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Maximum Medical Improvement & Stable/Stationary State

Recovery timelines and time-to-plateau after orthopaedic surgery. When is a patient stable or stationary? Months to maximum medical improvement (MMI) by procedure — primary / revision arthroplasty, cuff repair, stabilisation, fusion. Medicolegal impairment assessment framework.

Overview

Initial management of sports-related concussions prioritizes reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. Assessment of functional recovery requires validated tools; the Musculoskeletal Function Assessment Questionnaire demonstrates superior responsiveness and efficiency compared to the SF-36 for measuring functional changes between baseline and follow-up [2]. Clinicians must also account for testing intervals, as longer, clinically pragmatic intervals affect the test-retest reliability of baseline cognitive assessments using ImPACT [1].

In reconstructive and arthroplasty contexts, specific surgical techniques yield predictable stability and function. Double semitendinosus anterior cruciate ligament reconstruction restores satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [4]. For total knee arthroplasty, mobile and fixed-bearing all-polyethylene tibial component designs functioned equivalently in low-to-moderate-demand groups at early follow-up [5], while patients undergoing preoperative strengthening plus balance training are expected to present similar performance at 1 year postoperatively [6]. Similarly, highly cross-linked polyethylene cups against cobalt-chromium or zirconia heads show no significant differences in total penetration rate or steady-state wear rate [7].

Emerging technologies and regulatory landscapes require critical evaluation. The 2-year migration rate study of the trabecular metal monoblock acetabular cup system demonstrated very good early implant stability, with migration rates superior to available studies for similar designs in all but one case [10]. While autologous matrix-induced chondrogenesis shows promise, further long-term studies are needed to determine if the grafted area maintains structural and functional integrity [8]. Understanding current evidence and appropriate indications for emerging orthopaedic trauma technologies is of critical importance [17], particularly as substantial reforms of the European Union medical device regulation process within the next 5 to 10 years will result in a more stringent approach similar to that of the FDA, though changes in the FDA regulatory process are suggested but not imminent [12]. Finally, protocols now exist for randomized controlled trials investigating the safety, cost-effectiveness, and economic evaluation of outpatient total hip arthroplasty, including the first trial to use blinding for this comparison [42].

Anatomy & Pathophysiology

Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint [23], often associated with mechanical block from periarticular osteophytes [23]. In the context of chronic whiplash injury (WAD), patients demonstrate evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli [44].

Regarding predictive modeling for musculoskeletal outcomes, several psychological and physiological factors predicted change in the number of pain sites among employees [28]. Similarly, while each risk factor for growth retardation in children with juvenile idiopathic arthritis demonstrates moderate predictive value individually, their combined consideration significantly improves predictive accuracy [11].

Classification

Cognitive & Functional Assessment: ImPACT baseline cognitive assessments demonstrate long-term test-retest reliability over clinically pragmatic testing intervals [1]. The Musculoskeletal Function Assessment Questionnaire is more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [2]. Initial treatment for sports-related concussions consists of a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3].

Joint Reconstruction & Arthroplasty: Double semitendinosus anterior cruciate ligament reconstruction restores satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [4]. Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [5]. No significant differences were identified between groups for total penetration rate and steady-state wear rate in highly cross-linked polyethylene cups against cobalt-chromium or zirconia heads at minimum five-year follow-up [7]. The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction with a 4-year mean follow-up [14].

Pediatric & Rheumatologic Prognosis: While individual risk factors for growth retardation in children with juvenile idiopathic arthritis demonstrate moderate predictive value, their combined consideration significantly improves predictive accuracy [11]. Changes observed in diet groups in adults with Rheumatoid Arthritis are likely due to the improvement in overall diet quality irrespective of dietary prescription [40].

Impairment & Regulatory Standards: The fifth edition of the Guides to the Evaluation of Permanent Impairment retained the focus of earlier editions while incorporating updates in diagnostic criteria, clarifying key definitions, and enhancing readability, accessibility, and consistency through a blend of evidence-based medicine and specialty society consensus recommendations [18]. Substantial reforms of the European Union medical device regulation process within the next 5 to 10 years will result in a more stringent approach similar to that of the FDA [12].

Other Considerations: Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores on numerous scoring systems devised to evaluate patients with knee symptoms [36]. Healing indices may be useful only as a rough estimate of the duration of treatment required for each proposed procedure in distraction osteogenesis of the lower extremity [46]. Claimants in a series of uninformed injured workers did not have a familiarity with basic principles believed to be important in the management of their claim, and simply providing access to information appears to be insufficient [49].

Clinical Presentation

Initial evaluation of sports-related concussions relies on baseline cognitive assessments using ImPACT, which demonstrate long-term test-retest reliability over clinically pragmatic testing intervals [1]. For functional assessment, the Musculoskeletal Function Assessment Questionnaire proves more responsive than the SF-36 and more efficient in measuring changes between baseline and follow-up values [2]. In patients with juvenile idiopathic arthritis, while individual risk factors for growth retardation demonstrate moderate predictive value, their combined consideration significantly improves predictive accuracy [11].

Acute Injury Management: Initial treatment for sports-related concussions consists of a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. In cases presenting with a focal neurologic deficit, there is a substantial risk of acute stroke or TIA, warranting emergent imaging [20].

Chronic Arthropathy and Post-Operative Status: Double semitendinosus anterior cruciate ligament reconstruction restores satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [4]. Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [5]. Patients are expected to present similar performance at 1 year postoperatively following preoperative strengthening plus balance training for total knee replacement [6]. No significant differences were identified between groups for total penetration rate and steady-state wear rate in highly cross-linked polyethylene cups against cobalt-chromium or zirconia heads over a minimum five-year follow-up [7].

Pediatric and Specific Pathology Findings: Forty-seven (96 per cent) of forty-nine shoulders had a good clinical result after distal release of the deltoid muscle contracture [13]. Persistent symptoms were found in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees at the latest follow-up evaluation after total meniscectomy for discoid lateral meniscus in children [15]. A case report documents the first instance of Crohn's disease in a hemophilic arthropathy patient, demonstrating a highly pathogenic mutation locus and summarizing clinical experience of early diagnosis and treatment [30]. Increased proteasome activator 28 gamma (PA28γ) levels are unspecific but correlate with disease activity in patients with rheumatoid arthritis [27].

Complications and Legal Considerations: Postoperative pain and infection are the most frequent reasons for legal action after knee arthroscopy [16]. Patient information, close follow-up, and early and appropriate management of complications are the main ways to reduce complaints after knee arthroscopy [16]. The statement regarding the prevalence of symptom exaggeration in workers' compensation claims was unsubstantiated and misleading [33]. Focusing on detecting exaggerated symptoms will not eliminate costs or reduce litigation in workers' compensation cases [33]. Comprehensive initiatives to assist workers in returning to work are more effective than focusing on detecting exaggerated symptoms in workers' compensation cases [33].

Diagnostic and Follow-up Modalities: The fifth edition of the Guides to the Evaluation of Permanent Impairment incorporates updates in diagnostic criteria, clarifies key definitions, and enhances readability, accessibility, and consistency through a blend of evidence-based medicine and specialty society consensus recommendations [18]. Telemedicine has the same value as traditional clinical evaluations and enables patients to be followed over long distances and over time, minimizing any discomfort [19]. The presence of good collateral circulation allows for removal of a true aneurysm of the ulnar artery with proximal and distal ligation without impairment of circulation [31].

Investigations

Plain radiography: Standing X-rays are utilized to stabilize the evolution of degenerative lesions following double semitendinosus anterior cruciate ligament reconstruction [4]. In mid- to long-term results after bipolar radial head arthroplasty, despite a high incidence of radiographic signs of degenerative changes after 8.8 years, Judet's bipolar prosthesis achieved mainly good clinical results [21].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [47]. In patients presenting with a focal neurologic deficit, there is a substantial risk of acute stroke or TIA, warranting emergent imaging [20].

Other Considerations: Baseline cognitive assessments using ImPACT demonstrate long-term test-retest reliability over clinically pragmatic testing intervals [1]. The Musculoskeletal Function Assessment Questionnaire is more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [2]. Initial treatment for sports-related concussions consists of a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. Patients are expected to present similar performance at 1 year postoperatively following preoperative strengthening plus balance training for total knee replacement [6]. While individual risk factors for growth retardation in children with juvenile idiopathic arthritis demonstrate moderate predictive value, their combined consideration significantly improves predictive accuracy [11]. Total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible due to findings of persistent symptoms in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees at the latest follow-up evaluation [15]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [8]. A 2-year migration rate study showed very good early implant stability for the Trabecular Metal Monoblock Acetabular Cup System, superior to available studies for similar design acetabular cups in all cases except one [10]. The author's method for explaining emotional intelligence has been successful in one particularly severe case followed for seven years [9]. An erratum regarding secondary neurological deterioration in traumatic spinal injury corrected a data error noting that five patients initially classified as Frankel C who improved to Frankel D were mistakenly included [22]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [17]. The fifth edition of the Guides to the Evaluation of Permanent Impairment incorporates updates in diagnostic criteria, clarifies key definitions, and enhances readability, accessibility, and consistency through a blend of evidence-based medicine and specialty society consensus recommendations [18]. Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in low-to-moderate-demand patient groups [5].

Treatment

Non-Operative

Initial management for sports-related concussions involves reducing cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. For chronic, nonradicular, discogenic low back pain, intradiskal electrothermal therapy demonstrates reported therapeutic success rates of 60% to 80%, although precise quantification of clinical benefits requires further proof in randomized prospective trials [45]. In patients with rheumatoid arthritis, vaccines are well tolerated when administered subcutaneously with background DMARDs [38]. Transcranial magnetic stimulation serves as a feasible adjunctive treatment for stroke to improve various neurological deficits, though optimal stimulation parameters and mechanisms require further exploration [50].

Operative

Indications: Surgical management for coxa vara in childhood is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require surgery [48]. Total meniscectomy for discoid meniscus in children should be avoided whenever possible due to findings of persistent symptoms and evidence of osteoarthrosis at long-term follow-up [15].

Surgical Approach / Technique: The double semitendinosus anterior cruciate ligament reconstruction procedure is efficient in restoring satisfactory stability for most patients and stabilizes the evolution of degenerative lesions as shown by standing X-ray [4]. A method for explaining emotional intelligence has proved successful in one particularly severe case followed for seven years, offering a simple technical approach with little risk of serious loss of motion compared to procedures attempting to change joint contours [9].

Implant Selection: Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [5]. No significant differences were identified between groups for total penetration rate and steady-state wear rate in minimum five-year follow-up wear measurements of highly cross-linked polyethylene cups against cobalt-chromium or zirconia heads [7]. The 2-year migration rate study of the trabecular metal monoblock acetabular cup system showed very good early implant stability and, in all cases except one, superior results compared to available studies for similar design acetabular cups [10].

Other Considerations: Preoperative strengthening plus balance training is expected to result in similar performance at 1 year postoperatively following total knee replacement [6]. Patient information, close follow-up, and early and appropriate management of complications are the main ways to reduce complaints regarding postoperative pain and infection after knee arthroscopy [16]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [17]. Substantial reforms of the European Union medical device regulation process within the next 5 to 10 years will result in a more stringent approach to device regulation, similar to that of the FDA, while changes in the FDA regulatory process have been suggested but are not imminent [12].

Complications

Infection (PJI) / Wound complications: Postoperative pain and infection represent the most frequent reasons for legal action following knee arthroscopy [16]. To mitigate complaints, the primary strategies involve providing comprehensive patient information, ensuring close follow-up, and implementing early and appropriate management of complications [16].

Polyethylene wear: In highly cross-linked polyethylene cups paired against cobalt-chromium or zirconia heads, no significant differences were identified between groups regarding total penetration rate or steady-state wear rate at a minimum five-year follow-up [7].

Other Considerations: Initial treatment for sports-related concussions requires a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. Long-term test-retest reliability of baseline cognitive assessments using ImPACT is influenced by longer, clinically pragmatic testing intervals [1]. Secondary neurological deterioration in traumatic spinal injury has been associated with data errors, specifically where five patients initially classified as Frankel C who improved to Frankel D were mistakenly included [22]. Regarding shoulder pathology, forty-seven (96 per cent) of forty-nine shoulders achieved a good clinical result after distal release of the deltoid muscle contracture [13]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, Judet's bipolar prosthesis for radial head arthroplasty yielded mainly good clinical results [21]. The Discovery Elbow System demonstrated improved function, reduced pain, and high patient satisfaction with a 4-year mean follow-up [14]. A 2-year migration rate study of the Trabecular Metal Monoblock Acetabular Cup System indicated very good early implant stability, with superior stability compared to available studies for similar design acetabular cups in all cases except one [10]. An author's method for explaining emotional intelligence proved successful in one particularly severe case followed for seven years, with little risk of serious loss of motion [9]. Further studies with long-term follow-up are required to determine if the grafted area in Autologous Matrix-Induced Chondrogenesis will maintain structural and functional integrity over time [8]. The procedure for double semitendinosus anterior cruciate ligament reconstruction stabilizes the evolution of degenerative lesions as shown by standing X-ray [4]. Patients are expected to present similar performance at 1 year postoperatively following preoperative strengthening plus balance training for total knee replacement [6]. Two designs of mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [5].

Recovery

Light activity (weeks): Initial management for sports-related concussions mandates a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol [3]. For shoulder contracture release, 96% of patients achieved good clinical results following distal deltoid release, facilitating early functional engagement [13]. Telemedicine facilitates long-distance follow-up with minimal patient discomfort, supporting continuity of care during early recovery phases [19].

Full activity (months): Double semitendinosus anterior cruciate ligament reconstruction restores satisfactory stability for most patients, stabilizing the evolution of degenerative lesions as evidenced by standing X-ray [4]. The Discovery Elbow System demonstrated improved function and reduced pain with high patient satisfaction at a 4-year mean follow-up [14]. Patients undergoing total knee replacement present similar performance at 1 year postoperatively regardless of preoperative strengthening plus balance training [6].

Complete recovery / outcome plateau (months): ImPACT baseline cognitive assessments demonstrate long-term test-retest reliability over clinically pragmatic testing intervals, supporting the use of these metrics for determining stable cognitive status [1]. The Musculoskeletal Function Assessment Questionnaire is more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [2]. If adequately treated, avulsion fractures of the tibial spine show a good long-term prognosis [51]. A 2-year migration rate study of the Trabecular Metal Monoblock Acetabular Cup System showed very good early implant stability, superior to available studies for similar design acetabular cups in all cases except one [10].

Rehabilitation protocol: Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [5]. Direct exchange for infection after total hip replacement can yield a rate of success comparable with that of delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are used [52]. The author's method for treating a severe case proved successful over a seven-year follow-up, is technically simple, and carries little risk of serious loss of motion [9].

Functional milestones: Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [8].

Key Evidence

  • [L4] These data help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability. (10.1177/0363546509343805)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L5] Initial treatment consists of a reduction in cognitive activity and physical rest, followed by a stepwise return-to-play protocol. (10.5435/jaaos-d-16-00684)
  • [L4] The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. (10.1007/s001670050076)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)
  • [L2] Patients are expected to present similar performance at 1 year postoperatively. (10.1007/s00167-020-06029-x)
  • [L2] No significant differences were identified between the groups for total penetration rate and steady-state wear rate. (10.1016/j.arth.2009.09.006)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] The 2-year migration rate study showed very good early implant stability and, in all cases except one, superior to the available studies for similar design acetabular cups. (10.1016/j.arth.2008.09.027)
  • [L3] While each of these factors demonstrates moderate predictive value individually, their combined consideration significantly improves predictive accuracy. (10.1186/s12891-024-08247-7)
  • [L5] Substantial reforms of the European Union process within the next 5 to 10 years will result in a more stringent approach to device regulation, similar to that of the FDA, while changes in the FDA regulatory process have been suggested but are not imminent. (10.5435/jaaos-d-15-00403)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L4] The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction. (10.1016/j.jse.2014.08.013)
  • [L4] On the basis of our findings of persistent symptoms in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees at the latest follow-up evaluation, we believe that total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible. (10.2106/00004623-199811000-00003)
  • [L4] Patient information, close follow-up, and early and appropriate management of complications are the main ways to reduce complaints. (10.1007/s00167-021-06586-9)
  • [L4] Telemedicine has the same value as traditional clinical evaluations and enables patients to be followed over long distances and over time, minimizing any discomfort. (10.3390/jcm11133644)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. (10.2106/00004623-199806000-00015)
  • [L4] However, the correlation with disease activity in patients with RA suggests a prognostic value, which needs to be addressed by further studies. (10.1186/1471-2474-15-414)
  • [L2] Several psychological and physiological factors predicted change in the number of pain sites. (10.1186/s12891-017-1503-7)
  • [Case_report] This case report is the first report of this rare co-morbidity, demonstrating the highly pathogenic mutation locus and summarizing the clinical experience of early diagnosis and treatment. (10.1186/s12891-024-07610-y)
  • [L4] The presence of good collateral circulation allows for removal of the lesion with proximal and distal ligation without impairment of circulation. (10.1177/03635465030310032201)
  • [L5] The authors argue that the statement regarding the prevalence of symptom exaggeration in workers' compensation claims was unsubstantiated and misleading, emphasizing that focusing on detecting exaggerated symptoms will not eliminate costs or reduce litigation, and that comprehensive initiatives to assist workers in returning to work are more effective. (10.1016/j.jhsa.2008.02.023)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L3] Vaccines were well tolerated with SC abatacept with background DMARDs. (10.1186/s12891-016-1082-z)
  • [L1] The changes observed in both diet groups are likely due to the improvement in overall diet quality irrespective of dietary prescription. (10.1186/s12891-024-07742-1)
  • [L2] This protocol describes the first randomized trial to use blinding to evaluate outpatient THA compared to standard overnight stay and the first to prospectively perform a full economic evaluation. (10.1186/s12891-020-03699-z)
  • [L4] The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. (10.1186/1471-2474-11-29)
  • [L5] The treatment of chronic, nonradicular, discogenic low back pain remains controversial, and while intradiskal electrothermal therapy shows reported therapeutic success rates of 60% to 80%, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials. (10.5435/00124635-200301000-00003)
  • [L4] Healing indices may be useful only as a rough estimate of the duration of treatment required for each proposed procedure. (10.2106/00004623-199806000-00003)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L4] Claimants in this series did not have a familiarity with basic principles that were believed to be important in the management of their claim, and simply providing access to the information appears to be insufficient. (10.2106/jbjs.21.00182)
  • [L1] TMS is a feasible adjunctive treatment for stroke that can improve various post-stroke neurological deficits, though its potential mechanisms and optimal stimulation parameters require further exploration. (10.3389/fnins.2023.1177283)
  • [L4] If adequately treated, avulsion fractures of the tibial spine show a good long-term prognosis. (10.1007/s00167-003-0387-2)
  • [L4] The experience suggests that direct exchange can yield a rate of success comparable with that of delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are used. (10.2106/00004623-199807000-00004)

References

[1] Long-Term Test-Retest Reliability of Baseline Cognitive Assessments Using ImPACT. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509343805

[2] Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199709000-00006

[3] Managing Sports-related Concussions From Time of Injury Through Return to Play. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00684

[4] Double semitendinosus anterior cruciate ligament reconstruction: 10‐year results. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050076

[5] Mobile and Fixed-Bearing (All-Polyethylene Tibial Component) Total Knee Arthroplasty Designs. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.j.00157

[6] A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06029-x

[7] Minimum Five-Year Follow-Up Wear Measurement of Longevity Highly Cross-Linked Polyethylene Cup Against Cobalt-Chromium or Zirconia Heads. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.09.006

[8] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[9] EXPLAINING EMOTIONAL INTELLIGENCE. 2021.

[10] Migration of the Trabecular Metal Monoblock Acetabular Cup System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.09.027

[11] Risk factors for growth retardation in children with juvenile idiopathic arthritis: a case-control study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08247-7

[12] Medical Device Regulation: A Comparison of the United States and the European Union. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00403

[13] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

[14] Total elbow arthroplasty: a prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.08.013

[15] Discoid Lateral Meniscus in Children. Long-Term Follow-up After Total Meniscectomy. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199811000-00003

[16] Postoperative pain and infection are the most frequent reasons for legal action after knee arthroscopy: a 5‐year review based on two private insurance French companies after arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06586-9

[17] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[18] Guides to the Evaluation of Permanent Impairment. 2001.

[19] Traumatology: Adoption of the Sm@rtEven Application for the Remote Evaluation of Patients and Possible Medico-Legal Implications. Journal of Clinical Medicine. 2022. DOI: 10.3390/jcm11133644

[20] Head_Computed_Tomography_Is_Not_Useful_for_Evaluating_Patients_Change_in_Mental_S0883540313009406. n.d..

[21] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[22] Todd NV, Skinner D,Wilson-MacDonald J. Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases.. 2015.

[23] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[27] Increased proteasome activator 28 gamma (PA28γ) levels are unspecific but correlate with disease activity in rheumatoid arthritis. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-414

[28] Psychological predictors of change in the number of musculoskeletal pain sites among Norwegian employees: a prospective study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1503-7

[30] Crohn’s disease in hemophilic arthropathy patient: a case report. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07610-y

[31] True Aneurysm of the Ulnar Artery in a Soccer Goalkeeper. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310032201

[33] Overstating the Prevalence of Symptom Exaggeration in Workers' Compensation Cases. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.023

[36] Demographic Biases of Scoring Instruments for the Results of Total Knee Arthroplasty. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00009

[38] Antibody response to pneumococcal and influenza vaccination in patients with rheumatoid arthritis receiving abatacept. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1082-z

[40] Effects of a telehealth-delivered Mediterranean diet intervention in adults with Rheumatoid Arthritis (MEDRA): a randomised controlled trial. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07742-1

[42] A protocol for a randomized controlled trial investigating the safety and cost-effectiveness of outpatient total hip arthroplasty. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03699-z

[44] Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: An exploratory study in chronic whiplash patients. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-29

[45] Treatment of Chronic Discogenic Low Back Pain With Intradiskal Electrothermal Therapy. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200301000-00003

[46] Distraction Osteogenesis of the Lower Extremity with Use of Monolateral External Fixation. A Study of Two Hundred and Sixty-one Femora and Tibiae. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00003

[47] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[48] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[49] Ineffective Communication: The Uninformed Injured Worker. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00182

[50] Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke. Frontiers in Neuroscience. 2023. DOI: 10.3389/fnins.2023.1177283

[51] Treatment of malunited fractures of the anterior tibial spine. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0387-2

[52] Direct-Exchange Arthroplasty for the Treatment of Infection after Total Hip Replacement. An Average Ten-Year Follow-up. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199807000-00004

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

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3. Term. The term of this Public License is specified in Section 6(a).

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a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

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Section 3 -- License Conditions.

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i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

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iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

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b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

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b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

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b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

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2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

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b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

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