Patients' perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study.

INTRODUCTION: The most common major trauma injuries are multiple fractures. Orthopaedic trauma research has traditionally focused on surgical techniques, and the impact of this major life event on the patient is not well understood. This study explored how patients make sense of their rehabilitation and recovery following major orthopaedic trauma. DESIGN: Qualitative study using an Interpretative Phenomenological Analysis approach. METHODS: Semi-structured interviews of a purposive sample of 15 patients 3 to 6 months after sustaining major orthopaedic injuries, treated at a major trauma centre in England. FINDINGS: Recovery after trauma was conceptualised as a journey through repair and rehabilitation to achieve recovery. These phases were represented by three superordinate themes: getting back on your feet, getting the right help to get there, and regaining a sense of normality. Participants considered orthopaedic consultants and physiotherapists to be the primary professionals to provide the tools to enable them to help themselves. Improving physical function helped to restore emotional well-being, with recovery only attained when participants had normalised a new sense of self, and regained confidence or enjoyment in their chosen activities. CONCLUSION: Rehabilitation is a complex process of coming to terms with physical and social limitations to normalise a new sense of self. Individuals considered rehabilitation to be their responsibility; however, they needed expert help to know what to do. Physiotherapists were key to getting people back on their feet, and by facilitating physical recovery, physiotherapists were able to have a positive impact on emotional well-being.

Incomplete avulsion of the proximal insertion of the hamstring: outcome two years following surgical repair.

Incomplete avulsion of the proximal hamstrings can be a severely debilitating injury that causes weakness, pain while sitting and inability to run. The results of the surgical treatment of 23 consecutive patients with such injuries at least two years after surgery are described. The surgery consisted of the repair of the hamstrings directly onto the ischial tuberosity. At review, using a visual analogue scale (VAS, 0 to 100), pain while sitting improved from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p = 0.0001). According to a VAS, satisfaction was rated at a mean of 81 (0 to 100) and 20 patients (87%) would have the same procedure again. Hamstring strength measured pre- and post-operatively had improved significantly from a mean of 64% (0% to 95%) to 88% (50% to 114%) compared with the normal side. Most of these patients with symptomatic incomplete hamstring avulsions unresponsive to conservative treatment had an improved outcome after surgical repair.

Vascular endothelial growth factor receptors in osteoclast differentiation and function.

Osteoclasts are derived from haematopoietic stem cell precursors of the monocyte/macrophage cell lineage, through interaction with factors that are believed to include M-CSF and RANKL. VEGF is a proangiogenic cytokine that has been shown to promote osteoclast differentiation and survival. In this study, we assessed the role of VEGF and its receptors in osteoclastogenesis, in vitro, by culturing osteoclast precursors in the presence of VEGF, VEGF receptor-specific ligands, and blocking antibodies to VEGF receptors. Activation of VEGFR1 in the presence of RANKL induces osteoclast differentiation. Stimulating the receptors individually induced increased resorption by osteoclasts compared to controls but not to the level observed when stimulating both receptors simultaneously. We have shown that VEGF induces osteoclast differentiation through its action on VEGFR1. The way in which VEGF mediates its effect on mature osteoclast activity, however, may be through its interaction with both receptor subtypes.

Vascular endothelial growth factor acts as an osteolytic factor in breast cancer metastases to bone.

Vascular endothelial growth factor (VEGF) is a proangiogenic cytokine that is expressed highly in many solid tumours often correlating with a poor prognosis. In this study, we investigated the expression of VEGF and its receptors in bone metastases from primary human breast tumours and further characterised its effects on osteoclasts in vitro. Breast cancer metastases to bone were immunohistochemically stained for VEGF, its receptors VEGFR1 and 2 (vascular endothelial growth factor receptor 1 and 2), demonstrating that breast cancer metastases express VEGF strongly and that surrounding osteoclasts express both VEGFR1 and VEGFR2. RAW 264.7 cells (mouse monocyte cell line) and human peripheral blood mononuclear cells (PBMCs) were cultured with VEGF, RANKL and M-CSF. VEGF and RANKL together induced differentiation of multinucleated, tartrate-resistant acid phophatase (TRAP)-positive cells in similar numbers to M-CSF and RANKL. The PBMCs were also able to significantly stimulate resorption of mineralised matrix after treatment with M-CSF with RANKL and VEGF with RANKL. We have shown that VEGF in the presence of RANKL supports PBMC differentiation into osteoclast-like cells, able to resorb substrate. Vascular endothelial growth factor may therefore play a role in physiological bone resorption and in pathological situations. Consequently, VEGF signalling may be a therapeutic target for osteoclast inhibition in conditions such as tumour osteolysis.