Five facts about orthopaedic physiotherapy
APA Orthopaedic Group members Patricia Evans, Emma Blake and Brett Baxter provide commentary about some aspects of orthopaedic physiotherapy.
1. Steps can be taken to reduce the likelihood of refracture
More than 4.7 million Australians aged over 50 have osteoporosis, osteopenia or poor bone health; this equates to 19 per cent of the population. In New South Wales and the Australian Capital Territory, as many as 50,000 fractures occur every year, representing an annual cost of $740 million in treatment. These fractures can lead to people living with ongoing pain, reduced mobility, loss of function and associated loss of quality of life—and the real possibility of further fractures.
The Dubbo Osteoporosis Epidemiology Study (Bliuc et al 2015) found that 24 per cent of women and 20 per cent of men sustained a refracture within five years of their initial fracture. Further published data reports that any type of minimal trauma fracture can be a directly attributable factor in premature death.
Formative evaluation of the New South Wales Model of Care for Osteoporotic Refracture Prevention was undertaken in 2011 and 2012 to ascertain its impact and applicability across the various service sites in the state. If the model of care is implemented in its entirety across New South Wales and if the refracture rate is reduced by 10 per cent, highly positive outcomes would be achieved for patients and health services in the state over a 10-year period, including the avoidance of 10,000 refractures in previously admitted patients, making 100,000 bed days available for other patients.
Bliuc D, Alarkawi D, Nguyen TV, Eisman JA, Center JR. (2015): Risk of subsequent fractures and mortality in elderly women and men with fragility fractures with and without osteoporotic bone density: the Dubbo Osteoporosis Epidemiology Study. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research. 30(4):637-46.
2. Programs help postoperative patients return home quicker
Joint arthroplasty is a common surgical procedure to reduce pain, improve function and health-related quality of life. As the Australian population ages, the prevalence of osteoarthritis and the need for joint replacement surgery is increasing, and clinicians are advancing their knowledge in prosthetic design and surgical and anaesthetic techniques. Enhanced recovery after surgery (ERAS) programs consist of pre-operative education, early mobilisation, intensive inpatient physiotherapy and early discharge home (Wainwright et al 2010).
Pre-operative patient education is an integral component of an enhanced recovery program for lower limb joint arthroplasty. Patients who received pre- operative education have a shorter hospital length of stay (LOS), better outcome scores and were able to mobilise earlier (Yoon et al 2010, Jones et al 2011, Moulton et al 2015). They also required fewer postoperative inpatient physiotherapy visits and achieved readiness to discharge from physiotherapy faster (Soeters et al 2018).
Early mobilisation is also an essential component of an enhanced recovery program. Recently, many studies comparing standard pathways to enhanced recovery programs have included mobilisation on the day of surgery as a component of the fast track group. Patients who mobilised on the day of surgery were found to have a significant reduction in hospital LOS and were more likely to be discharged directly home (Smith et al 2012, Tayrose et al 2013, Yakkanti et al 2019). They were also found to have a decreased time to readiness for discharge (Okamoto et al 2016).
Wainwright T and Middleton R. An orthopaedic enhanced recovery pathway. Current Anaesthesia and Critical Care 2010; 21(3): 1-7
Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W. Patient education before hip and knee arthroplasty lowers length of stay. Journal of Arthroplasty 2010; 25(4): 547-551
Jones S, Alnaid M, Kokkinakis M, Wilkinson M, St Clair Gibson A, Kader, D. Pre-operative patient education reduces length of stay after knee arthroplasty. Annals The Royal College of Surgeons of England 2011; 93(1): 71-75
Moulton LS, Evans PA, Starks I, Smith T. Pre-operative education prior to elective hip arthroplasty surgery improves postoperative outcome. International Orthopaedics 2015; 39(8): 1483-1486
Soeters R, White PB, Murray-Weir M, Koltsov JBC, Alexiades MM, Ranawat AS. Preoperative physical therapy education reduces time to meet functional milestones after total joint arthroplasty. Clinical Orthopaedics and Related Research 2018; 476(1): 40-48
Smith TO, McCabe, Lister S, Christie SP, Cross J. Rehabilitation implications during the development of the Norwich Enhanced Recovery Program (NERP) for patients following total knee and total hip arthroplasty. Orthopaedics and Traumatology: Surgery and Research 2012; 98: 499-505
Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J 3rd. Rapid mobilization decreases length of stay in joint replacement patients. Bulletin of The Hospital for Joint Disease 2013; 71(3): 222-6
Yakkanti RR, Miller AJ, Smith LS, Feher AW, Mont MA, Malkani AL. Impact of early mobilisation on length of stay after primary total knee arthroplasty. Annals of Translational Medicine 2019; 7(4): 69
Okamoto T, Ridley R, Edmondston SJ, Visser M, Headford J, Yates PJ. Day-of-surgery mobilization reduces length of stay after elective hip arthroplasty. Journal of Arthroplasty 2016; 31 (10): 2227-30
3. No single conservative treatment for closed fifth finger metacarpal neck fractures is superior
Fractures of the fifth metacarpal neck are common injuries, accounting for about 20 per cent of all hand fractures. They are usually sustained by an axial blow on the metacarpophalangeal joint when flexed, and are commonly called a ‘boxer’s fracture’. Angulation of the fracture causes a shortening of the metacarpal neck, which can result in loss of the normal prominence of the fifth knuckle. The extent of acceptable palmar angulation remains under debate; recommendations in the literature vary from 20 to 70 degrees.
There is no consensus on the optimal management of these fractures. A Cochrane Systematic Review in 2005 compared functional treatment with immobilisation, different periods and types of immobilisation. From this, it was identified that there was no evidence that any of the treatments was significantly superior.
Based on current evidence, no single conservative method can be recommended as superior to another. Recovery is generally excellent whichever treatment was used; certain interventions may offer advantages in pain reduction or early return to work. The informed patient should decide if their personal priority is maximum pain reduction, earliest return to work or other outcome, and to be guided to the intervention most likely to confer that benefit.
4. The decision to wait or bear weight is influenced by several factors
Many factors are considered when determining weight-bearing post-lower limb fracture. These factors can be divided into those that relate to the patient, the fracture and the type of treatment to manage the fracture.
Patient factors include bone density and strength, compliance/ability to comply with weight-bearing restrictions, weight/ obesity, co-morbidities and medications, presence of infection and nutritional status. Fracture factors include type of fracture/ stability of the fracture pattern, location of the fracture (eg, peri articular/intra articular fracture), associated tissue damage (eg, skin, muscle, nerve, vascular supply) and whether it is an open or closed fracture.
Fixation factors include stability of the immobilisation device (eg, assessed in combination with the stability of the fracture pattern). If a patient undergoes internal fixation, the type of fixation device used and the amount of soft tissue disruption required to implant the device also impact on the stability and weight-bearing.
The principles of fracture management advise that the treatment method provides early stability to allow mobility and optimal function. The principles of weight-bearing protocols post-lower limb fracture treatment should optimise healing while avoiding loss of fracture position or implant failure. Kubiak et al (2013) identified that ‘for certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit’. Several randomised, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (>=6 weeks) weight-bearing.
It is important for physiotherapists who work with patients post-lower limb fracture, and are involved in developing and implementing treatment plans, to be aware of the factors that can influence the decision to weight or to wait.
Solomon L, Warwick D and Nayagam S (2010). Apley’s System of Orthopaedics and Fractures; Ninth Ed
Kubiak E. et al (2013): Early weight bearing after lower extremity fractures in adults Journal of the American Academy of Orthopaedic Surgeons. 21(12):727
5. Conservative management of knee osteoarthritis is recommended
About 2.1 million Australians are estimated to have osteoarthritis—with prevalence higher in women than men. Symptoms are usually uncommon in people aged under 45, but more than 25 per cent of people aged 65 or older report some joint symptoms.
Knee osteoarthritis causes a particularly high burden on patients and the healthcare system. Osteoarthritis is not an inevitable part of ageing and is not necessarily progressive. Being overweight doubles a person’s risk of developing knee osteoarthritis, and obesity increases the risk more than fourfold. Losing a moderate amount of weight can improve symptoms and the physical capability of people with knee osteoarthritis.
Knee osteoarthritis can be diagnosed on clinical grounds alone. There is a poor correlation between radiological evidence of osteoarthritis and symptoms. Current guidelines for osteoarthritis, including of the knee, recommend conservative management using a combination of non- pharmacological and pharmacological treatments. Core non-pharmacological treatment includes patient education and self-management, exercise and weight loss. Conservative management is recommended at all stages of the disease.
A multidisciplinary team approach is particularly important for the management of chronic diseases such as osteoarthritis, for which patients have complex care needs. Self-management of osteoarthritis can improve pain control and the patient’s functional status.
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