Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial.

BACKGROUND: Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA. METHODS: At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis. RESULTS: Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25). CONCLUSIONS: Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Analysis of rotator cuff muscles in adult human cadaveric specimens.

Management of irreparable massive rotator cuff tears remains a challenging and controversial problem. Defining glenohumeral force relations may allow for the development of treatment strategies based on biomechanical principles. Five fresh-frozen adult human cadaveric shoulder specimens were dissected to determine fiber length, mass, and lever arm of (a) the 3 bellies of the deltoid and (b) the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis). From these data, physiologic cross-sectional areas and moment relations were calculated. These relations provide evidence for a balanced axial force couple between the anterior and posterior rotator cuff. Demonstration of an axial force couple across the glenohumeral joint may have clinical significance for treatment of irreparable massive rotator cuff tears and may explain why many patients with full-thickness rotator cuff tears can regain acceptable shoulder function.

Anatomy, pathologic features, and treatment of acetabular labral tears.

There is an evolving body of knowledge regarding the acetabular labrum. Labral tears are most frequently anterior and often are associated with sudden twisting or pivoting motions. High clinical suspicion in association with positive physical findings are fundamental for the clinician to properly determine treatment for the suspected tear. Labral tears, especially those present for years, may contribute to the progression of hip osteoarthritis. Patients at risk include those with developmental dysplasia, those with tears greater than 5 years, and those with associated chondral full-thickness lesions. Chondral injuries may occur in association with a multitude of hip conditions including labral tears, loose bodies, osteonecrosis, slipped capital femoral epiphysis, dysplasia, and degenerative arthritis. Labral tears occurring at the watershed zone may destabilize the adjacent acetabular conditions. Arthroscopic observations support the concept that labral disruption, acetabular chondral lesions, or both frequently are part of a continuum of degenerative joint disease.