Relationship between gait parameter and spinal sagittal profiles in asymptomatic subjects.

BACKGROUND: To study the gait parameters in asymptomatic volunteers and investigate the correlation between the gait and several radiographic sagittal profiles. METHODS: Asymptomatic volunteers (20-50 years of age) were included and allocated into three subgroups depending on pelvic incidence (low, normal, and high). Standing whole spine radiographs and gait analysis data were obtained. The Pearson Coefficient Correlation was used to determine the relationship between the gait and radiographic profiles. RESULTS: A total of 55 volunteers (28 male and 27 females) were included. The mean age was 27.35 ± 6.37 years old. The average sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and PI-LL mismatch (PI-LL) were 37.78 ± 6.59, 14.51 ± 9.19 degrees, and 52.29 ± 10.87 degrees and - 0.36 ± 11.41, respectively. The mean velocity and stride of all the volunteers were 119.00 ± 30.12 cm/s and 130.25 ± 7.72 cm, correspondingly. The correlation between each of the radiographical and gait parameters was low (ranging from - 0.24 to 0.26). CONCLUSION: Gait parameters were not differenced significantly between each of the PI subgroups in asymptomatic volunteers. Spinal sagittal parameters also showed a low correlation with gait parameters.

Scapular dyskinesis after treatment of proximal humerus fracture, a 3-dimensional motion analysis and clinical outcomes.

BACKGROUND: The alteration of scapular kinematics can predispose patients to shoulder pathologies and dysfunction. Previous literature has associated various types of shoulder injuries with scapular dyskinesis, but there are limited studies regarding the effect that proximal humeral fractures (PHFs) have on scapular dyskinesis. This study aims to determine the change in scapulohumeral rhythm following treatment of a proximal humerus fracture as well as differences in shoulder motion and functional outcomes among patients who presented with or without scapular dyskinesis. We hypothesized that differences in scapular kinematics would be present following treatment of a proximal humerus fracture, and patients who presented with scapular dyskinesis would subsequently have inferior functional outcome scores. METHODS: Patients treated for a proximal humerus fracture from May 2018 to March 2021 were recruited for this study. The scapulohumeral rhythm and global shoulder motion were determined using a 3-dimensional motion analysis (3DMA) and the scapular dyskinesis test. Functional outcomes were then compared among patients with or without scapular dyskinesis, including the SICK (scapular malposition, inferomedial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) Scapula Rating Scale, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the visual analog scale (VAS) for pain, and the EuroQol-5 Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS: Twenty patients were included in this study with a mean age of 62.9 ± 11.8 years and follow-up time of 1.8 ± 0.2 years. Surgical fixation was performed in 9 of the patients (45%). Scapular dyskinesis was present in 50% of patients (n = 10). There was a significant increase in scapular protraction on the affected side of patients with scapular dyskinesis during abduction of the shoulder (P = .037). Additionally, patients with scapular dyskinesis demonstrated worse SICK scapula scores (2.4 ± 0.5 vs. 1.0 ± 0.4, P = .024) compared to those without scapular dyskinesis. The other functional outcome scores (ASES, VAS pain scores, and EQ-5D-5L) showed no significant differences among the 2 groups (P = .848, .713, and .268, respectively). CONCLUSIONS: Scapular dyskinesis affects a significant number of patients following treatment of their PHFs. Patients presenting with scapular dyskinesis exhibit inferior SICK scapula scores and have more scapular protraction during shoulder abduction compared to patients without scapular dyskinesis.

A new classification for combined greater tuberosity fracture and anterior shoulder dislocation: A study of fracture configurations and displacement after reduction.

OBJECTIVE: The aim of this study was to propose a new classification of combined greater tuberosity (GT) fractures and anterior shoulder dislocation and studied the degree of displacement, functional outcomes, and need for additional surgery after reduction. METHODS: A cross-sectional study was conducted. We evaluated radiographs of patients treated for combined GT fractures and anterior shoulder dislocation. Three morphologies were proposed; type 1 (a small avulsion), type 2 (GT fractures without articular head involvement), and type 3 (GT associated with articular head fractures). Two orthopedic surgeons independently measured all radiographs and classified fractures into three types. Patients were interviewed by telephone to assess functional outcomes (the simple shoulder test (SST) and EQ-5D-5L), and additional shoulder surgery was also performed. RESULTS: There were 52 eligible patients; 32 were male (61.5%) and the mean age was 57.3 · 17.1 years. Most cases were low-energy injuries (61.5%). Of all the cases, 32.7% were type I, 59.6% type II, and 7.7% type III cases. There were differences in the degree of displacement in each group at pre, post-reduction (both horizontal and vertical planes) and at two weeks post-reduction for HD (p < 0.05). Type III had more displacement than type I at pre- and post-reduction with a P value of less than 0.05. Type III also had higher rates of displacement than type II at post-reduction and at two-week postreduction (vertical plane). The intra and inter-rater reliabilities of measurement (ICC > 0.8) were in good to excellent agreement with the kappa value (>0.9). Three out of 52 cases (5.8%) required an additional surgery after closed reduction. Patients had good functional outcomes (SST score of 8) with an excellent utility index of EQ-5D-5L (0.9). CONCLUSION: This new classification exhibited good-to-excellent intra-and inter-rater reliabilities, with an ability to determine injury type. Type III seems to be linked to higher risk of fracture displacement and may require additional surgery. LEVEL OF EVIDENCE: Level IV, Diagnostic Study.

Cutoff Value for the Patient Acceptable Symptom State of the Thai IKDC Subjective Knee Form in Patients After Primary ACL Reconstruction.

Background: The Patient Acceptable Symptom State (PASS) cutoff is the value on a patient-reported outcome measure beyond which patients consider themselves to be "feeling well." There are limited data regarding the PASS threshold for non-English versions of the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF). Purpose: To establish the PASS cutoff for the Thai version of the IKDC-SKF for patients undergoing primary anterior cruciate ligament reconstruction (ACLR) and to identify factors to achieve PASS after surgery. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Included in this study were patients aged 18 to 50 years who had undergone primary unilateral ACLR between January 2016 and February 2020. After enrollment, patients completed the Thai IKDC-SKF and answered the anchor question for determining the PASS. Results: Questionnaires were sent to 321 patients, of whom 173 (53.9%) responded. The vast majority (156 patients; 90.2%) considered themselves to have achieved the PASS. This group of patients had significantly higher IKDC scores than did those who did not have an acceptable symptom state (79.6 ± 14.2 vs 60.7 ± 16.5; P < .001). The receiver operating characteristic curve of the IKDC score for predicting the PASS had an area under the curve of 0.82 (95% CI, 0.72-0.91). The optimum PASS cutoff of the Thai IKDC-SKF was a score of 74.2 (sensitivity, 0.72; specificity, 0.82). Factors that provided favorable odds for achieving the PASS were the use of a hamstring tendon autograft (odds ratio, 4.1; 95% CI, 1.5-20.6) and the absence of a patellofemoral chondral lesion (odds ratio, 3.8; 95% CI, 1.03-14.1). Conclusion: For patients undergoing ACLR, the cutoff for the PASS of the Thai version of the IKDC-SKF was a score of 74.2. Two surgery-related factors provided favorable odds for achieving the PASS: the use of a hamstring tendon autograft and the absence of a patellofemoral chondral lesion.

Three-dimensional motion analysis of ten common Asian sitting positions in daily living and factors affect range of hip motions.

BACKGROUND: Sitting involves many activities of daily life and requires most motion in the hip joint. Asians have more hip flexion and external rotation motions than Westerners owing to cultural and lifestyle differences. Being aware of the normal range of hip motion is essential in clinical practice. Limited research has focused on the hip motions of common sitting positions. The objective was to determine the hip motions of 10 common sitting positions, and to determine whether gender or being overweight affects the range of hip motions. METHODS: An experimental cross-sectional study was conducted to determine hip motions by using a standard, three-dimensional, motion-analysis system. Healthy subjects performed 10 sitting positions during 3 trials. All hip-kinematic data were measured on the dominant leg of each participant, except for the right- and left-monk positions (both hips were analyzed). Density plots were constructed and statistical analyses were performed to detect the differences between groups (male and female; non-overweight and overweight). RESULTS: The 48 participants comprised 24 males and 24 females. Most were right-leg dominant (45 participants, 93.8%). Of the 22 participants in the overweight group (body mass index ≥23 kg/m2), 18 (75%) were male. Squatting showed the highest flexion angle (99.7°, 47.3°-122°). Cross-legged sitting had the highest abduction angle (28.9°, 9.9°-45.7°) and the largest external rotation angle (62°, 37.6°-81.7°). In the female group, there were trends toward a greater flexion angle (4 out of 10 sitting positions) and a smaller abduction angle (6 out of 9 positions), with P values < 0.05. As to body weight, the overweight participants had a smaller flexion angle but a greater abduction angle, with 5 out of 9 positions having a P value < 0.05. Kinematic data of the transverse plane revealed that the heterogeneity of the rotational angles depended on the sitting position. CONCLUSIONS: This study provided the functional hip motions of common Asian sitting positions. The kinematic data can be utilized in clinical practice as reference values to determine safe positions. Gender and being overweight affected the hip angles in the sagittal and frontal planes. TRIAL REGISTRATION: Number TCTR20181021004 , retrospectively registered at the Thai Clinical Trials Registry (http//:www.clinicaltrials.in.th).

Validity and reliability of smartphone applications for measurement of hip rotation, compared with three-dimensional motion analysis.

BACKGROUND: Measurement of hip rotation is a crucial clinical parameter for the identification of hip problems and the monitoring of symptoms. The objective of this study was to determine whether the use of two smartphone applications is valid and reliable for the measurement of hip rotation. METHODS: An experimental, cross-sectional study was undertaken to assess passive hip internal and external rotation in three positions by two examiners. The hip rotational angles were measured by a smartphone clinometer application in the sitting and prone positions, and by a smartphone compass application in the supine position; their results were compared with those of the standard, three-dimensional, motion analysis system. The validities and inter-rater and intra-rater reliabilities of the smartphone applications were evaluated. RESULTS: The study involved 24 participants. The validities were good to excellent for the internal rotation angles in all positions (ICC 0.81-0.94), good for the external rotation angles in the prone position (ICC 0.79), and fair for the sitting and supine positions (ICC 0.70-0.73). The measurement of the hip internal rotation in the supine position had the highest ICC value of 0.94 (0.91, 0.96). The two smartphone applications showed good-to-excellent intra-rater reliability, but good-to-excellent inter-rater reliability for only three of the six positions (two other positions had fair reliability, while one position demonstrated poor reliability). CONCLUSIONS: The two smartphone applications have good-to-excellent validity and intra-rater reliability, but only fair-to-good inter-rater reliability for the measurement of the hip rotational angle. The most valid hip rotational position in this study was the supine IR angle measurement, while the lowest validity was the ER angle measurement in the sitting position. The smartphone application is one of the practical measurements in hip rotational angles. TRIAL REGISTRATION: Number 20181022003 at the Thai Clinical Trials Registry ( http://www.clinicaltrials.in.th ) which was retrospectively registered at 2018-10-18 15:30:29.

Arthroscopic Treatment of a Large Mass of the Medial Side of the Leg Caused by Distal Extension of a Meniscal Cyst: A Case Report.

CASE: We report a 39-year-old man who presented with a painful mass that had been growing over the anteromedial aspect of his left leg for 2 years and was recurrent after an open excisional biopsy. Magnetic resonance imaging showed a lobulated cyst that extended from the medial meniscus. Arthroscopic cyst decompression, anterior cruciate ligament reconstruction, partial meniscectomy, and repair of the meniscotibial capsule were performed. There was no recurrence during the 1-year follow-up. CONCLUSIONS: Arthroscopic cyst decompression and repair of the posterior meniscotibial capsule is a good and safe alternative procedure for the treatment of large-sized meniscal cysts with distal extensions.

Quantifying anterior knee pain during specific activities after using the bone-patellar tendon-bone graft for arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND/OBJECTIVE: There has been much debate about the optimal graft choice for an anterior cruciate ligament (ACL) reconstruction. Anterior knee pain is a common donor site problem when using a bone-patellar tendon-bone (BPTB) graft. However, knowledge of the characteristics of anterior knee pain during different daily activities is still limited. This study aimed to determine the incidence of anterior knee pain and to quantify the degree of pain during a range of daily living activities. METHODS: Thirty-five patients who were scheduled to undergo an ACL reconstruction with an autologous BPTB graft between February 2015 and December 2016 were enrolled. A visual analogue scale (VAS) for pain was recorded during each of the following activities: ascending at 30-degree slope, ascending and descending stairs, running, jumping, squatting, kneeling, sitting cross-legged, and sitting one-legged. Demographic data, the range of motion, the area of decreased sensation, and the IKDC score were collected and compared 3 and 6 months postoperatively. RESULTS: The 35 male patients had a mean age of 29.7 years. Postoperatively, the mean IKDC scores were 58.1 ±â€¯9.8 at 3 months and 72.7 ±â€¯10.5 at 6 months. The incidences of overall anterior knee pain were 62.9% and 34.3% at the 3- and 6-month time points. Kneeling was the only activity that produced severe pain. At 3 months postoperatively, kneeling's mean VAS pain score was 3.9 ±â€¯2.9 (2.9, 4.9; 95% CI for mean for 17 patients [48.5%] with considerable pain), whereas at 6 months postoperatively, it was 2 ±â€¯2.5 (1.2-2.9; 95% CI for mean for 9 patients [25.7%] with considerable pain). The area of numbness of the proximal leg decreased from 12.8 ±â€¯18.3 cm2 (6.4, 19.2; 95% CI for mean) to 3.2 ±â€¯9.1 cm2 (0.1, 6.5; 95% CI for mean) at 3 and 6 months postoperatively. CONCLUSIONS: Kneeling was the most challenging activity in terms of creating considerable levels of anterior knee pain in patients who had undergone an ACL reconstruction using a BPTB graft. Other knee activities, however, did not create moderate or severe degrees of anterior knee pain. Both anterior knee pain and numbness at the proximal leg improved over time.Trial registration number: TCTR2018-0630002.

A pilot study comparing the efficacy of two formulations of botulinum toxin type A for muscular calves contouring.

BACKGROUND: Enlarged, hypertrophy calf muscles are common in Asian women and can cause psychological burden. Botulinum toxin A (BTA) has been widely used in treating masseteric muscle hypertrophy and it's efficacious as a noninvasive method for calf-contouring has been reported. Food and Drug Administration has approved onabotulinumtoxin A (ONA, Botox; Allergan Inc, Irvine, CA, USA) for upper face rejuvenation and it has off-label uses for calf-contouring. A recently introduced Prabotulinumtoxin A (NABOTA® , PRA; Daewoong Pharmaceutical, Seoul, Korea) demonstrated a comparable efficacy and safety to ONA for masseter reduction. OBJECTIVE: To compare the efficacy and safety of PRA and ONA gastrocnemius muscle reduction. METHODS: This is an experimental, randomized, controlled double-blind study. Twenty-two patients were randomized to receive 100 units PRA and ONA on each calf and were asked to come for follow-up visit for up to 6 months. Clinical photographic documentation, calf circumference measurement (upright position and tiptoe), isokinetic analysis, and ultrasonographic imaging were performed to evaluate the treatment result. In addition, patients' satisfaction and side effect were also recorded. RESULTS: All patients completed the study without serious side effect occurred during the whole study period. The mean calf circumference of the ONA- and PRA-treated patients in upright position at baseline was 35.42 ± 1.35 cm and 36.49 ± 2.98 cm, respectively (P = 0.137). The mean calf circumference in upright position decreased significantly as early as 2 weeks after treatment, both in ONA group and in PRA group (P = 0.004 and P = 0.003, respectively), and continued to decrease until 6 months after treatment (P = 0.002 and P < 0.001, respectively). There was no statistically significant difference in mean calf circumference when comparing between ONA and PRA group at any time of follow-up period. For the tiptoe position, only in the PRA group that showed significant reduction as early as two weeks and lasted up to 6 months of follow-up (P < 0.001). The isokinetic analysis showed no significant reduction on both maximum torque and average work value in two groups. The ultrasonographic imaging revealed that the mean thickness of the lateral head of the gastrocnemius showed significant only in PRA-treated group at 2-, 3-, and 6-months of follow-up; meanwhile, the mean thickness of the medial head showed significant reduction at 2- and 6-months, with a slight increase at 3-months follow-up in two groups. The patients' satisfaction rate and doctor's evaluation also showed no statistically significant difference between both groups. CONCLUSION: This study demonstrated that PRA and ONA provided comparable efficacy and safety in gastrocnemius muscle reduction.

Evaluation of the Effectiveness of Preoperative Blood Ordering Guideline in Elective Spine, Knee Replacement, and Hip Replacement Surgery.

Background: Preoperative blood ordering is necessary in most of the major orthopedic operations. However, over-crossmatching 200 units/day results in technician workload and compromises blood stock for other patients at Siriraj Hospital. Objective: To evaluate the effectiveness of a new blood ordering guideline in spine and arthroplasty surgery at Siriraj Hospital by comparing the quantity of blood ordering between pre-guideline and guideline groups. Material and Method: The guideline was developed from data of 456 patients who underwent spine or arthroplasty surgery between January 2013 and December 2013 at Siriraj Hospital. To evaluate the effectiveness of the guideline, blood order, and use in 89 patients who received specific orthopedic surgical procedures between December 2014 and March 2015 were compared to blood order and use in pre-guideline patients. Results: Five hundred forty five patients were included. Mean age of subjects was 58 years and 71.49% were females. Mean cross-matched units between the pre-guideline group (1.81 units; 95% CI 1.70 to 1.92) and the guideline group (1.34 units; 95% CI 1.13 to 1.55) was significantly different (p<0.001). Conclusion: The blood ordering guideline does increase effectiveness of preoperative blood reservation, reduce unnecessary cost, and does not compromise patient safety. Consistent use and frequent evaluation of this guideline are encouraged.

The anatomical safe zone for medial opening oblique wedge high tibial osteotomy.

INTRODUCTION: The end of medial opening oblique wedge high tibial osteotomy (HTO) points into a narrow area between the articular cartilage of the posterolateral proximal tibia and proximal tibiofibular joint (PTFJ) at the tibial site, which is an anatomical safe zone (ASZ) for osteotomy. We studied the ASZ and its relation to the fibular tip, including the level of posterior cruciate ligament (PCL) insertion, to avoid penetration into the knee and PTFJ, and PCL injury by osteotomy. METHODS: Ten pairs of embalmed cadaveric legs were disarticulated at the knee joint and then examined. Soft tissues at the proximal tibia were removed. The posterior capsule of the PTFJ was incised to identify the articular cartilage of the PTFJ at the tibial site. The height of the fibular tip and the thickness of the ASZ were measured and calculated to determine the relationship between the ASZ and fibular tip. The level of PCL insertion was measured from the posterior articular surface of the proximal tibia to the distal attachment of the PCL. RESULTS: The average height of the fibular tip and the thickness of the ASZ were 5.43 ± 1.53 mm and 4.12 ± 1.60 mm, respectively. On average, the fibular tip was 1.31 ± 1.28 mm higher than the ASZ, and the level of PCL insertion was 10.10 ± 1.88 mm. CONCLUSION: To ensure safety during medial opening oblique wedge HTO, the end of osteotomy should point accurately into the ASZ at a level just below the fibular tip as reference. Proximal osteotomy thickness should not be less than 10 mm at the level of PCL insertion.

Radiographic assessment of the safe zone for medial oblique opening wedge high tibial osteotomy.

PURPOSE: To compare different cephalocaudal angles of the X-ray beam in measuring internal rotation of the proximal tibia that best demonstrates the safe zone. METHODS: 10 pairs of embalmed, disarticulated knee joints from 10 cadavers were used. Soft tissues around the proximal tibia and the proximal tibiofibular joint (PTFJ) were dissected to reveal the articular cartilage. A narrow area between the end of the articular cartilage of the posterolateral proximal tibia and of the PTFJ was identified as the safe zone with a U-shape metal used as a radiographic marker. Translation of the proximal tibia was controlled during internal rotation of the proximal tibia. Internal rotation of the proximal tibia that best demonstrated the safe zone (the U-shape metal at its most outermost point) was measured at 0º, 5º, 10º, 15º, 20º, and 25º cephalocaudal angles of the X-ray beam. RESULTS: The mean internal rotation of the proximal tibia that best demonstrated the safe zone at 0º, 5º, 10º, 15º, 20º, and 25º cephalocaudal angle of the X-ray beam were 50º, 45º, 37º, 32º, 23º, and 19º, respectively. CONCLUSION: The safe zone was best demonstrated with 50º and 45º internal rotation of the proximal tibia at 0º and 5º cephalocaudal angles of the X-ray beam, respectively.

Single-bundle versus double-bundle anterior cruciate ligament reconstruction: a meta-analysis.

OBJECTIVE: This meta-analysis study compares the treatment outcomes between single bundle (SB) and double bundle (DB) anterior cruciate ligament reconstructions (ACLR) including manual laxity tests, KT-1000 measurements and functional knee scores including International Knee Documentation Committee (IKDC) and Lysholm scores. DATA SOURCES: Medline, Scopus, Web of Science and Cochrane Central Register of Controlled Trials (January 1985 to March 2008). MATERIAL AND METHOD: All randomized controlled trials reporting one or more outcomes related to single bundle versus double bundle ACLR were recruited in the present study. Random effect models were used to pool the data. Heterogeneity in the effect of treatment was tested on the basis of study quality, randomization status and type of ACLR. RESULTS: There were 2,119 studies initially identified, 7 studies met our inclusion criteria. Four hundred and eighty two patients (238 in SB group and 244 in DB group) were included in the present study. The results of KT 1,000 arthrometry in 7 studies favor DB-ACLR with statistical significance (p < 0.05). Pivot shift test were available for 374 patients from 6 studies, 183 and 191 patients in SB group and DB group respectively. The results favor DB-ACLR with statistical significance (p < 0.001). IKDC scores were available for 257 patients from 4 studies. The results trend to favor DB-ACLR but not statistically significant (p = 0.17). Lysholm scores were available for 174 patients from 3 studies. The results trend to favor DB-ACLR without statistical significance (p = 0.10). CONCLUSION: The present study shows that DB-ACLR provides better AP and rotational stability than SB-ACLR. There is no difference in the results of functional scores. DB-ACLR should be considered in patients who particularly require rotational stability of the knee. In the future, the interesting issue is to develop the functional knee score that is more specific to rotational stability evaluation.

A spectral analysis of rotator cuff musculature electromyographic activity: surface and indwelling.

Electromyography (EMG) of the shoulder girdle is commonly performed; however, EMG spectral properties of shoulder muscles have not been clearly defined. The purpose of this study was to determine the maximum power frequency, Nyquist rate, and minimum sampling rate for indwelling and surface EMG of the normal shoulder girdle musculature. EMG signals were recorded using indwelling electrodes for the rotator cuff muscles and surface electrodes for ten additional shoulder muscles in ten healthy volunteers. A fast Fourier transform was performed on the raw EMG signal collected during maximal isometric contractions to derive the power spectral density. The 95% power frequency was calculated during the ramp and plateau subphase of each contraction. Data were analyzed with analysis of variance (ANOVA) and paired t tests. Indwelling EMG signals had more than twice the frequency content of surface EMG signals (p < .001). Mean 95% power frequencies ranged from 495 to 560 Hz for indwelling electrodes and from 152 to 260 Hz for surface electrodes. Significant differences in the mean 95% power frequencies existed among muscles monitored with surface electrodes (p = .002), but not among muscles monitored with indwelling electrodes (p = .961). No significant differences in the 95% power frequencies existed among contraction subphases for any of the muscle-electrode combinations. Maximum Nyquist rate was 893 Hz for surface electrodes and 1,764 Hz for indwelling electrodes. Our results suggest that when recording EMG of shoulder muscles, the minimum sampling frequency is 1,340 Hz for surface electrodes and 2,650 Hz for indwelling electrodes. The minimum sampling recommendations are higher than the 1,000 Hz reported in many studies involving EMG of the shoulder.

Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft.

Primary ACL reconstruction using a contralateral patellar tendon autograft is an effective means of achieving symmetrical range of motion and strength after surgery. When the graft is harvested from the ipsilateral knee, the rehabilitation for the ACL graft and for the graft-donor site are different and have opposing goals. Rehabilitation for the ACL graft involves obtaining full range of motion, reducing swelling, and providing the appropriate stress to achieve graft maturation. Rehabilitation for the graft-donor site involves performing high-repetition strengthening exercises to regain size and strength, best achieved when begun immediately after surgery.