Return to work following total knee arthroplasty: A multiple case study of stakeholder perspectives.

OBJECTIVE: The study's aim was to gain insights into factors influencing sustainable return to work following total knee arthroplasty (TKA). DESIGN: A descriptive multiple-case design was used. A case was defined as a worker's following TKA work disability situation. SETTINGS: The cases came from public hospitals in urban and semi-urban areas in Quebec (Canada) and involved mostly non-work-related TKAs. SUBJECTS: Workers had to be between 6 and 12 months post-TKA, have physical/manual jobs and currently employed. Their rehabilitation professionals and workplace representatives (employer and/or union) were also recruited, based on the work disability paradigm. MAIN MEASURES: Semi-structured interviews, questionnaires on pain, physical work demands (workers only), and observation of the work activities of those workers back at work were used. Cases were compared and categorized for worker-perceived levels of difficulty in returning to or staying at work: little or no difficulty (n = 8); some difficulty (n = 5); not back at work due to excessive difficulty with their knee (n = 4). RESULTS: A total of 17 cases were constituted. In only one case, the worker benefitted from an interdisciplinary work rehabilitation approach. Results highlight the interplay among these factors: (1) the workers' perceptions of their residual symptoms and ability to manage them, (2) the interaction between work adjustments and tools offered by the employers and the workers' own strategies, and (3) perceptions of the workers' physical capacities. CONCLUSION: Workers' who face high levels of work demands/difficulties and who have limited access to work adjustments and tools should be referred for work rehabilitation.

Atypical fracture of the tibial diaphysis associated with bisphosphonate therapy: a case report.

Atypical subtrochanteric femoral shaft fractures (AFFs) have recently emerged as a potential long-term complication of bisphosphonate therapy. In 2010, the American Society for Bone and Mineral Research (ASBMR) Task Force published a definition for AFF consisting of 5 major and 7 minor features. Little attention has so far been paid to the possibility that bisphosphonate-associated atypical fractures may also involve the diaphysis of other long bones. We report here the case of a patient on long-term bisphosphonate therapy who presented a diaphyseal tibial insufficiency fracture fulfilling all the major criteria (except for the location), and a number of the minor criteria of an atypical fracture. Our case report suggests the need for greater awareness of the possibility of atypical fractures at other sites, particularly in weight-bearing long bones other than the femur, and suggests that long-term bisphosphonate therapy may also contribute to the occurrence of these atypical fractures.

Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty.

Outcome measures in physical therapy provide the basis for determining the patient's rehabilitation needs, developing an individual intervention plan, and reassessing the evolution of the condition after therapeutic intervention. Questions surrounding the validity and reliability of outcome measures obtained in the context of telerehabilitation remain. The goal of this study was to explore which outcome measures can be used reliably in the context of telerehabilitation after discharge from an acute care hospital for lower limb orthopedic surgery. Fifteen patients recently discharged after total knee arthroplasty were evaluated by two experienced therapists. Each therapist evaluated under a given condition (face-to-face assessment, telerehabilitation assessment) eight outcome measures taken from standard clinical tests routinely used in the management of orthopedic rehabilitation after total knee arthroplasty. Evaluations were measured at 1-day intervals. Telerehabilitation evaluations were conducted with a videoconference link (H.264 CoDecs with Pan, Tilt, Zoom cameras) between either the participant's home or a clinical environment and a remote clinical station over residential DSL lines at 512 kbps. Interrater agreement between the two measurement modes was analyzed using the Bland and Altman method and Kripendorff's alpha reliability estimate. The 95% confidence interval for mean difference between evaluation methods varied between -20% and 8% for knee range of motion measures, -85% and 55% for scar management, -33% and 29% for functional evaluations. Five out of the eight outcome measures showed reliability estimates of >0.80, with lowest reliability obtained for the scar assessment scale (0.34) and the highest reliability for the evaluation of the range of motion at the knee (0.87 in flexion and 0.85 in extension). Clinical variables typically measured in face-to-face evaluations can be measured successfully under telerehabilitation conditions with moderate reliability.

The wait for total hip replacement in patients with osteoarthritis.

OBJECTIVES: We documented the following components of waiting time for total hip replacement (THR): first surgical consultation, date of decision to operate and date of surgery. We then explored whether these intervals differed by age, sex, occupation or quality-of-life score. METHODS: We used a cross-sectional design and collected the primary data from patients 2 to 4 weeks before they underwent THR. Trained interviewers administered the Medical Outcomes Study Short Form-36 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which included data on event dates, conservative treatment, demographic information and quality of life. We illustrated waiting times, quality of life and past use of conservative treatment (i.e., cane, exercise, physiotherapy) with descriptive statistics (mean [standard deviation] or median [intraquartile range]) for continuous variables and with percentages for categorical variables. We plotted KaplanMeier graphs for each waiting time component and employed log-rank analysis to determine whether any of these delays differed by age, sex, occupation or disability. We also performed a Cox regression to adjust for all covariates simultaneously. RESULTS: The median wait from surgical consultation to decision to operate was 0 months. There was no difference between age, sex or occupation. The median wait from decision to operate to the date of surgery was 6 months and did not differ by age, sex or occupation. However, subjects with more severe symptoms (WOMAC) underwent surgery earlier than did those with less severe disease. CONCLUSION: Although neither of the waiting time components were associated with age, sex or occupation, patients with more severe symptoms appear to be prioritized for surgery.