Author’s address: Michał Skalski, Leszetyckiego 5/11, 20-861 Lublin, Poland;
phone: +48 793728320; e-mail: ms.michal.skalski@gmail.com Received: 31.07.2019
Accepted: 12.08.2019 Published: 7.11.2019
REVIEW
Analysis of the course of treatment of patients
with corticosis using endoprosthesis in the context of the need to personalize the rehabilitation process
Analiza przebiegu leczenia pacjentów z koksartrozą za pomocą endoprotezolastyki w kontekście potrzeby personalizacji procesu usprawniania
Michał Skalski1, Jacek Gągała2, Milena Socha-Kania3
1 Independent Complex of Public Open Health Care Facilities Nr1 Warszawa-Wawer, Poland
2 Orthopedic and Traumatology Department Medical University of Lublin, Poland
3 Olimpia Fitness Club Lublin
Abstract
Introduction. Total hip replacement is a common and succesful treatment of the osteoarthritis of the hip.
Material and Methods. During the work on this article, an analysis of scientific articles on corticosis and hip arthroplasty has been made, with particular emphasis on studies investigating the influence of age and body weight on the obtained results of treatment. The second method of collecting research material was the analysis of medical records of patients operated on in Independent Public University Hospital 4 in Lublin. The analysis included 150 pa- tients undergoing total hip replacement surgery at the Independent Public Clinical Hospital No. 4 in Lublin in 2017. Among the respondents there were 54% (n = 81) men and 46% (n = 69) women. The most common diagnosis was primary cortherapy (M16) – 68.7% (n = 103), followed by other primary cortherosters (M16.1) – 14.7% (n = 22), other post-traumatic cortherapy and other secondary bilateral cortherapy (M16. 5 and M16.6) – after 3.3% (n = 5), another secondary cortherapy (M16.7) – 2.7% (n = 4). Other diagnoses included cases of bilateral corticosis resulting from dysplasia (M16.2), other dysplastic coxartrosis (M16.3), unspecified coxartosis (M16.9) and congenital hip deformity (Q65.0). During 90.7% (n = 136), post-lateral access was used, in 8% (n = 12) anterolateral access was used, back and front access was used in 1 case (0.7%).
Results. The average length of the procedure in the study group was 55 minutes (± 23 min), the minimum duration was 30 minutes and the maximum duration was 150 minutes. Among the respondents there were 4% (n = 6) operated in the early adulthood (18-34 years), 8.7% (n = 13) in middle adulthood (35-49 years), and later in adulthood (50 -64 years) there were 36% (n = 54) of the subjects, in the elderly (65-74 years) there were 28% (n = 42), and in senile age (75-89) was 23.3% (n = 35). Among the respondents, there were 77 people aged over 65 years, which is 51.3%. The obtained results coincides with the data obtained in the report commissioned by the Ministry of Health, according to which in 2015 the most operational interventions were performed among patients aged 60-69 and 70-79, which accounted for 58% of all endoprosthetic surgery.
Conclusions. Based on the analysis of research literature, older age, overweight and obesity as well as diabetes are factors that significantly affect the pre-operative and post-operative rehabilitation process in the case of arthroplasty. At the same time, there is a growing tendency to personalize the improvement process, which is associated with the need to improve the quality of life of patients undergoing surgery. In the case of people over 65 years of age and obese people, it is indicated not only for a specific post-operative approach, but also for a high value of preoperative improvement. The work done in the form of re-education and improve- ment of the gait function and increased mobility of the hip joint pays a faster return to the peak of functional efficiency after the procedure. In the case of diabetes and its impact on the healing of the joint and periarticular joints undergoing treatment, particular attention is paid to rehabilitation care including close coopera- tion between the physician, physiotherapist and patient, adjusting the rehabilitation plan to the current patient’s needs during the visit.
Key words: coxarthrosis, improvement process, hip arthroplasty
Streszczenie
Wstęp. Całkowita wymiana stawu biodrowego jest częstym i skutecznym sposobem leczenia choroby zwyrodnieniowej stawu biodrowego.
Materiał i metody. During the work on this article, an analysis of scientific articles on corticosis and hip arthroplasty has been made, with particular em- phasis on studies investigating the influence of age and body weight on the obtained results of treatment. The second method of collecting research mate- rial was the analysis of medical records of patients operated on in Independent Public University Hospital 4 in Lublin. The analysis included 150 patients undergoing total hip replacement surgery at the Independent Public Clinical Hospital No. 4 in Lublin in 2017. Among the respondents there were 54% (n = 81) men and 46% (n = 69) women. The most common diagnosis was primary cortherapy (M16) – 68,7% (n = 103), followed by other primary cortherosters (M16.1) – 14,7% (n = 22), other post-traumatic cortherapy and other secondary bilateral cortherapy (M16. 5 and M16.6) – after 3,3% (n = 5), another second- ary cortherapy (M16.7) – 2,7% (n = 4). Other diagnoses included cases of bilateral corticosis resulting from dysplasia (M16.2), other dysplastic coxartrosis (M16.3), unspecified coxartosis (M16.9) and congenital hip deformity (Q65.0). During 90,7% (n = 136), post-lateral access was used, in 8% (n = 12) anterolat- eral access was used, back and front access was used in 1 case (0,7%).
Wyniki. Średnia długość zabiegu w badanej grupie wynosiła 55 minut (±23 min), minimalny czas to 30 minut, a maksymalny 150 minut. Wśród badanych było 4% (n = 6) operowanych w wieku wczesnej dorosłości (18-34 rż.), 8,7% (n = 13) w wieku średniej dorosłości (35-49 rż.), w wieku później dorosłości (50- 64 rż.) było 36% (n = 54) badanych, w wieku podeszłym (65-74 rż.) było 28% (n = 42), a w wieku starczym (75-89 rż.) było 23,3% (n = 35). Wśród badanych było zatem 77 osób w wieku powyżej 65 rż, co stanowi 51,3%. Uzyskany wyniki pokrywa się z danymi uzyskanymi w raporcie zleconym przez Ministerstwo Zdrowia, według którego w 2015 roku najwięcej interwencji operacyjnych wykonano wśród pacjentów w przedziale wiekowym 60-69 lat oraz 70 -79 lat, co stanowiło 58% wszystkich zabiegów endoprotezoplastyki.
Wnioski. Na podstawie analizy literatury badawczej można stwierdzić, że starszy wiek, nadwaga i otyłość oraz cukrzyca są czynnikami, które istotne wpływają na proces rehabilitacji przed- i pooperacyjnej w przypadku zabiegu endoprotezoplastyki. Jednocześnie widoczna jest coraz większa tendencja do personalizacji procesu usprawniania, co wiąże się z potrzebą zwiększenia jakości życia pacjentów poddanych zabiegowi. W przypadku osób po 65 roku życia oraz osób otyłych wskazuje się nie tylko na specyficzne podejście pooperacyjne, ale również na dużą wartość usprawnia przedoperacyjnego. Wykonana wówczas praca w postaci reedukacji i usprawnienia funkcji chodu oraz zwiększenia ruchomości stawu biodrowego procentuje szybszym powrotem do szczytu sprawności funkcjonalnej po zabiegu. W przypadku cukrzycy i jej wpływu na gojenie objętego zabiegiem stawu i tkanek okołostawowych zwraca się szczególną uwagę na opiekę rehabilitacyjną obejmującą ścisłą współpracę między lekarzem, fizjoterapeutą a pacjentem, dostosowując podczas wizyt kontrolnych plan usprawniania do aktualnych potrzeb pacjenta.
Słowa kluczowe: koksartroza, proces usprawniania, protezoplastyka stawu biodrowego
Introduction
Osteoarthritis is a non-inflammatory chronic disorder with a multifactorial etiology. Its basis is the imbalance between the processes of degeneration and regeneration of vitreous cartilage and subchondral bone layer. Osteoarthritis of the hip joints is also referred to as cortherapy and most often af- fects the elderly. In recent years, there has been an increas- ingly serious tendency to recognize this unit in young people aged 20-30. Due to this fact and the significant social costs of treatment of corticosis, its treatment is currently an impor- tant clinical problem. Epidemiological estimates indicate that about 8 million people are treated in Poland due to osteoar- thritis and 40% have corticosis [1].
Osteoarthritis is treated in two ways – conservatively and surgically. Among the operating methods, the most popular method of advanced treatment of coke arthrosis is hip arthro- plasty. Currently, the most common is total endoprosthesis, where both the head and the acetabulum affected by the joint disease are replaced, the procedure can be performed using bone cement or not [2]. In Poland, 39.854 endoprosthetolas- tic hip procedures were performed in 2010, and in 2015 the number of treatments amounted to 46.685 [3]. On an inter- national scale, it is expected that the number of treatments will increase by 170% by 2030, which will also translate into an increase in statistics on the domestic medical market [4].
The final result of the treatment with the hip replacement is not only the professional performance of the surgery it- self, but also the physical and psychological preparation of the patient in the form of pre-operative and postoperative rehabilitation [5].
Aim
We present a case where the cause of the complication was a The aim of the work is to draw attention to the need to personalize the process of rehabilitation before and after hip replacement in patients with additional aggravating factors in the form of advanced age and obesity.
Materials and methods
During the work on this article, an analysis of scientific ar- ticles on corticosis and hip arthroplasty has been made, with particular emphasis on studies investigating the influence of age and body weight on the obtained results of treatment.
The second method of collecting research material was the analysis of medical records of patients operated on in Inde- pendent Public University Hospital 4 in Lublin.
The analysis included 150 patients undergoing total hip replacement surgery at the Independent Public Clinical Hos- pital No. 4 in Lublin in 2017. Among the respondents there were 54% (n = 81) men and 46% (n = 69) women. The most common diagnosis was primary cortherapy (M16) – 68.7%
(n = 103), followed by other primary cortherosters (M16.1) – 14.7% (n = 22), other post-traumatic cortherapy and other secondary bilateral cortherapy (M16. 5 and M16.6) – after 3.3% (n = 5), another secondary cortherapy (M16.7) – 2.7%
(n = 4). Other diagnoses included cases of bilateral corticosis resulting from dysplasia (M16.2), other dysplastic coxartro- sis (M16.3), unspecified coxartosis (M16.9) and congenital hip deformity (Q65.0).
During 90.7% (n = 136), post-lateral access was used, in 8% (n = 12) anterolateral access was used, back and front ac- cess was used in 1 case (0.7%).
Results
The average length of the procedure in the study group was 55 minutes (± 23 min), the minimum duration was 30 min- utes and the maximum duration was 150 minutes. Among the respondents there were 4% (n = 6) operated in the early adulthood (18-34 years), 8.7% (n = 13) in middle adulthood (35-49 years), and later in adulthood (50 -64 years) there were 36% (n = 54) of the subjects, in the elderly (65-74 years) there were 28% (n = 42), and in senile age (75-89) was 23.3%
(n = 35). Among the respondents, there were 77 people aged over 65 years, which is 51.3%. The obtained results coincides with the data obtained in the report commissioned by the Ministry of Health, according to which in 2015 the most op- erational interventions were performed among patients aged 60-69 and 70-79, which accounted for 58% of all endopros- thetic surgery [3].
Fig. 1. Treatment time in the researched group.
The correct body mass was 22% (n = 33) from the op- erated patients, overweight 31.3% (n = 47), grade I obesity 29.3% (n = 44), grade II obesity 12.7% (n = 19) ), and grade III obesity 4.7% (n = 7). Thus, obesity affected 70 subjects, which is 46.7% of patients undergoing surgery. In addition, 24.7% (n = 37) of the subjects had diabetes.
The average length of hospitalization of operated patients was 7.5 days (± 2.4). The minimum period of stay in the hos- pital was 2 days, and the maximum was 20 days. During the analysis of the age dependence on length of hospitalization, it can be noticed that the average length of hospitalization for patients under 65 was 6.7 days (± 1.6), and for patients aged 65 years or more 8.1 days (± 2.7 years) ). Age is there- fore a factor that extends the time of hospitalization, which increases the cost of treatment for a single patient.
Fig. 2. Age of the researched’ structure.
Fig. 3. BMI structure of the subjects.
Fig. 4. Length of hospitalization of the researched.
Fig. 5. Length of hospitalization of the researched.
Similar differences were not noticed when analyzing the effect of body weight on the length of hospitalization. Among patients with obesity and obesity, it was 7.3 (± 2.3), and among patients with normal body weight 7.9 days (± 2.6), thus the average time of hospitalization was similar.
The course of postoperative rehabilitation
According to the documentation attached to the information cards, on the first day after the surgery patients were included in the isometric exercises, self-service exercises, active stand- ing and preparation for walking on crutches. On the second day students started learning how to walk on crutches and locomotion activities, which is in line with the generally ac- cepted improvement scheme.
Postoperative complications occurred among 12 patients, which is 8% of the subjects. Three patients had high fever, two patients had Clostridium difficile infection, single pa- tients had deep vein thrombosis, glycemic disorders, post- operative edema, post-surgical wound exudate, haematuria and atrial fibrillation. In one case, as a result of leaving the operating thread, it was necessary to revisit the procedure and the patient also developed pneumonia and pulmonary embolism. In all of these cases, this was associated with the temporary cessation of post-operative rehabilitation.
Stinks the age of patients
The natural aging process of the body causes a decrease in the regeneration ability after the procedure. Over the years, neu- romuscular coordination, balance, defensive reactions and cognitive functions deteriorate. An additional factor hinder- ing the convalescence process in old age is osteoporosis and sarcopenia [6,7]. At the same time, elderly people constitute more than half of patients undergoing arthroplasty, which makes us pay special attention to this group of patients.
Sonoda et al. analyzed the influence of age on the results of treatment of patients undergoing lower limb arthroplasty.
It was shown then that patients who exceeded 65 years de- clared a lower level of quality of life due to the presence of pain and the risk of falls. The authors of the study stress that in people over 65 years there is a much greater risk of falls, which requires them to use a properly prepared improve- ment program [8].
Obtaining worse functional results among the oldest group of patients is also associated with a deterioration of cognitive functions. Sonoda et al. Believe that properly se- lected physical training can contribute to lowering the risk of post-operative depression and rapid recovery. it contributed to a decrease in the occurrence of depressive moods and a rapid increase in efficiency among the study group [8].
In studies on postoperative rehabilitation of older pa- tients undergoing arthroplasty, a positive effect of conduct- ing intensive post-surgical rehabilitation and an improve- ment of the gait function in a short time after surgery is indicated. At the same time, the research literature indicates that the greatest improvement in the quality of life depending on the health condition occurs shortly after the procedure. At the same time, it is not possible to determine when the peak moment of proper functioning after the procedure occurs.
According to some sources, the best functional state among older patients occurs after about 6 months after surgery and lasts up to 4 years. Other studies, however, state that peaks in functional efficiency were obtained after one year and de- creased within 7 years after surgery [6,7,9].
Heiberg et al. Studied the level of functional fitness among patients undergoing arthroplasty during the first year after surgery. The determinant of functional ability was a 6-min- ute walk test. The results of the study pointed out that better results were obtained by younger patients, men and people with a better range of mobility and greater distance traveled before surgery [10]. Therefore, it seems justified especially in older people to use preoperative rehabilitation aimed at im- proving the gait function and increasing the range of motion in the joint affected by degeneration.
Yet another approach should be used when working with patients over 80 years of age. It is a group that is particu- larly exposed to the occurrence of postoperative complica- tions and readmission. Then it is recommended to give up the classic intensive modem of rehabilitation, and often it is also necessary to extend the time of hospitalization caused by the presence of coexisting conditions. The oldest group of patients therefore requires particularly caring care, which must be adapted to the current state of health, and the post- operative rehabilitation process should not be limited only to the time of hospitalization, but should be continued in home or outpatient settings [9].
Overweight and obesity
The second common factor among patients undergoing hip arthroplasty, which can significantly affect the final results of treatment is overweight and obesity. 46.7% had obesity in the study group. As in the case of age, this factor affects the greater exposure of patients to complications due to the high workload of the body, unlike in patients whose weight re- mains normal. The literature also mentions that obese people find it difficult to restore correct walking patterns due to the difficulty in obtaining adequate muscle strength of the pelvic girdle. At the same time, it has been known for a long time that obesity accelerates the development of osteoarthritis and is one of the direct causes of a steady decline in the age of patients undergoing hip replacement [11].
Overweight and obesity are a serious burden on the body, and in many studies you can find data suggesting that this is a factor that increases post-operative mortality rates [12-17].
Research conducted among patients with different BMI (Body Mass Index) values leaves no doubt that people suf- fering from morbid obesity (BMI> 50) are exposed to signifi- cantly more serious postoperative complications, including the need for early reoperation, which is associated with an in- crease in Costs [18]. According to retrospective studies that check the presence of twelve ascending complications during the first 90 days after surgery, patients with morbid obesity are much more likely to be affected by: implant infections, need for revision, wound dehiscence, deep vein thrombosis, pulmonary embolism, implant failure, acute renal failure, myocardial infarction and implant dislocation [19].
Diabetes
Due to the significant share of elderly and obese people among patients undergoing arthroplasty, attention should be paid to another serious clinical problem that is diabetes. In the analyzed research material, 24.7% of patients with obesity also suffered from diabetes. The percentage of patients with diabetes and concomitant functional disability is growing rapidly and is now becoming an increasingly serious health problem. Patients suffering from diabetes who require surgi- cal intervention are a challenge for health care, because its presence is associated with numerous perioperative com- plications in the form of infections, delayed wound healing, metabolic complications and increased mortality [20]. Epi- demiological estimates indicate that the incidence of diabetes will increase by about 69% in developing countries and 20%
in developed countries in 2010-2030 [21].
Diabetes is an independent predictor of a 30-day readmis- sion rate. According to the Diabetes Control and Complica- tions Trial, reduction of diabetic complications is possible by about 70% in the case of advanced patient education and cooperation of the therapeutic team [22]. In order to reduce readmission rates, it is necessary to change the health care of diabetic patients who are to undergo arthroplasty. It is neces-
sary to improve communication with patients and motivate them to pre-operative health optimization [23]. Romano et al. indicates that in order to reduce the percentage of postop- erative complications, personalized postoperative treatment protocols should be introduced, divided due to the specific perioperative risk to which patients are exposed [24]. Pa- tients with high risk of complications should therefore be included in frequent medical consultations with established goals of recovery and adapted rehabilitation protocols [24].
In the light of trends aimed at improving the quality of life, it seems reasonable to consider diabetes in the post-surgical rehabilitation process of patients undergoing arthroplasty.
This is particularly important due to the fact that diabetes often coexists with obesity and affects a large percentage of older people.
Summary
Based on the analysis of research literature, older age, over- weight and obesity as well as diabetes are factors that signifi- cantly affect the pre-operative and post-operative rehabili- tation process in the case of arthroplasty. At the same time, there is a growing tendency to personalize the improvement process, which is associated with the need to improve the quality of life of patients undergoing surgery. In the case of people over 65 years of age and obese people, it is indicated not only for a specific post-operative approach, but also for a high value of preoperative improvement. The work done in the form of re-education and improvement of the gait func- tion and increased mobility of the hip joint pays a faster re- turn to the peak of functional efficiency after the procedure.
In the case of diabetes and its impact on the healing of the joint and periarticular joints undergoing treatment, partic- ular attention is paid to rehabilitation care including close cooperation between the physician, physiotherapist and pa- tient, adjusting the rehabilitation plan to the current patient’s needs during the visit.
References
1. Dziekońska M, Latosiewicz R, Kulikowska A: Pielęgnowanie pacjenta po endoprotezoplastyce stawu biodrowego. Hygeia Public Health 2013, 48(3):355-359.
2. Wang Z, Bao W, Hou JZ: Direct anterior versus lateral approaches for clinical outcomes after total hip arthroplasty: a meta-analysis. J Orthop Surg Res. 2019 Feb 26;14(1):63.
3. Endoprotezoplastyka stawu biodrowego – opieka kompleksowa. Ra- port. AOTMiT-WT-553-14/2015.
4. Dargel J, Oppermann J, Brüggemann GP, Eysel P: Dislocation Follow- ing Total Hip Replacement. Dtsch Arztebl Int. 2014 Dec; 111(51-52):
884-890.
5. Wang L, Lee M, Zhang Z, Moodie J: Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised con-
trolled trials. BMJ Open. 2016 Feb 2;6(2):e009857. doi: 10.1136/bmjo- pen-2015-009857.
6. Antapur P, Mahomed N, Gandhi R: Fractures in the elderly: when is hip replacement a necessity? Clin Interv Aging. 2011; 6: 1-7.
7. Marya SK, Thukral R, Singh C: Prosthetic replacement in femoral neck fracture in the elderly: Results and review of the literature. Indian J Orthop. 2008 Jan-Mar; 42(1): 61-67.
8. Sonoda Y, Sawano S, Kojima Y, Kugo M, Taniguchi M, Maegawa S, Ka- wasaki T: Comprehensive geriatric assessment of effects of hospitaliza- tion and long-term rehabilitation of patients following lower extremity arthroplasty. J Phys Ther Sci. 2016 Apr; 28(4): 1178-1187.
9. Malkani AL, Dilworth B, Ong K, Baykal D, Lau E, Mackin TN, Lee GC:
High Risk of Readmission in Octogenarians Undergoing Primary Hip Arthroplasty. Clin Orthop Relat Res. 2017 Jan 12. doi: 10.1007/s11999- 017-5241-9.
10. Heiberg KE, Ekeland A, Bruun-Olsen V, Mengshoel AM: Recovery and prediction of physical functioning outcomes during the first year after total hip arthroplasty. Arch Phys Med Rehabil. 2013 Jul;94(7):1352-9.
11. Haynes J, Nam D, Barrack RL: Obesity in total hip arthroplasty: does it make a difference? Bone Joint J. 2017 Jan;99-B(1 Supple A):31-36.
12. Büchele G, Günther KP, Brenner H, et al.: Osteoarthritis-patterns, cardio-metabolic risk factors and risk of all-cause mortality: 20 years follow-up in patients after hip or knee replacement. Sci Rep.
2018;8(1):5253. Published 2018 Mar 27. doi:10.1038/s41598-018- 23573-2
13. Stürmer T, Günther KP, Brenner H: Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study. J. Clin. Epidemiol.
2000;53:307–313. doi: 10.1016/S0895-4356(99)00162-6.
14. Thijssen E, van Caam A, van der Kraan PM: Obesity and osteoarthritis, more than just wear and tear: pivotal roles for inflamed adipose tissue and dyslipidaemia in obesity-induced osteoarthritis. Rheumatol. Oxf.
Engl. 2015;54:588–600. doi: 10.1093/rheumatology/keu464
15. Xing D, et al.: Osteoarthritis and all-cause mortality in worldwide populations: grading the evidence from a meta-analysis. Sci. Rep.
2016;6:24393. doi: 10.1038/srep24393.
16. Hochberg MC: Mortality in osteoarthritis. Clin. Exp. Rheumatol.
2008;26:S120-124.
17. Barbour KE, et al.: Hip Osteoarthritis and the Risk of All-Cause and Disease-Specific Mortality in Older Women: A Population-Based Co- hort Study. Arthritis Rheumatol. Hoboken NJ. 2015;67:1798-1805.
18. Werner BC, Higgins MD, Pehlivan HC, Carothers JT, Browne JA: Su- per Obesity Is an Independent Risk Factor for Complications After Pri- mary Total Hip Arthroplasty. J Arthroplasty. 2017 Feb;32(2):402-406.
19. Meller MM, Toossi N, Gonzalez MH, Son MS, Lau EC, Johanson N:
Surgical Risks and Costs of Care are Greater in Patients Who Are Super Obese and Undergoing THA. Clin Orthop Relat Res. 2016 Nov;474(11):2472-2481.
20. Leung V, Ragbir-Toolsie K: Perioperative management of patients with diabetes. Health Serv Insights. 2017;10.
21. Shaw JE, Sicree RA, Zimmet PZ: Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4–14. doi:
10.1016/j.diabres.2009.10.007.
22. Harris MI: Medical care for patients with diabetes. Epidemiologic as- pects. Ann Intern Med. 1996;124:117–122. doi: 10.7326/0003-4819- 124-1_Part_2-199601011-00007.
23. Lung BE, Bisogno M, Kanjiya S, Komatsu DE, Wang ED: Early post- operative complications and discharge time in diabetic patients un- dergoing total shoulder arthroplasty. J Orthop Surg Res. 2019;14(1):9.
Published 2019 Jan 8. doi:10.1186/s13018-018-1051-3.
24. Romano AM, Oliva F, Nastrucci G, Casillo P, Di Giunta A, Susanna M, Ascione F: Reverse shoulder arthroplasty patient personalized reha- bilitation protocol. Preliminary results according to prognostic groups.
Muscles Ligaments Tendons J. 2017;7(2):263–270. doi: 10.11138/
mltj/2017.7.2.263.
