 weeks in the intervention group. Education-based rehabilitation was conducted at home in the control group. The outcomes were evaluated at baseline (T0), 12 weeks (T1), and 16 weeks (T2). The primary outcome was the foot and ankle outcome score (FAOS). Ankle motor strength and spatiotemporal gait metrics were assessed as secondary outcomes. There were significant time and group interaction effects on the pain, symptoms, activities of daily living, sports activities, and quality of life (QOL) domains of the FAOS (P < 0.05, all). The patients in the intervention group showed larger improvements in all domains of the FAOS than did the control group at both T1 and T2 (P < 0.05, all). The time and group interaction effects on invertor and evertor strength were also significant (P = 0.047 and P = 0.044). Invertor and evertor strength improved significantly more in the intervention group than in the control group at T1 and T2 (P < 0.05, all). The preferred walking velocity, cadence, step length on the affected side, and double stance phase duration tended to improve over time. Postoperative hospital-based rehabilitation helped improve CAI pain, symptoms, independence in activities of daily living, sports activity levels, and QOL more effectively than did conventional rehabilitation at home.

Chronological Changes in Anterior Knee Stability after Anatomical Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone and Hamstring Grafts.

The clinical outcomes of anterior cruciate ligament (ACL) reconstruction are typically evaluated at specific time points only. This study aimed to characterize the chronological changes in anterior knee stability after anatomical ACL reconstruction and to compare the anterior knee stability achieved with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) grafts. A total of 59 patients underwent anatomical rectangular tunnel ACL reconstruction using the BPTB graft and 23 patients underwent anatomical double-bundle ACL reconstruction using the HT graft. Anterior knee stability was quantitatively assessed using the KneeLax 3 arthrometer at 6 months, 1 year, and 2 years after surgery using side-to-side differences. The values for anterior knee stability using the BPTB graft were 0.3 mm after 6 months, 0.2 mm after 1 year, and 0.2 mm after 2 years, and no significant differences were observed during the postoperative study period. Meanwhile, the values for anterior knee stability using the HT graft were -0.3 mm after 6 months, 0.5 mm after 1 year, and 1.2 mm after 2 years, and anterior knee stability decreased chronologically from 6 months up to 2 years. Regarding anterior stability, the HT graft showed significant laxity compared with the BPTB graft only after 2 years. No chronological changes in anterior stability were observed from 6 months up to 2 years after ACL reconstruction using the BPTB graft, whereas anterior laxity developed during the same period after ACL reconstruction using the HT graft. This is a Level IV, therapeutic case series study.

Rehabilitation, clinical outcome and return to sporting activities after posterolateral elbow instability: a systematic review.

INTRODUCTION: The aim of this study was to systematically review the literature for rehabilitation concepts, clinical outcome and sporting performance after surgical or non-surgical treatment of Posterolateral Rotatory Instability of the elbow (PLRI). EVIDENCE ACQUISITION: In order to identify any published clinical study reporting on rehabilitation concepts and sporting performance following surgical or non-surgical treatment of PLRI a systematic search in literature was conducted. Rehabilitation protocols were reviewed according to main rehabilitation protocol categories (bracing, range of motion [ROM], strengthening and return to sport [RTS]). EVIDENCE SYNTHESIS: Seven articles, including 148 patients met the inclusion criteria. Lateral ulnar collateral ligament (LUCL) repair with sutures or suture anchors was reported in two studies. In four studies, treatment was an isolated graft reconstruction and in one study a repair or graft reconstruction was performed. No study reporting on conservative treatment was found. Bracing with initially limiting ROM was declared in all studies. Duration of immobilization varied from one day to six weeks postoperative. Limitation of ROM to 30° of elbow extension was reported in the majority of studies. Strengthening was allowed from six to eight weeks postoperative. Postoperative improvement in elbow range of motion was noted in all studies. CONCLUSIONS: Although there is agreement concerning bracing and limiting ROM following PLRI surgery there is currently no consensus in the rehabilitative- and conservative treatment modalities for patients with symptomatic PLRI. The majority of surgically treated patients with PLRI regain high acceptable results but further research is needed to determine the postoperative level of performance of these athletes.

Chronic Lateral Ankle Instability: Topical Review.

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

Pediatric Trigger Thumb with Metacarpophalangeal Joint Hyperextension or Instability.

BACKGROUND The aim of this study was to provide the first on report on the mechanism and the different treatment measures of metacarpophalangeal joint hyperextension (MCPH) or metacarpophalangeal joint instability (MCPI) in cases of pediatric trigger thumb. Some pediatric trigger thumb patients have disease combined with excessive extension of metacarpophalangeal (MCP) joint or instability of MCP joint. MATERIAL AND METHODS A total of 1083 children with trigger thumb surgery were divided into 2 groups (the MCPH group and the MCPI group) by the extension degree of the MCP joint. After tendon sheath released, the MCPH group was treated by a cast and the MCPI group was treated by a cast and a brace. We compared the differences in baseline data and the further functional activities of interphalangeal (IP) and MCP joint between the 2 groups. RESULTS Among the 1083 cases, 154 cases (185 thumbs) were trigger thumb with MCPH or MCPI, of which 167 thumbs were placed in the MCPH group and 18 thumbs were placed in the MCPI group. The average age of the MCPH group was 2.8 years, with an average duration of disease of 13 months. The average age of the MCPI group was 6.6 years, with an average duration of disease of 33 months. MCPH still existed after cast removal. In the MCPI group, 12 out of 18 thumbs recovered; 6 thumbs relapsed at 2-4 months after brace removal. CONCLUSIONS Trigger thumb with MCPH and MCPI in children is significantly associated with multi-joint laxity. While there was still MCPH after cast treatment, there was no need for further treatment during the short-term follow-up. Cast and brace treatment after surgery was a simple, easy method for treatment of MCPI and had a good effect.

Enhanced rehabilitation guidance after arthroscopic capsulolabral repair of the shoulder: a randomized controlled trial.

OBJECTIVE: To compare the effects of a 12-month home-based exercise program to usual care in patients after arthroscopic capsulolabral repair of the shoulder. DESIGN: Randomized controlled trial. SETTING: Outpatient physical and rehabilitation medicine clinic. SUBJECTS: Forty-five patients (mean age: 35 years; standard deviation (SD): 10 years) who underwent arthroscopic capsulolabral repair due to labral lesion were randomized into an exercise group (EG) or a control group (CG). INTERVENTION: The EG received a 12-month home-based additional exercise program with four physiotherapy follow-up visits, while the CG received standard postoperative exercise instructions. MAIN MEASURES: Self-reported shoulder disability was assessed with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and quality of life with the Short-Form (SF)-36 Health Survey. The function of the operated shoulder was evaluated with strength and range of motion measurements. RESULTS: No between-group differences were observed in any of the outcomes at the follow-up. Mean ASES score improved by 16 (95% confidence interval (CI): 10-23) points from the baseline 78 (SD: 17) in the EG and 13 (95% CI: 7-19) points from the baseline 79 (SD: 17) in the CG. Both groups achieved a significant improvement in the dimensions of Physical Functioning, Role-Physical, and Bodily Pain of the SF-36 and in every aspect of strength and range of motion measures. In EG, exercise adherence was moderate (52%) during the first six months and poor (22%) during the last six months. CONCLUSION: Home-based additional exercises with four outpatient follow-up visits did not improve outcome after arthroscopic capsular repair of the shoulder.

A Clinical Comparison of Home-Based and Hospital-Based Exercise Programs Following Arthroscopic Capsulolabral Repair for Anterior Shoulder Instability.

CONTEXT: Ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before. OBJECTIVE: The aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair. DESIGN: Nonrandomized controlled trial. SETTING: Orthopedics and physical therapy units of a single institution. PATIENTS: Fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups. INTERVENTIONS: Both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months. MAIN OUTCOME MEASURES: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann-Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group. RESULTS: Groups were age and gender matched (P = .61, P = .69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P = .22), Constant (58.23 [14.23] vs 54.17 [10.46], P = .13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P = .12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P = .001, P = .001, and P = .001). No significant difference was observed between 2 groups regarding clinical scores in any time point. CONCLUSIONS: We have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability.

Beneficial Effects of Nonsurgical Treatment for Symptomatic Thumb Carpometacarpal Instability in Clinical Practice: A Cohort Study.

OBJECTIVE: To describe outcomes of nonsurgical treatment for symptomatic thumb carpometacarpal joint (CMC-1) instability. Secondary, to evaluate the conversion rate to surgical treatment. DESIGN: Prospective cohort study. SETTING: A total of 20 outpatient clinics for hand surgery and hand therapy in the Netherlands. PARTICIPANTS: A consecutive sample of patients with symptomatic CMC-1 instability (N=431). INTERVENTION: Nonsurgical treatment including exercise therapy and an orthosis. MAIN OUTCOME MEASURES: Pain (visual analog scale [VAS], 0-100) and hand function (Michigan Hand Outcomes Questionnaire [MHQ], 0-100) at baseline, 6 weeks, and 3 months. Conversion to surgery was recorded for all patients with a median follow-up of 2.8 years (range, 0.8-6.7y). RESULTS: VAS scores for pain during the last week, at rest, and during physical load improved with a mean difference at 3 months of 17 (97.5% CI, 9-25), 13 (97.5% CI, 9-18), and 19 (97.5% CI, 12-27), respectively (P<.001). No difference was present at 3 months for MHQ total score, but the subscales activities of daily living, work, pain, and satisfaction improved by 7 (97.5% CI, 1-14), 10 (97.5% CI, 4-16), 5 (97.5% CI, 2-9), and 12 (97.5% CI, 2-22) points, respectively (P<.001-.007). After median follow-up of 2.8 years, only 59 participants (14%) were surgically treated. Both in the subgroups that did and did not convert to surgery, VAS pain scores decreased at 3 months compared with baseline (P<.001-.010), whereas MHQ total score did not improve in both subgroups. However, VAS and MHQ scores remained worse for patients who eventually converted to surgery (P<.001). CONCLUSIONS: In this large sample of patients with symptomatic CMC-1 instability, nonsurgical treatment demonstrated clinically relevant improvements in pain and aspects of hand function. Furthermore, after 2.8 years, only 14% of all patients were surgically treated, indicating that nonsurgical treatment is a successful treatment of choice.

Return to sports after glenoid reconstruction using an implant-free iliac crest bone graft.

PURPOSE: The purpose of this study was to evaluate sports ability and the rate of return to sports after implant-free iliac bone graft for recurrent, anterior shoulder instability and anterior glenoid bone loss. Subgroups of younger and older patients and patients who had previous arthroscopic Bankart surgery and those who did not have such surgery before implant-free iliac bone graft were formed and compared. METHODS: We retrospectively analyzed 34 patients; 14 patients had previous arthroscopic Bankart surgery, and 20 patients did not have the surgery; The median age at the time of iliac bone graft was 35.3 years (range, 23 to 75), 17 patients were over the age of 35, and 17 patients were under the age of 35. The mean follow-up was 40 months (range: 25 to 56). RESULTS: All the 34 patients were engaged in pre- and post-operative sport, which represents a return to sport rate of 100%. Although the number of sport disciplines decreased significantly from 6 before the operation to 4.8 after the operation (p=0.002), the number of sports sessions per week did not change significantly, and the duration per session did not change significantly. More than two-thirds of all patients returned to sports within 6 months. Overall, 41% of patients changed sport disciplines, 15% of whom cited shoulder-related causes; however, all patients returned to the same sport level. CONCLUSIONS: Overall and within the subgroups, the return to sport rate after implant-free iliac bone grafting was high, with a high sense of well-being. The number of sport disciplines decreased significantly and more than one-third of the patients changed disciplines, of which 15% percent changed due to shoulder-related causes. The sport level remained equal, and no other parameters changed significantly compared with the time before the onset of restrictive shoulder symptoms.

Effect of subcritical glenoid bone loss on activities of daily living in patients with anterior shoulder instability.

BACKGROUND: It has been biomechanically demonstrated that 20% to 25% is a critical glenoid bone loss. Recently, there are several reports describing that a bone loss less than 20% to 25% needed to be treated because patients may have decreased quality of life without recurrent instability events. The purpose of this study was to clarify the presence of subcritical bone loss that would affect postoperative instability or quality of life. METHODS: Subjects were 43 patients aged≤40years with less than 25% glenoid bone loss who had undergone arthroscopic Bankart repair. These patients were assessed at a mean follow-up of 32months. The Western Ontario Shoulder Instability (WOSI) and Rowe scores were used for the clinical evaluation. Patients were divided in 3 groups based on the percentage of bone loss: group 1: <8%; group 2: 8% to 17%; and group 3: >17%. RESULTS: The recurrence rate was 7% (3/43 shoulders). A weak negative correlation was seen between bone loss and sports/recreation/work domain of the WOSI score (r=-0.304, p=0.0191). The WOSI for group 3 was significantly lower than that for group 1 and 2 (p=0.0009). The male WOSI scores were significantly lower than the female ones (p=0.0471). The WOSI scores of the contact athletes were significantly lower than those of non-contact athletes (p=0.0275). All the patients in Group 3 were males and participated in contact sports. CONCLUSION: Glenoid bone loss between 17% and 25% is considered to be a "subcritical bone loss" in our series, especially in male patients who are involved in sports or high-level activities. LEVEL OF EVIDENCE: III, retrospective study.