Can a physiotherapy student assume the role of an advanced practice physiotherapist in Orthopaedic surgery triage? A prospective observational study.

BACKGROUND: Advanced practice physiotherapists (APP) have helped improve accessibility to orthopaedic outpatient care. Several studies have validated the APP practice model in orthopaedic care, demonstrating high agreement between APPs and orthopaedic surgeons (OS) regarding diagnosis and management. However, as APPs tend to be experienced senior physiotherapists, such a study involving physiotherapy students (PS) has not yet been explored. The objective of this study was to evaluate the agreement for orthopaedic diagnoses and surgical triage between a PS and OSs. METHODS: A prospective study involving a final year PS and seven OSs was conducted in a university hospital, after the PS had undergone a three-week intensive training. Eighty-six adult patients referred to OSs for knee osteoarthritis, hip osteoarthritis or shoulder problem were independently evaluated by the PS, and then re-evaluated by an OS. The diagnoses and surgical triage recommendations of both clinicians were analyzed for agreement using raw percent agreement and Cohen's kappa. Patient satisfaction with the outpatient clinic experience was noted using a modified version of the Visit-Specific Satisfaction Instrument. RESULTS: Our sample consisted of 86 patients (mean age = 63.4 years). Reasons for consultation included shoulder problems (36%), knee osteoarthritis (52%) and hip osteoarthritis (12%). The raw percent agreement for diagnosis was 95.3%. The agreement for surgical triage was high (κ = 0.86, 95% CI: 0.74-0.98) with a raw agreement of 94.2%. Patient satisfaction was high. CONCLUSIONS: The PS and OSs made similar diagnoses and triage recommendations suggesting that clinical experience alone is not a prerequisite for physiotherapists to help increase accessibility to orthopaedic care.

Patient Satisfaction with In-Home Telerehabilitation After Total Knee Arthroplasty: Results from a Randomized Controlled Trial.

Background and Introduction: Telerehabilitation after total knee arthroplasty (TKA) is supported by strong evidence on the effectiveness of such intervention and from a cost-benefit point of view. Satisfaction of patients toward in-home telerehabilitation after TKA has not yet been examined thoroughly in large-scale clinical trials. This study aims to compare satisfaction level of patients following in-home telerehabilitation (TELE) after TKA to one of the patients following a usual face-to-face home visit (STD) rehabilitation. Secondarily, to determine if any clinical or personal variables were associated to the level of satisfaction. MATERIALS AND METHODS: This study was embedded in a multicenter randomized controlled trial with 205 patients randomized into two groups. Rehabilitation intervention was the same for both groups; only approach for service delivery differed (telerehabilitation or home visits). Participants were assessed at baseline (before TKA), at hospital discharge, and at 2 and 4 months postdischarge (E4) using functional outcomes. Patient satisfaction was measured using the validated Health Care Satisfaction Questionnaire (HCSQ) at E4. RESULTS: Characteristics of all participants were similar at baseline. Satisfaction level of both groups did not differ and was very high (over 85%). It was neither correlated to personal characteristics nor to improvements of functional level from preoperative to E4. Satisfaction was rather found associated to walking and stair-climbing performances. CONCLUSIONS: These results, in conjunction with evidences of clinical effectiveness and cost benefits demonstrated in the same sample of patients, strongly support the use of telerehabilitation to improve access to rehabilitation services and efficiency of service delivery after TKA.

Is an in-home telerehabilitation program for people with proximal humerus fracture as effective as a conventional face-to face rehabilitation program? A study protocol for a noninferiority randomized clinical trial.

BACKGROUND: Proximal humerus fractures can be treated surgically (eg: pinning, plate and screws) or conservatively by wearing a splint or a cast. Following both of these approaches, rehabilitation has proven effective to prevent functional limitations and to re-establish normal shoulder function. However, access to these rehabilitation services and compliance tends to be limited in elderly patients due to travelling difficulties caused by their precarious health status and, in some cases, social and marital status. Since the majority of patients with a proximal humerus fracture are elderly, it becomes relevant to find a new way to offer quick, simple and suitable rehabilitation service. Thus, the use of promising alternative approaches, as in-home telerehabilitation, can enhance access to rehabilitation services for such population. The main objective of the study is to compare the clinical effects of the innovative telerehabilitation approach (TELE group) compared to face-to-face visits to a clinic (CLINIC group) for patients treated for a proximal humerus fracture. METHODS/DESIGN: In this randomized controlled trial, individuals who have had a proximal humerus fracture treated conservatively at the Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie CHUS), and who are returning home will be included. Participants will be recruited during their visit to the emergency ward or outpatient clinic by the medical or research team and will then sign the informed consent form if they are interested to participate in the study. We expect to recruit 52 participants (26 per group). Randomization will be done by a random number generator with sealed envelopes. Each patient will be evaluated before the beginning of the rehabilitation (T1), and immediately after the 2-month intervention (T2). The following outcomes will be measured: 1) upper extremity function (Constant Shoulder Score and Disability of the Arm, Shoulder and Hand questionnaire [DASH]); 2) range of motion (conventional goniometer); 3) user satisfaction (Health Care Satisfaction questionnaire); and 4) cost of services to the public healthcare system. The difference between the two groups will be compared using a t-test or a chi-squared test, and through a cost-effectiveness economic analysis. DISCUSSION: We hypothesize that in-home telerehabilitation will provide a good alternative to conventional rehabilitation, in terms of its efficacy, simplicity, patient satisfaction, and low associated costs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02425267. April 22(nd), 2015.

Conditions of Use, Reliability, and Quality of Audio/Video-Mediated Communications During In-Home Rehabilitation Teletreatment for Postknee Arthroplasty.

BACKGROUND: Audio/video-mediated communication between patients and clinicians using videoconferencing over telecommunication networks is a key component of providing teletreatments in rehabilitation. OBJECTIVE: The objectives of this study were to (1) document the conditions of use, performance, and reliability of videoconferencing-based communication in the context of in-home teletreatment (TELE) following total knee arthroplasty (TKA) and (2) assess from the perspective of the providers, the quality attributes of the technology used and its impact on clinical objectives. MATERIALS AND METHODS: Descriptive embedded study in a randomized controlled trial using a sample of 97 post-TKA patients, who received a total of 1,431 TELE sessions. Technical support use, service delivery reliability, performance, and use of network connection were assessed using self-report data from a costing grid and automated logs captured from videoconferencing systems. Physical therapists assessed the quality and impact of video-mediated communications after each TELE session on seven attributes. RESULTS: Installation of a new Internet connection was required in 75% of the participants and average technician's time to install test and uninstall technology (including travel time) was 308.4 min. The reliability of service delivery was 96.5% of planned sessions with 21% of TELE session requiring a reconnection during the session. Remote technical support was solicited in 43% of the sessions (interventions were less than 3-min duration). Perceived technological impacts on video-mediated communications were minimal with quality of the overall technical environment evaluated as good or acceptable in 96% of the sessions and clinical objectives reached almost completely or completely in 99% of the sessions. CONCLUSIONS: In-home rehabilitation teletreatments can be delivered reliably but requires access to technical support for the initial setup and maintenance. Optimization of the processes of reliably connecting patients to the Internet, getting the telerehabilitation platform in the patient's home, installing, configuring, and testing will be needed to generalize this approach of service delivery.

Alterations in Monocyte Phenotypes and Functions after a Hip Fracture in Elderly Individuals: A 6-Month Longitudinal Study.

BACKGROUND: Healthy elderly individuals are particularly prone to catastrophic events at any moment of their lives. One stressful event for individuals aged 65 and older is a fall that results in a fracture of the hip (HF). HF causes a state of inflammation that may affect immune responses. In this connection, we have reported that HF induced alterations in neutrophil functions. OBJECTIVE: To assess the impact of HF on classical (cM), intermediate (iM) and non-classical (ncM) monocyte subsets. METHODS: Distribution, functions (chemotaxis, phagocytosis, superoxide production and cytokine production), phenotype and activation (NF-x03BA;B and PI3K) were evaluated in monocyte subsets before surgery and 6 weeks and 6 months after the event. RESULTS: The distribution of cM and ncM was unchanged, but iM transiently increased before surgery. Sustained increases (iM response to CCL2 and CX3CL1) and decreases (cM and ncM response to CCL2) in chemotaxis were observed. Phagocytosis and superoxide production were impaired in cM but not in iM or ncM. Sustained expression of HLA-DR occurred in cM but not in iM and ncM. Sustained decreased expression of CD11b occurred only in ncM. Sustained decreases (cM and ncM) and increases (iM) in CCR2 expression were observed. An elevated expression of CX3CR1 was found only in iM. cM produced elevated quantities of TNFα. There was a transient oxidative burst of production before surgery in iM and a sustained decrease in ncM. IL-10 production was severely impaired in cM and decreased in iM prior to surgery. Sustained activation (cM), inhibition (ncM) and transient activation (iM) of NF-x03BA;B were observed. Activation of PI3K was severely impaired in cM and ncM but was sustained in iM. CONCLUSION: HF had more impact on cM and ncM functions than on iM. HF triggered a switch in cM functions from phagocytic to inflammatory elevated TNFα-producing cells. These changes may impact clinical outcomes of HF with respect to inflammation, opportunistic infections and physical recovery.

Does Age Affect the Relationship Between Pain and Disability? A Descriptive Study in Individuals Suffering From Chronic Low Back Pain.

BACKGROUND: Previous studies have revealed a weak to moderate relationship between pain and disability in individuals suffering from low back pain (LBP). However, to our knowledge, no studies have evaluated if this relationship is different between young and older adults. PURPOSE: The objective of this descriptive, cross-sectional study was to determine whether the relationship between LBP intensity and physical disability is different between young and older adults. METHODS: Pain intensity (measured with a visual analog scale) and physical disability scores (measured with the Oswestry Disability Index) were collected from the medical files of 164 patients with LBP. Separate Pearson correlation coefficients were calculated between these 2 variables for young (mean age 40 ± 6 years, n = 82) and older (62 ± 9 years, n = 82) individuals and a Fisher r-to-z transformation was used to test for group differences in the strength of the relationship. Linear regression analyses were also performed to determine whether the slope of the association was different between the 2 groups. RESULTS: A significant and positive association was found between pain intensity and disability for both young and older individuals. However, the correlation was stronger in the young group (r = 0.66; P < .01) than in the older group (r = 0.44; P < .01) (Fisher Z = 2.03; P < .05). The linear regression model also revealed that the slope of the relationship was steeper in the young group (P < .05). CONCLUSION: Although both young and older individuals showed a significant association between pain intensity and disability, the relationship between these 2 variables was more tenuous in older individuals than in young patients. Future research is essential to identify the factors underlying this age-related difference.

In-Home Telerehabilitation Compared with Face-to-Face Rehabilitation After Total Knee Arthroplasty: A Noninferiority Randomized Controlled Trial.

BACKGROUND: The availability of less resource-intensive alternatives to home visits for rehabilitation following orthopaedic surgeries is important, given the increasing need for home care services and the shortage of health resources. The goal of this trial was to determine whether an in-home telerehabilitation program is not clinically inferior to a face-to-face home visit approach (standard care) after hospital discharge of patients following a total knee arthroplasty. METHODS: Two hundred and five patients who had a total knee arthroplasty were randomized before hospital discharge to the telerehabilitation group or the face-to-face home visit group. Both groups received the same rehabilitation intervention for two months after hospital discharge. Patients were evaluated at baseline (before total knee arthroplasty), immediately after the rehabilitation intervention (two months after discharge), and two months later (four months after discharge). The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the last follow-up evaluation. Secondary outcome measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, functional and strength tests, and knee range of motion. The noninferiority margin was set at 9% for the WOMAC. RESULTS: The demographic and clinical characteristics of the two groups of patients were similar at baseline. At the last follow-up evaluation, the mean differences between the groups with regard to the WOMAC gains, adjusted for baseline values, were near zero (for 182 patients in the per-protocol analysis): -1.6% (95% confidence interval [CI]: -5.6%, 2.3%) for the total score, -1.6% (95% CI: -5.9%, 2.8%) for pain, -0.7% (95% CI: -6.8%, 5.4%) for stiffness, and -1.8% (95% CI: -5.9%, 2.3%) for function. The confidence intervals were all within the predetermined zone of noninferiority. The secondary outcomes had similar results, as did the intention-to-treat analysis, which was conducted afterward for 198 patients. CONCLUSIONS: Our results demonstrated the noninferiority of in-home telerehabilitation and support its use as an effective alternative to face-to-face service delivery after hospital discharge of patients following a total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cost analysis of in-home telerehabilitation for post-knee arthroplasty.

BACKGROUND: Rehabilitation provided through home visits is part of the continuum of care after discharge from hospital following total knee arthroplasty (TKA). As demands for rehabilitation at home are growing and becoming more difficult to meet, in-home telerehabilitation has been proposed as an alternate service delivery method. However, there is a need for robust data concerning both the effectiveness and the cost of dispensing in-home telerehabilitation. OBJECTIVE: The objective of this study was to document, analyze, and compare real costs of two service delivery methods: in-home telerehabilitation and conventional home visits. METHODS: The economic analysis was conducted as part of a multicenter randomized controlled trial (RCT) on telerehabilitation for TKA, and involved data from 197 patients, post-TKA. Twice a week for 8 weeks, participants received supervised physiotherapy via two delivery methods, depending on their study group allocation: in-home telerehabilitation (TELE) and home-visit rehabilitation (VISIT). Patients were recruited from eight hospitals in the province of Quebec, Canada. The TELE group intervention was delivered by videoconferencing over high-speed Internet. The VISIT group received the same intervention at home. Costs related to the delivery of the two services (TELE and VISIT) were calculated. Student's t tests were used to compare costs per treatment between the two groups. To take distance into account, the two treatment groups were compared within distance strata using two-way analyses of variance (ANOVAs). RESULTS: The mean cost of a single session was Can $93.08 for the VISIT group (SD $35.70) and $80.99 for the TELE group (SD $26.60). When comparing both groups, real total cost analysis showed a cost differential in favor of the TELE group (TELE minus VISIT: -$263, 95% CI -$382 to -$143). However, when the patient's home was located less than 30 km round-trip from the health care center, the difference in costs between TELE and VISIT treatments was not significant (P=.25, .26, and .11 for the <10, 10-19, and 20-29 km strata, respectively). The cost of TELE treatments was lower than VISIT treatments when the distance was 30 km or more (30-49 km: $81<$103, P=.002; ≥50 km: $90<$152, P<.001). CONCLUSIONS: To our knowledge, this is the first study of the actual costs of in-home telerehabilitation covering all subcosts of telerehabilitation and distance between the health care center and the patient's home. The cost for a single session of in-home telerehabilitation compared to conventional home-visit rehabilitation was lower or about the same, depending on the distance between the patient's home and health care center. Under the controlled conditions of an RCT, a favorable cost differential was observed when the patient was more than 30 km from the provider. Stakeholders and program planners can use these data to guide decisions regarding introducing telerehabilitation as a new service in their clinic. TRIAL REGISTRATION: International Standard Registered Clinical Study Number (ISRCTN): 66285945; http://www.isrctn.com/ISRCTN66285945 (Archived by WebCite at http://www.webcitation.org/6WlT2nuX4).

Altered neutrophil functions in elderly patients during a 6-month follow-up period after a hip fracture.

BACKGROUND: Fracture of the hip (HF) is a significant cause of morbidity and mortality in elderly individuals. HF is an acute stress that triggers a state of inflammation which may affect immune responses and physical recovery. METHODS: Longitudinal study of the impact of HF on the functions of polymorphonuclear neutrophils (PMNs) in elderly subjects. Data were recorded prior to surgery, 6weeks and 6months later. RESULTS: PMN functions were severely impaired shortly after HF (chemotaxis, phagocytosis, superoxide production) but there was a time-related recovery of some PMN functions (chemotaxis, phagocytosis) over time, except in the case of superoxide production. Whereas FcγRII (CD32) expression remained unchanged, FcγRIII (CD16) increased from low values before surgery to levels of controls 6months post-surgery. This was also the case for the C5a complement receptor and CD11b. TLR2 and TLR4 expressions were unchanged. Cytokine and chemokine secretions by stimulated PMN were altered. TNFα and IL-10 secretions were increased following HF but IL-8 secretion was decreased. Impaired PMN functions prior to surgery were related to alterations in PI3K and NF-κB signaling pathways. Recovery of these functions paralleled increased PI3K activity, although superoxide production remained low. Sustained activation of the NF-κB pathway by TNFα has been reported to involve upregulation of IKKß kinase activity. Activated IKKß kinase inhibits ERK1/2 and results in concomitant downstream inhibition of NADPH oxidase complex which can account for sustained impaired production of ROS in HF patients. CONCLUSION: Our data showed that the stress caused by HF negatively affects initial PMN responses shortly after the event and that may negatively influence clinical outcomes such as resolving long-term inflammation and recovery, as well as explaining susceptibility to opportunistic infections.

Effects of Right Lower Limb Orthopedic Immobilization on Braking Function: An On-The-Road Experimental Study With Healthy Volunteers.

Little is known about how immobilization of the right lower limb might affect driving. The purpose of the present study was to evaluate the effect of 2 types of immobilization on the emergency braking time of healthy subjects during actual driving conditions. The emergency braking times of 14 healthy volunteers were assessed in a closed circuit under 3 conditions: wearing running shoes, wearing an Aircast Walker(®), or wearing a walking cast on their right lower limb. An instrumented car was used to measure the emergency braking times during braking tests with and without a distractor. The foot movement times were significantly increased with both immobilization devices compared with the running shoe (p < .01). The median total braking time with the running shoe during emergency braking without a distractor was 0.452 (interquartile range, 25th to 75th [IQR], 0.413 to 0.472) second. The results obtained with the Aircast Walker(®) or the walking cast were significantly longer (p < .01), at 0.480 (IQR, 0.431 to 0.537) second and 0.512 (IQR, 0.451 to 0.535) second, respectively. When a distractor was added, the total braking time with the running shoe, Aircast Walker(®), and walking cast was 0.489 (IQR, 0.429 to 0.575), 0.516 (IQR, 0.459 to 0.586), and 0.510 (IQR, 0.469 to 0.570) second, respectively, with no statistically significant differences among these 3 conditions. Wearing an immobilization device on the right lower limb minimally lengthens the emergency braking time in healthy drivers under actual driving conditions. Clinicians must nonetheless exercise caution when advising a driver wearing an orthopedic immobilization, because driving a motor vehicle is a complex psychomotor task that goes well beyond the emergency braking time.

The World Health Organization Fracture Risk Assessment Tool (FRAX) underestimates incident and recurrent fractures in consecutive patients with fragility fractures.

CONTEXT: The World Health Organization Fracture Risk Assessment tool (FRAX) was developed to identify patients at risk of sustaining a fragility fracture (FF). OBJECTIVE: The objective of the study was to evaluate estimated FRAX probabilities of FF at the time of a FF and to compare them with the observed incidence of recurrent FF. METHODS: A prospective cohort included men and women older than 50 years at the time of a FF. FRAX scores without bone mineral density [FRAX-body mass index (BMI)] were calculated prior to and after the inclusion FF. Recurrent FFs were recorded over a 4-year follow-up. Determinants associated with recurrent FF were determined by univariate and multivariate analyses. RESULTS: FRAX-BMI scores were available in 1399 of the 1409 recruited patients. A high-risk FRAX-BMI score was present in only 42.7% patients before and 56.4% after the incident FF. Most FF patients at low or moderate risk before their initial FF were men, younger than 65 years, or without previous FF. Over a median follow-up of 3 years, recurrent FF occurred in 108 patients (2.69 per 100 patient-years). The overall sensitivity of post-FF FRAX to predict a recurrent FF was 71.3% and was specifically lower in patients younger than 65 years (13%) and without previous FF (63%) at inclusion. CONCLUSIONS: The FRAX-BMI scores were below the Canadian threshold for treatment in more than half the patients at the time of a FF and in close to a third of patients with recurrent FF. FRAX-BMI severely underestimates the FF risk in patients younger than 65 years old and after a single FF.

In-home telerehabilitation for proximal humerus fractures: a pilot study.

The objective of this study was to investigate the feasibility of an in-home telerehabilitation program for proximal humerus fractures. Seventeen patients with proximal humerus fractures were recruited by an orthopedic specialist during emergency room visits. Telerehabilitation treatments were given at the patient's home over an 8-week period using a videoconferencing system. Pain (Short-Form McGill Pain Questionnaire [SF-MPQ]), disabilities including shoulder range of motion (flexion, extension, internal rotation, external rotation, abduction), and upper limb function (Disability of the Arm, Shoulder and Hand questionnaire [DASH]) were measured in face-to-face evaluations before (T1) and immediately after (T2) the program. Participant satisfaction with the health care received was also evaluated at T2 with the Health care satisfaction questionnaire. All the clinical outcomes improved post-intervention (p < 0.05). Also, patient satisfaction was high (overall score of 82 ± 7%). Therefore, in-home teletreatment seems to be a promising way to dispense rehabilitation services for this population.

Priming primary care physicians to treat osteoporosis after a fragility fracture: an integrated multidisciplinary approach.

OBJECTIVE: To evaluate 2 incremental levels of intervention designed to increase initiation of osteoporosis treatment by primary care physicians (PCP) following fragility fractures (FF). METHODS: Women and men over age 50 years were screened for incident FF in fracture clinics, and eligible outpatients were randomly assigned to standard care (SC) or to either minimal (MIN) or intensive (INT) interventions. The MIN and INT interventions were intended to educate and motivate both patients and PCP, but differed in their frequency of contact and information content. Delivery of osteoporosis medication was confirmed with pharmacists. Treatment rates were analyzed using an intention-to-treat approach. RESULTS: At inclusion, 74.3% of 881 outpatients with FF were untreated. Followup at 12 months was completed in 92.3% of patients. Up to 90% of patients treated at inclusion remained treated at 12 months. Among patients who initially were untreated, 18.8% in the SC group, 40.4% in the MIN, and 53.2% in the INT groups were treated at 12 months. Change in treatment rates (adjusted for age and initial treatment) increased significantly after both MIN and INT. Only the INT intervention significantly increased treatment rates in patients with previous fractures. Negative predictors of change in treatment status included non-major FF, age younger than 65 years, and male sex. CONCLUSION: Both interventions significantly increased initiation of osteoporosis treatment. Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized resources. Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term.

Partnership for fragility bone fracture care provision and prevention program (P4Bones): study protocol for a secondary fracture prevention pragmatic controlled trial.

BACKGROUND: Fractures associated with bone fragility in older adults signal the potential for secondary fracture. Fragility fractures often precipitate further decline in health and loss of mobility, with high associated costs for patients, families, society and the healthcare system. Promptly initiating a coordinated, comprehensive pharmacological bone health and falls prevention program post-fracture may improve osteoporosis treatment compliance; and reduce rates of falls and secondary fractures, and associated morbidity, mortality and costs. METHODS/DESIGN: This pragmatic, controlled trial at 11 hospital sites in eight regions in Quebec, Canada, will recruit community-dwelling patients over age 50 who have sustained a fragility fracture to an intervention coordinated program or to standard care, according to the site. Site study coordinators will identify and recruit 1,596 participants for each study arm. Coordinators at intervention sites will facilitate continuity of care for bone health, and arrange fall prevention programs including physical exercise. The intervention teams include medical bone specialists, primary care physicians, pharmacists, nurses, rehabilitation clinicians, and community program organizers.The primary outcome of this study is the incidence of secondary fragility fractures within an 18-month follow-up period. Secondary outcomes include initiation and compliance with bone health medication; time to first fall and number of clinically significant falls; fall-related hospitalization and mortality; physical activity; quality of life; fragility fracture-related costs; admission to a long term care facility; participants' perceptions of care integration, expectations and satisfaction with the program; and participants' compliance with the fall prevention program. Finally, professionals at intervention sites will participate in focus groups to identify barriers and facilitating factors for the integrated fragility fracture prevention program.This integrated program will facilitate knowledge translation and dissemination via the following: involvement of various collaborators during the development and set-up of the integrated program; distribution of pamphlets about osteoporosis and fall prevention strategies to primary care physicians in the intervention group and patients in the control group; participation in evaluation activities; and eventual dissemination of study results.

Irradiated allograft bone in spine surgery: to culture or not? A single center retrospective study.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: We aimed to document the rate of infection in our institution after the use of irradiated cancellous allograft or iliac crest bone autograft in vertebral fusion procedures. We also reviewed the pertinence of microbiological culture of cadaveric allograft bone prior to its implantation. SUMMARY OF BACKGROUND DATA: Recent studies have shown similar postoperative infection rates between allograft and autograft. The pertinence of microbiological culture of allograft bone prior to its implantation is currently controversial. METHODS: Retrospectively, we identified 338 patients who underwent spine fusion procedures for which there was a minimum of a 1-year follow-up. Files from both the neurosurgery and orthopedics divisions of the Centre hospitalier universitaire de Sherbrooke were reviewed during 1999 to 2009. Irradiated allografts were used in 164 patients and autografts were used in 174 patients. Of the 164 allografts implanted, 53 were cultured peroperatively. Postoperative spinal infection was based on documented positive spine cultures at the time of re-exploration for presumed infection. Infection rates were compared using Fisher exact test. RESULTS: From the 53 peroperative cultures, 5 were positive (9.4%) and none of them led to antibiotherapy or surgical revision at 1 year. No significant difference was observed in the rate of surgical site infection at 1 year, after the use of irradiated allografts (1.8%) or autografts (1.7%), P = 1.0. CONCLUSION: Perceived association with infection should not influence the surgeon in bone graft choice for spinal fusion. There is a lack of scientific evidence to recommend for or against routine cultures on allograft implantation in the literature. Our results strongly underline the pertinence of larger multicenter clinical trials to assess the pertinence of peroperative allograft bone culture.

Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: an embedded study in a randomized trial.

OBJECTIVE: We measured the satisfaction of both patients and healthcare professionals with the technologies and services provided during in-home telerehabilitation as an alternative to conventional rehabilitation after discharge from total knee arthroplasty surgery. METHODS: This study was embedded in a larger controlled trial where 48 community-living older adults who received total knee arthroplasty were recruited prior to discharge from acute care following surgery and randomly assigned to treatment arms (Tele and Comparison). The participants' satisfaction with the services was assessed at the end of the intervention for both groups using the Healthcare Satisfaction Questionnaire. For the Tele group, the patients' perception of in-home telehealth was assessed before treatment and after completion of teletreatments. The satisfaction of the healthcare professionals with the technology during the telerehabilitation services was noted at the end of each treatment session using a technical quality subjective appreciation questionnaire. RESULTS: Both groups of patients (Tele and Comparison) were satisfied with the services received and no significant difference was observed between them. Moreover, the physiotherapists' satisfaction with regard to goal achievement, patient-therapist relationship, overall session satisfaction, and quality and performance of the technological platform was high. CONCLUSIONS: As patient satisfaction is important in maintaining motivation and treatment compliance and the satisfaction of healthcare professionals must be high in order for new treatments to become mainstream in clinics, the results show that in-home telerehabilitation seems to be a promising alternative to traditional face-to-face treatments.

A randomized controlled trial of home telerehabilitation for post-knee arthroplasty.

We compared the effectiveness of home telerehabilitation with conventional rehabilitation following knee replacement surgery (total knee arthroplasty, TKA). Forty-eight patients (mean age 66 years) who received TKA were recruited prior to discharge from hospital after surgery and were randomly assigned to telerehabilitation or usual care. Telerehabilitation sessions (16 per participant over two months) were conducted by trained physiotherapists using videoconferencing to the patient's home via an Internet connection (512 kbit/s upload speed). Disability and function were measured using standardized outcome measures in face-to-face evaluations at three times (prior to and at the end of treatment, and four months after the end of treatment). Clinical outcomes improved significantly for all subjects in both groups between endpoints. Some variables showed larger improvements in the usual care group two months post-discharge from therapy than in the telerehabilitation group. Home telerehabilitation is at least as effective as usual care, and has the potential to increase access to therapy in areas with high speed Internet services.

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.

Effects of orthopaedic immobilization of the right lower limb on driving performance: an experimental study during simulated driving by healthy volunteers.

BACKGROUND: The effects of immobilization of the right lower limb on driving performance are unknown. Therefore, clinicians and legislators cannot put forth recommendations for road safety for patients requiring such immobilization. The objective of the present study was to evaluate the effect of two orthopaedic immobilization devices on the braking performances of healthy volunteers under simulated driving conditions. METHODS: The braking performances of forty-eight healthy volunteers were evaluated under three conditions: wearing a running shoe, wearing a walking cast, and wearing an Aircast Walker on the right lower limb. A computerized driving simulator was used to measure the maximum force applied on the brake pedal during braking as well as the braking reaction time and the total braking time during emergency braking with and without a distractor. RESULTS: The mean braking forces applied with the shoe, the walking cast, and the Aircast Walker were 293.8, 275.4, and 287.2 lb (133.3, 124.9, and 130.3 kg), respectively. The value with the walking cast was significantly lower than that with the shoe or Aircast Walker (p < 0.0001); there was no difference between the shoe and the Aircast Walker. The adjusted mean braking reaction times during emergency braking without a distractor were 0.580 second (shoe), 0.609 second (cast), and 0.619 second (Aircast Walker). The value with the running shoe was significantly lower than that with either type of immobilization (p < or = 0.0001). With a distractor, the mean braking reaction time was shorter with the running shoe than it was with either form of immobilization (p < or = 0.0001); the mean time was also shorter with the walking cast than it was with the Aircast Walker (p = 0.003). During both emergency braking tasks (with and without a distractor), the mean total braking time was shorter with the shoe than it was with either type of immobilization (p < 0.0001). With a distractor, the adjusted mean total braking time was shorter with the walking cast than it was with the Aircast Walker (p = 0.035). CONCLUSIONS: Immobilization of the right lower limb affects the braking force as well as the braking reaction time and total braking time during emergency braking by healthy volunteers. While these changes are significant, their impact on the ability to drive safely during emergency braking situations is questionable. Future research into the impact of such immobilization on the emergency braking performances of patients is warranted to confirm these observations.