Long-term effects of non-weight bearing and immobilization after anterior cruciate ligament reconstruction on joint contracture formation in rats.

PURPOSE: Non-weight bearing improves and immobilization worsens contracture induced by anterior cruciate ligament reconstruction (ACLR), but effect persistence after reloading and remobilization remains unclear, and the combined effects of these factors on ACLR-induced contracture are unknown. We aimed to determine 1) whether the effects of short-term (2-week) non-weight bearing or immobilization after ACLR on contracture would be sustained by reloading or remobilization during a 10-week observation period, and 2) how the combination of both interventions compared to the outcome of either alone. METHODS: We divided 88 ACL-reconstructed male rats into four groups: non-intervention, non-weight bearing, joint immobilization, and both interventions. Interventions were performed for 2 weeks, followed by rearing without intervention. Twelve untreated rats were used as controls. At 2, 4, and 12 weeks post-surgery, we assessed range of motion (ROM) and histological changes. RESULTS: ACLR resulted in persistent loss of ROM, accompanied by synovial shortening, capsule thickening, and osteophyte formation. Two weeks of non-weight bearing increased ROM and reduced osteophyte size, but the beneficial effects disappeared within 10 weeks after reloading. Two-week immobilization decreased ROM and facilitated synovial shortening. After remobilization, ROM partially recovered but remained below non-intervention levels at 12 weeks. When both interventions were combined, ROM was similar to immobilization alone. CONCLUSIONS: The beneficial effects of 2-week non-weight bearing on contracture diminished within 10 weeks after reloading. The adverse effects of 2-week immobilization on contracture persisted after 10 weeks of remobilization. The effects of the combined use of both interventions on contracture were primarily determined by immobilization.

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies.

BACKGROUND: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability. PURPOSE: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated. RESULTS: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups. CONCLUSION: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature

Abstract Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

Identification of Risk Factors for Intraoperative Acquired Pressure Injury in Patients Undergoing Neurosurgery: A Retrospective Single-Center Study.

BACKGROUND Risk factors for intraoperative acquired pressure injury (IAPI) in patients undergoing various surgical procedures have been described in previous studies. However, whether risk factors for IAPI in patients undergoing neurosurgery differ remains unknown. The aim of the present study was to explore independent risk factors for IAPI in patients undergoing neurosurgery. MATERIAL AND METHODS Data from 465 patients who underwent neurosurgery between October 2017and December 2018 and who were at high risk of IAPIs were retrospectively analyzed. Independent risk factors for IAPI were evaluated using univariate and multivariate logistic regression models. RESULTS Sixty-nine IAPIs (14.8%) in 465 patients undergoing neurosurgery were assessed. Multivariate logistic regression analyses showed that being overweight (odds ratio [OR] 2.685; 95% confidence interval [CI] 1.206-5.975; P=0.016), prone position (OR 7.502, 95% CI 2.470-22.787. P<0.001), lateral position (OR 15.301, 95% CI 4.903-47.753, P<0.001), use of a head frame (OR 3.716, 95% CI 1.431-9.653, P=0.007), surgical times of 4 to 8 h (OR 7.276, 95% CI 2.249-23.542, P<0.001), and surgical times ≥8 h (OR 173.248, 95% CI 32.629-919.896, P<0.001) all were associated with an increased risk of IAPI in patients undergoing neurosurgery. The factors associated with reduced risk of IAPI were high serum albumin levels (OR 0.099, 95% CI 0.016-0.608, P=0.013) and use of memory sponge pads (OR 0.064, 95% CI 0.020-0.202, P<0.001). CONCLUSIONS The present study indicates that being overweight, prone and lateral positioning, use of a head frame, and longer surgical times are associated with an increased risk of IAPI in patients undergoing neurosurgery. Prospective studies should be conducted to verify these findings and consideration should be given to use of these factors in clinical practice to identify high-risk patients.

Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature.

Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

The Effect of Balloon-Blowing Exercise on Postoperative Pulmonary Functions in Patients Undergoing Total Hip Arthroplasty.

General anesthesia, prolonged immobilization, and pain may adversely affect pulmonary function in patients undergoing prosthetic surgery. The aim of this study was to evaluate the effect of balloon-blowing exercises on pulmonary functions in patients undergoing total hip arthroplasty. The patients in the experimental group performed three sets of balloon-blowing exercises in the morning, at noon, and in the evening on the first to third days postoperatively. The increase in forced vital capacity (FVC) values between the control and experimental groups in the postoperative period was statistically significant (p < .001), in favor of the experimental group. The increase in forced expiratory volume during the first second (FEV1)/FVC ratio was found to be significantly higher in the experimental group than in the control group (p < .001). Patients who performed balloon-blowing exercises increased their FVC and FEV1/FVC ratio.

The Efficacy of PTH and Abaloparatide to Counteract Immobilization-Induced Osteopenia Is in General Similar.

Immobilization results in a substantial bone loss and increased fracture risk. Powerful bone anabolic therapies are necessary to counteract the bone loss and reduce fracture risk during periods with immobilization. Intermittent parathyroid hormone 1-34 (PTH) (teriparatide) and PTH related peptide analog abaloparatide (ABL) are potent bone anabolic therapies acting through the same receptor, but induce different durations of signaling response. We investigated the efficacy of PTH or ABL in preventing immobilization-induced bone loss in rats in a direct mole-to-mole comparison. Immobilization was achieved by injecting botulinum toxin type A (BTX) into the right hindlimb musculature. Sixty 14-week-old female Wistar rats were allocated to the following groups: Baseline, Control, BTX, BTX + PTH (80 µg/kg/day), and BTX + ABL (77 µg/kg/day). Immobilization resulted in a substantial and significant reduction in bone mineral density (aBMD), metaphyseal and epiphyseal trabecular bone volume fraction (BV/TV) and trabecular thickness (Tb.Th), metaphyseal trabecular number (Tb.N), and femoral neck bone strength. Both PTH and ABL prevented the immobilization-induced decrease in aBMD, metaphyseal and epiphyseal Tb.Th, and metaphyseal Tb.N. In addition, PTH rescued the reduction in metaphyseal BV/TV and femoral neck strength, while ABL did not. However, the effect of PTH and ABL did not differ significantly for serum calcium, aBMD, metaphyseal, and epiphyseal BV/TV, Tb.Th, or Tb.N. In conclusion, in a mole-to-mole comparison the efficacy of PTH and ABL is similar in counteracting immobilization-induced reduction in bone mineral density, deterioration in trabecular microarchitecture, and decrease in bone strength.

Prevention of Venous Thromboembolism in Hospitalized Medically Ill Patients: A U.S. Perspective.

Venous thromboembolism (VTE) remains a major cause of morbidity and mortality in hospitalized medically ill patients. These patients constitute a heterogeneous population, whose VTE risk is dependent upon the acute medical illness, immobility status, and patient-specific risk factors that have been incorporated into individualized VTE risk assessment models. Randomized placebo-controlled trials (RCTs) have shown both efficacy and net clinical benefit of in-hospital thromboprophylaxis, which is supported by guideline recommendations. The data for extended posthospital discharge thromboprophylaxis are more nuanced. RCTs comparing standardized duration low-molecular weight heparin versus extended duration direct oral anticoagulants, such as betrixaban and rivaroxaban, have shown efficacy and net clinical benefit in select groups of high VTE and low-bleed risk populations of hospitalized medically ill patients. These oral agents are now approved for both in-hospital and extended thromboprophylaxis. However, the most recent guidelines do not recommend routine use of these agents for extended thromboprophylaxis. Longitudinal studies in medically ill patients have shown that the majority of VTE events occur in the posthospital discharge setting within 6 weeks of hospitalization. This, coupled with the short hospital length-of-stay and lack of routine postdischarge thromboprophylaxis in U.S. health care settings, has dampened quality improvement efforts aimed at reducing hospital-acquired VTE. The aim of this multidisciplinary document is to provide an evidence-based framework to guide clinicians in assessing VTE and bleeding risk in hospitalized medically ill patients using an individualized, risk-adapted, and patient-centered approach, with the aim of providing clinical pathways toward the use of appropriate type and duration of available thromboprophylactic agents.

Risk Factors and Management of Osteoporosis Post-Transplant.

Bone and mineral disorders are common after organ transplantation. Osteoporosis post transplantation is associated with increased morbidity and mortality. Pathogenesis of bone disorders in this particular sub set of the population is complicated by multiple co-existing factors like preexisting bone disease, Vitamin D deficiency and parathyroid dysfunction. Risk factors include post-transplant immobilization, steroid usage, diabetes mellitus, low body mass index, older age, female sex, smoking, alcohol consumption and a sedentary lifestyle. Immunosuppressive medications post-transplant have a negative impact on outcomes, and further aggravate osteoporotic risk. Management is complex and challenging due to the sub-optimal sensitivity and specificity of non-invasive diagnostic tests, and the underutilization of bone biopsy. In this review, we summarize the prevalence, pathophysiology, diagnostic tests and management of osteoporosis in solid organ and hematopoietic stem cell transplant recipients.

Blood Cytokine Concentration in Rats during Antigenic Treatment after a Single Long-Term Stress Exposure.

We studied changes in the blood cytokine profile of rats 3 h, 1 day, and 8 days after acute stress on the model of 24-h immobilization followed by LPS administration (100 µg/kg intraperitoneally). The concentration of proinflammatory cytokines (particularly of IL-1ß and TNFα) significantly decreased at the early stage after stress exposure and physiological saline injection, but increased in the follow-up period and practically did not differ or even surpassed the control level by the end of observations. Under these conditions, the blood content of anti-inflammatory cytokine IL-10 increased most significantly on day 1 of the post-stress period. Restraint stress followed by LPS administration was accompanied by a decrease in the level of proinflammatory cytokines at the early (IFNγ and TNFα) and late stages (IL-1ß) of the experiment. Directed modulation of the immune status in animals after acute stress was followed by a significant increase in the content of IL-10 on days 1 and 8, as well as by a tendency toward elevation of IL-4 concentration by the end of the study. The directionality and degree of changes in the cytokine profile of mammalian tissues depend on the type of extreme exposure, duration of the post-stress period, and specific effects of exogenous pathogenic factors in the whole body.

Deep venous thrombosis after Achilles tendon rupture is associated with poor patient-reported outcome.

PURPOSE: The aim of this study was to investigate whether patient subjective and functional outcomes after Achilles tendon rupture (ATR) are related to deep venous thrombosis (DVT) during leg immobilization. METHODS: A cohort study with prospectively collected randomized data was conducted between 2010 and 2017. Two-hundred and fifty-one Patients with an Achilles tendon rupture (mean age = 41 ± 8), treated with uniform surgical techniques, were retrospectively analyzed. DVT incidence at 2 and 6 weeks was assessed using compression duplex ultrasound. At 12 months patient-reported outcomes were assessed using the Achilles tendon Total Rupture Score (ATRS), Foot- and Ankle Outcome Score (FAOS), Physical Activity Scale (PAS) and functional outcome with the calf-muscle endurance test. ANOVA analyses were used and adjusted for assumed confounding factors (patient age, sex, BMI and rehabilitation). RESULTS: The total DVT incidence was 122 out of 251 (49%). Patients suffering a DVT exhibited significantly lower ATRS at 1 year compared to patients without DVT (mean 76 vs 83, 95% CI 71-79 vs 80-87; p < 0.01). Sixty-seven percent (95% CI 57-77%) of the patients devoid of DVT reported a good outcome (ATRS > 80) compared to 51% (95% CI 41-61%) of the patients sustaining a DVT (p < 0.05). Quality of life displayed significantly better outcome in the non-DVT versus DVT patients (mean = 75 (95% CI 71-79) vs. mean = 68 (95% CI 64-72); p < 0.05). A significant difference in total concentric work was observed between non-DVT and DVT patients (median = 1.9 kJ (IQR = 0.9 kJ) vs. median = 1.6 kJ (IQR = 1.0 kJ); p < 0.01). CONCLUSION: Sustaining a DVT during leg immobilization significantly impairs patient-reported outcome at 1 year after surgical repair of ATR. LEVEL OF EVIDENCE: III.

CRISPR/Cas9-Mediated miR-29b Editing as a Treatment of Different Types of Muscle Atrophy in Mice.

Muscle atrophy is the loss of skeletal muscle mass and strength in response to diverse catabolic stimuli. At present, no effective treatments except exercise have been shown to reduce muscle atrophy clinically. Here, we report that CRISPR/Cas9-mediated genome editing through local injection into gastrocnemius muscles or tibialis anterior muscle efficiently targets the biogenesis processing sites in pre-miR-29b. In vivo, this CRISPR-based treatment prevented the muscle atrophy induced by angiotensin II (AngII), immobilization, and denervation via activation of the AKT-FOXO3A-mTOR signaling pathway and protected against AngII-induced myocyte apoptosis in mice, leading to significantly increased exercise capacity. Our work establishes CRISPR/Cas9-based gene targeting on miRNA as a potential durable therapy for the treatment of muscle atrophy and expands the strategies available interrogating miRNA function in vivo.

Rabbit Model of Extending Knee Joint Contracture: Progression of Joint Motion Restriction and Subsequent Joint Capsule Changes after Immobilization.

This study aimed to develop a rabbit model of knee contracture in extension and investigate the natural history of motion loss and time-dependent changes in the joint capsule after immobilization. We immobilized the unilateral knee joints of 32 rabbits by maintaining the knee joint in a plaster cast at full extension. Eight rabbits were euthanized at 2, 4, 6, and 8 weeks after casting, respectively, and the lower extremities were disarticulated at the hip joint. Eight control group rabbits that did not undergo immobilization were also examined. We assessed the progression of joint contracture by measuring the joint range of motion, evaluating the histologic alteration of the capsule, and assessing the mRNA levels of transforming growth factor ß1 (TGF-ß1) in the anterior and posterior joint capsules. After 2 weeks of joint immobilization, the knee joint range of motion was limited, the synovial membrane of the suprapatellar and posterior joint capsules was thickened, the collagen deposition was increased, and the mRNA levels of TGF-ß1 were elevated in the anterior and posterior joint capsules. These changes progressed rapidly until 6 weeks of immobilization and may advance slowly after 6 weeks. Joint contracture developed at the early stage of immobilization and progressed over time. The changes in the anterior and posterior joint capsules after joint immobilization may contribute to the limitation in flexion. The elevated mRNA expression of TGF-ß1 may be related to joint capsule fibrosis and may be one of the causes of joint contracture.

Intra-articular injection of mitomycin C prevents progression of immobilization-induced arthrogenic contracture in the remobilized rat knee.

This study tested whether cell cycle inhibitor mitomycin C (MMC) prevents arthrogenic contracture progression during remobilization by inhibiting fibroblast proliferation and fibrosis in the joint capsule. Rat knees were immobilized in a flexed position to generate flexion contracture. After three weeks, the fixation device was removed and rat knees were allowed to freely move for one week. Immediately after and three days after fixator removal, rats received intra-articular injections of MMC or saline. The passive extension range of motion (ROM) was measured before and after myotomy of the knee flexors to distinguish myogenic and arthrogenic contractures. In addition, both cellularity and fibrosis in the posterior joint capsule were assessed histologically. Joint immobilization significantly decreased ROMs both before and after myotomy compared with untreated controls. In saline-injected knees, remobilization increased ROM before myotomy, but further decreased that after myotomy compared with that of knees immediately after three weeks of immobilization. Histological analysis revealed that hypercellularity, mainly due to fibroblast proliferation, and fibrosis characterized by increases in collagen density and joint capsule thickness occurred after remobilization in saline-injected knees. Conversely, MMC injections were able to prevent the remobilization-enhanced reduction of ROM after myotomy by inhibiting both hypercellularity and joint capsule fibrosis. Our results suggest that joint capsule fibrosis accompanied by fibroblast proliferation is a potential cause of arthrogenic contracture progression during remobilization, and that inhibiting fibroblast proliferation may constitute an effective remedy.

Abdominal visceral adipose tissue is associated with unsuspected pulmonary embolism on routine CT scans in patients with gastrointestinal cancer.

OBJECTIVE: Unsuspected pulmonary embolism (UPE) has been increasingly diagnosed as an incidental finding on CT scans for routine staging in cancer patients. Previous studies suggest that obesity is an independent risk factor for venous thromboembolism in patients with malignant tumors. In this study, we aimed to investigate the association between abdominal adipose tissue, especially visceral adipose tissue (VAT) and the occurrence of UPE in hospitalized patients with gastrointestinal cancer. METHODS: Routine contrast-enhanced chest and abdominal CT scans of 1974 patients were retrospectively assessed for the presence of UPE, of which 58 patients were identified with UPE and 108 non-UPE patients were selected as the non-UPE control group based on several matching criteria. Abdominal adipose tissue was measured by volumes of VAT and subcutaneous adipose tissue (SAT) at the navel level. RESULTS: VAT, SAT, indwelling venous catheters, surgery, chemotherapy, and bed rest or immobilization were associated with the occurrence of UPE. Higher VAT volumes were associated with increased risk of UPE (odds ratio: 1.96; 95% confidence interval: 1.25, 3.06; p = 0.003) adjusting body mass index (BMI), bed rest or immobilization, surgery, chemotherapy and smoking, while SAT was not associated with UPE adjusting the same confounders (p = 0.117). No statistical association was found between BMI and UPE (p = 0.102). CONCLUSION: Higher VAT rather than SAT is associated with an increased risk of unsuspected pulmonary embolism on routine CT scans in hospitalized gastrointestinal cancer patients. ADVANCES IN KNOWLEDGE: Our findings indicate that VAT is a stronger risk factor for unsuspected pulmonary embolism than BMI and SAT in hospitalized patients with gastrointestinal cancer.

Beta-lapachone attenuates immobilization-induced skeletal muscle atrophy in mice.

Skeletal muscle atrophy reduces quality of life and increases morbidity and mortality in patients with chronic conditions. Oxidative stress is a key factor contributing to skeletal muscle atrophy by altering both protein synthesis and protein degradation pathways. Beta-lapachone (Beta-L) is known to act as a pro-oxidant in cancer cells but suppresses oxidative stress in normal cells and tissues. In the present study, we examined whether Beta-L (100 mg/kg body weight) prevents immobilization-induced skeletal muscle atrophy in male C57BL/6N mice. Skeletal muscle atrophy was induced by immobilization of left hindlimbs for two weeks, and right hindlimbs were used as controls. The muscle weights of gastrocnemius (0.132 ±â€¯0.003 g vs. 0.115 ±â€¯0.003 g in Beta-L and SLS, respectively, p < 0.01) and tibialis anterior (0.043 ±â€¯0.001 vs. 0.027 ±â€¯0.002 in Beta-L and SLS, respectively, p < 0.001) were significantly heavier in Beta-L-treated mice than that in SLS-treated mice in immobilization group, which was accompanied by improved skeletal muscle function as tested by treadmill exhaustion and grip strength test. Immobilization increased H2O2 levels, while Beta-L treatment normalized such levels (1.6 ±â€¯0.16 µM vs. 2.7 ±â€¯0.44 µM in Beta-L and vehicle, respectively, p < 0.05). Oxidative stress makers were also normalized by Beta-L treatment. Protein synthesis signaling pathways were unaltered in the case of both immobilization and Beta-L treatment. However, protein catabolic, ubiquitin-proteasomal, and autophagy-lysosomal pathways were stimulated by immobilization and were normalized by Beta-L treatment. Upregulation of transforming growth factor ß and Smad 2/3 after immobilization was significantly diminished by Beta-L treatment. These results suggest that Beta-L attenuates the loss of muscle weight and function induced by immobilization through suppression of oxidative stress.

Impact of chronic immobilization stress on parameters of colonic homeostasis in BALB/c mice.

The intestinal epithelium is a monolayer of cells arranged side­by­side and connected by tight junction (TJ) proteins expressed at the apical extreme of the paracellular membrane. This layer prevents stress­induced inflammatory responses, thus helping to maintain gut barrier function and gut homeostasis. The aim of the present study was to evaluate the effects of chronic immobilization stress on the colonic expression of various parameters of homeostasis. A total of two groups of female BALB/c mice (n=6) were included: A stressed group (short­term immobilization for 2 h/day for 4 consecutive days) and an unstressed (control) group. Colon samples were obtained to detect neutrophils and goblet cells by optical microscopy, TJ protein expression (occludin, and claudin ­2, ­4, ­7, ­12 and ­15) by western blotting, mRNA levels of TJ genes and proinflammatory cytokines [tumor necrosis factor (TNF)­α, interleukin (IL)­1ß, ­6 and ­8] by reverse transcription­quantitative PCR, fecal lactoferrin by ELISA and the number of colony­forming units of aerobic bacteria. Compared with goblet cells in control mice, goblet cells were enlarged and reduced in number in stressed mice, whereas neutrophil cellularity was unaltered. Stressed mice exhibited reduced mRNA expression for all evaluated TJ mRNAs, with the exception of claudin­7, which was upregulated. Protein levels of occludin and all claudins (with the exception of claudin­12) were decreased in stressed mice. Fecal lactoferrin, proinflammatory cytokine mRNA levels and aerobic bacterial counts were all increased in the stressed group. These results indicated that immobilization stress induced proinflammatory and potential remodeling effects in the colon by decreasing TJ protein expression. The present study may be a useful reference for therapies aiming to regulate the effects of stress on intestinal inflammatory dysfunction.

Protocol for a multi-centre pilot and feasibility randomised controlled trial with a nested qualitative study: rehabilitation following rotator cuff repair (the RaCeR study).

BACKGROUND: Shoulder pain is a highly prevalent complaint and disorders of the rotator cuff, including tears, are thought to be the most common cause. The number of operations repair the torn rotator cuff has risen significantly in recent years. While surgical techniques have progressed, becoming less invasive and more secure, rehabilitation programmes have remained largely like those initially developed when surgical techniques were less advanced and more invasive. Uncertainty remains in relation to the length of post-surgical immobilisation and the amount of early load permitted at the repair site. In the context of this uncertainty, current practice is to follow a generally cautious approach, including long periods of immobilisation in a sling and avoidance of early active rehabilitation. Systematic review evidence suggests early mobilisation might be beneficial but further high-quality studies are required to evaluate this. METHODS/DESIGN: RaCeR is a two-arm, multi-centre pilot and feasibility randomised controlled trial with nested qualitative interviews. A total of 76 patients with non-traumatic rotator cuff tears who are scheduled to have a surgical repair will be recruited from up to five UK NHS hospitals and randomly allocated to either early patient-directed rehabilitation or standard rehabilitation that incorporates sling immobilisation. RaCeR will assess the feasibility of a future, substantive, multi-centre randomised controlled trial to test the hypothesis that, compared to standard rehabilitation incorporating sling immobilisation, early patient-directed rehabilitation is both more clinically effective and more cost-effective. In addition, a sample of patients and clinicians will be interviewed to understand the acceptability of the interventions and the barriers and enablers to adherence to the interventions. DISCUSSION: Research to date suggests that there is the possibility of reducing the patient burden associated with post-operative immobilisation following surgery to repair the torn rotator cuff and improve clinical outcomes. There is a clear need for a high-quality, adequately powered, randomised trial to better inform clinical practice. Prior to a large-scale trial, we first need to undertake a pilot and feasibility trial to address current uncertainties about recruitment, retention and barriers to adherence to the interventions, particularly in relation to whether patients will be willing to begin moving their arm early after their operation. TRIAL REGISTRATION: ISRCTN Registry, 18357968 . Registered on 10 August 2018.

A ten-year retrospective study investigating the rate of venous thromboembolism in patients who require immobilization in a total contact lower limb cast.

AIMS: To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population. PATIENTS AND METHODS: Patients treated with a lower limb cast between 2006 and 2018 were identified using plaster room records. Their electronic records and radiological reports were reviewed for details about their cast, past medical history, and any VTE recorded in our hospital within a year of casting. RESULTS: There were 136 episodes of casting in 100 patients. The mean age was 55 years (22 to 91). The mean time in a cast was 45 days (five days to eight months). A total of 76 patients had neuropathy secondary to diabetes. No patient received chemical thromboprophylaxis while in a cast. One VTE (0.7% of casting episodes) was documented. This was confirmed by Doppler scan nine days after removing the cast. CONCLUSION: The frequency of VTE was higher than that of the general population (0.05%); this is most likely attributable to our patients' apparent increase in VTE risk as suggested by The National Institute for Health and Care Excellence (NICE). These findings suggest that thromboprophylaxis is not routinely indicated in patients who undergo immobilization of the lower limb in a cast, although the risks of VTE should be assessed. While the cast itself does not pose an increased risk, other pathologies, such as active cancer, mean that each individual case needs to be considered on their merit. Cite this article: Bone Joint J 2019;101-B:691-694.