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The Journal of Bone and Joint Surgery (American) 84:2312-2320 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.

Specialty Update

What's New in Orthopaedic Rehabilitation

Michael J. Botte, MD, Kace A. Ezzet, MD, Lorenzo L. Pacelli, MD, Madonna J. Guzman, PA-C, R. Scott Meyer, MD, Matthew J. Meunier, MD, Darryl D. D'Lima, MD and Clifford W. Colwell, MD


Michael J. Botte, MD
Kace A. Ezzet, MD
Lorenzo L. Pacelli, MD
Madonna J. Guzman, PA-C
Darryl D. D'Lima, MD
Clifford W. Colwell, MD
Division of Orthopaedic Surgery, Scripps Clinic, 10666 North Torrey Pines Road, MS116, La Jolla, California 92037

R. Scott Meyer, MD
Matthew J. Meunier, MD
Department of Orthopaedic Surgery, University of California, San Diego, School of Medicine, 200 West Arbor Drive, San Diego, California 92103

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

In the last year, several important research topics related to orthopaedic rehabilitation have been discussed at the national and international meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons, the SICOT/SIROT 2002 XXII World Congress, and the various COMSS (AAOS Council of Musculoskeletal Specialty Societies) subspecialty societies. To reflect the many subtopics of the specialty, this update is divided into several topics or regional areas. The papers that received the Jacqueline Perry Award and the Vernon Nickel Award, two prestigious awards in orthopaedic rehabilitation that are presented by the Orthopaedic Rehabilitation Association, are also reviewed.

Neuromuscular Disorders

New studies involving neuromuscular disorders have focused on problems associated with neurogenic heterotopic ossification in the knee 1 , the physiologic aspects of muscle spasticity 2 , and the use of motion analysis and polyelectromyograms in the evaluation of spastic disorders 3,4 .

Neurogenic Heterotopic Ossification: The Jacqueline Perry Award Paper
Neurogenic heterotopic ossification is a poorly understood affliction that involves spontaneous periarticular formation of bone in patients with acquired spasticity 5-8 . Patients with traumatic brain injury or spinal cord injury are frequently affected. Neurogenic heterotopic ossification commonly involves the hip, shoulder, elbow, and occasionally involves the knee. The authors of that paper (Arthur Mark, David A. Fuller, and Mary Ann E. Keenan) presented their research on the excision of neurogenic heterotopic bone from the knee at the Orthopaedic Rehabilitation Society meeting in February 2002 1 . While several authors have discussed heterotopic ossification involving other areas such as the hip, shoulder, and elbow 5-8 , the study by Mark et al. 1 represents one of the few investigations of neurogenic heterotopic ossification about the knee. Those authors studied seventeen consecutive patients with acquired spasticity who underwent operative resection of heterotopic bone from the knee. The arc of motion improved by 66° (to an average postoperative arc of 106°). The average improvement in extension was 13° (range, 0° to 45°), and the average improvement in flexion was 53° (range, 0° to 95°). Thirteen patients had improvement in walking ability; specifically, ten became community ambulators, two became household ambulators, and one became a limited ambulator. The authors concluded that removal of heterotopic bone from around the knee is a worthwhile procedure and should be considered for any patient who has painful or limited knee motion. For their work, the authors received the 2002 Jacqueline Perry Award for excellence in orthopaedic rehabilitation research, which was awarded in February 2002 in Dallas, Texas.

Physiologic Changes Following Muscle Spasticity
Little is known regarding the physiologic changes in skeletal muscle following acquired spasticity. Lieber and Friden recently evaluated the changes in muscle sarcomere length in patients with spastic wrist flexion contractures 2 . Sarcomere length was measured in the flexor carpi ulnaris muscles of six patients with severely spastic wrist flexion contractures as well as twelve patients with radial nerve injury. The average sarcomere length in the patients with spastic wrist flexion contractures (3.48 ± 0.44 μm) was much greater than that in the patients with radial nerve injury (2.41 ± 0.31 μm). In three of the patients with spastic wrist flexion contractures, the slope of the flexor carpi ulnaris sarcomere length-joint angle relationship was measured and was found to be essentially normal (0.017 ± 0.005 μm/degree), suggesting that serial sarcomere number (and therefore muscle fiber length) was unchanged in spite of the dramatic absolute change in sarcomere length. These results indicate that spasticity results in a major alteration of normal muscle-joint anatomical relationships.

Role of Dynamic Electromyograms in Spastic Limb Evaluation
The value of motion analysis and the use of dynamic electromyograms in the planning of the surgical treatment of spastic limb deformities was the subject of two recently presented papers 3,4 . Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision-making has not been established. Fuller and Keenan investigated the influence of gait analysis with dynamic electromyography on surgical planning in a study of patients with acquired spastic equinovarus deformity 3 . Thirty-six consecutive patients were evaluated clinically by two surgeons, and a surgical treatment plan was formulated. All patients then underwent instrumented gait analysis that included the collection of kinetic, kinematic, and polyelectromyographic data by a single experienced physiatrist with use of a standard protocol. With use of this information, a new surgical treatment plan was formulated. Surgical plans were compared for each surgeon before and after the gait study. The results of these comparisons showed that there was an overall change in 64% of the surgical plans when the data from the gait study were incorporated into the preoperative planning. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was achieved in all patients who underwent operative management. The authors concluded that gait studies do alter the surgical planning for patients with equinovarus deformity of the foot and ankle and can produce a higher degree of agreement between surgeons during the surgical planning process 3 .

In a similar study on the elbow, Keenan and associates studied the value and influence of dynamic polyelectromyographic studies in formulating a surgical plan for the treatment of spastic elbow flexion deformity 4 . Twenty-one patients with upper motor neuron syndromes (including stroke, traumatic brain injury, and cerebral palsy) were evaluated independently by two surgeons. A surgical plan for the correction of the elbow flexion deformity was formulated on the basis of a clinical examination alone. The patients then underwent dynamic polyelectromyographic evaluation of the elbow muscles. In addition, kinematic and kinetic data were obtained and the patients were videotaped. Surgical plans were then reformulated with the additional motion-study data taken into consideration. The surgical plans for correction of the elbow flexion deformities were changed an average of 57% of the time when these additional data were used. The authors concluded that clinical examination alone is not sufficient to fully understand the specific contribution of each muscle to elbow deformity and dysfunction. Since the choice of surgical options is based on knowledge of the specific pattern of neurologic control for each individual muscle, it follows that clinical assessment alone is not adequate for planning the optimal surgical correction of a spastic elbow flexion deformity 4 .

Rehabilitation After Total Joint Arthroplasty

Two significant problems related to rehabilitation following total joint arthroplasty have recently received attention: dislocation after total hip replacement and pain management following total knee replacement. An update on these problems as well as on new aspects of prosthetic knee design and trends in knee rehabilitation is presented below. A summary of new trends in total elbow arthroplasty is presented as well.

Dislocation After Hip Replacement
Dislocation of the hip remains a most distressing complication following total hip arthroplasty. Several studies in the last few years have added new insights into the epidemiology, prevention, and treatment of this complication.

Although abduction pillows are frequently used on an empirical basis to prevent postoperative posterior dislocation while patients are in bed, there is no consensus as to how long the pillows should be utilized. A recent study followed 289 patients who underwent routine primary or revision arthroplasty and were managed with a postoperative abduction pillow for only one day, followed by a soft "regular pillow" for six weeks 9 . Patients with neuromuscular disorders or cognitive impairment were excluded. No posterior dislocations occurred while the patients were in bed. The authors concluded that extended use of abduction pillows is unnecessary.

The importance of the surgical approach has been highlighted in recent years, with at least two studies documenting a dislocation rate of <1% in association with the use of a direct lateral or an anterolateral approach 10,11 . Various techniques to repair the posterior part of the capsule after a posterior approach have allowed the dislocation rate to fall to <1% as well 12-15 .

The epidemiology of hip dislocation has become better understood in recent years. A recent study tracked the cumulative prevalence of dislocation in a large cohort of patients who underwent total hip arthroplasty at the Mayo Clinic 16 . Contrary to conventional thinking, the number of patients who had at least one dislocation increased at a steady rate of 0.2% per year after the first year, with a prevalence of 7% reached by twenty-five years after the index procedure. Patients with the highest statistical risk for dislocation included women, patients who were more than seventy years old, and patients with osteonecrosis. A previous study from a different institution showed that 57.5% of forty hips that had a dislocation after total hip replacement had at least one redislocation and that 40% ultimately required revision 17 .

Numerous investigators have recently utilized computer-generated models and finite-element analysis to define prosthetic design characteristics that can maximize range of motion and minimize impingement and dislocation 18-23 . Design features that can improve stability include short modular neck tapers, narrow-diameter tapers, and thin femoral necks. The avoidance of skirted modular femoral heads and the use of larger diameter femoral heads are also important factors. The importance of the "head-to-neck ratio" has been highlighted by several authors. Increasing the degree of the bevel (chamfer) of the polyethylene acetabular insert can also improve range of motion prior to impingement, but this comes at the price of a reduced amount of force necessary to cause dislocation once impingement occurs. The optimal compromise between "impingement-free" range of motion and resistance to "lever-out" force has yet to be determined. The development of new bearing surfaces with lower potential wear rates has generated optimism that larger-diameter femoral heads might be a viable option in the future. Although in vitro testing has shown low wear rates in association with large heads and new bearings, collaborative in vivo studies are needed before their widespread use can be advocated on a routine basis. Despite efforts to define optimal design characteristics, it must also be kept in mind that these computer models have consistently shown that proper component positioning will influence range of motion far more than minor modifications in prosthetic design will. Interestingly, three studies that compared groups of patients with and without postoperative dislocation failed to demonstrate a correlation between modest differences in alignment and the dislocation rate 17,24,25 . Factors that did correlate with dislocation included "cerebral dysfunction" 24 as well as trochanteric nonunion, the surgical approach, and the use of a modular femoral head 17 . Patients who had a dislocation were also found to have an impaired sense of balance and reduced sensitivity to vibration 25 . Another clinical study showed that the prevalence of dislocation in patients who received a 28-mm head increased substantially if the acetabular diameter was 62 mm or greater 26 .

The outcome of surgical treatment of recurrent hip dislocation has been unpredictable in the past. Daly and Morrey, in an often-quoted paper from the Mayo Clinic that was published in 1992, reported a failure rate of 31% after the surgical correction of hip instability 27 . Several recent studies have demonstrated much better results in association with the use of newer approaches. Two recent studies documented encouraging results (with success rates of 77% and 82%) when recurrent dislocation was treated with isolated modular head and liner exchanges in carefully selected patients with satisfactory alignment 28,29 . At least two companies in the United States now sell constrained acetabular liners to address this problem. Several studies of patients who were treated with constrained liners demonstrated redislocation rates of 3%, 2.5%, 13.5%, 5%, and 0% as reported at the annual meeting of the American Academy of Orthopaedic Surgeons in 2002 30-34 . Cautious and judicious use of these devices is nevertheless required as substantial rates of mechanical failure (loosening) are becoming apparent with increasing durations of follow-up. A follow-up study of a previously described series of 101 patients who were managed with a constrained acetabular insert showed that the rate of mechanical failure increased from 4% at the five-year follow-up 35 to 17% at the ten-year follow-up 30 .

An alternative approach for the treatment of recurrent dislocation was recently described 36 . This approach involves the use of a "jumbo" femoral head in conjunction with a custom polyethylene modular insert with an inner diameter that is large enough to accept it. In the report by Beaule et al., ten of eleven hips that were treated with this method had had no additional episodes of instability after an average duration of follow-up of ten years. These devices require the use of high-quality polyethylene of sufficient thickness to avoid catastrophic polyethylene failure. At this time, the long-term risk of osteolysis is not yet known for these jumbo head articulations. Another novel approach involves the use of allograft tissue to augment a deficiency of the posterior part of the capsule 37,38 . Although the rate of success associated with allograft augmentation is not as predictable as that associated with the use of constrained liners or jumbo heads, this approach avoids the potential risk of higher loosening rates and catastrophic polyethylene wear.

Pain Management After Total Knee Replacement
The management of postoperative pain is a challenge that faces surgeons and patients alike after total knee arthroplasty. Two recent studies showed conclusively what many surgeons have noted empirically for years, namely, that total knee replacement is much more painful than total hip replacement 39,40 . Effective pain management can improve patient satisfaction and reduce the risk of narcotic-related complications, the duration of hospitalization, and the cost of the procedure. Effective pain management can also improve the ultimate range of motion by allowing earlier attainment of high degrees of flexion. Unfortunately, most previous attempts to modify postoperative pain had only limited success.

Recently, the anesthesia and orthopaedic literature has included an abundance of studies that have evaluated alternatives to conventional methods of pain management. An interesting Dutch study showed that the severity of preoperative pain as measured subjectively by patients with use of a visual analog scale was highly predictive of postoperative pain and narcotic use 41 . The value of preemptive analgesia with long-acting oral narcotics delivered on a fixed schedule rather than on an "as-needed" basis has been shown to improve pain control substantially 42,43 . COX-2 inhibitors have also received attention as an adjunctive form of analgesia that may help to decrease postoperative narcotic requirements 44 . Intra-articular anesthetic injections can also provide modest improvements in postoperative pain management for the first few hours following surgery 45,46 .

Nerve blocks have become increasingly accepted as a form of postoperative pain management. Although the knee is innervated through branches of the femoral, obturator, and sciatic nerves, the individual contributions of each of these nerves to pain patterns after total knee arthroplasty have not been well documented. The so-called 3-in-1 femoral block in the inguinal region produces a blockade of the femoral, obturator, and lateral femoral cutaneous nerves. Chelly et al. compared the effectiveness of patient-controlled analgesia with morphine, epidural analgesia, and combined femoral-sciatic blocks 47 . Substantial improvements were seen in terms of narcotic use, length of hospital stay, postoperative bleeding, range of motion, and overall complications in the group that received nerve blocks. Capdevila et al. likewise found that a continuous femoral nerve block offered substantial advantages compared with patient-controlled analgesia with morphine 48 . Continuous epidural analgesia provided pain relief similar to that with continuous femoral nerve block but was associated with more side effects 48 . Allen and colleagues also found substantially improved pain scores during the first eight postoperative hours among patients who received peripheral nerve blocks 49 . Singelyn and coworkers compared patient-controlled analgesia, continuous epidural infusion, and continuous femoral block (without sciatic block) 50 . The femoral block group had better short-term flexion, faster ambulation, a shorter hospital stay, and fewer side effects than did the other two groups. Pain scores were similar in the femoral block group and the epidural infusion group, with both groups reporting less pain than the patient-controlled analgesia group. Similarly, Reynolds et al. found that femoral nerve infusion can provide analgesia equal to continuous epidural infusion, with a lower risk of side effects 44 . McNamee et al. found that, in patients managed with spinal anesthesia, the addition of a femoral and sciatic nerve block led to substantially improved pain management 51 . Although many clinicians have empirically added sciatic blocks to complement femoral blocks, there are now data that call into question the value of sciatic blocks. Allen et al. showed that adding a sciatic nerve block to a femoral nerve block does not further improve analgesic efficacy compared with use of the femoral nerve block alone 49 . In contrast, Naux and colleagues showed that the addition of a sciatic block offered some further benefit as the mean visual analog pain score dropped from 40 mm to 0 mm with the addition of sciatic blockade 52 .

Traditionally, the femoral nerve block has been given either as a single postoperative injection or as a continuous postoperative infusion. Singelyn and Gouverneur recently reported on the use of patient-controlled boluses of bupivacaine that were administered via an indwelling femoral catheter 53 . The efficacy of this method was equal to that of continuous infusion, with less anesthetic being consumed.

Luber et al. reported on a group of patients who received lumbar plexus and sciatic nerve block as a form of intraoperative anesthesia as well as postoperative analgesia 54 . Although 22% of the patients required conversion to general anesthesia intraoperatively, the method appeared quite satisfactory for postoperative analgesia, with 92% of the patients being satisfied. Hartford et al. assessed the total hospital costs associated with regional anesthesia as opposed to general anesthesia and found substantial cost savings in association with regional approaches 55 . Although operating-room time was slightly less for patients who received general anesthesia, those who received regional anesthesia had lower total hospitalization costs because of faster rehabilitation, a shorter hospital stay, and decreased operating-room and anesthetic supply costs.

Although there is no consensus as to whether these peripheral blocks are best suited for continuous infusion, "on-demand" infusion, or single-bolus administration, it seems clear that all three forms can improve pain management. It also seems clear that isolated femoral block, even without the addition of sciatic block, can provide substantial reduction in early postoperative pain. The optimal dosage and the optimal anesthetic agents still need to be determined. The safety of indwelling catheters, if used for continuous nerve infusion, needs to be specifically addressed for patients receiving various anticoagulants.

Trends in Rehabilitation After Total Elbow Arthroplasty
Recent improvements in design and technique have led to an increase in the popularity and success of total elbow arthroplasty. Total elbow arthroplasty was first described in 1972 56 . Early results showed promising benefits in terms of pain relief and functional improvement, but most prosthetic designs were associated with substantial complication rates and disappointing outcomes. The advent of the loose-hinged, constrained elbow prosthesis has improved survivorship to the point that it equals that reported after hip and knee arthroplasty. The loose-hinged linked configuration allows 10&deg; of hinge laxity outside of the plane of elbow motion, which has been associated with a reduced rate of aseptic loosening in long-term studies 57,58 .

New component designs have focused on expanding the indications for elbow replacement. Numerous unlinked or unconstrained designs have been developed in an effort to replicate the anatomic properties of the elbow as a means of reducing bone loss and prolonging survivorship. Published reports have shown promising short-term results with reduced rates of aseptic loosening but have also demonstrated more complications in association with instability 59,60 . For this reason, the decision to use an unlinked design depends on the degree of bone destruction, the integrity of the capsule and ligamentous structures, and the surgeon's own personal experience with the device 58,61 .

The goal of total elbow arthroplasty is to restore a functional range of motion, which Morrey et al. reported to be 100&deg; of flexion-extension (from 30&deg; to 130&deg;) and 100&deg; of rotation (from 50&deg; of supination to 50&deg; of pronation) 62 . The indications for elbow replacement are similar to those for hip and knee replacement: pain, stiffness, and loss of motion. Rheumatoid arthritis remains the most common disease process, although osteoarthritis, posttraumatic arthritis, elbow dysfunction associated with hemophilia, and selected acute elbow fractures in elderly patients are also considered to be indications. A recent study demonstrated promising results when elbow replacement was used for the treatment of comminuted intra-articular distal humeral fractures in elderly patients 63 . This approach allows early range of motion and a quicker return to normal function. In general, careful consideration should be given to the patient's age and functional demands during the evaluation of whether elbow arthroplasty is appropriate. Complication and failure rates have been reported to be higher in young patients and patients who perform strenuous labor 58 . In general, adults with rheumatoid arthritis, patients sixty years of age or older with osteoarthritis and posttraumatic arthritis, and patients sixty-five years of age or older with an acute elbow fracture may be considered to be candidates for the procedure.

Rehabilitation after total elbow arthroplasty is determined by the type of implant selected. Elbows treated with a linked or hinged design are initially splinted in extension and are started on range-of-motion exercises by the first or second postoperative day. The triceps repair is protected for six weeks with active assisted flexion and passive gravity-assisted extension. Extension splinting at night is continued for six weeks. More caution is needed in association with unlinked designs in order to protect the collateral ligament repair and to prevent instability. With this device, extension past 30&deg; is avoided for the first three to four weeks. Motion is initiated early, but the forearm is held in full pronation to protect the lateral collateral ligament repair 58,64 . The use of a resting splint at night is continued for twelve weeks (for patients managed with a linked device) or until adequate stability is achieved (for those managed with an unlinked device). Patients are instructed not to lift >2 lb (0.9 kg). High-impact sports involving the upper extremity, including golf, tennis, and baseball, are subsequently avoided.

Several reports on both linked and unlinked total elbow arthroplasty designs have described excellent relief of pain and restoration of functional motion in >90% of patients. Gill and Morrey reported that the survivorship of the linked Coonrad-Morrey prosthesis (Zimmer, Warsaw, Indiana) was 92% at twelve years 57 , which is comparable with the survivorship rates that have been reported after total hip and knee replacement. Loosening rates have been low in patients with rheumatoid arthritis who have been treated with this device, but failure rates have remained considerably higher in patients with posttraumatic arthritis and in younger patients 58 . The survivorship of the unlinked arthroplasty design has been reported to be between 85% and 94% at seven years, with a very low rate of loosening 58-61 . However, instability has been reported in 0% to 20% of cases 58-61 .

Foot and Ankle Rehabilitation

Osteochondral Lesions of the Talus
Osteochondral lesions of the talus remain a challenging problem 65-78 . Within the last few years, several surgical techniques have been designed to improve results and to provide more rapid rehabilitation after treatment of this difficult lesion. These methods include arthroscopic drilling 65-67,69,70 , drilling and bone-grafting 65,66,79 , mosaic or plug autogenous osteochondral transplantation 67,80-83 , osteochondral allografting, and cartilage transplantation 67,69 .

Arthroscopic drilling with or without débridement remains a popular method for the treatment of osteochondral lesions 65,66,77-79,83-90 . Indications for management include pain, loose bodies from the lesion, and the presence of a relatively small lesion 69,81 . Conti suggested that in order for retrograde arthroscopic drilling to be considered, the patient should be less than fifty years old, the medial talar lesion should be <1 cm 2 , magnetic resonance imaging should suggest an intact subchondral plate with a well defined sclerotic border, and ankle ligament stability should be intact 66 . The lesion is unroofed or loose cartilage is removed, the lesion is curetted, and the bed is drilled through one to three portals with use of a transmalleolar or a retrograde transtalar path 65,66,69,70 . Postoperative rehabilitation includes non-weight-bearing for as long as eight weeks 66,69,70 . Mobilization and gentle strengthening exercises are initiated within seven to ten days. Computerized tomography scanning or magnetic resonance imaging is performed at six months to assess healing. In general, studies of various drilling techniques have shown that most patients have improvement 65,84,85-86 , with 65% to 88% of the patients having a good or excellent result 67,76,86,87,90 . The best results are observed in patients who are less than thirty years old 85 and those who have acute lesions 86 .

Osteochondral grafting with use of autografts 67,73,80,81 or allografts 67,91-94 is a new and promising technique, although the long-term results are sparse. The use of mosaic or plug osteochondral autografts is associated with the disadvantages of donor-site morbidity, the potential need for a medial malleolar osteotomy, and harvest-size limitations 67 , but this approach does have the advantage of being a single procedure, unlike autologous chondrocyte implantation. Scranton reported substantial improvement in ten patients who underwent this procedure with use of osteochondral autografts from the ipsilateral knee 73 . Hangody et al. reported that mosaic autogenous osteochondral transplantation produced good to excellent results in thirty-four (94%) of thirty-six patients, with no long-term donor-site morbidity 81 . Gross et al. reported on nine patients who were managed with an osteochondral allograft for the treatment of a defect of the talus 92 . Six of the nine grafts remained in situ after a mean of eleven years, but three ankles required a subsequent arthrodesis secondary to graft resorption and fragmentation.

Autogenous chondrocyte implantation, popularized by Peterson et al. in Sweden, involves the placement of in vitro cultured autologous chondrocytes under a periosteal graft that holds the cells in place 71,95-97 . These cells attach to the subchondral bone and repopulate the defect. Biopsy studies show progression from unorganized cells to well organized, mature, hyaline-like cartilage. Tissue-typing shows type-II articular cartilage. Follow-up arthroscopic studies show a gradual return to a firm tissue similar to the surrounding cartilage. The advantages of this approach include the use of autogenous tissue, the growth of hyaline-like tissue, and minimum donor-site morbidity. The disadvantages include the technical difficulty of the staged procedure, a high cost, the need for staged grafting if bone loss is present, and an extended recovery period 67 . Ferkel suggested that the procedure may be indicated if the patient is fifteen to fifty-five years old, the defect is focal and contained, the lesion is unipolar (with only the talus being affected), edge-loading is present, and the patient has had a failure of previous surgery 67 . Relative contraindications include multifocal lesions, early degenerative changes, and no previous surgery. Absolute contraindications include osteoarthritis, uncorrected malalignment, and uncorrected instability. Rehabilitation following the procedure includes an initial period of immobilization in a cast followed by the use of a removable CAM walker with early active range of motion. Weight-bearing is gradually increased to full weight-bearing over a period of twelve weeks; activities are increased over the third, fourth, and fifth months; and strengthening and training are progressed between the sixth and twelfth months. The reported results have been promising 67,71,97 . Giannini et al. noted decreased pain, swelling, and crepitation in eight patients 98 . Second-look arthroscopy revealed regenerated areas of cartilage that on biopsy showed histologically normal-appearing cartilage of normal thickness with viable chondrocytes and positive staining for type-2 collagen.

Trauma Rehabilitation: The Vernon Nickel Award Paper

At the thirteenth annual meeting of the Orthopaedic Rehabilitation Association, Craig Glauser, Kevin Coupe, and Mike Burris presented an investigation on the incidence of malunion in a group of forty-four distal tibial fractures that had been treated with intramedullary nailing 99 . The authors' specific objective was to determine the relationship between the rate of malunion and the distance of the fracture from the distal screw and the relationship between the rate of malunion and the configuration of the distal screw. They found no significant relationship between screw configuration and the rate of malunion. For their work, the authors received the Vernon Nickel Award for excellence in rehabilitation research.

Orthopaedic Rehabilitation Today: New Directions

The Physician Assistant: A New Member of the Rehabilitation Team
Orthopaedic rehabilitation requires a multidisciplinary team approach. Members of this rehabilitation team have traditionally included rehabilitation nurses, physical and occupational (and hand) therapists, orthotics and prosthetics specialists, bioengineers, social workers, psychologists, and physician colleagues from the fields of physical medicine and rehabilitation, neurology, psychiatry, and internal medicine. A new and valuable member of the rehabilitation team is the certified physician assistant, who is assuming an ever-increasing role on the orthopaedic and rehabilitation team 100 .

The physician assistant is a skilled member of the health-care team who practices medicine under the supervision of a licensed physician. This profession emerged in the mid-1960s as a way to increase the accessibility to health care in areas that were underserved by primary-care physicians. The discipline had its beginnings with the medics who were trained to treat battle injuries during the Vietnam War. Once these medical corpsmen returned home, they searched for a way to continue to utilize their medical skills in civilian life. In 1964, Dr. Eugene Stead of Duke University founded the first physician assistant (PA) training program. A PA program is two years in length and follows the completion of a BA or BS degree. The majority of students have more than four years of health-care experience before admission to a PA program. The training of the physician assistant is often compared with the training provided in the first and third years of medical school. The first year is generally a didactic phase that encompasses essential medical courses including anatomy, physiology, biochemistry, microbiology, pathology, pharmacology, clinical medicine, and physical diagnosis. The second year consists of clinical rotations in the disciplines of family practice, internal medicine, psychology, obstetrics and gynecology, orthopaedics, emergency medicine, and surgery. Once a physician assistant has completed training in an accredited program, he or she must pass a national certifying examination in order to achieve the title of Physician Assistant Certified (PA-C). In order to maintain the certification (which is required in most states), a physician assistant must complete 100 hours of continued medical education and take a recertification examination every six years 100 .

The physician assistant has a broad and varied role on the medical team. The physician assistant evaluates and treats patients in the outpatient setting, obtains patient histories, conducts physical examinations, carries out ward rounds on inpatients, performs minor procedures, assists surgeons in the operating room, and participates in night call. The role and involvement of the physician assistant in the orthopaedic rehabilitation team is now substantial in many medical centers, and it continues to expand.

The Orthopaedic Rehabilitation Association
The Orthopaedic Rehabilitation Association (ORA) had its beginnings at the annual meeting of the American Academy of Orthopaedic Surgeons that was held in 1989 in New Orleans. A group of approximately thirty orthopaedic surgeons who were interested in rehabilitation and in the surgical and medical management of patients with chronic neuromusculoskeletal disorders met and formed the organization.

The ORA held its first scientific meeting in San Antonio, Texas, in November 1989. After subsequent annual meetings, it applied for and became a member of the AAOS Council of Musculoskeletal Specialties (COMSS). Besides conducting an annual meeting, the ORA has produced a scientific meeting program for Specialty Day at the annual meeting of the AAOS every year since 1994. The members of the ORA represent several areas of orthopaedic and rehabilitation interest. The society has prepared scientific programs, exhibits, and symposia on such topics as spinal disorders, neuromuscular disorders (e.g., brain injury, stroke, spinal cord injury, cerebral palsy), interdisciplinary care, sports medicine, hand and upper extremity, foot and lower extremity, tumor surgery, adult reconstruction and joint arthroplasty, prosthetics, orthotics, robotics, and innovative scientific and engineering developments in rehabilitation. Regular membership is open to members of the AAOS who demonstrate an interest in orthopaedic rehabilitation. Other types of memberships are open to orthopaedic surgery residents and fellows, international orthopaedic surgeons, and other physicians, scientists, and allied health-care professionals involved in rehabilitation.

The fourteenth annual meeting of the ORA will be held in Corpus Christi, Texas, in November 2003. Those interested in participating in the fourteenth annual meeting (or subsequent AAOS/ORA Specialty Day meetings) should send inquires or abstracts to the Orthopaedic Rehabilitation Association Central Office, Attn: Gay Anderson, MD, P.O. Box 446, Winneconne, Wisconsin, 54986. The deadline for abstracts for the fourteenth annual meeting is August 30, 2003. Information regarding the Jacqueline Perry Award and the Vernon Nickel Award is also available. The awards are given each year by the ORA at the annual meeting or at the AAOS/ORA Specialty Day.

Trends in Orthopaedic Rehabilitation: Rehabilitation in Orthopaedics is a Surgical Specialty
There is a consensus among the members of the ORA that, in general, orthopaedic rehabilitation is a surgical subspecialty. Although orthopaedic rehabilitation involves a multidisciplinary team approach and relies on crucial input from our colleagues in the several disciplines comprising the rehabilitation team, the ORA emphasizes that a main part of orthopaedic rehabilitation is the reconstructive aspects involving operative methods. Surgery can be considered an important tool in rehabilitation in that it can be used to assist with the management of the unique and challenging problems presented by these often complicated patients. When applied in the rehabilitation setting, operative methods can be effectively used to correct limb deformity, relieve pain, and restore function. Orthopaedic rehabilitation does not necessarily start in the rehabilitation setting; in fact, it can and often should start in the acute phases of care whenever feasible.

ORA Membership
Today, the Orthopaedic Rehabilitation Association continues to attract new members from several disciplines, both locally and from abroad. Membership has expanded by approximately 10% per year over the last few years, and the Association encourages applications from new, interested prospective members. Membership categories are available for physicians, for those involved in research, and for allied health professionals and members of the multidisciplinary rehabilitation team. The organization enthusiastically extends an invitation to those who are interested in the field to apply for membership. Applications can be obtained from the Orthopaedic Rehabilitation Association Central Office, Attn: Gay Anderson, MD, P.O. Box 446, Winneconne, Wisconsin, 54986.

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